Voice Therapy

Jarrad Van Stan, PhD, CCC-SLP

Voice Disorders Course

MGH Institute of Health Professions

November 8th and 15th, 2023

 Disclosure slide
I am 1 of 9 copyright holders on the Manual for
Rehabilitation Treatment Specification

Salary from Massachusetts General Hospital

*The content of this presentation is solely the

responsibility of the authors and does not necessarily
represent the official views of the National Institutes of
Health or the Patient Centered Outcomes Research
Institute*
Collaborators
Rehabilitation Treatment Specification System (RTSS)
• Christine Chen, Marcel Djickers, Mary Ferraro, Tessa Hart, Andy
Packel, Lyn Tursktra, John Whyte, Jeanne Zanca
Voice Therapy Taxonomy and/or RTSS-Voice
• Julie Barkmeier-Kraemer, Patricia Doyle, Joseph Duffy, Shirley
Gherson, Robert Hillman, Lisa Kelchner, Jason Muise, Brian
Petty, Nelson Roy, Joseph Stemple, Susan Thibeault, Carol
Tolejano
Ambulatory Voice Monitoring and Biofeedback
• Robert Hillman, Dagmar Sternad, Andrew Ortiz, Daryush
Mehta, Annie Fox, MGH Voice Center Clinical Staff
Problem in rehabilitation treatments
The ”black box” of voice therapy Innovation

Jarrad’s
Everyday
Voice
Therapy

• What part of my therapy made the biggest impacts on

my patient’s vocal functioning?
• If you achieve great outcomes consistently, how can you
impart that to others?
• How can researchers look at your clinical Rehabilitation Treatment
documentation and figure out what is working (or not)? Specification System!
• All of these require better labeling!
Method to identify/test ingredients
• As pharmacology has fostered the identification and isolation of treatment
ingredients, the Rehabilitation Treatment Specification System (RTSS) is based on
pharmacology-like rules to identify and isolate behavioral treatment ingredients

• How do we change patient functioning?

• According to the RTSS, treatment must be studied according to a 3-part treatment

component:
Ingredients Mechanism of Target
Action
• What the • How the • Aspect of
therapist treatment is functioning
does (or expected to directly
selects) work targeted for
change
Hart et al., 2019 Archives of PMR
Method to identify/test ingredients

PHARMOCOLOGY

O D
TH
E
M
Willow bark TARGETS:
Decreased pain
(with a high dose)

Decreased blood
coagulation
(with a low dose)

INGREDIENT: Salicyclic Acid (Aspirin)

Method to identify/test ingredients
Rehabilitation
Treatment
Willow bark Specification System
O D
TH
E
M Decreased anterior
Apply pressure to the anterior neck
neck muscle
(not during voicing)
activation at rest

Voice Vocal practice (resonance, airflow) Decreased overall

Therapy Provide feedback on performance dysphonia
Approach
Provide information on the
Improved adherence
importance of home exercise program
Treatment Groupings

• We have defined 3 groups that we believe:

• Encompass, together, everything that might be done TO or WITH a patient in
rehabilitation; and
• Are mutually exclusive as to the kinds of targets they include and the kinds of
active ingredients that must be employed to change them.

The three treatment components are [1] Organ Functions, [2] Skills
and Habits, [3] Representations
1. Rely on physical mechanisms (eg. If you play a noise loudly in someone’s ear, they will
speak louder)
2. How accurately does someone do something – learning by doing. Most common for
Speech therapy
3. Neural representations – mood, emotions, propensity to do something they ask you to
do.
Group I: Organ Functions
Targets Changed or replaced organ functions

Mechanism of Varies by organ system: Up- or down-regulation of system;

Action passive learning mechanisms; replacement of organ with
artificial one; tissue stretch
Typical Ingredients Varies by organ system: energy applied to soft tissues;
exercise schedules for strengthening/ endurance training;
stimulus exposure parameters for habituation; devices for
organ replacement

