We've Partnered with MedBridge. Get Your Unlimited Discounted CEU's Here!

If you're like me, we have the disease of being busy. I have caseloads, business opportunities, blogs, family, taxes, billing, and as my head starts to spin, I could go on for days. In the past, I have waited for specific CEU's to roll around that I knew would be applicable to my patient demographic. Sometimes this would put me in a tough situation where I would have to spend money on airfare and hotels just to get certified in something that was voice or swallow related. 

MedBridge and I have partnered to offer quality CEU's at a very discounted rate so you can afford to educate yourself in the areas of knowledge specific to what you treat. MedBridge has observed that dealing with overpriced CEUs is a constant issue with SLPs (among other disciplines) and they have created a website that offers online continuing education and patient engagement tools. These video courses are accredited and contain excellent research based approaches. 

No longer do you have to travel to get CEU's (unless you want to, of course) and no longer do you have to shell out big bucks to do so! Since running my own business, all my CEU courses have been my financial responsiblity, and last year I spent over $1,000 for a course I attended in person. The year before that, it was a little less than $600 for an online certification in my area of specialty. NO MORE! Medbridge is offering a special pricing discount so you can earn your CEU's anywhere at anytime. (PJ's and coffee encouraged!) 

MedBridge has hundreds of CEU courses, live webinars and is an ASHA Approved CE provider. Use Promo Code: atempoVOICECENTER or click here to get your own discounted annual subscription to MedBridge for only $95! That's saving you $175 right away. 

You also get exclusive access to the home exercise program builder (HEP) which allows you to customize exercise programs specifically for your patients with over 5,000 video exercises. HEP's can be easily printed, texted or shared online. This means your patient is more likely to adhere to your home program, know what is expected and make progress. That's really what it's all about. 

Students? It's even better for you! If you use the student promo code: ATEMPOVOICECENTERstudent you will have a yearly subscription at only $75! Remember, you must sign up with your email address ending in ".edu" for this to be honored. You still get everything in the yearly regular SLP membership, except for CEU credit, because you aren't eligible to earn until you have your license. 

The best part is that huge names in the voice community have recorded webinars that are available to you 24/7! This means voice gurus like Joseph Stemple, Edie Hapner, Mary Sandage, Robert Grider, Sarah Schneider, and even Julie Barkmeier-Kraemer sharing valuable and applicable knowledge. If you are a Many Hats SLP, you can expand your knowledge in many other areas. Plus MedBridge is adding more every day.

I hope you'll take advantage of this fantastic offer, because you shouldn't feel like you are just getting CEU's to fill your quota. You should have affordable options to learn about areas specific to you. This benefits you as a clinician and most of all, your patients. 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Posted on September 21, 2017 .

A Day in the Life of a Voice SLP

Working for yourself is not an easy out. It takes dedication and learning how to sift through the murky waters to pull through to the sun above. You can enjoy, but you have to keep trying to get ahead. If you want a 9-5 where you leave it all at work, I would encourage you to re-think working your own business. As for me, I couldn't imagine it any other way....

Posted on August 16, 2017 .

But Your Swallow Study is Fine.....What is Muscle Tension Dysphagia?

As a graduate student in Speech-Language Pathology, there are so many names to learn about with regard to terms coined, rehabilitation techniques researched and therapy approaches we don't even use anymore. As a patient, you just want answers. Terminology is important, and Christina Kang, Joseph Hentz, and Dr. David Lott have pioneered a term to describe symptoms for dysphagia that does not show up routine swallow studies.

Kang and team took a retrospective look at folks who came into their clinic for swallow and laryngeal studies including VFSS and flexible laryngoscopy. VFSS stands for Videofluroscopic Swallow Study, or Modified Barium Swallow Study, which looks at the swallow function under x-ray with the patient drinking and eating barium. The important thing here is that no swallow weakness or organic pathology was observed in these tests. This means there was no structural cause for the patient complaints. 97% of the patients chosen for this study that were complaining of swallow issues, also had abnormal laryngeal muscle tension. 82 percent had laryngeal hyperresponsiveness. This means that the larynx would respond to stimuli even when it wasn't present, like in refractory chronic cough, paradoxical vocal fold motion and globus sensation. Inflammation, or swelling and irritation, was also found in 52% of these people. 

