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10/10/2014
1
Client-Centered Management
for Voice Disorders:
Using the ALERT model
Linda Rammage, PhD, RSLP, S-LP(C)
Director, PVCRP
BCASLPA, 2014
What is EBP? (Hjørland, 2011)
all practical decisions 1) based on research
studies and 2) research studies are selected
and interpreted according to specific norms
characteristic for EBP
norms typically disregard theoretical and
qualitative studies and consider quantitative
studies according to a narrow set of criteria
for evidence (Random Control Trials - RCT)
Tx based on other research designs
considered “research-based-practice”
EBP/RCT – “Gold Standard?” (Montgomery & Turkstra, 2003)
Means to support clinical reasoning, not “End”
Limitations in clinical research/Tx decisions:
Statistical signif ≠ clinically meaningful…
achieving both is a social judgement
Judgement always required for indiv. client
(“n of one”)… even RCT results cannot be
assumed to generalize to each individual
RCTs may be impractical/impossible
(eg. statistical power/study N required) or
design inappropriate for many clinical Q’s
Cochrane Reviews (RCT):
“Voice/Voice Therapy” Q: Is there evidence that any form of SLT is
more efficacious for IPD? (2012)
Author Conclusion: “Insufficient evidence due
to small N’s”
Q: Is there evidence that either direct or
indirect voice training or combined is effective
to prevent voice disorders in at-risk
population? (2007)
Author Conclusion: “No evidence from studies
that met review criteria. Need larger N and
better methodology (better control criteria)”
10/10/2014
2
Client-Centered Care (Rogers, 1959)
relationship of mutual respect and trust
between client and therapist
clinician facilitates information-sharing in a
non-directive approach
client’s role as “expert” in his/her experiences
of the problem is established at the outset
therapist demonstrates “unconditional positive
regard” by listening to and acknowledging the
client’s perspective without making judgment
Client/Person-Centered Care
Principles Get to know client as a person (not a Dx):
culture, beliefs, values, goals, dreams…
Share power and responsibility: respecting
preferences
Accessibility and flexibility: ensuring
sensitivity to values, preference, needs;
making info accessible to facilitate choices
Coordination & integration: team work;
minimize duplication; key contact
Environments: ensure working
philosophy/policy/environment facilitates PCC
EBP & Client/person-centered care
“Person-centred practice could make a difference to
health outcomes, patient/client satisfaction and can
improve one’s sense of professional worth” (Victorian
Department of Human Services, 2006)
“EBP acknowledges that good outcome must be defined
re value to patient…combining art of generalizations and
science of particulars” (Epstein & Street, 2011)
“PC planning associated with benefits in areas of
community involvement; contact with friends, family; and
choice” (Sanderson, Thompson & Kilbane, 2014)
Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
10/10/2014
3
ALERT to History
Determining contributions of factors:
Anatomical:
Lifestyle:
Emotional:
Reflux:
Technique:
The Client as
“Expert”:
Client Intake
History Form
Tool Paradigm Parameters Administration
Rating
Authors Select Clinical
Studies
Voice Handicap
Index (VHI)
Handicapping
effects of voice
impairment,
incl. voice
disability &
impact on daily
functioning
(WHO)(1980)
ICIDH
30 items:
10 - Physical
10 - Functional
10 - Emotional
5-point
frequency of
occurrence scale
Translated to
ordinal scale
Higher scores =
greater handicap
Jacobson et
al, 1997
Rosen et al, 2000
Billante et al, 2001
Roy et al, 2001
Spector et al, 2001
Weigelt et al, 2004
Maertens and de
Jong, 2007
Hazlett et al, 2009
Voice Handicap
Index-10
(VHI-10)
As with VHI 10 items:
Physical
Functional
Emotional
As with VHI Rosen et al
2004
Deary et al, 2004
da Costa de
Ceballos et al
2009
Pediatric VHI
(pVHI)
As with VHI 23 items:
7- Functional
9- Physical
7- Emotional
As with VHI Zur et al
2007
de Alarcon et al
2009
Voice-Related
Quality of Life
(V-RQOL)
Impact of
general or
specific states
of disease or
dysfunction on
Quality of Life
10 items:
5-Physical/Functional
5-Social/Emotional
Overall Voice quality
past 2 weeks
5-point severity
scale
Higher scores =
greater severity
Can be
converted to
Standard Score
Hogikyan
and
Sethuraman
1999
Hogikyan et al,
2000, 2001
Rubin et al,2004
Franic et al., 2005
Cohen et al, 2006
Oridate et al, 2009
Moukarbel et al
2010
10/10/2014
4
Pediatric
Voice-Related
Quality-of-Life
Survey
(PVRQOL)
Impact of general
or specific states
of disease or
dysfunction on
Quality of Life
10 items:
5-physical-
functional
5-social-
emotional
Parent –proxy
As with V-RQOL Boseley et al,
2006
Hartnick, 2002
Hartnick et al,
2003
Merati et al,
2008; Blumin et
al, 2008
Voice
Symptom
Scale
(VoiSS)
Handicapping
effects:
communication,
throat infections,
psych distress,
voice
sound/variability,
phlegm. ICIDH
30 items:
15-Impairment
15-Physiological
15-Emotional
5-item frequency of
occurrence scale
Translated to
ordinal scale
Higher scores =
greater handicap
Deary et al,
2003
Deary et al, 2003
Wilson et al,
2004
Webb et al, 2007
Hazlett et al,
2009
Vocal
Performance
Questionnaire
(VPQ)
Physical
symptoms and
socio-economic
impact of voice
disorder
12 questions
about voice
dysfunction
impact
5 potential
responses per
question to
indicate impact
Carding and
Horsley, 1992
Carding and
Horsley, 1992
Carding et al,
1999
Deary et al, 2004
Voice Activity
and
Participation
Profile
(VAPP)
Perception of
problem, activity
limitation,
participation
restriction
WHO ICIDH-2
Beta 1 (1997)
28 items:
1 - Severity
4 - Employment
12 - Daily
communication
4 - Social
communication
7 - Emotion
10 cm continuous
line visual analog:
Left = not affected
Right = always
affected
Measure cm., from
left end of line
Ma and Yiu,
2001
Ma and Yiu, 2001
Sukanen et al,
2007
Chung et al,
2010
Yiu et al, 2011
Voice-Related
Quality of Life
(V-RQOL)
Self-Report
Inventory.