Clinical Examples Endurance training, expiratory muscle strengthening,

tracheoesophageal prosthesis (TEP), masking noise, many
types of massage
Group I: Organ Functions

Examples of Organ Functions Treatments

Ingredient Mechanism of Action Target

Apply pressure to the Increased sarcomere Decreased suprahyoid muscle

suprahyoid region  length  activation (LMT)3
Laryngeal massage
Repeatedly exhale Increased number of Increased max expiratory
against pressure  sarcomeres  pressure during cough (EMST)4

Apply multi-talker
babble noise in the ear Reflexive Lombard Passively acquired increased
 effect  loudness (SpeechVive)5
during voicing
Group II: Skills & Habits
Targets • Improved ability to perform skills (Both mental and
physical tasks)
• New habits

Mechanism of Learning by doing

Action
Typical Ingredients Provision of opportunities for repeated practice (with or
without increasing demands); instruction, cues, guidance,
feedback, etc.
Clinical Examples Resonant voice training, Flow phonation, training in use of a
TEP or amplification device, training in the use of a chin tuck
swallowing maneuver, training in habit formation
Group II: Skills & Habits
Examples of Skills & Habits Treatments
Ingredient
Provide opportunities to
practice sustained, soft
voicing at a specific pitch
using an /ol/ buzz
Provide opportunities to
practice sustained, loud
voicing at a specific pitch on
an /a/ at 8/10 effort
Provide opportunities to
practice switching between
their old/disordered voice
and their new/improved voice
Mechanism of Action Target
Sustained phonation of a
specific time based on vital
  capacity divided by 80 mL/s
Learning (VFE)6
by
  Increased loudness (LSVT)7
doing
Increased accuracy switching
  between old and new voicing
(CLM8, CTT9)
 Mindfulness is part of this!

Group III: Representations

Targets Amount, completeness, accuracy of knowledge;
changes in attitudes, beliefs, value judgments; Range from
completely central (“knowledge for knowledge's sake”) to
need for action (“do exercises at home”)
Mechanism of Cognitive/ affective information processing
Action
Typical Ingredients Didactic instruction, prompts to process new or previously
acquired information; persuasion, motivational techniques;
prompts for action
Clinical Examples Patient/ caregiver education; counseling; motivational
interviewing; resource information; ‘how-to’ (w/o practice);
what to do outside of the clinic
Group III: Representations
Examples of Representation Group Treatments
Ingredient
Provide verbal and written
information regarding vocally
healthy and unhealthy
behaviors
Provide MP4 recordings of
vocal exercises containing
patient “self-as-model”
examples
Provide cues for the patient to
talk about positive changes
made in the past
Mechanism of Action Target
Increased knowledge about
vocally healthy/unhealthy
 
Cognitive / behaviors (vocal hygiene)10
affective
information Increased motivation to practice
exercises as prescribed at home
 processing 
(adherence)11
Modified beliefs regarding their
  ability to change their vocal
behavior (self-efficacy)12
 Volition is the amount of effort they need to apply to be successful in the
treatment. For massage, you don’t need to ask them to do anything, but most
Volition other treatments require buy-in from the patient.

• Roughly equates to effort applied to the performance of an action –

mental or physical
• Non-volitional treatments are done TO the patient without effort on
their part (medication, surgery, range of motion)
• Volition treatments require some active effort on the patient’s part
(vast majority of rehab treatments
• Capability, Opportunity, Motivation to perform a Behavior (COM-B)
framework.
This is work done by a psychologist.
If you want someone to do something (drink less, speak with better vocal habits), you need to
make sure they have the capability, opportunity and motivation to change.
RTSS: Treating patient volition
A treatment may “work” (direct targets) – but the patient has to volitionally follow
the treatment as directed outside of the session (volition targets)

Therefore, there is a second type of targets:

Volition Targets
• Increase the likelihood that the patient will perform the therapeutic activity as prescribed
(compliance)
 Adapted from
Whyte et al., 2019
Direct and Volition targets Arch. of PMR

