Posts tagged #voice

Resonant Voice Exercise is Better than Vocal Rest?

What Kittie Verdolini Abbott likes to call the "Scream Study" shows just that. She and her cohorts (including Ryan Branski and Clark Rosen) took a group of 9 folks and subjected them all to the same task to "tax" their vocal fold tissue (talking loudly for 1 hour, with a few small breaks in between). Then, they separated them into 3 groups.

Advice Post-Slice: Voice Recommendations After Surgery

How much voice rest is necessary after surgery to the vocal folds? When I had voice surgery 10 years ago, I was instructed to rest my voice strictly for 1 week. No talking, singing, throat clearing, grunting, you get the picture. It was unclear, however, how I was to get back to singing normally again. So what do I tell patients? It varies depending on the extensiveness of the laryngeal surgery, but I pull my recommendations from studies.

The Rat Pack

Leydon et al 2014 describes how forty rats, (I know they're not people,  but I'm sure the experimenters formed relationships with their little buddies for the duration of the trial) had the mucosal layer of the vocal folds removed. (That's the top layer.)  Then the rats' larynges were examined between 3-90 days at 5 different times. 

This image is pulled from Springer online: Operative Techniques in Laryngology

This image is pulled from Springer online: Operative Techniques in Laryngology

 

Researchers found that a vocal fold tissue structure regenerated quickly (like, within 5 days) with intercellular junctions and multi layered epithelium (the tissue on the very outside of the vocal folds that receives the biggest impact during vibration). 

However, atypical permeability of this layer of the TVF's was seen up to 5 weeks after surgery. This means that if you have vocal surgery, you should be sure to keep tabs on your vocal use for many weeks following surgery, as there is a very elevated risk for further damage as your body continues to rebuild where the surgeon worked. Intact structure does not necessarily mean you can demand vocal use you were using before surgery.

Scarring Woes

Scarring is frequently seen after surgery and results in issues with phonation. So obviously we want to minimize scarring. We can't exactly massage the vocal folds to soften this scar tissue, but perhaps gentle vocal exercises that stretch and contract the tissues, as well as utilize resonant voice can help

Another study by Branski et al from 2006 really looks at how a vocal fold wound heals, including inflammation and swelling, as well as scarring. Again, we're talking our animal friends' vocal folds. Scarring develops when there is an increased inflammatory response following an injury. The study discusses differences in lesions to the vocal folds, including nodules, polyps and cysts. Particularly interesting to me, was the suggestion that a cyst, especially one at the midpoint of the vocal fold, might be due to injury associated with impact stress. (Which further convinces me that my vocal fold cyst from years ago was likely a product of a poorly coached belting role I performed during High School.)

Lesions and Surgery

The Branski article suggests that vocal fold lesions are probably the body's way of healing a wound, much in the way a scar results from a cut. Applicable to many of my patients is the discussion of chemical vocal fold injury from LPR, and that 50% of patients with voice disorders also have LPR or GERD, or both. We must also consider the effect of reflux on the healing process after surgery.

So, how long should a person realistically expect to be on complete vocal rest after surgery? For 2 weeks-5 weeks post injury, epithelium remains permeable and impacted by the wound healing process. I say impacted and not weakened, because epithelialization (restoring structural integrity) occurs rapidly between 3-5 days after injury.  Complete rest during this rapid healing time with a very strict ease back into phonation over 2-5 weeks appears to win here. 

We're still learning so many things about how this delicate tissue heals itself, we can only recommend based on the information we have now. Every patient heals differently, and the degree of surgical manipulation will vary case to case. 

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.

Resources:

Leydon, Ciara, Imaizumi, mitsuyoshi, Yang, David, Thibeault, Susan L., & Fried, Marvin P. Structural and functional vocal fold epithelial integrity following injury. Laryngoscope 2014, Dec. 124 (12) 2764-2769

Branski, Ryan C, Verdolini, Katherine, Sandulache, Vlad, Rosen, Clark A., & Hebda, Patricia. Vocal fold wound healing: A review for clinicians, Journal of Voice, 2006 Vol 20, No 3, pp 432-442

 

Diagnoses Are Changed...There Must Be Something in the Water

It's Research Tuesday again! There may be "Something in the Water" for Carrie Underwood for her to be changed, and the same is true for the diagnosis of many voice disorders following videostroboscopic evaluation. In this recent article in the Laryngoscope, Seth Cohen (no not the one from the OC), Nelson Roy, Mark Courey and others take a look at how important Videolaryngostroboscopy (VLS) is as an evaluation tool. They did this retrospectively for patients from 2004-2008, who had been evaluated by an otolaryngologist and then had a specialty voice evaluation with a VLS component within 90 days. Findings? Half of the patients had a change in diagnosis following a VLS. HALF! That's insane. I love examining vocal folds with my strobe light and rigid endoscope, and now I love it even more. If this examination can correctly identify disorders that would have been misdiagnosed otherwise, I'll shout it from the mountain tops! Strobes matter!

