GENERAL VOICE THERAPY TECHNIQUES

·      Purposes of therapy

The purpose varies from patient to patient .In most of the case the intent is to improve the vocal communication, and in some cases to normalize the vocal function, that is to restore function.

·      Factors influencing the selection and success of therapy programmes

Voice therapy programmes may consist primarily of short term symptomatic techniques or may encompass  long term rehabilitation stratergies. The choice of  approaches and duration of the programme depends on clinical, personal and economic factors. In general individuals experiencing muscle misuse, psychogenic voice disorders with gradual onset, long term and consistent symptoms require longer, more comprehensive protocols than those whose onset was sudden, with short term and intermittent symptoms.

Presence of a primary or secondary organic component may complicate prognosis and influence the choice of therapy techniques.

If long  standing lesion is present in the larynx , for example, a fibrotic nodule, compensatory behaviour may have developed and been reinforced as part of an individuals day to day coping strategies, the same holds true for organic tremor, laryngeal dystonia or other neurological or systemic diseases.

In case where surgical intervention is indicated, pre-operative voice therapy may be introduced to reduce vocal abuses and inappropriate compensatory behaviour such as increased glottic resistance, splinting in the jaw and tongue and uncoordinated breathing.

Other factors that influence therapy selection and prognosis include hearing impairment, other sensory deficits, external support, and impact of the dysfunction on ones life and unresolved psychological conflicts or psychiatric disease.

 From the early foundation of voice rehabilitation, have arisen several general management philosophies.

·      SYMPTOMATIC THERAPY

This term implies that therapeutic techniques are selected to target a particular set of signs or symptoms of a voice disorder. The main focus of symptomatic therapy is helping the patient optimally use the systems of respiration, phonation and resonation for the easiest and best sounding voice possible.

This voice management approach is based on the premise that most voice disorders are caused by the functional misuse or abuse of the voice components including pitch, loudness, and respiration. Once identified, the misuses were eliminated through or reduced through various voice therapy facilitating techniques.

 The facilitating technique is that technique which when used by a particular patient, enables him to easily produce a good voice.

·      COMPREHENSIVE VOICE REHABILITATION PROGRAMMS

Many of the voice patients seen in an inter disciplinary voice clinic are occupational voice users. These individuals have high social, emotional and acoustic environments, yet rarely have training in vocal technique. Occupational voice users typically present with symptoms and signs of vocal abuse/overuse, muscle misuse, dysphonia and often primary or secondary anxiety or depression. As busy professionals some  individuals rely heavily on  caffeine, have poor dietary habits, conduct business in noisy environments and on the run, these life style features may contribute further to poor vocal health by adding dehydration, anxiety, reflux laryngitis and vocal abuse to the etiological profile.

So a successful vocal rehabilitation with occupational voice users needs to address all the life style, emotional and technical issues that are represented in a complex system of formation.

Most of the individuals respond well to a group therapy format for comprehensive voice rehabilitation.

The group therapy approach has the advantage of saving time and money for the health care system or the patient or both and providing a venue for problem solving, desensitization and carry over of techniques through peer monitoring and role playing exercises.

The minimal components of a comprehensive voice rehabilitation programmes are listed below:

Education

Problem solving

Relaxation training

Alignment –posture training

Specific relaxation exercises

Coordinated voice onset

Resonance enhancement

Vocal flexibility

Generalization

PSYCHOGENIC VOICE THERAPY

 This therapy focuses on identification and modification of the emotional and psychosocial disturbances associated with the onset and maintenance of the voice problem. Pure psychogenic voice therapy is based on the assumption of underlying emotional causes. Voice clinicians must develop superior interview skills, Counselling skills and the skills to know when the emotional /psychosocial problem will arise. A referral system of support professionals must be readily available.

ETILOGIC VOICE THERAPY

It is based on the premise that  identification , modification and elimination of the causes (abuse , misuse, medically related causes)of the voice disturbance  should be the primary focus of therapy (Stemple,1984).Once the etiologic factors are treated the vocal symptoms often improve without direct voice manipulation. For example: vocal nodule may cause breathiness, pitch modification and laryngeal tension. Utilizing an etiologic approach, therapy would focus on identifying and modifying/eliminating the abuses that caused the vocal symptom.  Therapy would not focus directly on the symptoms. Therefore facilitating techniques for pitch modification, muscle tension, and breathiness would not be chosen as the first line of management. However if inappropriate use of pitch, laryngeal muscle posture, and so on are identified as the primary causes of the voice disorder, then direct symptom modification would be necessary. Etiologic voice therapy presumes that every voice disorder has a cause. If that cause can be identified and modified /eliminated, then voice quality should improve.

PHYSIOLOGIC VOICE THERAPY

The ability to measure the acoustics and aerodynamics of vocal function objectively, together with the ability to observe the vocal fold vibratory patterns through stroboscopy, has given rise to a management approach we will call physiologic voice therapy. It uses objective data of laryngeal function to directly modify the function of the laryngeal musculature and the respiratory support of the voice production. Whatever the cause, the management approach is direct modification of the inappropriate physiologic activity through direct approach and manipulation of laryngeal musculature. Physiologic voice therapy presumes that a measurable voice disturbance is present which can be directly modified and monitored through physical exercise of the laryngeal and respiratory system.

