#053: A Crash Course in Voice for School-Based SLPs

Marisha: Hello there and welcome to the SLP Now Podcast. I am incredibly excited to have Kristie Knickerbocker on the show today. She 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 she also lectures on voice science nationally. So, she is an SLP rockstar and I've been waiting patiently or maybe a little impatiently to get to talk to her about all things voice, because she is such an amazing resource. I am really excited to get a peek at what she does today. But, she will also share some tips and suggestions for those of us who are working in the schools and trying to figure out what we're doing with these students. So without further ado, hello Kristie.

Kristie: Hi Marisha, how are you?

Marisha: Awesome. Super excited to get to learn a little bit about you today and all things voice. I'm super curious, can you tell us a little bit about your journey? How did you get started with voice therapy? We know that you have a private practice and I'm curious what that looks like for you today.

Kristie: That's a really great question. I'm an interesting story. When I was in high school and growing up, I've always been a singer, so I enjoy singing, I'm very musical. I enjoy writing, I enjoy playing instruments. I sat down on the back porch with my parents in high school, when you decide what are you going to do, are you going to go to college? I told them I really, really, really wanted to do music. So, I had auditioned for a music scholarship to go to Texas Christian University for a vocal performance degree, and I got the scholarship. So, we had all decided as a family that I was going to do that.
That same senior year, I was prepping for a competition where I had to sing a song, an art song by myself, and something was going on with my voice. It was nothing I could control. It was the weirdest thing. I just knew the sound wasn't coming out right. It wasn't coming out correctly. I discovered that if I pushed on my throat to the side, it didn't make that weird noise. So, I went to the competition and sang, and performed pushing on the side of my throat. The judge looked at me and asked, "Why are you doing that? What's wrong with you?" I said, "Well, my voice sounds really weird." So, she asked me a couple of questions and basically said what I was afraid she was going to say, which was, "You probably need to go see an ear, nose, throat doctor."
That was the push I needed to go get looked at. There was a bump on my vocal cord and I was devastated, been worried about next steps right away. I was told I needed to go see a voice therapist, a speech therapist is what they called it at the time. I was so concerned that this speech therapist wouldn't know anything about music, would know nothing about singing. I went and I met her. I was pleasantly surprised. She was a singer as well. She knew lots about music, and knew exactly where I was coming from, and that was really comforting because it was a really scary time. But, I ended up having surgery, and had the bump removed, and I was then in rehabilitation. So I had more voice therapy and then went and continued on in college like an injured athlete, where I wasn't really singing very difficult songs, trying to take care of things as I healed.
My voice teacher had a meeting with me and said, "You need to probably think about a different career path, because there's no way you're going to graduate on time with this injury." So, I was again, devastated but then got to thinking, "Well, what can I do?" I had considered doing nurse practitioner or a physician at some point during that backyard conversation with my parents. I said, "Well, what about doing the speech pathology? Doing what my speech pathologist had done for me, being that person that knows about singing, music, voice and then being able to marry that love of healthcare person, patient care with music at the same time."
So, fast forward to graduating graduate school, I had taken a semester, extra class on entrepreneur mindset and things you might need to be thinking about if you ever wanted to start a private practice. I thought that was really neat. I was scared of it though at the same time. I decided that I would incorporate after I got my license. So, my husband helped me. We chose the name O tempo Voice Center, because O tempo is a musical term. It means that you deviate, you have a rhythm, the beat of a song, you start off with that certain timing and that certain rhythm. You may deviate from that throughout the song to a slower part or a faster part, but then, the musical notation, it's like the map, it tells you o tempo, which means go back to the tempo that you started with. So, just like I try and do for my voice patients, and what I knew with my vision, to help them get back to that baseline. I wanted it to be named something healing, something that they could identify with.
It's not the best name when you're trying to talk to insurance companies because and they don't know, they expect an H after it. But, it's been an interesting journey to do that. It just found me, and then I found it and it has become me now.

Marisha: I love that. That is so cool, and very unfortunate that all of those things happened. But, I feel like sometimes things happen for a reason and now you get to help all of these other singers and musicians find their way back too, which is really cool.

Kristie: It's the best feeling. It really is, to be able to work with someone who you know exactly how scared they are for one. They're coming to you, not because it's me, it's like, "Oh, I'm coming to voice therapy." They're freaking out inside. They think that things are over for them. To give them answers, to get them goals to help them get back to what they were doing, is the best feeling.

