The patient was seen today for continued voice therapy, targeting improving functional voice use in the setting of muscle tension dysphonia. The patient states, this week, she was able to feel forward vibratory movement of her voice, especially when performing /m/-onset words. However, her practice was limited this week as she has been distracted with her physical therapy and other commitments. Therefore, the patient feels as though she has not been able to maintain improvements that she initially found through home practice.
Reviewed key steps in coordinating the vocal system with avoidance of laryngeal strain. The patient is able to independently identify that an initiating breath, relaxed open throat positioning, and forward resonance are optimal in promoting her best voice.
Reviewed /m/-onset words. The patient was 70% accurate with these, given cueing to slow her initiating breath and produce relaxed voice.
A frank discussion was held with the patient that although she has good conceptual and structured practice and grasp on given local techniques, carryover will be limited due to her restricted practice schedule. She understands that continued outpatient therapy is not indicated if she is unable to rehearse the techniques to promote voicing.
At this time, we will break from voice therapy. She was given comprehensive home program for continued rehearsal. She will complete physical therapy and attempt to return to voice exercises as she is able. Given her sound understanding of overall voice problem, her success through therapy is quite good, but this will only occur with structured home practice.
She will follow up in one month’s time. If she is unable to comply with voice therapy rehearsal at that time she will defer further intervention as her schedule permits this. She knows that she can contact us with any questions in the interim.
Sample #2
The patient was seen today for first session of voice therapy, targeting strengthening and bulking of the vocal folds in the presence of bilateral vocal fold bowing with hyperfunctional voice use. No specific changes or questions since initial evaluation.
Introduced isometric exercises for strengthening and bulking of the vocal folds. He is performing these appropriately and will do 20 x 3 times per day, pushing palms together with each production to help build strength.
Introduced neck stretches in the form of head turns, head tilts, and head rolls. These will be done immediately after isometric exercises.
Introduced laryngeal massage. The patient was able to independently find the thyrohyoid space and will do this for 3 to 5 minutes after neck stretches at each practice session.
The patient is provided with list of vocally abusive behaviors with alternative recommendations. He will review and follow up with any specific questions.
The patient will continue with program as outlined above for homework. At next week’s session, we will review hard glottal attack with likely movement towards varying phoneme level and initial instruction in diaphragmatic breathing.
Sample #3
The patient was seen today for his second session of voice therapy optimizing functional voice use in the presence of suspected hyperfunctional voice disorder.
He reports that he has incorporated neck stretches and laryngeal massage. This week, he came down with cold. He is wondering if laryngeal massage caused his congested symptoms, which it did not. He is continuing with given exercises, performing them with good technique.
Introduced diaphragmatic breathing. The patient easily transitioned to diaphragmatic breath pattern, requiring only slight cueing to relax the shoulders slightly. Otherwise, he was able to breathe without any specific breath hold, increased tension, or shallow breaths.
Introduced humming to optimize oral resonance. Given cueing, the patient was able to identify forward vibration of voice via kinesthetic feedback. He was also able to demonstrate through negative practice laryngeal tone focus and conceptualized the difference between this and forward resonance.
He will continue with exercises as outlined above. At next week’s session, will work further with partially occluded vocal tract exercises and move towards /m/ and /n/ onset syllables at the CV and CVC level.
