Transcript Rehabilitative Voice Pathology: Ball State Voice Disorders

THE VOICE:
The Role of Rehabilitative Voice
Pathology in the life of the
Teacher, Conductor, Singer and
Student
Rebecca Miles Risser, M.M.,M.A., CCC-SLP
Clinical Speech Pathologist, Voice Specialist
Performance Voice Solutions
12065 Old Meridian, Suite 255
Carmel, IN 46032
317.705.2732
[email protected]
The Voice Care Team
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The Primary Care Physician (PCP)
– Family Practitioner, Pediatrician, Internist
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The Otolaryngologist (ENT) or Laryngologist
Speech Language Pathologist (specialized in
voice)
Voice Scientist (Researchers)
Voice Teachers (Private, choral directors,
etc.) and voice coaches (private)
Our Group
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Performance Voice Solutions is a division of
Northside ENT, Inc., and together consists of
one slp and four ENTs.
Model of Care reflects strong autonomy and
respect between clinician/physician with
frequent, nearly daily, consultation re:
patients and current research.
“Voice Specialist”??
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ASHA does not formally recognize the distinction of
voice specialist or the additional training required
for a “voice specialist”, as it does for swallowing or
for dysfluency, for example.
Additional training includes training in the use of
videostroboscopy, training in normal vs. abnormal
anatomy, and therapy techniques.
My background:
– Masters of Music (1990) in Performance and
Pedagogy – NIU,
– Masters of Arts (2000) in Speech Language
Pathology – IU
– National Boards (2000) = Certificate of Clinical
Competency in Speech Language Pathology (CCCSLP) from ASHA
“What do you do,
anyway”?
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Voice Evaluation
Indexes to baseline
issues of reflux (Reflux
Symptom Index), the
Voice-Related Quality of
Life (V-RQOL) and the
Voice Handicap Index
(VHI), or the Singer’s
Voice Handicap Index (SVHI).
Acoustic evaluation,
using PRAAT software to
evaluate Fundamental
frequency, Relative
Average Perturbation,
“What do you do,
anyway”?
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Videostroboscopy
Slow motion
photography of the
vocal folds, as they are
vibrating.
Immediate, magnified
imaging for presence or
absence of pathology.
Allows clinician to view
even very small
changes in the vibratory
capacity of the vocal
folds
Gives the patient
immediate feedback
and opportunity to view
their vocal folds – great
Videostroboscopy
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Gives the patient
immediate feedback
and opportunity to
view their vocal folds –
great educational tool.
Once strobe obtained,
then complete the
Reflux Finding Score
(Belafsky, Kouffman, et
al.)
The most common diagnostics noted
with teachers, choral directors, singers
and voice students .
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At Performance Voice Solutions, the top
four diagnostics associated with teachers,
including singing teachers, choral
directors, singers (professional and nonprofessional) and voice students include:
Singers nodules
 Polyps/cysts
 Hyperfunctional dysphonia (depending on the
type of singing)
 Laryngopharyngeal Reflux Disease
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Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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In the United States, roughly 3-9% of the
general population has some type of voice
abnormality at any given moment.
With the advent of information age, voice
has assumed an increasingly important role
in job function.
Conservative estimates indicate that over
25% of the working population (i.e.
28,000,000 people) list voice as a critical
aspect in their job.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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The occupational risk factors for voice
disorder in US and Sweden:
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Singer
Counselor/social worker
Teacher
Lawyer
Clergy
Telemarketer
Ticket sales
Health care
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Let’s talk teachers…
– Various studies have been completed, with a
range of responses, but in general at the time of
the study, 32%-47.5% of the teachers
responded that they were currently hoarse.
– 20-30% indicated they had missed work the
previous school year because of voice problems.
– 38% reported negative effect of teaching on
voice
– 39% were currently reducing work (reducing
teaching activities) due to voice.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
 “Considering
only lost work
days and treatment expenses,
the societal cost of voice
problems in teachers alone
may be…about $2.5 billion
annually in the U.S.”
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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More on teachers…
– Female teachers reported voice problems
more frequently than males (38% vs.
26%).
– Physical education teachers presented
highest risk, independent of gender,
hours of teaching per day, number of
years teaching or age
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Other studies:
– 55% of respondents indicated dry throat;
– 45% had vocal fatigue
– 36% had scratchy sensation;
– 32% had throat discomfort
– 31% had to make an effort to talk after
teaching.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Now, singing teachers…
125 singing teachers with 49 control
subjects completed questionnaires.
21%of singing teachers had voice dysfunction
(18% of controls) = not a significant
difference
 HOWEVER, 64% of singing teachers had
voice problem in past (33% of
controls)…SIGNIFICANT
 A history of voice dysfunction in the past
increased likelihood of current voice problem
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Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Singing teachers continued…
The current use of dehydrating medications
increased the likelihood of current voice
problem by THREE.
