Episode 83: Voice Evaluation Components: What SLPs Should Know with Kristie Knickerbocker, MS, CCC-SLP

If you love this podcast and love easy and informative CEUs, then this is the deal for you. Speechtherapypd.com has over 175 hours of pod courses on demand with an average of 19 new pod courses released each month. You can get Asha continuing ed credit for every episode you listen to. And because I think you're terrific, I can offer $20 off a year's subscription when you use my code SUP20 for the insanely low rate of $59. This week on the Speech and Sensor podcast, we're breaking down the voice evaluation. Christy Nicarbacher is diving in deep onto what makes up a behavioral voice evaluation, what makes up acoustic and aerodynamic voice evaluations, and all about video strokeoscopy as well. So I'm super pumped to have Christy here. She is just a wealth of information. I feel like if you're not following her on Instagram, you are missing out. She just unleashes so much information there. She's constant absorbing fun things. So yeah, you're just going to get more of that in this episode. Christy just has so much to share. I'm really pleased. So I'm Leanne Porter, your host. This is the Speech and Sensor podcast and now let's get into it. Hello Christy, how's it going today? It's going so great, Leanne. How are you? I'm doing good. I am so pleased to have you on the podcast today. I'm really excited about our topic going into all the components of voice evaluation today with you. So all right, where should we start? We should start with you. Okay, Christy Nicarbacher, tell us a little bit about yourself. Well, I am a speech language pathologist and I specialize in singing voice and voice and voice disorders. I got into this field because I was an injured singer my senior year of high school. I had a vocal lesion and so I was a recipient of voice rehabilitation and vocal surgery and then more voice rehab after that. And it affected what I ended up doing in college because my acceptance and scholarship was based on singing voice at the time. And with rehab, it was very clear that I wasn't progressing as fast towards the music major. And so my voice teacher and I had a talk and she suggested I look into a different career path. So kind of a blow to the ego, but best thing I could have ever done and turned into a really fulfilling career because I remembered back to my voice therapist and I was worried initially as a kid, you know, that a speech therapist wouldn't know anything about singing voice. And so I was almost resistant to go because I thought that she would know nothing and she ended up being absolutely everything I didn't think she would be it was great. She was well versed in music knew exactly how to sing knew exactly how to talk my language and it made all the difference. So my thought was I can marry my love of medicine and health care and music all into one career. I decided to to change majors and then after I graduated, I worked at a hospital for about a year and a half got my license into my CF year. And all while still attending in person and online courses for voice knowing that I still wanted to specialize in that and then developed a private practice and started really small and grew and I'm still growing the private practice and the online educational part of it is a tempo voice center. And I really like about your online presence too is like you have a private practice, but you also develop tools for people to use who don't specialize in voice, but who will treat voice patients. And so I think that's really helpful. It's wild to think that with our degree, we have such a huge scope and to be able to treat effectively in every area of that, I just don't think it's humanly possible because we were chatting earlier, but I just all I do anymore is voice and I wouldn't be comfortable treating aphasia. So I would refer on to someone else who does that more frequently, but for rural SLPs so for for people who may not really have the option of referring a person because it's hours away of a drive for a voice specialist, my goal with creating the resources that I was using my own clinic anyway was to help teach them but then give them options to not have to feel like they had to pretend or that they had to just tell the patient, hey, I don't know what I'm doing. I don't know how to help you and then the patient doesn't get any help so good. All right, so all right, so let's begin with a background on voice disorders and then kind of flow into like maybe some different types of voice disorders that people might come across and all the different places that we can treat voice. So voice disorders, a general overview is that anything that is causing a person to have difficulty communicating with phonation so any issue with the ability of the vocal folds to come together to vibrate and there are types of those so a good general organizational category would be organic and that's just any kind of voice problem that results in changes to your lungs or changes to the larynx or the vocal tract, the epi larynx as ingotizo would call it the throat area, the pharynx and then the oral cavities and nasal structures as well. And you can have structural changes that would occur, you know, maybe pathologically, we could say where some things growing like a granny Loma or a cyst or a polyp or even vocal nodules or you have a paralysis. So maybe one vocal fold is stuck in a position and the other one is still working, but structurally you have an adequacy because you can't get a complete closure. You also have an organic type of voice disorder that we would consider neurogenic and that's going to be problems that are coming from the brain and functioning