Marisha: Yeah, that's amazing. So cool. You've lived it, so you're probably... I know you're amazing when it comes to, I don't know, just being there for them and knowing what to say and how to support and all that. So that's amazing.

Kristie: Yeah.

Marisha: Now, let's dive into some of the nitty gritty voice therapy stuff. The first thing that we decided to talk about was just the difference between behavioral and physiological voice therapy. So, can you tell us a little about that?

Kristie: When you think about voice therapy, maybe if you're listening to this, you had a little bit of a class part of a class, maybe half a semester, maybe you got a whole semester or maybe you got more than that in school, maybe you even got an extern placement where voice patients were being seen. But, it was always something that I was confused about. It was usually the way it was presented in class. So, voice therapy was this thing in the corner that nobody wanted to touch, nobody wanted to look at, but I was super excited about it because I knew that's what I wanted to do. But for everybody else, it was very visible to me that it was challenging. It was either they didn't know enough about it, so they just didn't care. They said somebody else can do that. But, I got to thinking, "Maybe it's just because the information is presented in a confusing way."
So, I want to talk about this because, I think it's important to help you piece together what these differences are, so that you know the types of voice therapy that you might need to give to very specific patients. Because, not all voice therapy approaches aren't created equal. Sometimes patients need more of those types than others. Sometimes they just need one approach. So, I wanted to dive into talking about the differences between that, so you understand it better.
The most common I think, behavioral voice therapy technique is resonant voice therapy. If you're thinking behavioral, this is the type of voice therapy where we're teaching patients what to do in the middle of their voice production. We're changing the technique of how they're creating sound, how they're using air and the shape of their throat and mouth to project that sound. It's something that's happening in the moment. So, that's what behavioral is. Then, physiological voice therapy is slightly different because, you're completing vocal tasks that might tax the system and overload it muscular-wise breath-wise, trying to get gains in what someone's able to do. An example of physiological voice therapy would be like LSVT, Lee Silverman Voice Therapy. Another example would be Joe Stemple's Vocal Function Exercises, the he, the glide up to glide down, and then there's five different notes that the person's singing. These are programs that are implemented with the idea that the person will make gains with how many times they're doing them per day.
Back to behavioral, the most common is resonant voice therapy. This is where you're humming or you're creating a very buzzy sound at the front of the face, vv or, zz, and most commonly hums, where you're trying to get vibration sensation somewhere in the mouth, somewhere in the nose, your cheekbones, and feeling what happens when you do that. The humming, the vv, zz, those are all types of semi occluded vocal tract exercises. That seems like a really scary long way to describe something, but in layman's terms, it is where your vocal cords are creating sound and then you're doing something to the tube that shapes that sound.
So, the throat is part of that tube, the pharynx is part of that tube, the mouth, the oral cavity is part of that tube. If you're putting something in the way of that tube being open for an ah, like you're closing your lips or you're bringing your tongue to your teeth, or you're completely shutting your mouth and having something come only out of your nose, your nostrils, that is a type of semi-occlusion, you're putting something in the way of that tube. That humming is one thing.
The benefits of semi-occlusion are that, it helps the vocal folds come together and not vibrate where they're colliding so hard. This is helpful for our patients who may have lesions, where we're not wanting the vocal cords to slap together so many times a second or so hard. It's helpful for patients who may have excess tension, and we're having them re-coordinate those behaviors. If they're straining because of that excess tension, or if they have pain from that excess tension, resonant voice therapy's a really great option. You may have heard of straw phonation, that is another type of semi-occluded vocal tract exercise, lip trills, tongue trills. There's even a new one. I was at a fall voice conference last year in 2019, and the guy was presenting research, and it was humming, but he was closing the nostril slightly with both fingers, so it was a muffled hum. That provided even more semi-occlusion, with the fingers almost sticking up the nose, sticking up the nostrils. So, I'm looking forward to reading research on that as well.
Then, another type of behavioral voice therapy is stretch and flow. This is where a person may be exhibiting breath holding patterns, or again tension or perhaps we want to again, alleviate some lesion by spacing the vocal folds out a little bit further, and not having them come together fully when you're creating sound. Stretch and flow is created by taking... It's the only approach that takes completely vocal cord vibrations away, but it keeps the articulation there. What I mean by that is you may start with just blowing on an U, and then you advance to actual articulation tasks. Some are rote like counting, and then you're able to advance up those counting hierarchies. You can mix and match days in the week, months in a year, just easy on the brain, but all, one, two, where your throat's really open and there's no vocal cord vibration. Then, you bring the vocal cord vibration back in, but you have it very, very minimally. So something like one, and then you can count like that, two, three.
A little bit different from the resident voice where, one, two, three, you're trying to aim for vibration at the front. The stretch and flow is more of how much air is coming out, how open and relaxed is your throat. But again, all of those are techniques that we can try to help shape what a person is doing and then have them continue on into their conversational speech, which is the ultimate goal. The goal shouldn't be they can do straw phonation with 100% accuracy. It should really be, they can use a variety of these tools, of these behavioral voice therapy tools to get the desired outcome, whether that's less pain when they talk, they sound better to themselves, they have better acoustic measures that we can test, that kind of thing.
But then the physiological, like I was saying earlier with the vocal function exercises, those were created by Joe Stemple, and there's a really good MedBridge course that he did where he describes exactly what they are, exactly how to do them. I think there's no better way to describe all those because he's actually teaching a patient in those videos. So, it's a perfect way to learn those. Like I was saying earlier, LSVT is another type of physiological voice therapy. A newer one is a PhoRTE. This is Edie Hapner and Aaron Ziegler, and they are creating again, a protocol the patient does daily. Then, you're taking these measures to see how well they're doing, and then you advance them as they respond to this type of therapy, and then you change it based on the patient's output.
So, there are different types of voice therapy. It's not a crazy amount of different types, but there definitely are considerations for your patient based on what their needs are. If you had somebody with both vocal cords where they are atrophying and not touching all the way, you might not want to put them on stretch and flow and make them breath here. We would potentially want to put them on the physiological type where they're really taxing their system, trying to bring the vocal cords a little closer together. Then if they were rough, we might throw in some resonant voice to help them sound less rough, that kind of thing.

