Voice Exam 3 - Facilitating Techniques

Describe the procedural aspects of the facilitating technique of Head Positioning

-Introduce approach by demonstrating various head positions and explain that head can either be tilted down or back or to the left or right and that no one position helps everyone -Best voicing task to use to search for head position influence is prolongation of vowels such as /i, I, E, ae, o/ or /u/. Once a helpful position is found, any kind of voice practice material can be used -many gradiations in positioning are possible between normal head position and one of the extremes described. -Neurologically impaired pts may experience some oral-pharyngeal symmetry from their disease so lateral movement of the head may make a noticeable improvement; digital pressure on the thyroid lamina while searching with pt to find head position to increase sub glottal pressure may result in a louder more functional phonation

For what population is the Laryngeal Massage facilitating technique helpful?

-It is recommended for use with patients with FUNCTIONAL voice disorders in which structural or neurogenic causal factors cannot be identified (ex: FUNCTIONAL DYSPHONIA including: hoarseness with no structural or organic cause, ventricular dysphonia, pubertonia, falsetto, and voicing with discomfort or pain; psychogenic dysphonia; and muscle tension dysphonia) -it is also recommended for patients who present with excessive upward excursion of the larynx (This is usually the technique used for a pt with high larynx and excess tension if the yawn-sign technique is not successful in lowering larynx and achieving greater muscle relaxation)

What are the 3 Digital Manipulation procedures?

1- Digital pressure for lowering pitch 2- monitoring the vertical movements of the larynx 3- unilateral digital pressure for patients with unilateral vocal fold paralysis

When should you NOT use the Chewing technique?

Patients with TMJ

What types of voice problems is the Change of Loudness approach useful for?

Those patients who have too loud, too soft, or voices with monoloudness.

What should be a part of any voice program wherein pt is trying to use vocal mechanisms with less effort and strain?

developing greater openness

What is basic to good vocal performance?

good posture and head positioning

How is true Glottal Fry produced?

in a relaxed manner with very little airflow and very little subglottic air pressure

What is true of Respiration Training?

it is very controversial in SLP

For whom is Glottal Fry a valuable Facilitating Technique?

patients with vocal noodles patients with other hyperfunctional problems such as: polyps, cord thickening, functional dysphonia, and even spasmodic dysphonia and ventricular phonation

Who may benefit from the facilitating technique of Respiration Training?

the typical patient with a FUNCTIONAL VOICE DISORDER when there is a demonstrated need to improve respiratory function for voice - patient may need only some instruction for developing better expiratory control (such as avoiding "squeezing" out final words of an utterance bc of lack of adequate breath support)

What is one of the most effective therapy techniques for minimizing the tension effects of vocal hyper function?

the yawn-sigh

Describe the procedural aspects of the Auditory Masking facilitating technique

**The masking approach is best used WITHOUT ANY PRIOR EXPLANATION! The increased voicing experienced under masking conditions is produced on a reflexive, nonvolitional basis. -Masking should be presented with pt wearing headphones. Pt is asked to read aloud and keep reading no matter what kind of interruption they may hear. Typically the pt will read for about 10 sec and masking will be introduced for about 5 sec; this process is alternated. We record the patient's oral reading and on playback hear the changes in voice seen during masking.

Explain the procedural process for the facilitating technique of Change of Loudness to achieve an INCREASE in loudness.

- 1st determine that the inappropriate softness of the voice is not related to a deeper psychological or physical problem (hearing loss particularly) - Discuss the soft, weak voice with the patient & record if necessary - Explore pitch level and fundamental frequency and try to achieve their optimal pitch level - usually found by having the patient sustain a vowel (/a/) and go from lowest to highest pitch. - Once optimal pitch is found, have patient practice using auditory feedback so that they can hear the voice they are producing - Sometimes respiration training is necessary to increase sub glottal air pressure, as this may increase loudness - The Lombard effect may be useful for those patients who seem unable to increase voice loudness - people reflexively voice at louder levels when reading or speaking against increasing competing noise.

Explain the procedural process for the facilitating technique of Change of Loudness to achieve a DECREASE in loudness.