(voicing versus compliance)

(compliance) (voicing)
Volition Target: Direct Target:
Perform exercises as Improved voicing in some
directed way

Perform vocal exercise program at Increased expiratory pressure

home
Modified voicing in some way
Use modified voicing during work
hours Hydration levels better at 2nd apt

Use a vocal hygiene strategy in daily

life
 Changing Direct and Volition Targets
(direct and volition ingredients)
According to the RTSS, there are TWO reasons to select a treatment ingredient (clinician action):
1. To directly affect patient functioning
2. to get the patient to perform an activity
Direct and Volition ingredients So the whole idea is that you need volition
(practice versus information) targets in addition to the actual therapy (direct
targets)

(compliance) (voicing)
Volition Target: Direct Target:
Perform exercises as directed Improved voicing in some way

(compliance) (voicing)
Volition Ingredients: Direct Ingredients:
How to do exercise, importance of Practice voicing in some way,
exercise, etc. Adapted from feedback on performance
Whyte et al., 2019
Arch. of PMR
COM-B:
Influencing patient compliance/volition
Capability (Adapted from
Michie et al., 2011) 12

Motivation Behavior

Opportunity
Capability: “the individual’s psychological and physical capacity to engage in the [behavior].”
Opportunity: “the factors that lie outside the individual that makes the behavior possible or
prompt it.”
Motivation: “the brain processes that energize and direct behavior, [including] goals and conscious
decision-making.”
How do I apply this? Skills/Habits
Target Ingredient Dosing
Increased forward Opportunities to Practice reps
resonance practice voicing Difficulty

OBSERVATION Ingredient Organ Functions

Clinician asks Target
Gross vocal fold Dosing
Increased true vocal
the patient fold adduction
adduction # of reps
to repeatedly exercises (during Resistance
(during voicing)
voice voicing)
^This is to stregthen the muscles with some resistance
to increase adduction Representations
Target Ingredient Dosing
Improved voice- Provide Amount and
related self information re: difficulty of
efficacy vocal control information
RTSS applied to voice therapy
RTSS = theory-driven framework to guide descriptions
But no standard terminology for specific/unique ingredients/targets…

RTSS-Voice15
TARGETS INGREDIENTS
• Pitch • Apply pressure
Delphi Rounds • Loudness • Voice
Voice Therapy based on RTSS14 • Voice quality amplification
Taxonomy13 • Respiratory • Practice voicing
coordination • Practice
• Muscle breathing
activation • Expiratory
levels resistance
• Resonance training
Unique Targets: Physical Overlap
Critical RTSS innovation: ↑ Endurance
SINGULAR target directly effected by their
ingredient(s).
Endurance and strength are the same (need practice with resistance and reps),
but they are different, because if you want more endurance, we need more reps,
and if you want more strength you need more resistance ↑ Strength
Circumlaryngeal Massage example of current
8

practice:
The hypothesized physiological effect of such
massage is reduced laryngeal height and
stiffness and increased mobility … range of ∆ Pitch
motion is normalized, reduced pain, reduced
focal tenderness or nodularity, increased
thyrohyoid space, and an improvement in vocal
effort, quality, and dynamic range should follow. ∆ Loudness
^With RTSS, we don’t want to have this whole group of effects. We want to target it for the goal. For gender
affirming, we don’t want increased pitch to also lead to increased loudness, for instance.
Unique Ingredients So, all of these therapy ingredients can be argued to end with the
thing on the right, but they have unique, specific effects

