what is ebp? for voice disorders: using the alert model · central sensitization amygdala: both...

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Client-Centered Management

for Voice Disorders:

Using the ALERT model

Linda Rammage, PhD, RSLP, S-LP(C)

Director, PVCRP

BCASLPA, 2014

What is EBP? (Hjørland, 2011)

all practical decisions 1) based on research

studies and 2) research studies are selected

and interpreted according to specific norms

characteristic for EBP

norms typically disregard theoretical and

qualitative studies and consider quantitative

studies according to a narrow set of criteria

for evidence (Random Control Trials - RCT)

Tx based on other research designs

considered “research-based-practice”

EBP/RCT – “Gold Standard?” (Montgomery & Turkstra, 2003)

Means to support clinical reasoning, not “End”

Limitations in clinical research/Tx decisions:

Statistical signif ≠ clinically meaningful…

achieving both is a social judgement

Judgement always required for indiv. client

(“n of one”)… even RCT results cannot be

assumed to generalize to each individual

RCTs may be impractical/impossible

(eg. statistical power/study N required) or

design inappropriate for many clinical Q’s

Cochrane Reviews (RCT):

“Voice/Voice Therapy” Q: Is there evidence that any form of SLT is

more efficacious for IPD? (2012)

Author Conclusion: “Insufficient evidence due

to small N’s”

Q: Is there evidence that either direct or

indirect voice training or combined is effective

to prevent voice disorders in at-risk

population? (2007)

Author Conclusion: “No evidence from studies

that met review criteria. Need larger N and

better methodology (better control criteria)”

http://en.wikipedia.org/wiki/Theoretical

http://en.wikipedia.org/wiki/Qualitative_property

http://en.wikipedia.org/wiki/Quantitative_property

http://en.wikipedia.org/wiki/Evidence

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Client-Centered Care (Rogers, 1959)

relationship of mutual respect and trust

between client and therapist

clinician facilitates information-sharing in a

non-directive approach

client’s role as “expert” in his/her experiences

of the problem is established at the outset

therapist demonstrates “unconditional positive

regard” by listening to and acknowledging the

client’s perspective without making judgment

Client/Person-Centered Care

Principles Get to know client as a person (not a Dx):

culture, beliefs, values, goals, dreams…

Share power and responsibility: respecting

preferences

Accessibility and flexibility: ensuring

sensitivity to values, preference, needs;

making info accessible to facilitate choices

Coordination & integration: team work;

minimize duplication; key contact

Environments: ensure working

philosophy/policy/environment facilitates PCC

EBP & Client/person-centered care

“Person-centred practice could make a difference to

health outcomes, patient/client satisfaction and can

improve one’s sense of professional worth” (Victorian

Department of Human Services, 2006)

“EBP acknowledges that good outcome must be defined

re value to patient…combining art of generalizations and

science of particulars” (Epstein & Street, 2011)

“PC planning associated with benefits in areas of

community involvement; contact with friends, family; and

choice” (Sanderson, Thompson & Kilbane, 2014)

Anatomical

Factors:Aging, Lesion

Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health

Occupational demands

Vocal dose

Emotion:Anxiety

Depression

Symbolic conversions

Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight

Technique:Alignment/Posture

Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

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ALERT to History

Determining contributions of factors:

Anatomical:

Lifestyle:

Emotional:

Reflux:

Technique:

The Client as

“Expert”:

Client Intake

History Form

Tool Paradigm Parameters Administration

Rating

Authors Select Clinical

Studies

Voice Handicap

Index (VHI)

Handicapping

effects of voice

impairment,

incl. voice

disability &

impact on daily

functioning

(WHO)(1980)

ICIDH

30 items:

10 - Physical

10 - Functional

10 - Emotional

5-point

frequency of

occurrence scale

Translated to

ordinal scale

Higher scores =

greater handicap

Jacobson et

al, 1997

Rosen et al, 2000

Billante et al, 2001

Roy et al, 2001

Spector et al, 2001

Weigelt et al, 2004

Maertens and de

Jong, 2007

Hazlett et al, 2009

Voice Handicap

Index-10

(VHI-10)

As with VHI 10 items:

Physical

Functional

Emotional

As with VHI Rosen et al

2004

Deary et al, 2004

da Costa de

Ceballos et al

2009

Pediatric VHI

(pVHI)

As with VHI 23 items:

7- Functional

9- Physical

7- Emotional

As with VHI Zur et al

2007

de Alarcon et al

2009

Voice-Related

Quality of Life

(V-RQOL)

Impact of

general or

specific states

of disease or

dysfunction on

Quality of Life

10 items:

5-Physical/Functional

5-Social/Emotional

Overall Voice quality

past 2 weeks

5-point severity

scale

Higher scores =

greater severity

Can be

converted to

Standard Score

Hogikyan

and

Sethuraman

1999

Hogikyan et al,

2000, 2001

Rubin et al,2004

Franic et al., 2005

Cohen et al, 2006

Oridate et al, 2009

Moukarbel et al

2010

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Pediatric

Voice-Related

Quality-of-Life

Survey

(PVRQOL)

Impact of general

or specific states

of disease or

dysfunction on

Quality of Life

10 items:

5-physical-

functional

5-social-

emotional

Parent –proxy

As with V-RQOL Boseley et al,

2006

Hartnick, 2002

Hartnick et al,

2003

Merati et al,

2008; Blumin et

al, 2008

Voice

Symptom

Scale

(VoiSS)

Handicapping

effects:

communication,

throat infections,

psych distress,

voice

sound/variability,

phlegm. ICIDH

30 items:

15-Impairment

15-Physiological

15-Emotional

5-item frequency of

occurrence scale

Translated to

ordinal scale

Higher scores =

greater handicap

Deary et al,

2003

Deary et al, 2003

Wilson et al,

2004

Webb et al, 2007

Hazlett et al,

2009

Vocal

Performance

Questionnaire

(VPQ)

Physical

symptoms and

socio-economic

impact of voice

disorder

12 questions

about voice

dysfunction

impact

5 potential

responses per

question to

indicate impact

Carding and

Horsley, 1992

Carding and

Horsley, 1992

Carding et al,

1999

Deary et al, 2004

Voice Activity

and

Participation

Profile

(VAPP)

Perception of

problem, activity

limitation,

participation

restriction

WHO ICIDH-2

Beta 1 (1997)

28 items:

1 - Severity

4 - Employment

12 - Daily

communication

4 - Social

communication

7 - Emotion

10 cm continuous

line visual analog:

Left = not affected

Right = always

affected

Measure cm., from

left end of line

Ma and Yiu,

2001

Ma and Yiu, 2001

Sukanen et al,

2007

Chung et al,

2010

Yiu et al, 2011

Voice-Related

Quality of Life

(V-RQOL)

Self-Report

Inventory.

(Hogikyan &

Sethuraman,

1999)

Anatomical Factors

Chronic non-infective laryngitis

Congenital Webs

Contact Ulcer/Granuloma (Reflux)

Crico-arytenoid Joint Problems

Cysts, Sulci, and Mucosal Bridges

Iatrogenic changes (eg. ablative surgery)

Infection: Bacterial; Viral (esp. parainfluenza)

Laryngeal Trauma

Mucosal changes from abuse/misuse

Tumours

Anatomical Anatomical Factors Examples:

Unilateral Cyst 10 Nodules 20

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Papilloma 10 Contact Ulcer/

Granuloma 20 Web (Congential / Iatrogenic)

Anatomical Factors:

Development and Aging

Hirano &

Bless,

1993

Aging and Speech-Breathing (Hoit & Hixon,1987;

Hoit et al, 1989; Hoit & Hixon, 1992; Melcon et al, 1989)

Rib cage ossifies

Reduced collagen in lungs

Reduced flexibility in system

Reduced vital capacity

Initiate voice at higher lung volumes

Use larger lung and rib cage excursions

Men use more lung vol/syllable (due to vocal

fold leaks) but not women (Hoit & Hixon, 1992)

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More time required for voice onsets

Reduced ability to sustain long phrases

(especially with incomplete v.f. closure)

