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1 Global Voice Therapy Model (GVTM): Components and Application OSLHA Convention Saturday, March 21, :45am-12:00pm Elizabeth Grillo, Ph.D., CCC-SLP Associate Professor Department of Communication Sciences and Disorders West Chester University, West Chester, PA Disclosure Statement Financial 1. Employee of West Chester University (WCU), West Chester, PA. 2. Pilot work funded by two WCU Faculty Professional Development Grants ( ) and ( ). 3. Royalty from NSS. Non-financial 1. Inventor of GVTM 2 Intellectual Property Information provided to you in this course through PowerPoint presentation is the intellectual property of the instructor and may not be reproduced without explicit permission of the instructor. 3 1

2 Introduction Overview Components of the GVTM Additional methods that augment and support the new voice Stimulability testing Treatment hierarchy New vs old voice Motor learning principles in the GVTM Research related to the GVTM Application of the GVTM 4 Learning Outcomes Participants will. 1. Describe the components of the GVTM. 2. Explain the motor learning principles applied to the GVTM 3. Understand the research supporting the GVTM. 4. Apply the GVTM to clinical practice. 5. Identify appropriate use of the GVTM in client examples and self-practice. 5 Introduction 2

3 Introduction Meet me Education Clinical Expertise Current Position 7 Statistics Voice disorders are the most common communication disorder. 7.5 million people in the USA (NIDCD, 2014) Across the of people will experience a voice problem, far greater than for other communication disorders (Roy et al., 2004) 8 Statistics By their sheer volume, voice disorders matter and deserve public attention. What s the best way to improve voice through voice therapy? What does the literature say? 9 3

4 Voice Rehabilitation Literature Voice production techniques for immediate improvement of vocal output. e.g., yawn-sigh (Boone & McFarland, 1993), twang (Estill, 2000; Lombard &Steinhauer, 2007), resonant voice (Stemple, 2000), increased airflow (Xu, Ikeda, & Komiyama, 1991), increased vocal fold adduction, loud voice, etc.) 10 Voice Rehabilitation Literature Clearly defined voice therapy models that are based on a specific voice production technique. e.g., LSVT (Ramig et al., 1994), accent method (Smith & Thyme, 1976), resonant voice therapy (Stemple, 2000), LMRVT (Verdolini-Abbott, 2008) 11 Voice Rehabilitation Literature What s missing from the literature? A model that promotes generalization and maintenance of the new voice to all spoken communication without relying on one specific voice production technique. 12 4

5 To Fill the Gap My Global Voice Therapy Model (GVTM) Grillo, E.U. (2012). Clinical investigation of the Global Voice Therapy Model. International Journal of Speech-Language Pathology, 14(2), Components of the GVTM Components of the GVTM Additional methods that augment and support the new voice Stimulability testing Treatment hierarchy New vs old voice 15 5

6 Additional Methods Vocal hygiene, vocal education, respiration exercises, vocal function exercises (Stemple et al., 1994), circumlaryngeal massage (Roy et al., 1997), etc. Anything that augments the target vocal output. 16 Stimulability Testing Have the client produce different techniques to see which one(s) facilitate the best vocal output. Grillo (2012) was the first and only study to address stimulability testing in voice. 17 Treatment Hierarchy Bottom-up from smallest unit of utterance up to the largest, while also increasing cognitive complexity. LSVT, LMRVT, accent method, and Stemple s resonant voice therapy all have a treatment hierarchy. Articulation and Fluency literature also support the use of a bottom-up tx hierarchy. (Secord, 1989; Van Riper, 1978; Van Riper & Emerich, 1984) 18 6

7 New vs. Old Voice Client produces new and old voice at all levels of the treatment hierarchy. On command by SLP Independently, SLP must guess the correct voice Grillo (2012) is the first and only study to address new and old voice ) What are the components of the GVTM? a. additional methods that augment and support the new voice, stimulability testing, treatment hierarchy, and new vs. old voice b. stimulability testing and "new" vs. "old" voice c. treatment hierarchy only 21 7

8 2) What are some examples of additional methods? a. vocal hygiene b. vocal education c. posture work d. relaxation exercises e. all of the above 22 3) Stimulability testing means that you always use one voice production technique for every client. For example, you use only resonant voice. a. true b. false 23 4) The treatment hierarchy begins at conversation. a. true b. false 5) When facilitating the "new" vs. "old" voice component, the client will produce both voices at each step of the treatment hierarchy. a. true b. false 24 8

