My journey to a voice specialty

My journey into speech therapy started in 2000 when a career advisor at my school did an online survey with me, asked me a whole load of questions about myself, my strengths and weaknesses, hobbies, values and the computer pinged out suggestions for me. Up flashed ‘Allied Health Professions’ with Speech Therapy at the top of the list. So my incredibly supportive mother helped me ring around local hospitals and speech therapy departments and I spent half of my summer holiday break after GCSEs shadowing therapists in a host of different specialties. I was so lucky, it’s much more difficult to do that now.

I spent four years at Newcastle University in the North East of England. Four brilliant years making friends for life, partying like only students can and of course working blooming hard to become qualified. During that time I had a very inspiring placement in North Tyneside with a therapist called Helen where I got experience with a voice caseload. Almost instantly there was no looking back. Clinical placements are a huge influence on students and I remember this every time I have a student on placement with me now.

At the point of graduating in 2007 I applied for any job I could find that had some voice work included. I was limited by location in as such that I knew I wanted to live in London but was happy to commute. I got my first job at Wexham Park Hospital in Slough and it was a bit of everything. Acute, community, neuro and voice caseloads. I’m pleased it was a mixed post for optimal experience and I gained my post grad dysphagia competencies and years of experience on stroke and general inpatient wards. But my manager at the time Eileen Daniel was a voice specialist an a great inspiration and I learnt so much from her. Within three years I’d decided that voice was the only specialty for me. Thanks to her support, flexibility and managerial planning I was able to go full time in a voice specialist role. Mr Nigel Bleach was my ENT inspiration at that time and he taught me so much that I needed to know during those years about the voice clinic and the joint management of voice disorders.

Of course post graduate training funds were limited but each year I attended various study days, voice Special Interest Groups, BVA days and courses such as Accent Method, Lee Silverman Voice Treatment, CBT skills for psychogenic voice and in house CPD sessions were invaluable. Some of it was self funded, this was frustrating and hard at times but completely worth it in the long run. Now I would advise new voice therapists to pick their CPD carefully and take advice about which courses are right for them and when in their career. You don’t need to do everything at once. And there’s plenty to be gained from reading a voice book or searching online and social media for amazing videos and graphics which are often free! I worked with a scruffy set of informal voice competencies for the first 12-24 months i worked in voice and thankfully had accessible and fantastic clinical support.

I was in my first job for seven years but, after having a baby, we moved house and it was time to move on so I took a two year role in High Wycombe Hospital where I could focus on my advanced clinical voice skills.

I had always wanted to work at the John Radcliffe Hospital in Oxford. I’d known the area and heard that the voice team, Penny Lennox, Caroline Fraser and Carol Harris were brilliant. In early 2017 the timing was just perfect and I was offered a clinical lead role in ENT. The role also included being student coordinator for the adult SLT team and a day funded by the community team to train and supervise the development of voice skills amongst the community SLT team. This was a wonderful opportunity to be involved in the organisation of student’s placements and the process of supporting therapist colleagues with their voice skills. I created a set of three level voice competencies for the Developing, Specialist and Consultant Voice Clinician. And I had opportunity to create and trial different ways that knowledge and skills could be achieved to reach competency, as well as train and supervise therapists in groups and one to one.

As part of my private practice VoiceFit I have been supporting students who want more voice knowledge, speech therapists who want to develop in voice and practitioners returning to work. And thus the idea of an online voice skills and competency course came about.  By the end of 2021 I will be launching a 6 module online voice skills course that will be designed alongside a set of voice competencies for the developing voice therapist (Level 1). The course will be online and designed to be completed alongside a voice clinical caseload. Supervision with me with be part of the package over a 3 month period. Keep your eyes peeled on my social media and website for more information.

Opportunity and support along the way were the two biggest factors allowing me to specialise in voice. I am forever grateful to those that helped me along the way and to all those who keep it possible. Thank you.

If you want any support or ideas about how to specialise in voice or further your voice knowledge and skills you can contact me anytime on Instagram or at torspence@voicefit.co.uk.

