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Voice Therapy
- 1. Voice Therapy CDIS 700
- 2. General Points RegardingVoice Therapy There is no single approach that will work with all clients/disorders. Successful therapy will use a holistic approach that combines: – Behavioral therapy – Cognitive training – Counseling
- 3. A “Typical” TherapySession Engage the client in general conversation. – Note how the client’s voice sounds when they are relaxed and therapy doesn’t seem like it has officially begun. Segue into how the client’s voice was and how practice of techniques from the previous session. Pick one or two techniques to work on during the session. End a bit early to assign “homework” for the next session. Be sure to leave time to address questions.
- 4. Facilitating Approaches Your authors provide a discussion of 25 therapeutic techniques that may be used to treat voice disorders. Review the DVD that accompanies your book Here we will cover some of the fundamentals: – Relaxation – Respiration training – Elimination of abuses – Yawn-sigh technique – Vocal Function Exercises
- 5. Relaxation Voice symptoms:diplophonia, dry throat and mouth, harsh voice quality, elevated pitch, functional dysphonia, shortness of breath. Progressive relaxation is a common type of relaxation training: http://www.youtube.com/watch?v=KmxfjjamcuY&feature=related Accompanying techniques: yawn-sigh, open-mouth approach
- 6. Respiration Training Voicesymptoms: Shortness of breath, “squeezing” out words, hyperfunctional voice. Clinician must be able to demonstrate good diaphragmatic breathing and explain how respiration works in client-appropriate terms. Start small and gradually increase length of utterance; do not let the client phonate longer than they can sustain a good quality voice. Compare and contrast voicing with good respiration and poor respiration. The client should be able to switch between the two and note the difference on voice production. http://www.youtube.com/watch?v=YMp-Zqbud_0
- 7. Elimination of Abuses Review with all clients those behaviors that constitute vocal abuse, including hard glottal attacks, using inappropriate pitch, etc. Counsel clients on these abuses/misuses. Ask them to identify which of these behaviors they use and how they might avoid them. Work to provide alternatives to abusive behaviors. Therapy ideas for children and tips for adults
- 8. Yawn Sigh Technique Relaxes the vocal mechanism Voice symptoms: functional dysphonia, spasmodic dysphonia, nodules, polyps, vocal fold thickening Accompanied by digital manipulation/laryngeal massage if necessary. Demonstrate the technique, beginning with a yawn and sighing with an open mouth. Add a vowel on the sigh, then proceed to words that start with /h/ = hah. Once the client has mastered this technique, they should remember the feeling that accompanies the yawn-sigh, and should be able to obtain the same effects without actually engaging in the technique. Sample of student clinicians
- 9. Stemple’s Vocal FunctionExercises 1. Warm-up. Sustain /i/ as long as possible on a comfortable note. 2. Stretching. Glide from the lowest to the highest note in the frequency range, using /o/. 3. Contraction. Glide from the highest to the lowest note in the frequency range, again using /o/. 4. Adductory Power Exercises. Sustain the notes C, D, E, F, and G (still using /o/) as long as possible. Middle C for females, one octave below for males. Do twice in a row (first very quietly) about twice daily. Many variations on these exercises: see YouTube example
- 10. How Can WeDocument Progress? According to Andrews (2006), we can: – Gather tape recordings of the pre- and post- therapy voice. – Obtain videorecordings of the vocal folds pre- and post-therapy. – Obtain instrumental measures (e.g., the Visi- Pitch or electroglottograph) when available. – Make graphs, or use rating scales, quizzes, etc. to chart progress.
- 11. Sample Dismissal Criteria (Andrews, 2006) Voice doesn’t sound tense People don’t ask if I have a cold Voice doesn’t tire quickly Voice carries well/people don’t ask me to speak up/people can hear me My voice sounds lively I understand how to protect my voice Voice is clear Voice is expressive I sound confident
- 12. Dismissal Criteria (cont.) Reduction of hard attacks by 80% Elimination of throat clearing Normal looking vocal folds Resolution of vocal nodules or pathology Clearance from otolaryngologist Replenishing breaths used 90% of the time
- 13. Summary No “cookbook”approach to voice therapy. Impossible to cover all techniques in class; be prepared to learn on your own Be flexible and be ready to substitute one technique for another depending on client’s needs.
Editor's Notes
- #2 Hi everyone. In this presentation I’m going to cover some of the basics related to conducting voice therapy.
- #3 It’s important to note that everyone’s voice symptoms, voice use, and vocal hygiene habits are different. So there is no single approach that will work best for all clients with a single type of voice disorder. So for example, even though two people may share a similar diagnosis of vocal nodules, one person may need to focus on specific vocal exercises, whereas another person may need to work more on developing healthy vocal habits. But for all clients, voice therapy has three components. These are behavioral therapy, or changing the way the voice is produced; cognitive training, or changing the way the client thinks, and counseling, which is helping the client to become more aware of or deal with emotional issues.
- #4 It’s also hard to say what a “typical” voice therapy session might entail, as settings and patients differ. But you should try to do the following for each client: First, engage the client in general conversation. Note how the client’s voice sounds when they are relaxed and therapy doesn’t seem like it has officially begun. Then segue into how the client’s voice was and how practice of techniques from the last session went. You will want to n ote any questions or concerns the client has. Address them immediately and/or come back to them throughout the session. Third, pick one or two techniques to work on during the session. Don’t overwhelm your client with too many techniques, but focus on mastery of a few at a time. Be sure that the client knows his or her goals, and can articulate why the techniques they are practicing in therapy will help them achieve these goals. Finally, I like to end a bit early to assign homework between the current session and the next one. You’ll also want to make sure that the client’s questions and concerns have all been answered.
