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LMRVT and CBCFT: Step by Step Introduction and Overview

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

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LMRVT and CBCFT: Step by Step Introduction and Overview

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  1. LMRVT and CBCFT: Step by Step Introduction and Overview KittieVerdolini Abbott, PhD, CCC-SLP; 2011 Communication Science and Disorders School of Health and Rehabilitation Sciences

  2. Lessac-Madsen Resonant Voice Therapy • Based on long-term clinical work and basic science studies • First loosely described by Verdolini, in Stemple (2000; 2009) • Includes direct and indirect voice therapy • Direct piece partly adapted from work by Lessac (1967, 1997) and Madsen (unpublished) • LMRVT connotes a specific, programmatic approach to hygiene and resonant voice training

  3. Arthur Lessac

  4. Mark Madsen

  5. 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). • Involves large-amplitude, low-impact VF oscillations (proposed biological prevention and healing factors) and low Ps (easy) • Preceding effects enhanced by use of semi-occluded vocal tract in training (SOVT) (e.g., voiced continuant consonants)

  6. The “what” of LMRVT: Direct therapy • Perceptually: • Voice with perceptible anterior oral vibrations in the context of easyphonation. • Note 2D continuum; both vibration and ease are required to some degree for a voice to be called “resonant” in LMRVT. RV = Vibrations Ease Not RV = No Vibrations Hard

  7. The “what” of LMRVT: Indirect therapy • Lean and mean • Hydration • Exogenous inflammation • Uncontrolled yelling and sceaming • georgeforemancooking.com georgeforemancooking.com

  8. 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). • Includes direct and indirect therapy. • Indirect therapy identical to LMRVT. • Direct therapy piece intended to be more “traditional” than LMRVT. susandwyerartworks.com

  9. Original idea for comparison tx • Quiet breathy (confidential) voice (that’s traditional!) • Idea was to offset communication impairment with QB/CV by training enhanced articulation (Lessac consonant orchestra). • Developed a program. revwheeler.wordpress.com

  10. 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!!!

  11. Janina Casper atsosxdev.doit.wisc.edu

  12. 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

  13. 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

  14. The birth of CBCFT • Oh great. relationship-economy.com

  15. 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

  16. Jackie Gartner-Schmidt (CBCFT)

  17. 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.

  18. 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.

  19. 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

  20. 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

  21. 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 2 3 1 4 5

  22. 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.”) FV = Easy Air all gone Not FV = Hard Air not all gone thatgamecompany.com

  23. 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

  24. 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.

  25. In greater detail regarding the “how” • Single training focus • Perceptual (introspective) • Attention to detail, especially around gestures’ effects • Exploratory not prescriptive • Literal training (specificity principle) • Flexible troubleshooting • It’s a “Spa Elf!”

  26. 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

  27. LMRVT and CBCFT (see manuals)

  28. 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

  29. Patient selection • Voice problem due to hyper- or hypoadduction • 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) • Usually some evidence of improved voice within first session

  30. Not appropriate populations • Hemorrhage (strongly contraindicated) • Immediate post-surgical • SD (probably won’t help; but see work by Connie Pike, SLP) • Parkinson’s disease (LSVT is appropriate; although see Florida work) • Gaping wide paralyses or otherwise huge glottal insufficiency (you won’t get anywhere)

  31. Other selection criterion • If you’re not already sick of it thenysehng.blogspot.com

  32. Data • R01 DC 005643 • Teachers with phonotrauma (most) or other phonogenic voice problem (e.g., MTD; a few) (mostly females) • Subjects run 2005-2009 • N=105 randomized (52 CBCFT; 53 LMRVT) • 4 wk therapy (2 back-to-back sessions/wk) • Follow-up immediately post tx, 3 mo post tx, and 1 yr post baseline • At 1 yr post baseline, N=40 CBCFT; 42 LMRVT)

  33. Primary outcome measure • Voice Handicap Index scielo.br

  34. Question • Where have you seen the curves on the preceding pages before? • Discussion.

  35. 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.com) chimneycricket.com

  36. Start with intake • Brief history • (Measures) • Baseline voice self-assessment (key as “anchor” for later daily ratings) • List of likely contributory causes (in Clinician and Patient Manuals • Goals (functional, medical, biomechanical) • Recommendations • Prognosis

  37. Set-up for therapy • Brief patient education about voice production, voice disorders • Personalized voice hygiene program pcna.net

  38. 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!)

  39. 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)

  40. 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?

  41. 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

  42. 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 Vocal hygiene:Screaming like crazy (bad)

  43. Direct therapy • Manuals and demos

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