9 Motor Learning Principles Motor Learning Principles Applied to GVTM Basic skill is acquired before increasing to a more complex pattern (bottom-up Tx. hierarchy) (Schmidt, 1975, 1976, 2003; Schmidt & Lee, 1999) Motor Learning Principles Applied to GVTM Treatment hierarchy is necessary to build from basic to complex utterances, while increasing cognitive load. Sentences Memorized speech acts Specific spontaneous speech acts slowly building instead of jumping from sentences to conversation. 27 9

10 Motor Learning Principles Applied to GVTM Negative practice of both old and new voice decreases likelihood that the person will return to the old pattern (Van Riper, 1978; Van Riper & Erickson, 1996) Negative practice. Self-awareness of both voices. 28 Motor Learning Principles Applied to GVTM Need for both blocked and random practice schedules (Lai & Shea, 1998; Lai et al., 2000; Shea et al., 2001; Wong et al., 2013) Motor Learning Principles Applied to GVTM Blocked and random practice schedules Blocked practice: ma 10 times in a row in the new voice, me 10 times in a row in the new voice Random practice: new and old voice at each step Do the blocked practice first. Client performs independently with 90% accuracy, then add random practice with old and new voice at the same level before advancing

11 Motor Learning Principles Applied to GVTM Blocked: Say 10 words in new voice Client independently meets goal at 90% accuracy. Random: Same 10 words, but now client produces them in either old or new voice 1) First on command by SLP & 2) Then independently and the SLP has to guess the voice. Client independently meets goal at 90% accuracy. 31 Motor Learning Principles Applied to GVTM Move up a step to phrases. Blocked: Say 10 phrases in new voice Client independently meets goal at 90% accuracy. Random: Same 10 phrases, but now client produces them in either old or new voice 1) First on command by SLP & 2) Then independently and the SLP has to guess the voice. Client independently meets goal at 90% accuracy. 32 Motor Learning Principles Applied to GVTM Blocked practice allows for faster acquisition of a new skill. Random practice promotes better generalization and maintenance to untrained items (Schmidt & Lee, 1999; Knock et al., 2000) The GVTM has both practice schedules. (Wong et al., 2013) 33 11

12 Motor Learning Principles Applied to GVTM Move up a step, etc. and so on 34 Motor Learning Principles Applied to GVTM Varying feedback depending upon the practice schedule. Blocked less often. Random more often (Wulf, 1991, 1992; Wulf & Schmidt, 1996) 35 Motor Learning Principles Applied to the GVTM Frequency of Feedback In blocked practice schedules, feedback after the 10 th word. In random practice schedules, feedback after every 2 or 3 words. This increased amount of feedback is necessary when first arriving at a step. As work proceeds at a step, amount of feedback may decrease. Make every effort to ask what they think first to develop their self-awareness skills. Consider recorded feedback. Play it back and ask what they think before offering your two cents

13 Motor Learning Principles Applied to the GVTM Pay attention to the effects of the mvt. rather than the individual body parts that form the movement. (Freedman et al., 2007; Lisman & Sadagopan, 2013; Wulf & Prinz, 2001) ) What are the two steps in the treatment hierarchy that are unique to the GVTM? a. memorized speech acts and specific spontaneous speech acts b. phrases and sentences c. monologue and conversation 39 13

14 2) What is an example of a specific spontaneous speech act? a. tell me what you did over summer vacation b. describe the outside of your house c. recite the Pledge of Allegiance 40 3) Producing the "new" voice at word level across 10 trials is an example of blocked practice. a. true b. false 4) Producing "new" and "old" voice at the word level is an example of random practice. a. true b. false 41 5) It is recommended to do what practice first to ensure acquisition of the new skill. a. blocked b. random 6) It is recommended to do what practice schedule after the new skill has been acquired at a certain step of the treatment hierarchy. a. blocked b. random 42 14

15 7) In blocked practice, you should provide more or less feedback. a. more b. less 8)In random practice, you should provide more or less feedback. a. more b. less 43 9) When training the new voice, you should focus on effects of the voice (e.g., what the new voice sounds like, what it feels like), rather than on the individual body parts that form the movement. a. true b. false 44 Research Supporting the GVTM 15

