10/10/2014 What is EBP? (Hjørland, 2011) Client-Centered Management for Voice Disorders: Using the ALERT model Linda Rammage, PhD, RSLP, S-LP(C) Director, PVCRP BCASLPA, 2014 all practical decisions 1) based on research studies and 2) research studies are selected and interpreted according to specific norms characteristic for EBP norms typically disregard theoretical and qualitative studies and consider quantitative studies according to a narrow set of criteria for evidence (Random Control Trials - RCT) Tx based on other research designs considered “research-based-practice” (Montgomery & Turkstra, 2003) Cochrane Reviews (RCT): “Voice/Voice Therapy” Means to support clinical reasoning, not “End” Q: Is there evidence that any form of SLT is EBP/RCT – “Gold Standard?” Limitations in clinical research/Tx decisions: Statistical signif ≠ clinically meaningful… achieving both is a social judgement Judgement always required for indiv. client (“n of one”)… even RCT results cannot be assumed to generalize to each individual RCTs may be impractical/impossible (eg. statistical power/study N required) or design inappropriate for many clinical Q’s more efficacious for IPD? (2012) Author Conclusion: “Insufficient evidence due to small N’s” Q: Is there evidence that either direct or indirect voice training or combined is effective to prevent voice disorders in at-risk population? (2007) Author Conclusion: “No evidence from studies that met review criteria. Need larger N and better methodology (better control criteria)” 1 10/10/2014 Client-Centered Care (Rogers, 1959) relationship of mutual respect and trust between client and therapist clinician facilitates information-sharing in a non-directive approach client’s role as “expert” in his/her experiences of the problem is established at the outset therapist demonstrates “unconditional positive regard” by listening to and acknowledging the client’s perspective without making judgment EBP & Client/person-centered care “Person-centred practice could make a difference to health outcomes, patient/client satisfaction and can improve one’s sense of professional worth” (Victorian Client/Person-Centered Care Principles Get to know client as a person (not a Dx): culture, beliefs, values, goals, dreams… Share power and responsibility: respecting preferences Accessibility and flexibility: ensuring sensitivity to values, preference, needs; making info accessible to facilitate choices Coordination & integration: team work; minimize duplication; key contact Environments: ensure working philosophy/policy/environment facilitates PCC Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Department of Human Services, 2006) “EBP acknowledges that good outcome must be defined re value to patient…combining art of generalizations and science of particulars” (Epstein & Street, 2011) “PC planning associated with benefits in areas of Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Aging, Lesion Disease Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing community involvement; contact with friends, family; and choice” (Sanderson, Thompson & Kilbane, 2014) 2 10/10/2014 ALERT to History Determining contributions of factors: The Client as “Expert”: Anatomical: Lifestyle: Emotional: Reflux: Technique: Client Intake History Form Tool Paradigm Parameters Administration Rating Voice Handicap Index (VHI) Handicapping effects of voice impairment, incl. voice disability & impact on daily functioning (WHO)(1980) ICIDH 30 items: 10 - Physical 10 - Functional 10 - Emotional 5-point Jacobson et frequency of al, 1997 occurrence scale Translated to ordinal scale Higher scores = greater handicap Rosen et al, 2000 Billante et al, 2001 Roy et al, 2001 Spector et al, 2001 Weigelt et al, 2004 Maertens and de Jong, 2007 Hazlett et al, 2009 Voice Handicap Index-10 (VHI-10) As with VHI As with VHI Rosen et al 2004 Pediatric VHI (pVHI) As with VHI As with VHI Zur et al 2007 Deary et al, 2004 da Costa de Ceballos et al 2009 de Alarcon et al 2009 Voice-Related Quality of Life (V-RQOL) Impact of general or specific states of disease or dysfunction on Quality of Life 10 items: Physical Functional Emotional 23 items: 7- Functional 9- Physical 7- Emotional 10 items: 5-Physical/Functional 5-Social/Emotional 5-point severity scale Higher scores = greater severity Can be converted to Standard Score Hogikyan and Sethuraman 1999 Overall Voice quality past 2 weeks Authors Select Clinical Studies Hogikyan et al, 2000, 2001 Rubin et al,2004 Franic et al., 2005 Cohen et al, 2006 Oridate et al, 2009 Moukarbel et al 2010 3 10/10/2014 Pediatric Voice-Related Quality-of-Life Survey (PVRQOL) Impact of general or specific states of disease or dysfunction on Quality of Life Voice Symptom Scale Handicapping effects: communication, throat infections, psych distress, voice sound/variability, phlegm. ICIDH Physical symptoms and socio-economic impact of voice disorder (VoiSS) Vocal Performance Questionnaire (VPQ) Voice Activity and Participation Profile (VAPP) Perception of problem, activity limitation, participation restriction WHO ICIDH-2 Beta 1 (1997) 10 items: 5-physicalfunctional 5-socialemotional Parent –proxy 30 items: 15-Impairment 15-Physiological 15-Emotional As with V-RQOL Boseley et al, 2006 12 questions about voice dysfunction impact 5 potential responses per question to indicate impact 28 items: 1 - Severity 4 - Employment 12 - Daily communication 4 - Social communication 7 - Emotion 10 cm continuous Ma and Yiu, line visual analog: 2001 Left = not affected Right = always affected Measure cm., from left end of line 5-item frequency of Deary et al, occurrence scale 2003 Translated to ordinal scale Higher scores = greater handicap Anatomical Factors Carding and Horsley, 1992 Hartnick, 2002 Hartnick et al, 2003 Merati et al, 2008; Blumin et al, 2008 Deary et al, 2003 Wilson et al, 2004 Webb et al, 2007 Hazlett et al, 2009 Voice-Related Quality of Life (V-RQOL) Self-Report Inventory. Carding and Horsley, 1992 Carding et al, 1999 Deary et al, 2004 (Hogikyan & Sethuraman, 1999) Ma and Yiu, 2001 Sukanen et al, 2007 Chung et al, 2010 Yiu et al, 2011 Anatomical Chronic non-infective laryngitis Congenital Webs Contact Ulcer/Granuloma (Reflux) Crico-arytenoid Joint Problems Cysts, Sulci, and Mucosal Bridges Iatrogenic changes (eg. ablative surgery) Infection: Bacterial; Viral (esp. parainfluenza) Laryngeal Trauma Mucosal changes from abuse/misuse Tumours Anatomical Factors Examples: Unilateral Cyst 10 Nodules 20 4 10/10/2014 Papilloma 10 Contact Ulcer/ Granuloma 20 Anatomical Factors: Development and Aging Web (Congential / Iatrogenic) Aging and Speech-Breathing (Hoit & Hixon,1987; Hoit et al, 1989; Hoit & Hixon, 1992; Melcon et al, 1989) Rib cage ossifies Reduced collagen in lungs Reduced flexibility in system Reduced vital capacity Hirano & Bless, 1993 Initiate voice at higher lung volumes Use larger lung and rib cage excursions Men use more lung vol/syllable (due to vocal fold leaks) but not women (Hoit & Hixon, 1992) 5 10/10/2014 Implications: More time required for voice onsets Reduced ability to sustain long phrases (especially with incomplete v.f. closure) More time required for inspiration Potentially less driving force for phonation Senescence affects posture Posture affects breathing Glottal leakage Higher airflow higher lung volumes (men) hyper-valving at glottis Aging and the Larynx (Honjo & Isshiki,1979; Kahane,1983a/b; Kahn, A. R. & Kahane,1986; Kersing, 1986; Linville & Korabic,1987; Mackenzie Beck, J. (1997 ) Cartilage