Marisha: That's super helpful. I love that overview. I think this definitely is more of a crash course and a comprehensive of how to do everything. But, I'm definitely interested in learning more like, how do we decide all of those? But, I think this is a great starting point, and it gives us just enough of a foundational knowledge to... Like if we have a student on our caseload who's receiving voice, then we at least have a basic overview of what might be happening depending on the approach, or if we are in a position where we're deciding, we at least have a starting point to figure out which approaches to look into. So, that's super helpful. Then I'm curious too, because I've heard a lot about straw phonation, where does that come in and when would you use that?

Kristie: That's a great question. Straw phonation falls under behavioral voice therapy. It is a type of semi-occluded vocal tract exercise. It was researched very heavily by a man named Ingo Titze. He found out with many studies that what was happening was that, when you're creating sound and air into a straw, you're putting your lips completely around the straw, and you're blowing air and sound through it, that, that creates something called inertive reactance. Again, a fancy word. But, you can just call it back pressure. That back pressure travels from where the straw limits where the air and sound's coming out at your lips, and it forces it back down towards the vocal cord level, the glottic level. It encourages the vocal folds to not vibrate so hard, they don't slam so hard together.
This is a really great tool I think for all ages. I'll tell you why. You can use, we've been calling it Blowfish, but where your lips are slightly parted, your cheeks are puffed up, where you're making the straw shape with your lips. I find that it's not appropriate for every patient. I also find that the straw gives the person something to hold, and when they see it becomes a visual cue. So, they're able to be reminded, "Oh yeah, I need to do my voice work today," or it's almost fun, right? They can grab the straw and say, "I'm doing something really great for my voice because, I have this tool and I'm able to do it," versus just maybe relying on their mouth or their lips. It takes it out of their body. Because, a lot of times if the tension is present, it's hard for us to get out of that mentally. If we can have an external thing, potentially we can help alleviate that.
So you would use straw phonation if you had a patient who has excess tension, or they may have dysphonia, which is just the fancy word for rough voice. But, you would want to test on probe just like we do for speech therapy anyway, to see if they're appropriate, to see if the straw actually does something that's good for them. In my evaluation sessions, I will hand the patient a straw after evaluating, to see if they're a good candidate for it, just because it's usually very easy to explain. Again, with that thing in their hand, they're reminded visually, "Oh yeah, I have to do something." So I'll have them wrap their lips around the straw and make noise. I'll have them pick a pitch and travel up and down in pitch to see where they feel the most vibration at their lips also. Then I'll ask them, "Do you feel if there's strain? Do you feel if you're pushing at the throat level?"
A lot of times you might hear that push or that strain, they might sound something like hoo, because their pattern of how they're creating sound is so tight, it's so uncoordinated and that's all that their body is remembering how to do when you ask them to vibrate their vocal cords. We see this a lot with people who have had an illness like laryngitis, or they have had some cold or upper respiratory infection where they cough a lot, or they're straining to make sound because their vocal cords are so swollen. This a lot of times will help break that habit for them. So, straw phonation is easy to do. You can have them do one to two minutes. You can even put just sounds, single notes. You can have him put it in water and blow bubbles into the water while they're making the sound. Sometimes that adds a little resistance, and it has them use breath in a different way. So I think that that's helpful as well.
But, straw phonation is not for everybody. It could cause more tension than you think it should. So, listen to your gut, right? Follow your instincts with it. Because, while it's good in theory, a lot of times I will try it with a patient because I'm thinking this is going to be perfect for them in the clinic, and then they try it and I completely throw it out the window, and they're walking out the door because I've given them something else by this time, and they will say, "What about that straw thing?" I'm like, "Forget we even did that. I tossed it. We don't need that." So, straw phonation is a good thing to know about. It's good to have in your toolbox, but it's not the end all be all.

