Hot Topics: Voice therapyin AdultsKittie Verdolini Abbott, Ph.D., CCC-SLPMSHA, March 2013Communication Science and DisordersSchool of Health and Rehabilitation SciencesUniversity of Pittsburgh

Context Historical– Voice therapy using aseries of “facilitatingtechniques” (e.g.,Boone)– Distinctive advance attime of introduction;first systematicassembly of widerange of voice therapytechniques, rationale,and case

Context Concern– Voice therapy approachesbased on trial and error– Not addressed: How to getfrom “here” to “there”– Approaches lacked cohesivetheoretical framework– Approaches lacked empiricaldata (difficult to research dueto idiosyncratic nature ofcombining “techniques” )

Next generation “Packaged” therapies– Lee Silverman VoiceTreatment (Ramig)– Vocal Function Exercises(Stemple)– Laryngeal massage (Roy)– Lessac-Madsen ResonantVoice Therapy (Verdolini)– Accent Method (Smith etal.)

Next generation Advantages– Cohesive frameworks– Systematic programsallowing for (a) formalclinician training; (b)scrutiny by evidencebased

Next generation Concerns– Nearly evangelicalenthusiasm for

Next generation Concerns Tendency towards“cookbook” orientation

Next generation Concerns– Questions about“evidence-basedmedicine” (warning:next slides, minortirade) Qualifier– EBM is a generally a goodthing, overall– I make a living doing EBM– I know how to do EBM– I simply voice somecautionary concerns meantto “temporize”

Stated differently New type of authority– Many cliniciansseemed as roboticabout the new master(EBM) as we did aboutthe old one (“expertopinion”).– We need to evaluatethe concept andpractice of “EBM”judiciously.

Evidence-based medicine “The dark side” (Term coined by Evavan Leer)

What’s the problem? The issue seemsinnocent enough. EBM defined as “Theconscientious, explicit andjudicious use of current bestevidence in making decisionsabout the care of individualpatients. The practice ofevidence-based medicinemeans integrating individualclinical experience with thebest available external clinicalevidence from systematicresearch.” Sackett et al. BMJ.1996;312:71-72.

Best research

EBM P1(RCT) RCTs and RCT meta-analysisas “best evidence” (why?) Reveal average results foraverage patient; what aboutyour patient? Success of randomizationdepends on the law of (really)large numbers (think insurancecompanies), which we neverhave in SLP

EBM P1(RCT) I.e., there areconcerns aboutdeductive reasoning– Deductive reasoning goesfrom population toindividual– Works well for actuarialpurposes (“average” result;relevant for insurancecompanies) but notnecessarily so well for yourindividual patients Casuistic reasoning isat least as defensiblefor clinical practice– Reasoning by analogy(e.g., similar cases)– Can be rigorous Tonelli, 1998; see also Samarkos,2006

EBM P2 (Role of “evidence”) “Evidence” crowdsout experience,values, and resourcesin the model Proponents of EBMremind us thatexperience, values,and resources are inthe 13445810/

EBM P2 (Role of “evidence”) Then why is it stillcalled “evidencebased medicine?”

EBM P3 (Philosophy of science) Philosophy of science– Basic assumption inscience is the futurewill act like the past(e.g., David Hume;John Cobb) Fundamental fallacy– Future conditions are neveridentical to past conditions– Even if conditions wereidentical, stochasticity(randomness) determinesdifferent results

EBM P3 (Philosophy of science) So are there basicphilosophical cautionsabout what evidencefrom the past can tellus about our patientin the future?

EBM P4 (Reality of nature) Moreover, humanhealth is much morecomplex thantypically implied bylinear models in mostEBM:– y mx b (linear) Complexity– Non-linearity– Variability– Stochasticity (randomelement) E.g. Li et al., 2009;

EBM P4 (Reality of nature)faculty.uca.edum

EBM P5 (Epistemology) Epistemology– How do we come to“know” things?– Only standing “outsidethe problem” as with“evidence,” or alsostanding “inside theproblem” (explanationfollows)?

EBM P6 (Evidence itself!) There is no evidencethat evidence-basedmedicine improvesclinical outcomes!

