Posts tagged #SLPeeps

Can it be...MTD? Muscle Tension Dysphonia Defined.

Completely over diagnosed. Wrongly diagnosed. Underdiagnosed. What the heck is MTD?

Muscle Tension Dysphonia is a term that describes a certain type of voice problem or voice disruption with massive underlying tension, and no other pathological cause. So you have an odd vocal quality or hoarseness, and you are as wound up as Lindsay Lohan's newest attorney. This tension can be found in the upper body area, like the shoulders, neck, jaw, base of tongue and the larynx. The tension can be painful, and many times there are concomitant conditions like stress and emotional conflict making the symptoms worse. There are 2 types of muscle tension dysphonia according to Clinical Voice Pathology by Stemple et al, and 3 according to the voice doctor, Dr. James Thomas.

Do you see cases of MTD in your practice? MTD can often be confused with Spasmodic Dysphonia, so it is important to correctly identify each. I see a lot of vocal hyperfunction, and it's a mix on the cause. Most of the time it is easy to see that there is overcompensation for lack of true vocal fold mass, movement, etc. You must make sure you are taking into consideration the type of examination when making a diagnosis. No one likes a rigid scope in the mouth, so some laryngeal tension could be caused from the exam itself. 

Three Types of MTD:

  1. Primary MTD (Non-organic hyperfunction)
  2. Primary MTD (muscle tension gap)
  3. Secondary MTD (hyperfunction in presence of vocal disturbance)

Stemple and colleagues describe Primary MTD as excessive tension affecting the voice with no other cause. Dr. Thomas agrees, and elaborates on two different types of Primary MTD. He divides the primary category into two: Non organic dysphonia/hyperfunction and muscle tension gap. Primary MTD can present as hyperfunction on a videostroboscopy examination with complete closure of the true vocal folds, however there is some type of superior constriction present. That means that you will see anterior-posterior or medial compression above the true vocal folds. The false vocal folds may be squeezing together so tightly that your view of the true folds is almost completely obscured. This might make it hard to see if there is underlying weakness. This type of patient may have developed this excessive hyperfunction gradually and now it has become the new normal for making sound. Voice therapy can ease the tension with upper body relaxation stretches, circumlaryngeal massage and tension-free phonation training.

Muscle tension gap is different, Thomas argues. He states that the vocal folds can remain open secondary to abductor and adductor muscles simultaneously contracting during phonation. Like the non-organic MTD, this can be learned and compensatory. It could be a muscular habit that will not die, like if vocal nodules are removed. Vocal nodules can be improved and eradicated usually by voice therapy alone, but some surgeons still operate. The patient has learned the way to make sound with the nodules present, a little like playing football with a poorly inflated football. (You can do it successfully after a learning curve, but it's probably going to cause some trouble. Sorry Tom Brady.) An hourglass vocal fold closure is all that can be achieved. The adductor muscles only have to bring the vocal folds together to a certain degree before the nodules prohibit any further contact with the remaining free edges of the folds. Fast forward to the nodules being suddenly removed by a surgeon, the muscles may maintain that same pattern, and only come together so closely. Voice therapy can teach the patient how to phonate completely (and achieve that full closure again) by teaching new motor patterns.

Secondary MTD involves a pathology of some kind like paralysis or lesions, where the patient is overcompensating for the deficit. Secondary MTD is dubbed hyperfunction representing hypofunction by Thomas. With a pathology present, the patient is utilizing hyperfunction to compensate for lack of true vocal fold use. You need to look beyond the superior constriction here to notice why the patient is squeezing. Is there a paralyzed vocal fold? Is there bilateral atrophy and bowing? Is there a polyp? Is there recurrent laryngeal nerve damage? Voice therapy can be beneficial here, but it would be best to address the underlying issue first. If it is atrophy, the patient's ENT might consider implants or injectables. If it is paralysis, the ENT might recommend waiting about 9 months to see if it is true paralysis before laryngoplasty.

Dr. Thomas has this nice educational video to aid in any persisting confusion.

So when you see a patient with laryngeal hyperfunction, make sure you are determining what is causing the hyperfunction. If you're coming up empty handed (not to be confused with a deflated football in hand), perhaps it is true MTD.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Acquire The Fire: Why Do We Care About Motor Learning Theory?

