Behavioral evaluation and treatment of dysphonia in the professional voice user are the responsibility of the speech-language pathologist. As a clinician, treating the professional voice user requires expert listening and management skills. Interdisciplinary team relationships are crucial for thorough care of this population. When treating the professional voice user additional information should be included while gathering the history because of differences in vocal demand and expectations when compared with the non-professional voice user. Voice therapy is patient-specific and when treating professional voice users it is necessary to consider previous training and use or rework current skills to enhance the therapy outcomes.
The practice of speech-language pathology includes prevention, habilitation, and rehabilitation of communication, swallowing, or other upper aerodigestive disorders; elective modification of communication behaviors, and enhancement of communication . The American Speech-Language-Hearing Association (ASHA) states that the speech-language pathologist should provide prevention, screening, consultation, assessment, treatment, intervention, management, counseling, and follow-up services for speech, voice, language, swallowing, cognition, and sensory awareness for communication, swallowing, and upper aerodigestive functions. In the area of treating voice disorders, the speech-language pathologist is concerned not with diagnosis and treatment of laryngeal diseases or other physiologic disorders, but rather with understanding, analyzing, and modifying vocal function.
If, perceptually, the voice is within normal limits for the patient and is being produced in a reasonably efficient, nonabusive manner, then intervention by a speech-language pathologist need not be conducted. It is not within the speech-language pathologist’s scope of practice to provide special training that develops range, power, control, stamina, and the esthetic quality required for artistic expression. The speech-language pathologist is concerned with the voice that presents with a current or potential problem, identifying and analyzing the problem, and then helping the voice user modify vocal behaviors to use the vocal mechanism with optimal efficiency. In the case of the professional voice user, increased demand and expectations for voice quality may be present and should be considered when judging normalcy of the voice. Responsibilities in ameliorating voice problems include: analyzing vocal behaviors perceptually and objectively; analyzing vocational, educational, and psychologic factors that may interact with vocal behaviors and precipitate, maintain, or exacerbate vocal difficulty; and designing and implementing an individual program for modifying vocal behaviors .
Similar to physicians and their subspecialites, speech-language pathologists vary in their backgrounds and experience in the treatment of voice disorders. Furthermore, the curricula that speech-language pathologists complete during education and training vary widely and typically only address normal and disordered voice production at a general level. Curricula rarely provide education or knowledge about the professional voice. Before making a referral to a speech-language pathologist for voice therapy, therefore, his or her background and training should be considered.
This article focuses on the speech-language pathologist’s treatment of voice disorders with special emphasis on the treatment of professional voice users. There are many factors to consider when working with professional voice users. The following is not meant to be an inclusive list but is intended merely to provide a framework of key considerations. Evaluation and treatment of a professional voice user requires increased sensitivity from the clinician. At first, when listening to the patient’s voice, it may sound normal. Sounding normal is relative, however. The professional voice user typically has increased awareness of minute changes in the voice production and quality. A speech-language pathologist must therefore be “super sensitive to super speaking.” The goals of the professional voice user or performer are typically different from those of a nonperformer and must be considered as such. With that in mind, it is important to learn the patient’s expectations and provide a realistic perspective on the possible outcome of therapy based on the diagnosis and response to trial therapy techniques during the initial assessment.
Further consideration must be given to body and self-awareness issues in performers versus nonperformers. Body and self-awareness, in this sense, refers to the patient’s awareness of his or her own behaviors and the ability to make changes as instructed. Professional voice users may have increased awareness of vocal behaviors, depending on their previous depth of training. Body and self-awareness are important skills to develop or maximize in the voice user. They aid the patient in developing, recognizing, and maintaining techniques for efficient voice use.
Environmental contributions also should be noted. As a professional voice user, the patient may be in detrimental performance situations that may not be obvious to a treating clinician. These may include poor acoustics while performing, interference of costumes and clothing, positional factors, and so forth, which can be significant contributing factors to suboptimal voice performance. The clinician must therefore ask specific questions or even attend a rehearsal or performance to make a complete assessment of conditions.