More time required for inspiration

Potentially less driving force for phonation

Senescence affects posture

Posture affects breathing

Glottal leakage higher lung volumes (men)

Higher airflow hyper-valving at glottis

Implications:

Aging and the Larynx (Honjo & Isshiki,1979;

Kahane,1983a/b; Kahn, A. R. & Kahane,1986; Kersing, 1986; Linville

& Korabic,1987; Mackenzie Beck, J. (1997 )

Cartilage ossifies

Collagen, elastin, muscle esp. men (Case 32)

Epithelium thickens, esp. women

Cumulative trauma thickens folds

Larynx descends, pharynx lengthens:

formant structure

Reduced neurological/structural stability:

wobble/tremolo/vibrato/perturbations

VF closure may

Increased jitter/shimmer/noise

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Vocal Senescence and Gender (Linville &

Fisher, 1985 a/b;; Linville, 1996; Mysak, 1959; McGlone & Hollien,1963)

Women:

• Epithelium

• F0 range descends

• More if smoker

• May be called “sir”

• May compensate to

pitch

• tension range/

flexibility

Men:

• Collagen, elastin,

muscle, epithelium

• F0 range ascends

• May be called “Ma’am”

• May compensate to

pitch

• tension range/

flexibility

Implications (L/E/T impact?):

Reduced loudness potential (Linville, 1996)

Reduced phonation duration (Linville, 1996)

Leaky VF (esp.men): mal-adapt speech-breathing

Delayed voice onset

“New-Normal” pitch range (Melcon et al, 1989)

Pharynx continues to grow: formants drop

May mal-adapt to aging with muscle misuse

vocal perturbations and noise

Exercise (general/voice-specific) may age effects (Peppard, 1990; Lowery, 1993)

Anatomical Factors: Neurological

Motor Speech Disorders

congenital (CP) / acquired (MSD)

MSDs and voice:

Vocal fold paralysis (flaccid)

Dystonia/spasmodic dysphonias

Spastic dysarthrias

Essential voice tremor

Parkinson’s Disease

Irritable Larynx as Central Sensitivity Syndrome?

Unilateral Paralysis (Case 29)

PD (Cases 49)

EVT (Case 52)

SD (Case 55)

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Anatomical Factors:

Irritable Larynx Syndrome (Morrison, Rammage, Emami, 1999) (Case 59)

definitive triggering stimulus

hyperkinetic laryngeal dysfunction

(laryngospasm-PVFM, cough, dysphonia/globus)

due to

CNS over-reaction to normal sensory

stimuli in response to a

Symptom Triggers

All 195 vs. Female PVFM (141)

All Pts: F-PVFM

Odors 106 54% (57%)

Stress 100 51% (50%)

Eating 36 18% (20%)

Lying down 38 19% (22%)

Talking 41 21% (21%)

Exercise 27 14% (13%)

ILS - Pathways to CNS Plastic Change

Chronic

Stimulation

GERD CNS

VIRUS

Psych

Factors

Habituation &

ILS Features

Set-up for spasm

hypertonic state

MUSCLE SPASM

Dysphonia Laryngospasm Globus & Cough

Irritants Tone

modulators

Non-triggered

ILS

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stimulus

c-fos

c-jun

Transcription of

I.E.Genes

P

FOS JUN

fos jun

DNA

binding

Neural plastic response to repetitive nocistimulation

depolarization

ILS: A Central Sensitivity Syndrome? (Morrison & Rammage, 2010)

Heightened sensitivity of central neurons

Altered activation thresholds, and enhanced responsiveness to synaptic inputs as with neuropathic pain (Woolf CJ, Slater MW. Science 2000; 288:1765-8)

Underlying Neuro-Endocrine-Immune (NEI) pathology? (Morrison et al, 1999; Yunus, 2000-2008)

CS verified by testing neurotransmitters, neuro

modulators with nociceptive spinal flexion reflex, Functional MRI and cerebral evoked potential by ElectroEncephaloGraphy (Yunus, 2005; 2007)

Central Sensitization

A defined input, or sensory stimulus, produces a sensory experience greater in amplitude and duration than would be expected

The sensitivity of the pain system is shifted such that normally innocuous inputs can activate it & perceptual responses to noxious inputs are exaggerated, prolonged & widely spread

This could represent a central amplification due to increased excitation or reduced inhibition

Normal Sensation

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Central Sensitization Amygdala: both enhances &

inhibits pain processing

Neugebauer et al. Amygdala & Persistent Pain. Neuroscientist. 2004 10:

221-234.

Clinical syndromes central

sensitization contributes to…..

Rheumatoid arthritis

Osteoarthritis

Temporomandibular disorders

Chronic Fatigue, Fibromyalgia

Migraines, headaches, TMJ

Neuropathic pain

Complex Regional Pain syndrome

Visceral pain hypersensitivity syndromes: IBS, noncardiac chest pain, chronic pancreatitis

Interstitial cystitis, endometriosis, vulvodynia

Multiple Chemical Sensitivity (Yunus, 2000-2008)

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Sniffing

Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

Lifestyle

Some occupations are vocally demanding

& stressful, leading to voice problems.

- work-related voice demands (teacher; swim

instructor; singer; customer service, etc)

- recreational voice demands (team sports;

coaching; group-socializing)

- family/caregiver voice demands (parenting;

elder-care, large family…etc)

Lifestyle factors

Vocal Dose

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Prevalence Of Voice Problems By Occupation

GROUP NUMBER INVESTIG % F % M FACTORS

Aerobics I. 50f / 4m Long et al 44 % 50 % Shouting

Duration

Army I. 130 f Sapir et al 76 % Loudness

Rapid Sp

Army Recr. 386 f Sapir et al 31 % Excess Sp

Swim. I. 155f /95m Rammage 79 % 58 % Loud Envir.

Teachers 250 m&f GotaasStarr 80 % > m&f Loud; Stress

PE/Music

Teachers 237 f Sapir et al 73 % Loud; Illness

Teachers 564f/313m Russell et al 22 %/67% (point/career)

13%/66% (point/career)

Loud;Gender

Various

Teachers 280f/274m Smith et al 18%/93% 9%/62% Loud;Course

Occupational Representation in Voice Clinics Titze et al, 1997

OCCUPATION % CLINIC (N=1593) % US EMPL. POP.

Teacher 19.6 % * 4.2 % *

Singer 11.5 % * .02 % *

Sales Rep: 10.3 % 13 %

Telesales 2.3 % * .78 % *

Ticket/Travel .4 % .21 %

Secretary/Clerk 8.6 % 10.6 %

Factory Worker 5.6 % 14.5 %

Reception/PR 3.5 % * .12 % *

Counselor 1.6 % * .19 % *

Occupational Representation for BC (N= 1181)

Occupat. % BCPop % Clinic % BC F % Clin F % BC M % Clin M

Singer .27%* 18%* 58% 67% 42% 33%

Teacher 3.8%* 17%* 62% 78% 38% 22%

Sec. * 13.4% 12% 86% 86% 14% 14%

BusAdm 6.9% 7.5% 41% 42% 59% 58%

Sales * 14.8% 7% 41% 65% 59% 35%

Actor .09%* 3%* 43% 66% 57% 34%

Nurse 1.6% 3% 95% 100% 5% 0%

Trades * 9.4% 3% 4% 15% 96% 85%

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Teachers: 7 Years in PVCRP

Year - % of Teachers/Employed PVCRP Pop.