(Hogikyan &
Sethuraman,
1999)
Anatomical Factors
Chronic non-infective laryngitis
Congenital Webs
Contact Ulcer/Granuloma (Reflux)
Crico-arytenoid Joint Problems
Cysts, Sulci, and Mucosal Bridges
Iatrogenic changes (eg. ablative surgery)
Infection: Bacterial; Viral (esp. parainfluenza)
Laryngeal Trauma
Mucosal changes from abuse/misuse
Tumours
Anatomical Anatomical Factors Examples:
Unilateral Cyst 10 Nodules 20
10/10/2014
5
Papilloma 10 Contact Ulcer/
Granuloma 20 Web (Congential / Iatrogenic)
Anatomical Factors:
Development and Aging
Hirano &
Bless,
1993
Aging and Speech-Breathing (Hoit & Hixon,1987;
Hoit et al, 1989; Hoit & Hixon, 1992; Melcon et al, 1989)
Rib cage ossifies
Reduced collagen in lungs
Reduced flexibility in system
Reduced vital capacity
Initiate voice at higher lung volumes
Use larger lung and rib cage excursions
Men use more lung vol/syllable (due to vocal
fold leaks) but not women (Hoit & Hixon, 1992)
10/10/2014
6
More time required for voice onsets
Reduced ability to sustain long phrases
(especially with incomplete v.f. closure)
More time required for inspiration
Potentially less driving force for phonation
Senescence affects posture
Posture affects breathing
Glottal leakage higher lung volumes (men)
Higher airflow hyper-valving at glottis
Implications:
Aging and the Larynx (Honjo & Isshiki,1979;
Kahane,1983a/b; Kahn, A. R. & Kahane,1986; Kersing, 1986; Linville
& Korabic,1987; Mackenzie Beck, J. (1997 )
Cartilage ossifies
Collagen, elastin, muscle esp. men (Case 32)
Epithelium thickens, esp. women
Cumulative trauma thickens folds
Larynx descends, pharynx lengthens:
formant structure
Reduced neurological/structural stability:
wobble/tremolo/vibrato/perturbations
VF closure may
Increased jitter/shimmer/noise
10/10/2014
7
Vocal Senescence and Gender (Linville &
Fisher, 1985 a/b;; Linville, 1996; Mysak, 1959; McGlone & Hollien,1963)
Women:
• Epithelium
• F0 range descends
• More if smoker
• May be called “sir”
• May compensate to
pitch
• tension range/
flexibility
Men:
• Collagen, elastin,
muscle, epithelium
• F0 range ascends
• May be called “Ma’am”
• May compensate to
pitch
• tension range/
flexibility
Implications (L/E/T impact?):
Reduced loudness potential (Linville, 1996)
Reduced phonation duration (Linville, 1996)
Leaky VF (esp.men): mal-adapt speech-breathing
Delayed voice onset
“New-Normal” pitch range (Melcon et al, 1989)
Pharynx continues to grow: formants drop
May mal-adapt to aging with muscle misuse
vocal perturbations and noise
Exercise (general/voice-specific) may age effects (Peppard, 1990; Lowery, 1993)
Anatomical Factors: Neurological
Motor Speech Disorders
congenital (CP) / acquired (MSD)
MSDs and voice:
Vocal fold paralysis (flaccid)
Dystonia/spasmodic dysphonias
Spastic dysarthrias
Essential voice tremor
Parkinson’s Disease
Irritable Larynx as Central Sensitivity Syndrome?
Unilateral Paralysis (Case 29)
PD (Cases 49)
EVT (Case 52)
SD (Case 55)
10/10/2014
8
Anatomical Factors:
Irritable Larynx Syndrome (Morrison, Rammage, Emami, 1999) (Case 59)
definitive triggering stimulus
hyperkinetic laryngeal dysfunction
(laryngospasm-PVFM, cough, dysphonia/globus)
due to
CNS over-reaction to normal sensory
stimuli in response to a
Symptom Triggers
All 195 vs. Female PVFM (141)
All Pts: F-PVFM
Odors 106 54% (57%)
Stress 100 51% (50%)
Eating 36 18% (20%)
Lying down 38 19% (22%)
Talking 41 21% (21%)
Exercise 27 14% (13%)
ILS - Pathways to CNS Plastic Change
Chronic
Stimulation
GERD CNS
VIRUS
Psych
Factors
Habituation &
ILS Features
Set-up for spasm
hypertonic state
MUSCLE SPASM
Dysphonia Laryngospasm Globus & Cough
Irritants Tone
modulators
Non-triggered
ILS
10/10/2014
9
stimulus
c-fos
c-jun
Transcription of
I.E.Genes
P
FOS JUN
fos jun
DNA
binding
Neural plastic response to repetitive nocistimulation
depolarization
ILS: A Central Sensitivity Syndrome? (Morrison & Rammage, 2010)
Heightened sensitivity of central neurons
Altered activation thresholds, and enhanced responsiveness to synaptic inputs as with neuropathic pain (Woolf CJ, Slater MW. Science 2000; 288:1765-8)
Underlying Neuro-Endocrine-Immune (NEI) pathology? (Morrison et al, 1999; Yunus, 2000-2008)
CS verified by testing neurotransmitters, neuro
modulators with nociceptive spinal flexion reflex, Functional MRI and cerebral evoked potential by ElectroEncephaloGraphy (Yunus, 2005; 2007)
Central Sensitization
A defined input, or sensory stimulus, produces a sensory experience greater in amplitude and duration than would be expected
The sensitivity of the pain system is shifted such that normally innocuous inputs can activate it & perceptual responses to noxious inputs are exaggerated, prolonged & widely spread
This could represent a central amplification due to increased excitation or reduced inhibition
Normal Sensation
10/10/2014
10
Central Sensitization Amygdala: both enhances &
inhibits pain processing
Neugebauer et al. Amygdala & Persistent Pain. Neuroscientist. 2004 10:
221-234.
Clinical syndromes central
sensitization contributes to…..
Rheumatoid arthritis
Osteoarthritis
Temporomandibular disorders
Chronic Fatigue, Fibromyalgia
Migraines, headaches, TMJ
Neuropathic pain
Complex Regional Pain syndrome
Visceral pain hypersensitivity syndromes: IBS, noncardiac chest pain, chronic pancreatitis
Interstitial cystitis, endometriosis, vulvodynia
Multiple Chemical Sensitivity (Yunus, 2000-2008)
10/10/2014
11
Sniffing
Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
Lifestyle
Some occupations are vocally demanding
& stressful, leading to voice problems.
- work-related voice demands (teacher; swim
instructor; singer; customer service, etc)
- recreational voice demands (team sports;
coaching; group-socializing)
- family/caregiver voice demands (parenting;
elder-care, large family…etc)
Lifestyle factors
Vocal Dose
10/10/2014
12
Prevalence Of Voice Problems By Occupation
GROUP NUMBER INVESTIG % F % M FACTORS
Aerobics I. 50f / 4m Long et al 44 % 50 % Shouting
Duration
Army I. 130 f Sapir et al 76 % Loudness
Rapid Sp
Army Recr. 386 f Sapir et al 31 % Excess Sp
Swim. I. 155f /95m Rammage 79 % 58 % Loud Envir.
Teachers 250 m&f GotaasStarr 80 % > m&f Loud; Stress
PE/Music
Teachers 237 f Sapir et al 73 % Loud; Illness
Teachers 564f/313m Russell et al 22 %/67% (point/career)
13%/66% (point/career)
Loud;Gender
Various
Teachers 280f/274m Smith et al 18%/93% 9%/62% Loud;Course
Occupational Representation in Voice Clinics Titze et al, 1997
OCCUPATION % CLINIC (N=1593) % US EMPL. POP.
Teacher 19.6 % * 4.2 % *
Singer 11.5 % * .02 % *
Sales Rep: 10.3 % 13 %
Telesales 2.3 % * .78 % *
Ticket/Travel .4 % .21 %
Secretary/Clerk 8.6 % 10.6 %
Factory Worker 5.6 % 14.5 %
Reception/PR 3.5 % * .12 % *
Counselor 1.6 % * .19 % *
Occupational Representation for BC (N= 1181)
Occupat. % BCPop % Clinic % BC F % Clin F % BC M % Clin M
Singer .27%* 18%* 58% 67% 42% 33%
Teacher 3.8%* 17%* 62% 78% 38% 22%
Sec. * 13.4% 12% 86% 86% 14% 14%
BusAdm 6.9% 7.5% 41% 42% 59% 58%
Sales * 14.8% 7% 41% 65% 59% 35%
Actor .09%* 3%* 43% 66% 57% 34%
Nurse 1.6% 3% 95% 100% 5% 0%
Trades * 9.4% 3% 4% 15% 96% 85%
10/10/2014
13
Teachers: 7 Years in PVCRP
Year - % of Teachers/Employed PVCRP Pop.
1999 - 17 % (68/400)
2000 - 18.54% (66/356)
2001 - 20.80% (104/500)
2002 - 16.96% (68/401)
2003 - 19.21 % ( 88/458)
2004 - 22.83 % (87/381)
2005 - 24.96% (115/460)
Dominant Factors for Dysphonic Teachers
(PVCRP 2007, N=149)
Dx # Teachers % Teachers % Female % Male
m misuse 68 46% 87% 13%
v nodules 13 9% 85% 15%
c laryngitis 12 8% 58% 42%
v paralysis 11 7% 91% 9%
v polyp 7 .5% 86% 14%
Lifestyle Factors:
Acoustic Environment
• Maximum noise level of unoccupied classroom: ANSI
S12.60: 35 dBA (normally-hearing adult)
• Optimal signal-to-noise ratio: =/> 15 dB (normally-hearing
adult, 1st language); Grade 1: SNR =/> 20dB (Bradley,
2008)
• Reverberation rates: between 0.4 and 0.6 sec
• (Typical comfortable speaking level: 65-75dB?- f/m adult)
Public school and university classrooms, daycare facilities and
restaurants in BC do not meet minimum acoustic standards
(Hodgson et al, 1999-2008). Occupational voice users talk above
comfortable loudness.
