Providing Voice Therapy

Questão	Responda
When planning voice therapy, determine:	Causal Factors Maintaining Factors The team (patient, family/friends, other professionals)
The patient must understand:	What the problem is What he/she is doing wrong What can be done about it
Why Counseling?	-A person's voice cannot be separated from persona (often vocal symptoms mirror psychological symptoms) -Patients must be aware of lifestyle issues that are maintaining vocal problems -Patients should be encouraged to be actively involved in changing life habits that are contributing to vocal problems -Patients must understand vocal physiology and how therapy can alter this -Patients need realistic expectations
What to do when counseling vocal abuse patients	-Provide info to client/parents -Elicit support of family -Discuss value of voice rest -Determine what attitudes will interfere with success -Determine emotional factors involved -Teach problem-solving techniques to reduce anger/frustration that results in tension/abuse
During your analysis of abusive behaviors...	-Identify abusive voice behaviors -Use vocal abuse checklist -Develop hierarchy from easiest to hardest to eliminate -Reduce incidences of abusive behavior -Increase use of non-abusive behaviors -Reduce vocal usage
Steps in systematic reduction of abusive vocal patterns (6)	1. Eliminate hard glottal attacks 2. Teach continuous phonation 3. Teach easy onset of phonation 4. Reduce habitual loudness 5. Ensure adequate breath support 6. Eliminate visible signs of tension
Voice Rest - How to approach	1. Plan 1-2 week period of voice rest (quick start) 2. Teach breathy voice (and practice) 3. Make plan for use of breathy voice during specific times (100% not possible) 4. Teach alternative non-abusive methods of communicating 5. Establish discrimination of abusive and non-abusive behaviors
Continuous Phonation	Smooth Connected speech with no break in phonation Teach as temporary strategy to reduce vocal effort Once acquired, work on normalizing the sound of the voice, retaining soft glottal attacks and light prolongation of sounds
Digital Manipulation	Apply slight pressure to thyroid cartilage to lower pitch (then patient can hear and experience lower pitch and match it without pressure) Use digital placement on larynx to monitor laryngeal movement (have them sing up and down scale with fingers on thyroid to feel movement) For Unilateral Paralysis - Use pressure on thyroid cartilage to assist in closure
Techniques for Relaxation and Elimination of Muscle Tension (6)	1. Laryngeal Massage 2. Progressive relaxation techniques 3. Specific relaxation of neck and laryngeal area 4. Chewing Method (may or may not help) 5. Posture improvement 6. Yawn-sigh technique
Laryngeal Massage Steps (a relaxation strategy)	1. Encircle hyoid bone with thumb and middle finger 2. Exert light pressure in a circular motion over tips of hyoid bone and ask if pt. feels pain 3. Repeat in thyrohyoid space (thyroid notch to posteriorly) 4. Repeat on posterior borders of thyroid cartilage just medial to sternocleidomastoid muscles 5. Place fingers over superior borders of thyroid cartilage and work the larynx downward and at times laterally
After laryngeal massage without phonation...	-Ask patient to prolong vowels during laryngeal massage, noting changes in quality or pitch -Once a voice change has taken place, patient should be allowed to experiment with the voice while massaging and repeating vowels, words, and sentences
In order to increase breath support for speech	GAIN CENTRAL CONTROL OF BREATHING BY: -Modeling relaxed efficient breathing -Practicing in standing position with one hand on abdomen and one on rib cage (this may not help if they are wasting air) -Incorporate voice and speech -Develop concept of chest expansion to increase air volume
The Foundation of most resonant voice issues is:	Respiration, tonal focus, and vocal projection in a relaxed way
Breathing for speech - therapy	Teach appropriate phrasing Teach use of "catch breaths" (helpful when using confidential voice because it requires more air) Manage Breath Economy Eliminate Tension during breathing (usually at level of clavicle) Eliminate pitch breaks and glottal fry
Use of Efficient Pitch	*This is ONLY addressed when pitch is obviously abusive -Use correct posture -Determine optimal/habitual pitch -Use visual feedback (Visipitch, etc) -Practice changing pitch is difficult and the work will probably exceed the benefit unless it is severe -Work on appropriate inflection
At the point on the pitch scale when voice is loudest...	Voice is most efficient
Tonal Disorders Sound like...	Voice is trapped (too far down in throat) so not resonating efficiently Requires effort and strain to speak and sometimes can even be caused by tension when speaking
Forward Tonal Focus - Therapy	-Explain vocal focus using diagram -Imitate the patient's voice stressing the problem -Describe how the poorly focused voice was produced -Practice front consonants and vowels to encourage frontal focus, back vowels and consonants to encourage posterior focus