1999 - 17 % (68/400)

2000 - 18.54% (66/356)

2001 - 20.80% (104/500)

2002 - 16.96% (68/401)

2003 - 19.21 % ( 88/458)

2004 - 22.83 % (87/381)

2005 - 24.96% (115/460)

Dominant Factors for Dysphonic Teachers

(PVCRP 2007, N=149)

Dx # Teachers % Teachers % Female % Male

m misuse 68 46% 87% 13%

v nodules 13 9% 85% 15%

c laryngitis 12 8% 58% 42%

v paralysis 11 7% 91% 9%

v polyp 7 .5% 86% 14%

Lifestyle Factors:

Acoustic Environment

• Maximum noise level of unoccupied classroom: ANSI

S12.60: 35 dBA (normally-hearing adult)

• Optimal signal-to-noise ratio: =/> 15 dB (normally-hearing

adult, 1st language); Grade 1: SNR =/> 20dB (Bradley,

2008)

• Reverberation rates: between 0.4 and 0.6 sec

• (Typical comfortable speaking level: 65-75dB?- f/m adult)

Public school and university classrooms, daycare facilities and

restaurants in BC do not meet minimum acoustic standards

(Hodgson et al, 1999-2008). Occupational voice users talk above

comfortable loudness.

Noise in the Classroom

Outside: Aircraft, traffic, hallway noise

Inside: Heating, ventilation, A/C systems

Computers, projectors

Movement of desks/chairs; walking/talking

noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990)

noise, reverberation and RASTI values (speech transmission) in most occupied classrooms unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990)

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School Classroom Survey:

Reverberation Time (unoccupied classroom)

optimum: RT0.5s (Hodgson,1999)

0.0

0.2

0.4

0.6

0.8

1.0

1.2

U-H

ill 1

07

U-H

ill 1

10

U-H

ill P

ort

UP

LY

NN

1

UP

LY

NN

2

CV

CLF

1

DO

RLY

N1

CA

NH

TS

DO

RLY

N2

PLY

M

SM

HTS

DO

RLY

N3

DO

RLY

N4

CLV

LN

D

MA

PLW

D

Ber

50 c

lass

Ber

60 c

lass

Ber

34 t

each

Ber

39 t

each

Ber

65 t

each

Classroom

RT

u (

s)

U-Hill North Vancouver Elementary Schools Berwick Preschool

School Classroom Survey: Ventilation-noise Levels (Hodgson, 1999)

optimum: noise < 40 dBA (normal), 30 dBA (HoH)

30

35

40

45

50

55

U-H

ill 1

07

U-H

ill 1

10

U-H

ill P

ort

UP

LY

NN

1

UP

LY

NN

2

CV

CLF

1

DO

RLY

N1

CA

NH

TS

DO

RLY

N2

PLY

M

SM

HTS

DO

RLY

N3

DO

RLY

N4

CLV

LN

D

MA

PLW

D

Ber

50 c

lass

Ber

60 c

lass

Ber

34 t

each

Ber

39 t

each

Ber

65 t

each

Classroom

VN

A (

dB

)


School Classroom Survey:

In-class Sound Levels (Hodgson, 1999)

optimum: noise < 40 dBA (normal), 30 dBA (HoH)

30

40

50

60

70

80

90

100

110

U-H

ill 1

07

U-H

ill 1

10

U-H

ill P

ort

UP

LY

NN

1

UP

LY

NN

2

CV

CLF

1

DO

RLY

N1

CA

NH

TS

DO

RLY

N2

PLY

M

SM

HTS

DO

RLY

N3

DO

RLY

N4

CLV

LN

D

MA

PLW

D

Ber

50 c

lass

Ber

60 c

lass

Ber

34 t

each

Ber

39 t

each

Ber

65 t

each

Ber

50 t

each

Ber

60 t

each

Classroom

Lp

(d

BA

)


Noise and the Voice

Noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990)

Speech-breathing changes in noise (Winkworth & Davis, 1997)

Noise, RT & RASTI values in most occupied classrooms unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990)

Amplification can improve speech recognition and voice function (ASHA, 1990)

Amplification of 8-10 dB reduces vocal SPL: 2 + dB (Sapienza et al, 1999)

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Socially-reinforced or addictive behaviours - smoking?

- alcohol?

- caffeinated beverages/chocolate, etc

- recreational drug use?

- role models/assumption? (habitual imitative use

of inappropriate pitch or voice quality … conscious or

subconscious?)

Occupational Factors:

Ergonomics/Posture

Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

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Emotion Psychological factors

The body reacts to stress and anxiety by

increasing resting tone in voluntary muscles.

Muscles do not contract as efficiently when they are hypertonic.

Voice is used to express ideas and

emotions, and dysphonia may result when

these emotions are intense and suppressed

or with low level of emotional awareness.

Self-Reported Psych Conditions (PVCRP, 2009; N = 472)

Condition 10 MTD Non-MTD

Anxiety 35% 12%

Depression 28% 18%

Psychiatric

Disorder

12% 12%

Autonomic nervous system:

dry mucosa in the vocal tract stiffer vocal folds

“fight or flight” anxiety responses:

eg. “fight”: holding breath (vocal fold adduction);

“avoidance” racing heart, ready to retreat

awareness of physical response may increase

anxiety

attempts to “suppress” emotion (eg. compressing

larynx to reduce involuntary shaking) may back-

fire

level of emotional awareness will predict ability to

modulate physical reactions

Voluntary nervous system:

muscle tension/misuse: speech breathing, larynx,

upper vocal tract, face/jaw/tongue

attempts to control ANS responses such as nervous

tremor (Imitate the sound of someone giving a

speech when they’re very nervous.)

affective disorders/anxiety/psychiatric conditions

affecting emotional awareness/inhibition

suppressed emotional expression…What is the

innate vocalization associated with:

happiness/joy ? fear?

grief/sadness ? anger ?

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Neurobiology of Affect Regulation:

Allan Schore

Orbitofrontal system

“thinking part of the

emotional brain”, plays

major role in affect

regulation

Internal state,

organization of behavior,

adjustment of emotional

responses

LIMBIC SYSTEM

CINGULATE GYRUS

HIPPOCAMPUS

AMYGDALA

HYPOTHALAMUS

Orbitofrontal cortex not functional at birth. Over the

1st year, limbic circuitries emerge in sequence:

amygdala ant cingulate insula orbitofrontal

The Attachment System

Attachment system improves chances of infant’s

survival

seeking proximity: protection from harm, attack,

separation from group

Attachment relationships crucial in organizing

neuronal growth of developing brain

emotional relationships have direct affect on

development on memory, narrative, emotion

regulation

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Genetic factors vulnerability for a disorder,

environmental factors, such as attachment, play

crucial role in ultimate expression of symptoms

In postnatal period there is genetically driven

overproduction of synapses

Pruning & maintenance of synaptic connections

in frontal, limbic, & temporal cortices influenced

by psychological factors

Early abuse experiences of neglect/trauma

excessive pruning = poor limbic connections …

Human connections create neuronal connections:

Major environmental factor in brain development

Affect regulation pathway:

orbitofrontal limbic system

Orbitofrontal

Cortex

Attachment experience

development of orbitofrontal

function affect/behavior

regulation

Orbitofrontal metabolic

dysfunction in autism,

schizophrenia, bipolar,

depression, PTSD, drug

addiction, cluster B

personality disorders

Attachment pattern

Child Caregiver

Secure Uses caregiver as a secure base for exploration. Protests caregiver's departure and seeks proximity and is comforted on return, returning to exploration. May be comforted by the stranger but shows clear preference for the caregiver.

Responds appropriately, promptly and consistently to needs. Caregiver has successfully formed a secure parental attachment bond to the child.

Anxious Clingy, unable to cope with absences of the caregiver. Seeks constant reassurances.

Excessively protective of the child, and unable to allow risk-taking, and steps towards independence.

Avoidant Little affective sharing in play. Little or no distress on departure, little or no visible response to return, ignoring or turning away with no effort to maintain contact if picked up. Treats the stranger similarly to the caregiver. The child feels that there is no attachment; the child is "rebellious" and has a lower self-image and self-esteem.

Little or no response to distressed child. Discourages crying and encourages independence.

Child and caregiver behaviour patterns before the age of 18 months

[Ainsworth et al, 1978; Main & Solomon, 1986]

Ambivalent/

Resistant

Unable to use caregiver as a secure

base, seeking proximity before

separation occurs. Distressed on

separation with ambivalence, anger,

reluctance to warm to caregiver and

return to play on return. Preoccupied

with caregiver's availability, seeking

contact but resisting angrily when it

is achieved. Not easily calmed by

stranger. In this relationship, the

child always feels anxious because

the caregiver's availability is never

consistent.

