Post on 11-Jul-2015
Strong, Clear & Easy:
Voice Science for the Clinic
Shelagh Davies, MSc, RSLP Speech-Language Pathologist Clinical Assistant Professor, UBC
What can theory offer practice?What can theory offer practice?
Guidelines for …Guidelines for …
1.1. Clear, consistent goalClear, consistent goal
2.2. Effective/efficient learning strategiesEffective/efficient learning strategies
3.3. Developing independence, confidenceDeveloping independence, confidence
1. Clear, consistent goal1. Clear, consistent goal
Strong, clear, easy voiceStrong, clear, easy voice What we and our patients wantWhat we and our patients want Corresponds to optimally efficient voice productionCorresponds to optimally efficient voice production
2. Effective/efficient learning strategies 2. Effective/efficient learning strategies
Psychology literature – principles of perceptual-Psychology literature – principles of perceptual-motor learning, how they apply to voicemotor learning, how they apply to voice For client: process of discovery through body For client: process of discovery through body
awareness awareness For clinicians: how to maximize learning For clinicians: how to maximize learning
opportunities opportunities
3. Guidelines for developing3. Guidelines for developing independence, confidence independence, confidence
Theory of compliance/non-complianceTheory of compliance/non-compliance Engaging the clientEngaging the client Structuring manageable practiceStructuring manageable practice Facilitating generalization of new skillsFacilitating generalization of new skills
Confidence & IndependenceConfidence & Independence Internal locus of controlInternal locus of control Clear understanding of what is harmful, helpfulClear understanding of what is harmful, helpful Strategies to reset voiceStrategies to reset voice Effects of voice disorder diminishing/disappearedEffects of voice disorder diminishing/disappeared
Tight jaw
refluxreflux
summer campssummer camps
Dehydration belting
Teaching swimming
Tight neck
dehydration
Poor acoustics
Clavicular
breathing
Runonphrases
Hig
h lary
nx
stress
Tongue tens ion
Vocal Vocal nodules
nodules
Posterior glottic.......gap
smoking
coffee
No vocal
training
Teaching physical education
Poor posture
8 shows a week
asthma
Thyroid issues
STRONG, CLEAR, EASY
Major Sources:Major Sources: National Center for Voice and Speech:National Center for Voice and Speech:
www.ncvs.orgwww.ncvs.org Summer Vocology Institute Summer Vocology Institute
Ingo Titze:Ingo Titze: Principles of Voice Production,Principles of Voice Production, 2000 2000 Fascinations with the Voice, Fascinations with the Voice, 20102010 Vocology, 2012Vocology, 2012
Katherine Verdolini-Abbot:Katherine Verdolini-Abbot: Vocology, Vocology, 20122012 Lessac Marsden Resonant Voice ProgramLessac Marsden Resonant Voice Program
Review of laryngeal biomechanicsReview of laryngeal biomechanics Courtesy NCVSCourtesy NCVS
For breathing arytenoids swivel vf’s apartFor breathing arytenoids swivel vf’s apart
To produce voice:To produce voice:
Arytenoids swivel vf’s togetherArytenoids swivel vf’s together
Courtesy NCVS Courtesy NCVS Most efficient vibratory Most efficient vibratory
posture:posture: .5 - .7 mm apart at tips of .5 - .7 mm apart at tips of
arytenoid processesarytenoid processes For voiceless sounds For voiceless sounds
arytenoids open glottis arytenoids open glottis up to 10 – 20,000 up to 10 – 20,000 times/day times/day (Titze, 2000)(Titze, 2000)
Most efficient vibratory posture Most efficient vibratory posture produces ‘resonant voice’produces ‘resonant voice’
Lowest phonation threshold pressure. (Higher PTP Lowest phonation threshold pressure. (Higher PTP associated with increased effort, rapid vocal fatigue) associated with increased effort, rapid vocal fatigue) (Titze, 1988,Verdolini-Marston, 1990; Soloman & DiMattia, 2000)(Titze, 1988,Verdolini-Marston, 1990; Soloman & DiMattia, 2000)
