Welcome to SLP Full Disclosure, the podcast for SLPs by SLPs, where we deep dive into a variety of topics to empower, educate, and entertain. Join us each episode to hear from expert guests and topics that matter most. Be sure to subscribe if you haven't already, and let's jump into this episode. Hello and welcome to SLP Full Disclosure. I'm one of your host Jennifer Martin, and I'm joined by my co-host Elissa Hunter. Hello. So again, I say this every time, but I mean it every time I'm so excited to have our two guests join us today. Today we have Dr. Julie Artiglier and Holly Cassanovic, and they are here from the Center for Vocal Health. And I'm going to just tell you a little bit about them before we get started. Julie, Dr. Julie Artiglier specializes in Vocal Health, Vocal Rehabilitation, Vocal Core Disfunction, Swallowing Disorders, Transgender Voice and Chronic Cough. And she has over 30 years experience helping those with vocal disorders, including singers, actors, and other professional vocalists that are looking to maintain or regain their voice. And we have Holly Cassanovic, and Holly has a variety of experience working with individuals in many clinical settings, including acute care, outpatient, cancer centers, skilled nursing, home health, and pediatrics, to name a few. She joined Julie at Center for Vocal Health in 2018, and now enjoys her specialty focus in treating primarily voice and swallowing disorders. Her specialty practice includes treatment of a variety of disorders, including various vocal pathologies, post-operative voice treatment, head and neck cancer, vocal core dysfunction, swallowing disorders, and neurological conditions. So you all together, I mean, voice experts, so we're so excited to have you join us. Thank you for joining us today. Thank you. Yes, we're so excited to learn more. It's not every day that you meet an SLP who's a voice expert. And so kind of starting from the beginning, this is my first time meeting you both. Tell us about your decision to initially become a speech language pathologist. Okay, I'll go first. So originally I was a biology major as an undergrad. That's, you know, when I came into school. That's what I decided on. And then, but I wasn't really sure what I wanted to do with that. So originally I was like, oh, I don't know if I want to go pre-med or nursing or, you know, exactly what I wanted to do. I knew I liked the science aspect of biology. And so I think that's one thing that I do like about our field and why I ended up going into it was, you know, you have that science background, but also working with people. So luckily my advisor at the time let me take a few courses. I think my first one was anatomy and physiology of the speech and hearing mechanism. And that kind of started everything. And then, you know, since I took that class, I think even that first year, I ended up going into speech and hearing science as a major finally. So I mean, wasn't super clear cut, but that's how I ended up in it. Yeah, that sounds like some nice background though in the science, but then thinking about science and combining it with face-to-face clinical skills. Yeah, yeah, it's amazing. What about you? Well, interestingly enough, when I was in high school, I decided to narrow my ideas of being either a teacher, speech, language, pathologist, or a physical therapist. So I had the opportunity to volunteer in one of our local elementary schools, my senior year in high school during one of my study halls. And I helped that SLP do follow up with her students while she wasn't there. And so decided this is great. I love it. And even in my high school yearbook, she's going to be a speech pathologist. So you're am. Wow, from the very start, I love that. Yeah, that's unique because a lot of times people change several times. So it was meant to be apparently. And so I remember in grad school, my voice class and feeling like, oh, wow, this is really intimidating. And this is a very unique specialty. So I'm very curious to know what led both of you to specialize in voice disorders and voice therapy? Holly, do you want to get started on that one? Yeah, sure. So I've worked in many different settings, acute care, skilled nursing, home health, mostly outpatient for most of my career. But in any of those settings, you have voice disorders, whether that's just press blairings from the aging, aging voice, Parkinson's disease, paralyzed vocal cord, anything like that. So even in all those settings, we always get