Módulo de visualizaciones - Sistema de validación y desarrollo para CoqR

Sistema de validación y desarrollo para CoqR

3.5. Módulo de visualizaciones

An important part of this patient’s voice therapy program was the use of Vocal Function Exercises. These exercises, first described by Barnes104_{and modi-}

fied by Stemple,92_{strive to balance the}

subsystems of voice production. The exercise program has proven successful in improving and enhancing the vocal function of speakers with normal voices and disordered voices.92,105_{In addition,}

Sabol, Lee, and Stemple106_demonstrated

the effectiveness of Vocal Function Exer- cises in the exercise regimens of singers. The program is rather simple to teach and, when presented appropri- ately, seems reasonable to patients. Many patients are enthusiastic to have a concrete program, similar in concept to physical therapy, during which they may plot the progress of their return to vocal efficiency. The program is as follows.

Describe the problem to the patient, using illustrations as needed or the patient’s own stroboscopic evaluation video. The patient is then taught a series of 4 exercises to be done at home, twice each, 2 times per day, preferably morning and evening. These exercises include: 1. Sustain the /i/ vowel for as long as

possible on a musical note F above middle C for all female patients and boys and F below middle C for mature male patients. (Notes may be modified up or down to fit the needs of the patient. Seldom are they modified by more than 2 notes in either direction.)

Goal: based on airflow volume.

(In our clinic the goal is based on reaching 80 to 100 mL/s of airflow. So, if the flow volume is equal to 4000 mL, then the goal is 40 to 50 seconds. When airflow measures

112 Voice Therapy: Clinical Case Studies

are not available, the goal is equal to the longest /s/ that the patient is able to sustain. Placement of the tone should be in an extreme forward focus that is almost, but not quite, nasal. All exercises are produced as softly as possible, but are not breathy. The voice must be “engaged.” This is considered a warm-up exercise.)

2. Glide from your lowest note to your highest note on the word “knoll.”

Goal: no voice breaks. (The glide

requires the use of all laryngeal muscles. It stretches the vocal folds and encourages a systematic, slow engagement of the cricothyroid muscles.) The word “knoll” encourages a forward placement of the tone as well as an expanded open pharynx. The patient’s lips are to be rounded and a sympathetic vibration should be felt on the lips. (May also use a lip trill, tongue trill, or the word “whoop.”) Voice breaks typically will occur in the transitions between low and high registers. When breaks occur, the patient is encouraged to continue the glide without hesita- tion. When the voice breaks at the top of the current range and the patient typically has more range, the glide may be continued without voice as the folds will continue to stretch. Glides improve muscular control and flexibility. This is considered a stretching exercise.) 3. Glide from a comfortable note to your

lowest note on the word “knoll.”

Goal: no voice breaks. (The patient

is instructed to feel a half-yawn in the throat throughout this exercise.)

By keeping the pharynx open and focusing the sympathetic vibration at the lips, the downward glide encourages a slow, systematic engagement of the thyroarytenoid muscles without the presence of a back-focused growl. In fact, no growl is permitted. (May also use a lip trill, tongue trill, or the word “boom.”) This is considered a con- tracting exercise.

4. Sustain the musical notes C, D, E, F, and G for as long as possible on the word “knoll” minus the “kn.” (Middle C for all female patients and boys, an octave below middle C for mature male patients.)

Goal: remains the same as for exer-

cise 1. (The “oll” is once again produced with an open pharynx and constricted, sympathetically vibrat- ing lips. The shape of the pharynx to the lips is likened to an inverted megaphone. The fourth exercise may be tailored to the patient’s present vocal ability. Although the basic range starting at middle C, an octave lower for mature male patients, is appropriate for most voices, the exercises may be customized up or down to fit the current vocal condition or a particular voice type. Seldom, however, are the exercises shifted more than 2 notes in either direction. This is considered a low- impact adductory power exercise.) Quality of the tone is also monitored for voice breaks, wavering, and breathi- ness. Quality improves as times increase and pathologies begin to resolve.

All exercises are done as softly, but engaged. It is much more difficult to produce soft tones; therefore, the vocal

Primary and Secondary Muscle Tension Dysphonia 113

subsystems will receive a better “work- out” than if louder tones were produced. Extreme care is taken to teach the production of a forward tone that lacks tension. In addition, attention is paid to the glottal onset of the tone. The patient is asked to breathe in deeply with attention paid to training abdominal breath- ing, posturing the vowel momentarily, and then initiating the exercise gesture without a forceful glottal attack or an aspirate breathy attack. It is explained to the patient that maximum phonation times increase as the efficiency of the vocal fold vibration improves. Times do not increase because of improved “lung capacity.” Even aerobic exercise does not improve lung capacity but rather the efficiency of oxygen exchange with the circulatory system, thus giving the sense of more air.

