11/22/2019
INDONESIAN SPEECH THERAPIST ASSOCIATION
Management of Voice Disorders: A Practical Approach
Intervention for Voice Disorder
Mr Khairy Anuar Mohd Khairuddin
Speech Pathology Program
School of Health Sciences
Universiti Sains Malaysia
Introduction 2
Vocal Hygiene • Phonotraumatic behaviours
• Efficient voice production
• Vocal warm-up
Breath Support • Respiratory control
Musculature • Tension
• Pain
• Fatigue
Voice • Quality VOICE THERAPY
• Pitch TECHNIQUES
• Loudness
khairyUSM©
Assessment 3
Structures and Functions Laryngeal Imaging
Laryngeal Palpation
Oro-motor Examination
Case Voice Characteristics Auditory Perceptual Rating
History Acoustic Analysis
EVALUATION
Breath Support Type of Breathing
Maximum Phonation Time
Aerodynamic Measurement
Self-perception Severity
Voice Impact
Screening
Vocal Hygiene Phonotrauma
Voice Production Efficiency
1
khairyUSM©
3
11/22/2019
Activity: Intervention Framework
Use arrows to identify the components of assessment that could provide the
evidence for the components of intervention.
Intervention Framework 5
Vocal
Hygiene • Phonotraumatic behaviours Structures and Functions
• Efficient voice production
• Vocal warm-up
Breath Voice Characteristics
Support • Respiratory control
Breath Support
Musculature • Tension
• Pain
• Fatigue Self-perception
Voice • Quality
• Pitch
Vocal Hygiene
• Loudness
khairyUSM©
Vocal Warm Up
2
6
11/22/2019
Introduction 7
to prepare the vocal folds before enduring high voice usage
either before
• therapy session
• vocational tasks
♦ a compulsory goal for a professional voice users
khairyUSM©
Procedures 8
choose either one
• gliding : /o/ or /u/
• scaling : “do re mi….”
• humming : “hmmm” or “hnnn”, “hngngng”
• tongue trill : “trrrr”
• bubbling : “brbrbrbr”
♦ all: move from low pitch high pitch low pitch = 1 cycle of pitch variation
khairyUSM©
Respiratory Control
3
9
11/22/2019
Introduction 10
to ensure adequate air supply for efficient vocal folds vibration
commonly with the use of diaphragmatic breathing
not for all cases
• significantly lower MPT
• indication of air wastage
♦ e.g., vocal fold paralysis
• professional voice users
♦ although normal MPT and type of breathing
DO NOT teach diaphragmatic breathing alone
• link with speech production
♦ i.e., speak using diaphragmatic breathing
can combine with any appropriate voice therapy technique
khairyUSM©
10
Procedures 11
place one hand
• on the upper chest
• below the ribcage
exhale through the mouth
• tighten the stomach
♦ unable press the stomach gently + slowly
• relax the stomach
♦ air will automatically rush in inhale through nose
make sure no significant movement of the chest/shoulder
repeat to ensure the pattern of inhalation exhalation is mastered
• if not, just ensure the exhalation is mastered
use of abdominal breathing in speech
• make sure the diaphragmatic breathing has been mastered
• instead of exhalation air only, exhale on sounds i.e., /s/ /z/ /a/
• gradually build up to one syllable word e.g., “1” “1, 2” “1, 2, 3”
• move to spontaneous words, phrase, sentences, conversation
khairyUSM©
11
Demonstration: Diaphragmatic Breathing
4
12
11/22/2019
Voice Therapy Techniques
khairyUSM©
13
Introduction 14
can be divided into
• physiologic voice therapy
• symptomatic voice therapy
(ASHA, n.d.)
khairyUSM©
14
Physiologic Voice Therapy 15
modifying the subsystems of voice production (respiration, phonation and
resonance)
• inherently a holistic approach to treatment
techniques:
• Accent Method (AM)
• Cup Bubble/Lax Vox (CB)
• Expiratory Muscle Strength Training (EMST)
• Lee Silverman Voice Treatment (LSVT)
• Manual Circumlaryngeal Technique (MCT)
• Phonation Resistance Training Exercise (PhoRTE)
• Resonant Voice Therapy (RVT)
• Stretch and Flow Phonation/Casper-Stone Flow Phonation (SFP)
• Vocal Function Exercise (VFE)
(ASHA, n.d.)
5
khairyUSM©
15
11/22/2019
Symptomatic Voice Therapy 16
modifying the deviant vocal symptoms or perceptual voice features
• working on isolated features
techniques
• Chant speech (CS)
• Confidential voice (CV)
• Straw Phonation
• Twang therapy (Twang)
• Yawn-Sigh technique (YS)
(ASHA, n.d.)