Inconsistent between appropriate

and neglectful responses.

Generally will only respond after

increased attachment

behavior from the infant.

Disorganized Stereotypies on return such as

freezing or rocking. Lack of coherent

attachment strategy shown by

contradictory, disoriented behaviours

such as approaching but with the

back turned.

Frightened or frightening

behaviour, intrusiveness,

withdrawal, negativity, role

confusion, affective

communication errors and

maltreatment. Very often

associated with many forms of

abuse towards the child.

Attachment

pattern Child Caregiver

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Avoidant attachment history biased toward

parasympathetic state: low arousal, reduced

emotionality; under stress vulnerable to

overregulation & internalization

psychopathologies

Ambivalent attachment sympathetic state:

high arousal, high emotionality; under stress

vulnerable to externalizing psychopathologies

Attachment and Psychopathologies (Main et al, 1987)

Common forms of psychopathologies Numerical values are path coefficients, representing the strength of

associations between constructs (Krueger & Markon, 2006)

Levels of Emotional Awareness (Lane & Schwartz, 1987; Lane, 2008)

• Cognitive developmental process

• Similar to Piagetian theory

• 5 basic levels follow developmental pattern:

infants to “fully aware” humans

• neurobiological correlates

• top-down modulation allows “aware” person to

regulate amygdala and change physiological R’s

(eg. relaxed breathing to stop fight-flight R’s) Parallels in the hierarchical organization of emotional experience,

and neural substrates. Levels filled in white are implicit levels;

those in grey are explicit levels. Lane & Schwartz, 1987

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LEVEL 5: PREFRONTAL

CORTEX ; ant cingulate,

medial prefrontal cortex

Reflective awareness:

complex analysis of

experiences of self and others

LEVEL 4: Blends of emotions: “I feel

disappointed with myself”

LEVEL 3: ant cingulate, insula,

temporal lobe, orbitofrontal

cortex

Single emotions: “I feel

sad/happy/angry”

LEVEL 2: amygdala, thalamus,

basal ganglia

Sensorimotor enactive; crude

distinctions between globally

+ or – states; gestures &

mvts: “I want to hit you!”

LEVEL 1: thalamus,

hypothalamus, brainstem

Automatic generation of

emotional responses: “My

stomach/throat/jaw hurts”

Neuroanatomical Model: Implicit VS

Explicit Emotional Processes (Lane, 2000)

Amygdala and Thalamo-Amygdala process

implicated in rapid, low-level implicit (sub-

conscious) processing of stimuli. Precedes

emergence of emotional “feeling” state.

Phylogenetically-older structures, protect

organism in life-threatening situations.

In contrast, Neocortical-Amygdala pathway

involved in slower, more differentiated

explicit (conscious) processing of stimuli.

Implicit and Explicit Processes (Post Piagetian Representational Redescription)

Implicit (automatic action/sensori-motor)

patterns of knowledge (Levels 1 & 2) are

transformed to Explicit (conscious: Levels 3-5)

representations through language.

(Karniloff-Smith, 1992)

Use of language to describe emotions modifies

one’s emotional awareness and experience at

conscious levels. (Werner & Kaplan, 1963)

Corresponds with “Top-Down” modulation of

emotional responses.

Implicit Processes

May induce postures in respiratory and laryngeal mechanisms to facilitate rapid/strong physical reactions, as in fight or flight: fixing thorax with vf adducted to enhance upper body strength / abducting vf to facilitate free respiration for running.

Absence of higher level emotional processing and lx/respiratory system postures not conducive to normal phonation may make individual more susceptible to muscle tension voice/laryngeal disorders.

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Baker & Lane, 2009

Implicit emotional responses reflect

“unformulated experience”: emotions not fully

formed/differentiated, so expressed 10

physically. Once discussed & processed, can

be experienced fully.

VS: Freudian concepts: unconscious fully

formulated emotions being repressed

Theory informs treatment approach

Explicit Emotional

Experience

Anatomical

Correlates:

1- ventro-medial

prefrontal cortex;

right parietal

cortex; insula,

temporal pole

2 - dorsal ACG

3 - paracingulate

region of medial

prefrontal cortex

Explicit Emotional Processes support cognitive neuroscience approach to emotion.

Engage paralimbic and neocortical

structures that are not specific to emotional processes.

Domain-general nature of these structures infers they compete with other (potentially interfering) input for conscious processing.

May explain differences in individual attention to and use of emotional info.

Explicit processing may make individuals less vulnerable to physiological states associated with muscle tension dysphonias.

Top Down Modulation

Bodily sensations

Action tendencies

Discrete Emotion

Blends of Emotion

Self reflection

Brainstem

Diencephalon

Limbic

Paralimbic

Prefrontal Cortex

PSYCHOLOGICAL NEUROANATOMICAL

Greater activity in

dorso-medial

prefrontal cortex

associated with

higher vagal tone (thus, reduced HR,

calming)

Verbal emotion

labelling inhibits

amygdala activity. (Amygdala preferentially

activated by aversive

stimuli.)

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The LEAS - Levels of Emotional

Awareness Scale (Lane et al, 1990)

Written performance measure

Patients describe anticipated reactions for

self and other person to short vignettes

Scored per specific structural criteria to

determine degree of specificity of emotion

words and range of emotions

Scoring unbiased by patient or rater due to

structure focus of criteria

Glossary for each level guides scoring

Examples of LEAS 0-5 scoring – “Self” and “Other” R’s given separate scores

Non-affective (non-emotional) words = 0

Physiological words to describe feelings = 1

Undifferentiated emotion (eg. I’d feel bad) or

action tendency = 2

Single word used conveying differentiated

emotion (eg. I’d feel happy/sad/angry) = 3

Two or more level 3 words used to enhanced

differentiation = 4

“Self” and “Other” scores = 4 and

differentiated = 5

LEAS Reliability & Validity

High inter-rater reliability; high internal

consistency (Lane et al, 1998)

Construct validity supports LEAS as measure

of cognitive-developmental continuum:

moderately positive correlations with other

cognitive-developmental measures: Sentence

Completion Test of Ego Dvlpt and Cognitive

Complexity of the Description of Parents (Lane, 2008)

Emotion Processing Deficits and

Psychosomatic Voice Dysfunction

Causal Model of Emotion Processing Deficits in

Women with “FVD”: more severe events/

difficulties, COSO events/difficulties, highly

anxious coping style, less emotionally

expressive families, more ambivalence re

expressing neg. emotions.

FVD result of strong negative emotional

reactions to events + emotional processing

interference.

(Baker et al, 2007; Baker, 2008)

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Childhood Abuse in Patients with

Conversion Disorder (Roelofs et al, 2002)

Compared patients with conversion to

patients with affective disorder with respect

to childhood abuse

Patients with conversion reported higher

incidence of physical/sexual abuse

Larger number of different types of abuse,

longer lasting incidents of sexual abuse,

more incestuous experiences

What to screen for in initial

assessment: Attachment experience:

History of trauma or abuse

Quality of relationships (family, partner, school, friends)

Evidence of low level of emotional awareness

Personality factors

Avoidant tendencies, somatization, externalization …

Significant acute stressor in an otherwise well functioning individual

Depression, anxiety

Observe: Postural/Gestural/Facial Postures

Voice / posture changes with topics

Lexicon used to describe significant

events/distress

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Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

Reflux

71% MTD Patients =/> 4/7 Reflux Sx, Vs

VC Population: 47% (2009, N=472)

Higher palpation scores for Thyro-hyoid *

and Pharyngeal Constrictors

Higher % with A-P compression *

Reflux increases Lx tension and exacerbates

co-existent dysphonia (Gill & Morrison, 1997)

Reflux control facilitates therapy and recovery

Reflux Factors

Reflux - LPR

Common Symptoms:

throat sensations, am dysphonia

waking at night coughing or choking

habitual throat clearing; chronic cough

globus pharyngeus

heartburn

“post-nasal drip”

adductory laryngospasm

asthma or other chronic breathing difficulties

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Common Signs:

erythema / edema: posterior glottis

sub-glottis

arytenoids

contact ulcer / granuloma

“pseudo-sulcus”

Contact Granuloma

“… but Doctor, I don’t have

heartburn!” 2011 (www.pvcrp.com)

Patient tutorial on LPR

Diagrams, script and vocal narration

Patient compliance self-ratings (Likert scale)

(Targeted) Lifestyle changes compliance (LC)

Medication compliance (MC)

Tutorial group (N= 20) LC: 19/20 high compliance

MC: 16/20 high compliance

No tutorial group (N=20) LC: 9/20 high compliance

MC: 14/20 high compliance

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Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

Technique

Bad habits become programmed by repetition

(Neural Plasticity / Motor Learning)

Postural misuses:

• neck, back, head/shoulders?