of the mechanism. So that's going to be things that may happen from diseases like progressive neurological things like a less or Parkinson's also you can just have a central vocal trimmer and not have anything else going on, which makes it challenging to treat in spasmodic dysphonia. So you have issues with spasms either making the vocal cords closed really tightly out of your control or open when they're not supposed to. So you have the adductor and the abductor different types of spasmodic dysphonia. And then you can also have a functional so that's going to be anything that you might have going on with commonly muscle tension dysphonium. So things that might occur from being sick with a cold or an upper respiratory infection or learn gytus of some kind where you're still having to vocalize or trying to phonate. And you end up recruiting muscles that you might not normally need when the vocal folds are functioning in a healthy way or they're not as swollen and heavy. You adopt that new configuration of phonation attempts and then maybe you get better and your vocal folds are back to normal state so they're not as fluffy and they're not as heavy. And you're still using that same muscle recruitment and that can result in fatigue or feeling like you have to strain to get the sound to come out and it also can cause pain. So a dyno phonia and so functional voices orders can be treated similarly and or are differently than organic. So give me an example of things we might see that are coming from an organic mythology like because you mentioned spasmodic dysphonia for an urgent polyps for structural muscle tension dysphonia for functional what would be something we would see with organic. And it can be if you had any kind of issue with the structure so changes like if you had something come in and have like trauma to the larynx we had a child not too long ago who had like fallen on a scooter. And the damage was caused by that blunt force trauma to the larynx and so you may have something happen there. I don't necessarily I wouldn't categorize that as neurogenic because it was something that happened outside but maybe that results in paralysis organic could be granny loma could be vocal fold swelling like green keys a demon. Whereas mocha and female and over 50 you have a lot greater chance of developing that gelatinous fluid that grows underneath the epithelium in the rinky space and stays there unless you get it surgically remove that can it's actually physical and organic change to the tissue itself. And that makes a lot more sense thank you for clarifying that and like as you've been going through this this is like this is like such like foundational basic knowledge and I'm thinking about when I get voice patients how I have not been considering that and that's like step one and I'm like oh my gosh lamb. But it's so complicated like it's difficult because with that base knowledge you have to also be listening to the patient at the same time and I rely on things that I have written down to because I can't think of everything all the time and then sometimes I get the patient out the door and I'm charting and I'm thinking my head oh my gosh that's exactly what. but I should have said and educated and I'll just educate the next session. And sometimes I will call or send an email with a different handout that I should have done. So it's not that you're thinking about it all the time, but your brain starts to change and work in a way where you're kind of deciding and differentially diagnosing the more you do it. But if you don't do it as often, it's harder to remember all the basic things. So I think that's normal. - Okay, okay, well that was very kind, thank you. (laughs) Okay, so we've got those core types. What's next? - Let's talk a little bit about the types of voice evaluations that you might need to do because if a person is on your caseload with a voice disorder, you may get a great referral from the physician that explains what they saw, what they think is going on and they're right on the money. And your work is done for you and you just need to kind of flesh out the education and recommendations for the patient. However, you don't always get that. And sometimes you get an incorrect diagnosis or the physician just says, "See this SLP for speech therapy." And then you're left with, well, I don't know what I'm going to be doing in evaluation. So there are types of voice evaluations that we'll get into in just a little bit, but the main categories are behavioral voice evaluation and that's gonna be CPT code 92524. Another option is acoustic and aerodynamic evaluations and that's gonna be 92520. And then the other option for voice evaluation would be a video stroke with scopic voice evaluation. So a video stroke of escape and that's gonna be CPT code 31579. Do you always have to do all three of these to be effective? No. Does it help to have the most data? Yes. Maybe you don't have access to a video stroke of escape or you're going off of the report that the physician sends and maybe you just get the words and without video. So you can still be effective at evaluating 'cause most people are doing, if you're taking basic measures, and I mean basic, basic, like you may be doing STZ ratio, you may be qualifying the voice in some way, like with KV or with a Gerbos perceptual rating scale, you may be giving the patient some patient measure reported outcomes, like some problems with the vocal handicap index or you may be giving them a reflex symptom index and then just kind of asking them their concerns and taking case history. And so if that's basically what you're doing, you're doing a behavioral voice evaluation, you're getting a history, you're