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

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

Check out our Mobile Videostroboscopy and FEES Clinic: Voice Diagnostix.

 

Posted on June 16, 2016 .

Advice Post-Slice: Voice Recommendations After Surgery

How much voice rest is necessary after surgery to the vocal folds? When I had voice surgery 10 years ago, I was instructed to rest my voice strictly for 1 week. No talking, singing, throat clearing, grunting, you get the picture. It was unclear, however, how I was to get back to singing normally again. So what do I tell patients? It varies depending on the extensiveness of the laryngeal surgery, but I pull my recommendations from studies.

The Rat Pack

Leydon et al 2014 describes how forty rats, (I know they're not people,  but I'm sure the experimenters formed relationships with their little buddies for the duration of the trial) had the mucosal layer of the vocal folds removed. (That's the top layer.)  Then the rats' larynges were examined between 3-90 days at 5 different times. 

This image is pulled from Springer online: Operative Techniques in Laryngology

This image is pulled from Springer online: Operative Techniques in Laryngology

 

Researchers found that a vocal fold tissue structure regenerated quickly (like, within 5 days) with intercellular junctions and multi layered epithelium (the tissue on the very outside of the vocal folds that receives the biggest impact during vibration). 

However, atypical permeability of this layer of the TVF's was seen up to 5 weeks after surgery. This means that if you have vocal surgery, you should be sure to keep tabs on your vocal use for many weeks following surgery, as there is a very elevated risk for further damage as your body continues to rebuild where the surgeon worked. Intact structure does not necessarily mean you can demand vocal use you were using before surgery.

Scarring Woes

Scarring is frequently seen after surgery and results in issues with phonation. So obviously we want to minimize scarring. We can't exactly massage the vocal folds to soften this scar tissue, but perhaps gentle vocal exercises that stretch and contract the tissues, as well as utilize resonant voice can help

Another study by Branski et al from 2006 really looks at how a vocal fold wound heals, including inflammation and swelling, as well as scarring. Again, we're talking our animal friends' vocal folds. Scarring develops when there is an increased inflammatory response following an injury. The study discusses differences in lesions to the vocal folds, including nodules, polyps and cysts. Particularly interesting to me, was the suggestion that a cyst, especially one at the midpoint of the vocal fold, might be due to injury associated with impact stress. (Which further convinces me that my vocal fold cyst from years ago was likely a product of a poorly coached belting role I performed during High School.)

Lesions and Surgery

The Branski article suggests that vocal fold lesions are probably the body's way of healing a wound, much in the way a scar results from a cut. Applicable to many of my patients is the discussion of chemical vocal fold injury from LPR, and that 50% of patients with voice disorders also have LPR or GERD, or both. We must also consider the effect of reflux on the healing process after surgery.

So, how long should a person realistically expect to be on complete vocal rest after surgery? For 2 weeks-5 weeks post injury, epithelium remains permeable and impacted by the wound healing process. I say impacted and not weakened, because epithelialization (restoring structural integrity) occurs rapidly between 3-5 days after injury.  Complete rest during this rapid healing time with a very strict ease back into phonation over 2-5 weeks appears to win here. 

We're still learning so many things about how this delicate tissue heals itself, we can only recommend based on the information we have now. Every patient heals differently, and the degree of surgical manipulation will vary case to case. 

Resources:

Leydon, Ciara, Imaizumi, mitsuyoshi, Yang, David, Thibeault, Susan L., & Fried, Marvin P. Structural and functional vocal fold epithelial integrity following injury. Laryngoscope 2014, Dec. 124 (12) 2764-2769

Branski, Ryan C, Verdolini, Katherine, Sandulache, Vlad, Rosen, Clark A., & Hebda, Patricia. Vocal fold wound healing: A review for clinicians, Journal of Voice, 2006 Vol 20, No 3, pp 432-442

Check out our Mobile Videostroboscopy and FEES Clinic: Voice Diagnostix.

A Pumice Stone for Your Vocal Folds? Of Nodules and Intervention

There are many factors that can cause an individual to be hoarse. Vocal fold swelling from sickness or overuse affects the ability for vocal folds to vibrate. Lesions, like polyp, cysts or nodules, can impact closure patterns and vibratory abilities with weight and stiffness. This can greatly affect vocal quality and pitch control. So if a person is diagnosed with one of these issues, is there effective treatment? 

It is important for each healthcare provider involved with a patient's case to weigh all factors when considering surgery like direct microlaryngoscopy. Whenever you are making cuts or removing portions of the vocal fold epithelium, you risk damaging the delicate tissue that is responsible for vibrating and displacing to make sound. Vocal folds are made up of 5 layers, the epithelium on top, the lamina propria (Superficial, intermediate and deep layers) and the thyroarytenoid muscle underneath. Surgeons must be conscious of each layer and do their best to prevent any excess damage, as this tissue will not regenerate with the same chemical makeup. Any surgical intervention will cause swelling, or edema, and can possibly result in worse vocal quality than before. Surgery can be very effective in vocal fold lesion cases, but should be carefully considered. 