ECLETIC VOICE THERAPY

Successful voice therapy depends upon the utilization of the management approach that happens to work for the therapist and the individual patient. The more management approaches understood and mastered by the clinician, the greater the likelihood of success. The techniques that prove successful for one patient may not be successful for a similar patient. Some techniques that work well for one therapist may prove to be difficult for the other. The clinician must have the knowledge to adjust the management approach, supreme confidence in understanding of the technique and ability to make that approach work successfully. Clinician’s confidence will determine the success or failure of therapy.

DIRECT AND INDIRECT VOCE THERAPY

Voice therapy had traditionally been divided into 2 categories, direct and indirect. Most literature indicates that the voice therapy programme that combines direct and indirect approaches is effective in most cases.

INDIRECT VOICE THERAPY

Historically, indirect voice therapy involved voice rest. For many patients, this treatment option is not feasible. For example, 4 weeks of voice rest for an elementary school teacher is often unreasonable. If an inefficient or traumatic manner of speaking is the cause of voice problems, most voices improve temporarily following voice rest; however, the dysphonia typically returns upon resumption of voice rest. In addition, teachers and others who use their voices professionally may suffer serious job-related consequences as a result of being placed long-term voice rest. Voce rests as a first stage of treatment remains controversial and may not provide a long term solution for the voice problem.

Indirect voice therapy also consists of educating the patient about the dangers of poor voice use and vocal hygiene. Educate the patient on the following:

  Normal vocal anatomy and physiology.

  Voice  care/ vocal hygiene

 Minimize shouting/ yelling

 Minimize whispering

 Minimize the amount of caffeine and alcohol consumed, as they are diuretics.

 Minimize coughing and throat clearing.

 Minimize grunting or vocalization during exercise.

 Do not compete vocally with noisy environments

 Eliminate tobacco use and exposure to second hand smoke.

 Rest voice during periods of excessive fatigue and stress.

  Eat a well balanced diet.

 Keep hydrated by drinking at least 8 glasses of water per day and 1 additional glass for every serving of caffeine or alcohol consumed. For additional hydration because of environmental dryness, humidifiers, steam inhalers, or both are often recommended.

 Increase awareness of potentially abusive vocal behaviors, and implement a life style plan that minimizes potentially abusive vocal behaviors. For example, a teacher may need to alter the teaching schedule to minimize vocal demands. This could be as simple as including more films in the lesson plan, selecting a student to teach the class for a day, or changing the teaching the format from lectures to small group discussions.

 Minimize gastro esophageal reflux through behaviour and dietary modifications.

Direct voice therapy

Direct voice therapy involves alteration of a patient’s speaking technique in an attempt to increase vocal efficiency and improve voice quality. Voice therapy typically requires 1-2 therapy sessions per week for approximately 6- 8 weeks. Exceptions exist, including voice therapy prior to phonosurgery, which is usually limited to several sessions before surgery and resumption of therapy approximately 1-2 weeks after the surgery.

 A properly trained voice clinician may use many different therapy approaches merging indirect and direct voice therapy to contour the programme that is most likely to yield the highest level of success. In addition great skill and training are required to use a combination of voice therapy techniques to achieve maximum voice rehabilitation.

CONFEDENTIAL VOICE THERAPY

Confidential voice therapy involves reducing overall loudness of the voice while increasing breathing  in order to reduce the vocal fold collision force and to reduce the supralaryngeal and laryngeal muscle tension (by using fecilitating techniques). Usually confidential vice therapy is indicated following acute vocal fold injury. It is also useful for several weeks following surgery prior to gradually and safely introducing increased loudness.

RESONANT VOICE THERAPY

This therapy involves training the patient to increase intra oral air pressure and is associated with vibratory sensations in nasal and facial bones. It is often used for organic lesions, functional dysphonias, mild vocal folds atrophy, and even vocal fold paralysis. This training is easily achieved by humming the consonant /m/. Resonant voice therapy is produced with vocal folds in slightly abducted or barely adducted position. This laryngeal posture is favorable for patients who present with laryngeal hyper function, hyper adduction (pressed voice), or both. This vocal fold positioning appears to produce the clearest and most prominent voice with little effort and decreased risk of injury.

VOCAL FUNCTION EXERCISES

 Vocal function exercises are based on the principle of systematic exercises to increase bulk, strength and coordination of laryngeal musculature and are used for hyper functional and hypo functional voice disorders.

There are three steps to the programme. Each step is to be completed twice, and the entire programme is to done twice a day.

 Steps include

 (1) Vocal warm up

 (2) Pitch glides (high to low and low to high)

 (3) Prolonged humming of (o) at selected pitches.

 Doing these exercises correctly, using a resonant voice without strain is imperative.

ACCENT METHOD VOICE THERAPY

Accent method voice therapy can be used for hyper functional and hypo functional voice disorders. It takes more holistic approach in that it involves whole body movements in order to improve vocal function. Those who support this method report increased pulmonary out put, reduced laryngeal muscle tension, and a normalized vibratory pattern of vocal folds during phonation. This therapy is performed by vocalizing rhythmic consonant sounds (called accents), usually in combination with body movements and while stressing respiratory support for each accent. Increasingly complex accents are produced untill carry over to the conversation level is achieved.

DIGITAL LARYNGEAL MANILPULATION

This is achieved by placing the thumb and forefinger in the Thyrohyoid space and massaging in small circles, starting at the anterior aspect of thyroid cartilage and moving posteriorly. Special attention should be paid to any areas of more intense focal pain.

This technique may yield only temporary improvement in voice, but it gives patients some feed back and a technique that they can use themselves. Digital laryngeal manipulation is indicated in any laryngeal condition involving excess muscle tension. (Eg: muscle tension, dysphonia), but it may also be effective for patients with organic lesions who have developed compensatory excessive muscle tension due to glottal incompetence.