- 1st must ALWAYS Perform a HEARING EVALUATION - For children 10 and under: Explain that the child has 5 voices: 1) whisper 2) voice used when trying not wake someone up 3) NORMAL voice 4) voice used when talking to someone across the room 5) yell - For patients 10+ discuss with the patient that they have an inappropriately loud voice - tape recorded samples may be helpful - convince them - Focus on making patient aware of the problem and motivate them to remediate it - Record the patient's voice and critique it together - practice quiet voice (voice 2) - record and critique 2 or 3 times

Describe the procedural aspects of the Chant Talk Approach

- A method that reduces the effort in talking. Especially important to point out that the method is TEMPORARY - The clinician must demonstrate and model chant talk - The patient then must read aloud and imitate the chant voicing pattern. The reading is recorded and played back for critique and discussion. - The patient should then advance to reading aloud alternating the regular voice and the chant voice. Record for playback and critique and discuss the different sound of the normal and the chant voice. - Once the patient is able to produce the chant talk with ease, they should try to reduce the chant quality, approximating normal voice production.

What relaxation technique may also be used?

- Head rotation - Open throat relaxation: have patient lower the head toward the chest and make an easy, prolonged, open yawn, concentrating on what the yawn feels like in the throat. The yawn should yield conscious sensations of an open throat during the prolonged inhalation. Any relaxed phonations produced under these conditions should be recorded and used as target voice models for the patient.

Explain the procedural process for the facilitating technique of Change of Loudness for a voice with MONOloudness.

- Record the patient's voice and play it for them. Discuss the voice and how the patient feels about it. - Use a loop-playback system. Record oral reading and then listen immediately and discuss the relative appropriateness of loudness or loudness variation

Explain the procedural aspects of the Chewing facilitating technique.

- first help the patient become aware of the need for greater mouth opening while speaking. - Clinician and patient look in a mirror as the clinician demonstrates exaggerated chewing - Then add light voice to the chewing - Once simultaneous chewing-speaking is established, ask the patient to count and chew or recite the alphabet and chew. - Next advance to words and phrases to practice chewing, and eventually sentences. - After several weeks of practice in chewing, the patient should be taught how to diminish the exaggerated chewing to resemble more normal mouth movements

Explain the procedural aspects of the Inhalation Phonation facilitating technique.

-Demonstrate inhalation phonation by phonating a high-pitched sound while elevating the shoulders (a marker for this technique) - it is important to time the initiations of the inhalation with the shoulder raising -after demonstrating several separate inhalations with simultaneous shoulder elevation and phonation match the high-pitched inhalation voice with an expiration voice (inhale, raising the shoulders & simultaneously humming in a high pitch, then dropping the shoulders on exhalation and producing the same voice) Repeat several times.

Describe the procedural aspects of the Tongue Protrusion /i/ facilitating technique

-Demonstrate to the pt what is expected by opening the mouth and protruding the tongue while producing a high-pitched, sustained /i/. Stress that the jaw is to "drop open" comfortably and the tongue is to be extended comfortably. -the pt should go up and down in pitch while sustaining the /i/ vowel with the mouth open and tongue out. Listen for improved vocal quality. - have pt chant /mimimimimi/ at this level with tongue still out, then instruct the patient to slowly slip the tongue back into mouth still producing the mimimimi. -At this point the pitch is usually still high - demonstrating a sustained low /i/ about 3 steps from the pitch they were using before often archives good quality on the first or first 2 steps.

Describe the procedure for the Laryngeal Massage technique

-Encircle hyoid bone with thumb and middle finger. Work posteriorly until major horns are felt -apply light pressure with fingers in a circular motion over tips of hyoid bone -repeat this procedure with fingers on the thyroid notch working posteriorly -find posterior borders of thyroid cartilage and repeat -with fingers over superior border of thyroid cartilage, begin to work larynx gently downward and laterally at times -ask pt to prolong vowels during these procedures noting changes in quality or pitch. CLEARER VOICE QUALITY & LOWER PITCH = RELIEF OF TENSION. be sure rest pds are provided -Improvement in voice should be greatly reinforced; practice should address voice in vowels, words, phrases, & sentences -Discuss with pt how voice tension has been reduced with this technique; repeat procedure and ask pt if they can maneuver own larynx to lower position.

