Review

Your eyes and ears are your best (and least expensive) tool!

How is the person making that sound (no matter what the medical diagnosis is)?

Ecologically, functionally valid assessment methods are best (i.e. connected speech!)

Attrition

• external to clinic: distance to therapy, transportation limitation, patient motivation and language barriers.

Hapner E, Portone-Maira C, Johns MM, 3rd. A study of voice therapy dropout. Journal of voice : official journal of the Voice Foundation. May 2009;23(3):337-340.

van Leer E, Connor NP. Patient perceptions of voice therapy adherence. Journal of voice : official journal of the Voice Foundation. Jul 2010;24(4):458-469.

What can we do?

When a patient is evaluated by a SLP at the initial visit with Laryngologist:

- VHI-10 scores decrease more following therapy.

- Voice therapy attendance improves.

Starmer HM, Liu Z, Akst LM, Gourin C. Attendance in voice therapy: can an interdisciplinary care model have an impact? The Annals of otology, rhinology, and laryngology. Feb 2014;123(2):117-123.

Litts J, Clary, M, Gartner-Schmidt J, Gillespie AI. Impact of laryngologist and speech pathologist co-assessment on outcomes and billing revenue. In press, Laryngoscope.

Stimulability

• The evaluation of an individual’s ability to modify a behavior when provided with models or cues.

• “Good stimulability” for changing a specific behavior when the stimulability production (following a model or cue) is better than the original, or spontaneous, production.

• First introduced in the SLP literature in 1954 for the evaluation of children with speech sound disorders.

Powell TW, Miccio AW. Stimulability: a useful clinical tool. J Commun Disord. Jul-Aug 1996;29(4):237-253.

Tyler AA. Assessing stimulability in toddlers. J Commun Disord. Jul-Aug 1996;29(4):279-297.

Stimulability in the voice literature

• Immediate voice improvements improve patient’s sense of mastery experience improve self-efficacy.

Bonilha HS, Dawson AE. Creating a mastery experience during the voice evaluation. Journal of voice : official journal of the Voice Foundation. Sep 2012;26(5):665.e661-667.

Bandura A. Toward a unifying theory of behavioral change. Psychological Review. 1977;84:191-215.

Adherence

Practice

Showing

up

Stimulability in the voice literature• Stimulability trial of resonant

voice.

• Acoustic improvements (F0, jitter, shimmer) following the stimulability trial.

Bonilha HS, Dawson AE. Creating a mastery experience during the voice evaluation. Journal of voice : official journal of the Voice Foundation. Sep 2012;26(5):665.e661-667.

Bandura A. Toward a unifying theory of behavioral change. Psychological Review. 1977;84:191-215.

aka Vocal Plasticity

• Variety of techniques: resonance, articulation, breathing, changes in intensity

• Positive correlation between the subjective rating of good vocal plasticity and therapeutic success

• Therapy success was determined as an improvement in acoustic analyses, stroboscopic analyses, or both.

Dejonckere PH, Lebacq J. Plasticity of voice quality: a prognostic factor for outcome of voice therapy? Journal of voice : official journal of the Voice Foundation. Jun 2001;15(2):251-256.

Time to Operationalize Stimulability

• “Clear speech”

• Initially developed as an intelligibility strategy for speaking to listeners with hearing loss.

• Increases in: phrase duration, number and duration of pauses, individual speech sound durations, intensity, intonation contour , range of F0

• Decreases: speaking rate

Picheny M, Durlach N, Braida L. Speaking clearly for the hard of hearing I: Intelligibility differences between clear and conversational speech. Journal of speech and hearing research. 1985;28(1):96-103.

Picheny M, Durlach N, Braida L. Speaking clearly for the hard of hearing. II: Acoustic characteristics of clear and conversational speech. Journal of speech and hearing research. 1986;29(4):434-446.

Procedures

• based on clinical acumen to have pathology amenable to voice therapy

110 new patients

First 4 sentences of the Rainbow Passage.

“Typical” voice (i.e. presenting, dysphonic voice).

• use “crisp, clear consonants” and “precise articulation” when reading. Vary intonation/pitch when reading “like you’re reading or telling an interesting story.”

“Clear speech”

Results: Aerodynamics

Airflow increased (p <

.001)

Total breaths taken increased

(p < .001)

Total reading time increased

(p < .001)

Breaths/second increased (p <

.001)

Results: Acoustics

dB SPL increased (p <

.001)

CSID- no change (p =

.268)

CPP F0 sd –no change (p

= .490)

Time one PAS

Quantify Breaths 3

Duration 23

Mean SPL 75

Pitch 130

Mean Airflow 60

Time two PAS

Quantify Breaths 4

Duration 31

Mean SPL 79

Pitch 171

Mean Airflow 150