Noise in the Classroom
Outside: Aircraft, traffic, hallway noise
Inside: Heating, ventilation, A/C systems
Computers, projectors
Movement of desks/chairs; walking/talking
noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990)
noise, reverberation and RASTI values (speech transmission) in most occupied classrooms unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990)
10/10/2014
14
School Classroom Survey:
Reverberation Time (unoccupied classroom)
optimum: RT0.5s (Hodgson,1999)
0.0
0.2
0.4
0.6
0.8
1.0
1.2
U-H
ill 1
07
U-H
ill 1
10
U-H
ill P
ort
UP
LY
NN
1
UP
LY
NN
2
CV
CLF
1
DO
RLY
N1
CA
NH
TS
DO
RLY
N2
PLY
M
SM
HTS
DO
RLY
N3
DO
RLY
N4
CLV
LN
D
MA
PLW
D
Ber
50 c
lass
Ber
60 c
lass
Ber
34 t
each
Ber
39 t
each
Ber
65 t
each
Classroom
RT
u (
s)
U-Hill North Vancouver Elementary Schools Berwick Preschool
School Classroom Survey: Ventilation-noise Levels (Hodgson, 1999)
optimum: noise < 40 dBA (normal), 30 dBA (HoH)
30
35
40
45
50
55
U-H
ill 1
07
U-H
ill 1
10
U-H
ill P
ort
UP
LY
NN
1
UP
LY
NN
2
CV
CLF
1
DO
RLY
N1
CA
NH
TS
DO
RLY
N2
PLY
M
SM
HTS
DO
RLY
N3
DO
RLY
N4
CLV
LN
D
MA
PLW
D
Ber
50 c
lass
Ber
60 c
lass
Ber
34 t
each
Ber
39 t
each
Ber
65 t
each
Classroom
VN
A (
dB
)
U-Hill North Vancouver Elementary Schools Berwick Preschool
School Classroom Survey:
In-class Sound Levels (Hodgson, 1999)
optimum: noise < 40 dBA (normal), 30 dBA (HoH)
30
40
50
60
70
80
90
100
110
U-H
ill 1
07
U-H
ill 1
10
U-H
ill P
ort
UP
LY
NN
1
UP
LY
NN
2
CV
CLF
1
DO
RLY
N1
CA
NH
TS
DO
RLY
N2
PLY
M
SM
HTS
DO
RLY
N3
DO
RLY
N4
CLV
LN
D
MA
PLW
D
Ber
50 c
lass
Ber
60 c
lass
Ber
34 t
each
Ber
39 t
each
Ber
65 t
each
Ber
50 t
each
Ber
60 t
each
Classroom
Lp
(d
BA
)
U-Hill North Vancouver Elementary Schools Berwick Preschool
Noise and the Voice
Noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990)
Speech-breathing changes in noise (Winkworth & Davis, 1997)
Noise, RT & RASTI values in most occupied classrooms unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990)
Amplification can improve speech recognition and voice function (ASHA, 1990)
Amplification of 8-10 dB reduces vocal SPL: 2 + dB (Sapienza et al, 1999)
10/10/2014
15
Socially-reinforced or addictive behaviours - smoking?
- alcohol?
- caffeinated beverages/chocolate, etc
- recreational drug use?
- role models/assumption? (habitual imitative use
of inappropriate pitch or voice quality … conscious or
subconscious?)
Occupational Factors:
Ergonomics/Posture
Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
10/10/2014
16
Emotion Psychological factors
The body reacts to stress and anxiety by
increasing resting tone in voluntary muscles.
Muscles do not contract as efficiently when they are hypertonic.
Voice is used to express ideas and
emotions, and dysphonia may result when
these emotions are intense and suppressed
or with low level of emotional awareness.
Self-Reported Psych Conditions (PVCRP, 2009; N = 472)
Condition 10 MTD Non-MTD
Anxiety 35% 12%
Depression 28% 18%
Psychiatric
Disorder
12% 12%
Autonomic nervous system:
dry mucosa in the vocal tract stiffer vocal folds
“fight or flight” anxiety responses:
eg. “fight”: holding breath (vocal fold adduction);
“avoidance” racing heart, ready to retreat
awareness of physical response may increase
anxiety
attempts to “suppress” emotion (eg. compressing
larynx to reduce involuntary shaking) may back-
fire
level of emotional awareness will predict ability to
modulate physical reactions
Voluntary nervous system:
muscle tension/misuse: speech breathing, larynx,
upper vocal tract, face/jaw/tongue
attempts to control ANS responses such as nervous
tremor (Imitate the sound of someone giving a
speech when they’re very nervous.)
affective disorders/anxiety/psychiatric conditions
affecting emotional awareness/inhibition
suppressed emotional expression…What is the
innate vocalization associated with:
happiness/joy ? fear?
grief/sadness ? anger ?
10/10/2014
17
Neurobiology of Affect Regulation:
Allan Schore
Orbitofrontal system
“thinking part of the
emotional brain”, plays
major role in affect
regulation
Internal state,
organization of behavior,
adjustment of emotional
responses
LIMBIC SYSTEM
CINGULATE GYRUS
HIPPOCAMPUS
AMYGDALA
HYPOTHALAMUS
Orbitofrontal cortex not functional at birth. Over the
1st year, limbic circuitries emerge in sequence:
amygdala ant cingulate insula orbitofrontal
The Attachment System
Attachment system improves chances of infant’s
survival
seeking proximity: protection from harm, attack,
separation from group
Attachment relationships crucial in organizing
neuronal growth of developing brain
emotional relationships have direct affect on
development on memory, narrative, emotion
regulation
10/10/2014
18
Genetic factors vulnerability for a disorder,
environmental factors, such as attachment, play
crucial role in ultimate expression of symptoms
In postnatal period there is genetically driven
overproduction of synapses
Pruning & maintenance of synaptic connections
in frontal, limbic, & temporal cortices influenced
by psychological factors
Early abuse experiences of neglect/trauma
excessive pruning = poor limbic connections …
Human connections create neuronal connections:
Major environmental factor in brain development
Affect regulation pathway:
orbitofrontal limbic system
Orbitofrontal
Cortex
Attachment experience
development of orbitofrontal
function affect/behavior
regulation
Orbitofrontal metabolic
dysfunction in autism,
schizophrenia, bipolar,
depression, PTSD, drug
addiction, cluster B
personality disorders
Attachment pattern
Child Caregiver
Secure Uses caregiver as a secure base for exploration. Protests caregiver's departure and seeks proximity and is comforted on return, returning to exploration. May be comforted by the stranger but shows clear preference for the caregiver.
Responds appropriately, promptly and consistently to needs. Caregiver has successfully formed a secure parental attachment bond to the child.
Anxious Clingy, unable to cope with absences of the caregiver. Seeks constant reassurances.
Excessively protective of the child, and unable to allow risk-taking, and steps towards independence.
Avoidant Little affective sharing in play. Little or no distress on departure, little or no visible response to return, ignoring or turning away with no effort to maintain contact if picked up. Treats the stranger similarly to the caregiver. The child feels that there is no attachment; the child is "rebellious" and has a lower self-image and self-esteem.
Little or no response to distressed child. Discourages crying and encourages independence.
Child and caregiver behaviour patterns before the age of 18 months
[Ainsworth et al, 1978; Main & Solomon, 1986]
Ambivalent/
Resistant
Unable to use caregiver as a secure
base, seeking proximity before
separation occurs. Distressed on
separation with ambivalence, anger,
reluctance to warm to caregiver and
return to play on return. Preoccupied
with caregiver's availability, seeking
contact but resisting angrily when it
is achieved. Not easily calmed by
stranger. In this relationship, the
child always feels anxious because
the caregiver's availability is never
consistent.
