THE VOICE: THE VOICE: The Role of Rehabilitative The Role of Rehabilitative Voice Pathology in the life of Voice Pathology in the life of thetheTeacher, Conductor, Singer Teacher, Conductor, Singer and Student and Student

Rebecca Miles Risser, M.M.,M.A., CCC-Rebecca Miles Risser, M.M.,M.A., CCC-SLPSLPClinical Speech Pathologist, Voice Clinical Speech Pathologist, Voice SpecialistSpecialistPerformance Voice SolutionsPerformance Voice Solutions12065 Old Meridian, Suite 25512065 Old Meridian, Suite 255Carmel, IN 46032Carmel, IN 46032317.705.2732317.705.2732rrisser@performancevoicesolutions.comrrisser@performancevoicesolutions.com

The Voice Care TeamThe Voice Care Team

The Primary Care Physician (PCP)The Primary Care Physician (PCP)– Family Practitioner, Pediatrician, InternistFamily Practitioner, Pediatrician, Internist

The Otolaryngologist (ENT) or The Otolaryngologist (ENT) or LaryngologistLaryngologist

Speech Language Pathologist Speech Language Pathologist (specialized in voice)(specialized in voice)

Voice Scientist (Researchers) Voice Scientist (Researchers) Voice Teachers (Private, choral directors, Voice Teachers (Private, choral directors,

etc.) and voice coaches (private)etc.) and voice coaches (private)

Our GroupOur Group

Performance Voice Solutions is a Performance Voice Solutions is a division of Northside ENT, Inc., and division of Northside ENT, Inc., and together consists of one slp and four together consists of one slp and four ENTs. ENTs.

Model of Care reflects strong Model of Care reflects strong autonomy and respect between autonomy and respect between clinician/physician with frequent, clinician/physician with frequent, nearly daily, consultation re: patients nearly daily, consultation re: patients and current research.and current research.

““Voice Specialist”??Voice Specialist”??

ASHA does not formally recognize the distinction of ASHA does not formally recognize the distinction of voice specialist or the additional training required for voice specialist or the additional training required for a “voice specialist”, as it does for swallowing or for a “voice specialist”, as it does for swallowing or for dysfluency, for example. dysfluency, for example.

Additional training includes training in the use of Additional training includes training in the use of videostroboscopy, training in normal vs. abnormal videostroboscopy, training in normal vs. abnormal anatomy, and therapy techniques.anatomy, and therapy techniques.

My background:My background:– Masters of Music (1990) in Performance and Pedagogy – Masters of Music (1990) in Performance and Pedagogy –

NIU, NIU, – Masters of Arts (2000) in Speech Language Pathology – Masters of Arts (2000) in Speech Language Pathology –

IUIU– National Boards (2000) = Certificate of Clinical National Boards (2000) = Certificate of Clinical

Competency in Speech Language Pathology (CCC-SLP) Competency in Speech Language Pathology (CCC-SLP) from ASHAfrom ASHA

– State Boards(2000) – licensed to practice in IndianaState Boards(2000) – licensed to practice in Indiana

““What do you do, What do you do, anyway”?anyway”?

Voice EvaluationVoice Evaluation Indexes to baseline issues Indexes to baseline issues

of reflux (Reflux Symptom of reflux (Reflux Symptom Index), the Voice-Related Index), the Voice-Related Quality of Life (V-RQOL) Quality of Life (V-RQOL) and the Voice Handicap and the Voice Handicap Index (VHI), or the Singer’s Index (VHI), or the Singer’s Voice Handicap Index (S-Voice Handicap Index (S-VHI).VHI).

Acoustic evaluation, using Acoustic evaluation, using PRAAT software to evaluate PRAAT software to evaluate Fundamental frequency, Fundamental frequency, Relative Average Relative Average Perturbation, Intensity, and Perturbation, Intensity, and MPT and s/z ratio.MPT and s/z ratio.

““What do you do, What do you do, anyway”?anyway”?

VideostroboscopyVideostroboscopy Slow motion Slow motion

photography of the vocal photography of the vocal folds, as they are folds, as they are vibrating.vibrating.

Immediate, magnified Immediate, magnified imaging for presence or imaging for presence or absence of pathology.absence of pathology.