Possible solutions Evidence: Expand thescope of type of“evidence” we use,beyond RCTs Beyond evidence:Reclaim– First principles– Intuition and

Possible solutions:Expanding scope of “evidence” SS evidence: Casuisticreasoning (reasoning byanalogy, includinganalogy with otherpatients of yours, i.e., “inmy hands” evidence)(Tonelli, 1998; see alsoSamarkos, 2006); I’m sparing you the George W. Bush look-alike

Possible solutions:Beyond “evidence” The principle of “firstprinciples”– Many first principlesdon’t need clinical“evidence” about theirclinical utility, and canbe used flexibly– E.g., parachute

Parachute studyInt J Prosthodont. 2006 Mar-Apr;19(2):126-8.Parachute use to prevent death and major trauma related to gravitational challenge: systematic reviewof randomised controlled trials.Smith GC, Pell JP.SourceDepartment of Obstetrics and Gynaecology, Cambridge University, United Kingdom. [email protected]:To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.Design Systematic review of randomised controlled trials.DATA SOURCES:Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citationlists.STUDY SELECTION:Studies showing the effects of using a parachute during free fall.MAIN OUTCOME MEASURE:Death or major trauma, defined as an injury severity score 15.RESULTS:We were unable to identify any randomised controlled trials of parachute intervention.CONCLUSIONS:As with many interventions intended to prevent ill health, the effectiveness of parachutes has not beensubjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicinehave criticised the adoption of interventions evaluated by using only observational data. We think that everyonemight benefit if the most radical protagonists of evidence based medicine organised and participated in adouble blind, randomised, placebo controlled, crossover trial of the parachute.

Beyond “evidence” First principles: To agreat extent, this courseis about first principles wecan use to flexibly createindividualized voicetherapy (with examples inpackaged “templates”).

Possible solutions:The case for intuition and creativity Reclaiming intuitionand creativity– First step is being fullypresent (to capturecues we miss whenwe’re “in our heads”)

Possible solutions:The case for intuition and creativity Reclaiming intuitionand creativity– Potential reliance on mirrorneurons to solve clinicalchallenges creatively in themoment (e.g., Rizzolatti &Craighero, 2004)– Potential reliance onnonconscious “data base” wehave accumulated clinically,allowing for “intuitive patterndetection (e.g., master chessplayers; Kahneman v. Klein,2009)

Possible solutions:The case for intuition and creativity Reclaiming intuitionand creativity– To a great extent, this courseis also about reclaimingintuition and creativity aspartially valid foundations forprincipled individualized

Purposes of this short course Provide brief introduction tocritical “building blocks” (firstprinciples; “hot topics”) forvoice tx in adults. Review recent data on theutility of the principles in voicetx. Demonstrate how theseprinciples can be appliedcreatively to the clinicalsituation “in the moment.”

Aside Vocal abuse/misuse:We’ve gotten rid ofthese terms, right?––––CircularPoorly definedIndistinctPotentially negative fortherapy outcome (byway of self-efficacyand compliance;Bandura, 1977) Verdolini, 1999

Basic building blocks Three parameters arenecessary and sufficient toaddress in voice therapy– Physiology (biomechanics,biology): “What?”– Learning: “How?”– Compliance: “If?” Verdolini-Marston et al.,

General proposal Knowledge regardingthe three parameters– Is distinct– Is desirable tooptimize likelihood oftherapy

Building block set #1:The “what” of voice training and therapy:Biomechanics and biology

Biomechanics and biology ofvoice Direct therapy (voicetraining; main focusfor most patients) Indirect therapy (voicehygiene; supportivefor most patients)

Direct therapy: Starting point Basic question: Isthere an idealbiomechanical set-upthat may optimizevoice for a range ofpeople?

Biomechanics “Biomechanical setup:” Here adduction “Optimizing voice:”– Intense (clear) voice (dB)– Limited injury (SI)– Limited effort (PS)–emedicine.medscape.comImage

BiomechanicsHow do we get good intensity? Excised andsimulation study(Berry et al., 2001)

BiomechanicsHow do we limit potential for injury? Excised study (Berryet al., 2001)

BiomechanicsHow do we get a lot of output intensity forlimited injury potential Divide output intensitycurve by impactintensity curve (“vocaleconomy;” Berry etal., 2001)

Biomechanics Summary: Vocal fold posturing yieldingbest vocal economy: barelyseparated vocal folds ( 0.6-0.7mm), for conditions tested Precisely replicated results forindependent human study Generally similar resultsexpected for other fundamentalfrequencies, possibly withslight shifts (existing studiesrun with Fo 155 – 196 Hz;Berry, osing.JPG

Biomechanics Problem: We wanted– Strong output ( )– Limited impact ( )– Limited effort (?)–;;radioarchives.dom Pick 2 out of 3?