listening to what they sound like, and then you're stimulating or probing to see if they feel better with the things that you're giving them. And I think it's really important to determine initially when you're evaluating a person, what their main concern is. Because if you're just getting the diagnosis of voices order or hoarseness, that's a really common diagnosis that you get, the person may not care at all what they sound like, but maybe voicing is extremely painful for them or it's very fatiguing. And so, although you will start to teach them things that help them sound better quality wise, you need to always keep in mind if their initial goal was to optimize by lessening the fatigue and lessening the pain, you need to still be making sure you're making progress towards that goal instead of getting caught up on, oh, listen to how great you sound, there's no roughness. Like they may not care at all. - That is so clear. I'm so glad you pointed that out because yeah, we might think we're over here like, oh my gosh, they sound so much better than we're making so gains. They must be so happy with what we're doing in therapy, but their concern was less effort, improving vocal stamina. And they really don't feel like they've made progress on that. So like you're wrapping up therapy and you're like, we're done here and they're like, I don't feel successful at all. - Yeah, yeah. In school, I think we're taught to make sure that we give the parts of therapy that include vocal health and vocal hygiene and wellness. Have we done all of that hydration, phonotramin prevention, big check mark, right? Have we optimized the vocal subsystem coordination with President Voicer, with straw phonation or with a stretch and flow check? And we forget to say, well, even if I don't meet all the goals that I had initially set up thinking I was gonna have them all still dovetail into the patient's overall main goal, it's okay. Like you can always abandon a goal, I used to think, oh, well, Miss Susan didn't get to 90% on that goal about hydration every day. We have to keep her on caseload because I need to make sure that I teach her that. And it's just, that's just not the case. Like Miss Susan probably didn't care if she was sitting there telling you, my life is better, I'm not coughing anymore, I don't bother the people at church, I can go see a movie and not have to leave early because my chronic cough is gone. That's what they want, they don't want to say, I'm 100% knowledgeable in everything to have to do with vocal wellness, health and hygiene. - Yeah, that's another excellent point, Christy. Thank you so much for bringing that up too. Yeah, you can abandon a goal. Like I've written crappy goals. I thought we're wonderful at the time as we get through therapy, they don't matter and maybe the needs shift or the priority shift. I will discharge that goal is not met and not feel like a failure. That is okay because like my success is contingent upon the patient's success and whatever that looks like, that's winning. So. - Yeah, most definitely. Anybody out there listening, like you can abandon a goal, you are not a failure, the patient is not a failure. - That's right, good point. - Needs shift and they may shift in a therapy session. And I think we had kind of talked a little bit about wanting to establish foundational knowledge on the settings in which an SLP might treat voice disorders. You can be in an inpatient hospital and have your laptop and have acoustic software set up really basic and take acoustic measures. You can have an outpatient clinic and do the same if they're coming to you. It's easier that way. You could do home health and bring your laptop with your setup and just be in the same room and calibrate your equipment where you're able to assess acoustically and assess aerodynamically for that patient. And even in private practice, which I'm at, I mean, I don't have the most expensive equipment out there. It does what I need it to do. There are articles and evidence-based approaches that I'm using for that evaluation. And it's totally doable. And I'm getting measures that I can use to mark and track progress that are objective. And I think that that is just as important as subjective assessment too. But then you could do it in a school setting. So if you are treating pediatric patients, you can have a setup in your speech room as well with a microphone, with an audio interface and not spend a whole lot of money on setting that up. But you really will be doing right by your patients to do so. So anywhere you can do a behavioral voice evaluation, you can really do acoustics and aerodynamics even without having to purchase the really, really expensive software that you used in grad school. Because that stuff's awesome. And it's great. It makes it very easy. And it prints out great charts and reports and things. But in the real world, you are likely going to be very lucky if you work in a center that has the funding to purchase something so great for you. And if they have awesome. But if not, I just want SLPs out there to know that there are options for doing these other evaluations that can be very useful kind of on the cheap. - We'll tell me all the things. - Yeah. So let's start with behavioral voice evaluation. What that might look like when you might want to use that and then how you could apply it. There is a really great article that was published in 2018 on Asha. And I have this linked in your show notes. But this was created by Rita Patel, a ton of people, she's in a one, Julie Barkman, a creamer, Mark Corey. And others, it's a huge document about being able to develop a protocol for assessment of vocal function. And what it goes through is