ossifies Collagen, elastin, muscle esp. men (Case 32) Epithelium thickens, esp. women Cumulative trauma thickens folds Larynx descends, pharynx lengthens: formant structure Reduced neurological/structural stability: wobble/tremolo/vibrato/perturbations VF closure may Increased jitter/shimmer/noise 6 10/10/2014 Vocal Senescence and Gender (Linville & Fisher, 1985 a/b;; Linville, 1996; Mysak, 1959; McGlone & Hollien,1963) Women: Men: • • Implications (L/E/T impact?): Reduced loudness potential • • • • • Epithelium F0 range descends More if smoker May be called “sir” May compensate to pitch tension range/ flexibility • • • • Collagen, elastin, muscle, epithelium F0 range ascends May be called “Ma’am” May compensate to pitch tension range/ flexibility Reduced phonation duration (Linville, 1996) (Linville, 1996) Leaky VF (esp.men): mal-adapt speech-breathing Delayed voice onset “New-Normal” pitch range (Melcon et al, 1989) Pharynx continues to grow: formants drop May mal-adapt to aging with muscle misuse vocal perturbations and noise Exercise (general/voice-specific) may age effects (Peppard, 1990; Lowery, 1993) Anatomical Factors: Neurological Motor Speech Disorders congenital (CP) / acquired (MSD) MSDs and voice: Vocal fold paralysis (flaccid) Dystonia/spasmodic dysphonias Spastic dysarthrias Essential voice tremor Parkinson’s Disease Irritable Larynx as Central Sensitivity Syndrome? Unilateral Paralysis (Case 29) PD (Cases 49) EVT (Case 52) SD (Case 55) 7 10/10/2014 Anatomical Factors: Irritable Larynx Syndrome (Morrison, Rammage, Emami, 1999) (Case 59) Symptom Triggers All 195 vs. Female PVFM (141) hyperkinetic laryngeal dysfunction (laryngospasm-PVFM, cough, dysphonia/globus) due to CNS over-reaction to normal sensory stimuli in response to a Odors Stress Eating Lying down Talking Exercise All Pts: 106 54% 100 51% 36 18% 38 19% 41 21% 27 14% F-PVFM (57%) (50%) (20%) (22%) (21%) (13%) definitive triggering stimulus ILS - Pathways to CNS Plastic Change ILS Chronic Stimulation Non-triggered hypertonic state Psych Factors & Habituation GERD CNS VIRUS Irritants Tone modulators ILS Features Set-up for spasm MUSCLE SPASM Dysphonia Laryngospasm Globus & Cough 8 10/10/2014 Neural plastic response to repetitive nocistimulation stimulus ILS: A Central Sensitivity Syndrome? (Morrison & Rammage, 2010) depolarization Heightened sensitivity of central neurons Altered activation thresholds, and enhanced P c-fos c-jun Transcription of I.E.Genes FOS JUN DNA binding jun fos Central Sensitization responsiveness to synaptic inputs as with neuropathic pain (Woolf CJ, Slater MW. Science 2000; 288:1765-8) Underlying Neuro-Endocrine-Immune (NEI) pathology? (Morrison et al, 1999; Yunus, 2000-2008) CS verified by testing neurotransmitters, neuro modulators with nociceptive spinal flexion reflex, Functional MRI and cerebral evoked potential by ElectroEncephaloGraphy (Yunus, 2005; 2007) Normal Sensation A defined input, or sensory stimulus, produces a sensory experience greater in amplitude and duration than would be expected The sensitivity of the pain system is shifted such that normally innocuous inputs can activate it & perceptual responses to noxious inputs are exaggerated, prolonged & widely spread This could represent a central amplification due to increased excitation or reduced inhibition 9 10/10/2014 Central Sensitization Amygdala: both enhances & inhibits pain processing Neugebauer et al. Amygdala & Persistent Pain. Neuroscientist. 2004 10: 221-234. Clinical syndromes central sensitization contributes to….. Rheumatoid arthritis Osteoarthritis Temporomandibular disorders Chronic Fatigue, Fibromyalgia Migraines, headaches, TMJ Neuropathic pain Complex Regional Pain syndrome Visceral pain hypersensitivity syndromes: IBS, noncardiac chest pain, chronic pancreatitis Interstitial cystitis, endometriosis, vulvodynia Multiple Chemical Sensitivity (Yunus, 2000-2008) 10 10/10/2014 Sniffing Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Lifestyle factors Aging, Lesion Disease Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing Lifestyle Vocal Dose - work-related voice demands (teacher; swim instructor; singer; customer service, etc) - recreational voice demands (team sports; coaching; group-socializing) - family/caregiver voice demands (parenting; elder-care, large family…etc) Some occupations are vocally demanding & stressful, leading to voice problems. 11 10/10/2014 Prevalence Of Voice Problems By Occupation Occupational Representation in Voice Clinics GROUP NUMBER INVESTIG %F %M FACTORS Aerobics I. 50f / 4m Long et al 44 % 50 % Shouting Duration OCCUPATION Teacher 19.6 % * 4.2 % * Army I. 130 f Sapir et al 76 % Loudness Rapid Sp Singer 11.5 % * .02 % * Army Recr. 386 f Sapir et al 31 % Excess Sp Sales Rep: 10.3 % 13 % Swim. I. 155f /95m Rammage 79 % 58 % Loud Envir. Telesales 2.3 % * .78 % * Teachers 250 m&f GotaasStarr 80 % > m&f Loud; Stress PE/Music Ticket/Travel .4 % .21 % Secretary/Clerk 8.6 % 10.6 % 237 f Sapir et al Factory Worker 5.6 % 14.5 % Teachers Loud; Illness 73 % Titze et al, 1997 % CLINIC (N=1593) % US EMPL. POP. Teachers 564f/313m Russell et al 22 %/67% 13%/66% Loud;Gender (point/career) (point/career) Various Reception/PR 3.5 % * .12 % * Teachers 280f/274m Smith et al Counselor 1.6 % * .19 % * 18%/93% 9%/62% Loud;Course Occupational Representation for BC (N= 1181) Occupat. % BCPop % Clinic % BC M % Clin M Singer .27%* 18%* 58% Teacher 67% 42% 33% 3.8%* 17%* Sec. * 62% 78% 38% 22% 13.4% 12% 86% 86% 14% 14% 6.9% 7.5% 41% 42% 59% 58% Sales * 14.8% 7% 41% 65% 59% 35% Actor .09%* 3%* 43% 66% 57% 34% Nurse 1.6% 3% 95% 100% 5% 0% Trades * 9.4% 3% 4% 15% 96% 85% BusAdm % BC F % Clin F 12 10/10/2014 Dominant Factors for Dysphonic Teachers (PVCRP 2007, N=149) Teachers: 7 Years in PVCRP Year - % of Teachers/Employed PVCRP Pop. 1999 - 17 % (68/400) 2000 - 18.54% (66/356) 2001 - 20.80% (104/500) 2002 - 16.96% (68/401) 2003 - 19.21 % ( 88/458) 2004 - 22.83 % (87/381) 2005 - 24.96% (115/460) Lifestyle Factors: Acoustic Environment • Maximum noise level of unoccupied classroom: ANSI S12.60: 35 dBA (normally-hearing adult) • Optimal signal-to-noise ratio: =/> 15 dB (normally-hearing adult, 1st language); Grade 1: SNR =/> 20dB (Bradley, 2008) • Reverberation rates: between 0.4 and 0.6 sec • (Typical comfortable speaking level: 65-75dB?- f/m adult) Public school and university classrooms, daycare facilities and restaurants in BC do not meet minimum acoustic standards (Hodgson et al, 1999-2008). Occupational voice users talk above comfortable loudness. # Teachers % Teachers % Female % Male m misuse 68 46% 87% 13% v nodules 13 9% 85% 15% c laryngitis 12 8% 58% 42% v paralysis 11 7% 91% 9% v polyp 7 .5% 86% 14% Dx Noise in the Classroom Outside: Aircraft, traffic, hallway noise Inside: Heating, ventilation, A/C systems Computers, projectors Movement of desks/chairs; walking/talking noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990) noise, reverberation and RASTI values (speech transmission) in most occupied classrooms unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990) 13 10/10/2014 School Classroom Survey: Reverberation Time (unoccupied classroom) optimum: RT0.5s (Hodgson,1999) School Classroom Survey: Ventilation-noise Levels (Hodgson, 1999) optimum: noise < 40 dBA (normal), 30 dBA (HoH) U-Hill North Vancouver Elementary Schools Berwick Preschool 1.0 55 0.8 50 0.6 VNA (dB) RTu (s) 1.2 0.4 U-Hill North Vancouver Elementary Schools Berwick Preschool 45 40 0.2 35 Ber 65 teach Ber 34 teach Ber 39 