Marisha: Okay, perfect. Let's do a quick recap. We talked about three different behavioral approaches. There's resonant voice therapy, stretch and flow and straw phonation. Then for straw phonation, you said that it's ideal for patients who have, or it can be a good approach for patients with excess tension or dysphonia, but we want to abandon that if we find that using the straw actually causes more tension. So who would you say, who would we use resonant voice therapy with? What would we see or what would an ideal patient be for that?

Kristie: Great question, very similar. So, somebody who may like routine and things where they can try a type of voice therapy in multiple occasions. The resonant voice therapy can be used in a hierarchy fashion where you're doing, Katy Verdolini Abbott calls it the Basic Training Gesture, mm-hmm (affirmative), like you're answering a yes question, and single words mention or moon. There's a chant version as well, where they're sustaining sound. My mom mails me money.
But, this will be good for patients who might have just, I mean, straw phonation too, might've just come off of vocal surgery and they need something that's not very taxing on the vocal folds. Any gentle phonation or gentle sound production to start off with might be good for patients again, who have pain when talking. If they come to you and they sound like this, and you need to rebalance how they're using breath and vocal cord vibration and resonance, you can teach them how to make the sound and then create that, take them way over their comfort zone, and naturalness of speech, because I sound really strange doing this right now. Teach them how to do this and then teach them how to draw back from that, where it actually sounds more normal, like natural conversation.
But, if they find themselves going back to that pattern, they can breathe in and then check back in with that resonant voice. So, it's more of something you're going to have a little bit more cognitive load to do that versus, stop do the straw for about a minute and then come back in. So, it's something that can be put within the context of a person's speech in a little bit of a different way. But yeah, it's a great approach. I think it is just like straw phonation, I think patient dependent. Sometimes we'll do really great with a patient with straw phonation during a session. They do it for one week, it's really great. They come back the second week and things have gone really downhill. We'll throw a resonant voice in there and then that helps things. Then, they can rely on both straw phonation and resonant voice to help them reach their target outcome.

Marisha: Awesome. Then, what about stretch and flow? Is that also similar in terms of crosstalk.

Kristie: For stretch and flow, you would want to use that on a patient who has a really difficult... A lot of times patients will have difficult time humming where it's relaxed. You would think that's not that hard, I can hum. But, sometimes their patterns or how they sound doesn't necessarily create smooth quality. They can't break the pattern of the tightness or the dysphonia with the humming alone, because it's too similar to their everyday speech. So, for those patients, and there's actually a study it was a non-inferiority study, meaning one wasn't worse than the other, and it looked at comparing resonant voice therapy to stretch and flow, finding that both were able to make an impact positively for patients. So, this would be if your patient can't do resonant voice therapy really well or if you think they're holding their breath and you want to go ahead and start there, you can.
But, because it takes away the vocal cord vibration and it focuses on airflow and output of air, I think it's a really good one, if your patient's personality or their presentation is one where their shoulders are really tight, they're holding their breath, they're talking really fast like this, absolutely it is like that, you really need to break down the systems so that you can build them back up again.
So you can say, "Hey patient, let's talk about breath. I want to teach you how to really focus and slow down on your articulation, how you're forming words. Breath happens the whole time." You're able to teach them utterances on one breath and how that feels. Then, you throw the voice back in. Because, sometimes it's too much to think about for a patient, because they've been vocalizing one way for so long.