Psychologic factors also commonly contribute to voice problems. The voice can be described as an emotional part of each person. Studies by Fonagy, described by Sundberg , have indicated that articulatory and laryngeal structures and respiratory muscle activity patterns change in relation to 10 different emotions. This finding indicates an emotional/psychologic connection to the voice. Psychologic factors may be related to the patient’s response to the voice disorder and its effect on his or her life. Or, the voice disorder may be the manifestation of a larger psychological issue that is causing a voice disorder, as in psychogenic voice disorders. In either case, treatment should be tailored to the needs of each patient with careful history taking and thorough examination. The speech-language pathologist may act as a patient advocate speaking with the physician and acting as a catalyst for a referral to the appropriate psychologic professional as deemed necessary by the physician.
Emotional factors also can affect the patient’s overall response to the voice disorder. Is the patient able to cope with the voice disorder? How will it affect his or her current life, voice demand and expectations, and career? Are past vocal experiences, the diagnosis, or other people’s responses affecting therapy sessions or outcomes ? These basic questions should be addressed with the patient.
Treating voice patients requires the interaction of many disciplines. Patients and clinicians alike benefit from a team approach to the voice patient’s care. Treatment by an interdisciplinary team is important when treating anyone who has a voice disorder and crucial when treating the professional voice user. The members of the team may include a laryngologist, speech-language pathologist, singing voice specialist or singing teacher, acting voice specialist, voice researcher or scientist, singing coach, or psychologist ( Table 1 ). Relationships with other arts medicine specialists are also important, including neurologists, pulmonologists, gastroenterologists, endocrinologists, physiatrists, psychiatrists, and others.
| Title | Role |
|---|---|
| Laryngologist | Primary medical member of the team; responsible for diagnosis and medical/surgical intervention |
| Speech-language pathologist | Conducts evaluation and treatment of the voice problem by promoting efficient use of the vocal mechanism |
| Singing voice specialist | Develops singing technique and singing voice production; may be beneficial to a nonsinger in teaching more efficient breathing and coordination with voicing that can be carried over into speaking |
| Acting voice specialist | Focuses on honing vocal skills, such as projected speech, and communication skills as they relate to vocally demanding professions; typically used once a patient has become efficient in speaking voice production with a speech-language pathologist |
| The patient | The most important member of the team; the patient must be motivated to participate in therapy, knowledgeable about the voice disorder and techniques for treatment as instructed by the clinician, and involved in therapy decision- making and planning |
In some centers the interdisciplinary team may be in one facility, but not always. Whenever possible, it is beneficial for voice therapy and singing voice therapy to be completed by two different professionals. When this occurs adequate time is spent on both areas of the voice, the clinicians can work together to target areas in the speaking and singing voice, and each clinician can advise the patient within the area in which they are working, regardless of the individual background. If team members are not within the same facility it is important to build relationships within the community to maximize patient care.
In specific cases other specialists may be included in the interdisciplinary team. The voice researcher or scientist can provide valuable insight and perspective regarding the care of a voice patient because of his or her specific knowledge and skill set in acoustic measurement and voice production. Referral to a singing voice coach may also be useful following rehabilitation work with the speech-language pathologist and singing voice specialist. The singing voice coach is a valuable aid in the development of artistic style and repertoire for the voice user. A psychologist or psychiatrist may prove valuable in a team setting, providing the patient with counseling for the management of emotional reactions to the voice disorder along with psychologic issues that may have contributed to its occurrence. In addition, a physiatrist may offer contributions in the way of addressing areas of tension or other injury throughout the body.
Regarding the interdisciplinary team, singing and acting voice specialists, in addition to the singing coach, have no formal licensing or certification board. It is therefore important to understand that resources from community to community can vary widely, as can the backgrounds and knowledge of various voice professionals. For example, singing and acting voice teachers and coaches are not trained to work with the injured voice and therefore may not have experience in this area. Singing voice specialists and acting voice specialists are experienced teachers who have acquired such training, usually through apprenticeships.