Inconsistent between appropriate
and neglectful responses.
Generally will only respond after
increased attachment
behavior from the infant.
Disorganized Stereotypies on return such as
freezing or rocking. Lack of coherent
attachment strategy shown by
contradictory, disoriented behaviours
such as approaching but with the
back turned.
Frightened or frightening
behaviour, intrusiveness,
withdrawal, negativity, role
confusion, affective
communication errors and
maltreatment. Very often
associated with many forms of
abuse towards the child.
Attachment
pattern Child Caregiver
10/10/2014
19
Avoidant attachment history biased toward
parasympathetic state: low arousal, reduced
emotionality; under stress vulnerable to
overregulation & internalization
psychopathologies
Ambivalent attachment sympathetic state:
high arousal, high emotionality; under stress
vulnerable to externalizing psychopathologies
Attachment and Psychopathologies (Main et al, 1987)
Common forms of psychopathologies Numerical values are path coefficients, representing the strength of
associations between constructs (Krueger & Markon, 2006)
Levels of Emotional Awareness (Lane & Schwartz, 1987; Lane, 2008)
• Cognitive developmental process
• Similar to Piagetian theory
• 5 basic levels follow developmental pattern:
infants to “fully aware” humans
• neurobiological correlates
• top-down modulation allows “aware” person to
regulate amygdala and change physiological R’s
(eg. relaxed breathing to stop fight-flight R’s) Parallels in the hierarchical organization of emotional experience,
and neural substrates. Levels filled in white are implicit levels;
those in grey are explicit levels. Lane & Schwartz, 1987
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LEVEL 5: PREFRONTAL
CORTEX ; ant cingulate,
medial prefrontal cortex
Reflective awareness:
complex analysis of
experiences of self and others
LEVEL 4: Blends of emotions: “I feel
disappointed with myself”
LEVEL 3: ant cingulate, insula,
temporal lobe, orbitofrontal
cortex
Single emotions: “I feel
sad/happy/angry”
LEVEL 2: amygdala, thalamus,
basal ganglia
Sensorimotor enactive; crude
distinctions between globally
+ or – states; gestures &
mvts: “I want to hit you!”
LEVEL 1: thalamus,
hypothalamus, brainstem
Automatic generation of
emotional responses: “My
stomach/throat/jaw hurts”
Neuroanatomical Model: Implicit VS
Explicit Emotional Processes (Lane, 2000)
Amygdala and Thalamo-Amygdala process
implicated in rapid, low-level implicit (sub-
conscious) processing of stimuli. Precedes
emergence of emotional “feeling” state.
Phylogenetically-older structures, protect
organism in life-threatening situations.
In contrast, Neocortical-Amygdala pathway
involved in slower, more differentiated
explicit (conscious) processing of stimuli.
Implicit and Explicit Processes (Post Piagetian Representational Redescription)
Implicit (automatic action/sensori-motor)
patterns of knowledge (Levels 1 & 2) are
transformed to Explicit (conscious: Levels 3-5)
representations through language.
(Karniloff-Smith, 1992)
Use of language to describe emotions modifies
one’s emotional awareness and experience at
conscious levels. (Werner & Kaplan, 1963)
Corresponds with “Top-Down” modulation of
emotional responses.
Implicit Processes
May induce postures in respiratory and laryngeal mechanisms to facilitate rapid/strong physical reactions, as in fight or flight: fixing thorax with vf adducted to enhance upper body strength / abducting vf to facilitate free respiration for running.
Absence of higher level emotional processing and lx/respiratory system postures not conducive to normal phonation may make individual more susceptible to muscle tension voice/laryngeal disorders.
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Baker & Lane, 2009
Implicit emotional responses reflect
“unformulated experience”: emotions not fully
formed/differentiated, so expressed 10
physically. Once discussed & processed, can
be experienced fully.
VS: Freudian concepts: unconscious fully
formulated emotions being repressed
Theory informs treatment approach
Explicit Emotional
Experience
Anatomical
Correlates:
1- ventro-medial
prefrontal cortex;
right parietal
cortex; insula,
temporal pole
2 - dorsal ACG
3 - paracingulate
region of medial
prefrontal cortex
Explicit Emotional Processes support cognitive neuroscience approach to emotion.
Engage paralimbic and neocortical
structures that are not specific to emotional processes.
Domain-general nature of these structures infers they compete with other (potentially interfering) input for conscious processing.
May explain differences in individual attention to and use of emotional info.
Explicit processing may make individuals less vulnerable to physiological states associated with muscle tension dysphonias.
Top Down Modulation
Bodily sensations
Action tendencies
Discrete Emotion
Blends of Emotion
Self reflection
Brainstem
Diencephalon
Limbic
Paralimbic
Prefrontal Cortex
PSYCHOLOGICAL NEUROANATOMICAL
Greater activity in
dorso-medial
prefrontal cortex
associated with
higher vagal tone (thus, reduced HR,
calming)
Verbal emotion
labelling inhibits
amygdala activity. (Amygdala preferentially
activated by aversive
stimuli.)
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The LEAS - Levels of Emotional
Awareness Scale (Lane et al, 1990)
Written performance measure
Patients describe anticipated reactions for
self and other person to short vignettes
Scored per specific structural criteria to
determine degree of specificity of emotion
words and range of emotions
Scoring unbiased by patient or rater due to
structure focus of criteria
Glossary for each level guides scoring
Examples of LEAS 0-5 scoring – “Self” and “Other” R’s given separate scores
Non-affective (non-emotional) words = 0
Physiological words to describe feelings = 1
Undifferentiated emotion (eg. I’d feel bad) or
action tendency = 2
Single word used conveying differentiated
emotion (eg. I’d feel happy/sad/angry) = 3
Two or more level 3 words used to enhanced
differentiation = 4
“Self” and “Other” scores = 4 and
differentiated = 5
LEAS Reliability & Validity
High inter-rater reliability; high internal
consistency (Lane et al, 1998)
Construct validity supports LEAS as measure
of cognitive-developmental continuum:
moderately positive correlations with other
cognitive-developmental measures: Sentence
Completion Test of Ego Dvlpt and Cognitive
Complexity of the Description of Parents (Lane, 2008)
Emotion Processing Deficits and
Psychosomatic Voice Dysfunction
Causal Model of Emotion Processing Deficits in
Women with “FVD”: more severe events/
difficulties, COSO events/difficulties, highly
anxious coping style, less emotionally
expressive families, more ambivalence re
expressing neg. emotions.
FVD result of strong negative emotional
reactions to events + emotional processing
interference.
(Baker et al, 2007; Baker, 2008)
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Childhood Abuse in Patients with
Conversion Disorder (Roelofs et al, 2002)
Compared patients with conversion to
patients with affective disorder with respect
to childhood abuse
Patients with conversion reported higher
incidence of physical/sexual abuse
Larger number of different types of abuse,
longer lasting incidents of sexual abuse,
more incestuous experiences
What to screen for in initial
assessment: Attachment experience:
History of trauma or abuse
Quality of relationships (family, partner, school, friends)
Evidence of low level of emotional awareness
Personality factors
Avoidant tendencies, somatization, externalization …
Significant acute stressor in an otherwise well functioning individual
Depression, anxiety
Observe: Postural/Gestural/Facial Postures
Voice / posture changes with topics
Lexicon used to describe significant
events/distress
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Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
Reflux
71% MTD Patients =/> 4/7 Reflux Sx, Vs
VC Population: 47% (2009, N=472)
Higher palpation scores for Thyro-hyoid *
and Pharyngeal Constrictors
Higher % with A-P compression *
Reflux increases Lx tension and exacerbates
co-existent dysphonia (Gill & Morrison, 1997)
Reflux control facilitates therapy and recovery
Reflux Factors
Reflux - LPR
Common Symptoms:
throat sensations, am dysphonia
waking at night coughing or choking
habitual throat clearing; chronic cough
globus pharyngeus
heartburn
“post-nasal drip”
adductory laryngospasm
asthma or other chronic breathing difficulties
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Common Signs:
erythema / edema: posterior glottis
sub-glottis
arytenoids
contact ulcer / granuloma
“pseudo-sulcus”
Contact Granuloma
“… but Doctor, I don’t have
heartburn!” 2011 (www.pvcrp.com)
Patient tutorial on LPR
Diagrams, script and vocal narration
Patient compliance self-ratings (Likert scale)
(Targeted) Lifestyle changes compliance (LC)
Medication compliance (MC)
Tutorial group (N= 20) LC: 19/20 high compliance
MC: 16/20 high compliance
No tutorial group (N=20) LC: 9/20 high compliance
MC: 14/20 high compliance
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Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
Technique
Bad habits become programmed by repetition
(Neural Plasticity / Motor Learning)
Postural misuses:
• neck, back, head/shoulders?