Marisha: That makes a lot of sense. Thank you for that overview. Then, what about the physiological one? We talked about LSVT, then Joe Stemple's vocal exercises and PhoRTE. So, Who would you use LSVT with?

Kristie: Yeah, great question. LSVT was formulated with a specific group of patients in mind, and that's patients with Parkinson's disease. Those patients with Parkinson's lose volume, they lose intelligibility. A lot of times they get, because of their age bode vocal cords. So, we're combating three things all at once. The LSVT is Lorraine Ramig and Cynthia Fox, and they created this where the person is holding out these long ohs. Their tagline is think loud. Speak Out is Samantha Elandary, she's doing something really similar with that as well. These long, loud productions of sound so many times a day, so many times a week, and they're aiming for overall system improvement and overall system change, by just physically completing those exercises. So, getting gains like you would at the gym, okay?

Marisha: Mm-hmm (affirmative), perfect.

Kristie: PhoRTE is really similar. It takes into consideration some vibrant talking, some exuberant voice exercises. It looks a little different from LSVT and Speak Out as well. However, it's different in that it's less sessions. The patient does a lot of work from home. LSVT has a component where you a lot of times will get dementia progressing slowly or rapidly with the Parkinson's. The LSVT requires the patient to complete the session with the therapist four times a week for four weeks. PhoRTE's a little bit different because, you can have these check-in sessions and we expect the patient to have a pretty high ability to be self motivated, cognitively aware enough to do what we ask them to do, because they're measuring their sound as they do it. So, I think PhoRTE's a great option. The patient's able to have more flexibility and not come in as frequently, or not be seen as frequently and getting great gains that last. I think that covered it.
What I didn't mention and I should have, I didn't, for behavioral voice therapy there's a newer one for behavioral as well called Conversation Training Therapy. That's Jackie Gartner-Schmidt and Amanda Gillespie. It's the first therapy, this also has a really great MedBridge course on it. It's great because for speech therapy, for language therapy, for things that you all are doing every day, most of the time you're doing a hierarchy approach, right? You're getting the child to a certain level or maybe even the adult. You're doing something and then they meet that criteria and then you're moving to a higher level. For conversation training therapy, you start with a certain type of cue and then you're able to add these other tenets of the therapy whenever and wherever you want.
So, I think it requires a good understanding of how voice therapy flows. But, I think both women do a great job explaining the how of it during that MedBridge course, where you're able to say, "That makes complete sense. I can always start there and then add these other components in. Then, I probably was doing that already with my other patients and I just didn't realize it." So, what they're finding with that is while traditional voice therapy may have required multiple sessions weekly for months, the CTT is actually creating an ability for patients to not be seen very frequently. They're learning it from the first session, learning how to generalize. Then, the results are lasting as well for quite a long time after. So, it's groundbreaking because why wouldn't you want your patient to advance as fast as possible? Of course, you would want that. But, I think the right type of patient for this training as well, needs to be taken into consideration, and cognitive level, the ability to multitask is one of those components.

Marisha: That's super helpful. Again, thank you. We've got a quick overview of the different types of therapy that we might use. Then, what do you do if you're one or multiple approaches and the child just isn't responding? What would you recommend then?