 Hmmmm….an increase in the estimated
hours of LOUD singing per day appeared to
have a protective effect; an increase in the
number of loud hours of singing inversely
predicted the likelihood of a current voice
problem by a factor of three. (authors
interpreted this as an effect of healthy voice
not a cause of a healthy voice).
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Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Singing voice teachers…
– Congratulations!
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Large proportion of singing teachers with
current (56%) or past (83%) voice problems
sought professional help.
– HOWEVER…in this study, no singer or
control respondent with a current voice
problem had received voice therapy for it.
Only 4% of respondents with a past voice
problem had received therapy.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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Choral singers:
– National Convention of Gospel Choirs and
Choruses (NCGCC) and American Choral
Directors Association (ACDA) were polled.
– Most of the NCGCC members were
African American; most of the ACDA
members were Caucasian.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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50% of gospel singers reported
current perceived hoarseness in
comparison to 35% of classical singers
Hoarse AA singers were neutral about
seeking voice treatment; hoarse
Caucasian singers were “likely” to seek
treatment or “intended” to seek
treatment.
Occupational Risks for Voice
Problems (Verdolini and
Ramig, 2001)
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For AA respondents, others’ opinions about
treatment appeared to predict the likelihood
of seeking treatment for current voice
problem. In other words, a cultural bias
influenced them.
For Caucasian respondents, one’s own
opinion or “feelings” about seeking
treatment predicted the likelihood of
seeking treatment. In other words, a
personal bias influenced them.
So how can we
fix the
problem?
Novel thought #1…
Let’s start
talking
with each
other!
Thoughts from my choral
director/patients
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“I wish someone had told me about the
connection between my singing voice and
my speaking voice.”
– What’s this about?
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How do we achieve vocal rest in a healthy
functional way apart from “shutting down”?
“Tell them that the speaking voice requires a
warm-up before the teaching day begins.”
Thoughts from my choral
director/patients
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“Talk about female teachers
demonstrating for male choirs”
– Recording parts on “smart music” and
emailing the parts to the students;
– Having a high school male record the
singing parts for extra credit.
– For noisy groups: visual cues mounted on
craft sticks.
Novel thought #2…
It IS possible to
use a healthy
voice to teach,
sing, AND even
have a voice
that’s as good or
better at the
end of the day!
Vocal Fold Wound Healing
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In 2003, Branski, et. al found that low
levels of dynamic, biomechanical
stress inhibited IL-1Beta (associated
with inflammation) in injured tissue.
Vocal tissue from rabbits were exposed
to variable levels of cyclic tensile strain
(repetitive rotating vibratory
movement similar to vocal cord
vibrations).
Results
1.
2.
CTS reduced inflammation by inducing the
increase of “collagen synthesis” (i.e. a
marker for healing of injured tissue) in the
presence of IL-1Beta.
Therefore, low-levels of biomechanical
stress induced wound healing by
decreasing the time it took to move from
inflammation to tissue rebuilding.
Results
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Another Branski study compared two groups
of performers, one with vocal fold nodules
and one with healthy larynxes.
– Both groups were able to produce a resonant
voice as compared to a pressed , a normal, and
a breathy voice.
– “resonance” approximated the configuration in
Branski’s study, in which low-level biomechanical
stress induced wound healing faster.
The missing link…
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“Resonant voice” also corresponded to
easy, clear resonance advocated by
Lessac Madsen Resonant Voice
Therapy, and to the “mask” resonance
advocated by singing teacher of solo
singers.
Voice therapy or tissue
re-engineering?
Therefore, voice therapy
techniques enhance biological
phases of wound healing in
recurrent, acute
phonotrauma.
So, what should I look for?
Let’s start
with your
students…
“How do I know if my
student needs to see a voice
specialist?”
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1. Speaking voice and singing voice should
both be smooth and easy, with no
roughness, no breathiness.
2. If they become hoarse, it should last no
more than two weeks, and this should be no
more than 1-2 times each YEAR.
3. Extroverted individuals will likely have
vocal fold nodules; introverted will likely
have muscle tension dysphonia.
But what if it’s not the
student !?!
Now let’s
take a look
at
YOU
“That ain’t right”
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1. Hoarseness is not normal.
2. Breathiness is not normal.
3. The “Monday-Friday effect” is not
normal.
3. Missing whole sections of your
voice? NOT NORMAL.
What can we do?
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1. Amplify. Get a microphone system
either through your school (no, really,
they sometimes do this…) or rig
something up at Radio Shack (not a
paid, promotional advertisement).
2. Warm up your speaking voice
before your first class (Vocal Function
Exercises).
What can we do?
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3. When you teach, it’s better to speak
10 minutes “on” then 10 minutes “off”
throughout your day.
4. Restore your voice through easy,
resonant glides to regain focus and
reduce effort
5. Listen to your body – where it is
tight?
The “Take Home”
Let’s learn a
fantastic
warm up
together…
Vocal Function Exercises
(Joseph C. Stemple, Ph.D.)
