1. Primary goal?
    to restore the best voice possible so voice is functional for emplyment and general communication

    restoring voice to pre-morbid status may not be possible
  2. Therapy should be ___ and ____ from understanding of ?

    Accurate ___ is critical to tx planning?
    • rooted in
    • derived
    • laryngeal anatomy and physiology

  3. Prognosis contributing factors?
    • patient compliance
    • willingness
    • depression
    • voice problem is amenable to resolution w/voice tx
    • appropriateness of pts expectations
    • Pt's general health status as well as current laryngeal status
    • Pt must recognize there is a problem
  4. Voice Tx:
    Pt education on?
    • normal respiration
    • normal phonation
    • normal resonance
    • abnormal phonation- how physiology have been altered
    • vocal hygiene and reflux
    • use pictures, graphics, etc and level of education and age
  5. Hygienic Voice Therapy

    Concentrates on discovering the ___ causes of the voice disorder and _____ of the causes to improve ____ and __?
    • behavioral
    • modification/elimination
    • vocal condition and voice quality
  6. Program of vocal hygiene:
    identify ___
    maintain ___
    ___ precautions
    ID ___?
    eliminate __
    • hyperfunctional behaviors
    • data on freq of misuse/abuse
    • voice usage
    • speaking in noise
    • hydration, reflux
    • exercise- weights, martial arts, vocalizations
    • throat clearing and coughing
    • irritants like smoke, dust, gases, cigarettes, etc.
  7. Symptomatic Voice Therapy
    Modification of deviant vocal symptoms such as __?

    organized and promoted by ?
    breathiness, inappropriate pitch, loudness, hard glottal attacks, and so on.

    Daniel Boone
  8. Psychogenic Voice Therapy
    Focus is on ___ and ___ status of the pt that led to and maintained the voice disorder?

    Organized by ?
    emotional and psychosocial

    Arnold Aronson
  9. Physiologic Voice Therapy
    Based on expanded knowledge of ___ as evaluated through objective voice assessment?

    Strives to improve ?

    Promotes ?
    vocal function

    balance among voice respiratory support, laryngeal muscle strength, control and stamina, and suprglottic modification of laryngeal tone.

    a healthy vocal fold cover
  10. Physiologic Tx organized by ?

    concentrates on the modification of the underlying physiology of the voice producing mechanisms:?

    • Colton and Casper
    • Stempl, Glaze, and Gerdeman

    respiration, phonation, resonance

    does not account for behavior
  11. Electic Voice Therapy
    Combination of ___?
    any and all of the previous orientations to affect positive vocal change.
  12. Strategies for Physiologic Voice Tx?
    • Vocal function exercises (stemple)
    • resonant voice therapy (Verdolini)
    • Accent Method (smith)
    • lee Silverman Voice therapy (Ramig)
  13. Vocal Function Exercises?

    a series of ___ similare in theory to ___ for the vocal folds, designed to ___ and to improve ___ ?
    • systematic voice manipulations
    • physical tx
    • strengthen and balance the laryngeal musculature
    • the efficiency of the relationship among airlfow, vocal fold vibration, and supraglottic tx of phonation
  14. Physiologic Voice Tx

    Rehab for injuries to the Larynx?
    • sometimes voice rest
    • vocal hygiene counseling
    • modify symptoms
    • continuation of previous voicing activities
  15. Physiologic Voice tx missing element?
    direct systematic exercises for restrengthening and balancing the laryngeal musculature and rebalancing the three laryngeal subsystems
  16. Physiologic Voice Tx:
    Vocal function exercises
    warm up?
    sustain the vowel /i/ for as long as possible on the musical note (f) above middle (c) for females below middle (c) for males.

    Goal = ___ sec
  17. Physiologic Voice Tx:Vocal function exercises

    stretching technique?