Pitch glides Provide

Loudness glides opportunities to
Breathy voicing practice voicing
Critical RTSS innovation:
Describe the ingredient
according to WHICH
CLINICIAN ACTIONS ARE Lip trills Semi-occluded vocal
RESPONSIBLE for the Tongue trills tract
desired therapeutic Straw phonation (delivery method)
effects (i.e., changes in
targets)
Massage
Myofascial release Apply pressure
Manual reposturing
RTSS and RTSS-Voice Resources
• For a very in-depth reading on the RTSS, you can freely download the Manual for
Rehabilitation Treatment Specification:
https://acrm.org/acrm-communities/rehabilitation-treatment-specification/manual-for-reha
bilitation-treatment-specification/
• Join or look through ACRM’s Rehabilitation Treatment Specification Networking
Group
For general information:
https://acrm.org/acrm-communities/rehabilitation-treatment-specification/
For an introductory RTSS webinar:
https://www.youtube.com/watch?v=STqan9Zra6I

• The RTSS-Voice and underlying methods are published:

• Can find on Pubmed
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934085/
 Voice Therapies according to the RTSS

I’m taking a “tradesman” approach here…

Focus: The actions you can do (ingredients), what you should expect to change in the patient (targets), broad rationales for why the ingredients often effect the target (mechs
of action)

Not the focus: A deep exploration into “why” (mechs of action)

 Special considerations
Vocal fold paralysis
Need vocal fold closure to some degree, so often therapy starts after surgery.

Psychotherapeutic approaches, counseling, etc

Refer to ASHA’s Scope of Practice document:
https://www.asha.org/policy/sp2016-00343/ ; “… refer individuals with disorders
to other professionals when counseling needs fall outside of those related to (a)
communication and (b) feeding and swallowing.”

Spasmodic dysphonia
While primarily treated with Botox injections, voice therapy can help reduce
maladaptive voice-related behaviors.
Organ Functions treatments
(will not include various surgeries, which would be under this category)
• SpeechVive (developer: Jessica Huber at Purdue)
• Laryngeal Manual Therapy (developer: Lesley Mathieson at UCL)
• Expiratory or Inspiratory Muscle Training (developer: Christine Sapienza at
Florida)
• Lax Vox tube (developer: Marketta Sihvo in Finland)
• Personal Amplification (first clinical trail use was with Nelson Roy at University
of Utah
• Voice rest (has been around for a long time, not one single person to point to
here…)
• Phonation Resistance Training Exercises (PhoRTE) (developers: Eadie Hapner at
Univ Alabama and Aaron Ziegler in Portland)
 Speech Vive
and discuss masking in general
Speech vive: Masking device
that changes the way they speak
and the way they voice

When you put a noise in

their ear they talk
louder. This device was
developed for
parkinsons

https://www.purdue.edu/hhs/motorspeechlab/speechvive-efficacy-studies/
Target – Increased loudness. We can measure this perceptually. We can also measure it objectively with a sound
level meter. Can also lead to clearer speech, but that’s not the “target”.
Ingredient – Speech vive applies noise when voicing. The dose is the dB level of the noise when voicing.
Lax Vox
and discussion of SOVTs are when you have some sort of occlusion in your supraglottal
tract. A semi-occlusion makes your voice more efficient because you are
SOVT’s phonating against resistance (back pressure). If you put the straw in
water, that increases the resistance even more.

Target population: Anybody who has a primary or secondary muscle

tension dysphonia. Primary is when theres no neurological or structural
problem, so you know the primary issue is how theyre using their voice.
Secondary is when there is a muscle tension problem secondary to the
primary issue.

Target: increased voice efficiency/muscle use for voicing leading to

reduced dysphonia (which can be measured perceptually with cape-v for
instance). CPP (dB) can also be measured pre/post therapy if theyre
rough or breathy.
Ingredient: Voicing against resistance (you can dose this with the length
or diameter of the straw, or depth in water)

https://www.laxvox.com/technique/
 Personal Amplification
how to look at these devices
These are often for people who have voice problems that require amplification.
Bilateral vocal fold paralysis or bilateral vocal fold scar. In this case, the target and
ingredients would be organ function.

Target: Increased loudness

Ingredient: Successful application of amplification. Dose – dB level that is added to
their sound.