#Researchtues

Featuring Integrated Implicit-Explicit Learning Approach to Voice Therapy by Cari M. Tellis

I wonder to myself all the time how I would train another SLP to be like me. Would I be good at it? Thank goodness I had skilled and patient mentors, because voice therapy is a difficult bear! And the skills you acquire should set a fire in you to save the world, one voice client at a time. You have to listen closely and train yourself to command poor productions as well as target ones. I wonder too, how did I obtain all of my skills at discriminatory listening and skilled productions? Which learning type was I? I wanted to spare you the hairy read of this very thought provoking article, and try to give you the quick and dirty. I had time to peruse this article thoroughly, so here is the scoop.

Don't freak out just yet. I had flashbacks to graduate school cognitive therapy classes and I almost began to have a melt down. Let's begin with Implicit Learning. This is what you pick up on in your unconscious learning abilities. Easy, right? You can think of it as how a child learns communication skills as he or she grows and develops. Babies, Implicit babies. Children demonstrate new receptive and expressive communication skills in new ways literally every day and they did not sit through a powerpoint presentation to do so. Plenty of studies have looked at Implicit Learning and say that skills learned implicitly mean that a person has no conscious memory of learning the skill.

Continue to breathe, do not freak out. Let's discuss Explicit Theory now. This is learning tasks or information after detailed instruction. You must easily be able to demonstrate this newly acquired skill on command. This can be done because you had someone telling you the most optimal way to achieve that target production or skill. Explicit teaching is thought to streamline you to the best possible outcome. Think of every CEU you have ever earned. Now, all of that information was most likely learned explicitly through whatever forum you decided to obtain it from...be it online, classroom instruction, one-on-one training, whatever. Explicit learning is usually the mode of choice for left brained individuals, and this is because it appeals to the organized and supported way to learn new information.

So now that we have defined Implicit and Explicit, there is one more potentially complicated term pair that might get your knickers in a twist: Top-down and bottom-up. Okay, the flashbacks are here again. Bottom-up is where you begin with implicit learning and scaffold to explicit learning. Top-down is the exact opposite. This article suggests that combining both, regardless of which is first, can support all learning avenues and give you the best outcome.

So why do we care about how a person learns new information? Because voice therapy attrition rates (fancy word for drop out) are climbing. With 30% of adults reporting voice issues, 65% of them drop out of voice therapy prior to achieving some sort of positive result. Is this because we as voice therapists aren't appealing to each person's learning type right off the bat? It's worth looking into how well you can identify a person's preferred skill acquisition type because your therapy can then propel the client on the most efficient path.

You don't want to overwhelm or confuse clients in the therapy room. Yes, you know your stuff, but they don't care. They just want to get better. So where do you start? Your run-of-the-mill voice therapy sessions utilize auditory-perceptual, implicit learning to get the job done. This is when you produce a target sound, the one you want the client to mimic, and they produce it exactly. Why do we do this? We hope that eventually after practice and repeating-repeating-repeating, the client will generalize because all toddlers walk eventually. Implicit babies, remember?

This is all well and good, but what about when the client is home and discharged from therapy. Can he or she conjure up the targets again? How will the client know if the targets are correct targets? This is where the importance of explicit learning comes into play. Explicit teaching needs to be completed by a therapist who is well versed in anatomy and how the anatomy functions properly and in error. We can only see so much of our speech mechanism (tongue, lips, teeth etc.) and we are left to depend on feeling, visualizing and hearing the rest. So we create metaphors for our clients. Kittie Verdolini cautions to be careful of over doing the metaphors in the therapy room because although they may facilitate, they may confuse.

So Misericordia University and its Voice Science Laboratory have come up with this 5 step process to combine the best of both learning processes for voice therapy purposes. This is because they feel that your brain works better if you are presented with easy and difficult tasks from day one. This should promote generalization outside the therapy room and cut down on in-therapy frustration.

Step 1 is to teach basic auditory perceptual cues to get the client to produce sounds. Have the client ahh like you, then ask the client assess the production. Based on the answers and production accuracy, you can then decide what the client is stimulable for and use that to guide your therapy technique choices. (Oh, and this is implicitby the way.)