Vocal fold nodules are very common benign vocal fold lesions. Nodules are unique in that they are usually bilateral, located on the portion of the vocal folds that creates the greatest movement when vibrating, and they are usually symmetrical. They can be gelatinous or hard fibrotic callouses. They occur from overuse of the voice that has caused the vocal fold mucosa to change composition in response to constant abuse. Vocal nodules can actually respond to behavioral voice therapy and can lessen or even disappear. Dr. Lesley Childs discusses why surgery for this is a last resort following conservative behavioral voice sessions. It is very important for patients to understand why they developed vocal fold nodules in the first place, so they can reverse bad vocal behaviors and prevent them from reoccurring. 

A case for conservative treatment can be made because often times money, time and tissue can be saved if the patient will commit to changing abusive vocal behaviors in therapy sessions. There is also the very likely chance of recurrence if nodules are surgically removed without the patient receiving voice rehabilitation therapy. Communicate with your referring surgeons and work together with them to determine the best and most comprehensive plan of care for each patient with nodules.

The key to the best patient care is communication and being open to suggestions. In my practice I operate as transparently as possible and with education with the patient in mind. A patient of mine asked me if I was like a "pumice stone for the vocal folds," and I had to laugh as I told her yes. What a gift to be able to help a person in the way a pumice stone does---aesthetically and functionally. 

 

-ATVC

Sources: Clinical Voice Pathology: Theory and Management 4th Edition, Stemple, Glaze & Klaben. Plural Publishing.

 

Check out our Mobile Videostroboscopy and FEES Clinic: Voice Diagnostix.

Posted on September 14, 2015 .

Singing in Chest Have You Stressed? Compared With Falsetto, What's Best?

Whether a professional singer or a singer for hobby, if you are developing a professional voice you should have a goal for maximum output with minimal effort. Acoustic output should be easily attained with very little physiological effort, so why do we feel like we have to push to get some sounds?

Source-Filter Theory should begin the discussion. You ask yourself, "Where did I learn about that first? Was it just something I memorized for a test?" It's actually quite easy to explain and the actions are in the name. Remembering that you have a source of sound (your vocal fold vibrations) and that the sound is modified by the filter of your vocal tract is all you have to know. The shape of your throat and mouth take the sound signal and dampen some formants and amplify others, creating your unique sound.

Think of your singing as training the intrinsic muscles of the larynx to strengthen your chest voice. This does not mean that you will always need to sing in your chest voice, but it is important to have control of your whole range, low and high, to master using each when appropriate. There is also the issue of correctly defining chest/belt and head/falsetto voice. I was at a conference at UTSW last month where Dr. Stephen F. Austin spoke regarding this issue. As a singer, you have to remember that your vocal cords or folds are not the only things working in your throat to make sound. He reminded the audience that firm phonation is a full contact sport, furthering the image that one must really commit to working out the voice muscles daily, as any athlete would, to avoid injury and have the best and most efficient working mechanism.

Chest voice can be created by increasing motor signals to the thyroarytenoid muscles (vocal folds). As the vocal folds contract, they bulge toward the middle (medially) and down (inferioraly). If you exercise your TA muscle, it will respond to the exercise because it is a skeletal muscle. Your aim is for creating a square glottis when you have phonation, or vocal fold vibration. With a larger area of contact during vibration comes a stronger sound.

Falsetto, or head voice, is created by decreasing the engagement of the thyroiarytenoid muscles, or the vocal folds. At the same time, you increase the cricothyroid and lateral crycoarytenoid muscles. When beginning your singing training, make sure there is a strong enough chest voice to have an audible break into falsetto. Once this is established, work begins on smoothing out between registers.

Yodeling, interestingly enough, is transitioning between the two types of voice very quickly. One has to relax the larynx enough to perform the switch to each octave along with coordinating the articulators (lips, teeth and tongue) to sprinkle /l/ and /d/ throughout different vowels.

Chest voice is always a "dangerous" subject, as most vocal training programs are tailored for classical singing. Dangerous  because it is like the plague and no one wants to touch it. Reality is, though, chest and belting voice is the most common vocal style in contemporary commercial music (CCM). That means most people with singing careers don't have formal training, but can have real problems that need an experienced teacher. Leborgne and Rosenberg state that 34% of university level teachers who train non-classical singers have never been trained in commercial music. So, why are we putting singers at risk by not being well trained in both classical and contemporary styles of singing? Just with chest singing, falsetto voice can be abused if not trained properly, so it is important to learn to do each the proper way to avoid injury. 

So don't let belting and chest voice singing stress you out. Just like falsetto singing, belting and chest voice singing needs to be taught correctly to avoid injury to the vocal mechanism. Remember, registration is a choice and with proper practice in each, you can keep an efficient larynx in good working order. Dr. Austin reminds us that everything we do can't be beautiful, we must experiment with our instruments.

 

References: Lecture by Dr. Stephen F. Austin at UTSW Singers Symposium 2015
The Vocal Athlete. Ronenberg, Marci & Leborgne, Wendy D. Plural Publishing 2014.
 
Check out our Mobile Videostroboscopy and FEES Clinic: Voice Diagnostix.
Posted on July 7, 2015 .