Posts tagged #Straw Phonation

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.

 

 

Making Functional Aphonia Treatment Functional

Functional aphonia, conversional aphonia, psychogenic aphonia, acute sudden voice loss, hysterical aphonia....They all are names for the same disorder. In school, I learned that functional aphonia was when a person lost his or her voice and couldn't figure out how to speak again despite trying. In clinical experience, I have found that many factors can contribute to functional aphonia, not all clients are "malingerers" and it takes skill, patience and experience to separate these malingerers from those truly in need of voice therapy.

With this diagnosis, many insurance companies deny at the hint of anything functional. They see "functional" and read it as the patient is "choosing" not to speak. It doesn't help that some patients receive secondary gain from this disorder and "milk it for all it is worth."  This may sometimes be the case, but for most functional aphonics, this disorder is something they cannot recover from without intervention. It usually occurs following an illness (such as an upper respiratory infection) or following a traumatic or emotional occurrence. It may even develop as a result of fear.

Before speech therapy was seen as an appropriate intervention technique, psychogenic aphonia was treated in very odd ways. One way was essentially "suffocating" the patient to evoke a vocal cry of alarm. Other treatments included using electricity, grabbing the tongue, water torture or cocaine applied to the laryngeal mucosa. Yikes...None of my therapy techniques include any of these thankfully.

The first functional aphonic patient I ever saw was by observation only. She was a young woman who had a child at home. Being a single mom, she worked at a very demanding job where she had to use her voice all day. She was receiving voice therapy fully paid for by her insurance company, and her job was giving her time off for short term disability. Each time she would come for a session, we made progress and she was able to find a wonderful and resonant target voice. The next time she would come in, the voice would be whispery and diminished again. It made me wonder if she was just using the time off for whatever personal reason, but the struggle in each session to achieve a normal sounding voice was all too real.

A memorable functional aphonia patient I saw was in a hospital where I worked. He had not been intubated, and I spend most of the evaluation trying to figure out if he was faking or not. Malingerers are out there... The more I found out about his family and the emotional trauma of what brought him to the hospital, the more I realized that the trauma itself had changed how this man functioned in every way, including how he spoke. It took 3 sessions before he even made a noise, but through semi-occluded vocal tract exercises with a straw in a cup of water, we were able to bring him into a complete and normal speaking voice in no time.

This population can be difficult to treat because, like most voice cases, no "one" treatment will work all the time. I have compiled a list of tricks and tips to help any SLP treating a functional aphonic achieve that "light bulb" moment.

  1. Bubbles in a cup. Begin with water in a cup, 1/3 of the way full or so. Have the patient place the straw in the water and blow air until bubbles are seen. This gives the patient visual feedback that air is indeed flowing. Next, have the patient begin to hum this way. Sometimes the distraction of the cup, the vibration of the bubbles and the noise made is all that is necessary to get phonation to occur again.

  2. Gargle. If the patient is appropriate and not an aspiration risk (i.e. not bedbound or on a ventilator), get some warm salt water, or plain water to gargle.

  3. Raspberries or tongue trills. These semi-occluded vocal tract exercises are based on the same scientific idea as straw phonation, but these easy productions may be the key for some patients.

  4. Laughing. Get out your joke book here. Sometimes all that is needed is good old-fashioned joking around. Some YouTube videos can be used as well. I like this old superbowl commercial about herding cats. It's hysterical.

  5. Being silly. Act out some lines from a play in ridiculous accents or at different tempos.

  6. Masking. If you have headphones with some white noise you want to use, great! If you are interested in a more budget friendly and quick trick, crinkle paper towels or plastic next to both ears while having the patient attempt to phonate.

  7. Technology. Use your phone or a small recording device to record the patient making these noises. Sometimes patients will not even believe it is really them in the recording, so videos are the next step here.

Laryngeal Reposturing (ideas from Nelson Roy) can also be helpful in these cases. The book, Exercises for Voice Rehabilitation, shows this nicely in detail, but it is best learned from a practicing clinician.

Make sure you are utilizing negative practice in your sessions because the quicker the patient regains the ability to reorganize his or her own kinesthetic framework for phonation, the quicker the patient can get back to a normal life.

-ATVC

 

References:

Kollbrunner, Juerg; Menet, Anne-Dorine; Seifert, Eberhard. Psychogenic aphonia: No fixation even after a lengthy period of aphonia. Swiss Med Weekly, 2010,; 140(1-2):12-17.

Stemple, Glaze & Klaben. Clinical Voice Pathology: Theory and Management, Fourth Edition. Plural Publishing, 2010.

 

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.

 

 

Avatars, Tigers and Bears Oh My! (and straws)

Avatars, Tigers and Bears Oh My! (and straws)

by atempovoicecenter atempovoicecenter on 06/09/14

 

Voice rest recommendation got you down?

Well, fear no more. I wish to share with you an amazing speech generator that you can use for yourself or recommend for your patients. I mean, this thing is right out of an episode of 30 Rock. You can find a Jack Donaghy-sounding voice and make him talk for you so you can really get the voice rest your speech pathologist is recommending. It features an avatar of your choice and can even speak in different accents.

 

Need a louder voice?

Here is a link for a cell phone amplifier. It can amplify up to 40dB! On this website, serene innovations, you can find other useful products as well.

 

And for kicks, here is Ingo Titze's Straw Phonation video from YouTube. This is helpful to "unwind" your voice. Semi-occluded Vocal Tract Exercises, like this one, allow you to make sound without any glottal pressure. This can be helpful to start your day off right with good vocal production, or when you need to re-set your voice after some bad-habit talking. Titze has some great tips in this video.

-ATVC

Posted on September 30, 2014 .