16 Learner Objectives You have met two of the Learner Objectives, 1. Describe the components of the GVTM. 2. Explain the motor learning principles applied to the GVTM Well done! Let s move on.. 46 Learner Objectives 3. Understand the research supporting the GVTM. 47 Question Will the GVTM facilitate an improvement in voice related measures (i.e., acoustic, aerodynamic, perceptual, and QOL) for 4 adult clients with voice disorders? (Grillo, 2012) 48 16

17 Methods 4 participants (i.e., 1 male and 3 females) 3 singers and 1 non-singer Diagnosed voice disorders; MTD, VF paresis, lesions (cyst and polyp) Voice therapy with me using GVTM once a week Sessions were minutes Total number of sessions ranged from Measures Pre- and post-treatment data collected Acoustic (F o, perturbation measures) Aerodynamic (LR, P s, airflow, MPT, s/z ratio) Self rating scales of vocal quality and vocal fatigue VHI 50 Results 51 17

18 Results 52 Results 53 Results 54 18

19 Results 55 Summary QOL improved post-tx as compared to pre-tx (VHI) Voice was more forward, facial, clear (increased F o and decreased NHR at post) Less effort with better movement of air (MPT and flow increased at post) Pre- and post video as example #2 pre (:48-1:23) #2 post (:55-2:20) 56 Summary Continued By 2 nd session, even non-singer using new voice in connected speech. Why so fast? New versus old at each step? Did I answer my question? 57 19

20 Future Directions Investigate why the fast result? Is it new versus old? Larger participant number with varied types of voice disorders Introduce more control through a control group or single-subject design with multiple baselines. Involve other clinicians to assess generality of the GVTM Compare GVTM to other Tx models 58 Prevention Prevention arm of Global Voice: Global Voice Prevention Model Same components Focused right now on teachers, physical education and vocal music student teachers. Past work (Grillo & Fugowski, 2011) Recent survey (Grillo, 2013) Pilot study of GVPM (Grillo, 2013) 59 Survey Participants: 74 PE undergraduate seniors 29 women, 45 men (average age 23 years) Administered during the 12th week (i.e., November) of the fall semester participants were student teaching 32 participants were finishing academic courses and had plans to begin student teaching spring semester

21 Survey There appears to be a disconnect of understanding Almost half said that teaching negatively effects voice, almost a third said they may develop a voice problem due to teaching, and only 17% thought a voice course/seminar was needed to learn strategies to prevent a problem. Why? Pilot Study They need vocal education, hygiene, and training presented through a voice disorders prevention model. Thus, the GVPM Pilot Study Two participants (one male and one female) completed the GVPM over 6 weekly 45- minute sessions. 2 sessions recorded pre- and post-data collection measures. Therefore, 4 sessions were dedicated to the GVPM

22 Pilot Study 64 Pilot Study 65 Pilot Study 66 22

23 Pilot Study Self-rating Scales Female Pre=Voice feels fatigued before talking for the day (mild problem) Pre=Overall, my voice is better after talking all day Pilot Study Self-rating Scales Female Post=No reports of fatigue Post=Overall, my voice is better now than before doing the GVPM Pilot Study Self-rating Scales Male Pre, overall, no problems with quality, strain or fatigue Post, overall no problems with quality, strain or fatigue Overall, my voice is better now than before doing the GVPM

24 Pilot Study: Summary Participants reported using his/her new voice during the week prior to the post-gvpm data of the time of the time (male). Male commented that he has less strain in his voice when talking over background noise at a bar or restaurant. Male s girlfriend noticed a positive change in his voice by the end of the GVPM. 70 Samples Pre-Post Videos Subject 1 voice attitudes (0:00-0:50) pre Subject 1 E Final Interview (0:00-1:35) post Subject 2 voice attitudes (0:00-0:30) pre Subject 2 Final Interview (0:00-1:45) post New vs Old Voice Session 3 (22:13-26:27) Healthy Yelling Training Session 4 (20:00-21:46)

25 1) Was the GVTM successful in improving voice related measures of four participants? a. true b. false 2) What were the results? a. VHI scores decreased at post-therapy b. F o increased at post-therapy c. participants reported better movement of air at post-therapy d. all of the above 73 Application of the GVTM Learner Objective You have met one of the Learner Objectives, 3. Understand the research supporting the GVTM. Well done! Let s move on