Biomechanics Nope. PL k B c wT– Titze, 1988– k constant– B damping coefficient( viscosity)– c speed of mucosal wave– w prephonatory width atvocal

Biomechanics Summary Barely touching or barelyseparated VF posturegives us biomechanicaltarget relevant for widesector of population withvoice disorders– Strong acoustic output– Minimal impact stress– Minimal phonatory 0Folds%20(vf)%20Opening%20and%20Closing.JPG

Biomechanics As chance wouldhave it “Resonant voice” –produced with thisgeneral posturing– Peterson et al., 1994– Verdolini et al., -SiaRPWY0pByJ7xMTTK-adcrj/singer.jpg

Biomechanics Resonant voice Voice produced withperceptible anterior oralvibrations, in the contextof “easy” voice Involves large-amplitude,low-impact vocal foldoscillations– Verdolini-Marston et al.,1995; Verdolini, 2000;Peterson et al., 1994;Verdolini et al., 1998;video

Biomechanics Summary to this point Barely ad/abducted vocal foldsoptimize relation betweenvoice output intensity (strong)and impact stress (small).Same configuration relativelyminimizes vocal effort as well. Target configurationcorresponds to percept of“resonant voice” (anterior oralvibrations, easy voice,involving large-amplitude, lowimpact VF Vocal%20Folds%20(vf)%20Opening%20and%20Closing.JPG

Links to a “spectrum”of




Momentary pause in the action Based on thisinformation (alone),which voice patternwould you select fordifferent patients invoice vices/Voicetherapy/index.htm

But what about the new “black” invoice science and therapy? The new buzz:“SEMIOCCLUDEDVOCAL TRACT”

What is a semi-occludedvocal tract? Vocal tract withnarrowing at any point Including– Epiglottal/pharyngealnarrowing– (Voiced) consonantproduction– Nasal sounds(narrowing at /uploads/2012/09/question-mark.jpg

BiomechanicsSOVT gets you Facilitation of VFoscillation (possiblyincreased outputintensity) Decreased VFadduction (decreasedimpact intensity) Decreased phonationthreshold pressure(increased vocalease) Titze, 1988; 2006;2009; 2011

Yay! We enhance all thosebenefits – which wewanted – from thebarely ad/abductedVF configuration(resonant voice).

Transition to Why is this exciting?– SOVT VF abduction maybe seen as biological injuryprevention factor (SIminimized)– SOVT Large VFvibrations may be a biologyinjury treatment factor (seewhy next slides)– SOVT reduced PTP maybe a physical ease

Biology Treatment factor:– Some forms of tissuemobilization—as withlarge amplitude VFvibrations from SOVT - may have antiinflammatory effects(e.g., periodontics)

Biology Relevant for us:– Anti-inflammatorybenefits of tissuemobilization appearsrelated to celldeformation fromtissue elongation .– .as may occur withlarge-amplitude VFvibrations (withSOVT)

Biology Inflammatorymediator modulationis important not onlyfor the acute phase ofwound healing, butalso for long-termphases of healing, asinitial events shapelong-term outcomes. (Agarwal et al. 2003; Charon, Luger, Mergenhagen,& Oppenheimer, 1982; Clark, 1988; Cockbill, 2002;Ghosh & Karin, 2002; Karin & Lin, 2002; Kirsner &Eaglstien, 1993; Long, Buckley, Liu, Kapur, &Agarwal, 2002; Long, Hu, Piesco, Buckley, &Agarwal, 2001; Viatour, Merville, Bours, & Chariot,2005; Witte & Barbul, 1997).

Biology Test in vocal fold

Biology First study showedwe detect(presumably) VFinflammatorymediatorconcentrations invocal fold secretions;controversialInterleukin-1beta (pg/mg protein)14012010080604020010 Min.Pre20 MinTimeTumor Necrosis Factor-alpha (pg/mg protein)21.510.50Pre10 Min.TimeMatrix Metalloproteinase-8 (pg/mg protein)3025Verdolini et al., 200320151050Pre10 MinTime20 Min20 Min.

BiologyIL-1beta12.0010.00Normalized Value Scream study14.00IL-1beta baseline8.00IL-1beta post-loadingIL-1 beta 4-hr post-treatment6.00IL-1beta 24-hr post-treatment4.002.000.00Spontaneous SpeechVoice RestResonant VoiceTreatment ConditionIL-670.0060.00Normalized Value50.00IL-6 baseline40.00IL-6 post-loadingIL-6 4-hr poast-treatment30.00IL-6 24-hr post-treatment20.0010.000.00Spontaneous SpeechVoice RestResonant VoiceTreatment ConditionMMP-816.0014.00Verdolini Abbott et al., 2012Normalized Value12.0010.00MMP-8 baselineMMP-8 post-loading8.00MMP-8 4-hr post-treatmentMMP-8 24-hr post-treatment6. SpeechVoice RestTreatment ConditionResonant Voice

