Voice Therapy 4 Review PDF

Voice therapy: Issues that affect voice productions: structural, behavioral or a combination of both Lifestyle modifications: reflux management, vocal health/hygiene Hydration: o Systemic: what we intake o Surface: steam inhalation and humidifier D...

Voice therapy: Issues that affect voice productions: structural, behavioral or a combination of both Lifestyle modifications: reflux management, vocal health/hygiene Hydration: o Systemic: what we intake o Surface: steam inhalation and humidifier Dehydration: possible influence of dehydration on phonatory performance and structure o Appears to INCREASE subglottic pressure and perception of vocal effect o Appears to deteriorate voice quality in the short term o Can INCREASE risk of phonotrauma and/or DECREASE the potential for healing from existing phonotrauma Reflux: o When stomach contents flow back up into the esophagus o Medication can be given o Triggers: certain foods (fried/fatty foods, spicy, citrus, tomato products, chocolate, alcohol, caffeinated beverages etc) and being overweight, a smoker, pregnant, or increased stress and anxiety o Medication can be given ▪ How are they taking it? ▪ PPI, H2 blocker o Changes in eating habits, bed wedges, elevate bed are all options o Notice any habits/behaviors that exacerbate reflux? ▪ Create strategies Vocally Traumatic Behaviors: o Any behavior that can result in vocal trauma o Some behaviors can be typical (how much/how often is a big factor) o Identify the bahviors ▪ Habitual/work related ▪ Strategies to avoid or decrease o Handouts should be: ▪ Simple/note worthy ▪ Contain positive language ▪ Key is lifestyle modification  Voice Therapy: o Improve coordination of the three subsystems of voice production (respiration, phonation, and resonance) o Improve ease of production o Improve quality of production o Increase awareness of sensations associated with new phonation patterns o May be used with a variety of disorders that result in hyper- and hypo- functional vocal patterns o Vocal therapy exercises: ▪ Many voice therapy techniques are based on singing and acting voice “warm-ups” that use a semi-occluded vocal tract ▪ Lip trills, tongue trills, bilabial fricatives, humming, and phonation into tubes or straw have been used by clinician, singing teachers, and voice coaches for training and rehabilitation ▪ Phonation becomes easier to produce and has more resonance improved quality) Semi-Occluded Vocal Tract (SOVT) o Exercises involving a narrowing of the vocal tract (supraglottic) in order to produce resonant voice o Maximizes interaction between the sound source (vocal fold vibration) and the sound filter (vocal tract) o Provides steady back pressure in the vocal tract to reduce tension during vocal fold adduction o Aims to make phonation more efficient and more economic o Exercises: narrows vocal tract, changes the point of constriction, optimizes the closure of the vocal folds, decreases phonation pressure threshold, lowers the larynx, opens the pharynx wider, gives tactile/kinesthetic feedback, feel a more “open throat” (less effortful phonation) can result in improved quality o Used by singers and voice teachers as “warm ups” o Used by SLPs as therapeutic approaches for voice disorders o INCREASED resistance is created by narrowing or lengthening the vocal tract o DECREASED resistance is created by opening and shortening the vocal tract o Higher to lower resistance: straw phonation, humming, voiced fricatives, lip or tongue trills, alveolar or velar nasal consonants, high vowels  ▪ Straw phonation: narrows/lengthens the vocal tract which INCREASES air pressure above the vocal folds. Reduces the amplitude of vibration and reduces the force of impact collision. Resistance can be manipulated by varying the length and diameter of the straw ▪ Lip trills and other things that buzz: provides a sensation of elevated pressure within the oral cavity which signal less effort or “pushing” in order to produce voice. Results in vibration on lips. Aims to impore breath support and produce phonation with tension. Trills are beneficial to decrease glottal onset. Flow resistance at the lips is HIGH but intraoral pressure is LOW. REDUCED transglottal pressure results in less collision force between VFs. REDUCED amplitude of vocal fold movement Resonant Voice therapy: o Aims to: ▪ Improve ease, quality and efficiency of phonation ▪ Decrease strain and effort of phonation ▪ Involves sensation of buzzing/vibration in the oral cavity ▪ Promotes vocal health ▪ Promotes decreased exacerbation of injury Other semi Occluded/ Resonant Voice exercises: o Lessac-Madsen Resonant Voice Therapy (LMRVT) -Verdolini ▪ Packaged program ▪ Basic training gesture transitioning to conversational speech  ▪ Self awareness and exploration of resonant voice o Vocal Function Exercises- Stemple ▪ Set of 4 systematic exercises to stregthen and coordinate laryngeal function ▪ Warm up, stretching, contraction, adductory power exercises ▪ Semi-occluded vocal tract without tension “knoll” ▪ Beneficial for hyper-function and hypo function More SOVT/RV o LaxVox: straw phonation on water o Accent method: ▪ Uses whole-body rhythmic exercises to facilitate the coordination of vocal fold vibration with appropriate air pressure and air flow ▪ Pitch, loudness and quality targeted simultaneously o Twang ▪ Part of the Estill method ▪ Narrows of the vocal tract using a twang voice ▪ Decreases phonatory effort and increases vocal efficiency ▪ Increases intensity (an quality) with low vocal effort Stretch and Flow phonation o Used to treat functional dysphonia or aphonia, excessive tension, hyperfunction o Beneficial for breath-holding behaviors o Focuses on coordination of airflow with phonation with a relaxed larynx to improve vocal quality o Biofeedback methods to monitor airflow: ▪ Placing a piece of tissue in front of the mouth ▪ Holding hand in front of mouth o Voicing is introduced after continuous airflow during exhalation is achieved o Increased airflow sometimes produces a breathy voice quality, although not the goal o Transition to speech tasks with decreased breathiness Other Flow Exercises: o The stretch and Flow therapy technique ▪ /u/ sighs to words, sentences, connected speech o Lips trills/ tongue trills/ trilled R o Voiceless to voices s--> z, F--> V o Yaen-Sigh  ▪ Yawn and sigh are produced with a maximum widening of the mouth and throat and gentle glottal attack ▪ Model exaggerated yawn, then sigh, then both in sequence ▪ Have patient produce vowels preceded by /h/ ▪ Progress to natural voice production o Confidential voice ▪ Refers to that voice which is not loud enough to awaken someone sleeping nearby ▪ Increases breathiness, slows speaking rate ▪ Emphasizes temporary nature of this voice use ▪ Start with oral reading then progress through hierarchy of speaking tasks o Open-Mouth ▪ Voice produced with an open mouth has better quality, is louder and is more resonant ▪ Visual feedback is key ▪ Vowel sounds are good stimuli o Chant talk ▪ Refers to smooth and connected with no breaks in between word ▪ Legato is a musical counterpart ▪ Marked by slightly elevated pitch, prolonged vowels, lack of syllable stress and softening of glottal attack o Chewing ▪ For those who speak like a ventriloquist ▪ Model exaggerated chewing ▪ Add voicing to it: wan-da-pan-da ▪ Progress through hierarchy of speaking tasks, backing off the chewing ▪ Often used with open-mouth approach o Tongue protrusion /i/ ▪ Helps to reduce laryngeal tension ▪ Protrude tongue comfortably and produce sustained /i/ follow this with /mimimimimi/ at a higher pitch ▪ Can use the other vowels, counting, days of the week, ▪ Progress toward moving tongue back into the mouth, maintianing good quality o Glottal Fry  ▪ Sometimes it is desirable to teach glottal fry phonation, because this mode requires very relaxed vocal folds and reduces hyperfunction ▪ Can be effective for puberphonia/functional aphonia o Inhalation phonation ▪ Phonation on inhalation ▪ Eventually target exhalation voice that matches inhalation voice ▪ Can be effective for functiona aphonia o Redirected phonation ▪ Using vegetative voicing to establish phonation coughing, gargling, humming, laughing, singing, trilling, “um-hmm” ▪ Also effective for functional aphonia/puberphonia “Strengthening” Exercises o DO NOT attempt excessive strain o Facilitate: ▪ TA=closure Vocal Function Exercises Semi-Occluded Vocal Tract ▪ CT= pitch control Rapid pitch changes Pitch glides High phonatory effort exercises for Parkinson’s and related disorders o Lee Silverman Voice Treatment (LSVT) **THINK LOUD** o SPEAK OUT! --Parkinson’s VOice Projet ▪ Speak with intent ▪ Loud Crowd – group session – singing Other High Phonatory effort exercises for age-related voice changes (presbyphonia) o Phonation Resistance Training Exercise (PhoRTE) ▪ High intensity vocal exercises to improve vocal endurance ▪ Combines loudness and pitch (low and high) with phrases Breathing o Low centered breathing o Abdominal/diaphragmatic breathing o Inhale=inflate o Exhale=deflate o Support= gentle squeeze of belly with deflation  o Often confusing and difficult to learn How to choose? o The family of facilitators or the “camp” you are