Step 2 is teaching anatomy and physiology for my favorite part of the body. The laryngeal mechanism and how it works can be taught two ways, depending on your learner. Part-whole and whole-Part. (Don't hyperventilate, no flashbacks please.) The part-whole peeps learn specific ahhs, oohs, eeehs, forward resonance, back resonance, etc. and then prefer to piece together how they add up to a target voice quality. The whole-part peeps prefer achieving the desired quality before those specifics are even discussed. Decide which your client is, then go. And don't worry, experts and novice voice clinicians both obtain a similar outcomes for patients when helping them while relying on perceptual measures only. Trust you ears and eyes people. (Step 2 is explicit, in case you were testing yourself, you overachiever you.)

Step 3 is adding gestures. Yes, like your voice teacher did with rainbow phrasing and your own personal arm rainbow. Yes, like you do with your little ones while teaching "sh" and running your hand up your arm. Yes, like you do when describing an exquisite Italian meatball dish your grandmother used to whip up. (Lip pucker optional.) Research shows that using gestures offloads the cognitive mechanism. Maybe the Italians are on to something...

Step 4 is, surprise, letting your clients do the work with your guidance. "Deliberate practice is important to skill learning and improves performance and reduces the potential for practicing improper voice productions." Help your clients generalize by giving them a firm base of implicitly and explicitly learned skills to pull from. Guide their practice so they can generalize in a variety of contexts.

Step 5 is nurturing fully capable clients. They have used top-down, bottom-up, part-whole, whole-part, implicit, explicit, however and whatever. They can troubleshoot their own productions and hopefully help themselves in the future because of the expert knowledge and skills you have given them.

Help decrease attrition! Acquire the fire! This study pulls from much hard work and it is right here at your fingertips to take to the streets....or therapy room...hey, you might givevoice therapy on the streets...I don't know. Anyway, happy Research Tuesday!

-ATVC

 

 

 

References:

Integrated Implicit-Explicit Learning Approach to Voice Therapy. SIG 3 Perspectives on Voice and Voice Disorders, November 2014, Vol. 24, 111-118. doi:10.1044/vvd24.3.111

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

The Theme is Scream: Can You Scream-Sing Properly?

Have you heard those heavy metal screaming bands? They may not be your cup of tea, but you might end up with a lead-singer from this type of genre on caseload someday. These singers growl and grunt on a nightly basis when on tour, so how is the voice not completely wrecked? Screaming is not only hard on some people's ears, it is hard on the vocal folds as well. There is, however, a ray of hope for those suffering from vocal issues as a direct result from their love affair with screaming metal music.

As Melissa Cross explains, proper screaming technique can be taught. She instructs singers to scream properly so they can avoid damage to their vocal folds. These screaming performances night after night will take a toll, so without proper training, she warns, it could end a career. You can scream using your true vocal folds and/or your false vocal folds. Your true folds are more delicate than your false, and they have no nerve endings. They vibrate together about 500 times per second, and can swell with overuse and misuse. This swelling is what causes roughness and hoarseness in the vocal quality, because the true vocal folds can no longer vibrate efficiently with increased weight.

Enter, the false vocal folds, sometimes called vestibular folds. The false folds are located right above the true folds and can vibrate together much like the walls of the throat would vibrate for a laryngectomee with a tracheoesophageal prosthesis. This man has had his voice box and vocal cords removed and is using a hands-free prosthesis to inhale air from his stoma. The air does not exit the way it entered, and is forced up through the throat tissue. That is why he sounds the way he does. This is also different from the electrolarynx. Have you seen that tobacco commercial? The electrolarynx is held against the outside of the neck and sends vibrations through the tissue that can be shaped by your mouth, tongue, teeth and lips to produce words and sentences.

Growling is utilized in mainstream music too, but much more infrequently. Artists like Carrie Underwood and Christina Aguilera both use their false vocal folds to add intensity to some of their phrasing. Here, Carrie growls at 1:23 on "fight" and here Christina does it on "My" at 0:03 and on "touch" at 2:38 here.