The photo is of me and Simone Such, a final year SLT student at the University of Reading and on placement with me. 2021. The Voice Pathology Poster is by Kristie Knickerbocker at A Tempo Voice.

Vocal Cord Histology

What are all the layers of the vocal cords?

The Mucosa or Cover (YELLOW) is made up of the Epithelium and the Superficial Lamina Propria.

The Epitehlium protects the under layers from damage.

The Superficial Lamina Propria is gelatinous and is made up of fluid and elastin.

The Vocal Ligament (RED) is made up of the Intermediate and the Deep Lamina Propria.

The Intermediate Lamina Propria is elastin fibres and lets the vocal cord lengthen and shorten.

The Deep Lamina Propria is made of collagen to limit elongation of the cord. The vocal ligament provides the voice with range and flexibility and pitch.

The Body (BLUE) is the Vocalis Muscle. This is stiff compared to the other layers. Its abducts (opens) and adducts (closes).

How does this link with vocal cord pathologies?

Vocal cord nodules are benign calluses (scar) that form along the mid-portions of the vocal cord edges in the Epithelium layer.

Vocal hemorrhage occurs when a blood vessel in the vocal cord ruptures, and leaks blood into the superficial lamina propria.

A cyst is a mass made up of a collection of material, usually mucus, that is surrounded by a membrane envelope. It is found underneath the epithelium, within the superficial lamina propria.

Reinke’s oedema, also called “polypoid corditis”, is a swelling of the entire layer of the superficial lamina propria (otherwise known as Reinke’s layer)

Vocal cord paralysis is when innervation to the body layer, the thyroarytenoid muscle is damaged and the muscle stops moving.

Voice and Upper Airway Book Reviews

BOOK REVIEW 📚

My five top texts:

Voice Work: Art and Science in Changing Voices By Christina Shewell. A perfect combination of art and science when it comes to voice and it’s packed full of practical ideas on improving breath, voice, posture and vocal health.

Speech Pathology Management of Chronic Refractory Cough and related disorders. By Anne Vertigan & Peter Gibson. The chronic cough bible for speech therapists! It has helped me develop my skills and the service I run and really understand the evidence base and theory behind chronic unexplained cough. A must read!

Laryngeal Endoscopy and Voice Therapy. A Clinical Guide. By Sue Jones. This helped me achieve my voice clinic and laryngoscopy competencies but it remains a brilliant guide to return to when updating procedures and ensuring good practice. It’s also great for the developing voice therapist and students in voice placements.

Psychosocial Perspectives on the Management of Voice Disorders. By Janet Baker. Clinically helpful and evidenced based. The second section is particularly relevant for speech therapists learning how to incorporate  counselling skills into their voice therapy approaches. It’s very clear and easy to read and follow. Inspiring for immediate use with patients as you read it. Includes some nice case studies and discussions.

Complete Guide to Respiratory Care in Athletes. Edited by John Dickinson & James Hull. A very detailed look at breathlessness in athletes. Most relevant to me are the excellent sections about exercise induced laryngeal obstruction, dysfunctional breathing patterns, allergic rhinitis in athletes and I learnt a lot more about respiratory system function during exercise. A very helpful read for me as I joined the airways MDT. Helped with MDT patient management and improved my knowledge.

How do speech therapists treat chronic refractory cough?

Speech and Language Therapy is evidence based, effective treatment for chronic refractory cough (medically unexplained persistent coughing for more than 8 weeks).⁣

𝐁𝐮𝐭 𝐰𝐡𝐚𝐭 𝐝𝐨 𝐰𝐞 𝐝𝐨 𝐭𝐨 𝐡𝐞𝐥𝐩 𝐩𝐞𝐨𝐩𝐥𝐞 𝐫𝐞𝐬𝐨𝐥𝐯𝐞 𝐭𝐡𝐞𝐬𝐞 𝐬𝐨𝐦𝐞𝐭𝐢𝐦𝐞𝐬 𝐝𝐞𝐛𝐢𝐥𝐢𝐭𝐚𝐭𝐢𝐧𝐠 𝐜𝐨𝐮𝐠𝐡 𝐬𝐲𝐦𝐩𝐭𝐨𝐦𝐬??⁣

