Strong, Clear

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Strong, Clear Easy Voice Science for the
Clinic
Shelagh Davies, MSc, RSLP Speech-Language
Pathologist Clinical Assistant Professor, UBC
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What can theory offer practice?
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Guidelines for

1. Clear, consistent goal
2. Effective/efficient learning strategies
3. Developing independence, confidence

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1. Clear, consistent goal

• Strong, clear, easy voice
• What we and our patients want
• Corresponds to optimally efficient voice
  production

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2. Effective/efficient learning strategies

• Psychology literature principles of
  perceptual-motor learning, how they apply to
  voice
• For client process of discovery through body
  awareness
• For clinicians how to maximize learning
  opportunities

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3. Guidelines for developing independence,
confidence

• Theory of compliance/non-compliance
• Engaging the client
• Structuring manageable practice
• Facilitating generalization of new skills
• Confidence Independence
• Internal locus of control
• Clear understanding of what is harmful, helpful
• Strategies to reset voice
• Effects of voice disorder diminishing/disappeared

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STRONG, CLEAR, EASY
Teaching swimming
Clavicular breathing
Tongue tension
Thyroid issues
Poor posture
Poor acoustics
Tight jaw
Tight neck
Dehydration
belting
reflux
stress
Posterior glottic.......gap
Vocal nodules
coffee
No vocal training
8 shows a week
Teaching physical education
dehydration
High larynx
Runonphrases
smoking
summer camps
asthma
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Major Sources

• National Center for Voice and Speech
• www.ncvs.org
• Summer Vocology Institute
• Ingo Titze
• Principles of Voice Production, 2000
• Fascinations with the Voice, 2010
• Vocology, 2012
• Katherine Verdolini-Abbot
• Vocology, 2012
• Lessac Marsden Resonant Voice Program

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Review of laryngeal biomechanics
Courtesy NCVS
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For breathing arytenoids swivel vfs apart
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To produce voice
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Arytenoids swivel vfs together

Courtesy NCVS

• Most efficient vibratory posture
• .5 - .7 mm apart at tips of arytenoid processes
• For voiceless sounds arytenoids open glottis up
  to 10 20,000 times/day (Titze, 2000)

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Most efficient vibratory posture produces
resonant voice

• Lowest phonation threshold pressure. (Higher PTP
  associated with increased effort, rapid vocal
  fatigue) (Titze, 1988,Verdolini-Marston, 1990
  Soloman DiMattia, 2000)
• Neutral state can move easily to lengthen,
  shorten (Titze, Verdolini-Abbot, 2012)
• Vfs barely touch during vibration (Titze,
  Talkin, 1979 Pelorson, et al, 1994)
• Least collision damage (Jiang,1994) (Grillo,
  2007)
• Good vf contact strong signal
• Is a sign of efficient source-filter coupling
  (Titze, 2001)
• Maximally efficient voice production (Sheng Hwa
  Chen et al, 2007)

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Sensations with resonant voice

• We feel strong vibrations in front of face, mouth
  (in speaking pitches) (Titze, 2001) (Edwin, Yiu,
  2012)
• No throat sensation
• Clear voice quality
• Can stimulate it behaviourally (Lessac, 1967,
  Verdolini, 2004)

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• Vocal fold vibration

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Exercise break

• Check in
• Getting to neutral
• Straw phonation

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Vocal flexibility and vocal fold composition

• Vocal fold is multilayered all layers bend and
  vibrate differently depending on pitch and
  loudness (Titze, 2000, 2010)
• 20 25 mucosa, ligament
• 75 80 thyroarytenoid muscle

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Vocal fold mucosa and ligamentBy permission,
from Fascinations with the Human Voice
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Mucosa

• Composed of epithelium (.05 - .1 mm thick)
  superficial layer of lamina propria (.5 1.0 mm
  thick)
• Always in motion during phonation
• Absorbs impact stresses from repeated collisions
  a gel-like layer
• Most vf pathologies occur here from repeated
  collisions during vibration
• Contributes another dimension to vibration
  ribbon-like deformations adds complexity to
  sound

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Vocal ligament

• 1 2 mm thick
• In motion in all but very soft sounds
• Can sustain high longitudinal tension for high
  pitches. Like guy rope for tent (muscle is like
  bungee cord)
• Allows us to make high pitches

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Thyroarytenoid muscle

• 75 80 of bulk of vocal fold
• Contracts anterior-posteriorly, shortening vocal
  fold
• On contraction, bottom of vf pushes medially
• Dominates vibration in modal (speaking) register,
  especially for men other layers vibrate loosely
• Barely or not in vibration for soft or high
  sounds
• Vibrations usually quite large in amplitude
  gives rich voice quality with many harmonics