Improving Focus in Patients with Poor Vertical Focus	- Use imagery to get voice out of throat (image voice in front of them) -Practice with increased nasalization, slowly add vowels (chant-talk) - GOAL = head resonance and chain to non-nasals -Open mouth wide -Improve respiratory support -Check for good posture and head position
Most Common Tonal Focus Problem:	Vertical focus
Voice Projection Techniques for improving poor vertical focus	Good posture, open mouth, respiratory support
If tonal focus is an issue...	Resonance therapy will be a big help
Resonance Voice Therapy	Focuses on using natural resonators and enough air support Use nasal sounds to be sure you are using head to resonate Can use sensory feedback to feel resonation in nose
Resonance voice therapy for kids	1. Use a straw in a cup of water to help push voice forward (resonate) - have child blow bubbles through the straw 2. Have the child continue to blow bubbles adding voice 3. Remove the straw from the cup and have the child voice 6. Remove the straw from the child's mouth while voicing
Puberphonia	Results from difficulty in adjusting to voice change in puberty (can be fear of change and attempt to be accepted) Can occur in boys & girls but more common in boys Typically easily corrected by using reflexive phonation strategies to achieve full fold vibration and habituating them
Ways to modify glottal attack (6)	1. Develop awareness via ear training (clinical models to help establish understanding) 2. Teach whisper or breathy onset for hard attacks 3. Use visipitch to provide visual feedback during practice (look @ soundwaves) 4. Use the mirror to provide additional visual cues (look for neck tension!) 5. Use negative practice (clinician models attack) to compare and contrast hard and soft contact 6. Use continuous phonation to relax hard attack **These can be used in reverse to teach hard attack to individuals with unilateral paralysis!
Why can glottal fry be used as a facilitative strategy?	-Fry is produced with relaxed closure and little airflow/subglottic pressure -It will help relax closure and cue how to produce voice with relaxed closure to some patients -Relaxed folds will produce better closure because can wrap around nodules and polps
When is glottal fry not to be used?	-Outside of therapy to talk or for vocal rest because damage can happen -If patient is running out of air because they are so tense
Teaching Glottal Fry	-Ear training -Let out half of air and phonate /i/ -When fry is produced, open mouth and protrude tongue to open the throat and provide a richer tone -Practice on inhalation and exhalation -Try facilitative phrases like "see the eagle", "easy does it" in normal voice
Open Mouth - Why?	Resonance decreases and full head resonance is perceived when mouth is open Goal = decreased nasality Has immediate effect on nasality, increasing tonal focus, and increasing voice projection
Open Mouth - Therapy	Most patients will do this easily with demonstration and modeling Immediate effect on vocal quality will reinforce use Use negative practice Develop patient awareness of closed versus open mouth while speaking
Modifying Inflection - Therapy	-Model -Practice first in single words -Reading passages with marks to cue inflectional changes are helpful -Use evaluation of taped samples (especially looped feedback recordings) **Takes a lot of practice and changing voice tends to create monotony so useful to produce relaxed voicing with inflections
Yawn-Sigh Technique	1. Explain physiology of yawn 2. Yawn and phonate (cue for relaxed phonation) 3. Initiate with yawn and say words, phrases, etc (chain from vowels) 4. Model sigh, and repeat teps 1-3 5. Discuss relaxed feel of this type of phonation **Not for everyday! Just to relax the area
Nasal Glide/Stimulation	Many patients who have difficulty producing relaxed phonation will find it easier in utterances with nasals and glides Try practicing words saturated with /n/, /m/, or /l/ This is another way to work on forward tonal focus.
Intervention for Neurogenic Voice Disorders: GOALS	*Goals are different than with other disorders because there is emphasis on symptom-based therapy 1. Restore best possible voice 2. Help patients understand and accept functional limitations 3. Improve daily functional abilities in whatever way possible 4. Help patients accept compensatory strategies (this one is a HUGE challenge!)
Symptoms to Treat	Breathiness Inadequate Breath Support Inadequate Volume Nasality Strain/Strangle
Treating Breathiness	-Use hyper-functional strategies to achieve closure (esp. with Parkinson's) -Use head position modifications to assist closure (may increase loudness) -Use digital pressure to assist closure of weak vocal folds -Use reflexive phonation to assist closure -Surgically assist closure (usually done with younger populations.
How to use hyperfunction in Neuro cases	Push/Pull with phonation to recruit other muscles while speaking VFs = flaccid Build up muscles around problem areas to help facilitate impaired muscles
Why Use Reflexive Phonation with Neuro Breathiness?	Closing vocal folds when going to choke is at the level of the brainstem and may be a preserved area in strokes So, this can be chained into speech!