coming from will be dictated by the specific needs of the patient “Un-scared voice therapy” Scan – Gel – Show – Tell o Scan: what sticks out? What needs to change? o Gel: try to get them to feel the desired change (no answers) ▪ Do it again and I want you to play around with.... o Show: Modeling, visual cues, hand over hand, tactile o Tell: Do it again but this time relax your jaw, open your mouth a bit SPECIAL POPS Paradoxical Vocal Fold Motion o AKA: Paradoxical vocal fold movement (PVFM) Paradoxical vocal fold movement disorder (PVFMD), Vocal cord Dysfunction, Laryyngospasm, irritable larynx, reactive airway o ADDuction of the vocal folds during inhalation o Respiratory distress that typically does not respond to treatment for asthma ▪ Can be misdiagnosed as Asthma ▪ Can co-occur with asthma ▪ Also with chronic cough o Possible etiologies: psychogenic (conversion disorder/reaction), Visceral (upper airway sensitivity), neurological (laryngeal dystonia) o Triggers: Inhaled (smoke, fumes, strong odors), temperature (cold air, high humidity), Activity (exercise/exertion, talking, laughing, swallowing, deep breathing) Intrinsic (throat sensations, shortness of breath, stress) o May not present with respiratory symptoms during evaluation o Treatment: ▪ Behavioral: rescue breathing, relaxed breathing ▪ Inhale – 2 quick sniffs through the nose, exhale through pursed lips ▪ Progress typically seen in a few sessions ▪ Voice therapy and reflux treatment Laryngectomy o -tomy: a surgical procedure to remove the larynx o -tomee: a person who has undergone a laryngectomy  o Role of SLP ▪ Pre-op education ▪ Involve spouse, caregiver etc in counseling ▪ Discuss functional communication options ▪ Be familiar with surgeon’s plans (primary vs secondary puncture) o Post-Op Considerations: ▪ Laryngectomy tube ▪ Neck drains ▪ Nasogastric tubes, PEG, stomagastric tube ▪ Aspiration risk ▪ Call ENT vs ER o General Safety Issues: ▪ Medic alert bracelets ▪ Emergency cards CPR- mouth to stoma ▪ Humidified air to stoma ▪ Neck breather o Phone Assistance ▪ TYY – text to telephone or TDD – telecommunication device for the deaf Device installed with phone – type messages. A TYY is required at both ends of the conversation in order to communicate ▪ STS- speech to speech relay Service that provides communication assistants (CAs) for people with speech disabilities who have difficulty being understood on the phone ▪ Phone amplifiers Communication Options o Artificial Larynx (electro-larynx) ▪ Mechanical sound introduced into the vocal tract ▪ Electronically generated vibrations pass through the skin ▪ Vibrations are shaped by articulatory movements for speech ▪ Advantages: fairly easy to learn, low cost, loud ▪ Disadvantages: dependence on batteries, mechanical sound, appearance, not always hands free, insurance issues ▪ Teaching: information, placement, articulation, timing, pitch and loudness o Tracheoesphegal Speech (TEP)  ▪ Tracheal air exhaled into pharynx through fistulous tract ▪ One way valve allowing exhaled air to pass into pharynx. Airstream vibrates the mucosa of the upper pharyngo-esophageal segment ▪ Advantages: natural phrasing, acoustically more typcial speech ▪ Disadvantages: tract can be difficult to maintain, leaks, candidiasis, infection ▪ Primary puncture: at time of laryngectomy ▪ Secondary puncture: after laryngectomy surgery heals ▪ Voice Prosthesis Indwelling: replaced by clinician (3-6 months), linger duration/less maintainence, determined by leakage of fluids around prosthesis or increases airflow resistance Non-indwelling: removed by patient (3-4 days), daily maintenance includes cleaning and flushing, ability of patient to maintain ▪ TEP Hands free valve Tracheo-stoma valve Closes the stoma when phonating Higher airflow for voice close a valve diaphragm When air source subsides, the valve closes and prevents aspiration of secretions Hands free speech o Heat and Moisture Exchangers ▪ Filter serves as a stoma cover --> creates a tight seal around the stoma ▪ Reduces airway irritation during high allergen seasons ▪ Increases the moisture within the lung, less mucus protection, decreases risk of mucus plugs ▪ Adds resistance to airflow o Esophageal Speech ▪ Air taken into esophagus and then propelled into pharyngo- esophageal segment causing mucosal vibrations ▪ Advantages: hands free, patient independent of devices ▪ Disadvantages: hard to learn, short duration of utterances, low fundamental frequency, intelligibility can be decreased  o Silent Articulation o Writing Voice evaluation: A voice evaluation involves an examination of the structures themselves. Indirect