Voice Therapy Notes

Voice Therapy for Hyperfunction

Voice Therapy Challenges

  • Efficacy of voice therapy techniques is debated in literature.

  • Avoid using a "blanket prescription" of tasks/exercises based solely on diagnosis.

  • The vocal quality produced in exercises may not be the ultimate goal, but a step towards habitual voice use (Schwartz, p. 90).

Traditional Approaches

  • Highly individualized, no fixed program.

  • Techniques applicable across problem types (organic, functional, neurogenic).

  • Use facilitating techniques to discover a “good” voice.

  • Therapist provides psychological support (implications for CDAs).

  • Therapy for vocal abuse must address generalized tension.

Boone's Facilitating Techniques

  • Traditional voice therapy basis: 25 techniques.

    1. Auditory feedback.

    2. Change of loudness.

    3. Chant talk.

    4. Chewing.

    5. Counselling.

    6. Digital manipulation.

    7. Elimination of abuses.

    8. Establishing a new pitch (e.g., Twang?).

    9. Focus.

    10. Glottal Fry.

    11. Hierarchy analysis- stretch and flow

    12. Inhalation phonation

    13. Laryngeal massage

    14. Masking - same as audiology, have noise/headphones on the patient and see the changes in the clients voice

    15. Nasal/glide stimulation "my" "your" yummy"(twang)

    16. Open-mouth approach

    17. Pitch Inflections

    18. Redirected phonation

    19. Relaxation

    20. Respiration training

    21. Tongue protrusion /i/

    22. Visual feedback

    23. Yawn/Sigh

    24. Stretch/flow

    25. Head positioning.

Change of Loudness: video

Chewing: video

  • loosening up the muscles to that we can accually articulate nad use our voice better.

Vocal Fry: video

  • Once a facilitating technique, now often a condition to treat.

Forward Focus: video
Inhalation Phonation: video

  • inhale while humming, and exhale while humming, then inhale while humming and exhale while humming into vowel.

Yawn-Sigh: Video

Reconsidering Voice Therapy

  • Concerns about traditional approaches:

    • Weak theoretical/scientific basis.

    • Unclear benefits.

    • Ambiguous cause-effect relationship (e.g., vocal abuse).

    • Potential harm to self-advocacy (exercise studies).

Resonant Voice Therapy (LMRVT)

  • Lessac-Madsen Resonant Voice Therapy (Verdolini-Abbot 2008).

  • Combines performing arts with science.

  • Addresses 3 areas:

    • Physiology.

    • Learning.

    • Compliance.

Principles of LMRVT

  • Focuses on VF over-adduction.

  • Aims for barely touching vocal folds for clear, easy voice.

  • Patient goals:

    1. Strong, clear voice (quality improvement).

    2. Reverse/prevent injury (harm prevention).

LMRVT Session Structure

  • Clinician & client manuals.

  • 30-45 min sessions, 1-2x weekly for 4-8 weeks.

  • Patient ranks voice feel each session.

  • Therapist explores history, establishes voice care protocol.

Initial Session

  • Therapist describes vocal fold vibration.

  • Introduces Resonant Voice Basic Training Gesture (RVBTG).

  • Sensory focus, not verbal instructions:

    • Where is your voice living?

    • What does it feel like?

    • What does it sound like?

Resonant Voice Definition

  • Feel voice resonating in front, not straining in throat.

  • Two questions to confirm correct technique:

    • Vibrations in the front of your face?

    • Easy?

Subsequent Sessions

  • RV Core Exercises:

    • Words (e.g., mention, moon, mundane).

    • Phrases (e.g., "The machine is broken.").

    • Chant (e.g., /mi mi mi/, /mi pi mi pi/).

  • RV Vocal Communicator:
    *Strategies to pull out of old voice to resonant voice (counting with thumbs up/down to mark RV/old voice)
    *RV Mini- recognizing and selfmonitoring.
    *Normal, quiet, loud over distance, speech in background noise, emotional speech, challenge conversation (clinician uses patient’s old voice)
    *RV Conversation- practicing in different settings/tones/capacities

  • Conversation using “mhm” (resonating, soft onset).