Kristie: That's a really, really great question. The type of therapy, you always want to start with what the child is stimulatable for. So, you may go through multiple, you may have them lip trill, you may have them hum, you may have them yawn and sigh on that yawn, you may have them blow bubbles in the cup with a straw, you may have them get louder, right? Whatever makes the best sound, you should go with. But, that may change the next time you see the child because maybe that isn't something they're responding to. So, you can always switch mid session. You can switch the next day, next time you see that child if they're not responding, and jumped around those techniques all while trying to attain where the child is going goal-wise.
You find this by discussing not only with the child, but the teacher and the family to determine why the child is in voice therapy in the first place. What are you trying to improve? What is out of the range of normal? But, maybe the child isn't responding to therapy at all, right? You're doing these indirect voice therapy things, and indirect is the component of voice therapy where we talk about hygiene or vocal wellness. We talk about preventing phonotrauma, so avoiding the throat clears, avoiding the yelling, that kind of thing, drinking the water, how well are you hydrated. These are all important things. Are you resting your voice after? Do you have a routine for your voice? Is there a warm up that you do? Those indirect things? Limiting the time you're on the playground because maybe you're helping to limit the yelling, as the child just can't stop yelling on the playground. Or changing what recess looks like for that child for a little while.
But, if they're not responding at all, meaning they haven't been able to carry over, maybe that's what that means to me, they're not responding. Meaning they may not, meaning carry over, I would want to know and talk with the family. I might make a couple of phone calls. How is Johnny doing his practice at home with you? What does that look like? Do you do the cards that we send home? Do you do the worksheets? Oh, that's boring, okay. What do you do at dinner? What does talking look like? Can you incorporate some of these techniques when you guys are talking at a meal? What does bath time routine look like? Or if the child's older, what are you doing when you drive Johnny to soccer practice? Is there a conversation going on in the car? I would really probe how the family is involved.
Also, there is a really great article, let me see here. I think it's Barbara Weinrich, it's Lisa Kelchner and some other person, Susan Baker Brehm. I was like, "If I can't remember it, I'm going to be..." I thought of it. But, their article looking at how voice therapy really impacts or how it's impacted by the family involvement, the therapy techniques may do very little to impact what we look at as the outcome. But, a huge component of that is how the family views voice therapy, what importance the family gives to doing the practice, carrying it over. So, I think if the response isn't there, I want to know what's happening at home.
Then, the other phone call would be to the teacher, or maybe trying to hop in and chat with him or her after the class one time, to see what's going on in the classroom, how the teacher is able to help facilitate the new voicing, phonotrauma prevention, the hydration, that kind of thing. See if there's something you can do to help troubleshoot. That's the first thing I would do.
Then, if you do that for a while and there's still no response to the therapy, I would really suggest potentially getting a reevaluation by the doctor. That might include getting visualized again. So, another video stroboscopy or at the very least a nasal endoscopy where they're going through the nose. Maybe they don't have the light to look at it in so much, but maybe they can look with the nose scope, to see if it's really what we thought it was to begin with. Sometimes you get the kid scoped and you think, "Oh, it looks like vocal nodules. These will go away if we do therapy and vocal rest." Then, if nothing's improving, you may go back in and then discover maybe with a more specific test, like a video stroboscopy you say, "Oh, this wasn't nodules at all. This looks like a cyst on one side and it's swollen on the other side, because the cyst has been hitting that other vocal cord every time they talk, and it's going to require surgical removal."
In that case, it's great because there's a reason the child wasn't responding to therapy, right? The child was doing everything, the family was doing everything, teacher, they were all superstars, but it was something that needed to be fixed surgically. So, had you not visualized, had you gone and continue to do what you do, Johnny will get better, year two goes by, nothing changes, you have frustrated parents, frustrated teacher. Johnny thinks he is the worst child ever because they can't fix his voice, when the easy answer was let's get another visualization here, and really see what's the problem.

Marisha: That makes a lot of sense. I remember from my voice classes that it was really important to have that exam before starting therapy. So, is that the truth? Why would that be the case?

Kristie: Yeah. I think most definitely it's the truth. We need to visualize what's going on, just like eating habits. I was talking about this at Sin City Laryngology in February, making a case for visualization before treatment, just like a doctor would not do any recommendations before an X Ray, for a broken arm or a broken leg. You wouldn't want to have any surgery on something unless you had done a scan, a CT scan or an MRI. We do these scans so we can have a better idea of what we're looking at. I think that's absolutely the same for voice therapy because, if you're not looking and you're creating a treatment plan you are saying, here's what I believe the problem to be based on what you hear, what you see the patient doing from the outside, and you're missing that inside component, you may be setting yourself up for harm in the way that what you do is futile. Everything you're doing is not going to fix the problem because the problem really needed to be fixed with surgery.
That doesn't mean that the surgery... Like you wouldn't do voice therapy if the person had had surgery, right? It's always a better outcome when there's a combination there. But, the expectation I think is the most important part. You have to be real and truthful with your patients about what they can expect. If they just expect voice therapy to fix the problem and it's not fixing the problem, there becomes a trust issue with you as the provider. You're no longer trustworthy because what you said was going to help is not helping. What are they supposed to do now?
I think having that video stroboscopy completed before implementing any treatment plan, helps you help them, it helps everybody. You get a lot of pushback because, if you see patients in the school and you're saying, "Hey, this kiddo needs an exam," the school doesn't necessarily want to pay for that. But, I think it's really important. A lot of times the parents may be scared. They may not want to have their child get examined. So, if they're very adamant that they don't want that exam, you can't force them to get that exam. But, I think you have to have these conversations about not... Limited knowledge on your part resulting in limited improvement potentially, you may not be able to have the whole picture. So, you may not be able to give them the outcome that they desire.