For someone with MTD, the goal for this might be to have decreased loudness into
the device. In this case it would be skills and habits targets and ingredients.
https://www.greatlakessport
s.com/amplivox-belt-blaster-
pro?gclid=CjwKCAjw7oeqBh
BwEiwALyHLM0wb3e-8FDT6
wCwZrRBoxFtt0cRUDC6DjdQ
xyA0pKlsR9aknfrh-axoCp4oQ
AvD_BwE
Voice rest
…and associated volition treatment component
We give voice rest to people who have had vocal fold
hemorrhages, post-surgery or nodules.
Target – Resolution of hemorrage, or good wound
healing, or reduction of vf swelling (for nodules).

Ingredient: reduced or no voice use

We will also need a volition target with COM-B to
make sure this happens. (capability, motivation,
opportunity). Dose of voice rest would be duration in
https://www.istockphoto.com/videos/shhh
time (of lack of voicing).
 Expiratory/Inspiratory Muscle Training
and discussion of resistance training
Forceful exhalation into an expiratory
Muscle trainer. Device is set at resistance
Equal to 75% of the Max Expiratory Pressure
Perform 5 reps, 5 times a day, 4 weeks

This is an example of an organ function target in theory. Clinicians aren’t

using this for vocal hyperfunction or muscle tension dysphonia, because it
doesn’t work well. It targets respiration, so its good for dysphagia
(increased cough) oooor if they have a weak voice as a result of weak
respiration that could be useful.
Population: Dysphagia or voice disorder due to compromised respiratory
system.

Target: Increased respiratory strength (MEP, Vital Capacity)

Ingredients: expiration against resistance, dose amount of resistance, Sapienza & Troche, Plural
number of reps Publishing, 1st edition, 2011
Laryngeal Manual Therapy
massage NOT during voicing

This treatment says they don’t want them to voice until all of the
muscles are sufficiently relaxed.

Population: VH, pMTD, sMTD if there are signs of excessive muscle

tension (or discomfort) in the anterior muscles

Target: reduced muscle activation levels (surface EMG, or most of the

time, subjective through palpation (the muscles feels less tense)), or
sometimes this is patient self reported

Ingredient: To do this you apply pressure, with two hands with finger
pads, kneading, starting at the sternocleidomastoids and going medially
as the muscle relaxes. Mathieson, Hirani, Epstein, Baken, Wood,
Rubin, J Voice, 2014
Phonation Resistance Training Exercises
PhoRTE
This is for people with presbyphonia (older) or VF bowing. These exercises try to address the sarcopenia
that comes from aging. There are many different exercises, which have different specific targets.

Target1: Phonatory strength increase You can measure this with how loud and long you can hold an Ahh
Target2: CT strength You can measure this with how wide the pitch range is
Target3: Endurance Self reported, how much fatigue

Ingredient1: Phonation against resistance.. How loud and long voicing occurs. Louder means more muscle effort.
Ingredient2: Increasing pitch against resistance

Belsky et al., Journal of Voice, 2021

Skills and Habits treatments
These are just a selection of the most commonly used evidenced-based
treatments in the USA…
• Vocal Function Exercises (developer: Joseph Stemple)
• Circumlaryngeal Massage and Respoturing (developer: Nelson Roy)
• Resonant Voice Therapy (developer: Joseph Stemple or Katherine Verdolini)
• Stretch and Flow Therapy (developer: Ed Stone)
• Conversation Training Therapy (developer: Amanda Gillespie and Jacqueline
Gartner-Schmidt)
• Lee Silverman Voice Therapy (developer: Lori Ramig)
• Exercise Induced Laryngeal Obstruction (developers: Emily Nauman and Tod
Olin)
• Vocal tremor treatment (developer: Julie Barkmeier-Kraemer)
Vocal Function Exercises
Exercise 1 Exercise 2 Exercise 3 Exercise 4
Population: Anyone with VH, pMTD, Hold soft, engaged, Hold soft, Hold soft, Hold soft,
sMTD nasty nasal /i/ for engaged /ol/ buzz engaged /ol/ buzz engaged, /ol/ buzz
as long as possible while gliding from a while gliding from a for as long as
on F above or comfortably low comfortably high possible on C-G
T1: sustain voicing for duration equal below middle C (if pitch to as high as pitch to as low as (middle C or C
to vital capacity divided by 80 mL/s
female or male) possible possible below middle C for
I1: Opportunities to practice max females, males)
sustained vowels.
Two times Two times Two times 10 reps
Dosing is numnber
Record duration Record amount of Record amount of Record duration
T2: No pitch breaks going up in pitch and amount of vocal instabilities vocal instabilities and amount of
T3: no pitch breaks going down in vocal instabilities and max pitch and max pitch vocal instabilities
pitch
I2+3: Opportunities to practice voicing
with an upwards (or downwards) glide Stemple, Seminars in Speech and Language, 2005
with forward resonance, and modified
mean airflow
These came out in 1985-1986 and work really well for people.
Circumlaryngeal Massage, Laryngeal Reposturing

