iVoiceTherapy  Muscle  Tension  Dysphonia  

       

 4.9.15  

12:00-­‐13:00  PST  

Meet  the  instructors  

                     Liza  Blumenfeld  

 

                                                               Erin  Walsh  

Candidacy  for  therapy  

•  How  long  have  they  had  MTD?  •  Were  they  sNmulable?  •  Other  major  medical  problems  more  pressing?  •  Primary  versus  secondary  MTD?  – Do  they  need  surgery?  

•  Irritable  larynx?    Reflux?    PND?  •  EmoNonal  state?  

TherapeuNc  approach  

•  Indirect  –  counseling,  managing  reflux/PND/allergies,  laryngeal  hygiene  

•  Direct  –  giving  them  tools  to  change  the  way  they  are  talking  

•  What  were  they  most  sNmulable  for  during  the  evaluaNon?  

Programming  iVoiceTherapy  

•  What  are  their  goals?  •  What  do  you  want  to  teach  them?  •  When  is  it  feasible  for  them  to  do  the  exercises?  

•  What  is  the  expected  Nmeline  you  feel  is  adequate  to  expect  results?  

•  How  o\en  do  you  plan  to  see  them  in  person  for  therapy?  

Case  #1  

•  36-­‐year-­‐old  female  a_orney    •  Coincided  with  MRSA,  sudden  dysphonia  •  PMH:    Depression  •  Meds:    ENT  placed  her  on  PPI  for  voice  •  Run  around  with  PCP  and  ENT  •  Eventually  referred  for  voice  therapy  •  Strobe  was  completely  normal  •  No  prior  dysphonia  •  Hygiene:  32oz  water,  20oz  coffee,  1  beer  

Case  #1  

•  NoNce  the  variability  in  her  voice?  •  All  vegetaNve  voicing  was  normal:  laugh,  cough,  sigh  

•  These  tasks  produced  normal/premorbid  phonaNon:    yawn/sigh,  gargle,  rolled  r,  lip  flu_er,  humming,  singing.  

•  Highly  sNmulable  •  Excellent  prognosis  

iVoiceTherapy  Programming  

•  Basics  

Case  #1  

•  Rebalancing  respiraNon  and  phonaNon  

•  Vocal  Yoga  –  filled  with  semi-­‐occluded  sounds  

•  Tone  flow  –  alleviate  effort  between  words  

•  Singing  –  effortlessly  restores  premorbid  voice  

Case  #1  

•  Voice  Sample  –  Record  your  own  unique  tried  and  true  methods  into  the  app  for  their  home  exercise.  

Case  #1  

•  Pitch  

Case  #1  

•  Alerts   •  Compliance  

Case  #1  •  Outcome  –  Fully  programmed  iVoiceTherapy  during  her  iniNal  consultaNon  

–  Scheduled  a  follow-­‐up  in  2  weeks  – Her  MTD  was  completely  gone  –  She  stated  that  having  the  auditory  model  and  biofeedback  measures  in  the  app  were  quite  helpful  

–  Voice  normalized  within  a  few  days  of  using  the  App  at  intervals  of  7am,  10am,  2pm,  6pm.      

–  It  was  intrinsically  moNvaNng  for  her  voice  to  sound  good,  so  she  pracNced  even  more  

Case  #2  •  59-­‐year-­‐old  female  homemaker  •  4  months  post  URI  –  voice  never  normalized  •  ENT,  pulmonary  &  GI  consults  unremarkable  •  2  rounds  anNbioNcs  –  ineffecNve  •  Videostrobe  –  mild  le\  paresis,  possibly  premorbid  and  likely  non-­‐contributory  given  disproporNonate  dysphonia  

•  PMH:  hypertension,  environmental  allergies,  GERD  

•  Meds:  Zyrtec,  Prilosec,  Atenolol  •  Hygiene:  64oz  water,  no  caffeine  or  ETOH  

Case  #2  •  Voice  extremely  variable  •  During  behavioral  voice  measures  (maximum  phonaNon  Nme,  S/Z  raNo,  pitch  range,  fundamental  frequency),  noNced  numerous  episodes  when  voice  would  normalize  

•  High  frequency  non-­‐producNve  cough  and  throat  clearing.    This  was  triggered  by  MTD.  