LEE SILVERMAN VOICE TREATMENT

Lee Silverman voice treatment is the most researched voice therapy protocol .LSVT was developed to address hypo kinetic dysphonia associated with Parkinson’s disease (PD). LSVT is a very systematic approach to voice therapy and is prescribed for 4 consecutive weeks at 4 sessions a week for optimal results. The primary goal of treatment is to increase overall loudness with little or no attention paid to other communication deficits commonly associated with PD (eg. dysarthria).

Within each of these more systemic treatment protocol, 4 major aspects of voice production must be addressed if they are problematic. SLP must recognize and rehabilitate any of the following:

1) Aberrant respiratory patterns

2) Pitch variation

3) Oral muscle tension

4) Abnormalities of onset of voicing.

In many of the cases , the patient must be trained in proper abdominal breathing .Ideally, little  clavicular movement should occur on inhalation; instead abdominal motion should be used to facilitate adequate and efficient breaths. On exhalation abdominal contraction is optimal to facilitate adequate sub glottal Pressure in order to minimize laryngeal constriction.

Voice therapy must also address the pitch of the voice. Often, patients must become reacquainted with their natural pitch. A patient speaking at an unhealthy pitch is placing unnecessary strain on the vocal musculature; this can either cause or worsen the problem. Patients who are unable to hear or feel appropriate pitch of their voice may benefit from some sort of bio feedback therapy. This  can be as simple as recording the patients voice and replaying it so that the patient can listen to the degree of vocal dysfunction, or it can consist of more complex computer base systems that c an provide a means of visual feedback with regard to pitch or numerous other voicing parameters.

Identifying any excess muscle tension in the oral cavity is also vital. Excessive buccal lingual and mandibular tension is not necessary and can have a negative effect on voice by increasing laryngeal height and by encouraging laryngeal hyper function. Patients must become aware of this tension and must be given exercises to alleviate it. The act of initiating the voice can be potentially harmful. Many patients present with a hard glottal onset, which involves an abrupt attack of vowel sounds that use high subglottic pressure. Initiating sound with such a high intraglottic contact force can be lead to increased laryngeal hyper function and often vocal fold pathology.

INDICATIONS FOR BEHAVIOURAL THERAPY

FUNCTIONAL VOICE DISORDER

Functional voice disorders are characterized by the presence of vocal symptoms without anatomical laryngeal abnormality. Muscle tension dysphonia (MTD) is the most common disorder in this category. Most literature suggests that a course of indirect and direct voice therapy is very effective in decreasing laryngeal hyper function associated with MTD.

During evaluation, it is often helpful to determine if the patient is able to improve voice quality and trails of direct voice therapy techniques. This is a strong indicator of future voice therapy success. However, the longer the patient has had dysphonia, the more guarded the prognosis for success with therapy. Psychogenic dysphonias, such as conversion dysphonia, also fall into the category of functional voice disorders. Combinatory therapy by a trained SLP and a mental health specialist is believed to treat these disorders effectively.

ORGANIC VOICE FOLD DISORDERS

Organic vocal fold disorders include, but are not limited to vocal fold nodules, cysts and polyps. Vocal nodules are small, commonly bilateral lesions of the superficial  layer of lamina propria,usually located at the junction of the anterior third and posterior two third of membraneous fold. Voice therapy is usually the sole treatment indicated for vocal nodules if they are not long standing in duration and not extremely fibrotic in nature.

Cyst and polyps are also lesions of the superficial layer of the lamina propria. Phonomicrosurgery  and voice therapy are usually indicated in the treatment of cysts and polyps.

Voice therapy is indicated prior to and following surgery and can improve the outcome. In these cases, voice therapy combined with surgery is thought to decrease the likelihood of lesion recurrence due to poor vocal technique and vocal misuse.

NEUROLOGICAL VOICE DISORDERS

Neurological voice disorders resulting in dysphonia include Parkinson’s disease, essential tremor (ET) and spasmodic dysphonia (SD). LSVT has been demonstrated to effective for treating the communication disorders associated with PD. Treatment is intensive, requiring 4 sessions a week for 4 weeks. The purpose of the treatment is to increase loudness, and in addition to improved voice, patients may develop increased respiratory out put, decreased glottal incompetence, improved articulatory precision and mobility, and improved over all intelligibility. In follow up studies, LSVT has been shown to be effective without continued treatment for 3-5 years.

Spasmodic dysphonia is a focal dystonia affecting the laryngeal musculature, most commonly treated with localized injections of botulinum toxin A (BOTOX). These injections temporarily weaken the muscles, thereby decreasing the dystonic laryngeal muscle activity. The duration of weakness varies from patient to patient and often from injection to injection. Murry and Woodson (1995) suggested that behavioral voice therapy used in combination with BOTOX injection therapy increases the effectiveness and duration of the BOTOX therapy.

VOCAL FOLD IMMOBILITY

 Success of therapy in patients with unilateral vocal fold immobility is dependent on the position of the paralysed vocal fold, the remaining vocal fold bulk, the tension present in the immobilized fold, the duration of the disorder and surgical correction if performed. Patients with a paralyzed vocal fold in the medial position are more likely to have successful therapy than are patients with an immobile vocal fold in a lateral position.