Initial assessment is very detailed and involves taking a medical, social and psychological history. Laryngoscopy is an examination of the voice box which rules out any laryngeal pathology and is often very reassuring for cough patients. Part of our role is to ensure all medical investigations for cough and medication checks are complete. Assessment will include patient rated outcome measures and symptom frequency and severity ratings. ⁣

Education is key to improving awareness and motivation for effective treatment. Speech therapy helps facilitate patients to control their cough. ⁣

Cough control strategies – various techniques for this. Teaching and modelling from SLT and lots of practice.⁣

Throat care is vital to optimise hydration and comfort in the upper airway. Advice about acid reflux management, hydration, good inhaler technique, diet, sleep, lifestyle, voice use, posture might be included here.⁣

Head and neck tension release – exercises and strategies for improving muscle tension balance in the neck and shoulders. This area of our bodies is prone to holding tension and its very muscular. Tension is common. ⁣

Voice Therapy techniques for easy, relaxed, resonant voice and optimal use of our instrument, particularly important for the professional voice user who is also coughing.⁣

Taking a counselling approach to supporting patients. There is a link between anxiety and cough. Chronic cough can significantly impact on quality of life and cause distress, relationship problems and confidence issues. Even more so now during the Covid 19 pandemic. ⁣

Taking a multidisciplinary approach to the treatment of chronic cough is gold standard. Physiotherapists are very often involved if there is a breathing pattern disorder or if the patient also has asthma, COPD or bronchiectasis. ⁣Having clinical psychology input is also helpful.

The Video Consultation Checklist

Check the following before you carryout a video consultation

🔹 Everything you will need during the session is within arms reach (water, pens, paper, diagrams, documents open for sharing, equipment, glasses, diary etc).⁣
🔹 Your space is quiet and the risk of disturbance is minimal.⁣
🔹 The WiFi is working.⁣
🔹 Equipment test complete.⁣
🔹 Headset and Mic available. ⁣
🔹 Camera is eye level.⁣
🔹 The client has been prepped about video access and tips for optimising their set up and environment (refer to VoiceFit Infographic – download here)⁣
🔹 Your voice is strong and prepped. ⁣
🔹 Lighting is adequate and will stay that way throughout. Consider the natural light changing if your consultation is in the evening as the sun sets. ⁣
🔹 You are ready and start the video call or enter the waiting room at least five minutes before the start time so you are there when your clients joins you. ⁣

How the Normal Voice Works

 

I often suggest to students new to clinical voice placements to develop and practise a description of how the normal voice works. It’s an integral part of understanding voice production and empowering the voice patient with knowledge about their own instrument. So here’s a basic description

The voice box is located in the front of the neck. It is otherwise known as the larynx. We have two vocal cord muscles, just behind the Adam’s apple, which are moved and controlled with the help of different muscles throughout the neck. The power source of voice is breath from the lungs. Think of the lungs being the fuel tank. At rest, your vocal cords are open to allow the air to move freely in and out of the lungs. When you want to speak, the vocal cord muscles are innervated by branches of the vagus cranial nerve; as air flows out from the lungs the vocal cords move, acting like a vibrating valve that chops up the airflow from the lungs into audible pulses that form the sound. The muscles of the larynx adjust the length and tension of the vocal cords to ‘fine tune’ the sound and alter the pitch and tone. The tone of voice may be modulated to indicate feeling and emotion. Varying the pitch of ones voice makes it sound interesting and pleasant to listen to. The articulators (the parts of the vocal tract above the larynx consisting of tongue, palate, cheek, lips, etc.) articulate and filter the sound emanating from the larynx to make speech. The male and female larynx differ in size. The male larynx grows larger and as a result of this the pitch of the voice drops and deepens as the vocal cords become longer and thicker and vibrate together slower. Male vocal cords vibrate an average of 110 cycles per second; female vocal cords 180-220 cycles per second but this will vary greatly between individuals and the type of speech or singing task.