““Neutral” state – can move easily to lengthen, shorten Neutral” state – can move easily to lengthen, shorten (Titze, Verdolini-Abbot, 2012)(Titze, Verdolini-Abbot, 2012)
Vf’s barely touch during vibration Vf’s barely touch during vibration (Titze, Talkin, 1979; Pelorson, et (Titze, Talkin, 1979; Pelorson, et al, 1994)al, 1994)
Least collision damage Least collision damage (Jiang,1994) (Grillo, 2007)(Jiang,1994) (Grillo, 2007)
Good vf contact; strong signalGood vf contact; strong signal Is a sign of efficient source-filter coupling Is a sign of efficient source-filter coupling (Titze, 2001)(Titze, 2001)
Maximally efficient voice production Maximally efficient voice production (Sheng Hwa Chen et al, 2007)(Sheng Hwa Chen et al, 2007)
Sensations with resonant voiceSensations with resonant voice
We feel strong vibrations in front of face, mouth We feel strong vibrations in front of face, mouth (in speaking pitches) (in speaking pitches) (Titze, 2001) (Edwin, Yiu, 2012)(Titze, 2001) (Edwin, Yiu, 2012)
No throat sensationNo throat sensation Clear voice qualityClear voice quality Can stimulate it behaviourally Can stimulate it behaviourally (Lessac, 1967, Verdolini, 2004)(Lessac, 1967, Verdolini, 2004)
Vocal fold vibration Vocal fold vibration
Exercise breakExercise break
1.1. Check inCheck in
2.2. Getting to neutralGetting to neutral
3.3. Straw phonationStraw phonation
Vocal flexibility and Vocal flexibility and vocal fold compositionvocal fold composition
Vocal fold is multilayered; all layers bend and Vocal fold is multilayered; all layers bend and vibrate differently depending on pitch and vibrate differently depending on pitch and loudness loudness (Titze, 2000, 2010)(Titze, 2000, 2010)
20 – 25% mucosa, ligament20 – 25% mucosa, ligament 75 – 80% thyroarytenoid muscle75 – 80% thyroarytenoid muscle
Vocal fold mucosa and ligamentVocal fold mucosa and ligamentBy permission, from By permission, from Fascinations with the Human VoiceFascinations with the Human Voice
Mucosa Mucosa
Composed of epithelium (.05 - .1 mm thick) + Composed of epithelium (.05 - .1 mm thick) + superficial layer of lamina propria (.5 – 1.0 mm superficial layer of lamina propria (.5 – 1.0 mm thick) thick)
Always in motion during phonationAlways in motion during phonation Absorbs impact stresses from repeated collisions – a Absorbs impact stresses from repeated collisions – a
gel-like layergel-like layer Most vf pathologies occur here from repeated Most vf pathologies occur here from repeated
collisions during vibrationcollisions during vibration Contributes another dimension to vibration – Contributes another dimension to vibration –
ribbon-like deformations – adds complexity to ribbon-like deformations – adds complexity to soundsound
Vocal ligamentVocal ligament
1 – 2 mm thick1 – 2 mm thick In motion in all but very soft soundsIn motion in all but very soft sounds Can sustain high longitudinal tension for high Can sustain high longitudinal tension for high
pitches. Like guy rope for tent; (muscle is like pitches. Like guy rope for tent; (muscle is like bungee cord) bungee cord)
Allows us to make high pitches Allows us to make high pitches
Thyroarytenoid muscleThyroarytenoid muscle
75 – 80% of bulk of vocal fold75 – 80% of bulk of vocal fold Contracts anterior-posteriorly, shortening vocal foldContracts anterior-posteriorly, shortening vocal fold On contraction, bottom of vf pushes mediallyOn contraction, bottom of vf pushes medially Dominates vibration in modal (speaking) register, Dominates vibration in modal (speaking) register,
especially for men; other layers vibrate looselyespecially for men; other layers vibrate loosely Barely or not in vibration for soft or high soundsBarely or not in vibration for soft or high sounds Vibrations usually quite large in amplitude; gives rich Vibrations usually quite large in amplitude; gives rich