Allows clinician to view Allows clinician to view even very small changes even very small changes in the vibratory capacity in the vibratory capacity of the vocal foldsof the vocal folds

Gives the patient Gives the patient immediate feedback and immediate feedback and opportunity to view their opportunity to view their vocal folds – great vocal folds – great educational tool.educational tool.

VideostroboscopyVideostroboscopy

Gives the patient Gives the patient immediate feedback immediate feedback and opportunity to and opportunity to view their vocal folds view their vocal folds – great educational – great educational tool.tool.

Once strobe obtained, Once strobe obtained, then complete the then complete the Reflux Finding Score Reflux Finding Score (Belafsky, Kouffman, (Belafsky, Kouffman, et al.)et al.)

The most common diagnostics The most common diagnostics noted with teachers, choral noted with teachers, choral directors, singers and voice directors, singers and voice students .students . At Performance Voice Solutions, the top At Performance Voice Solutions, the top

four diagnostics associated with four diagnostics associated with teachers, including singing teachers, teachers, including singing teachers, choral directors, singers (professional choral directors, singers (professional and non-professional) and voice and non-professional) and voice students includestudents include::

Singers nodulesSingers nodules Polyps/cystsPolyps/cysts Hyperfunctional dysphonia (depending on Hyperfunctional dysphonia (depending on

the type of singing)the type of singing) Laryngopharyngeal Reflux DiseaseLaryngopharyngeal Reflux Disease

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) In the United States, roughly 3-9% of the In the United States, roughly 3-9% of the

generalgeneral population has some type of population has some type of voice abnormality at any given moment.voice abnormality at any given moment.

With the advent of information age, With the advent of information age, voice has assumed an increasingly voice has assumed an increasingly important role in job function.important role in job function.

Conservative estimates indicate that Conservative estimates indicate that over 25% of the working population (i.e. over 25% of the working population (i.e. 28,000,000 people) list voice as a critical 28,000,000 people) list voice as a critical aspect in their job.aspect in their job.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) The occupational risk factors for voice The occupational risk factors for voice

disorder in US and Sweden:disorder in US and Sweden: SingerSinger Counselor/social workerCounselor/social worker TeacherTeacher LawyerLawyer ClergyClergy TelemarketerTelemarketer Ticket salesTicket sales Health careHealth care

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Let’s talk teachers…Let’s talk teachers…

– Various studies have been completed, with a Various studies have been completed, with a range of responses, but in general at the time range of responses, but in general at the time of the study, 32%-47.5% of the teachers of the study, 32%-47.5% of the teachers responded that they were currently hoarse.responded that they were currently hoarse.

– 20-30% indicated they had missed work the 20-30% indicated they had missed work the previous school year because of voice previous school year because of voice problems.problems.

– 38% reported negative effect of teaching on 38% reported negative effect of teaching on voicevoice

– 39% were currently reducing work (reducing 39% were currently reducing work (reducing teaching activities) due to voice.teaching activities) due to voice.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) ““Considering only lost work Considering only lost work

days and treatment days and treatment expenses, the societal cost expenses, the societal cost of voice problems in of voice problems in teachers alone may be…teachers alone may be…about $2.5 billion annually about $2.5 billion annually in the U.S.”in the U.S.”

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) More on teachers…More on teachers…

– Female teachers reported voice Female teachers reported voice problems more frequently than problems more frequently than males (38% vs. 26%).males (38% vs. 26%).

– Physical education teachers Physical education teachers presented highest risk, independent presented highest risk, independent of gender, hours of teaching per of gender, hours of teaching per day, number of years teaching or day, number of years teaching or ageage

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Other studies:Other studies:

– 55% of respondents indicated dry 55% of respondents indicated dry throat;throat;

– 45% had vocal fatigue45% had vocal fatigue– 36% had scratchy sensation;36% had scratchy sensation;– 32% had throat discomfort32% had throat discomfort– 31% had to make an effort to talk 31% had to make an effort to talk

after teaching.after teaching.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Now, singing teachers…Now, singing teachers… 125 singing teachers with 49 control 125 singing teachers with 49 control

subjects completed questionnaires.subjects completed questionnaires. 21%of singing teachers had voice dysfunction 21%of singing teachers had voice dysfunction

(18% of controls) = not a significant difference(18% of controls) = not a significant difference HOWEVER, 64% of singing teachers had voice HOWEVER, 64% of singing teachers had voice

problem in past (33% of controls)…problem in past (33% of controls)…SIGNIFICANTSIGNIFICANT

A history of voice dysfunction in the past A history of voice dysfunction in the past increased likelihood of current voice problem increased likelihood of current voice problem by a factor of FIVE.by a factor of FIVE.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Singing teachers continued…Singing teachers continued…

The current use of dehydrating medications The current use of dehydrating medications increased the likelihood of current voice increased the likelihood of current voice problem by THREE.problem by THREE.