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In our current climate of selfimprovement, voice improvement is
not only for the disordered voice but
also for those who want to enhance
vocal health and image.
Voice is one part of the physical,
emotional and life-style status of an
individual.
Wellness Line
Disordered voice
Outstanding voice
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Normal voice
The program
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1. Sustain “ee” vowel for as long as
possible on F3 for adult males, F4 for
adult females and children
– Goal: should be equal to sustained /s/ in
terms of time. Vocal quality is forward
but not quite nasal. Voice should be
engaged and not breathy. (I encourage a
“twang” sound to narrow the AES)
The program
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2. Glide from lowest note to highest on
“whoop”.
– Goal: no voice breaks. It engages all the
laryngeal muscles, and encourages a slow
engagement of the cricothyroid muscles.
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3. Glide from highest note to lowest note on
“boom”
– Goal: no voice breaks. By keeping an open
throat, it encourages the engagement of the
thyroarytenoid muscles without the presence of
a back-focused “growl” – No Growling!
The program
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4. Sustain musical notes (C-D-E-F-G)
for as long as possible (for lower
voices, A-B-C-D-E) on the word “knoll”
or “moe” or “no”.
– Goal: should be equal to sustained /s/ in
terms of time. Vocal quality is forward
but not quite nasal. Voice should be
engaged and not breathy. This is
considered a low impact, adductory
power exercise.
Program “Notes”
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All exercises are done as softly as
possible, per the author’s notes. In
keeping with other literature, it should
be kept as soft as possible, while
maintaining a clear tone.
Let’s keep our
conversation going…
GO FORTH
AND
PHONATE!
Bibliography
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Blaylock, Thomas R., Effects of Systematized Vocal
Warm-Up on Voices With Disorders of Various
Etiologies. Journal of Voice. Vol. 13, No. 1, pp. 4350.
Branski R.C., Verdolini, K., Sandulache, V., Rosen,
C.A., and Hebda, P.A. Vocal Fold Wound Healing: A
Review for Clinicians. Journal of Voice 20(3): 432442 September 2006.
Branski, RC, Verdolini, K, Rosen, CA, Hebda, PA.
Markers of wound healing in vocal fold secretions
from patients with laryngeal pathology. The Annals
of Otology, Rhinology, & Laryngology 113 (1): 2329, 2004.
Bibliography
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Branski , R, Perera, P, Verdolini, K, Rosen, CA,
Hebda, P, Agarwal S. Dynamic Biomechanical
Strain Inhibits IL-1β-induced Inflammation in Vocal
Fold Fibroblasts. Journal of Voice, 21(6): 651-660
2007.
Branski R, Verdolini K, Rosen, CA, Hebda, PA. Acute
vocal fold wound healing in a rabbit model. The
Annals of Otology, Rhinology & Laryngology 114(1):
19-24 2005.
Ford, J.K., Preferences for Strong or Weak Singer’s
forman Resonance in Choral Tone Quality.
International Journal of Research in Choral Singing,
Vol. 1(1) 2003.
Bibliography
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Jiang, J. Vocal Fold Impact Stress Analysis.
Journal of Voice, 15(1): 4-14. 2001
Johns, MM, Update on the etiology,
diagnosis,and treatment of vocal fold
nodules, polyps and cysts. Laryngology and
bronchoesophagology, Current opinion in
Otolaryngology & Head & Neck Surgery. 11
(6): 456-461, December 2003.
Krishna, P, Rosen, CA, Branksi, R, Wells, A,
Hebda P, Primed fibroblasts and exogenous
decorin: Potential treatments for subacute
vocal fold scar. Otolaryngology-Head and
Neck Surgery, 135(6): 937-945 2006.
Bibliography
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Li, NYK, Verdolini K, Clermont G, Mi Q. Rubinstein
EN, et al. (2008) A Patient-Specific in silico Model
of Inflammation and Hearing Tested in Acute
Vocal Fold Injury. PLoS ONE 3(7): e2789. doi:
10.1371/journal.pone.0002789.
Ruotsalainen JH, Sellman J., Lehto L, Jauhiainen
M, Vrbeek JH. Interventions for preventing voice
disorders in adults. Cochrane Databse of
Systematic Reviews 2007, Issue 4 Art
No:CD006372. DOI: 10.1002/14651858.
CD006372; pub2.
Bibliography
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Thomas, L., Stemple, J.C., Voice Therapy:
Does Science Support the Art?
Communication Disorders Review. Volume
1, Number 1, pp. 49-77.
Verdolini, K, Drucker, D, Palmer, P, Samawi,
H., Laryngeal Adduction in Resonant Voice.
Journal of Voice, 12(3): 315-327, 1998.
Verdolini, K., Ramig, L.O., Review:
Occupational risks for voice problems. Log.
Phon Vocol 2001; 26: 37-46.