You do this until your finger blanches, so the muscle cant extend
past where your finger is.
You are doing laryngeal reposturing to make sure the muscles
and larynx are in the right place while talking.

Population: VH, pMTD, sMTD

Target: Decreased overall dysphonia (This target isnt specific to

breathiness or strain. It’s broad because the therapy is the same
regardless)
Ingredient: Apply pressure unimanual with static pressure (not
kneading) over specific landmarks. During this, there will be
opportunities to practice voicing. Roy et al., Laryngoscope, 2017

You can also do negative practice with this, where you practice
the ”bad” voice, so you can volitionally change between the two.
Resonant Voice
Therapy
Target: improved forward
resonance. Can be measured
with a patient self report, or
perceptually.
Its good to have a singers
formant in this case.

Ingredient: opportunity to
practice voicing with forward
resonance.

Flow
Volition target: Practice for a waveform
specific amt of time on these
exercises.
Volition ingredient: COM-B
Pressure
waveform
Stretch and Flow Therapy
Stretch and flow (or flow phonation therapy) puts a lot of
emphasis on airflow (just like how resonance voice therapy
puts emphasis on resonance).

Population:VH, sMTD, pMTD

If you have too little airflow its because your VFs are too
adducted or theres too much muscle tension. This can
cause trauma. If you have too much airflow, you need to
use a lot of muscles also (to keep the vfs fairly abducted).

Target: Improved mean airflow during voicing.

Watts et al., Journal of Voice, 2015
Ingredients: Opportunities to practice voicing with
modified airflow (with the stretch and flow therapy
hierarchy)
Volition target: Practice a specific amount
Volition ingredient: COM-B
Conversation Training Therapy (w/ focus on clear speech)
Framework for Conversation training
therapy
Population: Vocal hyperfunction, sMTD, pMTD

Clear speech
They realized that if we have people use clear speech, they need appropriate
airflow and resonance. If they do the rainbow passage “speaking clearly”, their
acoustic and aerodynamic measures improve
Rapport building

Target: Reduced overall dysphonia (again, the treatment isn't modified based
on the specific perceptual irregularity, so we can just say overall dysphonia)
Ingredients: Opportunities to practice clear speech with improved mean airflow Auditory/kinesthetic awareness
and forward resonance on consonants. Negative practice can also be useful.

Target: Improved sensory discrimination. Can they tell whether they're using Negative practice and labeling
clear speech or not?

