Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Slide 1
SWO SLP Stroke Network
November 14, 2013
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 2
Role of ENT in treating voice disorders
Typical voice disorders associated with stroke
Treatment strategies for various voice difficulties
Signs that there may be “something else” going on
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 3
What is voice?
Voice Disorders Associated With Stroke
Instrumental assessment of Voice – need for visualization
Developing a Clinical Framework for Assessment or Treatment
Problem Solving
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 4
Considering Definitions and
Conceptualizing a structure for guiding assessment and treatment
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 5
VOICE
Where art...
Meets science
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 6
Body (Position & Tension)
Respiration
Phonation
Resonance
Articulation
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 7
Knowledge of:◦ Anatomy
◦ Physiology
◦ Aerodynamics
◦ Acoustics
◦ Laryngeal Pathology
◦ Etiological Correlates
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 8
A voice is a human gift; it should
be cherished and used, to utter
fully human speech as possible.
Powerlessness and silence go
together. Margaret Atwood
Words mean more than what is set
down on paper. It takes the human
voice to infuse them with shades of
deeper meaning.” Maya Angelou
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 9
SLP needs knowledge of:◦ Broader importance of
communication
◦ Mind-body connection
◦ Counselling and Motivation techniques
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 10
Normal voicing◦ Balance in respiration, phonation, resonance
◦ Appropriate quality, pitch and loudness
Achieving the best possible sound with the least amount of effort
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 11
Voice Disorder◦ Quality, pitch and loudness
◦ Similar age, gender, cultural background or geographical location
◦ Structure, Function or Both no longer meet voicing requirements
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 12
Identify the causes of the Voice Disorder
Describe the present Vocal Components
Develop an Individualized Management Plan
Informed by knowledge of anatomy, physiology, pathology and etiological factors
Informed by patient factors
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 13
Setting goals based on the physical limitations of the mechanism
Setting goals based on the client
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 14
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 15
Nothing specific for “stroke” Class 7000 – neurological disorders affecting
voice 7100 PNS pathology
SLN, RLN, myasthenia gravis, peripheral neuropathy, enhanced physiologic tremor
7200 Movement Disorders SD, dystonic tremor, essential tremor, orofacial dystonia,
tardive dyskinesia, Tourette’s
7300 CNS pathology ALS, Wallenberg, PD, PSP, MS, cerebellar disorders, HD,
central bilateral laryngeal nerve paralysis, myoclonus
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 16
Wallenberg’s syndrome
Mutism (?)
Any type of dysarthria
Voice issue is one of strength or coordination
Consider factors true for any “voice” patient
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 17
Age Male Female All
45-64 years polyps edema polyps
polyps edema
nodules cancer
Older than 64 years
Vocal fold paralysis
Vocal fold paralysis
Vocal fold paralysis
Cancer
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 18
Pre-existing History Past history of voice, cough, airway issues
Medications Dryness, cough, atrophy (www.ncvs.org)
Mental Health Anxiety, depression
Cognitive Function Concern, compliance
Dryness Systemic Environmental
Reflux Smoking History Hearing (or accuracy of perception) Other
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 19
Need for direct visualization OR how hard should I work for an ENT referral?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 20
Assessment of laryngeal structure & function Glottic closure status
Laryngeal pathology
Muscle tension patterns
Reflux
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 21
Cancer Paralysis/paresis/bowing Nodules, polyps or other mass adding lesion
Edema
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 22
Paralysis/paresis
Bowing
Vocal nodules
Vocal polyps or polypoid change
Granuloma
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 23
Compensatory for glottal closure issue
Primary issue related to imbalance in phonatory system
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 24
GER – gastroesophageal reflux
LPR – laryngopharyngeal or “silent” reflux
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 25
Ideal World vs Reality
Rule in or rule out pathology or malfunction Clinically no clear voice in any situation
Strong suspicion of reflux Option for medical intervention “on spec”
Patient (or clinician) frustration Limited improvement in face of cooperation and
motivation
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 26
Assessment or Treatment
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 27
Voice Skills Approach
Christina ShewellMotor Speech Assessment Rosenbek & LaPointe
Body Posture, movement, muscle tension,
sensation, health & exercise
Breath Placing & control
Channel Face, lips, jaw, tongue, soft palate,
pharyngeal, laryngeal
Phonation quality
Resonance Head, oral, chest resonance
Pitch Centre, range, intonation
Loudness Conversational, variety, control, emphasis
Articulation Clarity, pace, pause, fluency, rhythm
Posture/Tone/Strength Respiration Phonation Resonation Articulation Suprasegmentals &
prosody Need for AAC
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 28
Muscular Release
Breathing for Speech
Body Position
Voice Care & Education
Singing Oral Presentation
Reading
Vocal Basics
Beyond the Basics
Foundation for Voice
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
Producing the best voice possible with the least
amount of effort
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 29
Setting goals based on the physical limitations of the mechanism
Setting goals based on the client
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 30
Back to the history Past history of voice, cough, airway issues
Medications Dryness, cough, atrophy (www.ncvs.org)
Mental Health Anxiety, depression
Cognitive Function Concern, compliance
Dryness Systemic Environmental
Reflux Smoking History Hearing (or accuracy of perception)
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 31
A word about “posture”
Ambulatory?
Trunk control
Spinal flexibility
Head/spine relationship
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 32
Issues of muscle tone Flaccidity
Spasticity
Issues of excess muscle tension in face of normal muscle tone
Positioning
Stretching
Massage
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 33
Respiratory compromise
Habitual patterns
Role of body
Role of tension – especially jaw
Karaoke anyone?
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 34
Defining resonance
Impact of nasal air escape on voice
Impact of nasal air escape on articulation
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 35
Articulation and voice relationships
Articulation, rate and tension
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 36
What are the indicators that something else may be going on?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 37
Therapy outcome Unexplained deterioration in vocal quality Increased effort to voice Changes in other aerodigestive areas
Increased mucus
c/o bad taste, sore throat, bad breath
Globus, need to throat clear, difficulty swallowing
Increased “asthma-like” symptoms
Voice “cutting out” or sensation of choking or being unable to breathe (especially overnight)
Other
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 38
Re-visiting the “boxes”
Patient factors
Background factors
Trusting your clinical intuition
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 39
www.ncvs.org – check your medications tab
www.voiceproblem.org – reliable information on voice pathology; good section on reflux as it relates to voice
Christina Shewell’s “Voice Work: Art and Science in Changing Voices” Published in 2009 by Wiley-Blackwell – excellent resource for therapy options
Meribeth Bunch Dayme’s “The Performer’s Voice: Realizing your vocal potential”. Published in 2005 by WW Norton & Company – great anatomy & systems review (simple drawings) and good basic vocal training
Colton, Casper & Leonard’s “Understanding Voice Problems: A physiolgoical perspective for diagnosis and treatment” (3rd ed). Published in 2006 by Lippincott Williams & Wilkins – more academic discussion of neuroanatomy of voice & discussion of voice issues in dysarthrias and other neurological disorders
Lori Holmes, M.Sc.
Speech Language Pathologist & Voice Coach
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________