Voice therapy Voice therapy management management

dysphonias related to dysphonias related to laryngeal laryngeal

hyperfunctionhyperfunction

Voice restVoice rest

►Vocal rest either modified or total is a Vocal rest either modified or total is a progress in which the patient’s use of progress in which the patient’s use of the larynx is restricted for a specified the larynx is restricted for a specified period of time. Vocal rest is usually period of time. Vocal rest is usually prescribed for a period of 4 to 7 days, prescribed for a period of 4 to 7 days, with 6 weeks being the maximum with 6 weeks being the maximum duration.duration.

Indications for vocal restIndications for vocal rest

►Mandatory vocal rest is frequently Mandatory vocal rest is frequently prescribed for healing surgically prescribed for healing surgically traumatized tissues following laryngeal traumatized tissues following laryngeal surgery involving vocal folds.surgery involving vocal folds.

► Initial treatment of abuse related Initial treatment of abuse related lesions of larynx- chronic laryngitis & lesions of larynx- chronic laryngitis & vocal nodules.vocal nodules.

AdvantagesAdvantages

► It allows rapid reduction in size and It allows rapid reduction in size and severity of laryngeal lesion.severity of laryngeal lesion.

►Allows clinician to quickly determine Allows clinician to quickly determine the relationship between the dysphonia the relationship between the dysphonia and the patient’s abusive behaviorsand the patient’s abusive behaviors

► Identification of situation specific vocal Identification of situation specific vocal abuse by the patient to modify the abuse by the patient to modify the situations that promote vocal abuse.situations that promote vocal abuse.

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► Allow the speech pathologist to Allow the speech pathologist to determine a patient’s commitment to determine a patient’s commitment to the process of voice improvement.the process of voice improvement.

DisadvantageDisadvantagea.a. Patients who use their voice Patients who use their voice

professionally may find it financially professionally may find it financially impracticalimpractical

b.b. Extremely difficult task for the Extremely difficult task for the average person to adhere to a average person to adhere to a program of vocal restprogram of vocal rest

c.c. If a patient fails to do so, he\she must If a patient fails to do so, he\she must deal with negative feelingsdeal with negative feelings

Description of vocal rest Description of vocal rest programsprograms

►Patient should be given an explanation Patient should be given an explanation of normal vocal fold functioning and an of normal vocal fold functioning and an explanation of effects of vocal explanation of effects of vocal abuse/misuse upon the foldsabuse/misuse upon the folds

►When the patient is familiarized with When the patient is familiarized with the typical abusive vocal activities that the typical abusive vocal activities that result in laryngeal trauma, a recording result in laryngeal trauma, a recording of the patient’s voice should be made of the patient’s voice should be made using a standard reading passageusing a standard reading passage

Program of complete vocal Program of complete vocal restrest

► Instruct patient to eliminate all Instruct patient to eliminate all activities that adduct vocal folds into activities that adduct vocal folds into forced approximationforced approximation

►Activities to avoid – Activities to avoid – speaking, singing, speaking, singing, humming, whispering, coughing, humming, whispering, coughing, throat clearing, laughing, lifting or throat clearing, laughing, lifting or pushing heavy objects, forceful effort pushing heavy objects, forceful effort during bowel mvementduring bowel mvement

Method of silent coughing and Method of silent coughing and throat clearingthroat clearing

►Procedure- Procedure- instruct patient to push as instruct patient to push as much as possible from the lungs in much as possible from the lungs in short, blast like bursts, tell patient that short, blast like bursts, tell patient that the only sound procedure should be a the only sound procedure should be a quiet rush of airquiet rush of air

►Benefits- Benefits- it prevents vocal fold it prevents vocal fold adduction during coughing and throat adduction during coughing and throat clearing and reduces the duration of clearing and reduces the duration of throat clearingthroat clearing

Program of modified vocal rest Program of modified vocal rest for adultsfor adults

Slightly less rigid program than full vocal rest Slightly less rigid program than full vocal rest by allowing some talkingby allowing some talking