a little bit of voice therapy going on. And then when I started working with Julie, that's when I, you know, primarily started seeing more and more voice patients. So now I see our, you know, our case loads about 90% voice. Would you say Julie? That's it. Yeah, 90% voice. And then we also have 10% swallowing. So a lot of times with voice disorders, we also have the patients that also have trouble with dysphagia. So we see mostly those folks now. Yeah, and I was always interested in voice, but never had the opportunity. I enjoyed singing. But when I began my doctoral studies, I was very interested in the voice class and had the opportunity to do quite a few independent studies at the Denver Center for Performing Arts. So I became more and more interested in voice and the speech science behind it. So finished a dissertation focused on voice and around. Well, you don't think about how much of that will like, you know, both of you have mentioned the science. I mean, I feel like that's one area that there really is a lot of science and physics behind it. So I think that's fascinating that it's kind of full circle. So when you are seeing clients, I know you said 90% is vocal pathologies. What are the most common diagnoses that you find that you're treating in your practice? I can answer that. The typical vocal nodules and polyps from people from misuse and overuse, but we also see people post op thyroid surgery that have some difficulty from the thyroid nerve being either cut or stretched and then they have a paralyzed vocal cord. We also treat a lot of spasmotic dysphonia, vocal cord dysfunction, Parkinson's disease, pretty much anything within that happens with your vocal cords. So vocal cord dysfunction, obviously, is a breathing issue. So that's our realm because that has to do with the movement of the vocal cords. And we're both certified into programs for treating voice disorders and Parkinson's disease. So that's been a good addition to our practice in working with those folks as well. Oh, very cool. What are the two different certifications? There's LSBT loud and then the speak out program. Yeah, I hear of those are here, nothing but good things about both of those. So that's pretty pretty great that you both have those. And so when you're working with these different patients, where does the services mainly take place? Do you see them mainly outpatient? Do you ever go inpatient in home? Tell a health, what does it typically take place? Yeah, so most of our practice is an outpatient, but we do also offer telehealth services. So, you know, and whether that's seeing the patient first in the office and then doing the telehealth, you know, just for convenience, we can do that or we've also seen patients in evaluated patients over telehealth. And then, you know, ended up seeing them and their plane of care was fully through telehealth to so I mean, it's the age, you know, the technology now it's so incredible that, you know, people that before would not have been able to receive those services based on location. Now are able to so that's I think that's so incredible that you all are offering that. Because people in rural areas also are affected by these diagnoses. Right. What about, you know, what are the, you know, you already talked a little bit about, you know, some of the common conditions you're treating, but which anything specific, you know, related to vocal abuse and injury that you're seeing or, you know, I'm really curious as well about some of the psychogenic voice disorders that you all might treat. Yeah, so we see a lot of patients that, you know, overuse their voice or abuse their voice. So whether that's too loud too much. You know, we see a lot of those patients or even just a demon from over use. We see a lot of folks that are in sales or teachers that just have to use their voice a lot for their careers. So see a lot of those folks. We do see quite a few with hyper function or muscle tension dysphonia. So there's not actually an issue with the vocal cords. It's just they're overusing those extra muscles to, to overcompensate usually. But a lot of singers end up with vocal cord hemorrhages from either over singing or not being properly trained. Of course, that's seen on the physicians exam. But then we treat after that to reduce any of this falling around that area. Hopefully get them back singing. Well, I know some big name singers, you know, Adele. I think it was just in Timberlake. They've had to cancel parts of their group.
