6 Voice Therapy Flashcards
(33 cards)
Van Riper (1939) Components of Voice Therapy
- Recognition of the problem by the patient
- Production of a new, more appropriate sound
- Stabilization of the new vocal behaviour in many contexts
- Habituation of the new voicing behaviour in all situations
Therapy dosage and delivery
– traditionally 1/wk for __ weeks
Meerschman et al. (2018) compared
– Traditional voice therapy
– Short-term intensive individual voice therapy – Short-term intensive group voice therapy
– treatment blocks can be restrictive and make generalization difficult
– find that they achieve the same progress regardless of long and short term blocks
* Conclusions: All delivery models were effective. The authors cautioned that psychosocial progress may be more limited in intensive therapy models.
*In-person vs teletherapy
– Cutchin et al. 2023: Patients in teletherapy were more likely to initiate and attend therapy sessions, and less likely to cancel sessions
– still need to do scopes and imaging in person, but teletherapy is effective, accessible…etc.
– Conclusion: “… telepractice should be considered standard of care … as it removes many reported barriers to treatment.”
How many sessions are needed?
Brinton Fujiki & Thibeault (2023):
– Based on data from 558 voice clinic patients
– “Patients required an average of 5.32 (SD=3.43) sessions of voice therapy before voice outcomes were sufficiently improved for discharge.”
– Range 4.3 (presbyphonia) to 6.7 (benign lesions) sessions
– 14.5% of patients returned for additional sessions following initial discharge (~85% w/o recurrence)
*Criteria for the termination of voice therapy
- Positive reasons for termination
– Elimination or reduction of vocally symptomatic tissue changes
– Improved voice of a quality acceptable to the patient
– Elimination of physical symptoms of pain, discomfort and fatigue
– Habituation of changed vocal behaviours with no return of symptoms - Negative reason for termination
– Lack of improvement after an appropriate therapy trial (refer)
What therapy technique is optimal with limited time/resources?
Confidential Voice check
Confidential Voice Therapy
- Most useful when voice conservation is required (after recent injury or surgery)
- Confidential voice: Easy, quiet, breathy voice as if talking confidentially to somebody nearby
- There is no fixed therapy program, the clinician adapts the therapy to the specific patient and circumstances
- VFs are more stretched and have more space between folds
communicatively it works well, patients can pick up quickly
if nothing else works, recommend this
Schools of voice therapy
- Symptomatic voice therapy
- Hygienic voice therapy
- Psychogenic voice therapy
- Physiologic voice therapy
- Holistic voice therapy (one size fits all, “if x, then x”)
- Eclectic voice therapy
What is symptomatic voice therapy?
An approach that tries various tools in the toolkit, no specific tool to use first, it depends on what the patient needs (e.g., not all jobs need a hammer first, some need a saw)
What is eclectic voice therapy?
adjusting approaches from multiple sources
Classifying Boone & McFarlane’s symptomatic techniques for voice therapy
- Relaxing techniques for a hyperfunctional system
- Activating techniques for a hypofunctional system
- Techniques targeting secondary aspects of voice production
- Techniques related to counselling and awareness
True or false: start Boone & McFarlane’s symptomatic techniques with relaxation
True. Start with relaxation so you don’t strengthen someone thats already hyperfunctional. Strength may not be the issue, but relaxing is a safe bet.
(B&M facilitating technique 1) Auditory Feedback
- Beneficial for many patients groups, regardless of the etiology of the voice disorder
– Use with tact and good judgment - Real-time feedback: Hands cupped over the ears, “Task Master” or speaking tube, monitor signal for audio recording (then play back for patient)
- Looped feedback: Playback of audio recording, digital looping
– Historic: “Kay Facilitator”
– helps to hear yourself more objectively
(B&M facilitating techniques 2.1) Reducing Excessive Loudness
- Check the patient’s hearing
- For children: Develop a voice hierarchy
– Whisper
– Soft voice
– Normal conversation
– Raised voice
– Yelling voice - Adults/ adolescents: Discuss different loudness levels with the patient
- Discuss the negative psychosocial attributes of an excessively loud voice (but be kind!)