• Speech breathing patterns ?
• Lower face, jaw and tongue?
• Infra-hyoid muscles?
• Specific Misuse Patterns – Larynx/Glottis
Technique
Posture affects breathing
Look at :
Back Alignment (Lordosis; Scoliosis)
Shoulders/Scapulae
Head-Neck Relationship
Stance
Knees
Use of Furniture; Props
Mal-Adaptive Speech Breathing
Behaviours affect Glottal Closure
abs clenched: thoracic elevation
large lung volume: laryngeal pull,
results in greater glottal chink plus
compensatory hypervalving (Sundberg et al,
1991; Sundberg, 1999)
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Normal inspiration and
expiration for
speech/singing, compared
with two common
misuses: failure to use
inspiratory “checking”
forces during phonation
(top right); and
exaggerated abdominal
tension to “support” the
production of voice
(bottom right). Both these
misuses can lead to
hyper-valving in the larynx
to regulate airflow.
Aligned posture and
common patterns of
misalignment
Scapula
adduction
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Head-neck relationships. Neutral is “healthy” posture. Chronic
neck extension or flexion impact the laryngeal suspension
system and can affect voice and swallowing.
Neck Tension / Headaches and MTD (Self-Reported, PVCRP, 2009; N = 472)
Tension Site 10 MTD Non- MTD
Neck /
Shoulders
46% 28%
Chr. Headache 27% 13%
Both 15% 10%
Totals 88% 51%
Palpation Sites: Anterior Floor of
mouth: Supra-hyoids:
- at rest
- pitch glides
- speech, probes
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“Scalloped” tongue periphery from pressing the tongue against the teeth.
Common in individuals who misuse muscles of the jaw and tongue:
tension in supra-hyoid muscles and jaw clenching are typically
associated with this visual perceptual sign.
Thyrohyoids: - at rest, yawn
- pitch glides
- speech, probes
Cricothyroids:
- at rest, yawn
- pitch glides
Pharyngeal Constrictors - at rest
- phonation
Jaw-Tongue Functions
Critical anatomical links to larynx
Facial co-contraction patterns common
(eg. Eyebrow adduction + jaw clench)
FACS studies: upper face emotionally
more salient, therefore Tx targets both
54% of MMD patients “TMJ” dysfunction
vs. 22% non-MMD patients (excluding
ILS) (PVCRP, 2009; N = 472)
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TMJ: - opening; closing
- speech; singing
Sub-occipitals: - at rest
- pivot; swivel Muscle Misuse Type 1: (Case 61)
The Laryngeal Isometric
• Generalized tension in all laryngeal muscles
• Often associated with an exaggerated posterior glottal chink
• Often associated with 20 mucosal lesions: bilateral nodules, chronic laryngitis, polypoid degeneration
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Muscle Misuse Type 2a (Case 63)
• Lateral compression at the glottal level • Frequently seen with generalized postural misuses and tension • May be triggered by an infection or by gastro-esophageal reflux
Muscle Misuse Type 2b (Case 64*)
• Supra-glottal lateral compression • Hyper-adduction of the false vocal folds • Often psychologically based
Clinical Example (*Case 64)
47 year old female experiencing globus and dyshonia after episode of sinusitis + cough. Normal exam except lateral supra-glottal compression. “Held” larynx. Static facies: eyes, lips, hypertonic masseters
Co-owner/manager of fast-food franchise with husband. Minimal marital relationship beyond work/children. During aphonia, husband had to assume more responsibility. Accused her of “faking”.
Voice Sx started in work environment, when confronting a defiant young employee about wearing perfume that she thought triggered Sx. Sx gradually generalized to many situations, including home.
Scored 5/7 on reflux Sx score (LPR; no heartburn)
Background
Alcoholic chain-smoking father, abandoned family when Pt. was 13 yoa.
Pt., eldest of several sibs, had to assume child-care responsibilities. Mother took 2 jobs, and rarely home.
A younger sister had defied Pt.’s authority and frequently caused trouble in community. Sisters fought physically over these incidents. Pt. periodically recalled those incidents when dealing with defiant employee.
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Emotional Awareness
Pt. aware of co-occurrence of exposure to noxious odors and throat Sx. (Level 1)
Also aware of desire to hit employee when she wore perfume and husband when he accused her of “faking voice loss”. (Level 2)
Preoccupation with globus led her to worry she had lx CA, to which an uncle had recently succumbed. (GP had suggested LPR, but Pt. rejected Dx). (Level 4?)
Psychological factors….
Patient abandoned by father & in a sense, also by mother (insecure attachment history = compromised emotion regulation pathway); likely had to forgo her own needs & prioritize taking care of others (siblings), little space for her to express her emotions (anger, resentment)
Development of avoidant/introversion traits that predispose to development of psychosomatic voice dysfunction
Sensory-Emotional Trigger
Interaction with defiant employee acted as a
trigger: feelings of helplessness, anger that
she felt both in the past, dealing with her sister
& in the present, dealing with the
employee/husband; in both past & present her
experience may be that her needs are not
being acknowledged/addressed
Reflux/Globus sensation increased when
emotionally aroused, due to tension in
abs/ANS… enhancing anxiety about CA
A
L E
R T
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Management Approach
Psychotherapy:
Develop therapeutic alliance: trusting, secure
attachment with therapist
Give her tools to tolerate emotional distress:
breathing exercises, relaxation strategies,
mindfulness exercises
Target expression of emotion, validate her
experiences/needs
Voice Therapy
Explanation of relationship of LPR to lx hypertonicity/globus. (“But Doctor, ” www.pvcrp.com)
Top-down facial exercises to increase awareness of & reduce static facial postures. (Rammage, 1996; 2011)
Explanation & demo of inappropriate VS appropriate larynx / vf posture for phonation.
ID and application of most accessible & salient facilitation technique to restore normal phonation (glottal fry, gradually increasing intensity, while monitoring tactile feedback with fingers over lx)
Negative practice to increase voluntary control: desensitize to triggers; create “dysphonia”; apply facilitation technique to restore normal phonation.
Top Down Facial Gestures (Ekman, 1982)
Emotional experience in can be influenced by
feedback from facial muscles.
Emotional ambiguity reinforced by
incongruent facial postures for observer and
expresser.
Lower face more subject to facial “emblems”,
such as “perma-smile”.
Releasing lower facial postures dependent on
awareness/release of upper facial postures.
Top
Down
Facial
Muscle
Release
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Muscle Misuse Type 3 (Case 65)
• Antero-posterior supra-glottal compression
• Associated with high palpation scores in thyro-hyoid muscles
• Common technical misuse seen in mild, moderate and severe
forms
Muscle Misuse Type 4 (Case 67)
• Incomplete vocal fold closure • PCA, CT muscles contracted
• Distinguish from anatomical incompetence by symmetry and trial Tx
• Associated with conversion aphonia
Muscle Misuse Type 5 (Case 68)
• Vocal fold bowing caused by muscle misuse
• Distinguish from bowed vocal folds of aging/atrophy; sulcus/scarring; IPD…
Muscle Misuse Type 6 (Case 69)
•Laryngeal posture for falsetto register phonation •Typically seen in adolescent transitional voice disorder
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Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
Hypothetical
ALERT model for
young woman with
significant L, E & T
factors, and 20
vocal fold nodules
Diagnostic Voice Therapy
Facilitation Techniques for Dx / Symptomatic
Therapy …
Technique Indications Contraindications
Adduction (forced): pushing; pulling;
cough
Incomplete vocal fold closure in
conversion aphonia
Do not use if mucosal edema or
erythema is present. Articulation exaggeration; increased
orality
Hypernasality; restricted
jaw/tongue/lip movements
Do not allow exaggerated jaw
movements in individuals with TMJ
dysfunction.