Historically, voice therapy for vocal fold paralysis involved rigorous pushing/ pulling exercises, which actually induced laryngeal hyper function. Resultant hyper function is often more detrimental to the patients voice than the paralysis itself. These types of pulling / pushing exercises have no role in modern voice therapy. Vocal function exercises, resonant voice therapy, challenge therapy (modified LSVT), postural/ position alterations or a combination of these are indicated. In cases in which the paralysed vocal fold is extremely lateral (>3 cm), voice therapy usually follows surgical correction.

PARADOXICAL VOCAL FOLD MOVEMENT DISORDER (PVFMD)

PVFMD is a poorly understood disorder that involves inappropriate closure of the vocal folds during respiration. Patients may report dysnea, cough or globus sensation. As described above, a combined modality treatment involving respiratory retraining and reflux therapy appears to be an effective treatment option.

ESTABLISHING WHERE TO START VOICE THERAPY

Voice therapy must begin where the patient is able to perform. We cannot ask patients to do more than they capable of doing. Two important early steps must be taken for voice therapy.

1. an initial voice recording name, date, spontaneous conversation, oral reading, specific vowel and phrase repetitions) for both immediate analysis and later comparison.

2. A determination of the patients somatic feelings of the disorder (dryness, pain).

VOICE THERAPY FOR VOCAL HYPERFUNCTION

The specific goal of voice therapy will vary from patient to patient. However, in general, the goal of voice therapy is to restore the best voice possible, a voice that will be functional for purpose of employment and general communication. Voice therapy must be rooted in and derived from an understanding of laryngeal anatomy and phonatory physiology. Accurate diagnosis of voice disorders is critical to treatment planning. It is also important to recognize that there are differing approaches implemented for various disorders based on their own individual assumption concerning the disorder. The voice therapy programmes for vocal hyperfunction are highly individualized. A particular approach that works for one patient may not work for the other.

VOICE THERAPY FACILITATING TECHNIQUES

Voice therapy facilitating approach is a therapy technique that seems to produce optimum voice. Using such an approach generally allows an individual to produce voice with less effort and strain and perhaps even to sound better. This easy voice may be designated as the target voice in therapy. Once a particular approach is found helpful in producing the target voice, the approach is used as a practice focus in therapy. symptomatic voice therapy requires clinicians to probe continually with various facilitating techniques, using the one  that seems to produce the target voice, and avoiding  those that seems to produce the target voice, and avoiding those that seem to have negative or little effect. This kind of therapy requires that clinicians search continually for can do vocal behaviors. The selection of voice facilitating approaches in therapy is thus highly individualized. Although clinicians should be familiar with the application of all therapy techniques, they should apply such techniques selectively. The selection of a particular approach should not be an arbitrary, trail and error decision. Rather, the possible effects on the parameters of pitch, loudness, and quality, must be considered

BOONE ‘S APPROACH

Symptomatic voice therapy is an approach which uses direct modification that focuses on overt behavioral characteristics of the voice disorder. Boone provides a series of techniques that elicited, it is then shaped, stabilized, and habituated using a hierarchical pattern which increases in difficulty as therapy progresses. The first step is to identify behaviors which need to be eliminated or modified. The second step is to stimulate the desired target behaviour by using a facilitating technique.

Boone’s technique

1.      altering tongue position

2.      changing loudness

3.      ear training

4.      eliminating abuse

5.      eliminating hard glottal attack

6.      establishing a new pitch

7.      providing  feed back

8.      voice rest

9.      yawn sigh

10. chewing

11. digital manipulation

12. analyze the hierarchy

13. negative practice

14. opening the mouth

15. inflecting the pitch

16. pushing exercise

17. relaxation training

18. respiration training

19. selecting target models

1.      ALTERING TONGUE POSITION

The position of the tongue within the oral cavity has a direct influence on both vocal quality and resonance. Laver describes the lingual “neutral settings” as having the tongue body not too far forward or too far backward within the oral cavity. Some patients carry the tongue backward, almost occluding the pharynx, which contributes to a hollow sounding cul de sac resonance and some patients carry the tongue too far forward, creating a thin quality, which lacks the full resonance of back vowels. Both the muffled voice with posterior resonance focus and weak, thin voice with anterior carriage can some times be favorably improved by direct work in modifying tongue position.

For posterior tongue positioning:

1.      Explain and demonstrate the pharyngeal tongue positioning and effects on voice also check the posture.

2.      Begin practice with the whispered production of alveolar consonants, “such as /t/, /d/, /s/&/z/. whisper a rapid series of “ta”or “da” sounds 10 per breath for several minutes. Analysis with the patient what has just been done, for example, “what does the front of the mouth production feel like?” The other consonants that lead themselves to frontal practice are /w/,/p/,/f/,/v/&/l/ and the high vowels that can be used are /i/,/,I/.

3.      After some success with whispered production, add voice lightly. Use oral readings which are loaded with tongue tip consonants and front vowels. Practice contrasting new front resonance with old posterior resonance. Analyze the difference of the feeling with the patient.

 For anterior positioning

1.      Instruct the patient that he or she does not have to shape the tongue in any particular way.

2.      The vowels /a/, /o/, /u/, /v/should be practiced at first in isolation: then practice reading materials heavy with the back consonants /k/, /g/ and with back vowels.

2) CHANGING LOUDNESS

Some patients have voices that are too soft or too loud. The prolonged use of inappropriate loudness can result in pathologies of vocal folds, such as nodules or polyps.

For a decrease in loudness

1.      Audiological evaluation

2.      For ages three to ten: the change of loudness steps in Boone voice programme for children can be used. Here we ask the child to develop awareness of 5 different voices. The  voice :

 Presented as a whisper

 Presented as a quiet  voice

 Present a normal voice to talk to family

 Present a voice that can get attention across the room

 Present a yelling voice to call some one outside.

