Transcript lmrvt - Verdolini Voice
LMRVT and CBCFT: Step by Step Introduction and Overview Kittie Verdolini Abbott, PhD, CCC-SLP; 2011 Communication Science and Disorders School of Health and Rehabilitation Sciences
Lessac-Madsen Resonant Voice Therapy
• Based on long-term clinical work and basic science studies • Direct piece partly adapted from work by Lessac (1967, 1997) and Madsen (unpublished) • First loosely described by Verdolini, in Stemple (2000; 2009) • Includes direct and indirect voice therapy • LMRVT connotes a specific, programmatic approach to hygiene and resonant voice training
Arthur Lessac
Mark Madsen
The “what” of LMRVT: Direct therapy
• Biomechanically: – Barely ad/abducted vocal folds that optimize
output intensity
and relatively minimize
impact intensity
(departure from “traditional” thought in voice tx).
• Preceding effects enhanced by use of semi-occluded vocal tract in training (SOVT) (e.g., voiced continuant consonants) – Involves large-amplitude, low impact VF oscillations (proposed biological prevention and healing factors) and low Ps (easy)
The “what” of LMRVT: Direct therapy
• Perceptually: – Voice with perceptible anterior oral vibrations in the context of easy phonation.
Not RV
= No Vibrations Hard
RV
= Vibrations Ease – Note 2D continuum; both vibration and ease are required to some degree for a voice to be called “resonant” in LMRVT.
The “what” of LMRVT: Indirect therapy
• Lean and mean – – Hydration Exogenous inflammation – Uncontrolled yelling and sceaming • georgeforemancooking.
com georgeforemancooking.com
Casper-Based Confidential Flow Therapy
• Developed as comparison therapy in NIH-funded clinical trial on the utility of voice therapy for teachers (2005-2009) (R01 DC 005643).
• Direct therapy piece intended to be more “traditional” than LMRVT.
• Includes direct and indirect therapy.
• Indirect therapy identical to LMRVT.
susandwyerartworks.com
Original idea for comparison tx
• Quiet breathy (confidential) voice ( that’s traditional!) • Developed a program.
• Idea was to offset communication impairment with QB/CV by training enhanced articulation (Lessac consonant orchestra).
revwheeler.wordpress.com
Bright idea
• Then we had a bright idea.
• Why not ask someone who actually does this kind of therapy to have a look at this program!!!
Janina Casper
atsosxdev.doit.wisc.edu
The birth of CBCFT
• Dr. Casper took one look at the program (QB/C voice all the way through) and said
“THAT WILL NEVER WORK!”
• “I never have patients do QB/C voice for more than a week or two!” marinebuzz.com
The birth of CBCFT
• “Oh yeah, so after that, what do you do?” • “I teach them resonant voice – so they can be heard!!!” pdxcontemporaryart.com
• Oh great.
The birth of CBCFT
relationship-economy.com
The birth of CBCFT
• Well, natural sequence after “QB/C voice might be something like “flow voice” (aka “stretch and flow” ff Ed Stone).
• Jackie Gartner-Schmidt to the rescue dragoart.com
Jackie Gartner-Schmidt (CBCFT)
The “what” of CBCFT: 2 stages
• Biomechanically: – Stage 1: Widely abducted vocal folds, with small VF oscillations (about 1-2 wk). • Perceptually: – Stage 1: Quiet-breathy (confidential) voice.
The “what” of CBCFT
• Biomechanically: –
Stage 2: Slightly greater VF separation
than for RV, that nonetheless falls in the range of configurations corresponding to “optimal vocal economy” (output intensity/impact intensity). – VF
oscillations potentially a bit smaller than for RV
, and
impact stress potentially a bit smaller
as well.
–
No
explicit use of the
semi-occluded vocal tract
.
LEGEND (APPROX EQUIV) 1 = PRESSED VOICE 2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD , LSVT 3 = FLOW VOICE 4 = YAWN-SIGH/FALSETTO 5 = BREATHY VOICE 1 <-2 3 4 5
LEGEND (APPROX EQUIV) 1 = PRESSED VOICE 2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD , LSVT 3 = FLOW VOICE 4 = YAWN-SIGH/FALSETTO 5 = BREATHY VOICE 1 2
3 4 5
LEGEND (APPROX EQUIV) 1 = PRESSED VOICE 2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD , LSVT 3 = FLOW VOICE 4 = YAWN-SIGH/FALSETTO 5 = BREATHY VOICE 1 2
3 4 5
The “what” of CBCFT
• Perceptually: • Stage 2: Easy voice with “air all gone.” (Note again 2D continuum; both ease and “air all gone” are required for some degree for a voice to be truly “flow.”)
Not FV
= Hard Air not all gone
FV
= Easy Air all gone thatgamecompany.com
Comparison of the “whats”
• LMRVT – RV ~ 0.0-0.5 mm VP separation – RV ~ 120 ml/sec average airflow – Anterior oral vibrations; easy – RV: Basic training with
voiced continuant consonants
(semi occluded vocal tract) to enhance
resonance
• CBCFT – FV ~ 1.0 mm VP separation – FV ~ 180 ml/sec average airflow – Easy, “air all gone” – FV: Basic training with
unvoiced continuant consonants
to enhance
flow
Comparison of the “hows”
• Identical approaches – Used approach theoretically predicted to optimize learning, and empirically shown to optimize voice learning (sensory processing, variable practice).
• That approach produced best VHI results in prior study that held biomechanical and perceptual target of voice training constant (resonant voice), and varied training approach.