Laryngoscopy (mirror) Laryngeal endosopy o Ridged – through mouth o Flexible – through nose o with videostroboscopy Electromyography –EMG o Typically done by a neurologist Acoustic Measurements Aerodynamic Measurements Subjective Evaluation of Voice o More SLP depending on what instruments you have Indirect laryngoscopy: Ent visualizes vocal folds with mirror Touches posterior pharyngeal wall Quick peek Laryngoscopic observations: Vocal Fold Edge o Smoothness - Straightness o Presence of mass lesions or other pathologies Glottic Closure – do VF close all the way? o Closure patterns: ▪ Complete ▪ Hour-glass - anterior and posterior gap with mid-membranous vocal fold closure. ▪ Spindle (bowing)- anterior and posterior portions of the vocal folds are closed, but a large gap remains in the middle ▪ Incomplete - VF don’t touch Closure patterns: Amplitude of Vibration - How far do the V Fs move laterally from midline during phonation? o should travel one-half their visible width o Can be affected by fundamental frequency and intensity: ▪ Higher F0 = decreased excursion ▪ Greater intensity = increased excursion Mucosal Wave -“ripple-like” movement of the mucosa over the V F body o Wave should travel ½ the width of the V F, in medial to lateral direction o Assessed during normal pitch and loudness: ▪ Higher F0 = decreased wave ▪ Greater intensity = increased wave Vertical Level Approximation - Do the V Fs meet on the same vertical plane? Rarely do they not. Affects V F approximation one V F may overlap the other Supraglottic Activity - medio-lateral and antero-posterior involvement of supraglottic structures Squeezing of structures above VFs Phase Symmetry – are the VFs mirror images of each other while in motion? In phase: Moving in opposite directions Out of phase: Moving in same direction Acoustic analyses Sound spectrography  Fundamental frequency Frequency variability Maximum phonational frequency range Average/habitual intensity Intensity variability Dynamic range Perturbation and noise measures Computerized speech lab (CSL) and PRAAT Aerodynamic analyses: Lung volumes, lung capacities, air pressure, airflow, laryngeal resistance, durational measures. Phonotary Aerodynamic system (PAS)- this is compatible with CSL Voice evaluation: Can be done by o a patient self-rating and interview ▪ Patient self-rating scale: the impact that dysphonia has on the client’s quality of life. This includes the individual’s perception of his/her voice problem. ▪ Adult scales: Voice Handicap Index (VHI) Voice Symptom Scale (VoiSS) Voice Activity and Participation Profile Voice-Related Quality of Life Scale (V-RQOL) Voice Outcome Survey Voice Disability and Coping Questionnaire Vocal Performance Questionnaire Vocal Tract Discomfort Scale ▪ Pediatric: Pediatric Voice Handicap Index Pediatric Voice Outcomes Survey Pediatric Voice-Related Quality of Life Pediatric Voice Symptom Questionnaire Children’s Voice Handicap Index-10  Children’s Voice Handicap Index-10 for Parents o A perceptual evaluation which is subjective ▪ What you hear/see in your patient o Objective measures o A physical evaluation ▪ An oral mechanism exam o Patient education and/or trial therapy Scales for special populations: Singing VHI for adult singers (SVHI) V H I – Partner (adult proxy raters) Transsexual Voice Questionnaire (TVQ) Transgender Self-Evaluation Questionnaire (TSEQ) Voice Handicap Index (VHI) A 30 item self-questionnaire that addresses the influence of a voice problem on the patient’s life. 3 subscales for total score: o Functional o Emotional o Physical VHI-10 Singing voice handicap index (SVHI) Children’s voice Handicap Index-10 Children’s voice Handicap Index-10 for parents Caution: limited health literacy The average reading comprehension level of English-speaking adults in the United States is estimated to be only at the seventh- or eighth-grade level To facilitate health literacy, it is recommended that health-related materials targeted to adults be written at the fifth- or sixth-grade reading level. Readability of voice related patient reported outcome measures (PROMs) 11 English-language voice PROMS o All exceeded the recommended 5th to 6th Grade reading levels ▪ Seven were written at the 7th-8th grade reading level ▪ Four were written at the 9th grade reading level or higher Patient Interview Complaints What is the reason for the visit?? When did the problem start? o Is it recent or long term? o Antecedent event? How long has it been going on? o Intermittent or consistent? Please describe the problem Asking open-ended questions Provide a rating scale Leading questions: o