what you might need to include for evaluating for video stroboscopy, like looking at those and exactly what tasks because we don't really have things that are standardized for that. And it really goes through exactly what you might want to do what you're visualizing. The article also goes through recommendations for acoustic assessment. So things that you might want to be taking and why. So this article is linked in the show notes and I think quite great. But behavioral voice evaluation can include, like I was talking about earlier, those patient reported outcome measures or proms, depending on the type of complaint the patient has. So if a person comes and says, "I'm horse," or, "My singing voice fatigues really easily," or, "I just don't sound like I used to." My main things I'll have them fill out during that evaluation would be the vocal handicap index 10, or the VHI 10, the reflux symptom index of the RSI. And then if it's a singing voice problem, I would introduce the singing vocal handicap index, which those are all 10 questionnaires. If a person is having problems with chronic cough or paradoxical vocal fold motion or vocal chord dysfunction BCD, you have options of the dyspnea severity index, the cough severity index, and the vocal chord dysfunction questionnaire. And the VCD queue is, I believe, 60 questions. So it's a little bit, I'm sorry, it's 60 points. The rating system's larger. So using that can help you, even if you have no equipment to record and you have no video stratoscopy, you can use those. measures to help your patients because you know how they felt about their initial presentation. You can give that to them in a few weeks after you start to see that there's improvement and you're kind of trying to decide do I need to discharge, do we need to keep going? Can we go to once every two weeks, help and you make clinical decisions? But then also when they're good to go and you know it, have them fill it out again and see where they're scoring on that. You can also complete perceptual evaluation on your end so you can use something like the Cape V or the consensus auditory perceptual evaluation of voice. You can use the Gerbos which is grade roughness, Estinia which is weakness, weight breathiness. I'm like trying to spell it in my head and then strain and rating those as well. I grew up in school using just Cape V that doesn't mean Gerbos is inferior. Tens of people use it. I think the beautiful thing about Cape V is you can add your own categories because if you're just looking at overall severity, roughness, breathiness, strain, loudness, intensity, oh loudness is intensity pitch is the other one. You can add a category for tremor and then rate that on a zero to a hundred scale or you can add a category for a multiple phonia which is like more than one sound coming out at once or like is that really roughness? Like what is your ear really here and you can you can be more specific about what you're picking up as a clinician with your ear. The other thing you can do in a behavioral voice evaluation is put hands on the patient. You're going to kind of be limited if you're doing it virtually but what I've been doing virtually since COVID is actually having the patient touch themselves and I'm kind of guiding them on the virtual platform just so I can ask them what they feel because that's better than just eliminating it from the assessment in the first place but if I have them in front of me I'm palpating shoulders back of the neck jaw face of the tongue and the larynx moving outside to side and feeling in certain places to determine if the larynx is doing anything that might be abnormal. I'll also ask the patient if especially if they're complaining of pain so I would dioniponia. They touch themselves in a certain place on their throat or if I touch them if they have pain where it is and then what it feels like is it sharp and stabbing? Is it dull and aching? Is it you know fiery? Is it does it make them wince? That kind of thing. I want to tell you those different types of pain like stabbing versus you know pulsing. What does that tell you? So if it's a dull aching muscular pain I would think that's more of the body's response to overuse and this is just potentially right it could vary patient to patient but if it's a more of a sharp stabbing pain I might be more thinking that it's a granuloma like like a growth perhaps that that has been known to cause patients a lot of pain when they're talking or when they're phonating. Also it would help me determine if voice therapy is not working and the patient's still complaining of this pain. If I need to be thinking in my head referral to laryngeology to decide if they might need a superior laryngeal injection or if they might need to be evaluated to see if it's egocindrome. So if it might depend on how they're describing that pain and then if that pain is the same and persists day after day it might help me if voice therapy is not fixing that to give them the right referral and the right thoughts and questions to ask as they attempt that secondary referral to get better treatment to get them fixed. So what's egocindrome? egocindrome is it has to do with a stylohyoid muscle and there's actually a really great blog. I interviewed Grace Olmsted on my website. She had egocindrome and was treated with voice therapy and was not getting good answers and so I interviewed her for that blog to know to let people know more about that. Yeah I'm sorry I was wrong the styloid process. See I don't know everything after I remind myself but it's it elongates or calcifies or makes it really hard that stylohyoid ligament and you need surgery to fix that and so if that's really identified as the source