3. for patients over ten years, we might directly say that the patient has an inappropriately loud voice.

4. Focus on making the patient aware of the problem. Once aware, demonstrate how the loud voice may be perceived by others. Negative interpretations are usually sufficient to motivate him to learn to speak at a normal level.

    5. Practice using quiet voice. This can be facilitated by using the instruments     like visi- pitch and vocal loudness indicator for feed back.

   6. Provide practice drills for appropriate vocal loudness.

For an increase in loudness

1.      Determine if softness is not attributed to hearing loss, general physical weakness, or severe personality problems.

2.      Discuss with the patient the soft voice. Focus on making the patient aware of the problem. Once aware , demonstrate how the soft voice may be perceived by others

3.      Try to achieve a pitch level at which the patient is able with some ease to produce a louder level. Use the pitch Visi- pitch to help the patient associate changes in pitch with relative changes in intensity. Practice sustaining /a/ at that level for level for 5 seconds, concentrating on good vocal quality. Then take a deep breath and repeat the same pitch at a maximum loudness level. After some practice, ask the patient to sing /a/, up the scale for one octave, at one vocal production per breath: then have him/her to go down the scale , one note per breath, untill reaching the starting pitch.

4.      explore the best pitch, the one that produces the best loudness and quality.

5.      Respiration training may be necessary.

6.      Pushing approach may be necessary.

7.      For patients who appear to resist increasing the loudness, it might be necessary to introduce loud noise. The Lombard effect lends itself well therapeutically.

3. EAR TRAINING

 The basic input modality in developing appropriate phonation is the auditory system, particularly the patient’s hearing. Upto a certain level, gross pitch discrimination and tonal memory can be taught  by ear training practice, wherein the patient learns how to listen critically to his or her own good voice  and bad voices and to the voices of others.

1.      Obtain base line information on how well the patient can make pitch discriminations. Using recorded or live presentations, present a pair of stimuli and ask the patient if the stimuli are the same or different. If the patient is unable to discriminate between one whole note and it’s flat or sharp, the indication is that the patients pitch discrimination is not normal, but not necessarily that pitch discrimination therapy is needed. If the patient is unable to discriminate notes that are more than a third apart, some discrimination training is necessary, if the patient is ever going to match the target voice.

2.      Pitch discrimination training should begin at the patient’s base line. The clinician should provide variety of pitch stimuli and continue the practice untill the patient is able to discriminate one full musical note apart.

3.      Tonal memory also begins at the base line. That is, if the patient can remember a two tone sequence, the therapy should begin by presenting 2 two tone sequence and asking the patient to identify which note varies between the two presented. When the patient can hear a four note melody, tonal memory is probably good enough to recall various voice model presentations.

4.      When the patient is able to demonstrate a consistent ability to hear his or her good voice, ear training can be discontinued.

4. ELIMINATING ABUSE

There are many ways that one can abuse or misuse the voice. Vocal abuse comprises various behaviors and events that have some kind of deleterious effect on the larynx and voice and misuse means improper use of voice. Identification and reduction of vocal abuses and misuses are primary goals in voice therapy for hyper functional voice disorders. Therapy cannot be successful until contributory vocal abuse- misuse can be drastically reduced.

 1. The initial part is to identify the possible vocal abuses. Once the abuses are identified, the patient and the clinician should develop the base line of occurrence.

1.      Children with vocal abuse must become aware of its impact on the voice. Using story or picture cards, makes the child aware cognitively of the vocal abuse or the misuse.

2.      Discuss identified vocal abuse with the patient, emphasizing the need to reduce its daily frequency. Assign the task of counting the number of times each day they find themselves engaged in that particular abuse.

3.      Ask the patient to plot daily vocal abuse on a graph and bring it to each therapy sessions. Through awareness, vocal abuse should subside.

5. ELIMINATING HARD GLOTTAL ATTACK: LOUDNESS AND QUALITY

Speaking with abrupt vocal onsets is extremely taxing on the laryngeal mechanism. Hard glottal attack is often heard in patients with posterior lesions, such as contact ulcers.

1.      Demonstration of hard glottal attacks and easy glottal attacks should be provided for the patient.

2.      With children we demonstrate the Childs vocal attack by letting them hear their voice versus normal peer voice. Then practice using the word in the initial position of the sound /h/. When the /h/ words are produced correctly, introduce other words beginning with unvoiced consonants for similar practice. Then use the words beginning with vowels.

3.      Use the whisper phonation technique. The patients task is to whisper very lightly the initial vowel of monosyllabic words, prolonging it by gradually increasing the loudness of the whisper untill phonation has begun; finally the whole word is used. The whisper blends into soft phonation.

4.      The yawn-sigh approach is effective in eliminating hard glottal attack.

5.      the chewing approach and chant talk  almost always reduces the glottal stroke

6.      Use various instruments to provide feed back, such as Visi-pitch, the voice monitor, etc.

7.      Once the patient is able to produce easier glottal attack, make an audio recording of phonation. Ask the patient to listen from base line to now. The patient should think of the difference in both the sound and the contrasting feeling between the two models.

6. ESTABLISHING A NEW PITCH

1.       A tape recording should be made while the patient is searching for his optimal pitch and habitual pitches and then played back.

2.      Have the patient extend a /a/ at the desired pitch for about 5 seconds and record it with a loop tape recorder and then provide feedback.