• Speech breathing patterns ?

• Lower face, jaw and tongue?

• Infra-hyoid muscles?

• Specific Misuse Patterns – Larynx/Glottis

Technique

Posture affects breathing

Look at :

Back Alignment (Lordosis; Scoliosis)

Shoulders/Scapulae

Head-Neck Relationship

Stance

Knees

Use of Furniture; Props

Mal-Adaptive Speech Breathing

Behaviours affect Glottal Closure

abs clenched: thoracic elevation

large lung volume: laryngeal pull,

results in greater glottal chink plus

compensatory hypervalving (Sundberg et al,

1991; Sundberg, 1999)

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Normal inspiration and

expiration for

speech/singing, compared

with two common

misuses: failure to use

inspiratory “checking”

forces during phonation

(top right); and

exaggerated abdominal

tension to “support” the

production of voice

(bottom right). Both these

misuses can lead to

hyper-valving in the larynx

to regulate airflow.

Aligned posture and

common patterns of

misalignment

Scapula

adduction

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Head-neck relationships. Neutral is “healthy” posture. Chronic

neck extension or flexion impact the laryngeal suspension

system and can affect voice and swallowing.

Neck Tension / Headaches and MTD (Self-Reported, PVCRP, 2009; N = 472)

Tension Site 10 MTD Non- MTD

Neck /

Shoulders

46% 28%

Chr. Headache 27% 13%

Both 15% 10%

Totals 88% 51%

Palpation Sites: Anterior Floor of

mouth: Supra-hyoids:

- at rest

- pitch glides

- speech, probes

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“Scalloped” tongue periphery from pressing the tongue against the teeth.

Common in individuals who misuse muscles of the jaw and tongue:

tension in supra-hyoid muscles and jaw clenching are typically

associated with this visual perceptual sign.

Thyrohyoids: - at rest, yawn

- pitch glides

- speech, probes

Cricothyroids:

- at rest, yawn

- pitch glides

Pharyngeal Constrictors - at rest

- phonation

Jaw-Tongue Functions

Critical anatomical links to larynx

Facial co-contraction patterns common

(eg. Eyebrow adduction + jaw clench)

FACS studies: upper face emotionally

more salient, therefore Tx targets both

54% of MMD patients “TMJ” dysfunction

vs. 22% non-MMD patients (excluding

ILS) (PVCRP, 2009; N = 472)

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TMJ: - opening; closing

- speech; singing

Sub-occipitals: - at rest

- pivot; swivel Muscle Misuse Type 1: (Case 61)

The Laryngeal Isometric

• Generalized tension in all laryngeal muscles

• Often associated with an exaggerated posterior glottal chink

• Often associated with 20 mucosal lesions: bilateral nodules, chronic laryngitis, polypoid degeneration

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Muscle Misuse Type 2a (Case 63)

• Lateral compression at the glottal level • Frequently seen with generalized postural misuses and tension • May be triggered by an infection or by gastro-esophageal reflux

Muscle Misuse Type 2b (Case 64*)

• Supra-glottal lateral compression • Hyper-adduction of the false vocal folds • Often psychologically based

Clinical Example (*Case 64)

47 year old female experiencing globus and dyshonia after episode of sinusitis + cough. Normal exam except lateral supra-glottal compression. “Held” larynx. Static facies: eyes, lips, hypertonic masseters

Co-owner/manager of fast-food franchise with husband. Minimal marital relationship beyond work/children. During aphonia, husband had to assume more responsibility. Accused her of “faking”.

Voice Sx started in work environment, when confronting a defiant young employee about wearing perfume that she thought triggered Sx. Sx gradually generalized to many situations, including home.

Scored 5/7 on reflux Sx score (LPR; no heartburn)

Background

Alcoholic chain-smoking father, abandoned family when Pt. was 13 yoa.

Pt., eldest of several sibs, had to assume child-care responsibilities. Mother took 2 jobs, and rarely home.

A younger sister had defied Pt.’s authority and frequently caused trouble in community. Sisters fought physically over these incidents. Pt. periodically recalled those incidents when dealing with defiant employee.

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Emotional Awareness

Pt. aware of co-occurrence of exposure to noxious odors and throat Sx. (Level 1)

Also aware of desire to hit employee when she wore perfume and husband when he accused her of “faking voice loss”. (Level 2)

Preoccupation with globus led her to worry she had lx CA, to which an uncle had recently succumbed. (GP had suggested LPR, but Pt. rejected Dx). (Level 4?)

Psychological factors….

Patient abandoned by father & in a sense, also by mother (insecure attachment history = compromised emotion regulation pathway); likely had to forgo her own needs & prioritize taking care of others (siblings), little space for her to express her emotions (anger, resentment)

Development of avoidant/introversion traits that predispose to development of psychosomatic voice dysfunction

Sensory-Emotional Trigger

Interaction with defiant employee acted as a

trigger: feelings of helplessness, anger that

she felt both in the past, dealing with her sister

& in the present, dealing with the

employee/husband; in both past & present her

experience may be that her needs are not

being acknowledged/addressed

Reflux/Globus sensation increased when

emotionally aroused, due to tension in

abs/ANS… enhancing anxiety about CA

A

L E

R T

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Management Approach

Psychotherapy:

Develop therapeutic alliance: trusting, secure

attachment with therapist

Give her tools to tolerate emotional distress:

breathing exercises, relaxation strategies,

mindfulness exercises

Target expression of emotion, validate her

experiences/needs

Voice Therapy

Explanation of relationship of LPR to lx hypertonicity/globus. (“But Doctor, ” www.pvcrp.com)

Top-down facial exercises to increase awareness of & reduce static facial postures. (Rammage, 1996; 2011)

Explanation & demo of inappropriate VS appropriate larynx / vf posture for phonation.

ID and application of most accessible & salient facilitation technique to restore normal phonation (glottal fry, gradually increasing intensity, while monitoring tactile feedback with fingers over lx)

Negative practice to increase voluntary control: desensitize to triggers; create “dysphonia”; apply facilitation technique to restore normal phonation.

Top Down Facial Gestures (Ekman, 1982)

Emotional experience in can be influenced by

feedback from facial muscles.

Emotional ambiguity reinforced by

incongruent facial postures for observer and

expresser.

Lower face more subject to facial “emblems”,

such as “perma-smile”.

Releasing lower facial postures dependent on

awareness/release of upper facial postures.

Top

Down

Facial

Muscle

Release

http://www.pvcrp.com/

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Muscle Misuse Type 3 (Case 65)

• Antero-posterior supra-glottal compression

• Associated with high palpation scores in thyro-hyoid muscles

• Common technical misuse seen in mild, moderate and severe

forms


• Incomplete vocal fold closure • PCA, CT muscles contracted

• Distinguish from anatomical incompetence by symmetry and trial Tx

• Associated with conversion aphonia


• Vocal fold bowing caused by muscle misuse

• Distinguish from bowed vocal folds of aging/atrophy; sulcus/scarring; IPD…


•Laryngeal posture for falsetto register phonation •Typically seen in adolescent transitional voice disorder

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Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

Hypothetical

ALERT model for

young woman with

significant L, E & T

factors, and 20

vocal fold nodules

Diagnostic Voice Therapy

Facilitation Techniques for Dx / Symptomatic

Therapy …

Technique Indications Contraindications

Adduction (forced): pushing; pulling;

cough

Incomplete vocal fold closure in

conversion aphonia

Do not use if mucosal edema or

erythema is present. Articulation exaggeration; increased

orality

Hypernasality; restricted

jaw/tongue/lip movements

Do not allow exaggerated jaw

movements in individuals with TMJ

dysfunction.

