Live Expert eSeminarc772064.r64.cf2.rackcdn.com/event/04100/04195/5203183-tx...Lessac-Madsen Resonant Voice Therapy • Goal is to balance the subsystems of voice production for optimal

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Management and Treatment of the Professional Voice

Presenter:Wendy DeLeo LeBorgne, Ph.D., CCC-SLP

Moderated by:

Amy Hansen, M.A., CCC-SLP, CEU Administrator, SpeechPathology,com

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Management and Treatment of the Professional Voice

Wendy DeLeo LeBorgne, Ph.D., CCC-SLPVoice Pathologist & Singing Voice Specialist

Clinical Director,The Professional Voice Center of Greater Cincinnati

The Blaine Block Institute for Voice Analysis & Rehabilitation

Adjunct Assistant Professor, CCM-OMDA

[email protected]

WHAT IS AN ATHLETE?

Athlete: One who is trained or skilled in exercises, sports or games requiring physical

strength, agility or stamina (Webster’s Dictionary)

WHAT IS A VOCAL ATHLETE?

Vocal Athlete: One who is trained or skilled in singing or speaking, which requires vocal and

physical strength, agility, flexibility, and stamina

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VOCAL GYMNASTICS

PUTS YOU AT HIGH RISK OF INJURY

Pathologies

UCSF VOICE CONFERENCE 2008

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Principles of Training Physical Athletes

• Strength Training

• Stamina Training

• Drills to train flexibility & agilityDrills to train flexibility & agility

TRAIN MUSCLE MEMORY FOR A GIVEN TASK

How things are SUPPOSED to work

PHONATIONPHONATION

RESONANCERESONANCEAALLIIGGNN

AARRTTIISS

RESPIRATIONRESPIRATION

MMEENNTT

SSTTRRYY

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Normal Vocal Fold Vibration

What happens when the voice DOESN’T WORK correctly?y

PHONATIONPHONATION

RESONANCERESONANCEAALLIIGGNN

AARRTTIISS

RESPIRATIONRESPIRATION

MMEENNTT

SSTTRRYY

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Red Flags• Inability to sing high & soft• Pain• Vocal fatigue• Prolonged hoarseness• Effortful phonation

Ch i th t l i• Chronic throat clearing• Decreased flexibility/agility• Breaks, fuzziness, breathiness, holes, loss of range, loss

of dynamic control• Neck tightness, discomfort, aching (muscular) • Burning or bitter taste/raw throat• Laryngeal/pharyngeal dryness• Lump in the throat feeling

Sports/Dance Medicine Parallel

• Multitude of studies– Epidemiology of injuries – Nature/Type of injuries incurred within a given sport– Gender specific injury patterns and risk factors– Physiologic and anthropometric profiling of novice y g p p g

and elite athletes– Psychological profiling of novice and elite athletes– Fatigue management in elite athletes– Repetitive strain injuries in musicians– Injury prevention guidelines for novice and elite

athletes– Occupational hazards within a given sport/dance

Incidence/Prevalence of Vocal Injury in Performers

• Voice disorders within the general population (Roy, et al., 2005)

• Vocal injury within high vocal demand professions– Teaching – 57% reported vocal problems– Performing Arts

• Hoffman-Ruddy, et. al (2001) – Theme park performers• Tepe, et al (2002) – 129 young choral singers• Heman-Ackah, et al (2002) – Symptomatic and non-

symptomatic lesions in opera singers• Elias (1997) – Presence of pathology in non-symptomatic

opera singers• Lundy (1999) – College-level singing students

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High Risk Performers

• Vocal Demands– Long rehearsals– Vocal gymnastics– Intensive voice use– Increased vocal intensity– Singing while performing choreographyg g p g g p y

• Physical Demands– Choreography– Stage combat– Restrictive costumes/masks– Cardiovascular and weight training