The interdisciplinary approach to the treatment of voice disorders is increasingly important. Professional organizations are recognizing the development of these specialized relationships. ASHA has worked in conjunction with the National Association of Teachers of Singing and the Voice and Speech Trainers Association to present a joint statement, “The role of the speech language pathologists, the teacher of singing, and the speaking voice trainer in voice habilitation” . This statement is intended to encourage interdisciplinary treatment of voice disorders and to encourage professionals working with voice patients to work within the scope of practice and laws regarding treatment. It is important for professionals to stay within the bounds of their knowledge and remain within their area of expertise. ASHA has also worked with the Speech, Voice, and Swallowing Subcommittee of the American Academy of Otolaryngology–Head and Neck Surgery to generate a joint statement, “The use of voice therapy in the treatment of dysphonia” . This statement recognizes the importance of voice therapy in conjunction with medical and surgical management in treating voice disorders as supported by clinical research and expert experience. These statements should be used to advocate for speech pathology services to benefit the patients treated and the field as a whole.
Voice evaluation
The initial voice evaluation should include a thorough review of case history, performance of objective and subjective evaluation, trial therapy, and assembling initial impressions and recommendations. This evaluation provides the clinician with baseline information about vocal function, patient stimulability and possible therapy techniques and approaches, expectations of the voice user, and information from which to draw conclusions regarding success of therapy and possible outcomes.
Case history
A thorough case history should be elicited from the patient beginning with the onset and development of the voice problem and the circumstances under which it ensued. The patient’s previous or current medical diagnoses and treatments should be reviewed. The duration of the voice disorder and its constancy are also important factors. In some cases, voice problems can be intermittent over many years with the patient not having pursued treatment until the problem worsened significantly. Knowing this information can give the clinician perspective on the patient’s overall voice disorder. Whether or not the patient had received voice therapy previously should be documented. If so, when the treatment took place, its duration, techniques used, and whether previous treatment was effective should noted. These factors can indicate how receptive the patient will be to further intervention and how he or she will likely respond to different voice therapy techniques.
A complete inventory should be taken regarding vocal hygiene, including hydration and intake of drying agents; engagement in phonotraumatic behaviors, including yelling, shouting, loud talking, coughing, and throat clearing; exposure to other irritants, including smoking, exposure to secondhand smoke, and stage smoke; and behavioral factors that may include sleep patterns, overall rest, and environmental factors. In addition, vocal demands should be reviewed and the patient should provide examples of voice use during a typical day. Throughout this inventory, the patient should explain the primary vocal complaints so as to provide the clinician with a possible starting point for intervention. The patient’s initial concerns are addressed immediately and this may increase his or her motivation to continue therapeutic intervention.
Special factors must be considered when eliciting a history from a professional voice user. Learning vocal complaints as they relate to the performance voice can be helpful. The clinician should inquire about the history of professional voice use, whether it be singing, acting, public speaking, or a combination thereof. The clinician should also ask about the genre of music the patient is singing, voice classification, performance venues, and the size of his or her typical audience, if any. Knowing the extent of the professional voice user’s vocal training is also valuable, particularly when and how long he or she has studied, the specific school of training, and whether he or she is studying currently. This process provides information about the types of vocal techniques the patient may already use or be aware of, or those that may need to be developed or reworked further.
The clinician should request that the patient share his or her professional goals and expectations for voice. Ideally, voice therapy should be tailored to accommodate the patient’s professional and career goals concurrently with satisfying the clinician’s therapeutic objectives. Even though the singing voice specialist typically performs a more thorough evaluation of the complaints of a singer, the speech-language pathologist can play an important role in singing voice rehabilitation and development. The clinician can use knowledge of a patient’s background, education, and experience to assist in development of efficient daily speaking voice and in articulating the relationship between daily speaking routines and singing or stage voice.
Objective evaluation
Gathering and analyzing objective voice data is a crucial part of the complete voice evaluation. Completing pre- and posttherapy voice measures can supply objective data to assist in predicting therapy outcomes, to use in research, and to provide tangible voice statistics for use by insurance companies. The objective voice evaluation is discussed further in the article about laboratory and strobovideolaryngoscopy evaluation elsewhere in this issue.
