1

Intervention Techniques

2

Establishing Where to Start• Begins where patient is able to perform

• Documentation:– Site & size of lesion (if present)– Pre voice recordings to compare post therapy– Pre instrumental voice measurements– Physical sensations– Post recordings should have the same readings and

vowel productions as pre recordings

• Explore different facilitating approaches– One that works- continue

3

Voice therapy for Young Children

• Emphasis placed on early diagnosis & identification rather than voice therapy

• Define the need for surgery, speech therapy or counseling (may be only one or a combination of all three)– Preschool level: voice therapy for

hyperfunctional voice problems are not always warranted

– School-age: Remedial with voice therapy

4

Voice Therapy: School-Age• Early emphasis on identifying abuse-misuse

• Outline steps to reduce the occurrence of such behaviors

• Identification through observation (teachers, parents and child self report)

• Use siblings or peers to determine vocal patterns

• Collect baseline measures once vocally abusive behaviors are identified– ex. child may tally instances of vocal abuse on card

• Chart the behaviors over time with child

5

Voice Therapy: Adolescents & Adults

• Abusive behaviors of adults more difficult to isolate than children

• Voice problems related to occupation or general time and style of phonation

• Primary: Explore various therapy techniques that may produce “good” voice

• Once technique is chosen and patient is able to produce a model, then that technique becomes primary focus of therapy

• Hierarchies of stress identified

6

Facilitation Techniques• Therapy technique that produces

optimum voice:– Easy voice is designated target

– Selection of approach should not be random

– Based on possible effects on parameters: pitch, loudness & quality

– Examples of facilitating approaches:

• Altering tongue position• Chant Talk

• Digital Manipulation

• Ear Training

• Half-Swallow Boom (go over in paralysis lecture)

• Inhalation Phonation

• Open-Mouth approach

7

Altering Tongue Position• Problems for which this approach is

useful:– Direct influence on quality & resonance

• retraction of tongue= “cul-de-sac” resonance (hollow sounding)

– Deaf speakers- pharyngeal focus

– Tension causes retraction

– Improvement of posterior resonance focus (muffled voice) & anterior resonance focus (weak & thin)

8

Altering Tongue Position• Procedural aspects of the approach:

1) Forward tongue position-

a. Demonstration of back tongue position (pharyngeal) & its effects; be sure chin is not tucked in or excessively extended

b. Whispered productions of tongue tip alveolar consonants: /t/, /d/, /s/, /z/; rapid series of ta sounds (10 per breath); Discussion, “what does the front of the mouth production feel like?”

-Other consonants /w/, /p/, /b/, /f/, /v/ and high oral focus with joint

practice vowels /I/, / i/, /e/, /æ/, /

c. After whispered; add voice lightly; read orally exercises heavily loaded with tongue tip consonants and front vowels; contrast with old back resonance; Record & playback and listen to the difference; evaluate the feeling of both productions

9

Altering Tongue Position• Procedural aspects of the approach:

1) Development of normal tongue position if to anterior-

a. Determine if patient is using appropriate pitch

b. Do not have to shape the tongue in any way; By saying back vowels aloud the tongue should naturally go where it should

-Practice vowels in isolation, sustaining for 5 seconds-

/a/, /o/, u/

c. Practice reading with back vowel loaded passages; then contrast old methods of speaking; Discussion of different sensations

10

Chant Talk

• Problems: hyperfunctional voice

• Description: words running continuously together without stress or a change in prosody for individual word segments.

• “smooth and connected with no break between tones”

• Therapy is characterized by elevation in pitch, prolongation of vowels, lack of syllable stress and softening of glottal attack.

• Can be modified to resemble phonation

11

• Procedural aspects of the approach:

1) Explained to patient as a method that reduces the effort of talking, method is temporary, demonstrate by playing religious chant, produce same voicing style while reading

2) Urge patient to imitate same pattern, most can do with success

3) Patient should read aloud, alternating chant with regular voice, 20 seconds each reading condition

4) Record oral reading, contrast normal and chant voice, discuss pitch differences, phonatory prolongation's, soft glottal attacks

5) Once able to produce chant talk, reduce chant quality, approximate normal voice, slight prolongation's and soft glottal attack retained.