Marisha: Okay. Perfect. Thank you for that overview. I think that's a good reminder and refresh too. So, what other recommendations do you have for school-based SLPs? Maybe we can start with students who are seeing a voice therapist and who have gotten all of the visualizations like video stroboscopy, like there's the voice expert working with them. What do you recommend for SLPs in that situation?

Kristie: Well, a good behavioral voice exam. If you've had the doctor do the exam or an SLP in your area who does video stroboscopy, you have that done and that comes back to you, you still need to know what the child does well, where you're going to head with therapy. So, a good ability for behavioral probing, I would start there. I would gather acoustics, acoustic measures if I could, meaning fundamental frequency. So, the average pitch that the patient talks at, you could run acoustic measures, something like the Acoustic Voice Quality Index that gives you a number that indicates if dysphonia is present or not. So dysphonia again, messed up sound like hoarseness. The Acoustic Voice Quality Index supersedes jitter and shimmer. Those are maybe words that you look back in your brain and you think, "Oh yeah, that was something we learned in school. I can't remember what that means."
But, something has come out in recent years called Cepstral Peak Prominence. It is a much more sensitive indicator. It contains the ability to measure connected speech. So, the child talking in a sentence as well as sustained bell, where you may have only used jitter and shimmer to measure ah, and maybe the child sounds really great doing ah. But then, they start talking like this. So, how can you measure something that is really representative of what the child's output is? So, enter the Acoustic Voice Quality Index because that contains part of that Cepstral Peak Prominence and some other measures as well. You can gather some aerodynamic measurements as well. You can get vital capacity for the child to find out phonation quotient or estimated mean flow rate, to determine if the child's using air adequately.
All of those... I've put together a guideline on how to obtain those measures with a really concise measurement tool in Excel that I have in my online store. To walk you through and guide you with how to administer a behavioral acoustic or a dynamic evaluation. I added cards so that the child can hold the cards and then flip to the next one, where you have the target what they're about to do, they can read it out loud and then they have an idea of where they're headed. It's tangible. They can flip through the cards so they're not distracted.
Then, you would start determining goals. You would decide what they sounded best at, what made them sound better. Then, you would discuss with the child. I think it's super important to see where he or she has any opinion on the situation. That's going to help with motivation. I think that's really important as well as the family and the teacher, just discussing what support system they have at home, how they're going to practice, what that's going to look like. You can explain what it'll look like at school, and then how your check-ins are going to be, how the odds are going to look for the voice goals for that child.

Marisha: Awesome. I love that you have that voice assessment guide, because I know that could... If it's something that we don't do a lot of, I know that can be intimidating to dig up all of the notes, but that's an amazing resource.

Kristie: It was super intimidating to make Marisha because, I've been worried to make it for such a long time because, I was thinking, "How am I ever going to throw all the knowledge I have about what you do in an evaluation into something that can be replicated? That can be recreated and utilized?" But, the more I talked to people who really were just using S/Z Ratio and calling it a voice evaluation, I was like, "I can make something that can give them so much more information, and the ability to help mark progress in such a better way." So I made it. I had it tested. I had lots of people try it and give me feedback on it. I changed a lot of things about it as it was being made.
But, I had been making these other resources for my store for like resonant voice therapy games, stretch and flow games, straw phonation games, breathing training, that kind of thing, for pediatric patients because, why should speech and language kids have all the fun? You're looking for things for mixed groups and it's like, "I have nothing for this child with a voice disorder that's on my caseload." So I said, "There's nothing, so I'm going to make it."
But then, I kept getting these questions about, well, how do I know when to use resonant voice? How do I know when to implement straw phonation? So, part of the reason that guide was made as well is because it has suggestions and probing in it, like the no prep voice workbook that's in the store as well, the one that has... It's like, I want to say 120, or 128 pages I think, maybe it's more. But, that goes through again, probing what the child sounds like and then activities where you can bounce back and forth. If they're doing great with straw phonation one day and you need stretch and flow the next day, and then you have activities on that to work with your mixed groups.
So, out of that came... Out of making these came the need for guidance on how to implement them as well. So, that's why the guide I think is so important and great to use because, it includes a video demonstration of how to implement all of the measures, the testing, and shows you exactly what to do. So, you don't have to just do S/Z Ratio, you have a lot more at your disposal.