The patient is provided with an audio CD of live voice doing the exercises which is used to guide the home exercise sessions. We have found that patients who complain of “tone deaf- ness” often can be taught to approxi- mate the correct notes with practice and guidance from the voice pathologist.

Finally, patients are given a chart on which to mark their sustained times, which is a means of plotting progress (Table 3–5). Progress is monitored over time, and because of normal daily vari- ability, patients are encouraged not to compare one day with the next. Rather, weekly comparisons are encouraged. Estimated time of completion for the program is 8 to 10 weeks.

When the patient has reached the predetermined therapy goal and the voice quality and other vocal symptoms are improved, a tapering maintenance program is recommended. Although some professional voice users choose to

remain in peak vocal condition using the exercises, many of our patients desire to taper the program. The following systematic taper is recommended:

n Full program 2 times each, 2 times

per day

n Full program 2 times each, 1 time per

day (morning)

n Full program 1 time each, 1 time per

day (morning)

n Exercise 4, 2 times each, 1 time per

day (morning)

n Exercise 4, 1 time each, 1 time per day

(morning)

n Exercise 4, 1 time each, 3 times per

week (morning)

n Exercise 4, 1 time each, 1 time per

week (morning)

Each taper should last 1 week. Patients should maintain 85% of their peak time, otherwise they should move up 1 step in the taper until the 85% criterion is met.

In short, Vocal Function Exercises provide a holistic voice-treatment program that attends to the 3 major subsystems of voice production. The program appears to benefit patients with a wide range of voice disorders both hyperfunctional and hypofunctional. The daily exercises require a reasonable amount of time and effort. In addition, it is similar to other recognizable exercise programs; the concept of “physical therapy” to improve muscle function is understandable; progress may be easily plotted, which is inherently motivating; and it appears to balance airflow, laryngeal activity, and supraglottic placement (reprinted from Stemple, Glaze, and Klaben103_).

Vocal Function Exercises were help- ful in improving the overall condition of patient F’s vocal folds and helped to

114

Table 3–5. Vocal Function Daily Record

MON TuE WED THu FRI SAT SuN

Date E/F / / / / / / / C / / / / / / / AM D / / / / / / / E / / / / / / / F / / / / / / / g / / / / / / / E/F / / / / / / / C / / / / / / / PM D / / / / / / / E / / / / / / / F / / / / / / / g / / / / / / /

MON TuE WED THu FRI SAT SuN

Primary and Secondary Muscle Tension Dysphonia 115

retrain frontal focus. The patient’s base- line mean phonation time for sustaining the appropriate notes was 8.5 seconds. This measure improved to a mean of 18 seconds during 6 weeks of therapy.

Significant improvement was noted during 6 weeks of therapy for both sub- jective observations of voice quality and objective measures of vocal function. The patient was experiencing much less vocal fatigue and laryngeal dis- comfort. Audio recordings made while teaching demonstrated stabilization of new voicing habits and only very occa- sional throat clearing. She did, however, remain mildly dysphonic, characterized by a slight breathy hoarseness.

Objective measures demonstrated a fundamental frequency of 196 Hz and an expanded frequency range of 165 to 720 Hz. Jitter and shimmer measures were within normal limits. Airflow rates for comfort and low-pitched voices were decreased to 136 and 150 mL/s, respec- tively. Airflow rate for high-pitched voice was also decreased to 240 mL/s but was still above the normal limit of 200 mL/s.

Videostroboscopy also demonstrated improvement. The edema and erythema were resolved, and there was no evidence of the contact ulcer. A slight thickness was noted where the left nodule had been. The right nodule was still present but appeared much more cystlike. Glottic closure retained an hour- glass shape; however, the glottal chinks were much smaller. The amplitude of vibration was only slightly decreased left and moderately decreased right. The mucosal wave was normal on the left and moderately decreased around the right lesion. The open phase of the vibratory cycle was slightly dominant, whereas the symmetry of vibration remained irregular.

The results of the therapy program were discussed with patient F’s physi- cian. Considering the cystlike nature and stiffness of the right vocal fold lesion, it appeared unlikely that the lesion would resolve with therapy. It was decided to extend therapy for an additional month to be certain that this was the case. When the remaining lesion did not resolve, surgery was scheduled for the second week in June.