    • glide from your lowest note to your highest note on the word "knoll", "whoop" or tongue trill or lip trill
    • Goal= no voice breaks
  18. Physiologic Voice Tx: Vocal function exercises


    glide from your highest note to your lowest note on the word "knoll", " boom" or on a tongue or lip trill

    Goal= no voice breaks
  19. Physiologic Voice Tx:Vocal function exercises

    power technique?

    sustain the musical notes (C-D-E-F-G) for as long as possible on the word "old" without the /d/

    Goal= ___ sec

    • middle (c) females
    • octave below middle (c) males
  20. Vocal function exercies
    are done ? __ per day
    all exercises are done ?
    quality of tone is monitored for?
    extreme care is taken to ?
    attnetion is paid to the?
    appropriate ? is assured
    • 2 x each, 2x per day
    • as softly as possible
    • for breaks, wavering, and breathiness
    • to teach the production in a forward tone focus without tension
    • glottal onset of the tone to assure an easy onset without breathiness
    • breathing technique
  21. Vocal function exercises:
    notes as matched to ?
    daily ___ is charted by the pt?
    estimated time of completion ?
    some pts experience ___?
    • a pitch pipe, tape recorder, key board, piano
    • record
    • 8-10 weeks
    • minor laryngeal aching the first few days of exercise
  22. Vocal function exercises:
    explanation to the pt
    • that it seems silly
    • it to workout program, phy tx, weight lifting, etc
    • the necessity of systematic exercises without breaks
    • that the times do not increase due to increased lung capacity
  23. Vocal function exercises: Advantages for the pt
    systematic, permits?
    pt must?
    • understood, resonable model
    • plotting of progress
    • attend to th evoice at least two times per day
    • doing something positive as opposed to the "don't do's"
  24. Direct modification of Tone focus:
    pt ?
    1) ___ phrase production
    chant ___? on a ?
    • education
    • nasalized
    • oh no, oh my, oh me, etc
    • comfortable pitch and loudness
  25. Direct modification of Tone focus:
    nasalized phrase production cont.
    2) introduce __ and ___ using the same phrases
    • intensity
    • rate variations
    • 1) very slow and very soft
    • faster louder
    • fast loud
    • slower-softer
    • very slow and very soft
  26. Direct modification of Tone focus:
    nasalized phrase productio cont:
    3) introduce ___ and ___
    • inflected phrase and normal speech
    • 1) soft and slow
    • louder-faster
    • exaggerated inflection
    • normal speech
  27. Direct modification of Tone focus:nasalized phrase productio cont:
    4) expand to ?
    phrases, paragraph reading, conversation
  28. Resonant Voice Techniques
    for ___ or ___ to increase ___?
    • Verdolini-Martson, et. al
    • hyperfunctional /hypofunctional
    • loudness
  29. Resonant Voice Techniques
    • hyperfunction
    • medial compression of VFs
    • loudness/ ability to project
  30. Resonant Voice Techniques

    Consists of ____ uses ? then ?
    • frontal tone placement
    • syllables, words, sentences etc. with /m,n,j,r,z/ then generalize techniques to conversation
  31. Principles of Resonant Voice Techniques

    voice production involving ?
    in the context of ?
    where resonant voice is a ?
    oral vibratory sensations, usually on the anterior alveolar ridge or higher in the face

    easy phonation

    continuum of oral sensations and easy phonation build from basic speech gestures through conversational speech
  32. Principles of Resonance therapy cont:

    Training methodologies are experiential focusing on the processing of ___ info?

    training model assumes similar approaches for voice restoration and enhancing the ?

    normal voice (excellence training)
  33. Fundamental Characteristics of RT (resonance tx)

    Fundamental perceptual target is focused, ____ in the context of ?
    the singular training focus (resonance) is expected to affect?
    Large numbers of __ are used in varying speech contexts?
    Training is ? involving a dogged insistence upon the greatest possible ___ in the achievement of the perceptual tasks?
    • oral vibratory sensations
    • multiple levels of physiology (breathing and laryngeal)
    • repetitions
    • strongly goal (results)
    • precision
  34. Resonance Therapy targeted populations
    Any populations in which ?
    intra-vocal fold impact stress should be increased or decreased
  35. Resonance Therapy targeted populations

    Decreased ?

    edema, nodules, polps, cysts, granulomas,

    paresis, paralysis, atrophy, bowing, sulcus
  36. Resonance Therapy targeted populations

    ___ and ___ to process auditory and kinesthetic info related to voice and speech
    • able
    • willing
  37. Basic RVT training maneuvers

    Stretches and breathing warm-ups
    seconds per stretch

    (2) techniques
    3-10 seconds

    • touch elbows in back
    • stretch arms in front
  38. Basic RVT training maneuvers