you know, concerts for that. So it's, you know, definitely a big deal. - It is a real big deal. - Yeah. What about some of those psychogenic voice disorders that you might be working with? - Yeah, so with those patients, it's, you know, I recently read some research that there's about 30% of those patients also have anxiety or depression or something else going on as well. So, but the therapy for those patients looks the same as if they had a true voice disorder. So we would still treat them, you know, with maybe resonance therapy or, you know, just making sure they understand good vocal hygiene, head neck stretches to try to reduce laryngeal tension, all those types of things. - So as someone who does not specialize in voice and maybe there's some listeners out there as well, can you explain a little bit what a psychogenic voice disorder is and what that looks like? - Sure. Typically there are no lesions. There are no physical functional reason for the person to exhibit this voice disorder. Sometimes it's reinforced by a variety of issues. Maybe they're having trouble at work. They don't really want to go to work anymore. And oh my gosh, I can't talk. And we trust. - Same with you. - Same. - Same. - Yeah, we have to work through those things and find out is there a reinforcer for this type of voice use? And if it is, then we have to deal with that. - Wow, so really wearing a few different hats as a speech therapist. - And one thing I'm curious about, because, you know, as a mom, a speech pathologist, I know that I have used and probably abused my voice many times and there's some times where I've treated back to back patients or I'm talking all day. And I've never had a voice problem, never had any, you know, any injury, any problems. Are some people just more predisposed to having, you know, nodules or, you know, any sort of other diagnoses that goes with that? - Well, that's interesting as well. There aren't clear-cut data to support that, but it seems like there are more people that are in a way predisposed, not really, but, and a lot of it is functional. It's just the way that people are using their voices. So you may not realize it, but you're probably using your voice very well. And so, all right, good job. (laughing) So it's more of a functional. - Okay. - Cool. - Yeah, sometimes when I'm listening to these podcasts, I'm like, "Oh no, vocal fry must stop." (laughing) So I know we've spoken a little bit about how you work with performers and singers. Is it possible to make someone a better singer or do you teach them techniques more preventive, like to avoid vocal abuse and improve their longevity for their performance career? - Yeah, neither of us are actually voice singing teachers. So we try to make that distinction. We don't have a piano in our office and we don't sing scales, but we do definitely work on how to change pitch in a way that is not harmful to your voice. Most singers that we see are not trained very well. We do see some opera singers obviously are very well trained and some Broadway singers that are very well trained and they're just in an overused category. But in terms of making them a better singer, we leave that to their singing teacher, but we do discuss a lot of vocal health and use. - Interesting. So do you ever collaborate with someone's singing teacher? - Definitely. - Wow, that's so interesting. When you think of a typical interdisciplinary team, it would more so include other therapists or doctors, but thinking about bringing in more of a teacher like that. - I was really hoping you could make me a better singer, but it sounds like I was hoping they've sing us a tune. (laughing) - What can you do for me? Because I do listen to some of these like Adele. I'm like, how does she do that? Where is it coming from? I mean, it's amazing with those little tiny vocal cords. - I know. - I know, it's incredible. So I know you mentioned as well that you all do see some transgender clients that are in process of transitioning and I know again our voice is very much tied to our identity and who we are. So what does that therapeutic process look like? - Yeah, so working with patients, transgender clients that are transitioning, the therapeutic process for each individual varies. So we just like to start and see where they're at and they're transitioning and see how they're currently feeling about their voice. And then we sit down and set goals with them. So we might start out with a questionnaire or just kind of interviewing the patient and then we go from there. So for therapy, why is it encompasses more than just pitch? There's also articulation patterns, rhythm, prosody, intonation. So there's a lot that goes into it as well. So, and then also keeping it safe for their vocal mechanism, making sure they're not increasing tension and just making sure that it's the voice that they feel represents them. - What types of biofeedback do you use during that process? I know I've only done voice therapy with transgender clients a few times, but we used a lot of biofeedback and I felt like that really helped make those fine-tuned adjustments. Do you guys use any biofeedback? - On occasion, I'll use a little bit of, not really pitch matching, but actual visual looking at the waveform and see if you could match. Obviously a lot of voice recording to make a, let's listen to this, listen to that. Some clients actually ask, are there voices that I can listen to? And so I had to come up with a variety of women's voices and different pitch levels and different manners of speaking so that they could listen to those and then choose one to come follow along with and practice. - That's really cool. I wouldn't have thought about that. And as I'm thinking about this just as you all are speaking, I'm thinking how hard is that to permanently make those changes to your voice? Because I mean, is there, when you're working with them, do you feel like there's kind of this switch that's flipped where all of a sudden they don't have to consciously think about it every day? Because I'm just thinking how hard that would be, if I was to get up and use my voice in a different way, just when does that click? - Yeah, I think that's very individual. So it would be hard to make a blanket statement about that. And yeah, everyone just seems so individual. I've seen lots of different comments about, I really need to think about this all the time and other people's, this is just my natural way of speaking. I think what Holly touched on and to avoid the hyperfunction, I've seen a lot of hyperfunction that then we have to deal with reducing that hyperfunction and that occurs when people are trying to make a different kind of voice that just doesn't fit. - Gotcha. - And still needs to be in line with what they're capable of and what they can do. - Right, right. - Long term. - Gotcha. - That's really interesting. I love being an ally to this population and that we're a profession that can help make that part of the transition easier. So this is kind of gonna be a change in topics to another big thing that has changed in culture and why people might seek us out. But have you seen an increase of vocal issues with the rise of vaping or the legalization of marijuana in some states? - So I think Julie and I chatted about this a little bit, but we haven't really seen an uptick in patients with vocal issues just recently from marijuana use or vaping specifically, but it would be the same effects on the voice. So usually it's laryngeal edema, rink edema specifically and treating them. First we talked about vocal hygiene, but also stopping that behavior is probably the biggest thing that they could do for their voice. - You just used to term, I haven't heard since grad school. Rink edema. (laughing) - I'm a PTSD, do I have a quiz today? (laughing) I was like, wow, I have not heard that word in a long time. So again, I love one of my favorite things about being an SLP is just the number of people that we get to collaborate with. And I love working with other professionals. And I'm assuming that the physician that you would collaborate most with would be an ENT. And if so, what does that collaboration look like? How do you all work together to best support the patient? - We like to closely collaborate with ENT that or a lot of PA is that now that will refer to us. It's super important for us to have as much information about the laryngeal exam so that we can treat properly. If we're in office with the physician, we can actually attend the exam and sometimes have it get worse.