The pathologist’s report confirmed the lesion to be a cyst. Following surgery, the patient continued Vocal Func- tion Exercises for 1 month and began a maintenance exercise program for the remainder of the summer. Maxi- mum phonation times improved and stabilized at an average of 32 seconds. The voice quality improved to normal. Changes in objective measures included a higher frequency range (+900 Hz) and a normal airflow rate at high pitch (160 mL H2O/s). Videostroboscopic

examination performed just prior to the fall opening of school revealed all observations to be within normal limits except for the symmetry of vibration, which remained irregular at higher pitches.

Patient F was followed monthly to confirm her symptom-free status. Her voice remained normal. The combina- tion of medical and surgical treatment and a holistic voice therapy program proved successful in remediating a long- term voice disturbance in this patient.

Another voice therapy program, which is popular in Great Britain, Scandina- via, Europe, and the Middle East, is the Accent Method. In this study of a young singer, Sara Harris describes in detail the rationale and the management plan for this approach.

116 Voice Therapy: Clinical Case Studies

Case Study 14

Sara Harris

Accent Method in the Treatment of Secondary MTD

This case study discusses the Accent Method of Voice Therapy and describes its benefits in restoring efficient vocal function to a young singer with mid- third vocal fold thickening and a muscular tension pattern of dysphonia.16

The Accent Method is a holistic therapy regime designed to coordinate the muscles of respiration, phonation, and articulation to produce efficient voice production and clear, resonant, well- modulated speech.

Svend Smith, a Danish phoneti- cian, designed the Accent Method in the 1930s. It is used widely in Europe including the Scandinavian countries. Smith was keen to develop a dynamic technique for voice and speech skills that emphasized the whole commu- nication process, including nonverbal aspects such as eye contact and gesture. He was influenced greatly by the rhythmic patterns produced by the bongo drummer Joe Bogdana who accompa- nied the entertainer Josephine Baker. He saw a potential use of these rhythms to reinforce intonation and prosody, as well as to provide a framework in which to practice voice and articulatory skills. Smith and Bogdana worked together to devise the three tempos — largo, andante, and allegro — that are still used in the technique today.

The theoretical underpinning of the Accent Method is based on the following:

n the myoelastic-aerodynamic model

of vocal fold vibration

n conditioning (the unconscious pro-

cess of learning)

n focus on normal vocal function rather

than the pathology.107,108

The myoelastic-aerodynamic theory of vocal fold vibration was described in the 1950s by van den Berg109_{and relies}

on the concept of the Bernoulli effect. Although recent research has demonstrated that this effect cannot explain all the factors involved in sustaining vocal fold vibration, the need to establish and maintain a satisfactory subglottic pressure and transglottal airflow remains essential to efficient voice production.110

The conditioning of the desired phonation pattern takes place during long periods of repetition of the Accent Method exercises. The exercises include all the vowels and consonants used in spontaneous speech from which the patient produces sequences of sustained sounds and syllables to sentence level. These meaningless babbled sentences incorporate prosodic features such as rhythmic stresses, intonation, and loud-soft vocal dynamics. The practice sessions may range from anywhere between 10 and 30 minutes. Although concentration is needed in the early stages as patients establish the desired patterns, the unconscious processes of learning and overlearning take over as they practice. Carryover of the newly learned skills into spontaneous, con- tinuous speech then occurs easily and reliably, decreasing the likelihood of relapse. This is in stark contrast to other methods in which patients are asked to produce a sustained sound or short utterance but then discuss the effects of it using their habitual pattern of voice production.

The Accent Method exercises con- centrate on establishing efficient vocal

Primary and Secondary Muscle Tension Dysphonia 117

fold closures for speech in modal voice using simultaneous vocal onset coor- dinated with a stable, well-controlled expiratory airflow. Initially, the exercises deliberately encourage breathy phonation with gradual increase of vocal fold adduction until comfortable, clear voice is achieved. Research suggests that this phonation pattern made with the vocal folds barely touching produces efficient and particularly resonant voicing.72,111

It allows the therapist to work equally effectively with patients who are hyper- adducted or hypoadducted and explains why the Accent Method exercises have been reported as being successful with a wide range of vocal disorders.

In document UNIVERSIDAD DE CHILE FACULTAD DE CIENCIAS FÍSICAS Y MATEMÁTICAS DEPARTAMENTO DE CIENCIAS DE LA COMPUTACIÓN (página 45-50)