of the pain for the person no amount of voice therapy is going to fix that for them and so it's important to know about these types of things so that if if what you're doing is not seeming to it's presenting like muscle tension dysphonia you're doing what you think is right nothing's improving the patient's frustrated you're like I've used everything in my wheelhouse what do I do and then people don't believe you like they're like well we can't see anything you know and then they dismiss you. Yeah this blog's really great she talks about she's an SLP as well she she had surgery but she had done this because she googled it like she went online and her ENT scanned her and then she had two different surgeries which helped her. Anyway back to why we went off here the pain is important to describe because you want to know when that pain is happening and then how the patient's describing it to see if it stays consistent throughout treatment or if it changes all that information is going to be really helpful if you have to refer that patient on another thing you can do is assess breathing what you should be doing how fast a person might be talking or slow are they breathing clavicularly where they're really raising their chest and their shoulders every time they inhale are they using more of a thoracic expansion is it more abdominal that's going to help you determine something you could address if it's causing irritation to or causing tension or causing pain as well if they can focus the breath further down and they're not utilizing muscles above the shoulder level so neck level muscles just to breathe in also this is helpful to assess in VCD patients and chronic cough patients they may have no idea that that's happening they may just feel like I can get a breath in but they haven't really thought about what their whole body is doing and reacting when they when they get an attack or they have an episode so I was looking for but yeah that's a pretty good roundout on the things you can do and that's you know with no equipment like KB you can download from asha free it's it's easy to to do that and you can be like me and create a template that pre-populates in your software said that you know and you don't forget to address all of those things when the patients in your chair okay so are we ready for acoustic and aerodynamic voice eval I think we are super let's start with acoustic evaluations so if you're doing acoustic and you're doing aerodynamic both of those are going to fall under that 92520 CPT code a lot of people that I have talked to think acoustics may just be taking fundamental frequency or the pitch average that a person might be speaking at and and think that that's enough and they think aerodynamic assessment is taking s to z ratio and thinking that that's enough I mean I'm not here to tell you what you need to do with your license but what I will suggest is that I don't feel that s to z ratio alone constitutes an aerodynamic evaluation you need to be assessing a measurable amount of air in the lungs and how that's working so with acoustics to really get a good idea of quantitative data you should be in trying to include yes fundamental frequency yes maximum phonation time yes highs and lows to establish a voice range profile and if you don't have the fancy software to do that like CSL from Pentax you can download some programs that are free or that cost a little bit of money the free program you can use is Pratt and you can download that online Liz Grillo has created an app that you can send home with your patients and get measures to and that's called voice of value eight the number eight and that gathers measures as well you can use Pratt to collect the lowest note possible the highest note possible get the frequency amount that's the difference and then put that into your semi tone range formula to create to find semi tone range for that person and see if that's normal or not you can create loudness and softness so what loud intensity does to the voice and how loud they can be and how soft they can be important on the intensity would something like LSVT or speak out or forte be appropriate for your patient to help with them sounding better why do you care about voice range because if they can't go above a certain pitch they might have superior laryngeal nerve paralysis that you would have not caught on vitro-saccharoscopy these are important to catch and to be able to give quantitative data for because it helps guide your treatment and give your patient answers because if it's a singer and they're like I can't hit my high notes and you're like well your stroke looks fine you sound fine see you later they're like you're not listening to me and if you had just taken a voice and simple voice range profile you could have said oh you only have a 200 hertz difference between your lowest note and your highest note maybe you have some paralysis on a different you know branch of the nerve then the one that controls the opening and the closing of the vocal cords it's the one that actually tilts the larynx to allow for elongation of the folds to change pitch so then you would want to take I'm going to slow down here shimmer and jitter I did this on another thing the other day and I did it I switched on it was so bad we always have to be careful around shimmer and jitter if you are using those still they're antiquated you should be studying up and reading up on capstral peak prominence and taking that you can do that through Pat and then with phonanium plug which do cost a little bit, the phonanian plugins to Pratt allow you to find capital peak prominence and then that goes into another formula to find acoustic voice quality index and that is