Voice Therapy & Patient Management – Comprehensive Study Notes

Patient/Client Management – The Big Picture

• “Management” = entire continuum of care: referral ➔ case history ➔ interview ➔ evaluation ➔ goal-setting ➔ treatment implementation ➔ discharge & follow-up.

• Mind-set: every referral demands a holistic, global overview of the patient’s life, current function and desired outcomes.

  • Ask yourself each time:

  1. Why are they here? (etiology & urgency)

  2. Why now? (triggers, timeline)

  3. What are they complaining of? (subjective vs objective issues)

  4. How can I help? (feasible, functional change)

• Avoid “myopic therapy” (e.g., obsessing over Johnny’s /s/)—always reconnect goals to ultimate communicative function (e.g., intelligibility to strangers).

Habit 1 – Think Globally, Not Locally

• Step back and view interaction of medical, social, behavioral, cognitive and environmental variables.

• Sample snippet: 8-year-old Johnny unintelligible ➔ ultimate target = intelligibility, not simply articulatory correctness of /s/.

Habit 2 – Remember You Are a Behavior-Changer

• Speech-language pathology = systematic behavior modification (speech, language, voice, cognition, swallowing…)

• Talking about a problem ≠ therapy; Skilled Intervention is mandatory for payers and ethical practice.

• Components of skilled intervention:

  • Selection of target behavior (based on eval data)

  • Immediate, specific cues (auditory, visual, tactile, proprioceptive)

  • Real-time feedback & correction

  • Hierarchical task progression (isolation → syllable → word → phrase → spontaneous speech)

• Analogy: hot sauce on fingernails did not stop nail-biting; behavior only changes through consistently applied, systematic contingencies.

Non-Skilled vs Skilled Examples (Adults / Children)

Toolbox View of Voice Therapy

• Labels like hygienic, symptomatic, physiologic, psychogenic merely tell you which tools you might pull out.

• In session, clinician freely mixes tools according to moment-to-moment response (“I don’t say ‘I’m doing hygienic only.’ I reach for any tool that works.”).

Baseline, CLOF & PLOF

• Baseline: initial probe data at session 1.

• CLOF – Current Level of Function.

• PLOF – Previous Level of Function.

• Compare CLOF to eval findings; decide if patient worsened, improved, or maintained.

Target Behaviors in Voice Therapy

• Perceptual features: pitch, loudness, quality (hoarseness, breathiness), resonance, prosody.

• Physiologic contributors: breath support, posture, muscle tension, reflux status, vocal hygiene.

• Overarching aim = generalization & carry-over to daily contexts.

Clinical Cases & Associated Strategies

1. Contact Ulcers (Posterior Commissure)

• Etiology triad: reflux + chronic throat-clearing/cough + low pitch (especially males).

• Observable signs: patient localizes pain “right in the middle,” tickle sensation.

• Intervention targets:

  • Eliminate throat clearing ➔ substitute dry or water swallow, “silent cough,” or gentle hum.

  • Vocal hygiene routine: hydration every 15 min, sugar-free lozenges, reflux precautions.

  • Pitch elevation to reduce posterior glottal compression.

  • Reflux management plan (diet, timing of meds, lifestyle).

2. Idiopathic Unilateral Vocal Fold Paralysis (UVFP)

• Causes: viral neuropathy, post-surgical, unknown.

• Variable position of paralyzed fold (fully abducted to paramedian).

• Possible acoustic/functional outcomes:

  • If fold stuck fully abducted ➔ severely breathy/aphonic, ineffective cough.

  • Patient may recruit aryepiglottic folds & pharyngeal constrictors for airway closure.

• Therapy options:

  • Train alternative valving (false folds), hard glottal attacks → shape toward phonation.

  • Behavioral strengthening after medialization surgery (e.g., thyroplasty).

  • Amplification devices, AAC/text-to-speech as adjuncts.

  • Airway protection strategies and safe swallow training.

3. Postural Hypofunction & Reduced Loudness

• Slumped posture ↓ lung volume, ↓ sub-glottal pressure.

• Assessment: s/z ratio for glottal efficiency.

• Treatment:

  • Posture correction drills; if osteoporosis, modify within safe range.