Ms. Cross is interesting to me because she is a classically trained voice teacher and she is educating a select population on how to effectively use their mechanism for the sound of choice for their music style. She aims for multiple overtones in the screams she teaches, which I would hope would decrease any resultant hyperfunction from too low or too high of a scream. She warns not to utilize both folds simultaneously, for fear of overuse as well.

There is information that is erroneous out there too. Here is someone saying that the epiglottis is responsible for the growl. Um, no. We have this video, I don't know why she is teaching the student to vibrate his palatal arches, but she is. Perhaps she is trying to eradicate any accidental use of the true vocal folds? But why not educate the student on the whole mechanism? The diagram gives me shivers.

Ms. Cross is due to discuss her techniques on a NATS Chat in February, and I'm very interested to hear what she has to say. Her techniques are unusual, but obviously encourage a balanced vocal subsystem of equal parts air, sound and resonance. Your opera singing vocal teacher might cry blasphemy, but it is all the same mechanism, and I haven't run across anyone else who has taken on this niche. Very cool.

 

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Twang, Twang Into the Room: A Look Twang as a Therapy Technique

#researchtues and #bangbang

Resonant Voice Therapy might have let you hold its hand in school, but I'm gunna show you how to graduate...haha. I can't get that song off my radio!

When I came across the title to the research article I am featuring for this week's Research Tuesday, I wondered to myself about my own "twang" and how often it probably rises to the surface since I'm from Texas. I treat clients often who have a twang of their own and I smile when it is very apparent because it makes me proud to be a Texan and to call this great state my home.

You all may be familiar with Resonant Voice Therapy and its uses for unloading the vocal mechanism. You may not be familiar at all with "Twang Therapy Techniques." Joanna Lott defines it as, "an aryepiglottic narrowing to create a high intensity vocal quality while maintaining low vocal effort." This is narrowing the aryepiglottic sphincter, as evidenced in this video. Elpida Koutsoubaki, Voice Therapist (from Athens, Greece), is using this to review the patient’s progress. She had received 3 voice therapy sessions leading up to this. “She is one of many patients with bilateral vocal fold paralysis for whom twang therapy has mercifully delivered a fully rehabilitated and functional voice (and breath support),” Elpida says.

Still wondering how Twang sounds? Think Lois Griffin from Family Guy. Yanagisawa, Lombard & Steinhauer describe it similar to an oboe, banjo or duck quack. I'm thinking, 'Yeah I already have my patients try enough crazy sounds, what's one more animal sound-a-like?' It turns out, twanging, for lack of a better term (so as not to confuse others with Miley Cyrus and her antics) could really benefit a client in the therapy room.

Twang constricts the vocal tract in a way that clusters formants in an acoustically pleasing way because it complements the resonant frequency of the ear canal. Because it increases the perceived loudness levels for the listener, the client can increase volume without increasing effort. Pretty cool, huh?

And.....drumroll please....another guest appearance of, yes, wait for it..... INERTIVE REACTANCE. This is where the back pressure created by this "tube within a tube" eases the pressure and allows the vocal folds to self-sustain vibratory cycles with no excess effort for the patient or performer. (Just like Straw Phonation!)

But is there a danger of bad production habits? With any therapy technique, you must be knowledgeable about it going badly in order to keep your patients on the right side of the line. Aryepiglottic constriction has been found to be present in every-day vocal production, so it is safely utilized by the general public. Hyperfunction, on the other hand, is any false vocal fold medial constriction and is strictly prohibited because it recruits excess and unnecessary muscular effort to phonate. Make sure you are monitoring the difference carefully when utilizing this in the therapy room.

This can also treat the hypophonic voice, as a study by Lombard and Steinhauer proved in 2007. Vocal fold paralysis or atrophy can lead to a breathy, unsupported vocal quality. After receiving voice therapy sessions using twang intervention, all of the participants were very happy with the finished product and that they were increasing intensity without sacrificing effort or coming across like a country-music singer. I wonder how it would work with tandem with an LSVT approach?

When utilizingthis technique, it is important to know how to distinguish twang-y from nasal-y, as evidenced in this video. He is referencing Jo Estill's twang teaching, and educating on how to utilize your aryepiglottic folds when twanging. He explains about the soft palate movement nicely as well.

More studies are needed to determine the effects of twang therapy, so "get a ride in the engine that could...go..." and twang twang into the research scene!