going to be akin to data that you might get from the CSL software again. Shaheen Awan has done studies on finding what's normal and what's not for that and then Yuri Mirren and team has done studies for ABQI. So either way if you're using CSL great you're getting measures that are backed up. If you're using phonanian plugins with Pratt again different measures but you're still getting measures that you can use to identify dysphonia in a quantitative way. So that's what you should be striving to take for acoustic measures. Then you want to take that I say fundamental frequency like having them read the rainbow passage and and take an average of that if I didn't because you're going to pull to find ABQI you're pulling a sentence from the rainbow passage and you're pulling three seconds of sustained awe. So what I'll do is I'll record maximum phonation time on an aw. I'll select and extract three seconds of that to run ABQI script. But in the same way I'm taking that maximum phonation time and that helps me find the aerodynamic measures that I'm going to talk about. So if you're lucky enough to be able to do aerodynamics with the PAS system the pneumotack-a-graph device requires calibration. You get that as an option with the CSL software and that Pentax setup. But if you don't have the money for that or access to that you can still get measures to of them. Phonation quotient and estimated mean flow rate. There is a row in Beckett 1984 article on PubMed and if you want to read through that you can find out the formulas that they used to collect that data. You need a person, you need a sparameter and I got mine online and I think it was like 150 bucks and I use these tubes so they're not putting their mouth on this promenade every time. And then I have them blow, I get vital capacity from them and then I put that formula with the maximum phonation amount, maximum phonation time and then I'm finding that for phonation quotient and estimated mean flow rate. And it's important for those numbers, why would it matter? Like why do I need to know these things? For a patient who has issues with glotic closure those numbers might look a certain way and if you have a patient who has extreme hyperfunction so strain use of the false vocal folds speak of plecaventricularis if you're having those false vocal folds come in to either vibrate or just inhibit and restrict actual phonation from occurring from the true vocal folds then those aerodynamic measures look a different way as well. It's important to read up on the options that you have that you can actually get again more quantity of data to help you guide and it's funny because I had a chronic was a chronic offer VCD I had both this week but we were looking at her saying I had childhood asthma and do we think and my thought was like well do we really think that the asthma is contributing to the VCD she's been taking her inhaler but it hasn't been working or doing anything to improve her I wanted to know does she have a small vital capacity like is the ability for her to access air maybe making an impact and she had had a really normal vital capacity so I would have maybe done things slightly differently and talked about different things regarding who put her on that inhaler and if she should continue to stay on it while we're treating the VCD if it had looked a little bit different so the the acoustic measures that you can take are not a lot if you practice and kind of have a blueprint of what you're gonna be doing and the aerodynamic is I mean it takes no time at all you have them blow in the sprometer and what I did is I created an excel spreadsheet that did the formeless for me because I didn't become a speech pathologist because I was good at math but I don't like to do that math stuff so I plug in my numbers I get what I need and then I move on and use that in the evaluation report. It sounds like there's like a little bit of preparation to learn how to capture these measures but then and once you get like a blueprint in that like formula in place then you're just plugging in numbers and moving on and so it's like work at the setup and once you get familiar with that pattern and that routine you are good to go and it saves you time in the long run. You're absolutely right it it is totally scary you know overwhelming at first but isn't everything I remember the first time I gave the Goldman Fristo it was so long I was like this is so scary I mean they're gonna I'm I don't know what I'm doing you know or maybe the BDAE so if you do it practice it and then I joke in between like it's it's finesse now where if I've forgotten something I'm like oops forget this let's plug that in you know put that mic back on so even you might forget if you get to talking with the patient because you have good rapport I mean you always want good rapport so that's why I just have everything pre-made so I'm helping myself in the session to keep myself on track. So we have we're at 40 minutes now and we still need to go into video stroboscopy so are we ready for the final year we're ready I think so so we'll do video stroboscopy that's going to be CBT code 31579 and this is something that if you're listening to this podcast and your overseas so you're not in America I don't know scope of practice allowances for SLPs to complete video stroboscopy so you really would need to check with your governing board to determine if you're allowed to or not but in America we can without a doctor present or with but trained we have to know what we're doing and and abide by our code of ethics but we can provide these exams and it's great because if you get a referral from otolaryngologist who's just general ENT the patient comes maybe they