A voice quality will sound “normal” if the power source, the sound source and the articulators work in balance and efficiently. If one or other or all are disrupted voice may sound abnormal. A clinical case history and visual examination of the voice box is integral for diagnosis and to understand why a voice is not working normally.

Check out this Video and watch how the vocal cords vibrate as you speak and which muscles are involved.

 

How does voice change through the ages?

Let’s think about why voice quality changes as we grow and as we get older.

The larynx and phonatory system changes hugely over the course of a lifetime.⁣

At birth the vocal cords are 3mm long and the mucosal covering of the folds is thick and loose. The vocalis muscle fibres are incomplete.⁣

In early childhood the layers of vocalis muscle become more differentiated and the histology develops. The whole larynx descends from C1-C4. The complexity of sound a child can produce becomes more sophisticated. Between 5 and 8 years old pitch can extend to a two and a half octave range. Vocal differences between the sexes will begin to occur. ⁣

In adolescence, the male larynx changes dramatically  due to body growth and hormonal influence. The vocal folds double in length reaching an adult size of 17mm or more. The thyroid cartilage tips forward at an angle creating the Adam’s Apple. Modal pitch drops.⁣

The female voice will also deepen from childhood through adolescence due to general body growth.⁣
The adult larynx reaches mature final histological make up and differentiation of the structural layers at around 16 years old and will sit at a level between C3 and C6.⁣

Towards the end of middle age in women, hormonal changes can cause the vocal folds to thicken and stiffen and pitch might be lower. Men are more likely to notice an increase in pitch after middle age as the vocal folds loose some bulk becoming thinner. ⁣

Into old age as the layers thin and the vocalis muscle can atrophy and thin out, the vocal cords can bow and vibrate differently. Presbylarynx leads to higher, often unstable pitch and a weaker, breather voice. Laryngeal cartilages can also calcify with age and the cricoarytenoid joints can stiffen making it harder to close the vocal cords.⁣

For the most part ageing voice changes are gradual and are not seen or heard as abnormal. If it changes someone’s voice and affects quality of life impacting on every day responsibilities or hobbies then help can be sought from a voice specialist speech therapist. If you’re worried about your voice, first step speak to your GP. ⁣