• Emotional Stress– @ 55% of MT performers over a 6 year period reported high

personal stress– @ 8% of MT performers on anti-anxiety or anti-depressant

medications

Injury Management

The Voice Care Team

• Otolaryngologist

• Voice Pathologist

• Singing Voice Specialist

• Psychologist

• Gastroentrologist

• Endocrinologist

• GynecologistSpecialist

• Acting Voice Specialist

• Voice Teacher

• Voice Coach

• Gynecologist

• Allergist

• Pulmonologist

• Audiologist

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INJURY

MEDICAL SURGICAL REHAB

REST

HEALTHY PERFORMANCE

MECHANISM

REHAB/CONDITIONING

Resources for Treatment and Management

• Board Certified Laryngologist– www.entnet.org (American Academy of

Otolaryngology-Head & Neck Surgery)– www.alahns.org (American Laryngological

Association)

• Voice Pathologist/Singing Voice Specialist– www.asha.org (American Speech Language Hearing

Association) SIG-3 (Special Interest Group #3 – Voice & Voice Disorders)

Specific Treatment & Management Strategiesg g

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Overview of Treatment/Management

• Injury prevention strategies

• Vocal Rehabilitation for the Vocal Athlete

The Best Treatment is Prevention!

Injury Prevention Strategies for Vocal Athletes

SAVING THE VOICE:Train as an Athlete

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Warm-up & Cool-down

• Physical

• Vocal

• Mental

HYDRATE, HYDRATE, HYDRATE!!

• 64 oz. of WATER per day (“sing wet, pee pale”)C l i h idifi• Cool-air humidifier

• Personal steam inhalers• Avoid drying medications • Avoid caffeine

Optimize Their Speaking Voice

• Pitch• Loudness• Rate• Breathing & Support• Breathing & Support• Phonatory habits (hard glottal attacks,

breathy attacks)• Resonance (too dark, too bright, Glottal

Fry)

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Reduce Their Volume

• Vocally Enthusiastic People!!!!

• 3 foot rule…..

Reduce Their Stress?!?

• Alexander Technique

• Yoga

• Tai Chi

• Meditation

• Vacation!!!

Other Tips

• Take “vocal naps”• Exercise daily• Maintain a balanced diet• Utilize appropriate posture and breathing• Utilize appropriate posture and breathing

techniques• Train the instrument, practice daily• Learn music BEFORE rehearsals/lessons

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Singing Voice “swelling tests”

Swelling tests: Vocal tasks that potentially reveal vocal fold mucosal disturbances. These tasks incorporate high frequency (pitch) very low intensity (loudness) and(pitch), very low intensity (loudness), and sometimes rapid onset/offset of the voice.

Dr. Robert Bastian, Otolaryngologist, Bastian Voice Institute

Tests to Check for Vocal Fold Swelling1. Soft singing

– Sing the first phrase of Happy Birthday– Use the softest voice possible (boy soprano pianissimo) – Sing it at progressively higher pitches– At some pitch you will begin to experience delays in the

onset of phonation or you will be unable to produce a soft tone

– This pitch is your current vocal ceiling. It may be caused p y g yby swelling or physiologic and technical limitations

– This test can be used to monitor the degree of swelling by keeping track of your highest pitch

2. Staccato test – Sing the following phrase on a staccato – 5-5-5-5-5-4-3-2-1 – Increase by ½ steps to your highest pitch – Monitor the pitch at which only air comes out rather than a

tone

Dr. Robert Bastian, Otolaryngologist, Bastian Voice Institute

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Voice Therapy Strategies: Managing Vocal Athlete Injuriesg g j

Therapeutic Modalities

• Hygienic• Symptomatic• Psychogenic• Physiologic

Vocal Function Exercises– Vocal Function Exercises– Lessac-Madsen Resonant Voice Therapy– Circumlaryngeal Massage– Myofascial Release

• Eclectic• Combined*****• Singing Voice Therapy

Vocal Function Exercises

• Systematic program designed to balance and strengthen the subsystems of voice

• Easy to perform

P t d kl b i• Progress noted on a weekly basis

• Efficacy data supporting improvement in professional voice

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VFE References• Aerodynamic changes as a result of vocal function exercises in elderly men.Gorman