maybe they were scoped with a flex scope through the nose the doctor says okay I see vocal nodules the person's like okay so they go and then if you as the SLP can perform the video stroboscopy and say actually that's looking to me like it's more of a growth inside the vocal cord swollen up and on the other side there's just some reactionary swelling you would absolutely treat that person differently than if they had vocal nodules or they come in and you look and there's nothing there you say well you probably had some mucus that was clinging to these certain areas of the vocal cords it looked as though they were nodules but with this more sensitive exam we were able to rule that out and again the treatment is different but if that and that happens frequently in my clinic so if you're not sure what you're looking at the treatments different and the thing with video stroboscopy is that there there's a blog on my website I'm pretty sure it's diagnoses or changed there must be something in the water so it's a play on the carry under what song but if you find that the link to that article is there where they looked at people who had voice complaints who went to see general ENT they were scoped with just the eye so with just light and the doctor looking with their eyeball and when they and diagnosed with something whatever it may have been when they had videos stroboscopy completed their diagnosis was changed like 51 percent of the time so I don't think that you should say well I don't have video stroboscopy I can't give my patients good care that's not what I'm trying to say but if you have the option the patient's not making improvements I mean there's there's multiple things where you would really want to push for video stroboscopy I'm always to say yes get that done because it's going to give you the absolute most clear picture slow it down you can show the patient because it records on video what they have going on you would want to complete that and assess for closure if a person's having issues that the gross motor movement couldn't identify like a small gap like maybe they have small atrophy on one vocal cord and we just couldn't catch it with with endoscopy with the eye that that's or paralysis or parisis like the patients like I'm having problems I can feel this and the ENT says I don't see anything wrong but if the ENT has video stroboscopy or if you can complete that exam you're able to say it's not all in your head look we can see this deficit here are your options but you can do video stroboscopy with a rigid scope through the mouth you can do it with a flexible scope through the nose there are multiple different vendors who sell those machines at varying prices and I think it's a great option for really doing best for our patients and getting that instrumental because I'll say I'll say it then I'll say it now we can't treat what we can't see there's so much so much beautiful truth there like I mean in just the examples that you've given based on what you see you treat that patient totally different and in some cases they don't need treatment because maybe it was just some ucus there that has now cleared and so there is literally nothing to treat and all the time yeah yeah and then I can think of one patient who we were really sure it was vocal nodules I did not strobe her she'd come from a clinic that had video stroboscopy I treated the nodules she was not better we did everything and it was like seven weeks resting stretch and flow resident voice drop onation hydration throat clear prevention like all of these things know like zero improvement and she I think she'd come like after two weeks of strict voice rest or something I was like desperate I was like we've got to do something that kind of just kicks this kick starts this and I was like what do you think about strobing today she's like let's do it so I'm gonna do it do and it's not nodules. It's a cyst or it looks like a growth that's in the cord, inside it and round and mature. And I'm thinking in my head, I've been treating this thinking that these are going to recede and resolve and nothing is helping this person. She's at our witsend. I'm like, I don't know what else to give you, but we peaked and I was like, hey, I don't I wouldn't expect this to go away with voice therapy based on how it looks. So it's such a great thing to give your patient the knowledge that they're not crazy, that they are not a failure, because she felt like I'm doing everything you've asked me to do. Why is it not better? The power of seeing. Power of videos to bus. Did you cover everything that you wanted to for that section? I think so. Perfect. Okay. All right, well then we're at a good time to kind of think about our closing statements, our closing thoughts. What might be one thing that you want our listeners to kind of take away and walk away from this discussion? Well, from the very beginning of things, I've always wanted to make voice treatment not intimidating. It was always for at least in my experience in grad school that I knew I was interested in it, but it was confusing always when it was presented because it was like, well, here are these few things that are very finite and you can treat in this way. But then the very next statement might have been, but there are so many things you can do and like so many different things. And it's like, well, you just said it was finite, but now it's not finite. I'm very confused. The other thing, humming, resonant voice therapy is a type of semi-acluded vocal track dexercise. So when I figured that out, it was like, oh, it just seemed intuitive that it was separate. Like to me, I was like, well, resonant voices separate from semi-acluded vocal track