Professional Voice User Series #5 The Hairdresser

𝘝𝘰𝘤𝘢𝘭 𝘥𝘦𝘮𝘢𝘯𝘥 𝘧𝘰𝘳 𝘩𝘢𝘪𝘳𝘥𝘳𝘦𝘴𝘴𝘦𝘳𝘴, 𝘣𝘢𝘳𝘣𝘦𝘳𝘴, 𝘩𝘢𝘪𝘳𝘴𝘵𝘺𝘭𝘪𝘴𝘵𝘴, 𝘸𝘪𝘭𝘭 𝘷𝘢𝘳𝘺 𝘥𝘦𝘱𝘦𝘯𝘥𝘪𝘯𝘨 𝘰𝘯 𝘧𝘢𝘤𝘵𝘰𝘳𝘴 𝘴𝘶𝘤𝘩 𝘢𝘴 𝘸𝘰𝘳𝘬 𝘱𝘭𝘢𝘤𝘦, 𝘱𝘦𝘳𝘴𝘰𝘯𝘢𝘭𝘪𝘵𝘺 𝘢𝘯𝘥 𝘵𝘩𝘦 𝘤𝘭𝘪𝘦𝘯𝘵 𝘺𝘰𝘶 𝘢𝘳𝘦 𝘸𝘰𝘳𝘬𝘪𝘯𝘨 𝘸𝘪𝘵𝘩 𝘩𝘰𝘸𝘦𝘷𝘦𝘳 𝘵𝘩𝘦𝘳𝘦 𝘢𝘳𝘦 𝘴𝘰𝘮𝘦 𝘷𝘦𝘳𝘺 𝘴𝘱𝘦𝘤𝘪𝘧𝘪𝘤 𝘤𝘩𝘢𝘭𝘭𝘦𝘯𝘨𝘦𝘴 𝘢𝘯𝘥 𝘐 𝘩𝘢𝘷𝘦 𝘩𝘢𝘥 𝘵𝘰𝘰 𝘮𝘢𝘯𝘺 𝘷𝘰𝘪𝘤𝘦 𝘥𝘪𝘴𝘰𝘳𝘥𝘦𝘳𝘦𝘥 𝘱𝘢𝘵𝘪𝘦𝘯𝘵𝘴 𝘪𝘯 𝘵𝘩𝘪𝘴 𝘭𝘪𝘯𝘦 𝘰𝘧 𝘸𝘰𝘳𝘬 𝘵𝘰 𝘪𝘨𝘯𝘰𝘳𝘦. 𝘈𝘯𝘥 𝘯𝘰𝘸 𝘧𝘢𝘤𝘦 𝘮𝘢𝘴𝘬𝘴 𝘢𝘯𝘥 𝘴𝘩𝘪𝘦𝘭𝘥𝘴 𝘢𝘳𝘦 𝘢𝘥𝘥𝘪𝘯𝘨 𝘢 𝘧𝘶𝘳𝘵𝘩𝘦𝘳 𝘤𝘩𝘢𝘭𝘭𝘦𝘯𝘨𝘦. ⁣

Here are my top voice tips:⁣

1. It’s always lovely to chat away to a client and it’s important, however..! Sometimes allow the client to take the lead with conversation. You can’t control how much they want to chat but you can reduce your vocal initiations. You don’t have to stop asking any questions but limit it slightly to avoid vocal fatigue especially if you’re prone to it. ⁣

2. Allow yourself some voice naps e.g during break times, whilst washing or drying hair.⁣

3. Avoid talking at all over the noise of a hairdryer or loud music. ⁣

4. As often as possible look up and into the mirror or directly at a client when talking to them.⁣

5. Try not to raise your volume or strain to talk. Speak slowly and clearly instead. Slightly over articulate. This will help your clients who aren’t looking at you to hear you. If they ask you to repeat use your normal volume again. ⁣

6. Drink 300mls of water based fluid between each client. Xx

Top tips for improving your motivation to stay hydrated

𝗪𝐢𝐭𝐡 𝐛𝐮𝐬𝐲 𝐥𝐢𝐯𝐞𝐬 𝐡𝐨𝐰 𝐜𝐚𝐧 𝐰𝐞 𝐫𝐞𝐦𝐞𝐦𝐛𝐞𝐫 𝐭𝐨 𝐝𝐫𝐢𝐧𝐤 𝐞𝐧𝐨𝐮𝐠𝐡 𝐰𝐚𝐭𝐞𝐫 𝐭𝐨 𝐤𝐞𝐞𝐩 𝐨𝐮𝐫 𝐛𝐨𝐝𝐢𝐞𝐬 𝐚𝐧𝐝 𝐭𝐡𝐫𝐨𝐚𝐭𝐬 𝐰𝐞𝐥𝐥 𝐡𝐲𝐝𝐫𝐚𝐭𝐞𝐝 𝐚𝐧𝐝 𝐭𝐡𝐨𝐬𝐞 𝐭𝐞𝐞𝐧𝐲 𝐭𝐢𝐧𝐲 𝐯𝐨𝐜𝐚𝐥 𝐟𝐨𝐥𝐝𝐬 𝐥𝐮𝐛𝐫𝐢𝐜𝐚𝐭𝐞𝐝? ⁣

My top tips for improving your motivation to drink more water are:⁣

💧 You may have to trial a few but find the best water bottle that suits you, should be light and easy to carry around, allow you to drink quickly and efficiently, regularly throughout the day. My favourite is the @hydratem8 tracker bottle. ⁣