Think about the otolaryngologist. He sees 20-30 patients per day, and voice complaints usually result in a quick look with a flexible endoscope through the nose. This is to determine if there is something scary or not, and to determine the depth of evaluation necessity. The ENT will then usually refer the patient to a voice specialist for a videostroboscopic examination, or do it himself if he has the training, technology and time. He makes the best call he can for the technology and time he has, and when he knows the patient will benefit from further analysis, he refers. This is efficient.

What makes a videostroboscopy so much more comprehensive?

  1. It can be recorded and reviewed multiple times to educate the patient and to share with other care providers.
  2. It is magnified greater than a flexible endoscope, so you see the laryngeal vestibule in greater detail.
  3. The strobe light allows the vocal folds to be seen in motion. This helps us evaluate the vocal folds in five ways, as well as for color and structure.

This saves us money, it saves the patient money, and it saves insurance companies money. In this study, 83% of 125 individuals who had the diagnosis of acute laryngitis had their diagnosis changed to something different. This was not the only initial diagnosis, but it showed the biggest change. Difference in diagnosis means that there were differences in treatment patterns as well. This means that PPI's were only used when necessary, surgery wasn't performed if it wasn't necessary and voice therapy may have helped in many cases. I like the otolaryngologists I work closely with because they are very conservative when they treat. We provide voice therapy and wait and watch. Vocal folds are so delicate and unnecessary surgery could make a voice quality worse than what the person was complaining of. Each case is different, but many times voice therapy can make a huge difference and even help avoid surgery.

So what was being over diagnosed? Acute laryngitis and vocal fold paresis had a higher chance of being changed as a diagnosis than chronic laryngitis. Cancer and nonspecific dysphonia had less of a chance than chronic laryngitis. The article also states that ENT's are less comfortable with diagnosing specific voice disorders unless they are very visual in presentation, so even more reason for our specialty to shine. Get out there, stay educated on interpreting and strobe, people!

Source: Change in diagnosis and treatment following specialty voice evaluation: A national database analysis. Cohen, Seth; Kim, Jaewhan; Roy, Nelson; Wilk, Amber; Thomas, Steven, & Courey, Mark. Laryngoscope, 13 Feb 2015, doi: 10.1002/lary.25192

 

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.

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 .

Straw Phonation Takes Center Stage

Make Straw Phonation fun for your younger voice students. Click  Here !

Make Straw Phonation fun for your younger voice students. Click Here!


Try  Ellie Elephant  for Straw Phonation fun! 

Try Ellie Elephant for Straw Phonation fun! 

A light-hearted look at a Facebook group message that got over 64 comments. The funny group dynamic took it to boozy new heights and with a little science thrown in there, hopefully others learned about inertive reactance since Renee Fleming is already a fan.

I am a member of a classical singer forum on Facebook and never have I witnessed such a long winded comment section on a post until the other day. I wanted to share it with you all because I couldn't help but laugh out loud.

It began innocently enough with someone mentioning a recent master-class given by Renee Fleming. Ms. Fleming had been teaching singers to carry a straw with them at all times to warm up without disturbing others in close proximity with a full-out vocal blast to the ears. The comments began slyly rolling in about how straws should be saved for whiskey drinks, but others were intrigued. "Mind blown!" one said, "Great tip!" said another.

There were those who were confused, "How is it different than humming?" they wondered, "How is this straw supposed to work?" There were those who were gung-ho, "Is there a consensus among us that this works?" and, "Straw business is so hot right now."  (images of Hansel from Zoolander begin to swirl around in my head.) And there were those who were less than amused, "I hope she offered more than that." 

 

Folks were sneaking to fast food joints to grab a straw to try and experience this strange phenomenon and one woman even attempted with a turkey baster, to which her comrades replied that they hoped she removed the rubber part before attempting.

Some were defending this technique as if were their own flesh and blood, "It is not a sick joke! This was actually useful advice." One man even mentioned that a speech pathologist had taught him this trick and that he found it helpful. I smiled a bit there because straw phonation has been a shining star in my bag of tricks because of its ease of use. For easy to use diameters, try these. Narrow diameters produce more occlusive effect, like these. For the more environmentally conscious vocalist, these metal ones are great!

I chimed in with, "Straw phonation is a form of semi-occluded vocal tract exercises. Humming and lip trills and tongue trills and straw phonation are all semi-occluded vocal tract exercises. This allows for the singer to phonate with no excess glottic tension at the level of the vocal cords. It also elongates the vocal tract and narrows it, providing inertive reactance (back pressure) at the vocal cords. The vocal tract actually assists the vocal cords in vibration, easing their load."