Auditory masking during phonation Incomplete vocal fold closure in

conversion dysphonia; low intensity

Do not use if mucosal edema or

erythema is present.

Breathy-flow phonation (Increase

MFR)

Lateral compression of vocal folds

and/or false folds; glottal attacks

Chanting (Decrease intonation and

stress)

Muscle misuses resulting in pitch

and/or phonation breaks

Be aware of increase in muscle

misuse during chant.

Chewing with phonation Tension in supralaryngeal muscles Do not use if TMJ dysfunction

Character voices: Impersonate an

opera singer, puppet voices

Inappropriate pitch, resonance,

monotonicity, monointensity


misuse to imitate voices.

Coordinated voice onset (CVO):

“Hm!”

Most muscle misuse patterns; poor

speech breathing; glottal attacks

Distraction: eg, hum while walking,

turning pages, turning/shaking head

gently

General muscle and postural

misuse; psychological feed-forward

mechanisms restricting voice range

Inhalation phonation Supraglottal compression; poor

vocal fold closure; dysfluency (SD)

Do not use if paradoxical vocal fold

movements are present.

Intonation increase Monotonicity; inappropriate pitch

Jaw movements (ie. small, relaxed

pivotal movements) during syllable

repetition

Muscle misuse in lower face;

restricted jaw movements;

distraction

Do not allow exaggerated jaw

movements in individuals with TMJ

dysfunction.

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Loudness change Inappropriate loudness level; glottic

compression: ↓ level asthenia: ↑

level

Do not use exaggerated loudness

in presence of mucosal

edema/erythema

Lung volume change: reduce

volume: CVO increase volume:

sigh

Laryngeal isometric; inappropriate

speech breathing; breath-holding

Do not use sigh and exaggerated

lung volume for laryngeal isometric.

Manipulation (e.g.,): increase

thyrohyoid space; depress larynx

hold tongue forward; hold jaw open

Tense T-H; A-P compression

Tense suprahyoids/high larynx

Tense tongue/backed carriage

Lower facial tension/poor orality

Beware of TMJ

dysfunction.Clinician should have

appropriate training in laryngeal

manipulation techniques. Movements in upper body: head-

nods; shoulder rolls

General muscle/postural misuse;

distraction

Use only with advice of physical

therapist/medical practitioner in

cases of neck, back, shoulder

problems.

Pitch change Inappropriate pitch/register use;

Incomplete adduction in conversion

disorder; bowed vocal folds


misuse to achieve pitch change.

Posture adjustments (e.g.,):

head position: forward; back;

supine position; lean forward,

neck flexed

Distraction

Jaw jut; upper back/neck tension

Tense laryngeal suspensory

muscles

General postural misuse;

inappropriate speech breathing

Use head/neck posture changes

only with advice of physical

therapist/medical practitioner in

cases of neck, back, shoulder

problems.

Register change (e.g.,): falsetto,

glottal fry

Incomplete glottal closure; tense

cricothyoid muscles


misuse to achieve register change

Resonance focus adjustment:

forward: humming-buzzing;

backed: “covering”

Harsh/rough/breathy quality; poor

glottal closure; poor projection

Fronted tongue posture; thin sound


Semi-occluded upper vocal tract

tactics (straws; v/z productions;

lip raspberries)

Hyper/hypoadduction of v.f.; general

muscle misuse impacting phonation;

stiff/scarred vocal folds

Sometimes triggers

cough/larygospasm in ILS

Siren imitation/howling/etc Pitch range restrictions/

register breaks due to muscle misuse

Speech rate change Rapid or excessively slow speech;

inappropriate speech breathing;

laryngeal/supralaryngeal tension

Spontaneous phonation (e.g.,):

extend cough, laugh, CVO

Incomplete glottal closure in

conversion disorder; falsetto in

adolescent transitional disorder

Do not use aggressive cough if

mucosal edema is present

Taunting-Teasing

(ngya ngya ng-ngya-ya)

Incomplete glottal closure; laryngeal

isometric; poor resonance

Tongue position change Cul-de-sac resonance (front tongue)

Immature resonance (back tongue)

Trills: voiced lip or tongue trills Restricted pitch range; register

breaks

Voice mode change: singing to

speaking; speaking to singing

Laryngeal dysfluencies; inappropriate

resonance focus

Yawn-sigh phonation Restricted speech breathing

movements; supralaryngeal

compression

Beware of TMJ dysfunction.

Do not use for laryngeal isometric

muscle misuse.

From: Rammage et al, 2009

Anatomical


Disease

Lifestyle:Acoustics

Environment

Ergonomics

General health


Vocal dose

Emotion:Anxiety

Depression


Vocal expression

Vocal repression

Level of emotional

awareness

Reflux:Diet

Eating habits

Genetics

Medications

Posture

Weight


Muscle misuses:

Neck/Shoulders

Face/Jaw/Tongue

Pitch focus

Resonance focus

Speech breathing

Determining Treatment Purpose/Priorities

Relative “size”/primacy of A factor(s):

Cognitive/Emotional Factors:

Feedback Channels:

Duration of Sx:

Commitment to Tx: Client:

Clinician:

External Factors, eg. environmental/workplace:

Cultural-Social-Economic Factors:

Results of Dx Therapy:

Factors Influencing Selection and

Success of Therapy Programs

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Indirect and Direct Therapy

Indirect: Which ALERT Factors?

Lifestyle: Education

“Vocal Hygiene”/Hydration (Roy et al, 2001;

Verdolini-Marston et al,1990/94; Nanjundeswaran et al, 2012)

Voice use monitoring:

Informal or Instrumental: eg. dosimetry

Voice rest/conservation

Altering acoustic environment (SNAG, 2009)

Vocal amplification (Roy et al, 2002;2003)

“SNAG” Goals: Optimizing Classroom

Acoustical Environments (www.pvcrp.com)

Higher speech levels - good classroom design

- amplification system?

- preventive voice training?

Lower noise levels - quiet ventilation, equip’t - NO OPEN PLAN!! - class organization/control - sound-proof partitions - cushioned surfaces - quiet light ballasts

Appropriate reverberation - good classroom design - appropriate sound-absorbing materials

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Voice Amplification (Roy et al, 2002;2003)

Check room acoustics first: reverberation time?

If not .4-.6 sec., consider classroom modifications

SNR: min 15 dB (SNAG, 2009)

Appropriate gain potential

Uni-directional mic:

Monitor to reduce Lombard

Portable, if necessary

Post-Operative Voice Use Instructions for

Phonosurgery Patients

VOICE REST (first 48 hours after surgery):

Do not use your voice unless absolutely necessary

Speak 5 minutes maximum per hour

Only speak softly, in a quiet environment

Only speak in the middle of your vocal range

No throat-clearing or coughing

DO NOT WHISPER: Write your message instead

Cancel all social engagements

Stay at home and get plenty of rest and hydration*

* You can determine your hydration by observing your urine: it should be

pale in colour. If not, drink more non caffeinated, non-alcoholic beverages

RESTRICTED VOICE USE (+ 1 week after voice rest

period):

Use your voice normally in the middle of your vocal range in

quiet settings

Do not speak outside, in groups, in a vehicle, aeroplane or other

noisy environments, such as restaurants

When speaking you should be close enough to your listener to

touch his/her shoulder

Do not use vocal throat-clear or cough

DO NOT WHISPER

Be sure you are adequately hydrated by drinking at least 8

glasses of non-caffeinated, non-alcoholic beverages daily

PRUDENT VOICE USE (+ 2 weeks after

restricted voice use period):

Observe vocal hygiene rules: No yelling, cheering, screaming,

throat-clearing, coughing, loud or prolonged laughing/crying, whispering

Use the middle of your vocal range, avoiding extremes in pitch and

loudness

Speak within arm’s length of your listener

If you are speaking in a group larger then 20, outside or in a noisy

environment, use a vocal amplification system

Maintain adequate hydration

Schedule vocal rests throughout the day

ONGOING VOCAL HYGIENE (indefinite):

Refer to your Vocal Hygiene guidelines to ensure you maintain

healthy vocal habits.