Treating Inadequate Breath Support	Teach two stage diaphragmatic breathing Improve awareness of breath economy Teach use of catch breaths Modify phrasing to allow more frequent breaths Identify ways in which air is wasted
Limitations that contribute to inadequate breath support	Weakness, paresis, fixed postures They need to take in as much air as possible!
Catch breaths in neuro patients are used for...	phrasing if weak inhalation cannot be fixed
Two stages of diaphragmatic breathing	1. Hand on abdomen that pulls in 2. Hand on chest that puffs out
Treating Inadequate Volume	Use technology (i.e. microphone esp. with Parkinson's) Increase breath support Teach hyperfunction Use ear training and visual feedback (visipitch, sound level meters, taping client) Use kinesthetic perceptions (common with Parkinson's and hearing aids) Teach voice projection
Reducing Nasality	MULTISTEP PROCESS Ear train nasal and non-nasal sounds (w/clinician model or recording) Produce nasal and non-nasal sounds and discuss kinestheic cues Teach light articulatory contact Teach relaxed production Encourage relaxed tongue dorsum (to increase full head resonance) Experiment with tongue position (some forward, some back) Encourage open mouth Encourage distinct articulation Try increase intensity and slightly lowering pitch (increased pitch = increased nasality) Experiment with which phonemes sounds better and use them to facilitate Use negative practice
Nasality in neuro patients may be caused by	affected palatal movement
Light articulatory contact vs. hard contact	Light Contact: lightly touching lips and keeping articulators relaxed to decrease nasality Hard Contact: Pushes nasal resonance *Can use resonant voice therapy or stretch and flow
Phonemes that help facilitate decreased nasality	/d/, /t/, /l/ pull forward /g/, /k/ , /dz/ pull back
Surgical Intervention for Nasality	Pharyngeal flap - connects to teeth, makes voice less nasal but may increase denasality Palatal lift - lifts palate to pharyngeal wall to achieve closure Teflon/Gelfoam Injections - Puffs palate to meet pharyngeal wall Orthodontic intervention **Not usually done in neuro patients in case of complications and giving another surgery
Treating Strain/Struggle	*Occurs in many neuro patients -Same strategies as with vocal abuse (relaxed phonation, stretch&flow, resonance therapy) -Relaxation is important -Experiment with surprasegmentals (slow rate, modify prosody - monotone relaxes) -Eliminate interfering compensatory strategies -Proprioceptive neuromuscular facilitation (icing, brushing, stretching) - this is not as good as actual movement - Positioning and posture to achieve more relaxed phonatory style -Reflex inhibition strategies (by changing position) -Surgical recurrent laryngeal nerve resection -Botox injections
Spasticity may cause:	Hunched with high clavicular posture and tight muscles (stretch and flow helps!)
Stretch and Flow	Increases overall efficiency of phonation by increasing breath support and teaching relaxed phonatory process Helps increase awareness of tension and coordinate respiration, phonation, and resonation Patient uses breathy production and brings vocal folds closer until phonation is strong but relaxed (then move to inflection!)
Reflexive Phonation	FORCING VF CLOSURE Cough Laugh Swallow Grunt Pretend to lift * Use with paralysis or paresis at vocal fold level
Facilitative Head Positions	-Normal Straight -Neck extended forward with head tilted down while facing up (pushes vfs together in muscles of larynx - very tense so paralysis feels normal) -Neck flexed down with head tilted down and face looking down (okay to use if it makes voice louder) -Neck flexed unilaterally -Head upright and rotated left or right
Techniques to Modify Loudness	-Check hearing -Develop awareness of loudness -Modify pitch to see if changing pitch enhances louder voice (decreased pitch = increased loudness) -Improve respiratory support for speech -Use voice projection strategies -Teach hyperfunctional strategies (but this can be abusive!) -Use amplification system to augment volume if necessary **GOAL = Best possible voice
Auditory Feedback	Metronome provides pacing to help monitor rate Real time amplification helps patient focus on how he sounds Loop playback allows patient to evaluate utterance by listening on tape (phonic mirror, facilitator - client speaks, listen, clinician models with corrections, repeat) **This may sound different than real time ear perception
Why Intervene with Progressive Neurological Cases?	-Teach good compensatory strategies -Therapy can delay deterioration -Psychological benefits to working on communication -Work together with patient to get best possible voice

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Providing Voice Therapy

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	Criado por Linnea Larson quase 8 anos atrás