teach Ber 50 class Ber 60 class CLVLND MAPLWD DORLYN3 Classroom DORLYN4 PLYM SMHTS CANHTS DORLYN2 CVCLF1 DORLYN1 UPLYNN1 UPLYNN2 U-Hill Port U-Hill 107 30 U-Hill 110 Ber 65 teach Ber 34 teach Ber 39 teach Ber 50 class Ber 60 class CLVLND MAPLWD DORLYN3 DORLYN4 PLYM SMHTS CANHTS DORLYN2 CVCLF1 DORLYN1 UPLYNN2 U-Hill Port UPLYNN1 U-Hill 107 U-Hill 110 0.0 Classroom Noise and the Voice School Classroom Survey: In-class Sound Levels (Hodgson, 1999) optimum: noise < 40 dBA (normal), 30 dBA (HoH) Noise levels >40 dB affect voice use (Pekkarinen & Viljanen, 1990; van Heusden, 1979; Brewer & Briess, 1960; Hetu et al, 1990) 110 U-Hill North Vancouver Elementary Schools Berwick Preschool 100 Speech-breathing changes in noise (Winkworth & Davis, 1997) 80 70 Noise, RT & RASTI values in most occupied classrooms 60 unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990) 50 40 Classroom Ber 60 teach Ber 50 teach Ber 65 teach Ber 39 teach Ber 60 class Ber 34 teach MAPLWD Ber 50 class CLVLND DORLYN4 SMHTS DORLYN3 PLYM CANHTS DORLYN2 DORLYN1 CVCLF1 UPLYNN2 UPLYNN1 U-Hill Port U-Hill 110 30 U-Hill 107 Lp (dBA) 90 Amplification can improve speech recognition and voice function (ASHA, 1990) Amplification of 8-10 dB reduces vocal SPL: 2 + dB (Sapienza et al, 1999) 14 10/10/2014 Socially-reinforced or addictive behaviours Occupational Factors: Ergonomics/Posture - smoking? - alcohol? - caffeinated beverages/chocolate, etc - recreational drug use? - role models/assumption? (habitual imitative use of inappropriate pitch or voice quality … conscious or subconscious?) Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Aging, Lesion Disease Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing 15 10/10/2014 Psychological factors Emotion The body reacts to stress and anxiety by increasing resting tone in voluntary muscles. Muscles do not contract as efficiently when they are hypertonic. Voice is used to express ideas and emotions, and dysphonia may result when these emotions are intense and suppressed or with low level of emotional awareness. Autonomic nervous system: dry mucosa in the vocal tract stiffer vocal folds “fight or flight” anxiety responses: eg. “fight”: holding breath (vocal fold adduction); “avoidance” racing heart, ready to retreat awareness of physical response may increase anxiety attempts to “suppress” emotion (eg. compressing larynx to reduce involuntary shaking) may backfire level of emotional awareness will predict ability to modulate physical reactions Self-Reported Psych Conditions (PVCRP, 2009; N = 472) Condition 10 MTD Non-MTD Anxiety 35% 12% Depression 28% 18% Psychiatric Disorder 12% 12% Voluntary nervous system: muscle tension/misuse: speech breathing, larynx, upper vocal tract, face/jaw/tongue attempts to control ANS responses such as nervous tremor (Imitate the sound of someone giving a speech when they’re very nervous.) affective disorders/anxiety/psychiatric conditions affecting emotional awareness/inhibition suppressed emotional expression…What is the innate vocalization associated with: happiness/joy ? fear? grief/sadness ? anger ? 16 10/10/2014 Neurobiology of Affect Regulation: Allan Schore LIMBIC SYSTEM Orbitofrontal system “thinking part of the emotional brain”, plays major role in affect regulation Internal state, organization of behavior, adjustment of emotional responses Orbitofrontal cortex not functional at birth. Over the 1st year, limbic circuitries emerge in sequence: amygdala ant cingulate insula orbitofrontal CINGULATE GYRUS HYPOTHALAMUS HIPPOCAMPUS AMYGDALA The Attachment System Attachment system improves chances of infant’s survival seeking proximity: protection from harm, attack, separation from group Attachment relationships crucial in organizing neuronal growth of developing brain emotional relationships have direct affect on development on memory, narrative, emotion regulation 17 10/10/2014 Human connections create neuronal connections: Major environmental factor in brain development Affect regulation pathway: orbitofrontal limbic system Genetic factors vulnerability for a disorder, environmental factors, such as attachment, play crucial role in ultimate expression of symptoms In postnatal period there is genetically driven overproduction of synapses Pruning & maintenance of synaptic connections in frontal, limbic, & temporal cortices influenced by psychological factors Early abuse experiences of neglect/trauma excessive pruning = poor limbic connections … Child and caregiver behaviour patterns before the age of 18 months [Ainsworth et al, 1978; Main & Solomon, 1986] Attachment pattern Secure Anxious Avoidant Child Uses caregiver as a secure base for exploration. Protests caregiver's departure and seeks proximity and is comforted on return, returning to exploration. May be comforted by the stranger but shows clear preference for the caregiver. Clingy, unable to cope with absences of the caregiver. Seeks constant reassurances. Little affective sharing in play. Little or no distress on departure, little or no visible response to return, ignoring or turning away with no effort to maintain contact if picked up. Treats the stranger similarly to the caregiver. The child feels that there is no attachment; the child is "rebellious" and has a lower self-image and selfesteem. Caregiver Attachment experience development of orbitofrontal function affect/behavior regulation Orbitofrontal Cortex Attachment pattern Ambivalent/ Resistant Responds appropriately, promptly and consistently to needs. Caregiver has successfully formed a secure parental attachment bond to the child. Excessively protective of the child, and unable to allow risktaking, and steps towards independence. Little or no response to distressed child. Discourages crying and encourages independence. Orbitofrontal metabolic dysfunction in autism, schizophrenia, bipolar, depression, PTSD, drug addiction, cluster B personality disorders Disorganized Child Unable to use caregiver as a secure base, seeking proximity before separation occurs. Distressed on separation with ambivalence, anger, reluctance to warm to caregiver and return to play on return. Preoccupied with caregiver's availability, seeking contact but resisting angrily when it is achieved. Not easily calmed by stranger. In this relationship, the child always feels anxious because the caregiver's availability is never consistent. Stereotypies on return such as freezing or rocking. Lack of coherent attachment strategy shown by contradictory, disoriented behaviours such as approaching but with the back turned. Caregiver Inconsistent between appropriate and neglectful responses. Generally will only respond after increased attachment behavior from the infant. Frightened or frightening behaviour, intrusiveness, withdrawal, negativity, role confusion, affective communication errors and maltreatment. Very often associated with many forms of abuse towards the child. 