The Things of Nightmares....
If you're like most, it's a heck of a challenge to be a "Many-Hats SLP" in a world where we are supposed to know everything about everything. With graduate school occuring when you're trying to answer big questions about the rest of your life, it leaves little opportunity to do anything more than cram in as much information as you can about some SLP subspecialties while you pray to pass your Praxis.
We are required to get a good mix of observation and clinical hours, pediatric through geriatric, language through cognition. Voice patients may not be the most common and for some SLP's, they can be the things of nightmares. There are a few things you need to know to rest easily at night.
1) They Need Your Help
Some of us are the only SLP at our facility. Scarier yet, we may be the only SLP for miles. We do our best to figure out what is appropriate for our patients from evaluation, to goal formation, to discharge. Patients with voice disorders need your help. They most times have no idea what an SLP can do to help them, so there's an educational opportunity right there. We can't know everything, but we can do our best to educate ourselves as much as possible, knowing that a voice patient may pop up on our caseload from time to time.
Patient's don't want to hear that you have never had a voice patient before. They don't want to hear that you are apprehensive. Research what you can, find resources that will help you and inform the patient that you'll do everything to make sure they are getting the most appropriate care. Even if that most appropriate thing is a referral to a more skilled SLP, but you need to know your boundaries. If you don't know answers, tell the patient! It is so much better to say, "I'll check on that, but I don't know off the top of my head." The patient will appreciate your honesty so much more than you having to back track on what you have said.
2) You Don't Need Fancy Equipment To Evaluate The Patient...
There are low tech options to voice evaluation, with the program PRAAT. CAPE-V is available online, as is VHI (The Vocal Handicap Index) and RSI (Reflux Symptom Index). You owe it to your patient to get an ENT referral, and to rally for an instrumental evaluation, most appropriately a videostroboscopy. This way you can be sure your services are not contraindicated for the patient. For instance, there's no point in trying adduction exercises on a patient who has a huge glottic gap. You're likely just making the supraglottic compensation worse (that means squeezing of the muscles above the vocal folds). This patient will likely benefit from an injection or medialization surgery prior to beginning therapy, but you will only know this with appropriate diagnostic testing.
Get yourself a spirometer, a good condenser microphone, an audiogram and get to work. You can gather many acoustic measures, like F0 and Cepstral Peak Prominence to back up your data and to track progress in your patients. Self Questionnaires can give you great pre and post data on how your patient feels about the voice.
3) There Are Not A Million Voice Techniques...
In school, I remember believing there were a vast and infinite amount of techniques you could try with a patient to improve voicing. I remember feeling defeated, like I'd never know them all. Just when I thought I was getting to know what was out there, I would hear, "There are so many other things to try." What are these other things? Why haven't we talked about them?!? I thought I would go batty.
What you need to remember is, that for the most part, there are 3. (Now bear with me.) We can classify them into flow voice, resonant voice, and semi-occluded vocal tract exercises. (Not to confuse you, but humming/resonant voice is a type of SOVTE, but it has really taken on a form of its own thanks to Kittie Verdolini Abbott.)
Flow voice is therapy to reduce laryngeal hyperfunction by increasing airflow at the glottic level, like yawning, sighing, and breathy phonation. Resonant voice is therapy that uses humming to focus the sound forward and reduce laryngeal hyperfunction. Semi-occluded vocal tract exercises (like straw phonation, lip trills, cup phonation) help reduce laryngeal tension, by creating inertive reactance (Titze), and encourage the larynx to lessen the force of vocal fold collisions.
The only other things that you might find confusing are circumlaryngeal massage, myofascial release, laryngeal reposturing (Roy) and functional aphonia treatment. The first 3 (learned with a combination of observation and courses) are to help break pesky muscle tension behaviors, and treating functional aphonia can be as simple as having the patient cough or gargle.
4) No One Is An Expert...
Many greats in our field are viewed as experts on specific topics. If you talk to those folks, I mean really sit down and discuss things, I think you'll be surprised to find that they are humans who are just really interested in voice. They do not claim to know everything about voice, but instead strive to answer questions that need answering. They research, they publish, they treat, they collaborate. They even disagree on methods.
There is always something to learn, and that's why we do those CEU's. So don't beat yourself up if you are just starting to understand voice rehabilitation. Maybe you just viewed your first videostroboscopy. Maybe you just realized that vocal fold injections of Botox and Prolaryn Gel are two different treatments for two very different pathologies! Cheers to you, knowledge-seeker. Don't ever get discouraged or feel stupid for asking questions. Your patients depend on your fire and drive.
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 her website or on TPT. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.