Hmmmm….an increase in the estimated Hmmmm….an increase in the estimated hours of LOUD singing per day appeared to hours of LOUD singing per day appeared to have a protective effect; an increase in the have a protective effect; an increase in the number of loud hours of singing number of loud hours of singing inversely inversely predicted the likelihood of a current voice predicted the likelihood of a current voice problem by a factor of three. (authors problem by a factor of three. (authors interpreted this as an effect of healthy voice interpreted this as an effect of healthy voice not a cause of a healthy voice).not a cause of a healthy voice).

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Singing voice teachers…Singing voice teachers…

– Congratulations! Congratulations! Large proportion of singing teachers with Large proportion of singing teachers with

current (56%) or past (83%) voice problems current (56%) or past (83%) voice problems sought professional help.sought professional help.

– HOWEVER…in this study, no singer or HOWEVER…in this study, no singer or control respondent with a current voice control respondent with a current voice problem had received voice therapy for problem had received voice therapy for it. Only 4% of respondents with a past it. Only 4% of respondents with a past voice problem had received therapy.voice problem had received therapy.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) Choral singers: Choral singers:

– National Convention of Gospel National Convention of Gospel Choirs and Choruses (NCGCC) and Choirs and Choruses (NCGCC) and American Choral Directors American Choral Directors Association (ACDA) were polled. Association (ACDA) were polled.

– Most of the NCGCC members were Most of the NCGCC members were African American; most of the ACDA African American; most of the ACDA members were Caucasian. members were Caucasian.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) 50% of gospel singers reported 50% of gospel singers reported

current perceived hoarseness in current perceived hoarseness in comparison to 35% of classical comparison to 35% of classical singerssingers

Hoarse AA singers were neutral Hoarse AA singers were neutral about seeking voice treatment; about seeking voice treatment; hoarse Caucasian singers were hoarse Caucasian singers were “likely” to seek treatment or “likely” to seek treatment or “intended” to seek treatment.“intended” to seek treatment.

Occupational Risks for Occupational Risks for Voice Problems (Verdolini Voice Problems (Verdolini and Ramig, 2001)and Ramig, 2001) For AA respondents, For AA respondents, others’ opinionsothers’ opinions

about treatment appeared to predict about treatment appeared to predict the likelihood of seeking treatment for the likelihood of seeking treatment for current voice problem. In other words, current voice problem. In other words, a a cultural biascultural bias influenced them. influenced them.

For Caucasian respondents, one’s own For Caucasian respondents, one’s own opinion or “feelings” about seeking opinion or “feelings” about seeking treatment predicted the likelihood of treatment predicted the likelihood of seeking treatment. In other words, a seeking treatment. In other words, a personal biaspersonal bias influenced them. influenced them.

So how can we So how can we fix the fix the

problem?problem?

Novel thought #1…Novel thought #1…

Let’s start Let’s start talking talking

with with each each

other!other!

Thoughts from my choral Thoughts from my choral director/patientsdirector/patients

““I wish someone had told me about the I wish someone had told me about the connection between my singing voice and connection between my singing voice and my speaking voice.”my speaking voice.”– What’s this about?What’s this about?

How do we achieve vocal rest in a healthy How do we achieve vocal rest in a healthy functional way apart from “shutting functional way apart from “shutting down”?down”?

““Tell them that the speaking voice Tell them that the speaking voice requires a warm-up before the teaching requires a warm-up before the teaching day begins.”day begins.”

Thoughts from my Thoughts from my choral choral director/patientsdirector/patients ““Talk about female teachers Talk about female teachers

demonstrating for male choirs”demonstrating for male choirs”– Recording parts on “smart music” Recording parts on “smart music”

and emailing the parts to the and emailing the parts to the students;students;

– Having a high school male record the Having a high school male record the singing parts for extra credit.singing parts for extra credit.