voice quality with many harmonicsvoice quality with many harmonics
Changing vocal fold lengthChanging vocal fold lengthcourtesy National Center for Voice and Speechcourtesy National Center for Voice and Speech
Chest voiceChest voice
Heavy TA domination, longer closed phase, may Heavy TA domination, longer closed phase, may have increased pressure of mucosal contact and have increased pressure of mucosal contact and shearing stresses shearing stresses
Easier to produce; can become default setting:Easier to produce; can become default setting: Vf muscles faster than respiratory muscles in Vf muscles faster than respiratory muscles in
accenting in speechaccenting in speech more skill required to combine modes of vibration more skill required to combine modes of vibration
between cover and bodybetween cover and body
Mixed voiceMixed voice
Mixed (middle): Moves between TA dominant Mixed (middle): Moves between TA dominant and ligament/mucosa dominant modes, allowing and ligament/mucosa dominant modes, allowing good flexibilitygood flexibility
Associated with strong resonance sensations in Associated with strong resonance sensations in front of facefront of face
Can be strong when coupled with vocal tractCan be strong when coupled with vocal tract
FalsettoFalsetto
TA inactive; ligament bears tension; only TA inactive; ligament bears tension; only mucosa vibratesmucosa vibrates
Associated with high pitches, e.g. upper octave Associated with high pitches, e.g. upper octave of singing voiceof singing voice
Too thin, quiet for prolonged use in speaking Too thin, quiet for prolonged use in speaking voicevoice
Cricothyroid-Thyroarytenoid activityCricothyroid-Thyroarytenoid activity
Vocal flexibility: full, well controlled Vocal flexibility: full, well controlled pitch & loudness ranges pitch & loudness ranges
Easy switching among modes of vibration; Easy switching among modes of vibration;
soft – loud, high – lowsoft – loud, high – low As little collision and shearing stress as possible As little collision and shearing stress as possible
on mucosaon mucosa
Conditioning the vocal foldsConditioning the vocal folds
We spend most time at lower pitches:We spend most time at lower pitches: Generally speak in lower third of total pitch rangeGenerally speak in lower third of total pitch range Articulation is clearest at lower pitchesArticulation is clearest at lower pitches Easiest, most efficient use of air, muscular effort, Easiest, most efficient use of air, muscular effort,
vocal tract coupling vocal tract coupling
Need to stretch and unpress vocal foldsNeed to stretch and unpress vocal folds
Exercise breakExercise break
To train different modes of vibration To train different modes of vibration through pitch and loudness ranges:through pitch and loudness ranges:
Messa di voce through strawMessa di voce through straw
Pitch glide through strawPitch glide through straw
Conditioning the voiceConditioning the voice
Baseline: count to 10; pitch glide on /a/Baseline: count to 10; pitch glide on /a/ Using SOVT:Using SOVT:
Comfortable pitch sustain sound 5 secs. Comfortable pitch sustain sound 5 secs. Start sound as softly as you can, get louder then as soft as you Start sound as softly as you can, get louder then as soft as you
can. Aim for 10 secs. Start: C3 – men; C4 - Womencan. Aim for 10 secs. Start: C3 – men; C4 - Women Glide up as high as you can then as low as you can. Stay Glide up as high as you can then as low as you can. Stay
within comfort zone – no throat sensationwithin comfort zone – no throat sensation
NB: All exercises should ‘bypass’ the throatNB: All exercises should ‘bypass’ the throat Retest: counting; pitch glideRetest: counting; pitch glide
Dr.Dr. Ingo Titze and the strawIngo Titze and the straw(Watch on You Tube)(Watch on You Tube)
What’s with the straw?What’s with the straw?