One man thanked me for being scientific at this time of the morning and I provided video input from Ingo Titze's YouTube demonstration of straw phonation to aid quelling in any further confusion. The conversation soon turned to things I will not mention here on this blog, but in it somewhere were people mentioning Titze, tools, more alcohol, drunk tenorial overlords, and a woman carrying a straw since '82 and a commenter telling her she better change straws because that one is probably old. Ha.

When I speak to professional voice users about the many ways straw phonation can be used, I usually demonstrate how you can go from singing a line in a song, to straw phonating that line, to singing the line again to help improve your body's ability to reduce tension. You can access some materials for making this interesting and fun here.

Try this complete packet for making  straw phonation  fun.

Try this complete packet for making straw phonation fun.

 
Characters  for your straws!

Characters for your straws!

It helped me immensely to sing back and forth, with and without the straw to improve my own abilities and to cut back on vocal cracking and obtain a more easy and pleasant sound overall. No audience wants to watch a strained singer right? The audience likes to be enveloped in the artistic moment while watching a singer who produces notes and phrases as though it were syrup dripping right off the stage into the onlookers' laps.

Anyway, back to the Facebook hysterics, I tried to verbally explain this all to someone I hoped would find it as funny as I had, and he was not amused. Here's hoping the musician humor can be translated here.

-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.

 

A Cure for Stage Fright? Can Blood Pressure Medication Help or Hurt?

In honor of #ResearchTuesday, I have chosen to blog about a study I was given to peruse this past week about a double-blind controlled trial about how stage fright affects the voice. Stage fright is an issue for many performers and public speakers, and has varying degrees of intensity. The study wanted to explore quantifying these effects of stage fright stress on the human voice.

In previous studies, fundamental frequency (your voice's pitch) is the constant here, as it is documented to increase with stress. Conflicting evidence on vocal intensity (loudness) and speaking rate exists, so I guess for some individuals experiencing stage fright, you might get louder with a faster rate of speech or quieter and slower....or a combination....My mind begins to wander back to middle school presentations I had to give. I stood there at the front of the class, shaking and flushed in the face. I can't remember what my voice did, so I'm was interested in the outcome of this study.

Some folks don't like the shaky, sweaty palms, nausea or diarrhea that stage fright brings upon a person...I wonder why? So, they take beta-adrenergic blockers. This is your basic medication to lower the blood pressure by blocking adrenaline and slowing the heart beat, but side effects are a danger.

So this study took individuals and induced stress upon them by putting them in a room with 200 IEP goals to formulate in 1 hour's time. No, I'm kidding. They used cold pressor testing, then gave one group a placebo and one group medication and tested Fo (fundamental frequency), voice onset time, speaking rate, jitter (cycle-to-cycle differences in frequency or pitch), shimmer (cycle-to-cycle differences in amplitude or loudness), and a few other measures. Cold pressor testing is your hand in ice water for one whole minute (aka how one tries to prepare for the pain of child labor...ha. Just keep breathing and imaging yourself on a sunny beach...)

Findings were an increase in blood pressure more in female participants than in male, but both the placebo group and the medication group showed an increase. Jitter increased following medication for stage fright, and speaking rate increased with no medication following the cold water test. I am pretty sure I would have the same reaction if you made me hold my hand in an ice cold glass of water. "Please let me take my hand out now thank you very much yadayadayada....." It would be like truth serum.

It was interesting to me that the researchers hypothesized that the voice parameters measured would all increase in a person with stage fright. They thought the changes in the lungs from the body's reaction to the cold water test would increase the airflow in the throat and therefore increase the vocal fold vibratory speed (making the person's pitch increase). They found that without medication to combat the stress, a person's pitch increased.  

Unfortunately, the only statistically significant finding from this study was that jitter increased after receiving medication for the stress. This means that there is no reason to pop some blood pressure meds before your huge opera debut or that presentation you have to give this week to keep your voice from going all wonky. In fact, this study actually suggests that professional voice users should avoid any medication of this type before singing or speaking because it might be counterproductive, as it increases the noise in your voice.

I guess we will all have to just rely on practice, practice and more practice to keep the "jitters" away during any performance or speaking engagement. Fake it 'till you make it, and by then you will have performed so many times, the stage fright should only come from a ghost light...

-ATVC

 

References:

Beta-Adrenergic Blockade and Voice: A Double-Blind, Placebo-Controlled Trial. Giddens, Cheryl L.; Baron, Kirk W.; Clark, Keith F.; Warde, William D. Journal of Voice , Volume 24 , Issue 4 , 477 - 489.

 

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.