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Changing vocal fold lengthcourtesy National
Center for Voice and Speech
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Chest voice

• Heavy TA domination, longer closed phase, may
  have increased pressure of mucosal contact and
  shearing stresses
• Easier to produce can become default setting
• Vf muscles faster than respiratory muscles in
  accenting in speech
• more skill required to combine modes of vibration
  between cover and body

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Mixed voice

• Mixed (middle) Moves between TA dominant and
  ligament/mucosa dominant modes, allowing good
  flexibility
• Associated with strong resonance sensations in
  front of face
• Can be strong when coupled with vocal tract

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Falsetto

• TA inactive ligament bears tension only mucosa
  vibrates
• Associated with high pitches, e.g. upper octave
  of singing voice
• Too thin, quiet for prolonged use in speaking
  voice

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Cricothyroid-Thyroarytenoid activity
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Vocal flexibility full, well controlled pitch
loudness ranges

• Easy switching among modes of vibration
• soft loud, high low
• As little collision and shearing stress as
  possible on mucosa

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Conditioning the vocal folds

• We spend most time at lower pitches
• Generally speak in lower third of total pitch
  range
• Articulation is clearest at lower pitches
• Easiest, most efficient use of air, muscular
  effort, vocal tract coupling
• Need to stretch and unpress vocal folds

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Exercise break

• To train different modes of vibration through
  pitch and loudness ranges
• Messa di voce through straw
• Pitch glide through straw

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Conditioning the voice

• Baseline count to 10 pitch glide on /a/
• Using SOVT
• Comfortable pitch sustain sound 5 secs.
• Start sound as softly as you can, get louder then
  as soft as you can. Aim for 10 secs. Start C3
  men C4 - Women
• Glide up as high as you can then as low as you
  can. Stay within comfort zone no throat
  sensation
• NB All exercises should bypass the throat
• Retest counting pitch glide

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Dr. Ingo Titze and the straw(Watch on You Tube)
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Whats with the straw?

• Theory of semi-occluded vocal tract techniques

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Semi-occluded vocal tractLaukkanen, 1996 Titze,
2006 Nix, 2007 Simberg, 2007 SOVT conference,
2011, abstracts http//ncvs.org/blog/wp-content/u
ploads/2011/09/SOVT-abstracts.pdf

• Creates back pressure throughout vocal tract
  (Pascals law)
• Air pushes back down on the tops of the vocal
  folds, causing them to spread
• Air pressure between folds is reduced so
  vibrational amplitude is small
• Pushing folds down from top squares them so
  more surface contact during vibration, gives
  stronger voice

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Semi-occluded vocal tract

• Vocal folds barely touch so safe, even at high
  pitches
• Sensations strong sound but sound energy stays
  inside body so little risk of tissue damage
• May cue mid-body breathing movements
• May generalize carryover into speech, singing
• Pure motor learning not mediated by
  thinking/trying
• Long resonance tube (straw) creates very low
  formants so no glitches as harmonics pass
  through formants

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Generalize

• Semi-occluded vocal tract sounds
• BBBBBBbbbbbb
• Trrrrrrrr
• Mmmmm.
• Vvvvvvvvv
• Nnnnnnn
• /u/..
• /i/

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Principles of Perceptual Motor Learning
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1 Establish a clear sensory-motor target

• Strong, clear and easy
• Everything relates to target

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2 Focus attention on target rather than on
process

• E.g. clenching teeth
• Cupping hands
• Hand on stomach

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3. Body learns best undistracted

• Possible distractions
• Using images rather than clients direct sensory
  experience
• Too much feedback during practice
• Client seeking your approval for performance
  neutral tone allows experimentation
• Talking during practice

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4. If you want to do 2 things together you
must practice them together

• E.g. Using mid-body breathing movements
  during running speech
• E.g. Maintaining relaxed throat feeling during
  voicing onsets

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5. Motor learning is highly specific must
generalize to all situations
E.g. Keeping easy, efficient voice production
while conveying emotional content E.g.
Maintaining neutral jaw/neck posture while
speaking
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6. Performance is not the same as learning

• Learning must be habituated in the body through
  many repetitions. E.g. standing up straight does
  it need conscious attention or is it the default
  setting?
• Motor learning forms habits
• A learned action is robust in challenging
  situations, E.g. teacher can use resonant voice
  with excited kids at the Christmas assembly
• A learned action has been generalized it can
  transfer to novel situations e.g. typing on a
  different keyboard

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Principles of Perceptual-Motor Learning(Hampton,
1997 Schnidt, Lee, 2010 Verdolini-Abbot, Titze,
2012)