 

-ATVC

References:

Joanna Lott; The Use of the Twang Technique in Voice Therapy. Perspect Voice Voice Dis 2014;24(3):119-123. doi: 10.1044/vvd24.3.119.

Also, Elpida has offered to answer questions re. application of Twang to bilateral vocal fold paralysis.
You can reach her at ivoicetherapy@gmail.com

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

 

The Right Choice When Treating Transgender Voice

 

Transgender Voice Changes. Those words may be intimidating or "something I read a sentence about in graduate school," but they represent a much needed area of education and support. This is not a matter of agreeing or disagreeing with the transition to the opposite sex, but of helping patients in need. We, as speech-language pathologists, are bound by our code of ethics to maintain a cutting-edge perspective in our area of specialty. Any SLP with a license should be aware of this type of service and what is happening in current events.

Just as we are capable of effectively modifying phonemes in children, we have the skills to modify pitch and resonance in transgender voice intervention. We cannot, however, refuse to treat these patients because of our own beliefs. I may believe feeding tubes are unethical, but I cannot refuse to complete a swallow evaluation and treatment based on how I feel. I have a responsibility to evaluate and treat a person coming to me for help if I possess the skills to improve that person's quality of life. 

Voice sessions are usually one of the first things a client begins after hormone replacement therapy has started. Modifications to frequency, resonance, inflection, gestures and word choice are targeted with great care to avoid tension that would cause vocal damage. Sessions require anywhere from 4-9 months and are much more labor intensive than a surgical procedure. The journey to the opposite sex is different for each client, and sometimes gender fluid clients may have goals for a voice quality that is "in between." Clients are often emotional and full of uncertainty and apprehension about what to do next, so determining which personal pronoun your client prefers is important. Maintaining cultural competence and compassion for this population is vital because like the iceberg of fluency/stuttering, we only see 10% of what exists.  

A question is raised, though, about the ethics of providing services to modify or enhance communication performance. Is gender dysphoria a disorder? The DSM-5 recognizes it as a disorder with a specific diagnosis code, and it is not our place to determine the validity of medical diagnoses. Our scope of practice includes typical and atypical communication in the following areas: resonance, language and voice. It also specifically states that we provide clinical services to modify or enhance communication performance for things like accent modification or transgender voice. Speech treatment helps a person overcome an obstacle, and in our code of ethics, it specifically states we cannot discriminate in the delivery of professional services on the basis of gender, gender identity/gender expression or sexual orientation. We help children use fluency tools to overcome the obstacle of stuttering, we strengthen and re-educate swallow muscles to overcome the obstacle of aspiration, and we help those uncomfortable expressing themselves overcome that obstacle so they can fully express who they are. 

So what about billing? What we can bill for is diagnosis driven, and reimbursement is determined by the patient's individual insurance plan. As long as treatment is appropriate for diagnosis, you can bill for your services. As with any other service denial, appeals can be made, but sometimes the patient is left responsible for the balance. Yahoo news published an article about insurance coverage for transgender sex-reassignment health care. It stated that some Fortune 500 companies were adding coverage for this type of health care for their employees. This includes sex-reassignment surgery (SRS) and hormone therapy as well as some counseling. The coverage, however, is not extended to cosmetic surgery. Voices are used to communicate and they are the first thing others hear when we make a phone call, but at this point in time insurance companies do not consider transgender voice changes medically necessary. 

Voice intervention allows these patients to finalize a missing puzzle piece, check off a box and become more comfortable in their own skin. Transgender clients are just like other speech clients and only wish for the best quality of life. For them, that means voices to reflect who they are on the inside. A speech-language pathologist can make every difference by utilizing his or her unique skill set and experience to help.

Education is the most effective tool we have for helping clients generalize treatment goals, so why aren't we educating ourselves at every opportunity?  If you don't feel competent treating individuals who wish for transgender voice change, you are obligated to seek out and refer the patients to clinicians who do. There is a Facebook group which can help with finding a qualified clinician called "Transgender Voice & Communication." Also, WPATH SOC 7 has included voice and communication in their standards of care. We may encounter transgender patients, students, colleagues or clients, so whether or not we agree or feel comfortable with their lifestyles, we must strive to be culturally sensitive to all populations. 