Marisha: That is so cool. Then, I will put the link to the voice assessment and then the voice therapy workbook in the show notes. So, those will be at slpnow.com/51. There's even more resources that you've made that are amazing. So, I'll just put the link to your story there too. Then, what recommendations would you have for a student who, like we get a referral from the teacher, we find that they have, like their voice, they're having some dysphonia or whatever it may be. I assume that we still want to have that good behavioral voice exam. Then, we talked about trying to get a physician to look at the vocal folds before starting anything. But, do you have any other suggestions on how to navigate that?

Kristie: Yeah. That brings up a good point. I have a lot in the past in our clinic, been able to do video stroboscopy for SLPs who send their children, and then the child gets treated in the school. So, we can do the exam at our clinic and then collaborate with that SLP to say, here's what the child was really good at and here's your starting points, and then collaborate. You can collaborate with the SLP who may do voice all the time in your area, so that you know what to do and where to go with that child. So, I think that we're better together regarding our experiences because, if you don't know much about voice and you're trying to treat that child and you're thinking, "Well, I know enough where I can probably not harm the child," but I think it's really important to get the opinion of the specialist SLP because, you can still make a difference in the school. Maybe you need a little guidance, need a little collaboration with that person.
So, I would suggest in your area, getting an exam or at least giving a call to the SLP to say, "Hey, what would you do with this child? I have this child in my caseload. Here's what I'm thinking. What are your thoughts on that?" A mentor situation where you're going to benefit as the school SLP because you'll know what to do with the next child with a voice disorder. But then, that child's going to benefit too because, you're going to be a lot more equipped with better knowledge after that consult. Because, the thing you find, I find, is that if you didn't have a placement opportunity where you could go and watch voice therapy be done, it's scary or strange or odd.
Leah Helou actually talked at Sin City Laryngology in February also, about the Meta Therapy. What she describes is our dialogue, the things that we're saying, how we're saying it, the schemas that we build in our mind, the routines. It's how we as clinicians do these things methodically, to get the result we want in a session. It's our attempt at programming a framework that we use in each session. It may not look the same in every session, but if you're watching it go down, you know what that speech pathologist is doing.
So, this type of thing, and trying to let somebody know how that's happening, maybe by having that SLP come and observe, maybe the school says you can go observe at this voice clinic so you can learn how to treat our students better, I think that that's helpful as well. Because, then they get to see the Meta Therapy and they're not so bogged down with, "Okay, great. They did their hum in a hum level, now we can do an M word level." They have the idea of you don't have to have 50 M word sounds really resonant to move on. The repetitions are important, yes, but you need to be able to have that skill of stepping back and looking at the framework that you're using to conduct a session.
You all have frameworks so you use all the time with your speech and language arctic children. It looks the same with voice, but there's a little bit different considerations for that. So, I think if you're an SLP in a school and you have a student that needs an exam, maybe you can go and watch that exam, right? That's how you're going to learn, or potentially you can go and observe the SLP do the scope or the SLP do the eval, who maybe does voice more frequently or you can at least give a consult phone call to somebody who can mentor you and support you as you're supporting that student.

Marisha: Yeah, that's perfect. I love those ideas, and just getting really strategic with the resources that we have available. Yeah, definitely that mentorship, collaboration approach seems like it would benefit everyone involved.

Kristie: Yeah, most definitely. I really do feel like we're better if we can collaborate, but it's not always intuitive, right? Because you have so many students on your caseload, you're crammed with stuff to do until the day is over, you probably take work home with you and then it's time to hang out with your family because they need you too. But, I think it's important to collaborate nonetheless, to try to do better for your patients. Because, that's why we do this in the first place. We don't we don't go into speech language pathology without big hearts and loving what we do. We do that because we love our patients and we want them to succeed.

Marisha: Yes, I couldn't agree more. I mean, I wish... I feel like we could talk about all of this stuff for hours and hours, but we're almost at the end of our time. So, if SLPs want to find out more about you, where can they connect with you? I'll definitely be linking to your Teachers Pay Teachers store and your website, but where do you hang out and where can SLPs find out more?

Kristie: I do hang out on Instagram pretty frequently. My handle is @Kristie_voice. That's K-R-I-S-T-I-E_voice.

Marisha: Well, thank you so much, Kristie. This was an absolute treat. I so appreciate your time, and thank you for sharing your time with us.

Kristie: Thanks so much for having me, Marisha. I really appreciated it.