Credit: Kang et al 2016 article.

Credit: Kang et al 2016 article.

Kang thought, what if we targeted muscle tension in the larynx through voice rehabilitation, to see if these symptoms resolved? So, 13 of the initial 67 attended voice therapy sessions that specifically focused on unloading muscle tension. Treatments consisted of a combination of Resonant Voice Therapy, Semi-occluded vocal tract exercises, diaphragmatic/low breathing and cirumlaryngeal massage. 

Guess What? ALL 13 reported a complete resolution of dysphagia symptoms! Why is this so exciting? I don't know about you, but these patients seem to get pushed to the side if VFSS shows nothing abnormal, but the patient still feels symptoms. The most common symptom sometimes during my week at the clinic is, "I feel like something is stuck in my throat." Having complaints seemingly dismissed after a diagnostic test that shows no problems can make the patient upset, feel like it's "all in my head" and lead to continued and unnecessary testing and physician visits. Kang and team are proposing Muscle Tension Dysphagia or "MTDg" to describe a certain group of patients with functional dysphagia. 

The important and amazing thing here is that these patients improved! There is a possible solution to the problems that brought them to the doctor in the first place. We no longer have to send these patients away with no option for treatment.

Of course further testing is needed in this area, but what a great treatment option to offer patients who normally just get sent home and told to "stop worrying about choking, you'll be fine."

 

Reference: Kang, C.H.; Hentz, J.G.; Lott, D.G. Muscle Tension Dysphagia: Symptomology and Theoretical Framework. June 28, 2016. 

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

 

Posted on July 13, 2017 .

Resonant Voice Exercise is Better than Vocal Rest?

What Kittie Verdolini Abbott likes to call the "Scream Study" shows just that. She and her cohorts (including Ryan Branski and Clark Rosen) took a group of 9 folks and subjected them all to the same task to "tax" their vocal fold tissue (talking loudly for 1 hour, with a few small breaks in between). Then, they separated them into 3 groups.

But What About Voice Rehabilitation Goals? Part 2: Long Term

I've enjoyed hearing feedback from you all about short term goals and how they work for you. Many of you are more specific in creation, but are focused on the same end goal. If you have no idea what I'm talking about, check out Part I of this series about Short Term voice rehabilitation goals. 

Let's get to chatting about goals for the Long Term. Perhaps you abandoned some goals in the Short Term that were no longer appropriate. Maybe your patient has met all the Short Term goals and has a dramatically improved quality of life. This may be the perfect time to complete final acoustic measures, possibly a re-videostroboscopy, and a Vocal Handicap Index.

Long Term

(1) Patient will demonstrate voice production abilities which meet the needs for activities of daily living while maintaining health of true vocal folds within 12 weeks as evidenced by patient report and SLP observations. (I have 12 weeks, because I always guess that 9-12 weeks is long enough for a patient to come to 4-6 sessions, with illness, no-shows and cancellations. Is your patient able to talk for work? Is the fatigue or throat pain lowered or eradicated completely?)

(2) Patient will decrease or eliminate pathology while improving overall health of true vocal folds by eliminating vocal misuse within 12 weeks as evidenced by patient report and SLP observations. (Misuse is not only throat clears, coughs and yelling, but pressed talking, or talking for long periods of time with no break. Singing, and especially voice use after the show, is another area of misuse that should have been addressed and fixed before this goal is met.)

(3) Patient will maximize efficiency of the vocal mechanism relative to existing laryngeal disorder through coordinating subsystems of voice within 12 weeks as evidenced by patient report and SLP observations. (This is an expansion of STG #5, and this target voice should be present across your patient's speaking patterns. Diagnosis is important here, as it can sometimes be appropriate to have LTG 2 & 3 for a patient, but sometimes it's one or the other. For example, if a patient has vocal nodules, LTG 2 only would be appropriate. If the patient has Muscle Tension Dysphonia in response to a vocal cyst, both may be appropriate because you want to decrease or eliminate the MTD, but the patient may or may not be a surgical candidate for the cyst to be removed, so that disorder would remain existing. And sometimes, you get lucky and the excrescence goes away with voice rehabilitation alone!)