Describe the procedural aspects of the Yawn-Sigh facilitating technique

-Explain to children that opening mouth wide (like during a yawn) will relax it, and speaking at the end will be the best voice. With adolescents and adults explain the physiology of a yawn and that it represents prolonged INSPIRATION with MAXIMUM WIDENING OF THE SUPRAGLOTTAL AIRWAYS. Demonstrate a yawn and talk about what it feels like. -After pt yawns following your example, ask pt to yawn again and to exhale gently with light phonation. Many pts are able to feel an easy phonation for the first time -Once yawn-phonation is easily achieved, instruct pt to say words beginning with /h/ or open-mouthed vowels like /a/ -Demonstrate the sigh phase (the prolonged, easy open-mouthed exhalation after the yawn); then, omitting the yawn, demonstrate a quick, normal open-mouthed inhalation followed by the prolonged, open-mouthed sigh. -As soon as pt can produce a relaxed sigh, have them say "hah" at the beginning - follow this with a series of words beginning with glottal /h/. (addtnl words for prac should begin with mid and low vowels). -Once the yawn-sigh approach is developed have pt think of the relaxed oral feeling it provides - eventually they will be able to maintain relaxed phonation just by imagining the approach

Describe the procedural aspects of the Confidential Voice technique

-Model the light, breathy voice for the patient -Explain that the breathy voice will use more air and that patient may need to speak using shorter utterances -Explain that the technique is temporary -Patient should read orally using confidential voice With a child you may reference the 5 voice approach and instruct them to use voice #2 With an adult you may introduce some anatomy and physiology and talk about the various parts of the vocal mechanism

What patients profit from the facilitating technique of Inhalation Phonation? Why?

-Patients who have functional aphonia and functional dysphonia often profit from inhalation phonation -This can also be helpful for the patient who perseverates using ventricular phonation and often demonstrate difficulty "getting out of it" --Helpful technique because this introduces a high-pitched inhalation voice that is ALWAYS produced by TRUE vf vibration

For whom is Hierarchy Analysis a successful facilitating technique?

-Patients with hyperfunctional voice probs which by definition imply excessive overreacting -Pts with functional dysphonia or dysphonias accompanied by nodules, polyps, & vocal fold thickening - these pts frequently report that their degrees of dysphonia vary with the situation, therefore they may profit from hierarchy analysis

Describe the use of Visual Feedback as a facilitating technique

-Patients working to achieve a target F0 line fixed on a screen with the therapy task of attempting to match the line with their same F0 production. Converging lines is a visual reinforcement of a "correct" production. -Patients working on nasalance probs will often profit from using the Kay Elementics Nasometer which provides real-time visual feedback relative to the acoustic balance between oral and nasal resonance. -Biofeedback and feedback on positioning using a mirror can also help. MOST PATIENTS profit from receiving visual feedback relative to respiratory physiology, acoustic parameters of voice, and various digital feedback values (Air volumes, pressure flow, F0, or % nasal resonance)

Describe patients who may benefit from the Auditory Masking facilitating technique

-Pts with functional aphonia are often able to produce normal phonation under conditions of auditory masking -Using masking with pts who have functional dysphonia will often reveal a "window" of improved phonation - it appears many such patients may have poor real-time auditory monitoring. When masking is used it will often reveal changing phonation states that can be recorded and used as voice models in subsequent therapy.

Explain the types of voice problems that may require Counseling for Explanation of the Problem.

-SLP is NOT a psychologist, psychiatrist, or counselor; however, you CAN counsel issues related to voice/speech/language. -should always include counseling as part of a voice therapy approach

Describe the procedural aspects of the Pitch Inflection facilitating technique

-To create awareness of vocal monotony, a recording of pt can be played to provide a sample of a lack of pitch variability; this can be followed by samples of GOOD pitch variability provided by clinician. -Begin working on downward and upward inflectional shifts of the same word, exaggerating in the beginning of the extent of pitch change. -Have pt practice introducing inflectional shifts within specific words, keeping loudness levels about the same -Pitch inflections can be graphically displayed on many instruments (VisiPitch or PM 100 Pitch Analyzer); you may set target inflections for pt to see if they can make their pitch level reach the excursions or movement as the target model on the scope.