Theory of semi-occluded vocal tract Theory of semi-occluded vocal tract techniquestechniques
Semi-occluded vocal tractSemi-occluded vocal tractLaukkanen, 1996; Titze, 2006; Nix, 2007; Simberg, 2007; Laukkanen, 1996; Titze, 2006; Nix, 2007; Simberg, 2007;
SOVT conference, 2011, abstracts: SOVT conference, 2011, abstracts: http://ncvs.org/blog/wp-content/uploads/2011/09/SOVT-abstracts.pdfhttp://ncvs.org/blog/wp-content/uploads/2011/09/SOVT-abstracts.pdf
Creates back pressure throughout vocal tract (Pascal’s Creates back pressure throughout vocal tract (Pascal’s law)law)
Air pushes back down on the tops of the vocal folds, Air pushes back down on the tops of the vocal folds, causing them to spreadcausing them to spread
Air pressure between folds is reduced so vibrational Air pressure between folds is reduced so vibrational amplitude is smallamplitude is small
Pushing folds down from top ‘squares’ them so more Pushing folds down from top ‘squares’ them so more surface contact during vibration, gives stronger voicesurface contact during vibration, gives stronger voice
Vocal folds barely touch so safe, even at high pitches Vocal folds barely touch so safe, even at high pitches Sensations = strong sound but sound energy stays Sensations = strong sound but sound energy stays
inside body so little risk of tissue damageinside body so little risk of tissue damage May cue mid-body breathing movementsMay cue mid-body breathing movements May generalize carryover into speech, singingMay generalize carryover into speech, singing Pure motor learning – not mediated by thinking/tryingPure motor learning – not mediated by thinking/trying Long resonance tube (straw) creates very low Long resonance tube (straw) creates very low formants formants
so no glitches as harmonics pass through formantsso no glitches as harmonics pass through formants
Semi-occluded vocal tractSemi-occluded vocal tract
GeneralizeGeneralize
Semi-occluded vocal tract sounds:Semi-occluded vocal tract sounds: BBBBBBbbbbbbBBBBBBbbbbbb TrrrrrrrrTrrrrrrrr Mmmmm….Mmmmm…. Vvvvvvvvv……Vvvvvvvvv…… Nnnnnnn……Nnnnnnn…… /u/…../u/….. /i/……/i/……
Principles of Perceptual Principles of Perceptual Motor LearningMotor Learning
#1 Establish a clear sensory-motor target#1 Establish a clear sensory-motor target
Strong, clear and easyStrong, clear and easy Everything relates to target Everything relates to target
#2 Focus attention on target rather #2 Focus attention on target rather than on processthan on process
E.g. clenching teethE.g. clenching teeth Cupping handsCupping hands Hand on stomachHand on stomach
#3. Body learns best undistracted#3. Body learns best undistracted
Possible distractions:Possible distractions: Using images rather than client’s direct sensory Using images rather than client’s direct sensory
experienceexperience Too much feedback during practiceToo much feedback during practice Client seeking your approval for performance – Client seeking your approval for performance –
neutral tone allows experimentationneutral tone allows experimentation Talking during practiceTalking during practice
#4. If you want to do 2 things together #4. If you want to do 2 things together you must practice them together you must practice them together
E.g. Using mid-body breathing movements E.g. Using mid-body breathing movements during running speech during running speech
E.g. Maintaining ‘relaxed throat’ feeling during E.g. Maintaining ‘relaxed throat’ feeling during voicing onsets voicing onsets
#5. Motor learning is highly specific; #5. Motor learning is highly specific; must generalize to all situationsmust generalize to all situations
E.g. Keeping easy, E.g. Keeping easy, efficient voice efficient voice production while production while conveying emotional conveying emotional contentcontent
E.g. Maintaining E.g. Maintaining neutral jaw/neck neutral jaw/neck posture while speaking posture while speaking
#6. Performance is not the #6. Performance is not the same as learningsame as learning
Learning must be habituated in the body through many Learning must be habituated in the body through many repetitions. E.g. standing up straight; does it need repetitions. E.g. standing up straight; does it need conscious attention or is it the default setting?conscious attention or is it the default setting?
Motor learning forms habitsMotor learning forms habits A learned action is robust in challenging situations, E.g. A learned action is robust in challenging situations, E.g.