(4) Patient will achieve improved/normal voice assessed with perceptual scales, acoustic and/or aerodynamic measures within 12 weeks. (Using the CAPE-V, AVQI, VHI, Cepstral Peak Prominence, you can track progress for your patient and also help back up your data for insurance reimbursement. I mean, who doesn't like to see tangible progress that is quantitative? By the way, Cepstral Peak Prominence (CPP) is considered the most promising and robust way of determining severity of a dysphonia....that's right, more than Jitter...more than Shimmer......)

(5) Patient will return to vocal activities of daily living with reduction and/or elimination of complaints regarding vocal production within 12 weeks as evidenced by patient report and SLP observations. (Your patient sometimes will come in and meet this goal, without having met all the short term goals, and you have no choice but to say hooray for you, and you never see that person again. It know it's hard, since you didn't finish your plan of care as you initially indicated, but this was the outcome we were looking for! The patient is happy, you shouldn't just keep them on case to fill boxes.)

(6) Patient will acquire vocalization skills to meet personal and professional needs while maintaining and improving health of true vocal folds as evidenced by patient report, as measured by improvement in acoustic measures, and as assessed through videostroboscopy and through perceptual analysis. (You may delete this or combine it with #5, but it could stand on its own as well. Patient report and your skilled clinical assessment are both important factors here.)

(Special thanks to SLP's Kim Coker, Chis Watts and Shelby Diviney, as I drew from their teachings and materials to formulate the Short and Long term goals listed in this blog series. Thanks to them both for being my mentors and guiding me in being the clinician I strive to be.)

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Posted on March 30, 2017 .

But What About Voice Rehabilitation Goals? Part 1: Short Term

I have had inquiries from multiple sources about how I track progress in voice rehabilitation sessions, so I thought it was high-time that I sat down to create a blog post about what types of goals I use in my sessions and how you can tweak them to make it workable for your specific clients. (Read up on Part 2 of this series on Long Term Voice Rehabilitation Goals.)

If you have recently been assigned a voice client, and don't even know where to start, check out Voice in a Jiff: Hospital, Clinic or SNF for Adult resources and Voice in a Jiff: Pediatric Edition for help with children. Both manuals can be downloaded quickly and ready to use in minutes, either from here or TeachersPayTeachers

 

I divide my goals up into banks, one for Short Term and one for Long Term. I'll discuss Long Term goals in part 2 of this blog series. The Short Term goals are mostly appropriate for each patient, depending on if the patient has water intake restrictions. 

Short Term

(1) Patient/Client will demonstrate an understanding of voice production physiology and controlled voice utilization by describing/listing the phonation process and alternatives or modifications of current use in different environmental contexts with 90% accuracy within 4 weeks. (I measure this by education via video, picture and demonstration with biofeedback, to help the client better understand their own mechanism, so they have better control of their own ability to produce sound. This is also where I like to have the patient claim responsibility for the voice disorder, and stop referring to "the voice" in the third person, like it has power.)

(2) Patient will confirm implementation of hydration regimen in 3 consecutive sessions/weeks to decrease viscosity of reported throat mucus and irritation - as self-reported by patient with 100% accuracy. (There is not a published study about the specific amount of water best for the body, but a good rule of thumb is 8 glasses per day or 1/2 your body weight in ounces. Limiting alcohol and caffeine are also part of this goal, which you could technically create 2 separate goals for.) 

(3) Patient will eliminate vocal overuse to improve health of vocal folds by reducing or eliminating trauma to vocal tissues within 4 weeks as evidenced by patient report and SLP observations with 100% accuracy. (This is a great one to help focus the patient on a better vocal atmosphere, and you can dovetail goal 1 into this one as well.)