18 10/10/2014 Attachment and Psychopathologies Common forms of psychopathologies (Main et al, 1987) Numerical values are path coefficients, representing the strength of associations between constructs (Krueger & Markon, 2006) Avoidant attachment history biased toward parasympathetic state: low arousal, reduced emotionality; under stress vulnerable to overregulation & internalization psychopathologies Ambivalent attachment sympathetic state: high arousal, high emotionality; under stress vulnerable to externalizing psychopathologies Levels of Emotional Awareness (Lane & Schwartz, 1987; Lane, 2008) • Cognitive developmental process • Similar to Piagetian theory • 5 basic levels follow developmental pattern: infants to “fully aware” humans • neurobiological correlates • top-down modulation allows “aware” person to regulate amygdala and change physiological R’s (eg. relaxed breathing to stop fight-flight R’s) Parallels in the hierarchical organization of emotional experience, and neural substrates. Levels filled in white are implicit levels; those in grey are explicit levels. Lane & Schwartz, 1987 19 10/10/2014 LEVEL 5: PREFRONTAL CORTEX ; ant cingulate, medial prefrontal cortex Reflective awareness: complex analysis of experiences of self and others LEVEL 4: Blends of emotions: “I feel disappointed with myself” Single emotions: “I feel sad/happy/angry” LEVEL 3: ant cingulate, insula, temporal lobe, orbitofrontal cortex LEVEL 2: amygdala, thalamus, basal ganglia LEVEL 1: thalamus, hypothalamus, brainstem Sensorimotor enactive; crude distinctions between globally + or – states; gestures & mvts: “I want to hit you!” Automatic generation of emotional responses: “My stomach/throat/jaw hurts” Implicit and Explicit Processes (Post Piagetian Representational Redescription) Neuroanatomical Model: Implicit VS Explicit Emotional Processes (Lane, 2000) Amygdala and Thalamo-Amygdala process implicated in rapid, low-level implicit (subconscious) processing of stimuli. Precedes emergence of emotional “feeling” state. Phylogenetically-older structures, protect organism in life-threatening situations. In contrast, Neocortical-Amygdala pathway involved in slower, more differentiated explicit (conscious) processing of stimuli. Implicit Processes Implicit (automatic action/sensori-motor) May induce postures in respiratory and laryngeal patterns of knowledge (Levels 1 & 2) are transformed to Explicit (conscious: Levels 3-5) representations through language. (Karniloff-Smith, 1992) Use of language to describe emotions modifies one’s emotional awareness and experience at conscious levels. (Werner & Kaplan, 1963) Corresponds with “Top-Down” modulation of emotional responses. Absence of higher level emotional processing and mechanisms to facilitate rapid/strong physical reactions, as in fight or flight: fixing thorax with vf adducted to enhance upper body strength / abducting vf to facilitate free respiration for running. lx/respiratory system postures not conducive to normal phonation may make individual more susceptible to muscle tension voice/laryngeal disorders. 20 10/10/2014 Baker & Lane, 2009 Implicit emotional responses reflect “unformulated experience”: emotions not fully formed/differentiated, so expressed 10 physically. Once discussed & processed, can be experienced fully. VS: Freudian concepts: unconscious fully formulated emotions being repressed Explicit Emotional Experience Anatomical Correlates: 1- ventro-medial prefrontal cortex; right parietal cortex; insula, temporal pole 2 - dorsal ACG 3 - paracingulate region of medial prefrontal cortex Theory informs treatment approach Explicit Emotional Processes Top Down Modulation support cognitive neuroscience approach to emotion. Engage paralimbic and neocortical structures that are not specific to emotional processes. Domain-general nature of these structures infers they compete with other (potentially interfering) input for conscious processing. May explain differences in individual attention to and use of emotional info. Explicit processing may make individuals less vulnerable to physiological states associated with muscle tension dysphonias. PSYCHOLOGICAL Self reflection NEUROANATOMICAL Prefrontal Cortex Blends of Emotion Discrete Emotion Action tendencies Bodily sensations Paralimbic Limbic Diencephalon Brainstem Greater activity in dorso-medial prefrontal cortex associated with higher vagal tone (thus, reduced HR, calming) Verbal emotion labelling inhibits amygdala activity. (Amygdala preferentially activated by aversive stimuli.) 21 10/10/2014 The LEAS - Levels of Emotional Awareness Scale (Lane et al, 1990) Examples of LEAS 0-5 scoring – “Self” and “Other” R’s given separate scores Written performance measure Non-affective (non-emotional) words = 0 Patients describe anticipated reactions for Physiological words to describe feelings = 1 self and other person to short vignettes Scored per specific structural criteria to determine degree of specificity of emotion words and range of emotions Scoring unbiased by patient or rater due to structure focus of criteria Glossary for each level guides scoring Undifferentiated emotion (eg. I’d feel bad) or LEAS Reliability & Validity High inter-rater reliability; high internal consistency (Lane et al, 1998) Construct validity supports LEAS as measure of cognitive-developmental continuum: moderately positive correlations with other cognitive-developmental measures: Sentence Completion Test of Ego Dvlpt and Cognitive Complexity of the Description of Parents (Lane, 2008) action tendency = 2 Single word used conveying differentiated emotion (eg. I’d feel happy/sad/angry) = 3 Two or more level 3 words used to enhanced differentiation = 4 “Self” and “Other” scores = 4 and differentiated = 5 Emotion Processing Deficits and Psychosomatic Voice Dysfunction Causal Model of Emotion Processing Deficits in Women with “FVD”: more severe events/ difficulties, COSO events/difficulties, highly anxious coping style, less emotionally expressive families, more ambivalence re expressing neg. emotions. FVD result of strong negative emotional reactions to events + emotional processing interference. (Baker et al, 2007; Baker, 2008) 22 10/10/2014 Childhood Abuse in Patients with Conversion Disorder (Roelofs et al, 2002) Compared patients with conversion to patients with affective disorder with respect to childhood abuse Patients with conversion reported higher incidence of physical/sexual abuse Larger number of different types of abuse, longer lasting incidents of sexual abuse, more incestuous experiences What to screen for in initial assessment: Attachment experience: History of trauma or abuse Quality of relationships (family, partner, school, friends) Observe: Postural/Gestural/Facial Postures Voice / posture changes with topics Lexicon used to describe significant events/distress Evidence of low level of emotional awareness Personality factors Avoidant tendencies, somatization, externalization … Significant acute stressor in an otherwise well functioning individual Depression, anxiety 23 10/10/2014 24 10/10/2014 Reflux Factors Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Aging, Lesion Disease Diet Eating habits Genetics Medications Posture Weight Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing Reflux 71% MTD Patients =/> 4/7 Reflux Sx, Vs VC Population: 47% (2009, N=472) Higher palpation scores for Thyro-hyoid * and Pharyngeal Constrictors Higher % with A-P compression * Reflux increases Lx tension and exacerbates co-existent dysphonia (Gill & Morrison, 1997) Reflux control facilitates therapy and recovery Reflux - LPR Common Symptoms: throat sensations, am dysphonia waking at night coughing or choking habitual throat clearing; chronic cough globus pharyngeus heartburn “post-nasal drip” adductory laryngospasm asthma or other chronic breathing difficulties 25 10/10/2014 Common Signs: Contact Granuloma erythema / edema: posterior glottis sub-glottis arytenoids contact ulcer / granuloma “pseudo-sulcus” “… but Doctor, I don’t have heartburn!” 