Ingredients: Opportunity to practice sensory discrimination Embedded basic training gesture

Lee Silverman Voice Therapy
Population: Parkinson’s

Target: Increased habitual vocal intensity (sound level meter dB)

Ingredients: (1) Opportunity to practice voicing loudly with increased effort; hierarchical speech, pitch
(2) Feedback: direct sound level meter reading with different amts (100% is you show them the SPL
reading after every trial).
Exercise Induced Laryngeal Obstruction
*This used to be called PVFM
Population: EILO, VCD (vocal cord dysfunction, the old term), PVFM

Target: Reduced stridor during inhalation; improve ease during inhalation

Ingredients: (1) Opportunity to practice differential resistance exercise; hierarchy from at
rest to during exertion (2) provide feedback: direct; (3) volition ingredients (He started
talking now about this, but these are actually kind of always ingredients, because you
need them to do what you want in the therapy session, so COM-B without the O)

This therapy technique is creating inspiratory resistance with teeth lips or tongue.
Vocal Tremor Treatment
If you increase respiratory phonatory coordination, with easy onset or yawn sigh or resonant voicing, you relieve the
larynx of some effort. Since improvement of resonance or flow gets rid of tension, then you will get less tremor (its
sort of a secondary MTD treatment). Another thing with this is that tremor frequency is like the pitch of the tremor.
If you make your voicing periods short, then you have less time for there to be a tremor, so this can also improve.
Another thing, is that if you can link specific speech structures (like CT for instance) exhibiting tremor to contexts
that worsen or lessen vocal tremor, you can reduce the tremor (by having them speak monotonously for example).

Soo Population: Tremor

Target: Reduced tremor during speech (objective; perceptual)
Ingredients: (1) Opportunity to practice voicing with more airflow, resonance, shroter voiced duration, and tailor to
patient for pitch and/or loudness; (2) feedback: direct; (3) volition (again, kind of always a thing in session CM-B).

Volition targets and COM-B ingredients

Representations treatments
The provision of information (ingredient) to modify some mental representation
on the continuum of purely within the brain (knowledge) to the propensity to
actions such as adhere (volition)

• Education in voice therapy (contained in many therapies)

• Volition treatment components (contained in all Skill and Habits treatments
discussed and most Organ Functions treatments discussed)
• Motivational Interviewing and the Readiness Ruler
• Mindfulness
• Discussion of vocal hygiene
Education
Population: All patients
Targets: Increased knowledge about therapy, associated factors (like for anxiety increasing
symptoms) diagnosis and prognosis. You can measure this by pt acknowledges info w/o qs or they
recalled by telling the info back.

Ingredients: Delivering information on a topic; Amt of information

Volition, i.e., adherence
Target(s) and
ingredient(s) to be
filled in during class
discussion.
Motivational Interviewing
Readiness ruler: How ready are you to do this? If they aren’t a 4 or 5 out of 5 then they can explain
what reason is holding them back. This is problem identification elicitation. Then you say, why aren’t
you a 1? And they give reasons why they are better than nothing. This is change talk elicitation.
Don’t give suggestions, because you need them to come up with their own strategies.

Target: Increase adherence to suggestions; volition ingredients (indirect) are them talking about
their own COM-B
Mindfulness
Target: Reducing stress about voicing. It can also be useful for getting people to practice more. The
ingredients are instructions to focus on the present moment (sounds, sensations, etc.)
Target: skill/habit target (like decreased overall dysphonia).. Patient is distractable and not
practicing due to stressing out about poorer than expected performance… volitional ingredients
are the capability instruction like “I just need you to focus on how your voice feels and sounds and
nothing else”.
Vocal Hygiene
Population: People with lifestyle that would effect voice like nodules, polyps (from yelling for
example). Anyone who has reflux or is chronically dehydrated, or smokes. just things that will be
affecting their voice.

Educational target: Improved information about what hurts or helps the voice
Educational ingredients: Information delivered

Skills and habits target: Increase hydration in daily life (measured by patient report)
Alaryngeal Rehabilitation

https://www.laryngectomy.org.uk/laryngectomee-info/what-is-a-laryngectomy/
Alaryngeal rehabilitation
• Heat moisture exchanger (HME) and adhesive plates
• Tracheo-Esophageal Prosthesis (TEP) and cleaning supplies… If that is
their way of voicing
• Esophageal speech
• Electrolarynx, if that is their way of voicing
• Education on how to clean the area
• If applicable, how to clean TEP and what to do if TEP becomes
dislodged.