• 1 Establish a clear sensory-motor target
• 2 Focus attention on target rather than on the
  process
• 3. Body learns best undistracted
• 4. If you want to do two things together you
  must practice them together.
• 5. Motor learning is highly specific must
  generalize to all situations
• 6. Performing is not the same as learning

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Heirarchy of inputFrom Verdolini-Abbot Lessac
Marsden Resonant Voice Therapy

• Scan
• Gel
• Show
• Tell

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• Clip from Voice Council magazine

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Hierarchy of Practice

• SOVT techniques
• Straw phonation
• Lip/tongue bubble
• SOVT sounds, words
• /m/ m-words
• /n/ n-words
• Voiced fricatives, liquids, /u/, /i/

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• All voiced phrases
• We were away all year
• Every year we go a long way
• In all our ways
• Mixed words, phrases

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Cueing resonant speech

• Straw/lip bubble (or whatever facilitation
  technique worked) then word/phrase
• Do while saying word/phrase
• Shaking the bones
• Big shoulder movements
• To cue mid-body breathing hand on stomach

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Confidence and the Voice(Fleming, 2004)
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Fear shuts down the voice

• Protective posture fear of damaging
• Hyperadducted vfs, possible recruitment of
  extralaryngeal muscles for vf vibration
• Inadequate respiratory drive reduced loudness
• Backed resonance
• Voice feels and sounds stuck

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Restoring the circle

• Essential for lasting improvement
• Develop internal locus of control confirm
  clients ability establish responsibility
• Begins with success in first session
• Language is important
• Neutral words that avoid blame, shame
• Efficiency inefficiency instead of misuse
• Challenging situations instead of abuse

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Structuring Practice

• Going the gym for your voice a big commitment
• Hook them in first session with immediate
  improvement
• Sustain motivation with highly structured
  practice
• Record regularly and compare

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Suggestions for facilitating practice

• Engage client in tx design What has worked best
  for you?
• Keep it simple a few exercises, not a dozen
• Very clear instructions with recording, handouts
  Always review tx in the next session
• Maximum structure choose practice time/place, eg
  car, give practice log they must bring back
• The voice should feel/sound better afterwards. If
  it doesnt, let me know right away
• Re-record at each session discuss progress

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Sound AdviceImage by Robert Doisneau
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Sound Advice 3 rules

• 1. Keep your larynx healthy
• 2. Keep your larynx hydrated
• 3. Vocal limit stretch with training but keep
  within it

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Keep your larynx healthy

• No Pollutants
• Smoking
• Laryngopharyngeal reflux disease
• No Phonotrauma

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SmokingVerdolini, 2004

• Hot, dry, polluted air dehydrates, promotes
  reflux
• Produces erythema, edema
• Shuts down the mucocillary transport system that
  rehydrates them
• Polypoidal degeneration an irreversible
  condition
• Leading cause of laryngeal cancer

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Laryngopharyngeal reflux disease

• Shelagh Davies http//www.shelaghdavies.com/sounda
  dvice/
• PVCRP website http//pvcrp.com/throat_problems__
  _gastro_esophageal_reflux.php
• Dr Jamie Koufman http//www.jamiekoufman.com/2010
  /01/08/silent-reflux-laryngopharyngeal-reflux-lpr-
  is-ubiquitous/ http//www.refluxcookbook.com/

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Phonotrauma

• No yelling, screaming unless danger is involved
• Single scream can cause vocal fold haemorrhage,
  etc.

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Keep your larynx hydratedSoloman Di Mattia,
2000 Verdolini-Marston, Titze, 1990
Verdolini-Marston, 1994, Tanner, 2007 Roy et al,
2002)
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Effects of adequate hydration

• Extracellular matrix absorbs impact stresses
  during vibration needs to be adequately hydrated
• Helps reduce energy losses due to friction in
  vibration
• Edema may be a compensatory attempt to reduce
  friction
• Dry vfs require increased subglottal air
  pressure to vibrate

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Causes of dehydration

• External
• Dry environments
• Prolonged singing/speaking mouth breathing
• Internal
• Lack of fluid intake
• Smoking
• Certain medications see Vocology, 2012
• Alcohol, caffeine

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Hydration advice

• Pee pale and plentifully
• What we need is water BUT most hydration occurs
  through liquid-rich foods and drinks other than
  water
• When speaking or singing just keep sipping
• Non-caffeinated, non-alcoholic
• Can take several hours to reach vocal folds

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3. Vocal limit. Stretch with training but keep
within it
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In loud places

• Use one earplug
• Bar Star voice

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Goodbye and thanks for listening!