•  SNmulable  to  produce  premorbid  voice  with  hum,  chant  and  sing-­‐song  conversaNon.    There  was  some  immediate  carryover.  

•  UNlized  laryngeal  massage  as  well.      

Case  #2  

•  Irritable  Larynx  /  Cough  Count  

Case  #2  

•  Auditory  training  •  Visualizing  normal  videostrobe  –  hand  on  neck  to  feel  similar  uninterrupted  vibraNons  

•  Irritable  larynx  educaNon  

Case  #2  

•  Rebalancing  respiraNon  and  phonaNon  

•  Vocal  Yoga  –  filled  with  semi-­‐occluded  sounds  

•  Tone  flow  –  alleviate  effort  between  words  

•  Singing  –  effortlessly  restores  premorbid  voice  

Case  #2  

•  Alerts   •  Compliance  

Case  #2  

•  Fully  programmed  iVoiceTherapy  during  evaluaNon  a\er  determine  which  cues  were  most  facilitaNve  

•  Needed  2  sessions  face-­‐to-­‐face  training  to  improve  accuracy  of  target  sounds/laryngeal  posture  

•  Scheduled  1  follow-­‐up  a  month  later  •  All  progress  was  maintained  •  Educated  regarding  potenNal  future  URI  and  MTD  

Case  #3  

•  68-­‐year-­‐old  Hispanic  female  •  30  years  with  this  voice.    Family  urged  her  to  seek  medical  a_enNon.  

•  ENT  exam  did  not  reveal  pathology,  referred  for  voice  therapy  

•  PMH:  breast  cancer,  type  2  diabetes,  hypertension,  environmental  allergies  

•  Meds:  Memormin,  Norvasc  •  Hygiene:  2  glasses  water,  1  milk    

Case  #3  

•  Without  cueing  –  noNce  how  voice  normalized  during  oral  reading  passage?  

•  SNmulable  in  short  bursts  a\er  descending  pitch  glides,  yawn-­‐sigh  and  digital  manipulaNon  to  keep  pitch  low  

•  Discussed  relevance  of  contributory  factors  including  laryngeal  hygiene  and  allergy  mgmt  

•  Extensive  educaNon  regarding  paNent  moNvaNon.    Her  Voice  Handicap  Index  was  only  12!  

Case  #3  

•  Flexibility   •  Resonance  

Case  #3  

•  Pitch  

Case  #3  

•  Biofeedback!  

Case  #3  

•  Awareness   •  Compliance  

Case  #3  •  Given  firm  habituaNon  of  MTD,  scheduled  1x/week  x  4  weeks  

•  MoNvaNon  moderately  increased  when  there  were  periodic  episodes  of  improvement.      

•  Children  present  during  therapy  and  were  very  encouraging  

•  A\er  4  weeks,  she  could  change  her  voice  to  sound  normal  when  she  was  thinking  of  it,  although  it  o\en  slipped  back  into  her  MTD  pa_ern.    She  was  saNsfied  with  the  change.  

•  Scheduled  2  month  follow-­‐up.    Added  singing  to  home  exercise  regimen.  

Take  home  points    

•  We  only  presented  Primary  MTD  cases  •  Assure  thorough  work-­‐up  so  you  are  not  chasing  your  tail  therapeuNcally.      

•  They  might  have  good  reason  for  MTD  (e.g.,  poor  glo_al  closure,  reflux  laryngiNs)  

•  May  need  to  hold  therapy  and  allow  for  behavioral  health  services,  then  resume  

QuesNon  and  Answer  

 Thank  you!