2011 (www.pvcrp.com) Patient tutorial on LPR Diagrams, script and vocal narration Patient compliance self-ratings (Likert scale) (Targeted) Lifestyle changes compliance (LC) Medication compliance (MC) Tutorial group (N= 20) LC: 19/20 high compliance MC: 16/20 high compliance No tutorial group (N=20) LC: 9/20 high compliance MC: 14/20 high compliance 26 10/10/2014 Technique Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Aging, Lesion Disease Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing Posture affects breathing Look at : Back Alignment (Lordosis; Scoliosis) Shoulders/Scapulae Head-Neck Relationship Stance Knees Use of Furniture; Props Technique Bad habits become programmed by repetition (Neural Plasticity / Motor Learning) Postural misuses: • neck, back, head/shoulders? • Speech breathing patterns ? • Lower face, jaw and tongue? • Infra-hyoid muscles? • Specific Misuse Patterns – Larynx/Glottis Mal-Adaptive Speech Breathing Behaviours affect Glottal Closure abs clenched: thoracic elevation large lung volume: laryngeal pull, results in greater glottal chink plus compensatory hypervalving (Sundberg et al, 1991; Sundberg, 1999) 27 10/10/2014 Normal inspiration and expiration for speech/singing, compared with two common misuses: failure to use inspiratory “checking” forces during phonation (top right); and exaggerated abdominal tension to “support” the production of voice (bottom right). Both these misuses can lead to hyper-valving in the larynx to regulate airflow. Aligned posture and common patterns of misalignment Scapula adduction 28 10/10/2014 Head-neck relationships. Neutral is “healthy” posture. Chronic neck extension or flexion impact the laryngeal suspension system and can affect voice and swallowing. Neck Tension / Headaches and MTD (Self-Reported, PVCRP, 2009; N = 472) Tension Site 10 MTD Non- MTD Neck / Shoulders 46% 28% Chr. Headache 27% 13% Both 15% 10% Totals 88% 51% Palpation Sites: Anterior Floor of mouth: Supra-hyoids: - at rest - pitch glides - speech, probes 29 10/10/2014 “Scalloped” tongue periphery from pressing the tongue against the teeth. Common in individuals who misuse muscles of the jaw and tongue: tension in supra-hyoid muscles and jaw clenching are typically associated with this visual perceptual sign. Thyrohyoids: - at rest, yawn - pitch glides - speech, probes Cricothyroids: - at rest, yawn - pitch glides Pharyngeal Constrictors - at rest - phonation Jaw-Tongue Functions Critical anatomical links to larynx Facial co-contraction patterns common (eg. Eyebrow adduction + jaw clench) FACS studies: upper face emotionally more salient, therefore Tx targets both 54% of MMD patients “TMJ” dysfunction vs. 22% non-MMD patients (excluding ILS) (PVCRP, 2009; N = 472) 30 10/10/2014 TMJ: Sub-occipitals: - at rest - pivot; swivel - opening; closing - speech; singing Muscle Misuse Type 1: (Case 61) The Laryngeal Isometric • Generalized tension in all laryngeal muscles • Often associated with an exaggerated posterior glottal chink • Often associated with 20 mucosal lesions: bilateral nodules, chronic laryngitis, polypoid degeneration 31 10/10/2014 Muscle Misuse Type 2a (Case 63) Muscle Misuse Type 2b (Case 64*) • Lateral compression at the glottal level • Supra-glottal lateral compression • Frequently seen with generalized postural misuses and tension • Hyper-adduction of the false vocal folds • Often psychologically based • May be triggered by an infection or by gastro-esophageal reflux Clinical Example (*Case 64) 47 year old female experiencing globus and dyshonia after episode of sinusitis + cough. Normal exam except lateral supra-glottal compression. “Held” larynx. Static facies: eyes, lips, hypertonic masseters Co-owner/manager of fast-food franchise with husband. Minimal marital relationship beyond work/children. During aphonia, husband had to assume more responsibility. Accused her of “faking”. Voice Sx started in work environment, when confronting a defiant young employee about wearing perfume that she thought triggered Sx. Sx gradually generalized to many situations, including home. Scored 5/7 on reflux Sx score (LPR; no heartburn) Background Alcoholic chain-smoking father, abandoned family when Pt. was 13 yoa. Pt., eldest of several sibs, had to assume child-care responsibilities. Mother took 2 jobs, and rarely home. A younger sister had defied Pt.’s authority and frequently caused trouble in community. Sisters fought physically over these incidents. Pt. periodically recalled those incidents when dealing with defiant employee. 32 10/10/2014 Emotional Awareness Psychological factors…. Pt. aware of co-occurrence of exposure to Patient abandoned by father & in a sense, noxious odors and throat Sx. (Level 1) Also aware of desire to hit employee when she wore perfume and husband when he accused her of “faking voice loss”. (Level 2) Preoccupation with globus led her to worry she had lx CA, to which an uncle had recently succumbed. (GP had suggested LPR, but Pt. rejected Dx). (Level 4?) also by mother (insecure attachment history = compromised emotion regulation pathway); likely had to forgo her own needs & prioritize taking care of others (siblings), little space for her to express her emotions (anger, resentment) Development of avoidant/introversion traits that predispose to development of psychosomatic voice dysfunction Sensory-Emotional Trigger Interaction with defiant employee acted as a trigger: feelings of helplessness, anger that she felt both in the past, dealing with her sister & in the present, dealing with the employee/husband; in both past & present her experience may be that her needs are not being acknowledged/addressed Reflux/Globus sensation increased when emotionally aroused, due to tension in abs/ANS… enhancing anxiety about CA L R E A T 33 10/10/2014 Management Approach Psychotherapy: Develop therapeutic alliance: trusting, secure attachment with therapist Give her tools to tolerate emotional distress: breathing exercises, relaxation strategies, mindfulness exercises Target expression of emotion, validate her experiences/needs Voice Therapy Explanation of relationship of LPR to lx hypertonicity/globus. (“But Doctor, ” www.pvcrp.com) Top-down facial exercises to increase awareness of & reduce static facial postures. (Rammage, 1996; 2011) Explanation & demo of inappropriate VS appropriate larynx / vf posture for phonation. ID and application of most accessible & salient facilitation technique to restore normal phonation (glottal fry, gradually increasing intensity, while monitoring tactile feedback with fingers over lx) Negative practice to increase voluntary control: desensitize to triggers; create “dysphonia”; apply facilitation technique to restore normal phonation. Top Down Facial Gestures (Ekman, 1982) Emotional experience in can be influenced by feedback from facial muscles. Emotional ambiguity reinforced by incongruent facial postures for observer and expresser. Lower face more subject to facial “emblems”, such as “perma-smile”. Releasing lower facial postures dependent on awareness/release of upper facial postures. Top Down Facial Muscle Release 34 10/10/2014 Muscle Misuse Type 3 (Case 65) • Antero-posterior supraglottal compression • Associated with high palpation scores in thyrohyoid muscles • Common technical misuse seen in mild, moderate and severe forms Muscle Misuse Type 5 (Case 68) Muscle Misuse Type 4 (Case 67) • Incomplete vocal fold closure • PCA, CT muscles contracted • Distinguish from anatomical incompetence by symmetry and trial Tx • Associated with conversion aphonia Muscle Misuse Type 6 (Case 69) • Vocal fold bowing