3.      Use the VISI-PITCH for base line data and feed back.

4.      The tune master 111 is used for monitoring practice in establishing a new pitch.

5.      Once the new pitch is established, work on single words, preferably those beginning with a vowel, repeating each word in a pitch mono tone.

6.      Once the patient does well at the single word level, introduce phrases and short sentences. When success is achieved at the sentence level, assign the patient a reading passage.

7.      After reading well in monotone, the patient may try using the new pitch in some real –life conversations.

8.      record new pitch and use therapy model

7. PROVIDING FEED BACK: PITCH, QUALITY AND LOUDNESS

Tactual and proprioceptive feed back are common modalities through which we get some information about our voices, of this we primarily use the auditory feedback system maximum .with modern instrumentation we can provide needed feedback specific to the physiology of respiration, phonation and resonance.

The physiology of respiration can be studied by using the magnetometers on the chest wall and another pair on the abdomen. These magnetometers can provide valuable feedback to the patient attempting to develop more optimal breathing patterns.

Naso endoscopy and video endoscopy permits direct observation of the actual physiology of the various oral, pharyngeal, VP closure and laryngeal events during phonating.

 Kay Nasometer is a useful feedback device that provides an ongoing ratio of the relative oral – nasal resonance in the patient’s voice.

Information about pitch and quality ie digital and graphic data about the patient’s ongoing phonation can be provided by the PM PITCH ANALYSER, KAY- VISI PITCH.

 Bio feedback   specific to the patient’s relaxation state can be helpful in voice therapy. The patient will be introduced to some kind of bio feedback instrumentation that quantifies physiological changes, such as blood pressure, which are believed to be the correlates of anxiety or systemic tension.

VOICE REST

           

1.      Explain voice rest to patient, insisting that he or she not even whisper.

2.      The patient should be counselled about no coughing, throat clearing, or laughing.

3.      Situational voice rest is an option which can be used for certain patients.

YAWN- SIGH: LOUDNESS, PITCH AND QUALITY

The yawn-sigh is one of the most effective voice therapy techniques for minimizing the tension effects of vocal hyper function.  During yawn sigh, the larynx drops to a low position, the tongue is more back, there is slight opening between the vocal folds, and the pharynx is usually dilated.

1.       With children use pictures and narratives for explaining about tensed and effortful voice and how relaxed one would feel when yawning and sighs.

2.      With teenagers and adults explain the general physiology of yawn, ie, a yawn represents a prolonged inspiration with maximum widening of the supra glottal air way, then demonstrate a yawn.

3.      After the patient has yawned, ask them to yawn again and to exhale gently with a light phonation.

4.      Once yawn-phonation is achieved, instruct the patients to say words beginning with /h/ or with open mouthed vowels, one word per yawn in the beginning followed eventually by 4or 5 words in one exhalation.

5.       Demonstrate the sigh phase of the exercise, the prolonged, easy open mouthed exhalation after the yawn. Then omit the yawn entirely, demonstrating quick normal open mouthed inhalation followed by the prolonged open mouthed sigh.

6.      After the patient can produce a relaxed sigh, have him or her say the word “hah” after beginning the sigh. Follow this with a series of words beginning with the glottal /h/. Additional words for practice after the sigh should begin with middle and low vowels.

7.      Finally once the yawn sigh approach is well developed, have the patient think of the relaxed oral feeling it provides.

10. CHEWING: HELPFUL IN REDUCING VOCAL HYPER FUNCTION

1.      Explain to the patient that he or she is speaking with unnecessary tension.

2.       With both clinician and patient facing a mirror, ask patient to pretend to open mouth wide as if biting a handful of chips.

3.       Establish a natural exaggerated motion of chewing.

4.      Demonstrate chewing and add a very soft phonation. Have the patient imitate you (ie.”Yam yam”). Or the method to be effective, the natural movement of the tongue as experienced when actually chewing food should be maintained.

5.      Introduce some actual words and phrases, such as “lamp shade” “peaches and cream”, “candy chunks”.

6.      Once the chewing method is well established, ask the patient to count from 1 to 10 using same technique. If patient’s ability decreases, then go back to the earlier level.

7.      Introduce connected speech. Provide verbal material to say or passages to read aloud.

8.       The last practice step is to use the approach during conversational speech. If any difficulty experienced, return to the highest successful level ad guide forward from there.

9.      After several weeks of practice, teach patient how to diminish the exaggerated chewing to a more normal jaw movement. The patient must retain the same feeling and the same sound in his voice.

10. DIGITAL MANIPULATION: ESTBLISHMENT OF LOWER PITCH

In most of the cases of hyper function, the larynx is in an elevated position. Patients often report generalized neck pain and on palpation, focal areas of tenderness can be noted in the area of the thyroid musculature, along the superior edge of the thyroid cartilage, and along the inferior border of the hyoid bone. Patients may present with a significantly decreased thyro hyoid space.

The goal of digital laryngeal manipulation is to lower the larynx and to decrease supralaryngeal muscle tension. There are several ways that voice clinicians can facilitate a target voice by finger manipulation of the patient’s larynx. For voice problems relating to an inappropriately high pitch level, external digital pressure by the clinician on the patient’s thyroid cartilage is often effective in establishing a lower pitch. The external pressure nudges the thyroid cartilage slightly backwards and shortens the vocal folds; this increases the mass of the fold and produces a lower fundamental frequency.

The most active method of manipulation was recommended by Aronson (1990). Here the tension is reduced in the laryngeal area by maneuring the larynx to a lower position by placing the fingers over the superior borders of the thyroid cartilage and lowering the larynx gently and also moving it laterally at times.