IL-1βSSIL-6RestRVSSRestRVN111212Post1.21 (0.00)1.93 (0.00)1.51 (0.00)2.65 (1.33)10.62 (0.00)8.31 (1.24)4hr post3.13 (0.00)3.54 (0.00)3.68 (0.00)3.44 (2.12)20.94 (0.00)6.30 (5.96)24hr post12.52 (0.00)1.87 (0.00)0.45 (0.00)32.25 (31.61)9.16 (0.00)2.72 (2.72)IL-8SSTNF-αRestRVSSRestRVN101111Post4.57 (0.00)Nil6.22 (0.00)1.25 (0.00)1.18 (0.00)1.26 (0.00)4hr post4.18 (0.00)Nil4.23 (0.00)0.96 (0.00)1.22 (0.00)1.30 (0.00)24hr post14.81 (0.00)Nil2.08 (0.00)4.69 (0.00)1.11 (0.00)1.14 (0.00)MMP-8SSIL-10RestRVSSRestRVN111211Post3.04 (0.00)3.62 (0.00)1.21 (0.00)1.53 (0.44)2.48 (0.00)1.16 (0.00)4hr post3.33 (0.00)13.82 (0.00)1.18 (0.00)2.85 (1.07)0.56 (0.00)1.59 (0.00)24hr post13.34 (0.00)2.00 (0.00)0.38 (0.00)2.62 (1.54)1.38 (0.00)4.09 (0.00)

Biology Summary so far forbiology of resonantvoice using SOVT(proposal):– Low VF impact, helping tominimize (further) tissuedamage biologicalprevention factor– Large-amplitude VFoscillations (tissuemobilization) biologicalhealing s/Healing%20Hands%20Larger%201.jpg

Biology Branski et al. (2007;Best Basic Sciencepaper, J Voice)

Biology Branski et al. (2007;cont’d)

Biology Li: ABM simulation inphonotraumaBased on Li et al., 2005; Li etal., 2011

Biology But wait! We‘ve talked about value ofresonant voice for acute injury What about chronic injury,which is most of what we see? Phases of healing– Inflammation (several days);evidence is encouraging– Protein synthesis (a fewweeks)– Tissue remodelling (year orlonger) proteins alignaccording to force vectorsapplied during healing; thusfar clear evidence notavailable (possibly RV helpsreduce acute component ofchronic injury?)

How might these considerationsimpact clinical decisions? Discussion Clinical data

Data R01 DC 005643 Teachers withphonotrauma (most) orother phonogenic voiceproblem (e.g., MTD; afew) (mostly females) Subjects run 2005-2009 N 105 randomized (52CSCFT; 53 LMRVT) 4 wk therapy (2 back-to-backsessions/wk) Follow-up immediately post tx,3 mo post tx, and 1 yr postbaseline At 1 yr post baseline, N 40CSCFT; 42 LMRVT)

Primary outcome measure Voice Handicap

oLScheduled Follow-Up / Randomized Treatment Group12moC12moL

Next step Just how are wegoing to get people tolearn this laryngealconfiguration? Perceptual-motorlearning ent/uploads/2012/09/question-mark.jpg

Note So far, we’vediscussedbiomechanics andbiology of directtherapy. There’s also indirecttherapy to consider(aka voice hygiene)

We’ll make this quick(time permitting) Starting point inconsidering voicehygiene piece ofvoice therapy: Wewant targeted, not“shot gun”

Specifically We want program thatis mean and lean,minimizing thenumber of things weask people to do (see“compliance” lecture). en&site imghp&tbm isch&source hp&biw 1440&bih 900&q lean and mean&oq lean and mean&gs l .594.7j2.

Thus We will target 3parameters:– Hydration– Exogenousinflammation– Uncontrolled yellingand screaming We will further tailor ourinstructions to make

Vocal hygiene: Dehydration (bad) Increases the subglotticpressure required tooscillate the vocal foldsFisher et al., 2001; Jiang et al., 2000; Titze, 1988; Verdolini-Marstonet al., 1990; Verdolini et al., 1994; Verdolini et al., 2002 May increase the risk ofphonotraumaTitze, ojects/group13/namib%20desert%201.jpg

Vocal hygiene: Hydration (good) Reduces the subglotticpressure required tooscillate the vocal foldsJiang et al., 2000; Verdolini-Marston et al., 1990; Verdolini et al.,1994 May diminishphonotraumatic lesionsVerdolini-Marston et al., water-drop-a.jpg