Name examples of Vocal ABUSE

-Yelling and screaming -speaking against a background of loud noise -coughing and excessive throat clearing -smoking -excessive singing or talking -excessive talking or singing while having allergies or upper respiratory infection -excessive crying or laughing -weight lifting with effortful grunts

Describe the procedural aspects of the Facilitating Technique of Glottal Fry

-ask patient to let out half of their breath and then say /i/ softly, holding it until it fades away slowly. encourage pt to stretch /i/ as long as possible -Once patient has a well-sustained /i/ in glottal fry mode, have them open mouth medium wide and protrude the tongue. Then have pt make the tone "larger" by "opening the throat" (Desired tone is deep, resonant, and a slow series of individual "pops") -Have pt attempt to produce the same tone on inhalation as on exhalation. then have pt say words like "on" & "off", "in" and "out" in glottal fry mode on inhalation and exhalation -When pt can produce these words and sustain /i/ or /a/ in glottal fry mode, have them say phrases like "easy does it" "squeeze the peach" "See the eagle" in a normal voice- almost always produced with normal vocal quality. -have pt practice each day in glottal fry mode

Describe the procedural aspects of the focus approach for a Poor Vertical Focus

-develop an imagery of taking the voice "out" of the throat and "placing" it in front of the face; functionally, a change of focus can produce an immediate and dramatic change in the sound effect of the voice (though this cannot be demonstrated physiologically). give much time to this step. -A good way to begin higher focus is with increased nasalization ("one-a-one-a-one") and other monosyllabic nasal words (mom, me, many) and exaggerate nasality. -If pt confirms feeling vibrations of nasal consonants and nasalized vowels practice reading short nasal sentences with exaggerated nasal resonance. Contrast the feeling of higher-focused nasal voice with the lower throat voices- they should sound and feel different. -high front vowels (baby, beach, take) can also be used if nasals facilitate higher throat focus. Loop playback can be helpful as well.

Describe the procedural aspects of the Relaxation facilitating technique

-explain to pt what stress is (esp children) and methods for managing it - adults may be referred to literature regarding stress and stress reduction -introduce patient to the concept of differential relaxation: patient concentrates on a particular site of the body, deliberately relaxing and tensing certain muscles, discriminating between muscle contraction and relaxation. Have pt begin DISTALLY (usually at the feet) and once pt feels the tightness of contraction and the heaviness of relaxation, they move "up" the limb repeating the tightness-heaviness discrimination at each site eventually reaching the "voice box", throat, mouth, and parts of the face. -talk about tension and relaxation and how this relates to speaking with decreased tension

Describe the procedural aspects of the Open-Mouth Approach

-have pt view themselves in a mirror to observe the presence and absence of open-mouth behavior. Identify any lip tightness, mandibular restriction, or excessive neck muscle movement for the pt. -The ventriloquist/puppet example analogy may be helpful for children. -To establish further oral openness, ask pt to drop head toward the chest and let lips part and jaw drop open. Once pt can do this, have them practice some relaxed /a/ sounds. When head is tilted down and jaw is slightly open, a more relaxed phonation can often be achieved.

Who may benefit from the Tongue Protrusion /i/ facilitating technique?

-many HYPERfunctional voice probs are improved by this approach -This approach is especially useful for pts with VENTRICULAR PHONATION or "TIGHTNESS" in the voice, such as when the laryngeal aditus/collar is held in a somewhat closed position. (when tongue is held in a posterior position or the pharyngeal constrictor muscles are contracted to constrict the pharynx, the voice will sound strained or tight.)

Name the several distinct head positions that may be tried in therapy

-normal straight ahead -neck extended forward with head tilted down, face looking up -neck flexed downward with head tilted down, face looking down -neck flexed unilaterally with head tilted to either the right or the left, with tilted face looking forward -head upright and rotated toward left or right, face looking in that direction Any one change in head position may change pharyngeal-oral resonating structures in such way that a change in vocal quality (better or worse) may occur

For whom may Head Positioning be a beneficial Facilitating Technique?

-patients with unilateral vocal fold paralysis -finding optimum head positioning has been found to be helpful in chewing and swallowing with pts with various neurological disorders

Who may benefit from the facilitating technique of Nasal/Glide Stimulation?

-pts with probs of vocal HYPERFUNCTION -this approach is particularly useful for patients with functional dysphonia, spasmodic dysphonia, and dysphonias related to vf thickening, nodules, and polyps.

Name some examples of Vocal MISUSE

-speaking with hard glottal attack -singing excessively or at the upper or lower end of one's range -increasing vocal loudness by squeezing out the voice at the level of the larynx -speaking at excessive intensity levels -cheerleading -speaking over time at an inappropriate pitch level -speaking or singing (such as a prolonged rehearsal) for excessively long pds of time

What are the possible focus problems that may be seen?

