Voice therapy

VOICE THERAPYDR. GIRISH. S

GENERAL GOALTo rehabilitate the patient's voice to a level of function that enables the patient to fulfill his daily voice and/or speech communication needs.

To help a client produce a voice of the best possible pitch, loudness, and quality in relation to the individual's age and gender.

To reduce or eliminate the voice disorder

To prevent recurrence of the voice disorder

ELEMENTS OF VOICE THERAPY To educate the patient about the anatomy and physiology of the vocal system and how vocal pathology affect the voice production.

To modify or eliminate inappropriate hygienic behaviours Hygienic voice therapy

To modify air pressures and airflow in an attempt to bring about efficient voice production without unnecessary strain Symptomatic voice therapy

To improve voice production through better vocal folds approximation Symptomatic voice therapy

To modify functional hypernasality or hyponasality secondary to organic pathology Symptomatic voice therapy

To reduce laryngeal area muscles tension and effort (vocal hyperfunction) Symptomatic voice therapy

Home practice

Voice therapy methodsI. SPECIFIC METHODS.II. DIVERSE METHODS.III. HOLISTIC METHODS.

Specific methods1. Paralytic dysphonia (PUSHING TECHNIQUE).2. Mutational dysphonia (FINGER MANIPULATION AND PRESSURE).3. Psychogenic aphonia (COUGH, HUM, MASKING..).

Diverse methods1. Relaxation2. Altering tongue position 3. Pitch inflection 4. Yawn-sigh

5. Head rolling6. Laryngeal massage7. Inhalation phonation8. Chant talk

Holistic methods

Tackles respiratory, pulmonary, and articulatory mechanisms.

Accent Method

INDICATIONS1- DISORDERS OF VOICE

2- DISORDERS OF SPEECH:a- Dysarthria: Correcting defective breathing, dysprosody, and dysphonia.b- Stuttering: Improving breath control leading to better phrasing and rhythms.

3- DISORDERS OF LANGUAGE:Correcting dysprosody in selected language disorders in children and adults.

VOICE THERAPY APPROACHESSTEMPLE

4 CATEGORIES : - HYGEINICSYMPTOMATICPHYSIOLOGICPSYCHOGENIC

HYGIENIC VOICE THERAPY

HYGIENIC VOICE THERAPYTo modify or eliminate inappropriate hygienic behaviours. Hygienic voice therapy is considered as the first step in voice therapy programs.

Some examples of poor vocal hygiene behaviours shoutingtalking loudly over noise screaming background vocal noises coughing

throat clearing, poor hydration, taking excessive coffee, alcohol, and smoking

Poor vocal hygiene may also include the habitual use of voice components in an inappropriate manner, which is called Functional vocal behaviours.

PROCEDURES OF VOCAL HYGIENE THERAPY

Identify the trauma behaviour: The clinician will provide the patient with a behavioural chart to record all inappropriate hygienic behaviours Provide life-style modifications list that help the patient reduce laryngeal irritation

Describe the effects: To educate the patient about the anatomy and physiology of the vocal system and how vocal pathology affects the voice production.

Define specific occurrences Modify the behaviour.HydrationUse a warm mist humidifier in your roomBuild in periods of voice restConsider amplificationBreathe correctly when speaking

CORRECTION OF IMPROPER POSTUREemphasize an upright posture and proper head positioning.

This is to maximize lung capacity, breath support from the lungs and diaphragm and sound production.

MTD, Vocal nodule

SYMPTOMATIC VOICE THERAPY

Symptomatic Voice Therapy Techniques TECHNIQUES TO REDUCE LARYNGEAL AREA MUSCLES TENSION AND EFFORT

TECHNIQUES TO MODIFY AIRFLOW (RESPIRATORY RETRAINING)

TECHNIQUE TO MODIFY VOCAL PITCH

Symptomatic Voice Therapy Techniques TECHNIQUES TO REDUCE LARYNGEAL AREA MUSCLES TENSION AND EFFORTCircumlaryngeal Massage TechniqueChewing exercisesYawn-sigh approachBiofeedback training TECHNIQUES TO MODIFY AIRFLOW (RESPIRATORY RETRAINING)

TECHNIQUE TO MODIFY VOCAL PITCH

Symptomatic Voice Therapy Techniques TECHNIQUES TO REDUCE LARYNGEAL AREA MUSCLES TENSION AND EFFORT

TECHNIQUES TO MODIFY AIRFLOW (RESPIRATORY RETRAINING)Therapy approach for Breath support Abdominal/Diaphragmatic BreathingLee Silverman Voice Treatment Confidential Voice Therapy TECHNIQUE TO MODIFY VOCAL PITCH

Symptomatic Voice Therapy Techniques TECHNIQUES TO REDUCE LARYNGEAL AREA MUSCLES TENSION AND EFFORT

TECHNIQUES TO MODIFY AIRFLOW (RESPIRATORY RETRAINING)

TECHNIQUE TO MODIFY VOCAL PITCHTherapy approach for vocal pitch

TECHNIQUES TO REDUCE LARYNGEAL MUSCLES TENSION

Circumlaryngeal Massage TechniqueHands-on Approach in which patients are trained to massage their neck area while observing different changes in their voice quality.