(4) Patient will establish volitional control of respiration evidenced by utilization of diaphragmatic breathing during structured tasks within 4 weeks with 100% accuracy independently. (The basis of proper technique requires abdominal support, so this goal will be the one I work very diligently on during the first session and onward. The patient will have a challenging time if this goal is not mastered before beginning sound production.)

(5) Patient will coordinate vocal subsystems in hierarchical speech tasks by producing sound in an efficient manner yielding improved or normal voice quality and vocal endurance in the presence of existing laryngeal disorder with 90% accuracy independently. (This goal is very important, and the patient must reach this goal before number 7 can be achieved. Vocal Resonance, Flow Phonation and Semi-Occluded Vocal Tract Exercises can all be used to achieve this.)

(6) Patient will reduce vocal effort and fatigue by decreasing upper body tension as evidenced by a decrease in symptoms and lack of observable/palpable signs of hyperkinetic muscular behaviors. (I palpate my patients on the shoulders, neck, jaw, base of tongue and larynx to determine baseline tension and rate on a 0-3 scale with 3 begin severe tension. I monitor progress in these areas by what I feel and what I can see visually as the patient phonates or sits at rest.)

(7) Patient will implement generalization of goals with 80% accuracy independently to encourage the use of new vocal skills in varied speaking contexts. (This includes in sentences, paragraphs, conversation, with ambient background noise, while being masked with an audio source in headphones, on the phone, at the checkout counter.....Wherever the patient uses the voice, this goal applies. You can separate it out if you like, especially if your client is a child, but for adults this should take usually between 4-6 sessions.)

 

I hope this was helpful, and stay tuned for the blog post on Long-Term Goals for your Voice Rehabilitation clients! I'd love to hear how you are creating your voice goals, so feel free to comment below!

(Special thanks to SLP's Kim Coker and Shelby Diviney, as I drew from their teachings and materials to formulate the Short and Long term goals listed in this blog series. Thanks to them both for being my mentors and guiding me in being the clinician I strive to be.)

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

 

 

 

Posted on March 19, 2017 .

5 Tips on Treating Vocal Nodules in Kids & Teens

It's always a challenge to find fun and creative materials to help children and young adults want to take care of their voices. With recent research backing a behavioral approach to treating vocal nodules, versus surgical excision, it's even more important we keep these clients engaged. 

1. Start Simple: You don't want to overwhelm your young client with too much information at first, because there's a possibility of being "tuned out." Try bubbles in a cup at first to get them interested. This is a very inexpensive way to make voice rehabilitation very fun. First take a cup filled with 1-2 inches of water and put a narrow-diameter straw in it. Make sure no air comes out the nose, and blow bubbles in the water. Slowly add voice until you have the client vocalizing and making bubbles at the same time. This creates inertive reactance (back pressure at the level of the vocal folds) and helps re-educate the muscles during voice production. Need ideas? Try these easy to print interactive products:

Straw Phonation characters for decreasing phonotrauma

Straw Phonation characters for decreasing phonotrauma

Bubbles in Hot Chocolate!

Bubbles in Hot Chocolate!

Bubbles in a Cup for introducing Semi-occluded vocal tract exercises.

Bubbles in a Cup for introducing Semi-occluded vocal tract exercises.

2. Remember Breathing and Hygiene: It is important once your client is engaged, that you stress the importance of no stress! Two ways you can do this are by teaching diaphragmatic/abdominal breathing and good vocal hygiene. Breaths supported from the abdomen are much more likely to decrease upper body tension than breaths from the chest and shoulders. You're fighting gravity when you breathe from your upper body. Staying hydrated by drinking enough water and avoiding caffeine, ceasing yelling at sporting events or on the playground, and resting your voice are all easy ways to keep good vocal health. Get started with these fun additions to your toolkit: 