-voice too far forward -voice too far back -voice sounding too deep in the throat -->a nasal focus is NOT presented as a FOCUS problem

Describe the procedural aspects of the Elimination of Abuses facilitating technique

1- early in therapy time should be given to identifying possible abuse; once this has been identified the patient and clinician should develop a baseline of occurrence. 2-children with vocal abuse must become aware of the impact of such abuses on their voices. The focus of reducing abuse programs are to make the child cognitively aware of the relationship of vocal abuse-misuse to increasing symptoms of voice 3-dicuss identified abuses with pt and emphasize the need to reduce frequency. Assign pt the task of counting the # of times abuse occurs daily. Encourage self-monitoring and eventual reduction in abusive behaviors

What are the 3 forms of Auditory Feedback?

1- real time amplification 2- metronome pacing 3- loop playback

Describe the process of performing Digital Pressure for monitoring the vertical movements of the larynx

1- this is used for patients with excessive pitch variability & tension related to much vertical movement of the larynx. Demonstrate how to place the fingers on the THYROID cartilage and monitor laryngeal vertical movement while phonating 2- Ask the patient to produce one note at a time until they reach the lowest note in their pitch range (usually the larynx will lower its position in the neck at the low end of the pitch range). Then ask the patient to produce one note at a time until they reach the highest note in their pitch range (through which the pt should feel a slight elevation of the larynx) 3- next point out that in production of a speaking voice free of strain there is typically no vertical movement that should be felt digitally. Oral reading and speaking should be developed with little or no laryngeal movements that can be monitored through slight digital pressure of the thyroid cartilage.

For patients with chronic dysphonia as previously described, what 2 techniques do successful voice clinicians employ?

1- to improve respiratory control and resonance 2- to transfer patient's mental focus away from the larynx and place it with the activator (respiration) and the resonator (supra glottal vocal tract)

Describe the process of performing Digital Manipulation for unilateral pressure for patients with unilateral vocal fold paralysis

1- typically there appears to be a light phonation improvement by pressing on thyroid lamina on the paralyzed side (not always, though). The patient is asked look FORWARD and to phonate and extend a vowel. The clinician meanwhile exerts medium digital pressure on the lateral thyroid wall ON THE SIDE of v.f. PARALYSIS. If a louder, firmer voice results continue various phonation tasks with the same pressure until a better, more functional voice is produced and gradually habituated.

Describe the process of performing Digital Pressure for lowering pitch

1-Ask the pt to produce a long vowel (/a/ or /i/) and as the vowel is prolonged apply slight finger pressure on the THYROID cartilage. The pitch level will DROP immediately 2- Ask the patient to maintain the lower pitch after the fingers are removed. If pitch reverts, digital pressure should be reapplied 3- If this method is used to let the patient hear and feel a lower pitch, the patient should practice producing the lower pitch with and without digital pressure on the thyroid cartilage. 4- Patient should progress from vowel to syllable to words while maintaining this lower pitch level

Describe the procedural aspects of the facilitating technique for Establishing a New Pitch

1-record pt producing various pitches including the old, undesirable one and the projected target. Both should be played back for pt to hear and a discussion comparing the two pitches must follow. 2- Most voice patients can then imitate their own pitch models; a useful model can be produced by having pt extend an /i/ at the target pitch level for about 5 sec and record the phonation on a loop recorder. This will provide the pt with continuous playback of their own voice at the target pitch. 3- establishing the new pitch is facilitated by working first on single words (preferably beginning with vowels) 4- after single words move to phrases and short sentences during reading activities, not yet in conversation 5- after reading well in monotone the pt may attempt the new pitch in conversations

What must one do when speaking about a patient's voice?

ALWAYS speak about the voice objectively!!! don't make the critique of the voice extend to the patient as a person. Speak of the voice in 3rd person or refer to it as "the voice" NEVER "your voice." -Put anatomical and physiological aspects of voice in terms that the patient can understand -REFER if the problem is judged to be outside of your scope of practice

Explain the process of Loop Playback Auditory Feedback

Allows the patient to hear immediately what was just said. - The patient wears a headset and microphone and as they speak their production is recorded. - The recording is then immediately played back to provide playback for the patient to hear. -The patient is asked to evaluate the immediate playback of their speech. The clinician provides feedback as well. The patient may be asked to repeat the utterance and it is subsequently recorded and played back.

What types of voice problems can the Digital Manipulation Facilitating Technique be used for?

Anyone who appears to have excessive laryngeal vertical movement or who is concerned about laryngeal posturing at high or low levels.

What do most patients with chronic dysphonia experience?