Procedure:

For lowering the pitch

1.      Ask the patient prolong a vowel and as it is being prolonged apply slight pressure on the thyroid cartilage. This would lower the pitch.

2.      Ask patient to maintain the lower pitch even when our fingers are removed.

3.      Continue the procedure untill the patient is able to retain the lower pitch.

For maneuvering the larynx to a lower neck position

1.       Encircle the hyoid bone with the middle finger and thumb.

2.      With light finger pressure, place the fingers within the Thyrohyoid space, just above the thyroid notch. With the fingers over the superior border of the thyroid, begin gently to work the larynx downward with down ward pressure and slight lateral movements.

3.      With the larynx in lower position, ask the patient to prolong the vowels and monitor laryngeal positioning using the procedure.

 Note: this is an excellent method of producing lower pitch in problems of vocal hyper function, but is not effective in patients with falsetto. This technique produce immediate change of voice, but this may not be permanent change. Together with this counseling and psychotherapy has to be provided.

11. HIERARCHY ANALYSIS:HELPFUL WITH HYPER FUNCTIONAL VOICE DISORDERS WHERE ANXIETY INVOLVED

In hierarchy analysis the individual patients prepare a hierarchy of situations ranging from those in which they find their voices best to those in which they find them the worst.

1.      Develop patient’s general awareness of the hierarchical behaviors to be studied.

2.      Identify situations in which the patient feels most comfortable. Develop hierarchy of situations in which the patient experiences variations of voice.

3.      Have patient sequence voice situations from normal to most dysphonic.

4.      Begin therapy with good end of hierarchical sequence.

5.       Have the patient recall the good factors surrounding the optimum phonation. If the patient is successful in recreating the optimum situation, his phonation will sound relaxed and appropriate. The re-created optimum situation thus provides a best facilitator for the production of good voice.

6.      After some success in recreating the first situation in hierarchy, then move on to the second situation. Again the goal is to maintain optimum response.

7.      Progress through hierarchy as patient is able to be successful in each situation.

8.      By using the relaxed response in increasingly more tense situations, the patient is conditioning herself to more favorable, optimum behaviour.

9.      After the patient is conditioned to a more favorable optimum behaviour, have the patient practice his optimum responding the outside the clinic under good conditions and gradually progress towards more adverse situations.

13. NEGATIVE PRACTICE: HELPFUL METHOD OF FACILITATING CARRY OVER OF NEW VOICE PATTERN

1.      Once the patient is able to produce the target phonation free, ask him to voice deliberately an old phonation pattern.

2.      make an audio tape of target phonation patterns and have patient critique difference

3.      Have the patient identify the situation in which he is best to produce new voice.

4.       make specific plans to use old voice pattern deliberately. Then analyze contrasting vocal behaviors.

14. OPEN MOUTH APPROACH: REDUCES GENERALIZED VOCAL HYPER FUNCTION 

 The open mouth approach promotes more natural size mass adjustments and more optimum approximation of the vocal folds, which helps to correct problems of loudness, pitch and quality.

1.       Have the patient view self in a mirror to observe presence or absence of open mouth behaviour.

2.      The clinician should point out any areas of tension or restriction.

3.      Develop an awareness of oral openness during listening tasks. Patient should listen or read with teeth slightly apart.

4.      to establish oral openness, ask patient to drop head towards his chest and let his lips apart and jaw drop open, then  have the patient practice some relaxed /a/ sounds. When the head is tilted down and jaw is slightly open, a more relaxed phonation can be achieved.

5.      Have the patient develop conscious awareness of the feeling of open versus tight, closed mouth by keeping a note of each time he becomes aware of the mouth being closed unnecessarily.

6.      Once the oral openness is achieved, establish carry-over between orality and the speech –voicing task itself.

15. PITCH INFLECTION: HELP FUL IN REDUCING MONOTONOUS SPEEECH

The voice therapy for patients with monotonic pitch helps in establishing optimum pitch levels and also increases the amount of pitch variability.

1.       In order to make the patient aware of the monotonous pitch, provide the patient recorded samples of his voice and sample of voices with excellent pitch variation.

2.      Discuss differences with patient to increase awareness of lack of pitch variation.

3.      Begin working on downward and upward inflectional shifts of the same word, exaggerating in the beginning.

4.      Have the patient practice introducing pitch shifts within specific words.

5.      Record patient’s oral reading and conversation from time to time.

6.      Critically analyze these productions with regard to pitch variability.

16. PUSHING APPROACH: USEFUL WITH PROBLEMS OF VOCAL FOLD APPROXIMATION

1.      demonstrate pushing method by raising the patients fists to about shoulder height , and then pushing his arms down suddenly in a rapid , uninterrupted motion.(or have patient push his body off seat of chair)

2.      After the patient can perform above well, have the patient push and phonate simultaneously.

3.      Have the patient practice phonation at same loudness level without pushing.

4.      Carry over increased loudness without pushing to conversational tasks.

17. RELAXATION TRAINING: USEFUL FOR DYSPHONIAS

Using techniques like yawn –sigh and open mouth, it is possible to increase the relaxation of muscles contributing to the vocal function. These will relax the vocal folds but not lead to the over all systemic relaxation.  

1.       Use any method of relaxation. Jacobson’s classical method of differential relaxation is particularly useful.

2.       Under differential relaxation, the patient concentrates on a particular site of the body, deliberately tensing and relaxing certain muscles, discriminating between muscle contraction and relaxation. The typical procedure is to have the patient begin distally from the body, with the finger or the toes.