S, Weinrich B, Lee L, Stemple JC.Laryngoscope. 2008 Oct;118(10):1900-3.• A holistic approach to voice therapy.Stemple JC.Semin Speech Lang. 2005

May;26(2):131-7.• An evaluation of the effects of two treatment approaches for teachers with voice

disorders: a prospective randomized clinical trial.Roy N, Gray SD, Simon M, Dove H, Corbin-Lewis K, Stemple JC.J Speech Lang Hear Res. 2001 Apr;44(2):286-96.Th l f l f i i i h i i f i S b l JW• The value of vocal function exercises in the practice regimen of singers.Sabol JW, Lee L, Stemple JC.J Voice. 1995 Mar;9(1):27-36.

• Efficacy of vocal function exercises as a method of improving voice production.Stemple JC, Lee L, D'Amico B, Pickup B.J Voice. 1994 Sep;8(3):271-8.

• Vocal function exercises for presbylaryngis: a multidimensional assessment of treatment outcomes.Sauder C, Roy N, Tanner K, Houtz DR, Smith ME.Ann Otol Rhinol Laryngol. 2010 Jul;119(7):460-7.

• Three treatments for teachers with voice disorders: a randomized clinical trial.Roy N, Weinrich B, Gray SD, Tanner K, Stemple JC, Sapienza CM.J Speech Lang Hear Res. 2003 Jun;46(3):670-88.

Lessac-Madsen Resonant Voice Therapy

• Goal is to balance the subsystems of voice production for optimal output with least vocal fold impact.

• Organized, systematic approach for patients

• Relies on sensory feedback for patients

• Efficacy studies are ongoing

LMRVT References• Behavioral treatment of voice disorders in teachers.Ziegler A, Gillespie AI,

Abbott KV.Folia Phoniatr Logop. 2010;62(1-2):9-23. Epub 2010 Jan 8. Review

• Resonant voice in acting students: perceptual and acoustic correlates of the trained Y-Buzz by Lessac.Barrichelo-Lindström V, Behlau M.J Voice. 2009 Sep;23(5):603-9. Epub 2008 Apr 14.

• Evidence for distinguishing pressed, normal, resonant, and breathy voice qualities by laryngeal resistance and vocal efficiency in vocally trained

bj t G ill EU V d li i K J V i 2008 S 22(5) 546 52 E b 2007subjects.Grillo EU, Verdolini K.J Voice. 2008 Sep;22(5):546-52. Epub 2007 Apr 2.

• Outcome of resonant voice therapy for female teachers with voice disorders: perceptual, physiological, acoustic, aerodynamic, and functional measurements.Chen SH, Hsiao TY, Hsiao LC, Chung YM, Chiang SC.J Voice. 2007 Jul;21(4):415-25. Epub 2006 Apr 3

• Laryngeal adduction in resonant voice.Verdolini K, Druker DG, Palmer PM, Samawi H.J Voice. 1998 Sep;12(3):315-27.

• Preliminary study of two methods of treatment for laryngeal nodules.Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E.J Voice. 1995 Mar;9(1):74-85.

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Circumlaryngeal Massage & Myofascial Release

• Used to decrease laryngeal tension

• Minimal efficacy studies completed in laryngeal area (MFR)laryngeal area (MFR)

Additional References• Articulatory changes in muscle tension dysphonia: evidence of vowel space

expansion following manual circumlaryngeal therapy.Roy N, Nissen SL, Dromey C, Sapir S.J Commun Disord. 2009 Mar-Apr;42(2):124-35. Epub 2008 Nov 1.

• Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders.Roy N.Int J Speech Lang Pathol. 2008;10(4):195-209.

• Treatment of severe bilateral temporomandibular joint ankylosis in adults: p j your protocol.Turco M, Di Cosola M, Faccioni F, Cortelazzi R.Minerva Stomatol. 2007 Apr;56(4):181-90.

• Holistic manual therapy techniques.Ramsey SM.Prim Care. 1997 Dec;24(4):759-86. Review.