26 Learner Objectives 4. Apply the GVTM to clinical practice. 76 Goals We will apply each component of the GVTM through goals with client examples. Long-term goal (medical setting) = Goal (educational setting) Short-term goal (medical setting) = Objective (educational setting) 77 Long-Term Goal Client will return the voice to a level of adequacy that can be realistically achieved and that will satisfy the client s occupational and social needs in all spoken communication with 90% accuracy. FYI, you can substitute occupational with educational for children. This goal should be achieved in 4-6 weekly sessions

27 Short-Term Goal #1 Vocal Education Goal Client will demonstrate an understanding of the 3 interactive structures for voice production by verbal explanation to clinician with 90% accuracy. (5 minutes in first session) OR by answering 9/10 questions correctly. 79 Rationale. Short-term Goal #1 Where would you put this goal in my GVTM? 80 Examples: #4 1:00-2:32, #2 00-2:49, Fundamentals of Voice Therapy 81 27

28 Put it all together Describe how you will achieve a better voice based on power, source, and filter interactions. For example, atrophy vs. nodules 82 Short-Term Goal #2 Vocal hygiene goal Client will utilize vocal hygiene strategies throughout his or her day in 9 out of 10 opportunities. (5-10 minutes first session) OR Client will demonstrate understanding of vocal hygiene strategies by answering 9/10 questions correctly. Rationale. Hydration matters (Titze, 1988; Verdolini-Marston, Sandage, & Titze, 1994; Verdolini, Titze, & Fennel, 1994). Need to create the best possible environment for phonation. 83 Short-term Goal #2 Tailor vocal hygiene strategies to meet the needs of the client. Where would you put this goal in my GVTM? 84 28

29 Introduce Vocal Hygiene Based on disorder May be different for hyper versus hypofunctional oz. of water a day Don t clear throat (silent cough) Decrease talking in loud background noise Use other methods to get someone s attention instead of yelling Take reflux meds., elevate HOB Last meal, three hours before you lay down 85 Introduce Vocal Hygiene Continued Stop smoking (decrease exposure) Good posture Minimize caffeine Use microphone when teaching Use headset if on the telephone a lot Relax!!! Warm-ups and cool-downs Healthy Yelling Strategies 86 Vocal Hygiene for Performers Warm-up your voice before singing, acting Limit alcohol before performing If in a smoky bar, have tons of water with you. Monitor speakers for singer in a band Don t have milk or chocolate before performing The day of your performance, save your voice

30 How will the client monitor vocal hygiene? A diary or self-monitoring schedule How many times a day are you filling up your water bottle? A rubber band on wrist for throat clearing. Decrease smoking this week by half a pack. For every cup of caffeine, have a cup of water. 88 Vocal Hygiene STG Example (#4 2:32-7:10) 1 st session 90 30

31 1) This is an appropriate long-term goal for your client. "The client will use the "new" voice in words with 90% accuracy." a. true b. false 2) In writing a long-term voice goal for a child in a school setting, it is important to think about what? a. academic/educational impact b. occupational impact 91 3) This is an appropriate vocal hygiene shortterm goal. "The client will use vocal hygiene strategies." a. true b. false 92 4) Vocal hygiene could include the following: a. Hydration b. stop or decrease smoking c. treatment for reflux issues d. strategies to conserve the voice throughout the day e. vocal warm ups f. all of the above 93 31

32 5) This is an appropriate vocal education short-term goal. "The client will understand how the voice works." a. true b. false 6) Vocal education could include the following EXCEPT: a. hydration b. how the "new" voice is produced c. how the "old" voice is produced 94 Short-Term Goal #3 Stimulability Goal Client will participate in a stimulability exercise to achieve the best possible voice given the client s anatomic, physiologic, and psychological capabilities. (5-10 minutes in first session) 95 Short-term Goal #3 Rationale. Where would you put this goal in the GVTM? 96 32

33 What techniques should we use? Try different techniques. What makes the voice sound the best???? Try techniques based on the client s baseline phonation pattern. Resonant voice, twang, increased vocal fold adduction, increased airflow, pitch variability, etc. Stimulability example Disc 2 (1 of 2) 7:00-10:18 97 Voice Therapy Techniques Head or facial resonance Chest Resonance Twang Resistance (aka glottal attacks) Loud voice Increased airflow or yawn-sigh Chanting or sing-song Increased pitch variability 98 Voice Therapy Techniques Coughing and throat clearing Estill s work Just to name a few, the list could go on