Pain, strain, effort, fatigue Does it happen at a certain time of the day? Better or worse at certain times? Is there anything that makes it better or worse? Vocal hygiene Water intake Smoker/2nd hand smoke Caffeinated beverages Alcohol Eating habits Foods o Spicy, citrus, chocolate, mints, dairy Vocal behaviors Work vs. Socially Talker, loud talking, yelling/shouting  Other vocally abusive behaviors (throat clearing) Stress/sleep Medications: Antihistamines Aspirins, NSAIDS Asthma meds What does the client say is painful? Odynophonia- pain with phonation Scratchy sore throat or muscle achy Sore neck muscles After eating After use Ear pain Jaw Chronic pain Perceptual evaluation The overall severity Quality o What does the voice sound like? o 4 main qualities: ▪ Rough (raspy, harsh) ▪ Breathy (whispery-airy-hypofunction) ▪ Hoarse (combination of rough and breathy) ▪ Strained (effortful-hyper-function) ▪ Breaks in pitch/phonation ▪ tremor Pitch/intensity o WNL o Increased/decreased o Perceptual o Acoustic measurements (PRAAT, CSL) Airflow/breathing pattern  o Breathing pattern: ▪ Clavicular ▪ Thoracic ▪ Mixed ▪ Diaphragmatic- abdominal ▪ Any combination of these ▪ Coordinated or uncoordinated with phonation? o Airflow ▪ Reduced, increased, or adequate Resonance (oral and nasal) o Nasal resonance ▪ Disorder / Dysfunction: Hyper-nasality with or without nasal emission Hypo-nasality Culdesac resonance o Oral Resonance ▪ Sometimes quality descriptors relating to voice function Problems: o Posterior tone focus / back resonance o Anterior (thin, babyish) o Frontal focus / oral resonance (normal) Body: o Posture o Tension ▪ Jaw ▪ Neck ▪ Shoulders ▪ Chest ▪ Larynx ▪ Tongue Emotional/psychological status: o Emotional labile ▪ Excessive crying ▪ Laughter o Flat affect o Anger o Avoiding o Uncomfortable Objective measures: Protocols, scales and screeners: GRBAS scale o Grade o Roughness o Breathiness o Asthenia o Strain o 4-point scale from 0-3 ▪ 0=none or normal ▪ 1=slight ▪ 2=moderate ▪ 3=severe Consensus Auditory Perceptual Evaluation-Voice (CAPE-V) o Developed by ASHA SID-3: voice and voice disorders o Uses a technique called visual analog scaling o Left mark-normal; far right-most deviant o Tick mark location is measured and written in column in the right o There are two unlabeled lines to add features o Definitions of Vocal Attributes: o OVERALL SEVERITY: Global, integrated impression of voice deviance. o Roughness: Perceived irregularity in the voicing source. o Breathiness: Audible air escape in the voice. o Strain: Perception of excessive vocal effort (hyperfunction). o Pitch: Perceptual correlate of fundamental frequency. This scale rates whether the individual's pitch deviates from normal for that person's gender, age, and referent culture. The direction of deviance (high or low) should be indicated in the blank provided above the scale. o Loudness: Perceptual correlate of sound intensity. This scale indicates whether the individual's loudness deviates from normal for that person's gender, age, and referent culture. The direction of deviance (soft or loud) should be indicated in the blank provided above the scale. o Task 1: Sustained vowels: Two vowels were selected for this task. One is considered a lax vowel (/a/) and the other tense (/i/). In addition, the vowel, /i/, is the sustained vowel used during videostroboscopy. Thus, the use of this vowel during this task offers an auditory comparison to that produced during a stroboscopic exam. The clinician should say to the individual, “The first task is to say the sound, /a/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” (The clinician may provide a model of this task, if necessary). The individual performs this task three times for 3-5 sec each. “Next, say the sound, /i/. Hold it as steady as you can, in your typical voice, until I ask you to stop.” The individual performs this task three times for 3-5 sec each. o Task 2: Sentences: Six sentences were designed to elicit various laryngeal behaviors and clinical signs. The first sentence provides production of every vowel sound in the English language, the second sentence emphasizes easy onset with the /h/, the third sentence is all voiced, the fourth sentence elicits hard glottal  attack, the fifth sentence incorporates nasal sounds, and the final sentence is weighted with voiceless plosive sounds. The clinician says, “Please read the following sentences one at a time, as if you were speaking to somebody in a real conversation.” (Individual performs task, producing one exemplar of each sentence.) If the individual has difficulty reading, the clinician