- #5 Your authors provide 25 therapeutic techniques that may be used to treat voice disorders. Review the DVD that accompanies your book so you get an idea of how these techniques look in practice. In this presentation we are going to cover some fundamentals of voice therapy, which are relaxation, respiration training, elimination of abuse, yawn-sigh technique, and vocal function exercises.
- #6 Everyone has some degree of stress in their lives. Some of this stress may manifest itself in the larynx. Check clients for bodily tension. If they seem to have stiff posture or rigidity, it’s likely that they have a tense larynx, too. Certain voice symptoms and conditions may be relieved with relaxation exercises, such as an elevated pitch, shortness of breath, functional dysphonia, and more. SLPs may help their clients to relax by employing progressive relaxation techniques, among other strategies. I’ve given you an example of progressive relaxation on YouTube. Basically, you work your way up the body, relaxing every body part from the toes up to the head. You as the SLP can walk clients through this, or you can play a video for them. You should try this so you can see what a difference it makes. Other forms of relaxation may include guided imagery and yoga. The key is not to hold an aerobics or hypnosis class, but to spend 5-10 minutes focusing on releasing bodily tension.
- #7 As clinicians we need to ensure that our clients are using respiration appropriately. We also should be demonstrating good posture and diaphragmatic breathing for our clients. The key here is to have the client use good breath support while maintaining a relaxed, but not slouched, posture. One technique is to have the client sit in front of a mirror to observe their posture and breathing, or you can have the client put a hand on their abdomen so they know where to breathe from. The client can also watch you to see how you use good diaphragmatic breathing. The key is to help the client learn not to speak too much on a single breath of air. Clients should be cued to take replenishing breaths when needed as they work toward having a good vocal quality that is free from strain. Gradually ask them to speak longer utterances, but only to the point that they can do so without strain. As with all voice therapy techniques, it is most helpful if the client can learn to compare and contrast their old way of speaking with the new, preferred way of speaking. In the case of respiration, the client should learn to recognize the physiological and perceptual differences between vocalizing with good and poor respiration. I’ve given you a brief YouTube clip which emphasizes posture and breathing for a visual. There are many other videos available which discuss breathing for speech and singing.
- #8 We all know that poor vocal hygiene can cause many voice symptoms and disorders. I’ve provided some handouts with information for children and adults to give you some ideas about how to help clients recognize and reduce their vocally abusive behaviors. Remember that the quality of our voice and the way we use our voice is often tied to our identities and in many cases, our incomes. Make sure that you help your client to develop and implement realistic changes to their lifestyle which will not detract from their sense of self or their ability to perform their job.
- #9 Your authors do a good job of demonstrating the yawn sigh technique in the DVD, and I have found a YouTube clip of student clinicians practicing this technique. The purpose of the yawn sigh is to relax the vocal mechanism. The key is to practice good breathing techniques and combine this with easy phonation. The yawn helps to relax the vocal mechanism, and the sigh and eventual phonation, if done correctly, should also be relaxed. This is much like the concept of easy onset for clients who stutter. Start with a sigh, then an /h/ sound, and then move on to words that start with /h/. You’ll want to reassure your clients that the yawn is just for practice, and will eventually be phased out of therapy. Clients should focus on how relaxed their voice mechanism is after the yawn, but they will not produce speech with an accompanying yawn in their daily lives.
- #10 Remember that the VFs are muscles, and that like any muscle in the body, they may atrophy or become less flexible without regular use. Clients with vocal scaring, those with reduced range, and those whose voice are dysfunctional may benefit from a regimen of voice exercises. Joseph Stemple developed a set of relatively simple exercises that you can guide your clients through, and they can practice several times a day. I will let you read the steps involved as presented in the PPT slides, but I think it will be very helpful if you watch the accompanying YouTube clip for one variation on these exercises.
- #11 It’s very important also that we be able to document our client’s progress. You can get samples of pre- and post-therapy voice, including audio tape and videostroboscoapy recordings, as well as documenting acoustic measures from the Visi-Pitch or electroglottograph. You can also develop graphs or use ratings scales or quizzes to make sure that your client is making progress.
- #12 So how will we know when our client has made enough progress to be dismissed from our caseload? One way is to ask clients for their self-report about the way their voice feels. So if the client tells you that his voice no longer hurts, that he is well understood, and that his voice sounds energized, this is a very good sign of progress and it may be time to dismiss the client.
- #13 There are also more objective measures of progress. If the client greatly reduces throat clearing, hard glottal attacks, and uses appropriate breath support, for example, then it is likely that this client is ready to be dismissed. And of course, if the client undergoes laryngoscopy and the vocal folds look healthy, this is also a good indication that the clients goals have been met.
- #14 I know that students always want to get a sense of exactly what they should do in therapy with a client. Unfortunately, it’s a bit difficult when it comes to voice therapy, because clients will have different needs and may respond better to some techniques than to others. You should be very familiar with the techniques we’ve discussed in this presentation. Watch the YouTube videos and practice these therapy exercises yourself. Also watch the textbook DVD and thoroughly read the chapter so that you are familiar with the techniques that we have not discussed. Understand that there is rarely a single technique that should be used to address a client’s symptoms. For example, let’s say you have a client who has a small mouth opening and speaks with a clenched jaw. You know that the chewing technique is supposed to help with this problem, but your client has TMJ disorder and the chewing technique is painful. In this case, there are any number of other techniques you could use instead to achieve the same effect, such as the open mouth approach or the yawn-sigh. So focus on the client’s symptoms and their physiological cause, then experiment until you find the technique that seems best suited for that client. Remember, even though your authors describe 25 techniques, there are many, many more! So focus on having a really good understanding of how to help your clients use good breathing, a relaxed approach, and good vocal hygiene. The rest are techniques that you can put in to practice as you need.