12

Digital Manipulation

• Problems: inappropriately high pitch, hyperfunctional voice, too much force

• Description: facilitation of a target voice by finger manipulation of the patient’s larynx

• 3 main targets: 1) lowering pitch, 2)reducing force, 3) reducing tension

13

• Procedural aspects of the approach:

1) Digital pressure for lowering pitch-

-Prolong a vowel (/a/ or /I/)

-As vowel is prolonged, apply slight pressure on thyroid cartilage

-Pitch will drop immediately

-Ask patient to maintain lower pitch after fingers are removed

-If method is adopted let patient hear & feel a lower pitch, practice with & without digital pressure on thyroid

14

2. Monitoring vertical movement of larynx--For patient with excessive pitch variability & tension related to much vertical movmt. of the larynx

-Demonstrate placement of fingers on the thyroid cartilage & monitor laryngeal vertical movmt. while phonating

-Patient produces high pitch level, keeping fingers on thyroid cartilage, patient will lower pitch one note at a time to the lowest note in pitch range

-Larynx will lower in neck, then patient will raise pitch feeling elevation, review both lowering & raising of larynx

15

-Once patient experiences vertical movement, point out in normal speaking voice free of strain NO vertical movement should be felt

-Oral reading & speaking should be developed with little or no vertical movement

-Practice in oral reading with encouraged pitch variability can be monitored by slight digital pressure to thyroid with patient confirming no vertical movement.

16

3) Maneuvering the larynx to a lower neck position-

- Encircle the hyoid bone with the middle finger & thumb

-With light finger pressure, place fingers in thyrohyoid space (just above thyroid notch), then with fingers over superior border of thyroid cartilage begin to work the larynx downward, with downward pressure and lateral movements

-Larynx will move slightly downward with light pressure (can’t fight with tension)

17

Ear Training

• Problems: identification and elimination of faulty vocal habits

• Description: patient’s self hearing, make patients critical self listeners, make pitch discriminations, improve tonal memory (remembering sound of own target)

18

• Procedural aspects of the approach:

1) Take a base-line measurement of patient pitch discrimination, make your own tape of “live” discrimination presentations or pitch pipe

-Present pair of tonal stimuli

-Ask if they are the same or different

-If patient cannot get 50% accuracy they are not able to discriminate well

2) Pitch discrimination training should continue until patient can discriminate pitches one full musical note apart (C4-D4), can be practiced alone

19

3) Tonal memory therapy begins if patient can remember a two-note sequence (pitch pipe, piano or voice)

-Present 2 note sequences

-Ask patient to identify which note varies between the two presentations

-Therapy ends when patient can hear a four-note sequence, remember it, and successfully compare it with a second four-note melody

20

Inhalation Phonation• Problems: aphonia, ventricular phonation

• Description: excellent method of eliciting true phonation in patients experiencing functional aphonia, also with “puberphonia”

• Procedural aspects of the approach:

1) Demonstrate by phonating a high pitched hum while elevating shoulders, time inhalation with shoulder elevation to mark contrast between inhalation (raised), exhalation (lowered)

21

2) Demonstrate several separate inhalations with simultaneous shoulder elevation & inhalation

-Say “Now, I’ll match the high-pitched inhalation voice with an expiration voice”

-Inhale raising shoulders and humming in high pitch

-Then drop shoulders on exhalation and produce the same voice, repeat inhalation-exhalation several times

3) Ask patient to copy your example

22

4) Now extend the expiration,

-Demonstrate continuation of high pitch, sweeping downward from falsetto register to regular chest register on one long continuous expiration-Repeat several times

5) After some practice give patient word list (monosyllabic) for true voice practice

6) Once inspiration-expiration technique is established, instruct to reduce shoulder movement

7) single word practice until normal voicing is established

23

Open-Mouth Approach• Problems: general hyperfunction, deviant loudness,

pitch and quality

• Description: Encourages the patient to develop more openness which reduces general hyperfunction

• speaking and learning to listen with a slightly open mouth allow the patient to use their vocal mechanisms more optimally

• Promotes natural size-mass adjustments and more approximation of the vocal folds.

24

• Procedural aspects of the approach:

1) have patient view themselves in a mirror (or videotape) to observe presence or absence of open-mouth behavior (identify lip tightness, mandibular restriction etc.)

2) Differentiate using the ventriloquist’s puppet example, contrast between talking with a closed mouth and open one

3) Instruct patient to establish oral opening-let jaw relax, watch in mirror-drop head to chest letting lips part & jaw remains slightly open-practice relaxed /a/ sound

25

Readings

• Directed Reading: – Supplement on Treatment Efficacy: Part II

in Journal of Speech, Language, and Hearing Research, Volume 41, Number 1, S101; February, 1998• Ramig, L. & Verdolini, K. (1998). Treatment

Efficacy: Voice Disorders. Journal of Speech, Language,and Hearing Research.