may ask him or her to repeat sentences after verbal examples. This should be noted on the CAPE-V form. o Task 3: Running speech: The clinician should elicit at least 20 seconds of natural conversational speech using standard interview questions such as, “Tell me about your voice problem." or "Tell me how your voice is functioning.” Towne-Heuer Passage  o The number of hard glottal attacks for a population of 15 normal Philadelphia speakers with no history of vocal pathology ranged from 1 to 25.6 with a mean of 12.96 and a standard deviation (SD) of 6.22 for the group. The number of hard glottal attacks for a population of 15 vocal abuse-misuse Patients with verified vocal nodules ranged from 17.6 to 71 with a mean of 39.8 and a SD of 15.38. S/Z ratio and maximum phonation time (MPT) A measurement of respiratory and sound control relating to laryngeal efficiency This is not diagnostic of laryngeal pathology o Useful as an indicator of laryngeal inefficiency and are frequently used for monitoring progress Measures the efficiency of the vocal mechanism: indirect index of laryngeal airflow Compares sustained /s/ (voiceless) and sustained /z/ (voiced) If the vocal folds are valving effectively, the /s/ and the /z/ should be sustained for equal amounts of time. The ratio should be around 1:1. Interpretation: an s/z ratio of 1.40 or greater - indication of an inefficiency at the level of the vocal folds Crude measurement: Task-related issues Indirect index of laryngeal airflow M P T is the greatest length of time over which the /a/ vowel can be sustained at the patient’s most comfortable pitch and loudness following a maximal inhalation The longest of three trials is usually reported Interpretation: If airflow is high, M P T is shorter than normal; if airflow is low, M P T may be longer than normal Normative data for M P T across the age span  o Adults should typically be able to sustain for approximately 15 - 20 seconds – times vary Physical evaluation*- as appropriate palpate larynx base of tongue Supra-hyoid area SCM, NECK, SHOULDERS Patient education What is their perception of their dx? Do they understand what the doctor said to them? Translate Discuss concerns Reflux counseling Vocal hygiene Tell them what you hear Tell how their dx affects their voice production and relates to their complaint Purpose of tx Trial tx  Structure and function of larynx Aging voice Presbyphonia This is the clinical condition of elderly patients presenting to the otolaryngologist (ENT) with gradual weakening of the voice. o Patients complain of an inability to project their voice over background noise and of a hoarse voice quality that deteriorates throughout the day. o Patients also complain of poor health-related quality of life Laryngeal signs in presbyphonia: o Mild bowing of the vocal fold margins o Spindle-shape glottis o More anteriorly placed glottal gaps o Prominent arytenoid cartilage vocal processes o Vocal fold edema o Asymmetry of vocal fold vibration o Predominant open phase Auditory-perceptual features: o Tremor o Hoarseness o Breathiness o Voice breaks o Decreased loudness o Slower speaking rate o Change in habitual pitch (sex-dependent) Acoustic features: o May include: ▪ Increased F0 in males ▪ Decreased F0 in females ▪ Decreased SPL (loudness) ▪ Increased noise-to-harmonics ratio Management of presbyphonia: o Three treatment approaches (singly or in combination): ▪ 1. laryngoplasty ▪ 2. thyroplasty ▪ 3. voice therapy Vt is usually the first-line approach Transgender voice: Gender affirming voice therapy: Stages of transition: Pre-discovery –does not realize they may be transgender. May experience depression/anxiety Discovery – begins to question gender identity. May be experimenting with gender expression privately Acceptance – Accepted self, has not “come out” – Transgender identity begins to develop Disclosure – begins to come out as transgender to friends/family/colleagues. Gradually begins to change outward appearance publically. SLP role: Pre-discovery / Discovery o Refer client to counselor to address depression or anxiety. Make client feel welcome in a safe environment Acceptance / Disclosure o Clinician continues to cultivate a safe environment for client to be themselves and feel safe to bring up any questions about voice/gender identity o If client comes out to clinician and expresses concerns/has questions about voice, the clinician answers questions and begins with education, assessment, and therapy as appropriate. Clinician should contact other health professionals the client is seeing for their transition. Stages of transition: Presenting – full time or part time expression of gender identity. Experimenting with different aspects that align with their own perception of gender and authentic self. Post-transition – presents gender identity full time. Has achieved internal and external gender balance (feelings match outward appearance)- has “transitioned” SLP role: Presenting / Post-Transition o Clinician is open to client’s individual needs/gender identity. Clinician conducts appropriate assessment and therapy to address theses needs. Clinician should become a part of the client’s multi-disciplinary transition team. FAQs: Does every transgender person have surgery? o No! In fact, some people choose to undergo gender confirmation surgery and/or hormone therapy, while others choose to abstain from both. Are trans people gay? o They can be! But not always. Sexual orientation and gender identity are different and not related. A trans woman can be attracted to women and be a lesbian. Or, she can be attracted to men and be straight. Other terminology: Gender Dysphoria- The technical diagnosis of being transgender, as per the Diagnostic and Statistical Manual of Mental Disorders (DSM – 5). Presenting- The term used to describe when a person is dressed or “presenting” as their gender identity. Passing- When a person who is transgender “passes” for their gender, and is able to function within society as their gender without receiving prejudice. Clocked- When a person is presenting as their gender identity, but is perceived/noticed by other individuals as transgender. The opposite of “passing.” Known as “gender policing” in scholarly texts. Pronouns: Using the correct pronouns validate a person’s gender identity; using the incorrect pronouns can be psychologically distressing for people who are transgender. (he/she/they) ex. Pronouns – She/Her/Hers o Some people who are gender non-conforming use they/them/their pronouns. o The title: Mx marriage-neutral and gender-neutral; in Britain already used on driver’s licenses and other official documents. o If you’re not sure what someone’s pronouns are- ask. Do not assume. o Purposefully misgendering (i.e., using the wrong pronouns/gender) someone is considered a transphobic act. o If you accidentally make a mistake with someone’s pronouns- pause, briefly apologize, correct yourself, continue. Self-assessment: An interactive tool to evaluate cultural competence http://www.asha.org/practice/multicultural/self.htm http://www.asha.org/uploadedFiles/Cultural-Competence-Checklist-Personal- Reflection.pdf  http://www.asha.org/uploadedFiles/Cultural-Competence-Checklist-Policies- Procedures.pdf http://www.asha.org/uploadedFiles/Cultural-Competence-Checklist-Service-Delivery.pdf Voice therapy/voice training: Voice/speech characteristics: Pitch Intonation Resonance Voice quality Articulation Loudness Pacing (rate) / Phrasing (number of words per breath) Spoken Language Non-verbal Communication Feminine intonation: Wider range o 146 Hz vs. 82 for masculine More expressive by moving the pitch more Smooth movements -hills vs. sharp peaks Sounds are blended or connected to the next sound Slightly higher pitch at the ends of sentences (when appropriate) o no “valley girl” Feminine voice: Resonance – generally more ‘forward’ / ‘mask’ resonance Voice quality – slightly breathy Articulation – more precise movements / longer vowel duration Loudness – slightly decreased in general Pacing / Phrasing - longer flowing sentences Spoken language: Word choice  More polite and less direct Fewer interruptions More empathetic reactions More tag questions (“It’s cold in here, isn’t it?”) More disclosure about self, feelings, and relationships More conversational elaboration in general Body language: Fluid, continuous movements Sitting posture is S-shaped Leaning forward toward the speaker Eye contact and expressive face Keeping hands out of pockets Triple head nods to show interest More resources: The Genderbread Person v3.3 A visual guide to understanding gender, sex, sexual orientation, and identity http://itspronouncedmetrosexual.com/2015/03/the-genderbread-person-v3/ Transsexual Voice Questionnaire (TVQMtF) An informal self-assessment questionnaire for trans-women and their experience with voice http://www.shelaghdavies.com/questionnaire/questionnaire.html Know assessment tools to get objective data VHI, CAPEV GRAVIS Scale, max phonation time, s/z ratio --> measures vocal fold efficiency, not diagnostic of a breathing problem Know common communication traits of feminine vs masculine Know different types of communication with laryngectomy Know main idea and complaints of special pops