Transcript lmrvt - Verdolini Voice

LMRVT and CBCFT: Step by
Step Introduction and
Overview
Kittie Verdolini Abbott, PhD, CCC-SLP; 2011
Communication Science and Disorders
School of Health and Rehabilitation Sciences
Lessac-Madsen
Resonant Voice Therapy
• Based on long-term
clinical work and basic
science studies
• First loosely described
by Verdolini, in Stemple
(2000; 2009)
• Includes direct and
indirect voice therapy
• Direct piece partly
adapted from work by
Lessac (1967, 1997) and
Madsen (unpublished)
• LMRVT connotes a
specific, programmatic
approach to hygiene
and resonant voice
training
Arthur Lessac
Mark Madsen
The “what” of LMRVT: Direct therapy
• Biomechanically:
– Barely ad/abducted vocal
folds that optimize output
intensity and relatively
minimize impact intensity
(departure from “traditional”
thought in voice tx).
– Involves large-amplitude, lowimpact VF oscillations
(proposed biological
prevention and healing
factors) and low Ps (easy)
• Preceding effects
enhanced by use of
semi-occluded vocal
tract in training (SOVT)
(e.g., voiced continuant
consonants)
The “what” of LMRVT: Direct therapy
• Perceptually:
– Voice with perceptible
anterior oral vibrations
in the context of easy
phonation.
– Note 2D continuum;
both vibration and ease
are required to some
degree for a voice to be
called “resonant” in
LMRVT.
Not RV =
No Vibrations
Hard
RV =
Vibrations
Ease
The “what” of LMRVT: Indirect therapy
• Lean and mean
– Hydration
– Exogenous inflammation
– Uncontrolled yelling and
sceaming
• georgeforemancooking.
com
georgeforemancooking.com
Casper-Based Confidential Flow Therapy
• Developed as comparison
therapy in NIH-funded
clinical trial on the utility of
voice therapy for teachers
(2005-2009) (R01 DC
005643).
• Direct therapy piece
intended to be more
“traditional” than
LMRVT.
• Includes direct and indirect
therapy.
• Indirect therapy identical to
LMRVT.
susandwyerartworks.com
Original idea for comparison tx
• Quiet breathy
(confidential) voice
(that’s traditional!)
• Developed a program.
• Idea was to offset
communication
impairment with QB/CV
by training enhanced
articulation (Lessac
consonant orchestra).
revwheeler.wordpress.com
Bright idea
• Then we had a bright
idea.
• Why not ask someone
who actually does this
kind of therapy to have
a look at this program!!!
Janina Casper
atsosxdev.doit.wisc.edu
The birth of CBCFT
• Dr. Casper took one
look at the program
(QB/C voice all the way
through) and said
“THAT WILL NEVER
WORK!”
• “I never have patients
do QB/C voice for more
than a week or two!”
marinebuzz.com
The birth of CBCFT
• “Oh yeah, so after that,
what do you do?”
• “I teach them resonant
voice – so they can be
heard!!!”
pdxcontemporaryart.com
The birth of CBCFT
• Oh great.
relationship-economy.com
The birth of CBCFT
• Well, natural sequence
after “QB/C voice might
be something like “flow
voice” (aka “stretch and
flow” ff Ed Stone).
• Jackie Gartner-Schmidt
to the rescue 
dragoart.com
Jackie Gartner-Schmidt (CBCFT)
The “what” of CBCFT: 2 stages
• Biomechanically:
– Stage 1: Widely
abducted vocal folds,
with small VF oscillations
(about 1-2 wk).
• Perceptually:
– Stage 1: Quiet-breathy
(confidential) voice.
The “what” of CBCFT
• Biomechanically:
– Stage 2: Slightly greater
VF separation than for
RV, that nonetheless falls
in the range of
configurations
corresponding to
“optimal vocal economy”
(output intensity/impact
intensity).
– VF oscillations
potentially a bit smaller
than for RV, and impact
stress potentially a bit
smaller as well.
– No explicit use of the
semi-occluded vocal
tract.