34 Combination of techniques Some of the techniques are usually combined in treatment. For example, resonant voice with increased pitch variability and chanting. 100 Head or Facial Resonant Voice Used with most hyperfunctional voice disorders Increase airflow and decrease muscle Usually forward focus. Decrease tension (laryngeal massage) Minimizes vocal fold impact Barely ab/aducted VFs (Berry et al., 2001; Verdolini et al., 1998) Minimum respiratory effort for phonation 101 Head or Facial Resonant Voice Hummmmm.. (bring voice forward) Feel buzz on lips Feel sinuses vibrate Can use singing to facilitate When Humming, your VFs are getting a massage youuuuuuu Buzz on palate moves to lips and mouth

35 Head or Facial Resonant Voice Humming into me,me,me, More,more,more Maybe Monday Is the client able to carry-over the new voice into these words? Do you like the voice quality the client is achieving? Resonant voice will combine with chanting or sing-song and pitch variability. Can the client discriminate the old from the 103 new voice? Pitch variability and chanting or sing-song Pitch variability: opposite of monotone. Why is this important for the health of the VFs? Sing-song: opposite of hard glottal attacks Words are connected to one another. It is easier to maintain resonance with pitch variability and a sing-song quality. 104 Head or Facial Resonant Voice Demonstration

36 Chest Resonance Same benefits from Head or Facial Resonance, just not placed high in face. Placed in chest, while still maintaining a forward focus. Combine with pitch variability and sing-song. Use /h/ initial words, hello, how are you? Use humming Can the client carry-over the new voice into single-words? Can the client discriminate between the old and new voice? Do you like the voice quality with the new voice? 106 Demonstration Chest Resonance 107 Twang Extreme form of oral or nasal resonance Most successful with paralysis or paresis clients. I have used it with VF scar and cyst. Creates a pocket of resonance above the vocal folds by A-P squeeze. (Lombard & Steinhauer, 2007) Ask your client to cackle like a witch, tease like a kid Place your voice in your mouth. Slam it against the back part of your face or mouth More and more.maybe Monday

37 Twang Can the client transfer the voice to other words? Can the client distinguish between the old and the new voice? Do you like the voice quality? Demonstration 109 Resistance Therapy (aka glottal attacks) (developed by Lori Lombard, Ph.D.) Used with hypofunctional voice disorders Decrease airflow and increase muscle Focus is back bottom of throat Uh, uh, uh, uh: Try and limit to just VFs Cue client to relax tongue, drop jaw Facilitator phrases are ones with hard onsets (over and over, on and on, up and down, always and always) Can use throat clear or cough 110 Resistance Therapy Can the client carry-over the new voice to other phrases? Again, new versus old voice? Do you like the new voice quality? Demonstration

38 Loud Voice Loud Voice is the technique used in LSVT. Developed for people with Parkinson s Disease (PD) (Ramig et al., 1994). Think LOUD Daily variables practiced 3 times a day. Repetition and calibration are the most important aspect of LSVT. Use Loud Voice as a technique, but apply to the GVTM. I have used loud voice with PD and other types of neurological disorders. Demonstration 112 Increased Airflow or Yawn-Sigh Used with Hyper-Functional Drops larynx and widens the glottal opening during voice (Boone & McFarland, 1993) Incorporate this into resonant voice therapy or relaxation therapy 113 Chanting or Sing-song Eliminates hard glottal attacks, reduces vocal fold impact stress Try on one pitch at first, then move to varying the pitch Used with hyper-functional voice

39 Increased pitch variability Incorporate with other techniques Helps client to stay out of glottal fry zone ROM for the VFs 115 Coughing and Throat Clearing Used for hypo-function, specifically puberphonia, psychogenic (MTA). Facilitate a cough into a vowel Facilitate a cough into a lip trill Lip trill on a pitch (will get voice) 116 Estill s work

40 118 1) Head or facial resonance facilitates what a. barely ab/adducted vocal folds b. hard glottal attacks c. more muscle effort and less airflow 2) Resistance therapy (aka glottal attacks) facilitates what? a. more muscle, less airflow b. better vocal fold adduction during phonation c. all of the above 119 3) Twang facilitates what? a. better resonance by narrowing the epilarynx in an anterior-posterior configuration b. better respiratory support for phonation

41 4) When choosing the techniques for stimulability, you must have an understanding of the physiology of the client's baseline phonation pattern and how the "new" voice technique will improve upon that pattern. a. true b. false 121 Something works, now what? Short-Term Goal #4 Client will produce the new voice in syllables, words, phrases, sentences, memorized speech acts, specific spontaneous speech acts, monologue, and conversation with 90% accuracy. (the rest of the first session and into the 2 nd, 3 rd, and 4 th sessions) Rationale Blocked practice

