Posts tagged #Voice Therapy

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.

 

Textbook Hyperfunction or Something Else: When Can Hoarseness be ALS?

When a patient comes to you with complaints of hoarseness, the first thing you do is probably perform your evaluation. Check. You make sure the patient has been seen by an ENT, and then you perform a videostroboscopy. You'll most likely follow with a behavioral voice evaluation and/or a laryngeal function study. You have an idea in your head of what the diagnosis might be before the patient even steps in the room. Case history can lead you in the right direction,  but sometimes it is important to be aware of all possible causes of symptoms, even the very rare. You patient comes in:

1. The voice is strained, pressed and sounds strangled. Hoarseness is present, as well as a mild hypernasal quality and vocal fry.

2.  The patient has a low pitch, it's lower than normal for gender and age.

3. Voice onset for vowels is difficult, and the patient speaks softer than normal.

Initially, you think there is a strong possibility that the patient has Muscle Tension Dysphonia because of the strain. You want to make sure and rule out Adductor Spasmodic Dysphonia, however. You have your patient count from 80-89 to listen for laryngeal spasms. Your videostroboscopy reveals some vestibular fold hyperfunction paired with hypoadduction of the true vocal folds. Your patient is also complaining of some mild dysphagia.

You're still uncertain of what your diagnosis is. There are just some missing pieces. Something is just not adding up. How can you explain the low pitch and low intensity? It might be MTD, but what if it is something else...

Amytrophic Lateral Sclerosis (ALS) has been all over social media lately with the viral Ice Bucket Challenges. It usually presents with extremity weakness, atrophy, and decreased muscle tone. Sometimes, however, it begins with voice quality changes before anything else. A person can develop a voice that sounds strained, strangled, harsh or breathy. The voice might waver with tremor or have unsteady pitch. A patient might also have some hypernasality to boot. A certain kind of ALS onset, called bulbar (affecting the lower motor neurons), can be the culprit. It affects the lower motor neurons in the brain stem, and your videostroboscopy might show some hypoadduction. A patient with this bulbar onset might show signs of mild dysphagia and dysarthria early on, and quite possibly have hyperfunction of false vocal folds and ventricular compression to compensate for that hypofunction.

So how do you determine if it is ALS? ALS has a very rapid onset time, and within months you start to see the degenerative progression in multiple areas. One case study (to be taken with a grain of salt) showed that after 4 months, with the usual treatment for vocal fold atrophy/bowing, there was no improvement. Dysphagia worsened as well as the dysarthria. So, time might be a deciding factor here.

Knowing that ALS is a possible cause for hyperfunction and hypofunction in the larynx is something to hold in your back pocket. It will not happen often as a diagnosis, but it is worth being aware of. Just treat the symptoms you see, and if your patient's condition gets progressively worse despite intervention, there's a good chance you might be dealing with a progressive neurological disease. You should always refer back to the neurologist if you suspect this component.

But with what type of treatment can help you with this differential diagnosis? For bowing or atrophy of the TVF's, you might find success with Lee Silverman Voice Treatment (LSVT) as it has helped improve individuals suffering from age related bowing or Parkinson's disease. You might try to improve the hyperfunction by trying Lessac-Madsen Resonant Voice Therapy (LMRVT) or Casper-Stone Confidential Flow Therapy (CS-CFT) or a variation of Stone & Casteel's Stretch-and-Flow. With whatever is appropriate for your patient, pay close attention to whether there is benefit, or whether quality worsens despite your best efforts.

 

-ATVC

 

References: Watts, Christopher R, and Martine Vanryckeghem. “Laryngeal Dysfunction in Amyotrophic Lateral Sclerosis: a Review and Case Report.” BMC Ear, Nose, and Throat Disorders 1 (2001): 1. PMC. Web. 10 Jan. 2015.

 

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.

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.