Purpose of this technique is to eliminate pain while speaking, relax muscles in the laryngeal area, and reduce tension in the upper body

Circumlaryngeal Massage TechniqueINDICATIONS: It is used in patients who report neck tension , stiffness, or tenderness along with vocal symptoms. It is also used for muscle tension dysphonia (functional dysphonia)

CIRCUMLARYNGEAL MASSAGE

CHEWING EXERCISES

ADVNTG - Better vocal fold approximation and optimum muscular adjustment of the vocal folds.

Reduction of hard glottal attack & simultaneous improvements in loudness, pitch, and vocal quality.

PROCEDUREHave the patient sit facing a mirror. Ask the patient to pretend he or she is chewing a cotton candy .

Tell the patient to chew in a relaxed, open-mouthed, exaggerated manner and to pretend to move the cotton candy around in the mouth with exaggerated movements of the tongue.

Ask him to start phonating softly.

Ask him or her to inhale deeply and to chew and phonate the outgoing air stream. Encourage the patient to let the vocal pitch vary erratically.

Next, the patient should be told to simultaneously chew, phonate, and articulate brief two- or three-word combinations that begin with vowels (e.g., "I am in," "I am over," "I am up").

Daily practice with the chewing technique should continue until the patient begins to demonstrate diminished laryngeal dysfunction in conversational speech.

YAWN-SIGH APPROACH YAWN expand the pharynx ; stretch and then relax the extrinsic laryngeal muscles, thus lowering the larynx in the neck to a more neutral position and permit a more forward placement of the tongue in the oral cavity.

YAWN-SIGH TECHNIQUE

The patient is advised to practise yawning, followed by generation of a sighing sound.

This procedure reduces the tension on the vocal folds.

HALF SWALLOWBOOMTECHNIQUEIn this technique the patient is asked to swallow.

While swallowing is in progress the patient is asked to say "Boom".

Then the patient is asked to turn to one side and say "BOOM". The sameexerciseis repeated by turning the head to the opposite side.

The patient is then asked to lower the chin, and say Boom.

HALF SWALLOWBOOMTECHNIQUEThe swallow procedure is known to maximise the closure of larynx. The sound Boom is produced by posterior pressure to the larynx. The patient gradually learns to lower the pitch of his voice.

BIOFEEDBACK TRAINING Basis of biofeedback self- control of physiological functions is possible with continuous, immediate information about the internal bodily state.

Electromyographic biofeedback permits patients to monitor electrical activities of their muscles and to exert some control over these areas.

TECHNIQUES TO MODIFY AIRFLOW (RESPIRATORY RETRAINING)

THERAPY APPROACH FOR BREATH SUPPORTFocuses on coordinating breathing with vocalization.It is often used in conjunction with the treatment of reflux.

INDICATIONS:-1. Talking with decreased breath support2. Professional speakers who may require greater breath support during presentation than during normal conversational speech3. Patients with excessive cough4. Paradoxical vocal fold motion disorder5. Vocal spasm or laryngeal irritation

ProceduresEAR TRAINING: Ask the patient to read a paragraph and tape-record sample of his/her voice and use it to monitor the patients respiration strategy

Ask the patient to say as many numbers as possible on one normal expiration and to stop before any force or strain is evident.

Give the patient a paragraph with phrase markers, and ask the patient to read it aloud with normal inhalation occurring at each phrase marker.

The patient is asked to monitor his or her voice daily during non-therapy conversational times.

Abdominal/Diaphragmatic BreathingAlthough the diaphragm is always active during respiration in normally healthy individuals, some use a greater amount of thoracic or chest breathings during respiration.

Chest breathing patterns may be adequate for voice support, although a more efficient means of breathing for speech can be achieved when the diaphragmatic movements predominate over other respiratory chest wall movements.

The most efficient method of air intake for the support of voice is through the downward contraction of the bottom the diaphragm.

When the diaphragm contracts downward, the abdomen is forced outward, and the cavity expands to its maximum extent.

This expansion permits a greater flow of file air into the lungs. The air may then be used to better support your voice.

This technique is simply used to introduce the patient to proper abdominal movement during respiration.

ABDOMINAL BREATHINGThe patient is asked to lie down in a supine position.

Then, a book may be placed on the abdomen while the patient is asked to observe the natural movement of the abdomen during breathing. As the patient inhales, the book will rise. The opposite movement will be observed during exhalation.