caused by muscle misuse •Laryngeal posture for falsetto register phonation • Distinguish from bowed vocal folds of aging/atrophy; sulcus/scarring; IPD… •Typically seen in adolescent transitional voice disorder 35 10/10/2014 Lifestyle: Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Aging, Lesion Disease Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing Diagnostic Voice Therapy Facilitation Techniques for Dx / Symptomatic Therapy … Hypothetical ALERT model for young woman with significant L, E & T factors, and 20 vocal fold nodules Technique Indications Contraindications Adduction (forced): pushing; pulling; cough Articulation exaggeration; increased orality Incomplete vocal fold closure in conversion aphonia Hypernasality; restricted jaw/tongue/lip movements Auditory masking during phonation Incomplete vocal fold closure in conversion dysphonia; low intensity Do not use if mucosal edema or erythema is present. Do not allow exaggerated jaw movements in individuals with TMJ dysfunction. Do not use if mucosal edema or erythema is present. Breathy-flow phonation (Increase MFR) Lateral compression of vocal folds and/or false folds; glottal attacks Chanting (Decrease intonation and stress) Muscle misuses resulting in pitch and/or phonation breaks Be aware of increase in muscle misuse during chant. Chewing with phonation Tension in supralaryngeal muscles Do not use if TMJ dysfunction Character voices: Impersonate an opera singer, puppet voices Inappropriate pitch, resonance, monotonicity, monointensity Be aware of increase in muscle misuse to imitate voices. Coordinated voice onset (CVO): “Hm!” Most muscle misuse patterns; poor speech breathing; glottal attacks Distraction: eg, hum while walking, turning pages, turning/shaking head gently General muscle and postural misuse; psychological feed-forward mechanisms restricting voice range Inhalation phonation Supraglottal compression; poor vocal fold closure; dysfluency (SD) Intonation increase Monotonicity; inappropriate pitch Jaw movements (ie. small, relaxed pivotal movements) during syllable repetition Muscle misuse in lower face; restricted jaw movements; distraction Do not use if paradoxical vocal fold movements are present. Do not allow exaggerated jaw movements in individuals with TMJ dysfunction. 36 10/10/2014 Technique Indications Contraindications Loudness change Inappropriate loudness level; glottic compression: ↓ level asthenia: ↑ level Laryngeal isometric; inappropriate speech breathing; breath-holding Do not use exaggerated loudness in presence of mucosal edema/erythema Do not use sigh and exaggerated lung volume for laryngeal isometric. Lung volume change: reduce volume: CVO increase volume: sigh Manipulation (e.g.,): increase Tense T-H; A-P compression thyrohyoid space; depress larynx Tense suprahyoids/high larynx hold tongue forward; hold jaw open Tense tongue/backed carriage Lower facial tension/poor orality Movements in upper body: headGeneral muscle/postural misuse; nods; shoulder rolls distraction Pitch change Register change (e.g.,): falsetto, glottal fry Inappropriate pitch/register use; Incomplete adduction in conversion disorder; bowed vocal folds Distraction Jaw jut; upper back/neck tension Tense laryngeal suspensory muscles General postural misuse; inappropriate speech breathing Incomplete glottal closure; tense cricothyoid muscles Resonance focus adjustment: forward: humming-buzzing; backed: “covering” Harsh/rough/breathy quality; poor glottal closure; poor projection Fronted tongue posture; thin sound Posture adjustments (e.g.,): head position: forward; back; supine position; lean forward, neck flexed Beware of TMJ dysfunction.Clinician should have appropriate training in laryngeal manipulation techniques. Use only with advice of physical therapist/medical practitioner in cases of neck, back, shoulder problems. Be aware of increase in muscle misuse to achieve pitch change. Be aware of increase in muscle misuse to achieve register change Emotion: Acoustics Environment Ergonomics General health Occupational demands Vocal dose Anxiety Depression Symbolic conversions Vocal expression Vocal repression Level of emotional awareness Anatomical Factors: Reflux: Diet Eating habits Genetics Medications Posture Weight Indications Contraindications Semi-occluded upper vocal tract tactics (straws; v/z productions; lip raspberries) Siren imitation/howling/etc Hyper/hypoadduction of v.f.; general muscle misuse impacting phonation; stiff/scarred vocal folds Pitch range restrictions/ register breaks due to muscle misuse Rapid or excessively slow speech; inappropriate speech breathing; laryngeal/supralaryngeal tension Incomplete glottal closure in conversion disorder; falsetto in adolescent transitional disorder Incomplete glottal closure; laryngeal isometric; poor resonance Cul-de-sac resonance (front tongue) Immature resonance (back tongue) Restricted pitch range; register breaks Laryngeal dysfluencies; inappropriate resonance focus Restricted speech breathing movements; supralaryngeal compression Sometimes triggers cough/larygospasm in ILS Speech rate change Spontaneous phonation (e.g.,): extend cough, laugh, CVO Taunting-Teasing (ngya ngya ng-ngya-ya) Tongue position change Trills: voiced lip or tongue trills Use head/neck posture changes only with advice of physical therapist/medical practitioner in cases of neck, back, shoulder problems. Lifestyle: Aging, Lesion Disease Technique Technique: Alignment/Posture Muscle misuses: Neck/Shoulders Face/Jaw/Tongue Pitch focus Resonance focus Speech breathing Voice mode change: singing to speaking; speaking to singing Yawn-sigh phonation Do not use aggressive cough if mucosal edema is present Beware of TMJ dysfunction. Do not use for laryngeal isometric muscle misuse. From: Rammage et al, 2009 Factors Influencing Selection and Success of Therapy Programs Relative “size”/primacy of A factor(s): Cognitive/Emotional Factors: Feedback Channels: Duration of Sx: Commitment to Tx: Client: Clinician: External Factors, eg. environmental/workplace: Cultural-Social-Economic Factors: Results of Dx Therapy: Determining Treatment Purpose/Priorities 37 10/10/2014 Indirect and Direct Therapy Indirect: Which ALERT Factors? Lifestyle: Education “Vocal Hygiene”/Hydration (Roy et al, 2001; Verdolini-Marston et al,1990/94; Nanjundeswaran et al, 2012) Voice use monitoring: Informal or Instrumental: eg. dosimetry Voice rest/conservation Altering acoustic environment (SNAG, 2009) Vocal amplification (Roy et al, 2002;2003) “SNAG” Goals: Optimizing Classroom Acoustical Environments (www.pvcrp.com) Higher speech levels - good classroom design amplification system? preventive voice training? Lower noise levels - quiet ventilation, equip’t class organization/control cushioned surfaces - NO OPEN PLAN!! - sound-proof partitions - quiet light ballasts Appropriate reverberation - good classroom design - appropriate sound-absorbing materials 38 10/10/2014 Voice Amplification (Roy et al, 2002;2003) Post-Operative Voice Use Instructions for Phonosurgery Patients VOICE REST (first 48 hours after surgery): Check room acoustics first: reverberation time? If not .4-.6 sec., consider classroom modifications Do not use your voice unless absolutely necessary Speak 5 minutes maximum per hour Only speak softly, in a quiet environment SNR: min 15 dB (SNAG, 2009) Only speak in the middle of your vocal range No throat-clearing or coughing Appropriate gain potential DO NOT WHISPER: Write your message instead Cancel all social engagements