Both difficulty finding their voices and continued expectancy of vocal failure. They clear their throats continually, make phonation rehearsals, and worry about possible poor vocal quality next time they speak.

What two facilitating techniques are good for patients with almost ANY hyperfunctional voice behavior? Why?

Chewing and Chant-talk; these two techniques relax the entire vocal tract

What are the procedural aspects of Anterior Focus training?

Clinician uses a diagram to show the patient where their voice comes from, and says that it appears that their voice sounds too far forward in their mouth and it seems to be caused by carrying their tongue high and forward. This makes the voice sound babyish or thin. -front of mouth focus can often be corrected by producing back of mouth sounds in rapid succession -compare old thin voice with the new, back voice using some kind of loop or recorded feedback

Describe the procedural aspects of the Respiration Training facilitating technique

Demonstrate how expiratory air can set up vibration (by blowing air through your lips) -Provide a brief explanation of respiratory physiology - air comes into lungs making the chest bigger, chest becomes smaller and the chest goes out, passing through the larynx, and the outgoing airstream sets vf in vibration to produce voice. -Demonstrate a deep inhalation/exhalation, then demonstrate a quick inhalation and prolonged exhalation as needed for a normal speaking task. See if pt can do this and if so extend the count by 1 # at a time. -Various duration tasks such as prolonging vowels can provide excellent practice in expiratory control.

Who may benefit from the Open-Mouth Approach as a facilitating technique for a good voice?

Encouraging the patient to develop more oral openness often reduces generalized vocal HYPERFUNCTION -Opening mouth more while speaking and learning to listen with a slightly open mouth allows pt to use vocal mechanisms more optimally. This approach promotes more natural size-mass adjustments and more optimum approximation of the vf. This helps correct PROBLEMS of LOUDNESS, PITCH, & QUALITY. -Opening mouth more is also recommended to INCREASE ORAL RESONANCE and to IMPROVE OVERALL VOICE QUALITY. The voice also sounds LOUDER (usually louder voice within limits =better quality).

Describe what the purpose of the facilitating technique Focus is and when it may be used.

Good focus of the voice is characterized by: the voice coming from the middle of the mouth, just above the surface of the tongue. Problems in "horizontal" voice focus occur when tongue is too far forward or backward within the mouth.

Describe the primary goal of the facilitating technique of Elimination of Abuses

Identification and reduction of vocal abuse-misuse are PRIMARY GOALS in voice therapy for hyperfunctional disorders. Therapy CANNOT be successful until contributory vocal abuse-misuse can be drastically reduced

What is vocal MISUSE?

Improper use of voice - overuse or incorrectly using the voice

Who may benefit from the Yawn-Sign facilitating technique?

In vocal hyperfunction, we see the larynx rise, the tongue lifted high and forward, the vocal folds tightly compressed, and the pharynx constricted. *The Yawn-Sigh provides a dramatic contrast: the larynx drops to a low position, tongue is more forward, there is a slight opening between vf (glottal chink), and pharynx is usually dilated. --The Yawn-Sigh is frequently combined with other therapy approaches for some probs such as FUNCTIONAL DYSPHONIA, SPASMODIC DYSPHONIA, & DYSPHONIA related to THICKENING, VOCAL NODULES, & POLYPS. -Any pt who might profit from a lower, more relaxed carriage of the larynx is a candidate to receive either laryngeal massage or the yawn-sigh approach

Define "inflection" and "shift" in relation to pitch

Inflection: a modulation of pitch during phonation Shift: a change of pitch from one end of the phonation to the beginning of the next

What instruments can be used to provide real-time display of frequency and provide a feedback loop of the desired pitch level ?

PM 100 Pitch Analyzer, Phonatory Function Analyzer, Visi-Pitch, and B & K Real-Time Frequency Analyzer.

Who may benefit from the Redirected Phonation facilitating technique?

Patients with FUNCTIONAL APHONIA or FUNCTIONAL DYSPHONIA - children and adults who have difficulty "finding" their voices.