  • Strategies to shift from old to resonant voice.

  • RV Messa di Voce: crescendo.

  • Variable practice in different settings.

  • Evaluate goals, establish home practice, review in 3 months.

  • Discharge.

LMRVT Voice Care Principles

  1. Hydration:

    • 2 liters water daily.

    • Monitor urine color and sweating.

    • External hydration: shower steam, steam inhaler, vaporizer.

  2. Avoid Irritants:

    • Laryngopharyngeal reflux (LPR) management: limit spicy/fatty foods, alcohol, caffeine.

    • Elevate head during sleep, avoid eating 3-4 hours before bed, lose weight.

    • Consider medications and surgery (last resort).

    • Smoking cessation.

  3. Reduce Abusive Behaviors:

    • Stop screaming (except in emergencies).

    • Use earplugs in noisy environments.

Homework

  • Minimize the number of things you ask people to do! Verdolini-Abbott (2008, 2009)

Semi-Occluded Vocal Tract (SOVT)

  • Narrowing along the vocal tract.
    Open vocal tract: Open your mouth and say “AHHHH”. No obstruction of the airflow.

  • Semi-occluded vocal tract: Say the OO /u/, V /v/, Z /z/, J /ʤ/, or M /m/ sounds - notice how your lips and/or teeth come together to shape the sound. This also happens with a lip or a tongue trill - the airflow is “semi” closed off to make a sound.

  • Fully closed vocal tract: Close your mouth and purse your lips together. Your vocal tract is closed (except for your nasal passage for breathing)

Benefits of SOVT

  • Increased back pressure at lips reflects to vocal folds, easing vibration.

Straw Technique

  • Use straw for 15 minutes daily for warm-up, cool-down, or reset.

  • Ensure no air escapes around lips/nose.

Other Considerations

  • Over articulation strategies

  • 'aural rehabilitation' practices can also be beneficial for preserving voice

  • McGurk Effect.

  • Consider what you learn in other classes- breath control, optimal breath grouping, LSVT, to help clients control their voice and use voice more efficiently- know the "machine"!-understand the rationale behind an exercises to know if it will benefit a client.

Spasmodic Dysphonia (SD)

  • Spasm of arytenoids and true vocal folds.

  • May involve surrounding areas (false folds, neck, shoulder).

  • Often linked to emotional symptoms.

  • Types:

    • Adductor (most common): strained voice, abrupt onset.

    • Abductor: breathiness, delayed onset, reduced pitch.

Treatment

  • Unknown cause (neurological).

  • Symptoms similar to other conditions.

  • May trial exercises.

  • Botox is common treatment.

Therapeutic Effects of Botox

  • Blocks neuromuscular junction (nerve impulse blocker).

  • Initial breathiness (2 weeks post-injection).

  • Risk of aspiration increases for 2 weeks.

  • Voice returns to normal without spasm after 2 weeks.

  • Effects last 2-4 months.

Study Notes for Quiz 3

  • Covers Voice Therapy PowerPoint, Boone techniques, LMRVT, and vocal hygiene.

Key Topics

  1. Boone's 25 Facilitating Techniques: Describe and explain rationale for techniques like chewing, open-mouth, redirected phonation, respiration training, focus, yawn-sigh, and relaxation.

  2. Problems with Traditional Approaches: Explain why some experts find these approaches problematic.

  3. LMRVT Principles: Briefly describe the basic principles of LMRVT.

  4. LMRVT Instructions: How does a clinician using LMRVT presents instructions

  5. LMRVT Voice Care Principles: What are the 3 voice care principles required by LMRVT?

  6. Vocal Hygiene: List at least 5 suggestions for improving vocal hygiene, and explain why they would be important and which suggestions you might highlight for people in different professions.

  7. Client Compliance: What would you do as a clinician if the level of compliance to your suggestions by a voice client is very poor. What factors might be contributing to this low compliance? How would you modify your suggestions or expectations to increase compliance?

  8. Spasmodic Dysphonia: Consider Spasmodic Dysphonia- how is it different from hyperfunction? How is it treated? How would you identify abductor vs adductor? how are they treated?