Uni-directional mic: Monitor to reduce Lombard Portable, if necessary RESTRICTED VOICE USE (+ 1 week after voice rest period): Stay at home and get plenty of rest and hydration* * You can determine your hydration by observing your urine: it should be pale in colour. If not, drink more non caffeinated, non-alcoholic beverages PRUDENT VOICE USE (+ 2 weeks after restricted voice use period): Observe vocal hygiene rules: No yelling, cheering, screaming, throat-clearing, coughing, loud or prolonged laughing/crying, whispering Use your voice normally in the middle of your vocal range in quiet settings Use the middle of your vocal range, avoiding extremes in pitch and loudness Do not speak outside, in groups, in a vehicle, aeroplane or other noisy environments, such as restaurants Speak within arm’s length of your listener When speaking you should be close enough to your listener to touch his/her shoulder Do not use vocal throat-clear or cough DO NOT WHISPER Be sure you are adequately hydrated by drinking at least 8 glasses of non-caffeinated, non-alcoholic beverages daily If you are speaking in a group larger then 20, outside or in a noisy environment, use a vocal amplification system Maintain adequate hydration Schedule vocal rests throughout the day ONGOING VOCAL HYGIENE (indefinite): Refer to your Vocal Hygiene guidelines to ensure you maintain healthy vocal habits. 39 10/10/2014 Indirect Tx Sample vocal hygiene protocol. See full protocol in text. Emotional Factors: SLP Role? If E is dominant/10, refer to MHP When psychological interference evident during therapy, refer to MHP Reflux Factors: SLP Role? Behaviour specialist: guide lifestyle Educate re effect on lx function: “But Doctor”… www.pvcrp.com Available at: www.pvcrp. com Direct Therapy Principles:Technique Change Comprehensive (eg. Vocalizing with Ease) hierarchical motor re-learning program: body alignment; head, neck and shoulder muscles; specific relaxation for tongue, jaw and facial muscles; speech breathing and voice onset; resonance enhancement; vocal flexibility; vocal dynamics; phrasing Focused (Symptomatic) short-term / specific symptoms of voice dysfunction. Based on Dx therapy outcomes. May include manual therapy techniques Holistic Eg. yoga; Feldenkrais; Pilates; Alexander technique; massage therapy; acupuncture; relaxation; fitness programs Motor learning theory: Basic re-programming Simple tasks Frequent repetition Instant feedback, 10 kinaesthetic Ownership: We provide the remedy, you (the client) provide the cure! 40 10/10/2014 Technique Changes: Voice Therapy Motor-Learning & Neural Plasticity Fundamental Tasks Generalizing Effects (“Up-regulation of chemicals”?: Rosenbek, 2010) Neural Plasticity Use & Experience Specific! Symptomatic: Change Specific Symptom/s: Comprehensive: Treat the Whole System: Holistic: Treat the Whole Person: Physiological (eg,reduce glottal chink) Acoustic (eg,elevate pitch) A-Z Alignment...Buzzzing General and Specific Motor Relearning General Approach Accent Method Progressive Relaxation Yoga, etc. (eg.,Kleim & Jones, 2008; Ludlow et al: JSLHR 51, 2008) Training Cells: Repetition/Intensity/Variability Feedback: salient Skills are slow to develop in CNS, but become permanently encoded… (Adkins et al, J.Applied Physiol,101, 1776-1782, 2007) Summary of Direct Therapy Techniques in Common Use to Manage Voice Dysfunction … Technique Theoretical Bases Procedures; Training Application/Evidence Accent Method (Video) Easy, resonant voice facilitated by: Abdominal support Rhythmic speech breathing gestures Open airway Aerodynamic principles of phonation Graduated body orientation: Graduated levels of voicing during rhythmic breathing. Graduated complexity of rhythms and phonemic pattern. Fricatives for aerodynamic effect in vocal tract. Training: audio-video samples or experienced clinician. Adductor SD (Kotby et al, Relaxed phonation facilitated by: Vowel prolongation Reduced prosodic stress Monotone voice Easy voice onset Elevated pitch Clinician models during oral reading: elevated pitch, prolonged vowels, minimal syllable stress/intonation, smooth syllable transitions. Once the skill is acquired, chanting is alternated with regular speech for carry-over. Benign essential tremor. (Smith and Thyme, 1976) Chant Talk (Boone, 1971) Limitations/ Contraindications Program extends over 30 or more Functional voice disorders sessions, so (Fex et al, 1994) consumes extensive Variety of voice disorders clinician and client (Kotby et al, 1991; Bassiouny, time/resources. 1991) 1998) Vocal fold paralysis (Khidr, 2003) Speech dysfluency (Kotby and Fex, 1998) Dworkin and Meleca (1999) Vocal hyper-function (Boone et al, 2010) Vocal fatigue in teachers (McCabe and Titze, 2002) Spasmodic voice disorders. Elevated f0 may result in increased laryngeal effort/tension in some individuals. Monotone pitch may exacerbate muscle misuse. 41 10/10/2014 Chewing Use of vegetative jaw (Froeschels, and tongue 1952) movements frees laryngeal suspension system to allow for more relaxed voice production. Vocal effort Confidential and tension Voice reduced by soft, breathy (Colton et voice al, 2006) Easy concept for adults and children to understand and learn (Boone et al, 2010) SemiOccluded Vocal Tract Increased P0 / length in upper vocal tract: phonation near lowered F1: (Sovijärvi, abducted vocal 1965 folds reduces Titze, vocal fold 2001; collision. Glottal 2006) width of a few millimetres is associated greater vocal efficiency. (Titze, 2001; 2006) Vocal Application of Function principles of Exercises exercise (VFE) physiology improve (Briess, strength, 1959) balance and Stemple et flexibility in the al, 1994) vocal system. Exaggerated chewing motions modeled and trained. Voice is added to chewing movements on nonsense syllables; serial speech tasks. Range of movements reduced over time: client imagines chewing activity. Patient instructed to use the softest voice possible without whispering. Clinician models relaxed, low intensity, breathy sound with natural pitch and prosody. Individuals with restricted jaw and lip movements during speech (Boone, 1971; Boone et al , 2010) Vocal fold injuries, post phonosurgery; vocal hyperfunction (Colton et al, 2006) Vocal fold nodules (Verdolini-Marston et al, 1995) Client phonates while blowing into straws. Resistance reduced by increasing straw diameter. Client phonates during bilabial fricatives, lip or tongue trills, nasal phonemes, high vowels. Client produces pitch glides simultaneous with semioccluded vocal tract techniques. Client uses pitch changes during singing and speech activities, with reduced laryngeal effort. 