Conditions Conditions 1.1. Conversation should be limited to a total Conversation should be limited to a total

time of no more than 15 minutes per day.time of no more than 15 minutes per day.2.2. Each period of talking must be limited to Each period of talking must be limited to

no more than 5 minute durationno more than 5 minute duration3.3. Conversation must be on a one to one Conversation must be on a one to one

basis and in an environment that has a basis and in an environment that has a min level of background noisemin level of background noise

Program for modified vocal rest Program for modified vocal rest for childrenfor children

Amount of talking time that is permitted Amount of talking time that is permitted in a modified vocal rest for a child is in a modified vocal rest for a child is usually grater than that given to adultusually grater than that given to adult

1.Start with a child who understands 1.Start with a child who understands what has caused his laryngeal lesionwhat has caused his laryngeal lesion

2. Tell child that the responsibility for 2. Tell child that the responsibility for changing his vocal behavior belongs to changing his vocal behavior belongs to him alonehim alone

3. The program will be difficult for the 3. The program will be difficult for the child to adhere to he should be child to adhere to he should be reminded that talking is restricted only reminded that talking is restricted only for 10 daysfor 10 days

4. A reward system can be established 4. A reward system can be established as an incentive for the child to follow as an incentive for the child to follow through the modified vocal rest through the modified vocal rest programprogram

5. All members of the family should be 5. All members of the family should be involvedinvolved

Guidelines for child to followGuidelines for child to follow

►child is allowed to talk quietly to the child is allowed to talk quietly to the parents in morning before going to parents in morning before going to schoolschool

►He can answer ques. in the class but He can answer ques. in the class but should be excused from activities that should be excused from activities that require talking to large groups of require talking to large groups of people. no singing at allpeople. no singing at all

►Absolutely no talking during recess, Absolutely no talking during recess, lunch & physical education classlunch & physical education class

►Allowed to talk quietly to parents after Allowed to talk quietly to parents after school only for a brief periodschool only for a brief period

►Talk quietly to family during supperTalk quietly to family during supper►The child’s talking time during evening The child’s talking time during evening

hours should be as limited as possible hours should be as limited as possible

A non abusive technique A non abusive technique children can use to get attentionchildren can use to get attention►One of the primary ways in which One of the primary ways in which

children abuse their vocal mechanisms children abuse their vocal mechanisms is by shouting to get attentionis by shouting to get attention

►One successful technique is to give the One successful technique is to give the child a whistle that can b worn around child a whistle that can b worn around the neck all the timethe neck all the time

►Child is instructed to use it instead of Child is instructed to use it instead of yelling to attract someone’s attentionyelling to attract someone’s attention

Selecting patients for a program Selecting patients for a program of vocal restof vocal rest

► Involves critical evaluation of many Involves critical evaluation of many facets of the patientfacets of the patient

►Occupational requirements of voice Occupational requirements of voice use. professionals like receptionists, use. professionals like receptionists, real estate agents, sales person, real estate agents, sales person, telephone operators, teachers, singers telephone operators, teachers, singers and so on.and so on.

►Voice rest may cause undue financial Voice rest may cause undue financial hardships.hardships.

►The patient’s motivation follow through The patient’s motivation follow through with the vocal rest program should be with the vocal rest program should be evaluated.evaluated.

►Most highly motivated patients have no Most highly motivated patients have no difficulty following vocal rest programdifficulty following vocal rest program

►Patients with low motivation benefit most Patients with low motivation benefit most from hearing the dramatic voice from hearing the dramatic voice improvement that results from 4 to 7 vocal improvement that results from 4 to 7 vocal rest programrest program

►Explore any signs of reluctance in the Explore any signs of reluctance in the patient. counsel. if not successful, don’t go patient. counsel. if not successful, don’t go in for vocal rest program. Dangers of in for vocal rest program. Dangers of facing failure at any stage of vocal rest facing failure at any stage of vocal rest programprogram