Auditory masking during phonation Incomplete vocal fold closure in
conversion dysphonia; low intensity
Do not use if mucosal edema or
erythema is present.
Breathy-flow phonation (Increase
MFR)
Lateral compression of vocal folds
and/or false folds; glottal attacks
Chanting (Decrease intonation and
stress)
Muscle misuses resulting in pitch
and/or phonation breaks
Be aware of increase in muscle
misuse during chant.
Chewing with phonation Tension in supralaryngeal muscles Do not use if TMJ dysfunction
Character voices: Impersonate an
opera singer, puppet voices
Inappropriate pitch, resonance,
monotonicity, monointensity
Be aware of increase in muscle
misuse to imitate voices.
Coordinated voice onset (CVO):
“Hm!”
Most muscle misuse patterns; poor
speech breathing; glottal attacks
Distraction: eg, hum while walking,
turning pages, turning/shaking head
gently
General muscle and postural
misuse; psychological feed-forward
mechanisms restricting voice range
Inhalation phonation Supraglottal compression; poor
vocal fold closure; dysfluency (SD)
Do not use if paradoxical vocal fold
movements are present.
Intonation increase Monotonicity; inappropriate pitch
Jaw movements (ie. small, relaxed
pivotal movements) during syllable
repetition
Muscle misuse in lower face;
restricted jaw movements;
distraction
Do not allow exaggerated jaw
movements in individuals with TMJ
dysfunction.
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Technique Indications Contraindications
Loudness change Inappropriate loudness level; glottic
compression: ↓ level asthenia: ↑
level
Do not use exaggerated loudness
in presence of mucosal
edema/erythema
Lung volume change: reduce
volume: CVO increase volume:
sigh
Laryngeal isometric; inappropriate
speech breathing; breath-holding
Do not use sigh and exaggerated
lung volume for laryngeal isometric.
Manipulation (e.g.,): increase
thyrohyoid space; depress larynx
hold tongue forward; hold jaw open
Tense T-H; A-P compression
Tense suprahyoids/high larynx
Tense tongue/backed carriage
Lower facial tension/poor orality
Beware of TMJ
dysfunction.Clinician should have
appropriate training in laryngeal
manipulation techniques. Movements in upper body: head-
nods; shoulder rolls
General muscle/postural misuse;
distraction
Use only with advice of physical
therapist/medical practitioner in
cases of neck, back, shoulder
problems.
Pitch change Inappropriate pitch/register use;
Incomplete adduction in conversion
disorder; bowed vocal folds
Be aware of increase in muscle
misuse to achieve pitch change.
Posture adjustments (e.g.,):
head position: forward; back;
supine position; lean forward,
neck flexed
Distraction
Jaw jut; upper back/neck tension
Tense laryngeal suspensory
muscles
General postural misuse;
inappropriate speech breathing
Use head/neck posture changes
only with advice of physical
therapist/medical practitioner in
cases of neck, back, shoulder
problems.
Register change (e.g.,): falsetto,
glottal fry
Incomplete glottal closure; tense
cricothyoid muscles
Be aware of increase in muscle
misuse to achieve register change
Resonance focus adjustment:
forward: humming-buzzing;
backed: “covering”
Harsh/rough/breathy quality; poor
glottal closure; poor projection
Fronted tongue posture; thin sound
Technique Indications Contraindications
Semi-occluded upper vocal tract
tactics (straws; v/z productions;
lip raspberries)
Hyper/hypoadduction of v.f.; general
muscle misuse impacting phonation;
stiff/scarred vocal folds
Sometimes triggers
cough/larygospasm in ILS
Siren imitation/howling/etc Pitch range restrictions/
register breaks due to muscle misuse
Speech rate change Rapid or excessively slow speech;
inappropriate speech breathing;
laryngeal/supralaryngeal tension
Spontaneous phonation (e.g.,):
extend cough, laugh, CVO
Incomplete glottal closure in
conversion disorder; falsetto in
adolescent transitional disorder
Do not use aggressive cough if
mucosal edema is present
Taunting-Teasing
(ngya ngya ng-ngya-ya)
Incomplete glottal closure; laryngeal
isometric; poor resonance
Tongue position change Cul-de-sac resonance (front tongue)
Immature resonance (back tongue)
Trills: voiced lip or tongue trills Restricted pitch range; register
breaks
Voice mode change: singing to
speaking; speaking to singing
Laryngeal dysfluencies; inappropriate
resonance focus
Yawn-sigh phonation Restricted speech breathing
movements; supralaryngeal
compression
Beware of TMJ dysfunction.
Do not use for laryngeal isometric
muscle misuse.
From: Rammage et al, 2009
Anatomical
Factors:Aging, Lesion
Disease
Lifestyle:Acoustics
Environment
Ergonomics
General health
Occupational demands
Vocal dose
Emotion:Anxiety
Depression
Symbolic conversions
Vocal expression
Vocal repression
Level of emotional
awareness
Reflux:Diet
Eating habits
Genetics
Medications
Posture
Weight
Technique:Alignment/Posture
Muscle misuses:
Neck/Shoulders
Face/Jaw/Tongue
Pitch focus
Resonance focus
Speech breathing
Determining Treatment Purpose/Priorities
Relative “size”/primacy of A factor(s):
Cognitive/Emotional Factors:
Feedback Channels:
Duration of Sx:
Commitment to Tx: Client:
Clinician:
External Factors, eg. environmental/workplace:
Cultural-Social-Economic Factors:
Results of Dx Therapy:
Factors Influencing Selection and
Success of Therapy Programs
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Indirect and Direct Therapy
Indirect: Which ALERT Factors?
Lifestyle: Education
“Vocal Hygiene”/Hydration (Roy et al, 2001;
Verdolini-Marston et al,1990/94; Nanjundeswaran et al, 2012)
Voice use monitoring:
Informal or Instrumental: eg. dosimetry
Voice rest/conservation
Altering acoustic environment (SNAG, 2009)
Vocal amplification (Roy et al, 2002;2003)
“SNAG” Goals: Optimizing Classroom
Acoustical Environments (www.pvcrp.com)
Higher speech levels - good classroom design
- amplification system?
- preventive voice training?
Lower noise levels - quiet ventilation, equip’t - NO OPEN PLAN!! - class organization/control - sound-proof partitions - cushioned surfaces - quiet light ballasts
Appropriate reverberation - good classroom design - appropriate sound-absorbing materials
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Voice Amplification (Roy et al, 2002;2003)
Check room acoustics first: reverberation time?
If not .4-.6 sec., consider classroom modifications
SNR: min 15 dB (SNAG, 2009)
Appropriate gain potential
Uni-directional mic:
Monitor to reduce Lombard
Portable, if necessary
Post-Operative Voice Use Instructions for
Phonosurgery Patients
VOICE REST (first 48 hours after surgery):
Do not use your voice unless absolutely necessary
Speak 5 minutes maximum per hour
Only speak softly, in a quiet environment
Only speak in the middle of your vocal range
No throat-clearing or coughing
DO NOT WHISPER: Write your message instead
Cancel all social engagements
Stay at home and get plenty of rest and hydration*
* You can determine your hydration by observing your urine: it should be
pale in colour. If not, drink more non caffeinated, non-alcoholic beverages
RESTRICTED VOICE USE (+ 1 week after voice rest
period):
Use your voice normally in the middle of your vocal range in
quiet settings
Do not speak outside, in groups, in a vehicle, aeroplane or other
noisy environments, such as restaurants
When speaking you should be close enough to your listener to
touch his/her shoulder
Do not use vocal throat-clear or cough
DO NOT WHISPER
Be sure you are adequately hydrated by drinking at least 8
glasses of non-caffeinated, non-alcoholic beverages daily
PRUDENT VOICE USE (+ 2 weeks after
restricted voice use period):
Observe vocal hygiene rules: No yelling, cheering, screaming,
throat-clearing, coughing, loud or prolonged laughing/crying, whispering
Use the middle of your vocal range, avoiding extremes in pitch and
loudness
Speak within arm’s length of your listener
If you are speaking in a group larger then 20, outside or in a noisy
environment, use a vocal amplification system
Maintain adequate hydration
Schedule vocal rests throughout the day
ONGOING VOCAL HYGIENE (indefinite):
Refer to your Vocal Hygiene guidelines to ensure you maintain
healthy vocal habits.
