Posts tagged #Voice

Yodel-ay-i-ay-i-OMG!

Have you ever had a singer on your caseload? Ever had a yodeler? Vocal Hyperfunction can occur in regular singing as well as in yodeling. Classically trained singers and musical theatre style singers use many of the same vocal techniques. Both styles depend on smooth transitions between notes. Rosenberg and LeBorgne refer to a "hybrid singer" in their 2014 publication "The Vocal Athlete," and most singers these days are that. It is important to know about the different types of singing your client might be doing to treat in the most comprehensive way. Treating folks in the south, I get a small group of those who yodel. You are not just born knowing how to yodel, just like you are not born knowing how to sing. Yodeling is an art. It is difficult to do without practice. Just try it! Better yet, try to do what this 12 year old yodeler can do:

So how does one yodel? Yodeling is oozes with heritage because it actually was used to communicate in the extremely tall mountains, where it was difficult to hear because of wind and other climate factors. Yodeling transitioned from this communication option, to being popular in country music. Up until the 1950's, it was prevalent in this scene.

Yodeling is actually the exact opposite of a smooth transition between notes. In classical singing training, we are taught that we should float to notes, never scoop up to them, and definitely never land on them hard. We are instructed to make clean transitions and be thoughtful with where we place the different pitches. Register breaks are seen as improper technique and are discouraged. Yodeling opposes all of that teaching; It is changing your vocal fold tension from high to low registers and actually allowing the break to occur. EMBRACE THE BREAK. It doesn't always have to be in octaves. This goes against all I was taught in my classical voice lessons, but it is relatively easy to mimic if you try it. You deliberately have to break vibratory smoothness, by relaxing. Ha.

So what does yodeling look like? It might help you to see what vocal folds do when yodeling occurs. Here is an examination of the vocal folds, via videostroboscopy. We can see the true vocal folds switch from chest to falsetto registers during the pitch changes. They shorten and lengthen quickly as they do this.

Yodeling, just like any other type of singing, can develop laryngeal tension when it isn't necessary. Make sure when you are yodeling, you keep a relaxed larynx at all times, just like when you are singing in any other style. Make sure you are using enough breath support so you have enough gas in your tank and you don't begin to squeeze those laryngeal muscles.  Hey, if that 12 year old can learn from a tape, maybe you and I can too? And maybe we can give this guy a run for his money.

-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.

Shine Bright Like a Voice Analysis

Why does a voice sound disordered? Does it sound harsh? Does it sound breathy? Does it sound too high pitched? We can hear a voice and perceptually tell that it sounds unnatural. How do we prove this? There are perceptual scales, like the CAPE-V and the GRBAS, and I use the Vanderbilt FITQ scale. (It's a rating scale for Frequency, Intensity, Timing and Quality on a 0-3 rating.) There are self-perception measures like the Vocal Handicap Index and the Reflux Symptom Index. Unfortunately, we can't just say someone sounds dysphonic and expect the service to be covered. Insurance companies tend to prefer hard numbers and measurable data. The perceptual scales are measurable, however they are subject to intra and inter rater reliability issues because on any given day each of us hears things differently.

Many clinicians utilize acoustic measures like Jitter and Shimmer, as well as noise-to-harmonic ratio when they gather data. Jitter is displacement in frequency periods or pitch variations, and shimmer is changes in intensity or amplitude. Noise-to-harmonic ratio is simply comparing the relationship of good sounds to bad ones, and if the noise outweighs the harmonies, then there is dysphonia. These measures are limited because they require the person to sustain a vowel to capture data, and that can be difficult for some voice patients. While it is important to measure sustained vowel productions, but it is vital to measure the voice in connected speech as well. There are reasons for this: 1) Adductor spasmodic dysphonia sounds relatively normal during a sustained "ahh" but is very apparent during connected speech. 2) Sustained vowels are not as multidimensional as speech. Speech contains rapid voice onsets, offsets, inflections, stress, pauses, voiced and non voiced sounds.