Subjective voice evaluation
Respiration
The respiratory system is the source of power for voice production. Many voice problems can be related to poorly coordinated breathing. The clinician should pay special attention to the manner in which the voice user inhales and then exhales air to produce voice during the evaluation. Observation of the patient’s breathing pattern should be completed during reading and conversational speech. Breathing patterns that may be inefficient for voice production include clavicular breathing, upper thoracic breathing, or a combination of the two. So-called “diaphragmatic breathing” can be the most efficient breathing pattern because it tends to provide optimal balance of inspiratory and expiratory muscle use. Speaking on residual air, shortness of breath while speaking, gasping for air during inhalation, forced exhalation, or decreased airflow during phonation are also common indicators of vocal misuse.
Phonation
Phonation is defined as the production of sound at the level of the vocal folds. A perceptual evaluation of phonation (vocal quality, loudness and pitch) during reading and conversation should be completed. Vocal quality characteristics may include: hoarseness, breathiness, roughness, raspiness, vocal fry, diplophonia, voice breaks, pitch breaks, and others. Vocal intensity or loudness should be judged as appropriate, increased, or decreased for the particular setting. The pitch of the patient’s voice should be judged as appropriate, high, or low for the age and gender. In addition, the frequency of hard glottal attacks should be assessed.
Resonance
Vocal resonance refers to the way sound is shaped acoustically as it travels through the vocal tract. Phonation begins at the level of the vocal folds and moves up through the pharynx, oral cavity, and nasal cavity. Frontal resonance or forward focus of sound is ideal for most efficient voice production. It optimizes acoustics of the vocal tract while balancing oronasal resonance. The use of resonant voice therapy, which places emphasis on frontal tone focus, can increase perceived vocal loudness levels, which then may allow the voice to be heard better in noisy situations without excessive strain. Various resonance patterns may be observed while making a perceptual judgment of the voice, including oral, oropharyngeal, nasal, nasopharyngeal, and hypopharyngeal.
Posture
Body posture, how the body is held up against gravity, can have a direct effect on respiration, phonation, and resonance. Posture is a complicated interaction of muscle groups throughout the body. There are multiple disciplines that target body work to improve posture and overall wellness, including Alexander, Feldenkrais, Pilates, and Rolf . Posture should be assessed paying attention to placement of the hips, spine, shoulders, neck, head, jaw, and even tongue while at rest and in movement. Posture may be assessed statically in the sitting or standing position and in movement while walking, running, dancing, teaching, and so forth. Considerations should be made to observe the patient during activities in which they engage daily.
A brief explanation may be given to the patient so that posture can be better understood. While sitting, posture can be described as the feet resting flat on the ground, knees at a 90° angle, hips at a 90° angle, shoulders above the hips, and ears above the shoulders. The chin should be in a neutral position with the crown of the head as the uppermost point. At rest, the tongue maybe resting on the alveolar ridge or behind the bottom incisors and the jaw should be released. Postural adjustments should not produce stiff movement but should allow for relaxation within a position. Abnormal postures that negatively influence efficient voice production may include, but are not limited to: posteriorly tilted hips, a c-shaped spine, arching the lower back, high shoulder placement, rounded shoulders, forward chin placement, elevated chin placement, clenched jaw, or retracted tongue. Small adjustments made in posture may allow the larynx to relax in the anterior neck, permit easier breathing, and subsequently result in more coordinated voice production.
Articulation
A global assessment of articulation should be completed judging clarity and accuracy of articulatory movement for intelligible speech production.
Prosody
Prosody may have a subtle affect on voice production and should be assessed generally paying attention to the rhythm, fluency, rate, pauses, and intonation or inflection patterns used.
Muscle tension
Muscle tension can have an adverse affect on voice production causing vocal fatigue, pain, or changes in the ease and quality of voice production. Locating these areas of tension is vital in breaking patterns of tension and retraining efficient muscle patterns. Box 1 provides examples of general and specific areas where tension may occur.