dexercises, but then there's humming, but then how is that different? It's a type of it, but it just has a protocol. So and you know, Kitty, Kitty really added creating Billy Sac Madsen, resonant voice therapy, is a protocol, just like just simple creating vocal function exercises is a protocol, but it includes, both of those approaches include semi-acluded vocal track dexercises, but you could totally use semi-acluded vocal track dexercises as a treatment approach on their own, like send a patient home with straw phonation four to six times a day for a minute or two in water, you know, that could be your approach. And just one patient or people who are listening to take away that it is not scary and my goal is to create resources and education opportunities so that people can be able to access that virtually to make them better, to make them more confident in treating the voice disorders, because the patient, I mean, they need the help. They come to us after experiencing this difficulty for a while and it's not getting better, sometimes it's getting worse. And like with your example, you were like, why am I saying a speech therapist for my voice problems? So they might even be coming to us with hesitations to begin with, and then if we don't feel confident in the skills that we have to offer, then we might be reinforcing that thought that the patient had. So there's so many tools out there to help us become more confident and clarify our approaches to the evaluation and the treatment process. So I really appreciate when our specialists who do voice, who can wrap their head around all of this and break it down for us and teach us who have to be generalists and give us the tools and the skills to increase that confidence. That's really helpful. Basilian, I appreciate what you do because we learned years ago from textbooks and it takes a long time to get the textbook written, to get the textbook proofed and in the textbook published. And so kids coming through school might be using a textbook that six years old. What you're doing with this podcast is amazing because you're able to get the information out there that's newer from the research articles that are just coming out. And the information can then be disseminated to the masses of speech pathologists who need it now. It's amazing and we're lucky to live in this day and age because our patients are really benefiting because of the things that you know people like you are doing with these podcasts. Well thank you. Yeah, it's a big mission to just spread that information because as a clinician searching for it, I had a hard time finding it. So it was like it really just comes down to having conversations with the people in the know who are doing the research or who are practicing or who are specializing and then making that available. So that's the beauty of a podcast I reckon. You do a great job. Oh, you're appreciate it. All right. Well that's our time. Thank you so much, Christy. This was amazing. How can people reach out if they want to learn more about what you do and some of the tools that you have to offer? Yeah. So my website is at tempovoyscenter.com, ATMPO. Or if you just put that into Google, my website will pop up. It includes blog, my emails, their links to my social media, which I'm very active on Instagram and newly on TikTok. You should go. Yes, don't look at that TikTok. It is fabulous. I've been loving it. So Christy, kill it. Go get it girl. But yeah, on Instagram, I'm K-R-I-S-T-I-E underscore voice. On my website, you can join the voice community email list and I send links to my blogs. I send products. I send freebies. I send discount codes for new products that I create. If you want to have a blueprint of what we were, I was discussing with the evaluation, I have created an adult voice evaluation guide and a pediatric one with actual flip cards that the kids can hold so that they have something tangible. You can go through that and those are both available on my website and then also on my teacher's pay teacher's store. On Pinterest, I'm at tempovoys. I'm Pinterest.com/aut tempovoys and then most recently, Cara Bryan, Erin Zingler and I have created the Component Clinician Cooperative, which is, our mission is to virtually provide training and consulting and education for voice therapy. So our goal is to create, hopefully, educational opportunities and then like a therapy library where you can go figure out, okay, I have a patient with this problem potentially. Can I go watch therapy being done live, you know, recorded so I can make sure that I feel confident and seeing examples of that, especially now because COVID's really put a hamper on voice placement externship's periods, CF-Y opportunities and then also jobs being, you know, hired and then it's really thrust us into providing virtual therapy. So we created a webinar back in April about troubleshooting voice voice therapy and voice evaluation even virtually and what you need to be considering and thinking about what you can try ethically and all that. Yeah. All right, good. All right, folks, go out there, find those things, learn about stuff. It's great. All right, Kristi, thank you so much. Thanks, Leanne. Thanks for listening to another edition of the Speech Uncensored podcast. Show notes with links to resources mentioned in the episode are posted on speechuncensored.com. I'd love for you to subscribe to the podcast and leave a thoughtful review on Apple podcasts. Shout out to the hardworking team at speechtherapypd.com for their sweet editing skills and for sponsoring ASHA's CEU credit for this episode. And finally, I'd like to leave you with my wish for you to nourish your mind so that your practice can flourish.