teacher can use resonant voice with excited kids at the teacher can use resonant voice with excited kids at the Christmas assembly Christmas assembly
A learned action has been generalized; it can transfer to A learned action has been generalized; it can transfer to novel situations e.g. typing on a different keyboardnovel situations e.g. typing on a different keyboard
Principles of Perceptual-Motor LearningPrinciples of Perceptual-Motor Learning(Hampton, 1997; Schnidt, Lee, 2010; Verdolini-Abbot, Titze, 2012)(Hampton, 1997; Schnidt, Lee, 2010; Verdolini-Abbot, Titze, 2012)
#1 Establish a clear sensory-motor target#1 Establish a clear sensory-motor target #2 Focus attention on target rather #2 Focus attention on target rather
than on the processthan on the process #3. Body learns best undistracted#3. Body learns best undistracted #4. If you want to do two things together you #4. If you want to do two things together you
must practice them together. must practice them together. #5. Motor learning is highly specific; must #5. Motor learning is highly specific; must
generalize to all situationsgeneralize to all situations #6. Performing is not the same as learning#6. Performing is not the same as learning
Heirarchy of inputHeirarchy of inputFrom Verdolini-AbbotFrom Verdolini-Abbot: :
Lessac Marsden Resonant Voice TherapyLessac Marsden Resonant Voice Therapy
ScanScan GelGel ShowShow TellTell
Clip from Voice Council magazineClip from Voice Council magazine
Hierarchy of PracticeHierarchy of Practice
SOVT techniques SOVT techniques Straw phonationStraw phonation Lip/tongue bubbleLip/tongue bubble
SOVT sounds, wordsSOVT sounds, words /m/ + m-words/m/ + m-words /n/ + n-words /n/ + n-words Voiced fricatives, liquids, /u/, /i/Voiced fricatives, liquids, /u/, /i/
All voiced phrasesAll voiced phrases We were away all yearWe were away all year Every year we go a long wayEvery year we go a long way In all our waysIn all our ways
Mixed words, phrases Mixed words, phrases
Cueing resonant speechCueing resonant speech
Straw/lip bubble (or whatever facilitation Straw/lip bubble (or whatever facilitation technique worked) then word/phrasetechnique worked) then word/phrase
Do while saying word/phrase:Do while saying word/phrase: Shaking the bonesShaking the bones Big shoulder movementsBig shoulder movements To cue mid-body breathing: hand on stomachTo cue mid-body breathing: hand on stomach
Confidence and the VoiceConfidence and the Voice(Fleming, 2004)(Fleming, 2004)
Vocal Technique
Trust
Confidence
Fear shuts down the voiceFear shuts down the voice
““Protective” posture – fear of damaging Protective” posture – fear of damaging Hyperadducted vf’s, possible recruitment of Hyperadducted vf’s, possible recruitment of
extralaryngeal muscles for vf vibrationextralaryngeal muscles for vf vibration Inadequate respiratory drive; reduced loudnessInadequate respiratory drive; reduced loudness Backed resonanceBacked resonance Voice feels and sounds stuckVoice feels and sounds stuck
Restoring the circleRestoring the circle
Essential for lasting improvementEssential for lasting improvement Develop internal locus of control: confirm Develop internal locus of control: confirm
client’s ability; establish responsibilityclient’s ability; establish responsibility Begins with success in first sessionBegins with success in first session Language is important:Language is important:
Neutral words that avoid blame, shame: Neutral words that avoid blame, shame: Efficiency – inefficiency instead of misuseEfficiency – inefficiency instead of misuse Challenging situations instead of abuseChallenging situations instead of abuse
Structuring PracticeStructuring Practice
Going the gym for your voice: a big Going the gym for your voice: a big commitmentcommitment
Hook them in first session with immediate Hook them in first session with immediate improvement improvement
Sustain motivation with highly structured Sustain motivation with highly structured practicepractice
Record regularly and compare Record regularly and compare
Suggestions for facilitating practiceSuggestions for facilitating practice Engage client in tx design: “What has worked Engage client in tx design: “What has worked
best for you?”best for you?” Keep it simple – a few exercises, not a dozenKeep it simple – a few exercises, not a dozen Very clear instructions with recording, handouts Very clear instructions with recording, handouts
Always review tx in the next sessionAlways review tx in the next session Maximum structure: choose practice time/place, Maximum structure: choose practice time/place,
eg car, give practice log they must bring backeg car, give practice log they must bring back The voice should feel/sound better afterwards. The voice should feel/sound better afterwards.