Elephants Don't Forget Good Vocal Hygiene

Elephants Don't Forget Good Vocal Hygiene

Voice-O-Poly: Challenge your Vocal Health Knoweldge

Voice-O-Poly: Challenge your Vocal Health Knoweldge

3. Vocal Resonance: Humming at the front of your face is a type of semi-occluded vocal tract exercise, but it can get boring quickly. To keep kids engaged find materials that are applicable to lesson plans that they are already doing in the regular classroom. You might also find that sending home fun "hum" activities to try during meal times can help the child remember to practice. Yummy! The following materials can dovetail humming into fun games during your sessions:

Halloween Themed Resonance for Voice

Halloween Themed Resonance for Voice

My Mom Makes Lemon Muffins: Vocal Resonance 

My Mom Makes Lemon Muffins: Vocal Resonance 

For the boys! Resonance Football

For the boys! Resonance Football

4. Use Flow Voice when the laryngeal squeezing is intense. Some clients have struggles with producing sound with "humming" in a healthy way after developing a voice disorder. Flow voice, with roots with Casper, Stone and Casteel, can help break the habit of vocal overcompensation. Kleenex tissue can also be used as great visual feedback to let the client know if the airflow is coming out at the same time as the voice. Find out more and use the following products to teach this type of voicing. 

Stretch your vowels and flow with Frogs and leaping!

Stretch your vowels and flow with Frogs and leaping!

Flow phonation with tissues!

Flow phonation with tissues!

 

5. Straw phonation is the newest craze! Cheap, easy, fun and full of benefit. Ingo Titze has done an amazing job with researching benefits that come from phonating or making noise through a narrow straw. This is so perfect for children because they can take their straws anywhere and improve their voicing while letting their friends join in. This is even great for your whole classroom, and for teachers to share on the vocal benefits. I take straw phonation breaks all the time. Keep kids interested with these: 

Climb mountains with straw phonation

Climb mountains with straw phonation

Fly your airplanes with straw phonation

Fly your airplanes with straw phonation

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Terminating...Why Words Matter

In an age where we are all faced with political correctness, it proves beneficial to be well versed in all the ways a person could describe something. Lately we have been how to describe very delicate subjects such as the transgender policy on bathrooms, ISIS driven hatred and even touchy terminology from our presidential candidates. Everyone has a platform on the internet, and now more than ever we must be very careful with our words.

Also introducing, Blake Shelton's creative new song about how (presumably Gwen Stefani) has a Way With Words. 

I find it very important to try my best to use the most appropriate terminology in life and in my vocal rehabilitation sessions. I want to address the movement to terminate the word "vocal abuse" and use "phonotrauma" in its stead.

What we've been using for a while to describe screaming, pressed talking, throat clearing, etc.

What we've been using for a while to describe screaming, pressed talking, throat clearing, etc.

Where we're headed.

Where we're headed.

The idea, brought forth to me by Kittie Verdolini Abbott in her latest lecture I attended in February, suggests that using the term "vocal abuse"  is detrimental to the vocal rehabilitation process.  Vocal abuse describes behaviors like pressed talking, screaming/shouting, coughing, singing loudly, and excessive talking. She suggests using "phonotrauma" instead, so as not to describe a person's habits with such negative context. This can help with the process of shaping and creating new and efficient vocal habits because people want to know what they're doing well, and they may tend to focus on the bad and hear nothing else you say. (And a lot of beneficial information is given during an evaluation or session.)

I relate this to ASHA's policy to refer to speech therapy as intervention or sessions. To me, that says we are moving away from the idea that the services SLP's provide are therapy. However, I find that much of what I do when working with voice and swallowing patients is therapeutic. I can understand and also like considering Speech-Language Pathology as more professional and holding our skilled services to higher standards. 

Other terms I'd like your input on:

  • Calling a person gender ambiguous or gender neutral. What's appropriate?
  • Vocology instead of Voice Disorders. Do you think it will cause confusion referring to an SLP as a Vocologist instead of a Speech Language Pathologist?
  • Laryngeal Dystonia or Vocal Dystonia instead of Spastic/Spasmodic Dysphonia. Does Vocal sound like Focal? Will it be similar to telling the difference between Dysphagia and Dysphasia?

I would love to hear your thoughts and input.

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Posted on June 16, 2016 .