input at that time. So it's a very close collaboration. And I might add that more and more, we receive referrals from pulmonary doctors and allergy doctors as well for sometimes for horseness, of course, but also for vocal cord dysfunction or paradoxical vocal cord motion. So we're in close contact with those physicians as well. And Holly's going to speak a little bit about the fees procedure that we do as well. Yeah, so we are both trained in fees swallow studies, so that's fiber optic, endoscopic evaluations of swallowing. And that's an inoffice procedure where you pass a scope through the nose, and then you have the patient eat and drink. So we do those inoffice oftentimes with the EPA or an ENT doc just for a second set of eyes and a second set of hands to be able to feed the patient and then see how they do on that. So it's similar. I mean, we get good information similar to a modified barium swallow. It's a little bit of a different view that we get. But we can still see if there's aspiration, penetration, for angel residue. So that's another time when we would work with closely with the ENT doctors in the office. And we've gotten some really good feedback from patients who really appreciate actually seeing where the residue is. On the obviously, some people need a little bit more of a in-depth study in radiology, but patients don't understand the radiological image. So when they actually see it in person, it actually helps in therapy as well. Yeah, and I've, you know, with my time at the hospital participated in a lot of swallow studies, but then recently had fees done on myself. And one of the things that struck me the most is just when we were getting a patient ready for an MBS, it was-- there's a lot of steps to be taken to get them ready for that. Whereas the fees was literally like, you know, couple of sprays to the nose. And then here it comes. And it was like, wow, it was really quick and easy. And I felt like it was a great way to get information quickly and easily. And again, I know they both provide. They both have their place. But that was the one thing that struck me. It was, that was quick and easy. So-- Yeah. And there's no radiation as well. So that's a benefit to the patient as well. Although I do love the lead vest. But-- [LAUGHTER] So that I used a canna. Yeah, it would blink. Yeah, it's very cool. So I know you said that you collaborate a lot with doctors. And of course, in all types of speech, language, therapy, family often is incorporated to help make those behavioral and language changes. How is family incorporated into vocal therapy? It depends on the patient. So if it's a young child, the family is very, very much involved. We set goals. And the parents will follow up with those goals on changing the behaviors that are causing the vocal abuse in most children, of course, its nodules. If it's, for example, a Parkinson's patient, it's very important that the exercises that we practice are followed every day for a certain amount of time. And so the spouse or caregiver is very involved in that as well. For other general patients, we like to involve the patient's family just in terms of trying to find out what their voice sounded like before or in how they perceive their voice now, because we have no way of knowing what that voice sounded like before. And sometimes I'll ask them, do you ever recording on your phone or your message or whatever? I can listen to that, but if I can't, I'd like to get information from a family member. Yeah, and I think that'd be so important as well. One of the things I stress to any-- but I'm supervising or just even think to myself is, I don't want to ever be thought of as like, you come see me. I have my magic wand. I fix you, and then you leave. And then you say, well, I'm not getting any better. But are you doing anything that we talked about when you leave this room? And so I think that's where involving the family I think would be so important for a voice, because they can hear and immediately, if somebody's falling back into an old habit or doing something that's vocally abusive, they can call them on it in a way that they might not be able to realize themselves. Definitely. So again, I think this is-- I've learned so much from you both. And I guess I really didn't realize how in depth one could go with voice disorders or just all the very cool things that you could do within this specialty. So we have a lot of people that listen to this podcast that are starting out on their career, or they may still be in grad school. And what piece of advice would each of you give to a speech pathologist who's looking to specialize in voice therapy? My main piece of advice would be take voice lessons, singing