If it doesn’t, let me know right awayIf it doesn’t, let me know right away Re-record at each session; discuss progressRe-record at each session; discuss progress
Sound AdviceSound AdviceImage by Robert DoisneauImage by Robert Doisneau
Sound Advice: 3 rulesSound Advice: 3 rules
1. Keep your larynx healthy1. Keep your larynx healthy 2. Keep your larynx hydrated2. Keep your larynx hydrated 3. Vocal limit: stretch with training but keep 3. Vocal limit: stretch with training but keep
within itwithin it
Keep your larynx healthyKeep your larynx healthy
No Pollutants:No Pollutants: Smoking Smoking Laryngopharyngeal reflux disease Laryngopharyngeal reflux disease
No PhonotraumaNo Phonotrauma
SmokingSmokingVerdolini, 2004Verdolini, 2004
Hot, dry, polluted air Hot, dry, polluted air dehydrates, promotes refluxdehydrates, promotes reflux
Produces erythema, edemaProduces erythema, edema Shuts down the mucocillary Shuts down the mucocillary
transport system that transport system that rehydrates themrehydrates them
Polypoidal degeneration; an Polypoidal degeneration; an irreversible conditionirreversible condition
Leading cause of laryngeal Leading cause of laryngeal cancercancer
Laryngopharyngeal reflux diseaseLaryngopharyngeal reflux disease
Shelagh DaviesShelagh Davies http://www.shelaghdavies.com/soundadvice/http://www.shelaghdavies.com/soundadvice/
PVCRP website:PVCRP website:
http://pvcrp.com/throat_problems___gastro_esophageal_reflux.phphttp://pvcrp.com/throat_problems___gastro_esophageal_reflux.php
Dr Jamie Koufman:Dr Jamie Koufman:
http://www.jamiekoufman.com/2010/01/08/silent-reflux-laryngopharyngeal-reflux-lpr-is-ubiquitous/http://www.jamiekoufman.com/2010/01/08/silent-reflux-laryngopharyngeal-reflux-lpr-is-ubiquitous/ http://www.refluxcookbook.com/http://www.refluxcookbook.com/
PhonotraumaPhonotrauma
No yelling, screaming No yelling, screaming unless danger is unless danger is involvedinvolved
Single scream can Single scream can cause vocal fold cause vocal fold haemorrhage, etc.haemorrhage, etc.
Keep your larynx hydratedKeep your larynx hydratedSoloman & Di Mattia, 2000; Verdolini-Marston, Titze, 1990; Verdolini-Soloman & Di Mattia, 2000; Verdolini-Marston, Titze, 1990; Verdolini-
Marston, 1994, Tanner, 2007; Roy et al, 2002)Marston, 1994, Tanner, 2007; Roy et al, 2002)
Effects of adequate hydrationEffects of adequate hydration
Extracellular matrix absorbs impact stresses Extracellular matrix absorbs impact stresses during vibration; needs to be adequately during vibration; needs to be adequately hydratedhydrated
Helps reduce energy losses due to friction in Helps reduce energy losses due to friction in vibrationvibration
Edema may be a compensatory attempt to Edema may be a compensatory attempt to reduce frictionreduce friction
Dry vf’s require increased subglottal air pressure Dry vf’s require increased subglottal air pressure to vibrateto vibrate
Causes of dehydrationCauses of dehydration
External:External: Dry environmentsDry environments Prolonged singing/speaking – mouth breathingProlonged singing/speaking – mouth breathing
InternalInternal Lack of fluid intakeLack of fluid intake SmokingSmoking Certain medications – see Certain medications – see Vocology, 2012Vocology, 2012 Alcohol, caffeineAlcohol, caffeine
Hydration adviceHydration advice
Pee pale and plentifullyPee pale and plentifully What we need is water BUT most hydration What we need is water BUT most hydration
occurs through liquid-rich foods and drinks occurs through liquid-rich foods and drinks other than waterother than water
When speaking or singing just keep sippingWhen speaking or singing just keep sipping Non-caffeinated, non-alcoholic Non-caffeinated, non-alcoholic Can take several hours to reach vocal foldsCan take several hours to reach vocal folds
3. Vocal limit. Stretch with training 3. Vocal limit. Stretch with training but keep within itbut keep within it
In loud places …In loud places …
Use one earplug Use one earplug Bar Star voiceBar Star voice
Goodbye and Goodbye and thanks for listening!thanks for listening!