LEGEND (APPROX EQUIV)
1 = PRESSED VOICE
2 = NORMAL VOICE,
RESONANT VOICE, VOCAL
FUNCTION EXERCISES,
ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE
1 <-2
3
4
5
LEGEND (APPROX EQUIV)
1 = PRESSED VOICE
2 = NORMAL VOICE,
RESONANT VOICE, VOCAL
FUNCTION EXERCISES,
ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE
1
2
3
4
5
LEGEND (APPROX EQUIV)
1 = PRESSED VOICE
2 = NORMAL VOICE,
RESONANT VOICE, VOCAL
FUNCTION EXERCISES,
ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE
2
1
3
4
5
The “what” of CBCFT
• Perceptually:
• Stage 2: Easy voice with
“air all gone.” (Note
again 2D continuum;
both ease and “air all
gone” are required for
some degree for a voice
to be truly “flow.”)
thatgamecompany.com
Not FV =
Hard
Air not all gone
FV =
Easy
Air all gone
Comparison of the “whats”
• LMRVT
– RV ~ 0.0-0.5 mm VP
separation
– RV ~ 120 ml/sec average
airflow
– Anterior oral vibrations;
easy
– RV: Basic training with
voiced continuant
consonants (semioccluded vocal tract) to
enhance resonance
• CBCFT
– FV ~ 1.0 mm VP
separation
– FV ~ 180 ml/sec average
airflow
– Easy, “air all gone”
– FV: Basic training with
unvoiced continuant
consonants to enhance
flow
Comparison of the “hows”
• Identical approaches
– Used approach
theoretically predicted
to optimize learning, and
empirically shown to
optimize voice learning
(sensory processing,
variable practice).
• That approach produced
best VHI results in prior
study that held
biomechanical and
perceptual target of voice
training constant (resonant
voice), and varied training
approach.
• Recall prior lecture.
In greater detail regarding the “how”
• Single training focus
• Perceptual
(introspective)
• Attention to detail,
especially around
gestures’ effects
• Exploratory not
prescriptive
• Literal training
(specificity principle)
• Flexible troubleshooting
– It’s a “Spa Elf!”
Comparison of the “ifs”
• Identical approach
– Parallel clinician and
patient manuals, with
patient education (to
enhance confidence in
treatment).
– Same requirements in
terms of amount and
type of practice.
– Written and audio
recorded instructions.
– Etc.
• You might consider
return audio records
and/or excel file for
patient compliance
reporting
LMRVT and CBCFT (see manuals)
Hygiene
(10-15
min)
Stretches
(5-10
min)
Core
(5-10
min)
Xxx
(xxx)
(xxx)
II
xxx
III
Chant
(5-10
min)
“VC”
(5-10
min)
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
IV
xxx
xxx
xxx
(xxx)
xxx
C1+2
V
xxx
xxx
xxx
(xxx)
xxx
C3
VI
xxx
xxx
(xxx)
xxx
C4
VII
xxx
xxx
xxx
C5
VIII
xxx
xxx
I
“Mini”
(5 min)
“Messa
di voce”
(5-10
min)
Converse
(5-20
min)
Own Tx
(15-20
min)
C1
C2
C6
xxx
Claim to use LMRVT or CBCFT
• After 2-day training
session by Verdolini or
designated associate,
assuming relatively
“mature” clinician with
emphasis in voice.