Vocal hygieneVocal hygiene

Program of vocal hygieneProgram of vocal hygiene

A prerequisite of successful voice A prerequisite of successful voice rehabilitation is a program of vocal rehabilitation is a program of vocal hygiene. The primary purpose of such hygiene. The primary purpose of such a program is to first identify and then a program is to first identify and then to modify or eliminate factors causing to modify or eliminate factors causing the abusethe abuse

Development of listening Development of listening skillsskills

►Using live prerecorded samples, the Using live prerecorded samples, the clinician should demonstrate and clinician should demonstrate and contrast appropriate and abusive vocal contrast appropriate and abusive vocal patterns. Teach discrimination and patterns. Teach discrimination and discuss characteristicsdiscuss characteristics

►Demonstrate abusive vocal patterns Demonstrate abusive vocal patterns and create patient awareness of and create patient awareness of abusive vocal patterns.abusive vocal patterns.

Identification of the patient’s Identification of the patient’s abusive patternsabusive patterns

►Defining and isolating abusive vocal Defining and isolating abusive vocal behaviors – define and isolate abusive behaviors – define and isolate abusive behavior. Demonstration of typical behavior. Demonstration of typical behaviors. Discuss voice usage during behaviors. Discuss voice usage during a typical a typical with children- enlist child’s vocal with children- enlist child’s vocal behavior, include parents, siblings, behavior, include parents, siblings, teachers, and friends teachers, and friends

Maintaining data on frequency Maintaining data on frequency of abusive vocal behaviorsof abusive vocal behaviors

►Ask patient to maintain data on Ask patient to maintain data on frequency of occurrence for a week. frequency of occurrence for a week. Ask him to keep an absolute tally of Ask him to keep an absolute tally of number of times AVB were performednumber of times AVB were performed

►Discuss circumstances and Discuss circumstances and surroundings of AVB surroundings of AVB

►Make a comparison of these Make a comparison of these causes .keep a record. Determine the causes .keep a record. Determine the situations that promote the patient’s situations that promote the patient’s poor vocal habits. poor vocal habits.

Explanation of the effects of Explanation of the effects of vocal abusevocal abuse

►Describe to the patient the physiologic Describe to the patient the physiologic effect these patterns of vocal abuse effect these patterns of vocal abuse have on normal voice productionhave on normal voice production

►Speech pathologist should explain Speech pathologist should explain what voice therapy techniques are what voice therapy techniques are recommended and what changes can recommended and what changes can be expected from voice therapybe expected from voice therapy

Program of good vocal Program of good vocal hygienehygiene

►Limit amount of talkingLimit amount of talking►Do not compete vocally with excessive Do not compete vocally with excessive

background noisebackground noise►Do not use strained vocal productions Do not use strained vocal productions ►Avoid excessive coughing or throat Avoid excessive coughing or throat

clearingclearing►Avoid airborne laryngeal irritants Avoid airborne laryngeal irritants

Voice therapyVoice therapy

Goals Goals

► After optional program of vocal rest After optional program of vocal rest and after program of vocal hygiene. A and after program of vocal hygiene. A program of voice therapy is initiatedprogram of voice therapy is initiated

1.1. Eliminating the cause of vocal abuseEliminating the cause of vocal abuse

2.2. Softening the patient’s glottal attackSoftening the patient’s glottal attack

3.3. Reducing vocal intensityReducing vocal intensity

4.4. Adjusting the patient’s pitch to an Adjusting the patient’s pitch to an appropriate levelappropriate level

General principlesGeneral principles

►Simple techniques that help the Simple techniques that help the patient to produce good voicepatient to produce good voice

►Speech pathologist and patient listen Speech pathologist and patient listen carefully to changes in pitch, quality, carefully to changes in pitch, quality, and loudnessand loudness

►Speech pathologist must be quick to Speech pathologist must be quick to identify instances of improvement and identify instances of improvement and reinforce the patientreinforce the patient