– For noisy groups: visual cues For noisy groups: visual cues mounted on craft sticks.mounted on craft sticks.

Novel thought #2…Novel thought #2…

It It ISIS possible to possible to use a healthy use a healthy voice to teach, voice to teach, sing, AND even sing, AND even

have a voice have a voice that’s that’s as good as good

or betteror better at the at the end of the day!end of the day!

Vocal Fold Wound Vocal Fold Wound HealingHealing In 2003, Branski, et. al found that low In 2003, Branski, et. al found that low

levels of dynamic, biomechanical levels of dynamic, biomechanical stress inhibited IL-1Beta (associated stress inhibited IL-1Beta (associated with inflammation) in injured tissue. with inflammation) in injured tissue.

Vocal tissue from rabbits were Vocal tissue from rabbits were exposed to variable levels of cyclic exposed to variable levels of cyclic tensile strain (repetitive rotating tensile strain (repetitive rotating vibratory movement similar to vocal vibratory movement similar to vocal cord vibrations). cord vibrations).

ResultsResults

1.1. CTS reduced inflammation by inducing CTS reduced inflammation by inducing the increase of “collagen synthesis” the increase of “collagen synthesis” (i.e. a marker for healing of injured (i.e. a marker for healing of injured tissue) tissue) in the presencein the presence of IL-1Beta. of IL-1Beta.

2.2. Therefore, low-levels of biomechanical Therefore, low-levels of biomechanical stress stress inducedinduced wound healing by wound healing by decreasing the time it took to move decreasing the time it took to move from inflammation to tissue rebuildingfrom inflammation to tissue rebuilding..

ResultsResults

Another Branski study compared two Another Branski study compared two groups of performers, one with vocal fold groups of performers, one with vocal fold nodules and one with healthy larynxes. nodules and one with healthy larynxes. – Both groups were able to produce a resonant Both groups were able to produce a resonant

voice as compared to a pressed , a normal, voice as compared to a pressed , a normal, and a breathy voice.and a breathy voice.

– ““resonance” approximated the configuration resonance” approximated the configuration in Branski’s study, in which low-level in Branski’s study, in which low-level biomechanical stress induced wound healing biomechanical stress induced wound healing faster. faster.

The missing link…The missing link…

““Resonant voice” also Resonant voice” also corresponded to easy, clear corresponded to easy, clear resonance advocated by Lessac resonance advocated by Lessac Madsen Resonant Voice Therapy, Madsen Resonant Voice Therapy, and to the “mask” resonance and to the “mask” resonance advocated by singing teacher of advocated by singing teacher of solo singers.solo singers.

Voice therapy or tissue Voice therapy or tissue re-engineering?re-engineering?

Therefore, voice therapy Therefore, voice therapy techniques enhance techniques enhance

biological phases of wound biological phases of wound healing in recurrent, acute healing in recurrent, acute

phonotraumaphonotrauma..

So, what should I look So, what should I look for?for?

Let’s start Let’s start with your with your studentsstudents

……

““How do I know if my How do I know if my student needs to see a student needs to see a

voice specialist?”voice specialist?” 1. Speaking voice and singing voice 1. Speaking voice and singing voice

should both be smooth and easy, with no should both be smooth and easy, with no roughness, no breathiness.roughness, no breathiness.

2. If they become hoarse, it should last 2. If they become hoarse, it should last no more than two weeks, and this should no more than two weeks, and this should be no more than 1-2 times each YEAR.be no more than 1-2 times each YEAR.

3. Extroverted individuals will likely have 3. Extroverted individuals will likely have vocal fold nodules; introverted will likely vocal fold nodules; introverted will likely have muscle tension dysphonia.have muscle tension dysphonia.

But what if it’s not the But what if it’s not the student !?!student !?!

Now let’s Now let’s take a take a look at look at

YOUYOU

““That ain’t right”That ain’t right”

1. Hoarseness is not normal.1. Hoarseness is not normal. 2. Breathiness is not normal.2. Breathiness is not normal. 3. The “Monday-Friday effect” is 3. The “Monday-Friday effect” is

not normal.not normal. 3. Missing whole sections of your 3. Missing whole sections of your

voice? voice? NOT NORMALNOT NORMAL..

