Voice Therapy Concepts and Techniques

Issues Affecting Voice Production

• Voice issues can stem from structural or behavioral causes, or a combination of both.
• Lifestyle modifications include reflux management and vocal health/hygiene practices.

Hydration and Dehydration

• Systemic hydration refers to fluid intake; surface hydration includes steam inhalation and humidifiers.
• Dehydration can increase subglottic pressure and negatively impact vocal quality in the short term.
• Dehydration raises the risk of phonotrauma and hampers recovery from existing vocal injuries.

Reflux Management

• Reflux occurs when stomach contents flow back into the esophagus and can be managed through medication or lifestyle changes.
• Common reflux triggers include fatty foods, spices, citrus, and habits like smoking or high stress.
• Strategies to manage reflux include dietary changes and lifestyle adjustments like elevating the bed.

Vocal Trauma and Habits

• Vocal trauma can result from habitual or work-related behaviors.
• Identifying potentially harmful vocal habits is crucial; strategies should promote lifestyle modifications.
• Handouts for patients should emphasize positive language and be easy to understand.

Voice Therapy Goals

• Improve coordination of respiration, phonation, and resonance for better voice production.
• Enhance ease, quality, and awareness of vocal sensations linked with new phonation patterns.
• Applicable to various disorders with hyper- and hypo-functional vocal patterns.

Semi-Occluded Vocal Tract (SOVT)

• SOVT exercises narrow the vocal tract to produce a resonant voice, maximizing interaction between sound source and filter.
• Such exercises reduce tension, increase efficiency, and can improve vocal quality.
• Activities include straw phonation, lip trills, humming, and using voiced fricatives.

Resonant Voice Therapy

• Focuses on improving ease, quality, and efficiency of phonation, along with reducing strain.
• Sensations of buzzing in the oral cavity encourage vocal health and minimize injury exacerbation.
• Lessac-Madsen Resonant Voice Therapy (LMRVT) and Vocal Function Exercises aim to strengthen laryngeal function.

Additional Voice Therapy Techniques

• LaxVox utilizes straw phonation with water; the Accent method incorporates rhythmic exercises for airflow and vocal fold coordination.
• Twang voice technique narrows the vocal tract for increased efficiency and reduced effort in phonation.

Flow Phonation Techniques

• Stretch and Flow therapy addresses functional dysphonia and excessive tension while focusing on airflow coordination.
• Techniques like Yawn-Sigh facilitate phonation while monitoring airflow through biofeedback methods.
• Other exercises include Confidential voice, Open-Mouth techniques, and Chant talk for smoother vocal delivery.

Exercises for Vocal Tension Reduction

• Tongue protrusion and glottal fry are used to reduce laryngeal tension and promote relaxed vocal fold function.
• Inhalation phonation can be beneficial for establishing phonation in cases of functional aphonia.

Strength and High-Effort Exercises

• Vocal Function Exercises and semi-occluded techniques support physical aspects of voice production.
• High phonatory effort exercises, like Lee Silverman Voice Treatment (LSVT), target patients with Parkinson’s and related disorders.

Breathing Techniques

• Emphasis on low-centered and diaphragmatic breathing for proper vocal support.
• Vocal training selections should be patient-specific based on individual needs and background.

Special Populations

• Paradoxical Vocal Fold Motion (PVFM) characterized by inappropriate adduction during inhalation can mimic asthma symptoms.
• Treatment for PVFM includes relaxed breathing techniques and voice therapy.

Laryngectomy Considerations

• Laryngectomy involves surgical removal of the larynx, requiring a multifaceted approach to communication post-surgery.
• Communication options for laryngectomees include electro-larynx, tracheoesophageal speech, and esophageal speech techniques.

Voice Evaluation Techniques

• Voice evaluations encompass various assessments, including indirect laryngoscopy, acoustic, aerodynamic, and subjective measures.
• Laryngoscopic observations focus on vocal fold edge, closure patterns, vibration amplitude, and mucosal wave assessments.

Acoustic and Aerodynamic Analyses

• Acoustic measurements assess fundamental frequency, intensity variability, and other vocal parameters.
• Aerodynamic evaluations measure lung volumes, airflow, and laryngeal resistance for comprehensive voice assessments.

Patient Self-Rating

• Self-evaluation includes the patient's perception of how dysphonia affects their quality of life, aiding in targeted interventions.

Voice Assessment Tools

• Adult Scales: Include Voice Handicap Index (VHI), Voice Symptom Scale (VoiSS), Vocal Tract Discomfort Scale, and more.
• Pediatric Scales: Pediatric Voice Handicap Index, Children’s Voice Handicap Index-10, and related assessments for parents.
• Special Populations: Singing VHI for singers, Transsexual Voice Questionnaire, and Transgender Self-Evaluation Questionnaire.

Voice Handicap Index (VHI)

• A 30-item self-questionnaire evaluating how voice problems affect life, scored across three subscales: Functional, Emotional, and Physical.
• Variants include VHI-10 and Singing Voice Handicap Index (SVHI).

Health Literacy Considerations

• Average reading level for English-speaking adults in the U.S. is at or below seventh grade.
• Health materials should target fifth or sixth-grade reading levels for better comprehension.

Patient Interview Techniques

• Use open-ended questions to gather comprehensive patient histories about their voice complaints and habits.
• Assess vocal hygiene, lifestyle factors (e.g., smoking and hydration), and medications that may affect voice quality.

Vocal Behavioral Assessment

• Analyze vocal behaviors in different settings (work vs. social).
• Identify potential vocal abuse (e.g., yelling, excessive throat clearing) and associated stressors.

Perceptual Evaluation

• Assess overall severity and qualities of voice, including roughness, breathiness, hoarseness, and strain.
• Evaluate pitch intensity and breathing patterns.

Objective Measures

• GRBAS Scale: Measures Grade, Roughness, Breathiness, Asthenia, and Strain on a 0-3 scale.
• CAPE-V: Consensus auditory perceptual evaluation focusing on global voice severity, roughness, breathiness, strain, pitch, and loudness.

Physical Evaluation

• Involves laryngeal palpation and tension assessment in areas like the jaw, neck, and shoulders.

Aging Voice and Presbyphonia

• Presbyphonia results in weak, hoarse voices impacting quality of life in aging populations.
• Key signs include vocal fold bowing and asymmetry, leading to perceptual features like tremor and decreased loudness.
• Management may include laryngoplasty, thyroplasty, and voice therapy.

Transgender Voice Therapy

• Stages of transition include Pre-discovery, Discovery, Acceptance, and Disclosure, with distinct emotional and social implications.
• SLP should foster a supportive environment and collaborate with a multidisciplinary team for individualized care.

Feminine vs. Masculine Voice Characteristics

• Feminine voice typically features a wider pitch range, forward resonance, and breathier quality.
• Feminine communication includes more empathetic language and less directness, with fluid body language and expressive gestures.

Assessment Measures Summary

• Utilize tools like the VHI, CAPE-V, and s/z ratio to gauge vocal fold efficiency rather than directly diagnosing respiratory issues.
• Recognize the differences in communication traits among various populations, including post-laryngectomy patients.

Additional Resources

• The Genderbread Person: A guide to understanding gender and identity.
• Transsexual Voice Questionnaire: An assessment tool for trans-women's vocal experiences.