💧Visual reminders are very helpful. A good old post-it note in a strategic place should do the job but for a higher tech reminder I LOVE the @thirstyulla reminder device – one size fits all water bottles. ⁣

💧 If you’re on your phone or a tablet regularly set alarm reminders to take a drink of water. Or I LOVE the @plantnanny_us app. It’s very child friendly too if you want to involve the family or if you are supporting a child to drink more. ⁣

💧 Finally, make water visible so that you’ll see it and be naturally reminded to take regular sips. At the start of the day fill enough glasses or bottles to cover your desired daily intake – a target helps with motivation ⁣and place them around the house or office where you’ll see them.

There is abundant evidence that good hydration improves vocal stamina and endurance and reduces the risk of vocal injury. Forgive yourself if you have a ‘bad’ water day but plan for how to improve the next day. Xx

Professional Voice User Series #4 The Gym Instructor

𝘎𝘺𝘮 𝘢𝘯𝘥 𝘍𝘪𝘵𝘯𝘦𝘴𝘴 𝘐𝘯𝘴𝘵𝘳𝘶𝘤𝘵𝘰𝘳𝘴 𝘢𝘳𝘦 𝘱𝘳𝘰𝘧𝘦𝘴𝘴𝘪𝘰𝘯𝘢𝘭 𝘷𝘰𝘪𝘤𝘦 𝘶𝘴𝘦𝘳𝘴. ⁣

Recent research indicates that most instructors think of themselves as occupational voice users but the majority do not have any previous voice training. Dehydration and hoarse voice seem to be common problems in the industry. ⁣

It is of upmost importance, to effectively carry out their job and teach and empower clients, that fitness instructors follow some voice care and training guidance as part of self care. They are vocal athletes and without their voices could not effectively do their job. ⁣

My 𝐭𝐨𝐩 𝟑 𝐯𝐨𝐢𝐜𝐞 𝐭𝐢𝐩𝐬 for fitness class instructors are:⁣

1. 𝐎𝐩𝐭𝐢𝐦𝐢𝐬𝐞 𝐡𝐲𝐝𝐫𝐚𝐭𝐢𝐨𝐧. Consider your age, weight and level of physical and vocal activity and make sure you achieve overall good systemic hydration and also surface hydration for your voice. Have your own familiar and distinctive water bottle for motivation. Invest in a water tracker. I’d recommend a Thirtsy Ulla.

2. 𝐔𝐬𝐞 𝐠𝐨𝐨𝐝 𝐪𝐮𝐚𝐥𝐢𝐭𝐲 𝐚𝐦𝐩𝐥𝐢𝐟𝐢𝐜𝐚𝐭𝐢𝐨𝐧 when teaching classes. Do your research for the best option of headset for you. And practice helps too. The main reason for having a mic is to reduce vocal strain so speaking at a normal volume and slowing your speech rate is vital, but this can feel strange at first. ⁣

3. Consider your voice like any other muscle in the bode. Before, during and after a work out you need to 𝐰𝐚𝐫𝐦 𝐮𝐩, 𝐦𝐨𝐧𝐢𝐭𝐨𝐫 𝐦𝐮𝐬𝐜𝐥𝐞 𝐩𝐞𝐫𝐟𝐨𝐫𝐦𝐚𝐧𝐜𝐞 𝐚𝐧𝐝 𝐭𝐡𝐞𝐧 𝐜𝐨𝐨𝐥 𝐝𝐨𝐰𝐧. Have a voice routine just like you do and your teach during your classes for other muscles. It will only take a few minutes out of your day and will make all the difference to your voice.⁣

Here’s an extra tip that wasn’t in my original blog post…follow Sara Davis @voxfit_ on Instagram and check out her podcast episode as a guest on ‘Off the Bike’ with Crystal Bonham Episode # 4. Both are packed full of useful voice care tips. Sara is a voice specialist speech therapist, passionate advocate for the professional voice and a gym class instructor. She has done research on the need for voice training for fitness instructors.