What can we do?What can we do?

1. Amplify. Get a microphone 1. Amplify. Get a microphone system either through your school system either through your school (no, really, they sometimes do (no, really, they sometimes do this…) or rig something up at Radio this…) or rig something up at Radio Shack (not a paid, promotional Shack (not a paid, promotional advertisement).advertisement).

2. Warm up your speaking voice 2. Warm up your speaking voice before your first class (Vocal before your first class (Vocal Function Exercises).Function Exercises).

What can we do?What can we do?

3. When you teach, it’s better to 3. When you teach, it’s better to speak 10 minutes “on” then 10 speak 10 minutes “on” then 10 minutes “off” throughout your minutes “off” throughout your day.day.

4. Restore your voice through 4. Restore your voice through easy, resonant glides to regain easy, resonant glides to regain focus and reduce effortfocus and reduce effort

5. Listen to your body – where it 5. Listen to your body – where it is tight?is tight?

The “Take Home” The “Take Home”

Let’s learn Let’s learn a fantastic a fantastic warm up warm up

together…together…

Vocal Function Exercises Vocal Function Exercises (Joseph C. Stemple, (Joseph C. Stemple, Ph.D.)Ph.D.) In our current climate of self-In our current climate of self-

improvement, voice improvement improvement, voice improvement is not only for the disordered voice is not only for the disordered voice but also for those who want to but also for those who want to enhance vocal health and image.enhance vocal health and image.

Voice is one part of the physical, Voice is one part of the physical, emotional and life-style status of emotional and life-style status of an individual.an individual.

Wellness LineWellness Line

Disordered voiceDisordered voice Outstanding Outstanding voice voice

________________________________________________________________Normal voiceNormal voice

The programThe program

1. Sustain “ee” vowel for as long 1. Sustain “ee” vowel for as long as possible on F3 for adult males, as possible on F3 for adult males, F4 for adult females and childrenF4 for adult females and children– Goal: should be equal to sustained Goal: should be equal to sustained

/s/ in terms of time. Vocal quality is /s/ in terms of time. Vocal quality is forward but not quite nasal. Voice forward but not quite nasal. Voice should be engaged and not breathy. should be engaged and not breathy. (I encourage a “twang” sound to (I encourage a “twang” sound to narrow the AES)narrow the AES)

The programThe program

2. Glide from lowest note to highest on 2. Glide from lowest note to highest on “whoop”.“whoop”.– Goal: no voice breaks. It engages all the Goal: no voice breaks. It engages all the

laryngeal muscles, and encourages a slow laryngeal muscles, and encourages a slow engagement of the cricothyroid muscles.engagement of the cricothyroid muscles.

3. Glide from highest note to lowest 3. Glide from highest note to lowest note on “boom”note on “boom”– Goal: no voice breaks. By keeping an Goal: no voice breaks. By keeping an

open throat, it encourages the open throat, it encourages the engagement of the thyroarytenoid engagement of the thyroarytenoid muscles without the presence of a back-muscles without the presence of a back-focused “growl” – No Growling!focused “growl” – No Growling!

The programThe program

4. Sustain musical notes (C-D-E-F-G) 4. Sustain musical notes (C-D-E-F-G) for as long as possible (for lower for as long as possible (for lower voices, A-B-C-D-E) on the word “knoll” voices, A-B-C-D-E) on the word “knoll” or “moe” or “no”. or “moe” or “no”. – Goal: should be equal to sustained /s/ in Goal: should be equal to sustained /s/ in

terms of time. Vocal quality is forward terms of time. Vocal quality is forward but not quite nasal. Voice should be but not quite nasal. Voice should be engaged and not breathy. This is engaged and not breathy. This is considered a low impact, adductory considered a low impact, adductory power exercise.power exercise.

Program “Notes”Program “Notes”

All exercises are done as softly as All exercises are done as softly as possible, per the author’s notes. possible, per the author’s notes. In keeping with other literature, it In keeping with other literature, it should be kept as soft as possible, should be kept as soft as possible, while maintaining a clear tone.while maintaining a clear tone.

Let’s keep our Let’s keep our conversation going…conversation going…

GO FORTH GO FORTH AND AND

PHONATEPHONATE!!

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