Describe the types of patients who may benefit from the Relaxation facilitating technique

Patients with hyperfunctional voices often develop vocal symptoms as a part of their stress reactions; "When you can't change the world, you can change your response to it" and because stress is part of the human condition, it is important how we react. Among particular voice symptoms related to stress are: Diplophonia, dry throat and mouth, harshness, elevated pitch, functional dysphonia, and shortness of breath. A frequent goal in voice therapy is to take the "Work" out of phonation by using such voice therapy techniques as the Open-Mouth and Yawn-Sigh along with Relaxation

Describe an additional facilitating method used in respiration training

Pt is encouraged to feel abdomen tightening on expiration. Some practice should be given to following inhalation (accomplished primarily thru chest wall expansion) by gradual tightening (contraction) of the abdominal muscles. As soon as pt demonstrates some ability to contract the abdominal muscles on expiration, add phonation activities. The voice pt who has been spking from the level of the throat without adequate breath support will feel the difference that a bigger breath makes when phonation is desired.

Explain the process of Real Time Amplification Auditory Feedback

Real-time amplification of speech and voice enables one to hear oneself more clearly than would be possible without such focus; the clinician uses an amplifying instrument that provides real-time feedback as the patient speaks. -The patient is asked to listen closely on headphones to what they will be saying; then they are asked to listen closely to the sound of the voice while they are using the approach -The patient is then asked to evaluate voice and if adjustments are made, they are listened to again with the real-time amplification

What does the SLP do in the Redirected Phonation technique?

SLP searches with pt to find some kind of VEGETATIVE PHONATION (coughing, gargling, laughing, throat clearing) OR some kind of INTENTIONAL VOICING (playing a comb or kazoo, humming, singing, trilling) or saying "UMM-HMMM." -If the patient has the capability of voicing one or more of these non communicative sounds (NOT umm-hmm) then the sounds might be redirected into production of the speaking voice.

What other problem may be assisted by Respiration Training?

Singers, actors, or lecturers who need some formal respiration training. Sometimes seen after strokes - paradoxical phonation, in which phonation is produced on inspiration instead of expiration - very inefficient

What is the most vital part of the Yawn-Sigh approach ?

Take care to blend in, toward middle of the sigh, an easy, relaxed, relatively soft phonation. This blending of the phonation into the sigh is often difficult initially, but it is the MOST VITAL part of the approach for eliminating hard glottal contacts.

What is the Confidential Voice facilitating technique?

Technique that calls for the patient to use a soft, breathy voice like the voice they would use when telling a secret or not trying to wake someone up

What additional finding has been presented?

That nasal consonants combine very well with the /l/ and /r/ phonemes and many glide words contain nasal consonants. Using monosyllabic /l/ and /r/ words with an /a/ between them seems to produce good voice, such as "lee a lee a lee"

What concept is the Auditory Masking technique based on?

The Lombard test/effect: when asked to phonate in a loud-noise background, pts will typically increase loudness reflexively. This test was first introduced as a method of finding voice with pts who had functional aphonia that produced a light voice in presence of loud-noise background. It is also known to aid pts with functional dysphonia, who may experience clearer voices when they cannot monitor their productions due to the loud masking

What is typically done by the SLP when treating problems with pitch variability?

The SLP typically COMBINES work on INCREASING LOUDNESS (Intensity) with efforts to INCREASE PITCH VARIABILITY - working on pitch alone is difficult without influencing loudness variations.

Explain the process of Metronome Pacing Auditory Feedback

The clicks or beats of a metronome may provide good auditory pacing for those patients needing to decrease or increase rate of speech - helps with SPEECH RATE

Describe the facilitating technique of Hierarchy Analysis.

The patient lists various situations that ordinarily produce some anxiety and arranges those situations in sequential order from the least to most anxiety provoking. Individual patients may prepare a hierarchy of situations, ranging from those in which they find their voices best to those in which they find them worst. This technique is borrowed from Wolpe's method of reciprocal inhibition which teaches patient relaxed responses to anxiety-evoking situations. After identifying their hierarchy, the pt begins by employing the relaxed responses in the least anxious situation and gradually works their way up the hierarchy, eventually reconditioning their previously established responses.

What patients may benefit from the facilitating technique of Pitch Inflections?

The prosodic and stress patterns of normal speaking voice are characterized by changes in pitch, loudness, and duration. In some individuals, the lack of PITCH is noticeable due to the resulting MONOTONE voice. Speaking on this same pitch level with little variation requires the inhibition of natural inflection. --This is usually observed in OVERCONTROLLED PEOPLE who display VERY LITTLE OVERT AFFECT.

What types of voices are seen when there are problems in "horizontal" voice focus?

Tongue too high and forward: "thin" or baby sounding voice Tongue elevated in back of mouth: back-focused country bumpkin voice

What are the procedural aspects of Posterior Focus training?