ncvs.org
Patient selection
• Voice problem due to
hyper- or hypoadduction
• Demonstrates kinesthetic
(and preferably auditoryperceptual) discrimination
capabilities and willingness
(Vocal Function Exercises
will get you the same
biomechanical and
biological targets, with
outward focus)
• Usually some evidence of
improved voice within first
session
Not appropriate populations
• Hemorrhage (strongly
contraindicated)
• Immediate post-surgical
• SD (probably won’t
help; but see work by
Connie Pike, SLP)
• Parkinson’s disease
(LSVT is appropriate;
although see Florida
work)
• Gaping wide paralyses
or otherwise huge
glottal insufficiency (you
won’t get anywhere)
Other selection criterion
• If you’re not already
sick of it
thenysehng.blogspot.com
Data
• R01 DC 005643
• N=105 randomized (52
CBCFT; 53 LMRVT)
• Teachers with phonotrauma
(most) or other phonogenic
voice problem (e.g., MTD; a
few) (mostly females)
• 4 wk therapy (2 back-toback sessions/wk)
• Subjects run 2005-2009
• Follow-up immediately post
tx, 3 mo post tx, and 1 yr
post baseline
• At 1 yr post baseline, N=40
CBCFT; 42 LMRVT)
Primary outcome measure
• Voice Handicap Index
scielo.br
'
VHI
100
90
80
70
60
50
40
30
20
10
0
B
L
C
B
C
B
L
L
M
R
1
m
o
C
1
m
o
L
3
m
o
C
3
m
o
L
Scheduled Follow-Up / Randomized Treatment Group
1
2
m
o
C
1
2
m
o
L
Question
• Where have you seen
the curves on the
preceding pages
before?
• Discussion.
Step by step details
• Manuals
– CBCFT Clinician and
Patient Manuals
included with the
course.
– LMRVT Clinician and
Patient Manuals (and
DVD) available from
Plural Publishing, Inc.
(www.pluralpublishing.c
om)
chimneycricket.com
Start with intake
• Brief history
• (Measures)
• Baseline voice selfassessment (key as
“anchor” for later daily
ratings)
• List of likely contributory
causes (in Clinician and
Patient Manuals
• Goals (functional, medical,
biomechanical)
• Recommendations
• Prognosis
Set-up for therapy
• Brief patient education
about voice production,
voice disorders
• Personalized voice
hygiene program
pcna.net
Hydration risks (from case history)
• Systemic risks
– Insufficient intake of
hydrating fluid in general (<
1.5 qt/day “rule of thumb”)
– Insufficient fluid replacement
with perspiration
– Consumption of dehydrating
beverages (caffeine, alcohol)
– Use of diuretics (medically
indicated or not, e.g., “water
pills”)
• Recommendations
– 1.5-2 qt water/day (clinical
“rule of thumb”)
– Increase water intake with
perspiration
– Decrease dehydrating
beverages (negotiate!!)
– Decrease use of non-essential
diuretics (negotiate!)
Hydration risks (from case history)
• Surface dehydration
– Exposure to dry ambient
air
– Use of medications that
dry secretions
(decongestants,
antihistamines,
psychotropic drugs)
– Mouth breathing (sleep;
sports)
• Recommendations
– Use direct steam inhalation (5
min/BID, clinical ROT; practice in
clinic)
– Use ambient humidifiers if
necessary ($10-150; hot water;
discuss placement)
– Discontinue non-essential meds
(or seek non-drying alternatives)
– Seek medical evaluation and
treatment for mouth breathing
– Train sports breathing (inhale
through nose if possible); postactivity steam
– Increase water intake (“crosstalk” between systemic and
surface hydration)
Exogenous inflammation risks
(from case history)
• Risks
– LPR
– Smoke exposure (self or
others)
– Chemical exposure
(including workplace;
e.g., theatre)
– Environmental pollution
• Recommendations
– Behavioral LPR
precautions (see
manual; negotiate!)
– Reduce or stop smoking
(negotiate!)
– Address chemical
exposures where
relevant
– Possible use of face
mask?
Uncontrolled yelling and screaming
risks (from case history)
• Risks
–
–
–
–
–
Sports
Work demands
Social
Background noise
Personality, habit (the
“Richie” syndrome)
– Hearing loss
• Recommendations
– Advise you will train
them in loud voice; tell
them to “cool it” for now
until you get there in
therapy
– Hearing loss: Address as
appropriate
– Background noise: Next
page
Vocal hygiene:
Screaming like crazy (bad)
• Specifically: Earplug in one ear in
background noise
• Increases bone conduction; you
hear yourself better and don’t
scream
• Two earplugs even better than
one (hear others’ speech better
too)
http://www.activevibrant.com/catalog/images/hearing/Reusable%20Ear%20Plug
%201260.jpg
Direct therapy
• Manuals and demos