    (5) techniques
    • drop head down slowly in fractions
    • rotate head up until right on top of the neck, feel neck muscles "turn off" when the crown and ball of head are balanced
    • lift head away from the neck
    • cross fiber stretch toward shoulders with fingers
    • tilt ear to shoulder and stretch out opposite arm
  39. Basic RVT training maneuvers

    • massage the masseters, pull down and forward
    • push thumbs into masseters with slightly open mouth
  40. Basic RVT training maneuvers

    Floor of Mouth (FOM)
    • press thumb into floor of mouth
    • first make no sound, thne produce a vowel with no tongue stiffness
  41. Basic RVT training maneuvers

    • -lip trill
    • no voice
    • continuous voice
    • alternating off/on
  42. Basic RVT training maneuvers


    • 1)-tongue trill
    • no voice
    • continuous voice
    • alternating off/on

    • 2) protrude tongue out and down, hands behind back
    • voiceless breathing
    • voiced
  43. Basic RVT training maneuvers

    • yawn
    • yawn-sigh with voice
    • -stretch the pharynx with these maneuvers
  44. Basic RVT training maneuvers

    • 1) breathe out all air on /f/; do not breathe in until you must; when you must, simply release the abdomen, it will breathe for you
    • 2) breathe-release-breathe-release, etc with and without voice
  45. Basic training gesture for RT maneuvers
    Step 1 for all stages of RT

    ____ as a sigh?
    Extreme ?
    Make ?
    Pt should feel?
    • Hmmm-molm-molm-molm-
    • forward focus is required with appropriate breath support
    • the connection from the abdominal muscles of the lips
    • very relaxed at the end of this gesture
  46. RT Hierarchy stage 1 "all voiced"
    molm-molm-molm ___
    eventually focus on?
    Increase ?
    • sustained pitch
    • the rate only
    • the vibrations; experiment with broad and narrow vibrations
    • the narrow vibration "like a narrow beam of light"
    • the ease of production by reducing the effort by 1/2 and 1/2 again
    • "lift" (as if pitch were increasing)
  47. RT Hierarchy stage 1 "all voiced"
    • molm-molm-molm
    • slow-fast-slow
    • soft-loud-soft on __ note
  48. RT Hierarchy stage 1 "all voiced"
    • molm-molm-molm as speech
    • use non linguistic phrases
    • vary the rate, pitch, and loudness
    • make the connection from the abdonminal muscles to the lips
  49. RT Hierarchy stage 1 "all voiced"
    • Chant the following voiced phrases on the musical note ___
    • mary made me sad
    • my mother made marmalade
  50. RT Hierarchy stage 1 "all voiced"
    Over-inflect these phrases as speech
  51. RT Hierarchy stage 2 "Voice-Voiceless Contrasts"
    Basic Training Gesture
    mamapapa vary the rate on ___ note
  52. RT Hierarchy stage 2 "Voice-Voiceless Contrasts"Basic Training Gesture
    • mamapapa
    • slow-fast-slow
    • soft-loud-soft on ___ note
  53. RT Hierarchy stage 2 "Voice-Voiceless Contrasts"Basic Training Gesture
    • mamapapa as speech
    • use non-linguistic phrases
    • vary the rate, pitch, and loudness;
    • make the connection from the abdominal muscles to the lips
  54. RT Hierarchy stage 2 "Voice-Voiceless Contrasts"Basic Training Gesture
    • chant the following voiced/voiceless phrases on the musical note __
    • Mom may put Paul on the moon
    • Mom Told Tom to copy my manner
  55. RT Hierarchy stage 2 "Voice-Voiceless Contrasts"Basic Training Gesture
    Over-inflect these phrases as speech
  56. RT Hierarchy stage 3 "Any Phrase"
    Basic Training Gesture
    Produce the following phrases in sequence as follows?
    • First chant the phrase on the note__
    • then over inflect it with extreme forward focus
    • then finally repeat it as natural speech with a forward focus