4 components: warm-up; stretching; contraction; adductory power exercises. Sustain phonation quietly on prescribed pitches; pitch glides. Clinician models to train frontal resonance focus. Practice regime: 2 reps per exercise, 2x daily. May be contraindicated for clients who have dysfunction at the temporo-mandibular joint. Some individuals may be reluctant to perform the exaggerated movements Should be used as a temporary voice conservation approach. Extended use of breathy voice may exacerbate certain muscle misuses, such as laryngeal isometric postures with exaggerated posterior glottal gap, and maladaptive speechbreathing. Hyperfunctional voice Habitual muscle misuse in problems (Sovijärvi, lower face /lips/jaw may be 1969; Simberg, 2001; exacerbated by exercises Titze, 2006; Simberg and encouraging increased Laine, 2007) resistance at the oral outlet: Vocal nodules (Sovijärvi, may be necessary to reduce 1969; Simberg, 2001) muscle tension in jaw, Chronic laryngitis tongue face, lips. (Sovijärvi, 1969; Simberg, Individuals with vocal 2001) Student teachers with hyperfunction due to motor mild voice problems speech disorders may not be able to achieve the (Simberg et al, 2006) Vocal fold stiffness required articulator post injury resistance and/or Variability (Gaskill & respiratory drive for some Quinney, 2012) activities. Vocal fold stiffness Care should be taken to post injury or phono- minimize common muscle surgery, with misuses during maximum associated vocal performance tasks, such hyper-function as jaw extension, supra(Stemple et al, 1994) hyoid tension and larynx Singers (Sabol et al, elevation during upward 1995) pitch glides. Teachers with voice disorders (Roy et al, LSVT LoudTM Intensive individual therapy 1 hr, 4 X/wk, 4-wk + home practice. Sustained phonation, vowels; pitch changes to increase laryngeal flexibility Effort to and stability. increase “Functional phrases” loudness Clinician coaching improves vocal facilitates calibration (client fold adduction adjustment to increased and has effort, loudness). globally positive Clinician training: on-site or effect on on-line certification speech program. Parkinson’s hypophonia (Ramig et al, Humming = phonation with semi-occluded vocal tract, associated with an optimal vocal fold posture and vocal efficiency (Titze, 2001; 2006) Occupational voice users (Roy et al, 2003; Principles from muscle training, motor learning, (Ramig et al, neuro-plasticity 1994) & neuropsych ResonanceHumming (Lessac, 1973; Linklater, 1976) Resonant Voice Therapy (RVT) (Verdolini, 1998) Yawn-Sigh (Boone, 1971) Larynx is lower, pharynx is wider during yawning. (Boone and McFarlane, 1993) Relaxation recoil forces are employed primarily for exhalation during the voiced sigh. RVT: Systematic ten-step program incorporates posture, relaxation, exploration of resonance sensations on nasal phonemes, pitch variations, extending resonance sensation to words, phrases, sentences. Clinician training: Structured training program is offered. Clinician explains difference in the larynx position and reduced effort of yawn-sigh and models. Initially phonation on sigh is somewhat breathy. /h/ used extensively to encourage slightly abducted vocal fold position. Sensations of more open pharynx and smooth voice onset are maintained as the yawn is phased out. Intensive treatment may be difficult for clients with 1994; 1995; 1996; 2001; significant health Smith et al, 1995) compromises. Spastic dysarthria in MS (Sapir et al, 2001) Dysphagia (El Sharkawi et al, 2002) Communicative gestures (Duncan, Clinician certification requirement, cost and inaccessibility of therapy may be prohibitive for some clients. 2002) Facial expression (Spielman et al, 2003) Senile atrophy (LSVT Training Manual, 2010) Resonant voice training may be enhanced by relaxation techniques, manual therapy / postural changes, esp. with severe muscle misuse. Unilateral vocal fold Ensure each client paralysis. (Schindler et experiences enhanced al, 2008) resonance in the absence of Vocal fold edema maladaptive muscle misuse (Verdolini et al, 2012) behaviours such as labial or Vocal fold scar supra-hyoid tension. Chen et al, 2007; Nanjundeswaran et al, 2012) (Hapner and Klein, 2009) Inappropriately high larynx posture and hyperfunctional laryngeal activity (Boone Sighing may reinforce use of inappropriately high lung volumes for speech, associated with vocal fold and McFarlane, 1993) abduction (Sundberg et al, 1991). Carry over to Voice-disordered clients speech may be difficult for able to master the individuals who are unable technique and carry to restore normal lung over to regular speech volumes and re-balance (Xu et al, 1991) relaxation and muscular forces for speech Essential voice tremor breathing. (Barkmeier-Kraemer et al, Yawning may be 2011) contraindicated in individuals with TMJ dysfunction. 2001) 42 10/10/2014 Role of Manual Therapy Does Preventive Voice Care Work? Primary approach to release specific muscle Duffy & Hazlett (N.Ireland, 2004): tension Eg. CT muscle: Harris, 1993; Postural/laryngeal suspension/intrinsic laryngeal muscle mechanisms: Lieberman (1998) Adjuvant therapy to medical-surgical / traditional voice Rx: Harris et al, 1998; Marszalek et al, 2012 Requires intimate knowledge of anatomy and competency for manual therapy skills Indirect education: physiology, vocal hygiene, etc. Does Preventive Voice Care Work? Teachers’ Perceptions Yiu et al, Hong Kong, 2002 Direct: comprehensive training: posture, speech- breathing, reduced tension, resonance, voice projection Longitudinal data: Control group: no change Indirect group: no change Direct group: improved Does Voice Rx Work? Roy et al, Utah/Ohio, 2002 Surveyed teachers’ perceptions of impact and 3 Rx: voice amp; voice hygiene; control VHI/acoustic perturbations reduced only with voice amp preventive measures Roy et al, Utah/Ohio, 2001 Significant impact on personal/professional lives 3 Rx: V.F.Exc.(Briess/Stemple); vocal hygiene; control Only VFE group improved with VHI From large menu of treatments, teachers believed more info on breathing exercises and vocal hygiene most important for prevention Sapienza et al, Florida, 1998 Teachers using voice amp reduced vocal SPL (2.42 dB SPL) with 8-10 dB amp. 43 10/10/2014 Vocalizing with Ease – Group Rx Optimizing Technique 14 hours comprehensive Rx (7 weeks or 5 days) Posture & Alignment Optional “refresher” sessions Voice-Related QOL (Hogikyan et al, 1999; 2000) Significant + scores: immediately after Rx: 50% (N = 300) (NS with + trend: 47%) Coordinated Voice Onset Enhancing Resonance Liberating Articulators Increasing Vocal Flexibility 1 year post-treatment: 70% (N = 100) (NS with + trend: 23%) Intonation Physical Phrasing 44 10/10/2014 Natural Speech Breathing Establish natural posture Control muscle misuses, e.g., “Tongue-Breathing” Don’t “over-prepare” (inspiration) Use spontaneous utterances: Hm! UmHm Use natural phrase boundaries Optimizing Voice Onset Spontaneous vocalizations for natural coordination/pitch: “Hm!”; “Um Hm” (Silent “h” for optimal glottal width) Capitalize on elasticity around REL (32-40% VC): using passive + active forces “Hm(rr*)Hm (rr)…” Facilitating postures optimize feedback Low-level practice transfer saliency: “Hm; Hi!” CVO extension speech phrasing *(rr = respiratory release = inspiration) 45 10/10/2014 46 10/10/2014 Releasing the Jaw/Tongue Drag-on the Larynx Release: neckfacejawtongue NO JAW JUT! Lip movements jaw release Passive pivotal jaw movements The tongue is a rug, on the floor: neutralize! Dynamics: more jaw, less tongue, stuttering & articulation Rx too! 47 10/10/2014 Q: Why does Humming Help? Vowels buzz too! A: Semi-Occluded Vocal Tract (optimizes v.fold closure/PTP; Provides real-time feedback…) The Vocal Siren (find “head voice”; blend upper and lower registers) 48 10/10/2014 Other semi-occl. v-tract techniques Z – Swell (semi-occluded vocal tract, coordinated speech breathing, oral vibration feedback, natural intonation, transition to speech phrases.) Z Zoom (semi-occluded vocal tract start, natural intonation on vowel, hum-buzz finish, transition to speech phrases) Race Car: z-z-z-oo-oo-oo-oo-oo-oo-oo-m! (feel abs!) z-z-oo-oo-oo-m-z-oo-oo-oo-m! Z z-z-oo-oo-m-z-oo-oo-m-z-oo-oo-m! z-oo-oo-m-z-oo-oo-m-o-n-e! Z…o-n-e……t-w-o…….t-h-r-e-e ……. z-oo-oo-m-z-oo-m-o-n-e….t-w-o … 49
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