42 Short-Term Goal #4 Where does this goal fit in my GVTM? Example: #4 25:27-26:05 1 st session Disc3 3 of 6 (0:00 3:25) 124 Short-Term Goal #5 Client will produce the new and the old voice in syllables, words, phrases, sentences, memorized speech acts, specific spontaneous speech acts, monologue, and conversation with 90% accuracy. (the rest of the first session and into the 2 nd, 3 rd, and 4 th sessions) 125 Short-Term Goal #5 Rationale: Negative practice may facilitate faster generalization and maintenance, which allows for quick movement through the hierarchy. Random practice How? Because self-awareness of voice is happening through auditory & kinesthetic feedback. And it offers random practice (Grillo et al., 2010) Where does this goal fit in my GVTM? Example: (#4 32:53-36:20) 1 st session Disc3 4 of 6 (whole track 3:50)

43 Methods for spontaneous speech Self-monitoring schedule, taped conversations Think about the new voice before you pick up the phone, sign on desk Role play on phone and in conference hall Role play with children in therapy room, but move out to other settings in school or home Observe child in classroom, hallways, lunch, etc. 127 Short-Term Goal #6 Client will maintain the new voice over a 2- week break period from voice therapy with 90% accuracy. Rationale: Let s see how they do away from you for 2 weeks before cutting the cord. If not good, then keep them. If good, then client met Long-Term Goal No further concerns, d/c from Tx

44 1) This is an appropriate short-term goal for blocked practice in the treatment hierarchy. "The client will produce "new" and "old" voice in memorized speech acts with 90% accuracy." a. true b. false 130 2) What are the steps in the treatment hierarchy? a. technique level, words, phrases b. technique level, words, phrases, sentences c. technique level, words, phrases, sentences, memorized speech acts, specific spontaneous speech acts, monologue, and conversation 131 3) This is an appropriate short-term goal for the "new" vs. "old voice component with random practice. "Client will produce "new" and "old" voice in words with 90% accuracy." a. true b. false

45 4) What component has blocked practice built in? a. treatment hierarchy b. new" vs. "old" voice 5) What component has random practice built in? a. treatment hierarchy b. new" vs. "old" voice 133 Client Examples and Self-practice Learner Objective You have met one of the Learner Objectives, 4. Apply the GVTM to clinical practice. Well done! One more to go

46 Learner Objective 5. Identify appropriate use of the GVTM in client examples and selfpractice. 136 Case #1, What s the long-term goal? What are the short-term goals? What techniques will you try? Disc 1, Track 12 of 12 (0:00-1:40) 2 nd session Disc 3 1 of 6, (0:00-4:10) This is what he sounded like when he walked in to the 2 nd session. What do you think? 137 Self-Practice From the STGs that you will address in that first session, what types of methods will you use to target the goal? Vocal hygiene methods for children and adults. How will you ensure mastery or use of the methods? Vocal education methods for children and adults. How will you ensure mastery?

47 Self-Practice By the way, in what component of the GVTM can we find vocal hygiene and education? Self-Practice Stimulability Exercise In what component of the GVTM can you find stimulability? Your turn. Pick a partner and try different voice production techniques, resonant voice, yawnsigh, glottal attacks, loud voice, twang, etc. Can you get carry-over of the new voice into phrases? Self-Practice Now, that you found a technique that you want to use, let s do treatment hierarchy and new vs. old voice. Your turn

48 Case Studies What goals am I addressing and why? Disc 1 5of12 (4:00 to the end) Disc 1 6of12 (0:00 to 5:10) Your client: Disc 1 1of12 (0:00-1:10) (old voice) What would you do for stimulability? This is the new voice Disc 1 2of12 (3:40-to the end) 142 Your client Sally, 40 y/o female, has been diagnosed with a vocal fold paresis. Her average airflow is 300 ml/sec. She complains that she can t project her voice and it is too breathy. What are you going to do? Use the GVTM. State your goals and why. What techniques for stimulability? 143 Your client Michael is a 12 y/o male. In school, kids are teasing him because of his voice. His pitch is too high. Teachers are having trouble hearing or understanding him because of his voice. Michael is not participating in class because he is ashamed of his voice. His parents took him to a laryngologist and she diagnosed puberphonia. Voice therapy was recommended. What are you going to do? Use the GVTM. State your goals and why. What techniques for stimulability?