Monitoring of productionsMonitoring of productions

►Heighten patient’s auditory feedback Heighten patient’s auditory feedback channel as patients start recognizing channel as patients start recognizing improved vocal productionsimproved vocal productions

►Learn how to duplicate the improved Learn how to duplicate the improved productions productions

Techniques to facilitate Techniques to facilitate reduction of vocal loudnessreduction of vocal loudness

►Discuss with the patient about vocal Discuss with the patient about vocal loudnessloudness

►Determine how loud the voice should Determine how loud the voice should bebe

**loud enough to surpass the level of loud enough to surpass the level of competing background noisecompeting background noise

**physical distance between speaker and physical distance between speaker and listener listener

►Developing auditory discrimination for Developing auditory discrimination for vocal loudnessvocal loudness

►Reduction of the patient’s vocal Reduction of the patient’s vocal loudness levelloudness level

►Visual monitoring of vocal loudnessVisual monitoring of vocal loudness►Continuing vocal loudness monitoring Continuing vocal loudness monitoring

with a body worn monitoring devicewith a body worn monitoring device

Techniques for reduction of hard Techniques for reduction of hard glottal attackglottal attack

►Developing auditory discrimination of Developing auditory discrimination of hard glottal attackhard glottal attack

►Chewing techniqueChewing technique

*technique is a means of obtaining *technique is a means of obtaining muscle balance in vocal mechanismmuscle balance in vocal mechanism

*ask patient to pretend chewing a chunk *ask patient to pretend chewing a chunk of cotton candyof cotton candy

Chew in relaxed, open mouthed, Chew in relaxed, open mouthed, exaggerated mannerexaggerated manner

*do not proceed until patient is capable of *do not proceed until patient is capable of producing a natural & exaggerated producing a natural & exaggerated manner of chewingmanner of chewing

*after this, ask the patient to phonate softly*after this, ask the patient to phonate softly

*produce variety of vowel like sounds*produce variety of vowel like sounds

*encourage the patient to use exaggerated *encourage the patient to use exaggerated tongue movementstongue movements

*once accomplished, ask to inhale deeply *once accomplished, ask to inhale deeply and to chew and phonate the outgoing and to chew and phonate the outgoing streamstream

*next, ask to articulate 2,3 word *next, ask to articulate 2,3 word combinationscombinations

Vocal pitch, loudness, quality should not Vocal pitch, loudness, quality should not change change

Techniques that utilize Techniques that utilize prephonation glottal airflowprephonation glottal airflow

►Production of words beginning with the Production of words beginning with the fricative /h/ produced by sending air fricative /h/ produced by sending air through the glottisthrough the glottis

► /h/ followed by a vowel sound, without a /h/ followed by a vowel sound, without a vocal catchvocal catch

►Next, 2,3 syllable words that begin Next, 2,3 syllable words that begin with /h/with /h/

►Words beginning with unvoiced Words beginning with unvoiced fricatives fricatives

Whisper techniqueWhisper technique

►Having the patient to whisper Having the patient to whisper sustained vowel productionssustained vowel productions

►Practice until transition from whisper to Practice until transition from whisper to phonation is smoothly accomplishedphonation is smoothly accomplished

►Whisper words begin with vowels, Whisper words begin with vowels, prolong initial vowel in whisper and prolong initial vowel in whisper and then gradually add gentle phonation as then gradually add gentle phonation as last part of vowel and remainder of the last part of vowel and remainder of the word is spokenword is spoken

Chant talk techniqueChant talk technique

►A technique particularly useful for A technique particularly useful for reduction of hard glottal attackreduction of hard glottal attack

►Play a recording of religious chant for Play a recording of religious chant for the patient the patient

►Patient practice alternately using the Patient practice alternately using the “chant voice” “chant voice”

►Drills should be directed at achieving a Drills should be directed at achieving a style of voice production that is style of voice production that is characterized by a softened glottal characterized by a softened glottal attackattack