- Practice quiet voice with feedback
(B&M facilitating techniques 2.2) Increasing loudness in quiet speakers
- Check the patient’s hearing, middle ear function, general health, fitness, and personality factors
- Discuss the psychosocial implications of a soft voice (but be kind!)
- Identify a comfortable fundamental frequency (the ‘home base’ pitch level)
- If indicated, work on the breathing pattern and support
- Supportive techniques:
– Gentle pushing (have client push hands together mid-phonation to increase loudness)
– Auditory masking (Lombard effect)
(B&M facilitating techniques 3) Chant talk
- Easy, continuous phonation in the style of religious chant (psalmody) or legato singing is beneficial for vocal hyperfunction
- Explanation of the procedure to the patient
- Practice chanting
- Alternate the chant and the regular voice in 20 second intervals
- Record the two different voices and discuss them with the patient
- Carry over the relaxed approach into conversational speech
may be useful for patient with vocal nodules
True or false: The components of Chant talk should be done in order
False, each component is individual
(B&M facilitating techniques 4) Froeschel’s chewing
- Beneficial for vocal hyperfunction and muscular tension dysphonia
- Explain to the patient how chewing can reduce tension
- Pretend chewing of a tasty food (if necessary, start with real food), exaggerate the chewing motions, take ‘large bites’ and chew with a ‘full mouth’.
- Add soft phonation and start mumbling with a full mouth. The tongue must move around (not just jaw motion) - use natural and non-speech phonation)
- Alternate chewing and word production
- Expand to longer phrases and counting
- Provide auditory feedback
- Expand to conversational speech and reduce chewing (generalize)
(B&M facilitating techniques 5) Counselling
- Counselling and a proper explanation of the voice disorder should be an integral part of every voice therapy program
- The counselling procedure varies between patients
- The patient should never be “blamed” for the voice disorder
- Remain inside your professional boundaries! If significant psychological issues are noted, refer to a qualified counsellor
(B&M facilitating techniques 6.1): Digital manipulation of the larynx: Anterior-posterior pressure for lowering the pitch
- not as common with voice therapists, but may be done by ENT and surgeons.
- As an initial facilitative technique, application of gentle pressure onto the thyroid prominence should automatically lower the pitch because the vocal folds are compressed and shortened by this maneuver
- The patient should then try to maintain this new easy pitch without the digital pressure
(B&M facilitating techniques 6.2): Digital manipulation of the larynx: Monitoring of the vertical laryngeal excursion
- Beneficial for patients with laryngeal tension
- The monitoring of the position of the thyroid prominence can help to ‘anchor’ the larynx and reduce the vertical movement
- The establishment of a relaxed laryngeal suspension can be practiced by singing low and high notes
- Maximum elevation and lowering can be demonstrated with swallowing and yawning
(B&M facilitating techniques 6.3): Digital manipulation of the larynx: Maneuvering the larynx to a lower position
- Relaxed, tension-free phonation is usually characterized by a lower larynx
- Encircle the hyoid bone with the middle finger and thumb
- Apply gentle pressure in the thyrohyoid space
- From there, work the larynx downward with light lateral movements
- May require several attempts: Repeat as necessary
- Can be helpful to bring the larynx down. singers generally hold larynx high.
(B&M facilitating techniques 6.4): Digital manipulation of the larynx: Unilateral digital pressure in unilateral vocal fold paralysis
- Apply gentle pressure on the side of the vocal fold paralysis while the patient phonates. Watch for improvements of voice quality and loudness
- If better voice quality and loudness cannot be achieved, apply gentle pressure on the contralateral side
- If there is still no improvement, add head rotation to the procedure, first ipsi- then contralateral
- If there is still no improvement, combine bilateral gentle pressure onto the thyroid lamina with head turning
- Still no improvement? Move on to a different technique!
- Helpful for pateints who have had VF removed from cancer, or paralyzed VFs
(B&M facilitating techniques 7): Elimination of misuses
- Procedure:
– Create awareness and discuss the necessity of reducing the misuse behaviour with the patient
– The patient (or a relative) should tally the misuses Log the daily frequency on a chart
– Log the daily frequency on a chart - for patients who throat clear or yell a lot (sports, work…etc.)
– may be helpful to introduce client to a replacement behaviour (instead of yelling/coughing)