The patient is asked to breathe in this manner with out phonation and then gradually introduce the voice component

LEE SILVERMAN VOICE TREATMENTLSVT was developed to address the hypokinetic dysphonia most frequently associated with Parkinson disease.

LSVT is a systematic voice therapy approach that focuses on increasing loudness during four sessions per week for 4 weeks.

LEE SILVERMAN VOICE TREATMENTIt advocates increasing the effort with which patients speak thereby "pushing" the voice and making it stronger.

Patients are trained to exhale higher volumes of air out of their lungs, more forcefully while simultaneously closing their vocal folds more completely. Louder and stronger voice.

CONFIDENTIAL VOICE THERAPYIt is used to reduce the force of vocal fold collision and excessive laryngeal hyperfunction during phonation.It is encouraged for a prescribed period to promote mucosal healing.It is only used for a period of time to promote vocal fold healing.

CONFIDENTIAL VOICE THERAPYFirst-Line Voice Therapy Regimen During Early Recovery Period of VOCAL CORD INJURY / VOCAL M.TENSION

Patients are trained to produce a soft, breathy voice without full vocal fold closure.

The main goal of this technique is to allow patients to speak while vocal fold health improves/ heals.

INSPIRATORY MUSCLE STRENGTHTRAINING (IMST)Described by Christine Sapienza.

She developed a device that consists of a mouthpiece with a one-way valve. The valve blocks airflow until the threshold pressure is produced to overcome the spring force.

INSPIRATORY MUSCLE STRENGTHTRAINING (IMST)The patient must generate sufficient inspiratory pressure using inspiratory musculature to open the valve and allow the air to flow.

IMST has shown to be successful in a case of a patient with bilateral abductor vocal fold paralysis and a patient with paradoxical vocal fold motion.

INHALATION PHONATIONBOONE [1966]

Phonation during inspiration results in adduction of true vocal cords without associated false vocal folds adduction.

PHYSIOLOGIC AND HOLISTIC VOICE THERAPY TECHNIQUES

VOCAL FUNCTIONAL EXERCISESProgram of systematic exercises that strengthen and rebalance the subsystems involved in voice production (respiration, phonation, and resonance).

Exercises include maximum vowel prolongations and pitch glides using specific pitch and phonetic contexts.

Series of 4 systematic exercises for the intrinsic laryngeal muscles.

RESPIRATION PHONATION RESONANCE

VOCAL FUNCTIONAL EXERCISESvocal warm-up by sustaining the vowel ee for as long as possible.stretching of the laryngeal muscles by gliding from the lowest note to the highest note.contracting of the laryngeal muscles by gliding from the highest note to the lowest note.building muscular power by sustaining musical notes for as long as possible.

VOCAL FUNCTIONAL EXERCISESAt home, the patient is taught four exercises two times each, twice per day, preferably morning and evening.

To strengthen and increase the flexibility of the laryngeal muscles, improve balance among subsystems.

VFEVFE is necessary to regain the balance among airflow, to this laryngeal muscle activity, to the supraglottic placement of the tone.

INDICATIONS:-Vocal fold lesions Muscle tension dysphonia Hypophonia

Resonant Voice Therapy ARTHUR LESSAC

Resonant voice refers to a voice that resonates or echoes within the face or facial bones.

Voice produced in mask of face is most efficient form of voice.

Tool used to help patients feel the vibrations of their voices along the lips, tongue, and nose, and then use those sensations to help better project their voices.

LESSAC-MADSEN RESONANT VOICE THERAPY (LMRVT)

This approach aims to produce voice with the vocal folds lightly touching rather than closed tightly achieving sound volume through resonance.

The use of humming or chanting is an integral part of this approach

Resonant Voice Therapy

Resonant Voice Therapy

ACCENT METHOD Based upon use of pulsed abdominal breaths to facilitate glottal closure

Uses principle of Bernoulli effect

Builds new respiratory / voice pattern from basic syllable intonations through conversation

ACCENT METHOD focuses on improving breathing technique to increase voice clarity.

Patients are taught to use accentuated and rhythmic movements in both their pronunciations and in related body movements.

It helps relax the vocal muscles while also helping to synchronize voice production with a recognizable rhythm produced by another part of the body.

PSYCHOGENIC VOICE THERAPY

Psychogenic Voice Therapy focuses on identification and modification of the emotional and psychosocial disturbances associated with the onset and maintenance of the voice problem.

when the psychogenic causes are resolved, the voice disorder dissipates.

CAUSES OF FAILURE OF VOICE THERAPY1. Inappropriate referral from ENT.2. Not stimulable for a better voice.3. Decreased motivation for change (i.e wants a quick fix).4. Non-compliant to vocal hygiene advices.5. Will not accept responsibility.