voice lessons if you want to work with singers so that you know exactly how it feels to sing and the difficulties in learning those skills, and then also learning how voice teachers work with singers. And again, if you want to work with actors, take a beginning acting course. I've done both of these things. It's very interesting. Obviously, we're not actors. But you will, even in the beginning, acting course stage acting. And how you present your voice and use your voice in that arena is much different. And it's much better if you understand it while you're doing it. I also had the opportunity to work with Arthur Lesak quite a while ago, early in my doctoral program. And I learned a lot about resident voice from him. And through that six-week program that I studied with him, very intensively, I developed a therapy program that I use today for a resident voice. So I think a thing to keep in mind is that as in all of our specialties, you won't learn everything you need to know in a college classroom in that specialty. So you'll have to branch out and somehow, within your time limits and your interest, learn more about the voice through these other ways. Yeah, so I definitely agree with Julie. One of the biggest things that she had me do when I started seeing primarily voice patients was attending singing voice lessons. And not being a singer that was kind of an interesting way to get into and understand what singers go through in learning their techniques for singing. And then also it was a good insight into how they're trained. And it definitely gave me some information on how I could best help them. So they have different ways of-- a little bit different ways of teaching breast support and even within the specialty of voice, I think one thing is great about our field is that even if you've worked with one patient on a certain diagnosis, there's always this other patient that maybe has that same diagnoses, but they present very differently. And so working to figure out how can I best help that patient is one of the good things about our field and definitely doing the singing lessons was helpful and kind of having me adjust things for different patients. And do you feel like-- because I feel like this is just such a really cool specialization-- would you recommend finding a mentor or another professional that specializes in this that would take you under their wing? And do you feel like having a mentor or somebody that you can learn from is helpful as well? I think that's really helpful, but I feel like it's helpful in all of our specialties. Yes. And not just voice, but there are-- after years of experience, again, like in any specialty, there are little tricks and ideas that you have to work with different patients. And so you wouldn't immediately think of those things with voice, and so it would be helpful. Yes, we're a big on mentorship. And have a huge mentorship program here that we both, Jennifer and I, participate in, and we're always talking about it. It's kind of like a generational thing in our profession, where it's like the one generation helps the next and the next. Definitely, yes. So on, which is really cool. Well, thank you so much for joining us today. I know that some of our listeners may want to get in touch with you guys, whether it be to ask more questions or learn more about your practice or referrals. What is the best way for people to reach you? Yeah, so there's a couple of different ways they can reach us. One would be our website, which is www.yourvocalhealth.com. And we have a page on there where they can just contact us through email. And then we're also located at Peaky and T. and Voice Center in Brumfield. Our address is 403.
Summit Boulevard, Boulevard, Suite 204. And again, that's Roomfield, Colorado. And then our phone number to make an appointment is 7204012139. Thank you both so much for joining us. It was a great learning experience, and I really appreciate your time. Thanks for having us. Thank you. [MUSIC PLAYING] And if you'd like to get in touch with us at the podcast, send us an email at
[email protected]. And each episode's show notes are available at the website. Go with advanced.com/SLPVuldisclosure. And make sure to subscribe to our podcast on Apple, Google, Spotify, wherever you listen to get the latest updates. And if you want to give us a little shout out, make sure to leave us a review on Apple podcasts. It really helps spread the word. Also, special thanks to Jonathan Carey for producing this episode and Aiden Dykes for the music and editing. And as always, this episode was powered by advanced travel therapy. See you next time. [MUSIC PLAYING]
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