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Sample
vocal
hygiene
protocol.
See full
protocol in
text.
Available at:
www.pvcrp.
com
Indirect Tx
Emotional Factors: SLP Role?
If E is dominant/10, refer to MHP
When psychological interference
evident during therapy, refer to MHP
Reflux Factors: SLP Role?
Behaviour specialist: guide lifestyle
Educate re effect on lx function:
“But Doctor”… www.pvcrp.com
Direct Therapy
Comprehensive (eg. Vocalizing with Ease)
hierarchical motor re-learning program: body
alignment; head, neck and shoulder muscles; specific
relaxation for tongue, jaw and facial muscles; speech
breathing and voice onset; resonance enhancement;
vocal flexibility; vocal dynamics; phrasing
Focused (Symptomatic) short-term / specific
symptoms of voice dysfunction. Based on Dx therapy
outcomes. May include manual therapy techniques
Holistic Eg. yoga; Feldenkrais; Pilates; Alexander
technique; massage therapy; acupuncture; relaxation;
fitness programs
Principles:Technique Change
Motor learning theory:
Basic re-programming
Simple tasks
Frequent repetition
Instant feedback, 10 kinaesthetic
Ownership: We provide the remedy, you
(the client) provide the cure!
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Motor-Learning & Neural Plasticity
Fundamental Tasks Generalizing Effects
(“Up-regulation of chemicals”?: Rosenbek, 2010)
Neural Plasticity Use & Experience Specific! (eg.,Kleim & Jones, 2008; Ludlow et al: JSLHR 51, 2008)
Training Cells: Repetition/Intensity/Variability
Feedback: salient
Skills are slow to develop in CNS, but become
permanently encoded… (Adkins et al, J.Applied Physiol,101, 1776-1782, 2007)
Physiological
(eg,reduce glottal chink)
Acoustic
(eg,elevate pitch)
Symptomatic:
Change Specific
Symptom/s:
A - Z
Alignment...Buzzzing
General and Specific
Motor Relearning
Comprehensive:
Treat the Whole
System:
General Approach
Accent Method
Progressive Relaxation
Yoga, etc.
Holistic:
Treat the Whole
Person:
Technique Changes:
Voice Therapy
Summary of Direct Therapy Techniques
in Common Use to Manage Voice
Dysfunction …
Technique Theoretical
Bases
Procedures; Training Application/Evidence Limitations/
Contraindications
Accent
Method
(Video)
(Smith and
Thyme,
1976)
Easy, resonant
voice facilitated
by:
Abdominal
support
Rhythmic speech
breathing
gestures
Open airway
Aerodynamic
principles of
phonation
Graduated body
orientation: Graduated
levels of voicing during
rhythmic breathing.
Graduated complexity of
rhythms and phonemic
pattern. Fricatives for
aerodynamic effect in
vocal tract.
Training: audio-video
samples or experienced
clinician.
Adductor SD (Kotby et al,
1991)
Functional voice disorders
(Fex et al, 1994)
Variety of voice disorders
(Kotby et al, 1991; Bassiouny,
1998)
Vocal fold paralysis (Khidr,
2003)
Speech dysfluency (Kotby
and Fex, 1998)
Program extends
over 30 or more
sessions, so
consumes extensive
clinician and client
time/resources.
Chant Talk
(Boone,
1971)
Relaxed
phonation
facilitated by:
Vowel
prolongation
Reduced
prosodic stress
Monotone voice
Easy voice onset
Elevated pitch
Clinician models during
oral reading: elevated
pitch, prolonged vowels,
minimal syllable
stress/intonation, smooth
syllable transitions.
Once the skill is
acquired, chanting is
alternated with regular
speech for carry-over.
Benign essential tremor. Dworkin and Meleca (1999)
Vocal hyper-function
(Boone et al, 2010)
Vocal fatigue in teachers
(McCabe and Titze, 2002)
Spasmodic voice
disorders.
Elevated f0 may
result in increased
laryngeal
effort/tension in some
individuals.
Monotone pitch may
exacerbate muscle
misuse.
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Chewing
(Froeschels,
1952)
Use of
vegetative jaw
and tongue
movements
frees laryngeal
suspension
system to
allow for more
relaxed voice
production.
Exaggerated chewing
motions modeled and
trained. Voice is added
to chewing movements
on nonsense syllables;
serial speech tasks.
Range of movements
reduced over time:
client imagines chewing
activity.
Individuals with
restricted jaw and lip
movements during
speech (Boone, 1971;
Boone et al , 2010)
May be contraindicated for
clients who have
dysfunction at the
temporo-mandibular joint.
Some individuals may be
reluctant to perform the
exaggerated movements
Confidential
Voice
(Colton et
al, 2006)
Vocal effort
and tension
reduced by
soft, breathy
voice
Easy concept
for adults and
children to
understand
and learn
(Boone et al,
2010)
Patient instructed to use
the softest voice
possible without
whispering.
Clinician models
relaxed, low intensity,
breathy sound with
natural pitch and
prosody.
Vocal fold injuries, post
phonosurgery; vocal
hyperfunction (Colton et
al, 2006)
Vocal fold nodules (Verdolini-Marston et al,
1995)
Should be used as a
temporary voice
conservation approach.
Extended use of breathy
voice may exacerbate
certain muscle misuses,
such as laryngeal
isometric postures with
exaggerated posterior
glottal gap, and
maladaptive speech-
breathing.
LSVT
LoudTM
(Ramig et al,
1994)
Principles from
muscle training,
motor learning,
neuro-plasticity
& neuropsych
Effort to
increase
loudness
improves vocal
fold adduction
and has
globally positive
effect on
speech
Intensive individual therapy
1 hr, 4 X/wk, 4-wk + home
practice.
Sustained phonation,
vowels; pitch changes to
increase laryngeal flexibility
and stability.
“Functional phrases”
Clinician coaching
facilitates calibration (client
adjustment to increased
effort, loudness).
Clinician training: on-site or
on-line certification
program.
Parkinson’s hypo-
phonia (Ramig et al,
1994; 1995; 1996; 2001;
Smith et al, 1995)
Spastic dysarthria in
MS (Sapir et al, 2001)
Dysphagia (El
Sharkawi et al, 2002)
Communicative
gestures (Duncan,
2002)
Facial expression
(Spielman et al, 2003)
Senile atrophy (LSVT
Training Manual, 2010)
Intensive treatment may be
difficult for clients with
significant health
compromises.
Clinician certification
requirement, cost and
inaccessibility of therapy
may be prohibitive for some
clients.
Resonance-
Humming
(Lessac,
1973;
Linklater,
1976)
Resonant
Voice
Therapy
(RVT)
(Verdolini,
1998)
Humming =
phonation with
semi-occluded
vocal tract,
associated with
an optimal
vocal fold
posture and
vocal efficiency
(Titze, 2001;
2006)
RVT: Systematic ten-step
program incorporates
posture, relaxation,
exploration of resonance
sensations on nasal
phonemes, pitch variations,
extending resonance
sensation to words,
phrases, sentences.
Clinician training:
Structured training program
is offered.
Occupational voice
users (Roy et al, 2003;
Chen et al, 2007;
Nanjundeswaran et al,
2012)
Unilateral vocal fold
paralysis. (Schindler et
al, 2008)
Vocal fold edema
(Verdolini et al, 2012)
Vocal fold scar
(Hapner and Klein, 2009)
Resonant voice training may
be enhanced by relaxation
techniques, manual therapy
/ postural changes, esp. with
severe muscle misuse.