• Recall prior lecture.
In greater detail regarding the “how”
• Single training focus • Exploratory not prescriptive • Perceptual (introspective) • Literal training (specificity principle) • Attention to detail, especially around gestures’ effects • Flexible troubleshooting – It’s a “Spa Elf!”
Comparison of the “ifs”
• Identical approach – Parallel clinician and patient manuals, with patient education (to enhance confidence in treatment).
– Same requirements in terms of amount and type of practice.
– Written and audio recorded instructions.
– Etc.
• You might consider return audio records and/or excel file for patient compliance reporting
I II III IV V VI VII VIII
LMRVT and CBCFT (see manuals)
Hygiene (10-15 min) Stretches (5-10 min) Core (5-10 min) Chant (5-10 min) “VC” (5-10 min) “Mini” (5 min) “Messa di voce” (5-10 min) Converse (5-20 min) Own Tx (15-20 min)
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Claim to use LMRVT or CBCFT
• After 2-day training session by Verdolini or designated associate, assuming relatively “mature” clinician with emphasis in voice.
ncvs.org
Patient selection
• Voice problem due to hyper- or hypoadduction • Usually some evidence of improved voice within first session • Demonstrates kinesthetic (and preferably auditory perceptual) discrimination capabilities and willingness (Vocal Function Exercises will get you the same biomechanical and biological targets, with outward focus)
Not appropriate populations
• • Hemorrhage (strongly contraindicated) • Immediate post-surgical • Parkinson’s disease (LSVT is appropriate; although see Florida work) SD (probably won’t help; but see work by Connie Pike, SLP) • Gaping wide paralyses or otherwise huge glottal insufficiency (you won’t get anywhere)
Other selection criterion
• If you’re not already sick of it thenysehng.blogspot.com
Data
• • R01 DC 005643 • Teachers with phonotrauma (most) or other phonogenic voice problem (e.g., MTD; a few) (mostly females) • 4 wk therapy (2 back-to back sessions/wk) Subjects run 2005-2009 • N=105 randomized (52 CBCFT; 53 LMRVT) • Follow-up immediately post tx, 3 mo post tx, and 1 yr post baseline • At 1 yr post baseline, N=40 CBCFT; 42 LMRVT)
Primary outcome measure
•
Voice Handicap Index
scielo.br
' 40 30 20 10 0 VHI 100 90 80 70 60 50 B L C B C B L L M R 1 m o C 1 m o L 3 m o C 3 m o L Scheduled Follow-Up / Randomized Treatment Group 1 2 m o C 1 2 m o L
Question
• Where have you seen the curves on the preceding pages before?
•
Discussion.
Step by step details
• Manuals – CBCFT Clinician and Patient Manuals included with the course.
– LMRVT Clinician and Patient Manuals (and DVD) available from Plural Publishing, Inc. ( www.pluralpublishing.c
om ) chimneycricket.com
• Brief history
Start with intake
• List of likely contributory causes (in Clinician and Patient Manuals • (Measures) • Baseline voice self assessment (key as “anchor” for later daily ratings) • Goals (functional, medical, biomechanical) • Recommendations • Prognosis
Set-up for therapy
• Brief patient education about voice production, voice disorders • Personalized voice hygiene program pcna.net
Hydration risks (from case history)
• Systemic risks – Insufficient intake of hydrating fluid in general (< 1.5 qt/day “rule of thumb”) – Insufficient fluid replacement with perspiration – Consumption of dehydrating beverages (caffeine, alcohol) – Use of diuretics (medically indicated or not, e.g., “water pills”) • Recommendations – 1.5-2 qt water/day (clinical “rule of thumb”) – – – Increase water intake with perspiration Decrease dehydrating beverages (negotiate!!) Decrease use of non-essential diuretics (negotiate!)
Hydration risks (from case history)
• Surface dehydration – Exposure to dry ambient air – Use of medications that dry secretions (decongestants, antihistamines, psychotropic drugs) – Mouth breathing (sleep; sports) • Recommendations – Use direct steam inhalation (5 min/BID, clinical ROT; practice in clinic) – Use ambient humidifiers if necessary ($10-150; hot water; discuss placement) – Discontinue non-essential meds (or seek non-drying alternatives) – Seek medical evaluation and treatment for mouth breathing – Train sports breathing (inhale through nose if possible); post activity steam – Increase water intake (“cross talk” between systemic and surface hydration)
Exogenous inflammation risks (from case history)
• Risks – LPR – Smoke exposure (self or others) – Chemical exposure (including workplace; e.g., theatre) – Environmental pollution • Recommendations – Behavioral LPR precautions (see manual; negotiate!) – Reduce or stop smoking (negotiate!) – Address chemical exposures where relevant – Possible use of face mask?
Uncontrolled yelling and screaming risks (from case history)
• Risks – – Sports Work demands – Social – Background noise – Personality, habit (the “Richie” syndrome) – Hearing loss • Recommendations – Advise you will train them in loud voice; tell them to “cool it” for now until you get there in therapy – Hearing loss: Address as appropriate – Background noise: Next page
Vocal hygiene:
Screaming like crazy (bad) • Specifically: Earplug in one ear in background noise • Increases bone conduction; you hear yourself better and don’t scream • Two earplugs even better than one (hear others’ speech better too) http://www.activevibrant.com/catalog/images/hearing/Reusable%20Ear%20Plug %201260.jpg
Direct therapy
• Manuals and demos