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!