Use diagram to show the patient where their voice comes from, and say that their voice sounds back in their mouth, which seems to come from the tongue being placed too far back. tell the pt that we can bring the tongue forward by practicing some front-of-mouth sounds -posterior-to-anterior shift of focus is established quicker when only whisper is used on first practice words. Pt repeats front-of-mouth words like peep and pipe rapidly 4-5 times. -th voiceless words are whispered in rapid succession 4-5 times -/s/ words repeated in rapid series. -whispered series is then repeated with light voice

What voice problems can be remediating by employing the Chant-Talk facilitating technique

Voice problems related to HYPERfunction - it is a technique used to relax the vocal mechanism

What should be done if digital pressure to the paralyzed lateral thyroid wall does not yield a better voice ?

While the patient continues to look forward, the clinician applies pressure to the opposite side of the thyroid cartilage with attempted phonation tasks to determine if a better voice is produced.

Describe the procedural aspects of the Nasal/Glide Stimulation approach

Words that contain nasal or glide consonants will often produce the best-sounding voice with the least amount of effort -The clinician may find a number of mono- and poly-syllabic words containing nasal consonants for the pt to practice saying as the response when using various facilitating approaches. (man, moon, many, morning, miami, many men, etc) -a variation is to use nasal monosyllabic words and introduce an /a/ between each word; ask pt to produce 3 words in a row with a neutral /a/ between each word ("man a man a man") -The same procedure is used for words containing glide consonants

What may facilitate a better voice in pts with various kinds of voice probs?

changing head positioning

What is the Laryngeal Massage facilitating technique?

it follows the procedures (modified slightly) for manual circumlaryngeal therapy (presented by Aronson) which offers gentle manipulation and massage of the larynx

What head position may be helpful for pts with vocal hyper function who use too much effort to talk ?

neck flexion with chin tucked down toward the chest - such downward carriage of the head seems to promote greater vocal tract relaxation

Sometimes the breathy, weak voice used for the Confidential Voice technique becomes habitually used by the patient; is this harmful to the vocal mechanism?

no; it is a relatively inefficient way of speaking but not harmful.

What voice problems can be remediated by using the Chewing facilitating technique?

problems of vocal hyper function in individuals who appear to speak through clenched teeth with very little mandibular or labial movement. Chewing is also helpful for the patient who speaks with great tension and hard glottal attacks.

What should be done if digital pressure to either thyroid lamina with the patient looking ahead does not produce a better voice ?

provide lamina pressure with the head turned to one side. If the head is turned to the left, first apply pressure to the left lamina; if unsuccessful keep the head turned left with pressure given to the right lamina. The final posture is the head turned to the right with pressure first applied to the right lamina and then the left to find a better, more functional voice.

What patients may benefit from the facilitating technique of Auditory Feedback?

regardless of causal factor of the disorder (organic, neurogenic, or functional) the loudness quality of the patient's voice may improve when using this facilitating technique

What is the most common focus problem seen in patients with voice disorders? What do these patients profit from?

the voice sounding as if it were deep in the throat; these patients profit from resonant therapy or the FRONT-focus approach because it shifts their mental imagery from the throat to upper vocal tract.

What is poor vertical focus?

the voice sounding as though it is focused deep in the throat; produces poor vocal quality; is the MOST COMMON PROBLEM seen in voice clinic!!! Getting the voice out of the throat is a problem of mental imagery.

What kind of voice problems can be remediating by the facilitating technique of Establishing a New Pitch?

those who speak at the bottom of their pitch range (which requires too much force and effort) or those who speak at the top of their pitch range (which can be vocally fatiguing) A change of pitch often has positive effects on voice such as improving vocal quality and loudness.

What is most helpful when Establishing a New Pitch?

to record the patient's voice as they search to establish a new and different pitch level. When the pt is able to produce a good voice at proper pitch level, their own "best" voice can then become the therapy model.

What voice problems can be remediated by the Confidential voice facilitating technique?

to reduce HYPERfunctional voice problems - reduces Vocal nodules ESPECIALLY;

What is the focus of the Nasal/Glide Stimulation technique?

using words that contain many nasal and glide consonants, often help patient produce desired "target" vocalizations as these consonants typically relax the vocal mechanism and reduce tension

What is vocal ABUSE?

various behaviors that have a deleterious effect on the larynx and the voice - behaviors that should NEVER be done