Portions of this blog were originally published in November 2014 on www.atempovoicecenter.com, but have been updated and modified for this post.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Posted on November 24, 2014 .

Voice Rx: Birth Control, Tylenol and Breath Support?

I was listening to a podcast from NATS (National Association of Teachers of Singing) this week and was surprised when I heard that Dr. Robert Sataloff was being interviewed. He is a special physician because he has his Doctor of Musical Arts in Vocal Performance from Combs College of Music in addition to being an otolaryngologist and a musician, which peaked my interest immediately. I am sure that others know of him already, but this was news to me and it made me excited. I couldn't wait to hear the questions that the NATS group had for him.

This chat was on the subject of performing arts medicine and care of the professional voice. The first question raised was in regards to PMS. I immediately thought back to voice changes that Moya Andrews talked about around "that time of the month" in one of her books. The doctor said to consider avoiding any diuretics or water-shedding pills when you are about to start your period. Why? Because during the pre-menstrual time, the vocal folds are swollen, like other muscles in your body, with a protein-bound edema fluid which will not be expelled by a diuretic. The only thing that taking these pills would do is strip the essential epithelial lubrication on your vocal folds and make them more susceptible to damage from overuse and misuse. The swelling remains until the woman's period has finished. His recommendation for the few days prior to your period beginning? Stay hydrated. I'm thinking, yeah....let's add more fluid to the mix....Mucinex will not compensate for the benefits of hydration, but it might help you thin secretions when they are too thick. You should avoid any bloating pills if you are a professional voice user. He also recommends in some extreme cases that birth control pills can help with avoiding that fluid overload altogether by hormone regulation.

Next he addressed pain killers. Ibuprofen and aspirin were discussed in detail in regards to the effects on the voice, but the consensus was that Tylenol or any acetaminophen was usually safe for the vocal performer. Ibuprofen (Advil and Motrin) thins your blood and puts you at risk for vocal fold bleeding for only about 24 hours. For the time the drug is still in your system, you should be careful not to strain or overuse your voice. Aspirin, he warned, is even more dangerous to the professional voice because its effects last 7-10 days after just popping one pill. It interferes with platelet function, so it increases the bleeding risk for a person. He also says that if your blood vessels are already dilated and delicate (ie you are about to begin a period or are sick with laryngitis or a cold) and then you consume ibuprofen or aspirin, you are at very high risk for hemorrhage of the vocal folds. Old types of birth control pills with high doses of hormones used to cause some consumers to lose part of the upper vocal register and when pills were ceased, the voice returned to normal. New BC pills, though lacking formal studies, don't seem to be having that dramatic of an effect on the voice because they contain much lower amounts of hormones. He warns women to be wary of birth control pills containing androgens (male hormones), as they may lower the pitch of the voice.

He discussed vocal fry with one listener. This is the way a Kardashian speaks, with a low, guttural creak at the end of almost every utterance. We categorize our voices within 3 registers or physiological frequency ranges: modal (normal)-- falsetto (high)-- and fry (lower). For modal register, the vocal fold vibratory cycle contains vocal folds spending an equal amount of time open as they spend closed. Falsetto produces sound with the vocal folds barely touching or not at all. Vocal fry is different. Vocal Fry produces sound with a very long vocal fold contact time. Here, the majority of the sound production time is spent with closed vocal folds. It is this constant contact in combination with the pressing that causes the vocal fold damage and makes this a vocally abusive behavior. Most of the time, Dr. Sataloff says, people are using poor breath support when they utilize the fry register. I know I find myself doing it when I'm lying in bed on the phone or when I'm tired.

When a person presses, he or she is squeezing the muscles of the larynx to make sound instead of letting the breath do the work. He reminds us that most of the time, using vocal fry is abusive to the vocal folds.

He also discussed the importance of diaphragmatic breathing and body awareness to treat MTD or Muscle Tension Dysphonia. He encouraged relaxation awareness to improve outcomes for professional voice users and even gave a "shout out" to Speech-Language Pathologists and singing voice specialists and our important role in treating this disorder in speakers and singers.

This was a nice breath of fresh air about voice and medicine and I am thankful this was shared on a twitter account I follow.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.