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Sample

vocal

hygiene

protocol.

See full

protocol in

text.

Available at:

www.pvcrp.

com

Indirect Tx

Emotional Factors: SLP Role?

If E is dominant/10, refer to MHP

When psychological interference

evident during therapy, refer to MHP

Reflux Factors: SLP Role?

Behaviour specialist: guide lifestyle

Educate re effect on lx function:

“But Doctor”… www.pvcrp.com

Direct Therapy

Comprehensive (eg. Vocalizing with Ease)

hierarchical motor re-learning program: body

alignment; head, neck and shoulder muscles; specific

relaxation for tongue, jaw and facial muscles; speech

breathing and voice onset; resonance enhancement;

vocal flexibility; vocal dynamics; phrasing

Focused (Symptomatic) short-term / specific

symptoms of voice dysfunction. Based on Dx therapy

outcomes. May include manual therapy techniques

Holistic Eg. yoga; Feldenkrais; Pilates; Alexander

technique; massage therapy; acupuncture; relaxation;

fitness programs

Principles:Technique Change

Motor learning theory:

Basic re-programming

Simple tasks

Frequent repetition

Instant feedback, 10 kinaesthetic

Ownership: We provide the remedy, you

(the client) provide the cure!

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Motor-Learning & Neural Plasticity

Fundamental Tasks Generalizing Effects

(“Up-regulation of chemicals”?: Rosenbek, 2010)

Neural Plasticity Use & Experience Specific! (eg.,Kleim & Jones, 2008; Ludlow et al: JSLHR 51, 2008)

Training Cells: Repetition/Intensity/Variability

Feedback: salient

Skills are slow to develop in CNS, but become

permanently encoded… (Adkins et al, J.Applied Physiol,101, 1776-1782, 2007)

Physiological

(eg,reduce glottal chink)

Acoustic

(eg,elevate pitch)

Symptomatic:

Change Specific

Symptom/s:

A - Z

Alignment...Buzzzing

General and Specific

Motor Relearning

Comprehensive:

Treat the Whole

System:

General Approach

Accent Method

Progressive Relaxation

Yoga, etc.

Holistic:

Treat the Whole

Person:

Technique Changes:

Voice Therapy

Summary of Direct Therapy Techniques

in Common Use to Manage Voice

Dysfunction …

Technique Theoretical

Bases

Procedures; Training Application/Evidence Limitations/

Contraindications

Accent

Method

(Video)

(Smith and

Thyme,

1976)

Easy, resonant

voice facilitated

by:

Abdominal

support

Rhythmic speech

breathing

gestures

Open airway

Aerodynamic

principles of

phonation

Graduated body

orientation: Graduated

levels of voicing during

rhythmic breathing.

Graduated complexity of

rhythms and phonemic

pattern. Fricatives for

aerodynamic effect in

vocal tract.

Training: audio-video

samples or experienced

clinician.

Adductor SD (Kotby et al,

1991)

Functional voice disorders

(Fex et al, 1994)

Variety of voice disorders

(Kotby et al, 1991; Bassiouny,

1998)

Vocal fold paralysis (Khidr,

2003)

Speech dysfluency (Kotby

and Fex, 1998)

Program extends

over 30 or more

sessions, so

consumes extensive

clinician and client

time/resources.

Chant Talk

(Boone,

1971)

Relaxed

phonation

facilitated by:

Vowel

prolongation

Reduced

prosodic stress

Monotone voice

Easy voice onset

Elevated pitch

Clinician models during

oral reading: elevated

pitch, prolonged vowels,

minimal syllable

stress/intonation, smooth

syllable transitions.

Once the skill is

acquired, chanting is

alternated with regular

speech for carry-over.

Benign essential tremor. Dworkin and Meleca (1999)

Vocal hyper-function

(Boone et al, 2010)

Vocal fatigue in teachers

(McCabe and Titze, 2002)

Spasmodic voice

disorders.

Elevated f0 may

result in increased

laryngeal

effort/tension in some

individuals.

Monotone pitch may

exacerbate muscle

misuse.

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42

Chewing

(Froeschels,

1952)

Use of

vegetative jaw

and tongue

movements

frees laryngeal

suspension

system to

allow for more

relaxed voice

production.

Exaggerated chewing

motions modeled and

trained. Voice is added

to chewing movements

on nonsense syllables;

serial speech tasks.

Range of movements

reduced over time:

client imagines chewing

activity.

Individuals with

restricted jaw and lip

movements during

speech (Boone, 1971;

Boone et al , 2010)

May be contraindicated for

clients who have

dysfunction at the

temporo-mandibular joint.

Some individuals may be

reluctant to perform the

exaggerated movements

Confidential

Voice

(Colton et

al, 2006)

Vocal effort

and tension

reduced by

soft, breathy

voice

Easy concept

for adults and

children to

understand

and learn

(Boone et al,

2010)

Patient instructed to use

the softest voice

possible without

whispering.

Clinician models

relaxed, low intensity,

breathy sound with

natural pitch and

prosody.

Vocal fold injuries, post

phonosurgery; vocal

hyperfunction (Colton et

al, 2006)

Vocal fold nodules (Verdolini-Marston et al,

1995)

Should be used as a

temporary voice

conservation approach.

Extended use of breathy

voice may exacerbate

certain muscle misuses,

such as laryngeal

isometric postures with

exaggerated posterior

glottal gap, and

maladaptive speech-

breathing.

LSVT

LoudTM

(Ramig et al,

1994)

Principles from

muscle training,

motor learning,

neuro-plasticity

& neuropsych

Effort to

increase

loudness

improves vocal

fold adduction

and has

globally positive

effect on

speech

Intensive individual therapy

1 hr, 4 X/wk, 4-wk + home

practice.

Sustained phonation,

vowels; pitch changes to

increase laryngeal flexibility

and stability.

“Functional phrases”

Clinician coaching

facilitates calibration (client

adjustment to increased

effort, loudness).

Clinician training: on-site or

on-line certification

program.

Parkinson’s hypo-

phonia (Ramig et al,

1994; 1995; 1996; 2001;

Smith et al, 1995)

Spastic dysarthria in

MS (Sapir et al, 2001)

Dysphagia (El

Sharkawi et al, 2002)

Communicative

gestures (Duncan,

2002)

Facial expression

(Spielman et al, 2003)

Senile atrophy (LSVT

Training Manual, 2010)

Intensive treatment may be

difficult for clients with

significant health

compromises.

Clinician certification

requirement, cost and

inaccessibility of therapy

may be prohibitive for some

clients.

Resonance-

Humming

(Lessac,

1973;

Linklater,

1976)

Resonant

Voice

Therapy

(RVT)

(Verdolini,

1998)

Humming =

phonation with

semi-occluded

vocal tract,

associated with

an optimal

vocal fold

posture and

vocal efficiency

(Titze, 2001;

2006)

RVT: Systematic ten-step

program incorporates

posture, relaxation,

exploration of resonance

sensations on nasal

phonemes, pitch variations,

extending resonance

sensation to words,

phrases, sentences.

Clinician training:

Structured training program

is offered.

Occupational voice

users (Roy et al, 2003;

Chen et al, 2007;

Nanjundeswaran et al,

2012)

Unilateral vocal fold

paralysis. (Schindler et

al, 2008)

Vocal fold edema

(Verdolini et al, 2012)

Vocal fold scar

(Hapner and Klein, 2009)

Resonant voice training may

be enhanced by relaxation

techniques, manual therapy

/ postural changes, esp. with

severe muscle misuse.