18. RESPIRATION TRAINING: IMPROVEMENT OF TOTAL RESPIRATION

1.       Begin with simple explanation of the phonatory physiology, emphasizing that outgoing air stream vibrates the vocal folds.

2.      Demonstrate slightly exaggerated breath, as used in sighing.

3.      Demonstrate the quick inhalation and prolonged exhalation needed for normal speaking tasks.

4.      Practice extending an even phonation for as long as possible without any noticeable phonation break or change of quality.

5.       Prolong /s/, /z/, /a/, /i/ for as long as possible. Take a base line measurement in the beginning and see if this duration can be extended. Avoid using deep inhalation. See if the patient can extend this for 5 seconds and then progressively increase the extension time to 8, 12, 15, then 20 seconds.

6.      Present reading materials to develop breath control and encourage the patient to take quick inhalations between the phrases.

19. TARGET VOICE MODELS: SELECTION OF PATIENTS OWN BEST VOICE PRODUCTION

1.      Discuss various ways of production of voice.

2.      Explain that the goal of treatment is to produce voicing with the least among of effort.

3.      review phonation  of patient as detected during evaluation

4.       Experiment with various pitches, body positions, etc. to find patients optimum pitch level.

5.      Tape records this speech. Once target phonation is determined, it may be played back as a model.

6.      Have the patient listen to own model recording and attempt to modify voice to match that phonation.

7.      Once target phonation achieved, introduce oral reading.

8.      Continue to present various tasks untill spontaneous conversation reached using optimum voice production.

INHALATION- PHONATION

The high pitched vocalization produced during inhalation is always produced by true vocal fold vibration. This technique is useful in patients who are aphonic or in ventricular dysphonia or functional aphonia.williams , Farquharson, Anthony (1975) have written that reverse phonation viewed by fiber- optic endoscopy shows vibrating vocal folds well.

1.      Demonstrate inhalation phonation by phonating high pitched high pitched hum while elevating the shoulders. The elevation of shoulders shows the contrast between inhalation and exhalation.

2.      Inhale raising the shoulders and simultaneously humming in a high pitch, then dropping the shoulders on exhalation and producing the same voice. Repeat the inhalation- exhalation matched phonation several times.

3.      Demonstrate the continuation of the high pitch, sweeping down from the falsetto to the regular chest register on one long continuous expiration. Repeat this several times.

4.       After some practice, use monosyllabic words for practice.

5.      Now reduce the pronounced shoulder movements.

6.      Stay at the single word practice level untill normal voicing is established.   

 HALF SWALLOW BOOM METHOD

 This technique is more useful in patients who have unilateral vocal fold paralysis, severe bowing of the vocal folds or falsetto voice. All of these patients have low loudness level and air wastage.

1.      Here we ask the patient not to swallow completely and say boom… rather say boom during the swallow. We ask them to say a low pitch boom.

2.      After two to three attempts, the boom is said in a louder and less breathy voice.

3.      Record this voice and show the dramatic improvement in voice.

4.      Usually we do this with the head turned to one side and the other. Also we do this with the chin lowered and tucked in.

5.      Once the best boom is produced ask the patient to say boom one etc.

6.      Gradually increase the length of the phrase after the boom and then phase out boom. Then phase out the swallow and then move the head back to the midline and raise the chin to the normal position.

NOTE: the swallow produces as much closure of the larynx as possible. The word ‘boom’ is composed of  voiced sounds  that can all be produced as the air is produced from the constricted larynx and the oral opening is minimum which produces  some back pressure on the  larynx. The head turning assist in mechanical sense.

HEAD POSITIONING

The production of normal voice is some times facilitated by changing the position of the head.  Several distinct head position can be tried to find the one that facilitates better voice.

      Normal straight forward head.

      Neck extends forward with head tilted down, face looking up.

      Neck flexed downwards with head tilted downward, face looking down

      Neck flexed unilaterally with head tilted to either the left or right, with tilted              face looking forward.

      Head upright and rotated towards left or right, face looking in either         direction.

 Any one position may change the pharyngeal- oral resonating structures in such a way that a change in vocal quality may occur.

These positioning can be used in combination with other facilitating techniques.

Procedure

1.       Introduce the approach by demonstrating various head positions. A simple explanation of the technique should accompany the demonstration.

2.       Prolongation of vowels like /i/, /I/, /o/, /u/ can be used as the best voicing task to search for the head position.

3.      Whenever a change is noted in a particular position of head, the head should be kept at that position and the activities have to carry out.

4.      Neurologically impaired patients may have some oro-pharyngeal asymmetry from their disease. A particular lateral movement of the head may make a sudden and noticeable improvement in the voice in such patients. Then ask the patient to practice voice material with the head in the lateral position.

5.      In case of vocal hyper function, the patients profit from the neck flexion with the chin tucked down towards the chest. This downward carriage seems to promote greater vocal tract relaxation.

 Functional voice problems usually respond to  the same techniques of voice treatment as dysphonias related to cord thickening, vocal nodules, polyps , contact ulcers, etc. a differential treatment approach  is not needed for each voice disorder. Rather our treatment might be more effective and relevant if, after analyzing the voice disorder along the dimensions of pitch, loudness, and quality, we then applied a therapy appropriate to these dimensions.

“The voice therapist must continually search for the patient’s best and most appropriate voice production. The selection of what to do in voice treatment is related to what the patient is doing and what we can give him to do to produce a ‘good’ voice”