khairyUSM©
16
Accent Method 17
coordinated production
single sounds utterances
purpose
• improve efficient use of breath support
khairyUSM©
17
Accent Method 18
Procedures
facilitate abdominal breathing
make sure the pattern has been mastered
• i.e., inhale exhale with contracted abdomen
speech production
• isolations
♦ add other voiceless sounds
► e.g., /s/ /s/ or /f/ /f/
♦ move to voiced sounds
► e.g., /z/ /z/ or /v/ /v/
• words
♦ e.g. “wo-wof”, “su-su”, “mo-mmy”
• phrases
♦ “keep going”, “come here”
• sentences
♦ e.g., “How are you?”, “I am fine”
6
khairyUSM©
18
11/22/2019
Activity: Accent Method
19
Demonstration: Accent Method
20
Yawn-Sigh Technique 21
breathy production
single sounds utterances
purpose
• reduce vocal folds impact
7
khairyUSM©
21
11/22/2019
Yawn-Sigh Technique 22
Procedures
simulate yawn with open mouth
• relax, do not tensed
produce a relaxed, effortless, natural + sigh without voicing
• may use breathy /h/ sound
• may exhale on the back of the palm to get a tactile cue
♦ feel large areas of exhalation of air
speech production
• isolations: e.g., “ha”, “he”, “hi”
• words: e.g., “hate”, “hill”, “hole”, “has”, “hive”, “how”, “him”
• phrases: e.g., “Hey Harry”, “Hate him”, “Her hair”
• sentences: e.g., “He hates him”, “He holds her”
khairyUSM©
22
Activity: Yawn-Sigh Technique
23
Demonstration: Yawn-Sigh Technique
8
24
11/22/2019
Resonant Voice Therapy 25
forward production
single sounds utterances
purpose
• reduce laryngeal effort
• improve voice projection
khairyUSM©
25
Resonant Voice Therapy 26
Procedures
prolong a nasal sound /m/
• can also use other nasal sounds e.g., /n/, /ng/
feel the vibration
• putting the hands the on top of head, bridge of noise, cheekbones
• do not press the hands
• do not cover the mouth and nostrils
focus on the vibratory tactile feedback
• do not listen to the voice
• do not push for loudness
speech production
• isolations: e.g., “ma”, “me”, “mi”
• words: e.g., “mom”, “man”, “mime”, “mean”, “mommy”, “muffin”, “number”,
• phrases: e.g., “My mom”, “No more”, “Lemon muffin”, “Many more”
• sentences: e.g., “My name is Mariam”, “Never mind mom”
khairyUSM©
26
Activity: Resonant Voice Therapy
9
27
11/22/2019
Demonstration: Resonant Voice Therapy
28
Manual Circumlaryngeal Techniques 29
released production
single sounds utterances
purpose
• reduce laryngeal tension
• re-position the larynx
khairyUSM©
29
Manual Circumlaryngeal Techniques 30
Procedures
use thumb and forefinger or middle finger to find the posterior thyrohyoid space
massage the larynx by
• pushing-back within the thyrohyoid space
♦ gently exert medial compression within this space
• pulling-down the thyroid cartilage
♦ gently pull downward the larynx
combine both manoeuvres to form
• backward downward release movements
repeat, to gently pull down the larynx
ask the patient to phonate usually with nasal or voiced sounds
• perceive the voice changes
if voice becomes better, maintain the laryngeal posture
• increase the phonation complexity
10
khairyUSM©
30
11/22/2019
Phonation Resistance Training Exercise 31
strong production
purpose
• increase power of phonation
khairyUSM©
31
Phonation Resistance Training Exercise 32
Procedures
produce loud maximum sustained phonation on /a/
produce loud ascending and descending pitch glides over the entire pitch range on
/a/
practice participant-specific functional phrases in
• a loud and high voice
• a loud and low voice
maintain a SPL between 80 and 90 dB
• by a sound level meter with a microphone-to-mouth distance of 30 cm
one session/week
home practice
(Ziegler, et al. 2014)
khairyUSM©
32
Vocal Function Exercise 33
stretched production
purpose
• improve pliability of the vocal folds
• strengthen the vocal folds
11
khairyUSM©
33
11/22/2019
Vocal Function Exercise 34
Procedures
sustain /i/ for as long as possible on
• time the durations
glide on word “knoll” or lip trill or tongue trill
• from lowest to highest
• from highest to lowest
♦ voice without breaks, if breaks occur, continue gliding
sustain “ol” as in “old” without /d/ on increasing musical notes as long as possible
• time the durations
all tasks: twice daily e.g., morning and evening
khairyUSM©
34
Demonstration: Vocal Function Exercise
35
Straw Phonation 36
less effort phonation
purpose
• decrease the vocal folds impact
• reduce vocal fatigue
12
khairyUSM©
36
11/22/2019
Straw Phonation 37
Procedures
siren
• glide from low to high to low pitches
accents
• start at the low pitch
• gradually build the note and the volume
• all with different accents
melody
• choose any song
• sing the song through the straw
khairyUSM©
37
Demonstration: Straw Phonation
38
References 39
American Speech-Language-Hearing Association (ASHA) (n.d.). Voice disorders. Retrieved September, 11, 2017,
from http://www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/.
Ziegler, A., Verdolini Abbott, K., Johns, M., Klein, A., & Hapner, E. R. (2014). Preliminary data on two voice therapy
interventions in the treatment of presbyphonia. The Laryngoscope, 124(8), 1869-1876.
13
khairyUSM©
39
11/22/2019
Thank You
Transforming Higher Education For A Sustainable Tomorrow
[email protected]
40
14