Ensure each client
experiences enhanced
resonance in the absence of
maladaptive muscle misuse
behaviours such as labial or
supra-hyoid tension.
Semi-
Occluded
Vocal
Tract
(Sovijärvi,
1965
Titze,
2001;
2006)
Increased P0 /
length in upper
vocal tract:
phonation near
lowered F1:
abducted vocal
folds reduces
vocal fold
collision. Glottal
width of a few
millimetres is
associated
greater vocal
efficiency.
(Titze, 2001;
2006)
Client phonates while
blowing into straws.
Resistance reduced by
increasing straw diameter.
Client phonates during
bilabial fricatives, lip or
tongue trills, nasal
phonemes, high vowels.
Client produces pitch glides
simultaneous with semi-
occluded vocal tract
techniques.
Client uses pitch changes
during singing and speech
activities, with reduced
laryngeal effort.
Hyperfunctional voice
problems (Sovijärvi,
1969; Simberg, 2001;
Titze, 2006; Simberg and
Laine, 2007)
Vocal nodules (Sovijärvi,
1969; Simberg, 2001)
Chronic laryngitis
(Sovijärvi, 1969; Simberg,
2001)
Student teachers with
mild voice problems
(Simberg et al, 2006)
Vocal fold stiffness
post injury
Variability (Gaskill &
Quinney, 2012)
Habitual muscle misuse in
lower face /lips/jaw may be
exacerbated by exercises
encouraging increased
resistance at the oral outlet:
may be necessary to reduce
muscle tension in jaw,
tongue face, lips.
Individuals with vocal
hyperfunction due to motor
speech disorders may not
be able to achieve the
required articulator
resistance and/or
respiratory drive for some
activities.
Vocal
Function
Exercises
(VFE)
(Briess,
1959)
Stemple et
al, 1994)
Application of
principles of
exercise
physiology
improve
strength,
balance and
flexibility in the
vocal system.
4 components: warm-up;
stretching; contraction;
adductory power exercises.
Sustain phonation quietly on
prescribed pitches; pitch
glides.
Clinician models to train
frontal resonance focus.
Practice regime: 2 reps per
exercise, 2x daily.
Vocal fold stiffness
post injury or phono-
surgery, with
associated vocal
hyper-function
(Stemple et al, 1994)
Singers (Sabol et al,
1995)
Teachers with voice
disorders (Roy et al,
2001)
Care should be taken to
minimize common muscle
misuses during maximum
performance tasks, such
as jaw extension, supra-
hyoid tension and larynx
elevation during upward
pitch glides.
Yawn-Sigh
(Boone,
1971)
Larynx is
lower, pharynx
is wider during
yawning.
(Boone and
McFarlane,
1993)
Relaxation
recoil forces
are employed
primarily for
exhalation
during the
voiced sigh.
Clinician explains
difference in the larynx
position and reduced
effort of yawn-sigh and
models.
Initially phonation on
sigh is somewhat
breathy.
/h/ used extensively to
encourage slightly
abducted vocal fold
position.
Sensations of more
open pharynx and
smooth voice onset are
maintained as the yawn
is phased out.
Inappropriately high
larynx posture and
hyperfunctional
laryngeal activity (Boone
and McFarlane, 1993)
Voice-disordered clients
able to master the
technique and carry
over to regular speech
(Xu et al, 1991)
Essential voice tremor
(Barkmeier-Kraemer et al,
2011)
Sighing may reinforce use
of inappropriately high
lung volumes for speech,
associated with vocal fold
abduction (Sundberg et al,
1991). Carry over to
speech may be difficult for
individuals who are unable
to restore normal lung
volumes and re-balance
relaxation and muscular
forces for speech
breathing.
Yawning may be
contraindicated in
individuals with TMJ
dysfunction.
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Role of Manual Therapy
Primary approach to release specific muscle
tension Eg. CT muscle: Harris, 1993;
Postural/laryngeal suspension/intrinsic
laryngeal muscle mechanisms: Lieberman
(1998)
Adjuvant therapy to medical-surgical /
traditional voice Rx: Harris et al, 1998;
Marszalek et al, 2012
Requires intimate knowledge of anatomy and
competency for manual therapy skills
Does Preventive Voice Care Work?
Duffy & Hazlett (N.Ireland, 2004):
Indirect education: physiology, vocal hygiene, etc.
Direct: comprehensive training: posture, speech-
breathing, reduced tension, resonance, voice
projection
Longitudinal data:
Control group: no change
Indirect group: no change
Direct group: improved
Does Preventive Voice Care Work?
Teachers’ Perceptions
Yiu et al, Hong Kong, 2002
Surveyed teachers’ perceptions of impact and preventive measures
Significant impact on personal/professional lives
From large menu of treatments, teachers believed more info on breathing exercises and vocal hygiene most important for prevention
Does Voice Rx Work?
Roy et al, Utah/Ohio, 2002
3 Rx: voice amp; voice hygiene; control
VHI/acoustic perturbations reduced only with voice amp
Roy et al, Utah/Ohio, 2001
3 Rx: V.F.Exc.(Briess/Stemple); vocal hygiene; control
Only VFE group improved with VHI
Sapienza et al, Florida, 1998
Teachers using voice amp reduced vocal SPL (2.42 dB
SPL) with 8-10 dB amp.
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Vocalizing with Ease – Group Rx
14 hours comprehensive Rx (7 weeks or 5 days)
Optional “refresher” sessions
Voice-Related QOL (Hogikyan et al, 1999; 2000)
Significant + scores: immediately after Rx: 50% (N = 300)
(NS with + trend: 47%)
1 year post-treatment: 70% (N = 100) (NS with + trend: 23%)
Enhancing
Resonance
Intonation Physical Phrasing
Increasing
Vocal Flexibility
Coordinated Voice Onset Liberating Articulators
Posture & Alignment
Optimizing Technique
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Natural Speech Breathing
Establish natural posture
Control muscle misuses, e.g.,
“Tongue-Breathing”
Don’t “over-prepare” (inspiration)
Use spontaneous utterances:
Hm! UmHm
Use natural phrase boundaries
Optimizing Voice Onset
Spontaneous vocalizations for natural
coordination/pitch: “Hm!”; “Um Hm”
(Silent “h” for optimal glottal width)
Capitalize on elasticity around REL (32-40% VC):
using passive + active forces “Hm(rr*)Hm (rr)…”
Facilitating postures optimize feedback
Low-level practice transfer saliency: “Hm; Hi!”
CVO extension speech phrasing
*(rr = respiratory release = inspiration)
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Releasing the Jaw/Tongue
Drag-on the Larynx
Release: neckfacejawtongue
NO JAW JUT!
Lip movements jaw release
Passive pivotal jaw movements
The tongue is a rug, on the floor:
neutralize!
Dynamics: more jaw, less tongue,
stuttering & articulation Rx too!
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Q: Why does Humming Help? A: Semi-Occluded Vocal Tract (optimizes v.fold
closure/PTP; Provides real-time feedback…)
Vowels buzz too! The Vocal Siren (find “head voice”;
blend upper and lower registers)
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Other semi-occl. v-tract techniques
Z – Swell (semi-occluded vocal tract, coordinated speech
breathing, oral vibration feedback, natural
intonation, transition to speech phrases.)
Z
Z
(feel abs!)
Z…o-n-e……t-w-o…….t-h-r-e-e …….
Zoom (semi-occluded vocal tract start, natural intonation on
vowel, hum-buzz finish, transition to speech phrases)
Race Car: z-z-z-oo-oo-oo-oo-oo-oo-oo-m!
z-z-oo-oo-oo-m-z-oo-oo-oo-m!
z-z-oo-oo-m-z-oo-oo-m-z-oo-oo-m!
z-oo-oo-m-z-oo-oo-m-o-n-e!
z-oo-oo-m-z-oo-m-o-n-e….t-w-o …