• Myofascial release for craniomandibular pain and dysfunction.Barnes JF.Int J Orofacial Myology. 1996 Nov;22:20-2.

Singing Voice Therapy

• Modality used to transition the injured vocal athlete back into performance through the use of singing exercises g g g(vocalises)

• Limited efficacy studies

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One Size DOES NOT fit all!

Case Studies

CASE STUDY #1:Musical Theater Performer

• 21 y/o female• Got URI three months prior to visit• Levaquin x 10 days with minimal improvement• Complete laryngitis x 3 days• Chest x-ray confirmed bronchitis• 2nd round antibiotics and Medrol dose pack• At time of visit: cough had subsided (3 weeks

prior), congestion cleared, but voice remained dysphonic in mid-range

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CASE STUDY #1:Medical History

• No surgeries

• No SOB

• No neurological symptomsNo neurological symptoms

• No dysphagia

• TMJ dysfunction

• Current Medication: Nexium (x 2weeks), Clarinex

CASE STUDY #1:Vocal Complaints

• Voice has not returned to normal in over three months

• Difficulty with dynamic control (both loud & soft)

• Loss of upper range

• Vocal fatigue

• Voice never “warms up” ; always feels stiff

• Tickle sensation in throat

• Diplophonia around G#4

CASE STUDY #1:Performance Demands

• Six performances in next two weeks

• Begins rehearsals in one month for l di l i d tileading role in new production

• Private lessons – 1 hr/week

• Coaching – 1 hr/week

• Total years of training – 8+

• Possibility of 72 performances this summer

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CASE STUDY #1:Videostroboscopy

Videostrobe

CASE STUDY #1:Treatment Plan

• Options discussed with patient– Do nothing for now

– Voice therapy with probable surgery

– Surgery followed by voice therapy

– Complete voice rest x one week & re-assess

• Patient decided on immediate surgery with intensive rehabilitation

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CASE STUDY #1:Post-Surgery Videostroboscopy

Videostrobe Post-Surgery

Rehabilitation Following Vocal Fold Surgery

• Vocal Rest Recommendations– 2-3 days

7 10 days– 7-10 days

• Singing Recommendations– Need initial rest

– Look to historical pedagogical texts

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CASE STUDY #1:Rehabilitative Treatment Plan

• VFE’s – to re-strengthen and re-balance the mechanism

11 6s pre– 11.6s pre

– 21.5s 1wk post

– 28.2s 2wks post

CASE STUDY #1:Vocal Reconditioning

• Week 1: 5-10 minutes 3-5 times/day• Mid-range• Mid-intensity• Vocalise only

• Week 2: 10-15 minutes 3-4 times/dayBegin range extension• Begin range extension

• Dynamic expansion• Agility • Flexibility

• Week 3: 15-20 minutes up to 4 times/day• Begin easy, comfortable repertoire• Continue with above exercises

• Week 4: 20-30 minutes 3 times/day• Moderate literature

Case #2

Uniqueness gets hired

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Case #2

Sound Clip – “For Good”

Case #2

Sound Clip – “Fame”

Case #2

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QUESTIONS?

References

• Clinical Voice Pathology: Theory and Management; Stemple, Glaze, & Klaben. Plural Publishing. http://www.pluralpublishing.com/publication_cvp.htm

• Voice Disorders; Sapienza & Ruddy. Plural Publishing.http://www.pluralpublishing.com/publication_vd.htm

• Prevalence of voice disorders in teachers and the general• Prevalence of voice disorders in teachers and the general population.Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM.J Speech Lang Hear Res. 2004 Apr;47(2):281-93.

• Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices.Roy N, Merrill RM, Thibeault S, Gray SD, Smith EM.J Speech Lang Hear Res. 2004 Jun;47(3):542-51.

• Occupational risk factors associated with voice disorders among teachers.Thibeault SL, Merrill RM, Roy N, Gray SD, Smith EM.Ann Epidemiol. 2004 Nov;14(10):786-92.