49 Your client Mary, 40 y/o female, with bilateral vocal fold nodules. She is a teacher. Her voice is hoarse, runs out on her by the end of the day. What are you going to do? Use the GVTM. State your goals and why. What techniques for stimulability? Your client Jessica, 6 y/o female, in 1 st grade. Voice is negatively affecting her academic performance. Teachers can t understand her when she talks because of hoarseness. Kids are teasing her. She speaks less and less during school. Diagnosed with bilateral vocal fold cysts. Parents reported that she has always sounded like this. Mom sounds the same. What are you going to do? Use the GVTM. State your goals and why. What techniques for stimulability? Learner Objective Congratulations! You met the final Learner Objective: 5. Identify appropriate use of the GVTM in client examples and self-practice

50 To Recap Look at all that you achieved! You can now: 1. Describe the components of the GVTM. 2. Explain the motor learning principles applied to the GVTM 3. Understand the research supporting the GVTM. 4. Apply the GVTM to clinical practice. 5. Identify appropriate use of the GVTM in client examples and self-practice Thank You for Your Participation! 149 References Berry, D.A., Verdolini, K., Montequin, D., Hess, M.M., Chan, R., Titze, I.R. (2001). A quantitative output-cost ratio in voice production. Journal of Speech Language Hearing Research, 44, Boone, D. R., & McFarland, S. C. (1993). A critical review of the yawnsigh as a voice therapy technique. Journal of Voice, 7(1), Estill, J. (2000). Level one primer of basic figures. Santa Rosa, CA: Estill Voice Training Systems. Fant, G. (1960). Acoustic theory of speech production. The Hague: Mouton. Freedman, S.E., Maas, E., Caligiuri, M.P., Wulf, G., & Robin, D.A. (2007). Internal versus external: oral-motor performance as a function of attentional focus. Journal of Speech Language Hearing Research, 50(1), Grillo, E.U. (2012). Clinical investigation of the Global Voice Therapy 1116 Model. International Journal of Speech-Language Pathology, (2),

51 References Grillo, E.U. (2013). Voice Disorders Prevention Program for Physical Education Student Teachers. Invited poster presentation at the American Speech Language Hearing Association s (ASHA) annual convention (November 2013), Chicago, IL. Grillo, E.U. & Fugowski, J.M. (2011). Voice characteristics of female physical education student teachers. Journal of Voice, 25 (3), Grillo, E. U., Perta, K., & Smith, L. (2009). Laryngeal resistance distinguished pressed, normal, and breathy voice in vocally untrained females. Logopedics Phoniatrics Vocology, 34(1), Grillo, E. U., & Verdolini, K. (2008). Evidence for distinguishing pressed, normal, resonant, and breathy voice qualities by laryngeal resistance and vocal efficiency in vocally trained subjects. Journal of Voice, 22(5), References Grillo, E. U., Verdolini Abbott, K., & Lee, T. (2010). Effects of masking noise on laryngeal resistance for breathy, normal, and pressed voice. Journal of Speech, Language, and Hearing Research, 53(4), Jacobson, B. H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, F., Benninger, M. S., & Newman, C. W. (1997). The Voice Handicap Index (VHI): Development and validation. American Journal of Speech-Language Pathology, 6, Knock, T., Ballard, K., Robin, D., & Schmidt, R. (2000). Influence of order of stimulus presentation on speech motor learning: A principled approach to treatment for apraxia of speech. Aphasiology, 14, Lai, Q., & Shea, C.H. (1998). Generalized motor program learning: Effects of reduced frequency of knowledge of results and practice variability. Journal of Motor Behavior, 30, References Lai, Q., Shea, C.H., Wulf, G., & Wright, D.L. (2000). Optimizing generalized motor program and parameter learning. Research Quarterly for Exercise and Sport, 71, Lisman, A.L., & Sadagopan, N. (2013). Focus of attention and speech motor performance. Journal of Communication Disorders, 46(3), Lombard, L. E., & Steinhauer, K. M. (2007). A novel treatment for hypophonic voice: Twang therapy. Journal of Voice, 21(3), National Institute on Deafness and Other Communication Disorders (NIDCD). (2014). Statistics on Voice Speech and Language. Retrieved January 29, 2014, from:

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