Ensure each client

experiences enhanced

resonance in the absence of

maladaptive muscle misuse

behaviours such as labial or

supra-hyoid tension.

Semi-

Occluded

Vocal

Tract

(Sovijärvi,

1965

Titze,

2001;

2006)

Increased P0 /

length in upper

vocal tract:

phonation near

lowered F1:

abducted vocal

folds reduces

vocal fold

collision. Glottal

width of a few

millimetres is

associated

greater vocal

efficiency.

(Titze, 2001;

2006)

Client phonates while

blowing into straws.

Resistance reduced by

increasing straw diameter.

Client phonates during

bilabial fricatives, lip or

tongue trills, nasal

phonemes, high vowels.

Client produces pitch glides

simultaneous with semi-

occluded vocal tract

techniques.

Client uses pitch changes

during singing and speech

activities, with reduced

laryngeal effort.

Hyperfunctional voice

problems (Sovijärvi,

1969; Simberg, 2001;

Titze, 2006; Simberg and

Laine, 2007)

Vocal nodules (Sovijärvi,

1969; Simberg, 2001)

Chronic laryngitis

(Sovijärvi, 1969; Simberg,

2001)

Student teachers with

mild voice problems

(Simberg et al, 2006)

Vocal fold stiffness

post injury

Variability (Gaskill &

Quinney, 2012)

Habitual muscle misuse in

lower face /lips/jaw may be

exacerbated by exercises

encouraging increased

resistance at the oral outlet:

may be necessary to reduce

muscle tension in jaw,

tongue face, lips.

Individuals with vocal

hyperfunction due to motor

speech disorders may not

be able to achieve the

required articulator

resistance and/or

respiratory drive for some

activities.

Vocal

Function

Exercises

(VFE)

(Briess,

1959)

Stemple et

al, 1994)

Application of

principles of

exercise

physiology

improve

strength,

balance and

flexibility in the

vocal system.

4 components: warm-up;

stretching; contraction;

adductory power exercises.

Sustain phonation quietly on

prescribed pitches; pitch

glides.

Clinician models to train

frontal resonance focus.

Practice regime: 2 reps per

exercise, 2x daily.

Vocal fold stiffness

post injury or phono-

surgery, with

associated vocal

hyper-function

(Stemple et al, 1994)

Singers (Sabol et al,

1995)

Teachers with voice

disorders (Roy et al,

2001)

Care should be taken to

minimize common muscle

misuses during maximum

performance tasks, such

as jaw extension, supra-

hyoid tension and larynx

elevation during upward

pitch glides.

Yawn-Sigh

(Boone,

1971)

Larynx is

lower, pharynx

is wider during

yawning.

(Boone and

McFarlane,

1993)

Relaxation

recoil forces

are employed

primarily for

exhalation

during the

voiced sigh.

Clinician explains

difference in the larynx

position and reduced

effort of yawn-sigh and

models.

Initially phonation on

sigh is somewhat

breathy.

/h/ used extensively to

encourage slightly

abducted vocal fold

position.

Sensations of more

open pharynx and

smooth voice onset are

maintained as the yawn

is phased out.

Inappropriately high

larynx posture and

hyperfunctional

laryngeal activity (Boone

and McFarlane, 1993)

Voice-disordered clients

able to master the

technique and carry

over to regular speech

(Xu et al, 1991)

Essential voice tremor

(Barkmeier-Kraemer et al,

2011)

Sighing may reinforce use

of inappropriately high

lung volumes for speech,

associated with vocal fold

abduction (Sundberg et al,

1991). Carry over to

speech may be difficult for

individuals who are unable

to restore normal lung

volumes and re-balance

relaxation and muscular

forces for speech

breathing.

Yawning may be

contraindicated in

individuals with TMJ

dysfunction.

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Role of Manual Therapy

Primary approach to release specific muscle

tension Eg. CT muscle: Harris, 1993;

Postural/laryngeal suspension/intrinsic

laryngeal muscle mechanisms: Lieberman

(1998)

Adjuvant therapy to medical-surgical /

traditional voice Rx: Harris et al, 1998;

Marszalek et al, 2012

Requires intimate knowledge of anatomy and

competency for manual therapy skills

Does Preventive Voice Care Work?

Duffy & Hazlett (N.Ireland, 2004):

Indirect education: physiology, vocal hygiene, etc.

Direct: comprehensive training: posture, speech-

breathing, reduced tension, resonance, voice

projection

Longitudinal data:

Control group: no change

Indirect group: no change

Direct group: improved

Does Preventive Voice Care Work?

Teachers’ Perceptions

Yiu et al, Hong Kong, 2002

Surveyed teachers’ perceptions of impact and preventive measures

Significant impact on personal/professional lives

From large menu of treatments, teachers believed more info on breathing exercises and vocal hygiene most important for prevention

Does Voice Rx Work?

Roy et al, Utah/Ohio, 2002

3 Rx: voice amp; voice hygiene; control

VHI/acoustic perturbations reduced only with voice amp

Roy et al, Utah/Ohio, 2001

3 Rx: V.F.Exc.(Briess/Stemple); vocal hygiene; control

Only VFE group improved with VHI

Sapienza et al, Florida, 1998

Teachers using voice amp reduced vocal SPL (2.42 dB

SPL) with 8-10 dB amp.

10/10/2014

44

Vocalizing with Ease – Group Rx

14 hours comprehensive Rx (7 weeks or 5 days)

Optional “refresher” sessions

Voice-Related QOL (Hogikyan et al, 1999; 2000)

Significant + scores: immediately after Rx: 50% (N = 300)

(NS with + trend: 47%)

1 year post-treatment: 70% (N = 100) (NS with + trend: 23%)

Enhancing

Resonance

Intonation Physical Phrasing

Increasing

Vocal Flexibility

Coordinated Voice Onset Liberating Articulators

Posture & Alignment

Optimizing Technique

10/10/2014

45

Natural Speech Breathing

Establish natural posture

Control muscle misuses, e.g.,

“Tongue-Breathing”

Don’t “over-prepare” (inspiration)

Use spontaneous utterances:

Hm! UmHm

Use natural phrase boundaries

Optimizing Voice Onset

Spontaneous vocalizations for natural

coordination/pitch: “Hm!”; “Um Hm”

(Silent “h” for optimal glottal width)

Capitalize on elasticity around REL (32-40% VC):

using passive + active forces “Hm(rr*)Hm (rr)…”

Facilitating postures optimize feedback

Low-level practice transfer saliency: “Hm; Hi!”

CVO extension speech phrasing

*(rr = respiratory release = inspiration)

10/10/2014

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10/10/2014

47

Releasing the Jaw/Tongue

Drag-on the Larynx

Release: neckfacejawtongue

NO JAW JUT!

Lip movements jaw release

Passive pivotal jaw movements

The tongue is a rug, on the floor:

neutralize!

Dynamics: more jaw, less tongue,

stuttering & articulation Rx too!

10/10/2014

48

Q: Why does Humming Help? A: Semi-Occluded Vocal Tract (optimizes v.fold

closure/PTP; Provides real-time feedback…)

Vowels buzz too! The Vocal Siren (find “head voice”;

blend upper and lower registers)

10/10/2014

49

Other semi-occl. v-tract techniques

Z – Swell (semi-occluded vocal tract, coordinated speech

breathing, oral vibration feedback, natural

intonation, transition to speech phrases.)

Z

Z

(feel abs!)

Z…o-n-e……t-w-o…….t-h-r-e-e …….

Zoom (semi-occluded vocal tract start, natural intonation on

vowel, hum-buzz finish, transition to speech phrases)

Race Car: z-z-z-oo-oo-oo-oo-oo-oo-oo-m!

z-z-oo-oo-oo-m-z-oo-oo-oo-m!

z-z-oo-oo-m-z-oo-oo-m-z-oo-oo-m!

z-oo-oo-m-z-oo-oo-m-o-n-e!

z-oo-oo-m-z-oo-m-o-n-e….t-w-o …

what is ebp? for voice disorders: using the alert model · central sensitization amygdala: both...

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