What if we could somehow combine how we measure both connected speech and prolonged vowels? Youri Maryn, Marc De Bodt and Nelson Roy developed a protocol that is multifaceted, like a diamond. The voice has many layers and dimensions, so shouldn't it be analyzed the same way? It's called the Acoustic Voice Quality Index. It takes into consideration 6 parameters:  shimmer local, shimmer local dB, harmonics-to-noise ratio, general slope of spectrum, tilt of regression line through the spectrum and smoothed cepstral peak prominence. If these are unfamiliar terms, that's okay. Just know that the sound signal is being analyzed in different ways and tested to determine if the numbers accurately reflect what is heard perceptually. The testers in this article are making sure that if a voice quality sounds disordered, the numbers consistently reflect this when compared with numbers from a normal sounding voice. 

Cepstral peak prominence is an emerging measure for acoustic analysis. (Cepstrum is spectrum with the letters rearranged, but it the calculations to find it are a bit more involved.) The more periodic a sound signal is, the more you will see a prominent cepstral peak, so we are looking for a low number to represent a dysphonic voice. The great thing about cepstral peak is that it is the only acoustic metric that shows dysphonia in sustained vowel productions and connected speech. Jitter, Shimmer and NHR are limited to the former.

Simply by using PRAAT, a free program, you can easily obtain data in a non-invasive way. Maryn et al 2010 says that there are other similar models of voice data analysis, but none utilize continuous speech and sustained vowels to determine how severe a person's dysphonia is. Maryn and team cross-validated the AVQI in 2009 with 251 subjects. This 2010 study looked at 72 voice samples, as well as 33 other samples to determine the AVQI's responsiveness to change. Acoustic measures were taken using James Hillenbrand's "SpeechTool" (another free program) and PRAAT.

AVQI was developed specifically to be widely available to those providing voice therapy with limited budgets. It's super nice to have CSL software from Kay Pentax, but for the vast majority of clinicians in hospitals, private practices, schools and clinics, budgets are tight. PRAAT can be downloaded on Mac or PC, so it is easily accessible. If you were like me, you might have been collecting data with PRAAT and SpeechTool, but with this measure you can streamline your data collection and use only one program. This saves you time and money, as well as provides you with better data. Excellent... The script necessary to complete calculations can be found in the appendix data for Maryn 2014.

So why the AVQI? Maryn and Weenink found that listeners rate sustained vowels more severely than connected speech when there is dysphonia present. I can vouch for this because my patients usually can only hear a target production in isolated sustained vowels, not in connected speech when I demonstrate both. The AVQI has also been tested across multiple languages, like Dutch and German. Studies have found that despite language differences, the measure remains reliable and valid.

The 2014 article cautions for clinicians to make sure they are accounting for environmental noise in the room as well as mobile phone interference. Recommendations are for a head-mounted condenser microphone with XLR connection as well as an external mixer soundcard to improve the quality of the audio signal and to keep it the same across patients. Remember to tilt the microphone away from the mouth and record voice sounds with a sampling frequency of at least 26kHz.

Using the AVQI has allowed me to streamline my evaluations by a few minutes, as well as show a picture representation of the voice to my patients. Visual is always good. Minutes of each day all are precious because they add up, so I hope you will read up on this available and easy-to-use option for acoustic measurements.

-ATVC

Resources: The Acoustic Voice Quality Index: Toward improved treatment outcomes assessment in voice disorders Youri Maryn, Marc De Bodt, Nelson Roy. Journal of Communication Disorders 43 (2010) 161–174

Objective Dysphonia Measures in the Program Praat: Smoothed Cepstral Peak Prominence and Acoustic Voice Quality Index. Marin, Youri & Weenink, David. J Voice. 2015 Jan;29(1):35-43. doi: 10.1016/j.jvoice.2014.06.015. Epub 2014 Dec 9.

 

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.

 

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.

 

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.