Transcript Rehabilitative Voice Pathology: Ball State Voice Disorders

THE VOICE
Teacher, Conductor, Singer,
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)
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Family Practitioner, Pediatrician, Internist
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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Besides traditional speech pathology training, a voice specialist
has additional training, which includes training in the use of
videostroboscopy, training in normal vs. abnormal anatomy, and
therapy techniques.
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My background:
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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 (CCC-SLP) from ASHA
State Boards(2000) – licensed to practice in Indiana
“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
(S-VHI).
Acoustic evaluation, using
PRAAT software to evaluate
Fundamental frequency, Relative
Average Perturbation, Intensity,
and MPT and s/z ratio.
“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
Videostroboscopy
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Gives the patient
immediate feedback and
opportunity to view their
vocal folds – great
educational tool.
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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
non-professional) 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 the 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.
Occupations at Risk for Voice Problems
(Verdolini and Ramig, 2001)
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The occupational risk factors for voice disorder in US
and Sweden:
Singer
 Counselor/social worker
 Teacher
 Lawyer
 Clergy
 Telemarketer
 Ticket sales
 Health care
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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 this study,
32%-47.5% of responding teachers reported 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.
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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
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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
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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 by a factor of FIVE.
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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 hours of loud 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…
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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.
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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.”
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What’s this about?
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.
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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 IL1Beta (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
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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.
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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 reengineering?
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.
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 self-improvement,
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
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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”.
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Goal: no voice breaks. It engages all the laryngeal muscles,
and encourages a slow engagement of the cricothyroid
muscles.
3. Glide from highest note to lowest note on “boom”
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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”.
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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…(I’m in Booth 419!)
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. 43-50.
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): 432-442 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): 23-29, 2004.
Bibliography
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Branski , R, Perera, P, Verdolini, K, Rosen, CA, Hebda, P,
Agarwal S. Dynamic Biomechanical Strain Inhibits IL-1βinduced 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 formant
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): 937945 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.