    Each individual phrase should be produced following this 3-step sequence before moving on to the next phrase.
  57. RT Hierarchy stage4 "Paragraph Reading"
    • read paragraph with phrase markers
    • separate each phrase only by the natural inhalation of air
    • exaggerate focus and then repeat with a more normal speech/voice production
    • repeat the above without phrase markers
  58. RT Hierarchy stage 5 "controlled Conversation"
    • practice forward speech placement in conversation
    • do not permit glottal attacks, glottal fry, etc.
  59. RT Hierarchy stage 6 "Environmental Manipulations"
    • simulate actual speaking environments
    • use tapes of background noise
    • go to noisy cafeteria
  60. RT Hierarchy stage7 "emotional manipulations"
    use materials and topics that increasingly engage and challenge the patient
  61. RT Home Exercises
    The critical portion of each exercise for each week is ___ as a home exercise example. The home program involves ___ sessions, ___ per day with ___ as needed
    • tape recorded
    • 15-20 minute
    • two times"minis"

    • 1. stretches
    • 2. basic RV gesture
    • 3. selected level of hierarchy
  62. Accent Method (person)
    focus on ?
    • Kotby
    • hyperfunction
    • diaphragmatic breathing
    • aspirated attack
    • rythmic intonation in speech
    • appropriate pitch and loudness
  63. Accent Method
    • dec hydration
    • coordinate respiration and phonation
  64. Accent Method
    Consists of productions of ?
    • diff rhythmic patterns of the syllable "ha' produced while physically moving the body
    • i.e. stepping forward, etc.
  65. Symptomatic Voice Therapy Techniques
    Techniques to dec
    Techniques to dec
    Techniques to incre
    • laryngeal muscle tension
    • hard glottal attacks
    • glottic closure
  66. Voice Tx: Use of Pre-phonation Glottal Airflow to eliminate hard glottal attacks
    ___-idea of constant airflow, connected flowing speech; link vowels & consonants "she ate the apple and orange'
    __? (has constant air flow)
    __? (use of instrumental devices)
    • easy onset/linking
    • yawn-sigh
    • chewing talk technique for hard glottal attacks/hyperfunction
    • Biofeedback monitoring of productions
  67. Voice Tx: Dec Laryngeal Muscle Tension
    ____: dec muscle tension, can lower larynx, dec thyrohyoid tension

    How to dec 'supraglottic' muscle tension (3)?
    Circumlaryngeal massage & digital manipulation

    • 1. tongue stretches
    • 2. yawns
    • 3. 'deep sniff'
  68. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)
    ___ used post-surgically or post injury (nodules, polyps, swelling, etc) eliminate hard glottal attacks?
    Confidential Voice
  69. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)

    easy onset of phonation, dec impact stress & dec medial compression
  70. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)

    Consists of ?

    Is a ____ voicing technique, not a ___ technique?
    just audible breathy phonation but NOT a whisper


  71. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)

    Improve glottic closure, VF strength
  72. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)

    Useful for:?
    • VF paresis
    • VF paralysis
    • bowing
    • lower motor neuron damage
  73. Therapy techniques for Hyperfunctional Disorders (misuse/abuse)


    Possibly -?
    • pushing/pulling with phonation
    • hard glottal attack, high loud phonation on 'ee'
    • vocal function Exs
    • Resonant Voice (incr loudness, dec strain)

    P: laryngeal muscle relaxation exs
  74. Lee Silverman Voice Therapy (person)?
    Designed specifically for __ pts but can be used for many ___ pts. Where ___ is present?
    • (Ramig)
    • Parkinson's pt
    • hypofunctional voice pts
    • dysarthria
  75. Lee Silverman Voice Therapy
    Focus is on?

    loud phonation and recalibration of level of effort

    • Loud sustained /a/
    • pitch glides up and down
    • loud phonation on 10 functional phrases then generalized
  76. Voice TX: additional technique
    • Teaching auditory discrimination
    • Relaxation tx- progressive relaxation
    • Relaxation exs for jaw, tongue, neck, shoulders
    • Shaping vegetative vocal productions like laugh, cough, throat clear, hum, yawn-sigh, phonation on inhalation
  77. Voice Tx: Improving Breath Support
    Breathing exs to train?
    Breathing exs to increase?
    Breathing exs to train ___ of breathing and phonation?
    • diaphragmatic breathing
    • control of expiration
    • coordination
  78. Voice Tx: breath support
    • lower back breathing or abd'l breathing
    • Pavone Exs
    • Vocal Function Sustain Exescises
    • Teach expiration w/ voice occuring simultaneously (no breath holding)
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