  • Breathing re-education (abdomen, lower ribs).

  • Optimal pitch discovery & practice.

4. Neurologic Conditions

• Spasmodic Dysphonia → Botox into intrinsic laryngeal muscles; therapy = compensatory voice techniques.

• Essential Tremor → Medication + voice strengthening once tremor reduced.

Goal Writing Framework

1. Identify Functional Limitations (not every deficit needs treatment).

2. Assign Treatment Diagnosis + CPT Code (e.g., Voice Therapy 92507).

3. Long-Term Goals (LTG): broad communicative endpoint.

   • Example: “Patient will produce appropriate conversational loudness across all daily speaking contexts.”

4. Short-Term Goals (STG): measurable steps & skilled procedures.

   • E.g., “Using tactile/visual cues, patient will maintain diaphragmatic breathing with < 10 % clavicular movement in 8/10 trials.”

5. Procedures embedded in STGs: type, frequency, cueing hierarchy, tools.

Skilled Intervention Techniques Mentioned

• Mirror work for visual feedback.

• Tactile cues: laryngeal massage, neck relaxation.

• Auditory discrimination (“here’s what I heard vs what I want”).

• Hierarchical progression: sustained vowels ➔ voiced CVs/words (all-voiced) ➔ phrases ➔ conversation.

• Use of \text{“uh-huh”} pitch-matching to find optimal Fo.

• Vocal function exercises, Laryngeal relaxation stretches.

Reflux Counseling Essentials

• Understand pharmacokinetics: OTC PPIs/H2 blockers ≈ 6–7 hr half-life; timing before meals.

• Liquid Gaviscon recommended for mechanical bubble break & mucosal coating.

• Risks of long-term acid suppression: impaired digestion → ↑ gastric pressure → continued non-acid reflux.

• Diet modifications: smaller meals, live enzymes (fruits/vegetables), avoid late-night eating.

• Behavior plan tied directly to laryngeal tissue healing (“wound care” analogy).

Documentation, Education & Adherence

• High attrition stats:

  • > 33\% never attend initial SLP evaluation after ENT referral.

  • > 50\% no-show for 1st therapy session.

  • > 50\% of those who start, drop out.

• Key factors to improve adherence:

  1. Build value – explain relevance & expected gains.

  2. Rapport & trust – patients like personable, empathic clinicians.

  3. Concrete take-aways – notebooks, written cues, layered multimodal learning (auditory + visual + kinesthetic).

  4. Realistic scheduling – if attendance < 50\% (3 of 6 sessions), consider discharge & re-entry later.

  5. Telepractice as alternative for touring/remote clients.

Professionalism & Service Mind-Set

• “Take off the personal-problem hat” when entering clinic.

• Therapy is a business requiring value-based selling; absence of inherent perceived value means you must actively demonstrate it.

• Ethical mandate: do not waste patient or payer resources; treatment must be clinically justified & outcome driven.

Key Abbreviations & Terms

• CLOF – Current Level of Function

• PLOF – Previous Level of Function

• LTG / STG – Long-Term / Short-Term Goal

• 92507 – CPT code for individual speech/voice therapy

• Carry-over – generalized use of the target behavior in daily life.

• Granulation tissue – reactive growth over ulcers (seen in contact ulcers).

• Medialization thyroplasty – surgical implant to approximate a paralyzed VF.

• Hard Glottal Attack – forceful adduction used therapeutically to strengthen closure.

Numerical / Statistical References

• 50\% attendance rule of thumb for possible discharge due to poor compliance.

• Medication half-life ≈ 6–7\text{ h} for many OTC reflux drugs.

Practical Check-List for Upcoming Clinic/Exam

• [ ] Always begin with Why? Why now? What complaints?

• [ ] Identify functional limitation ➔ decide if treatable & worth treating.

• [ ] Establish CLOF, compare to eval, probe baseline.

• [ ] Write LTG (broad functional) and STG (procedural, measurable).

• [ ] Choose skilled interventions: cueing type, feedback schedule, task hierarchy.

• [ ] Document, educate, train using multiple modalities.

• [ ] Monitor adherence; discharge if < 50\% session completion.

• [ ] Maintain professional rapport; sell the value of therapy every visit.