Vocal hygiene: Inflammation (bad)Laryngopharyngeal reflux LPR could increase therisk of phonotraumaticlesions and otherconditions (e.g. cancer;paralysis) According to some data,effective treatment ofLPR may improve vocalfold condition and voice(Koufman, 1991; Shaw et al., 1996, age/Year11/Acid and baseimage/Acid med.jpg

Vocal hygiene: Inflammation (bad)Laryngopharyngeal reflux However– Scary (next store/2009/4/5/128834617768108870.jpg

Laryngoscope. 2006 Jan;116(1):144-8. LinksEmpiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematicreview.Karkos PD, Wilson JA.Department of Otolaryngology, The Freeman Hospital, Newcastle upon Tyne, UK.OBJECTIVE: The objective of this study was to define the outcome of empiric treatment ofsuspected laryngopharyngeal reflux (LPR) symptoms with proton pump inhibitors (PPIs). DESIGN:The authors conducted a systematic review of the English and foreign literature. Studies that usedPPIs as an empiric treatment modality for suspected LPR, whether alone or in combination withother acid suppressants and/or placebo, were included. Studies that did not include PPIs as atreatment option were excluded. MAIN OUTCOME MEASURES: A lack of common outcomemeasures was evident in the uncontrolled studies. In the randomized, controlled trials, outcomemeasures included symptom questionnaires and videolaryngoscopy. Only one study usedcomputerized voice analysis. RESULTS: Fourteen uncontrolled studies together with one unblinded,nonrandomized study with a control group of healthy volunteers and six double-blind, placebocontrolled randomized trials were identified from 1994 to 2004. Selection bias, blinding of the results,and lack of common outcome measures were some of the problems preventing a formalmetaanalysis. Although uncontrolled series reported positive results, randomized, controlled trialsdemonstrated no statistically significant differences for changes in severity or frequency ofsymptoms associated with suspected reflux between PPIs and placebo. CONCLUSIONS:Recommendations for empiric treatment of suspected LPR with PPIs, by far the most common ear,nose and throat practice in the United Kingdom, are based on poor levels of evidence fromuncontrolled studies. The few randomized, controlled trials have failed to demonstrate superiority ofPPIs over placebo for treatment of suspected LPR.

Vocal hygiene: Inflammation (bad)Smoking and other Exogenous inflammationimpairs voice and mayincrease the risk ofphonotrauma as well. Includes smoke and otherpollutants and allergens(e.g., petrol pollution,chemical exposures) andallergens.E.g. Richter et g.jpg

Vocal hygiene:Screaming like crazy (bad) Phonotraumatic;threshold forphonotrauma personspecific. Unless you havespecialized training inscreaming by aknowledgeable theatretrainer (use of epiglottisas noise source;vocalization in falsetto).– E.g. Ufema & Montequin,unpublished ads/2007/03/holler2.jpg

Recent data Randomized study,31 student teachers(healthy/voiceproblems)– Voice hygiene alone(targeted)– Voice hygiene voicetraining– Control Hygiene alone: Sufficientto prevent voice problemsin healthy studentteachers Hygiene voice training:Required to improveresults over controlcondition(Nanjundeswaran et al.,2012)

Whew Glad that’s done. Next let’s move on

Building block set #2:The “how” of voice trainingand therapy: Perceptualmotor learning

We’ve discussed “what” we mighttrain in voice therapy The best answer dependson learner needs andgoals “Idealized” focus was– Barely ad/abducted VFs– Semi-occluded vocal tract Clinician may elect toaddress other issues aswell, depending onclinician and JawTongueNeck adjustmentsEtc.

But “how” to train? “Please abduct yourvocal folds by 0.6-0.7mm, at the vocalprocesses.” “Please utilize anarrowed epilarynxwhile you’re at it.”

Intro: Definitions Motor Learning “A set of processes associated withpractice or experience leading to relativelypermanent changes in the capability formovement.” (Schmidt & Lee, 1999)

Intro: Implications Seen shortly indiscussion of “laws ofpractice” Things we do in the clinicto improve immediateperformance may messup learning seen in thelong term Things we do in the clinicthat mess up immediateperformance mayenhance learning seen inthe long term

Intro: Of interest Key concept is thatmotor learning perceptual-motorlearning Seen for example instudies ofneurologicalsubstrates in motorlearning

Summary from Cabeza & Nyberg, 2000 (p. 30); regions of activation

Model of motor learning Distinction between“declarative” and“procedural” learning Definitions– Declarative learning: Memory for specific eventsand general facts about theworld; seen by verbalreports (“introspection”)– Procedural learning: Memory for processes orprocedures; seen byperformance changesfollowing practice orexposure (not verbalreports or insight) E.g. Squire, 1986

Model of motor learning Evidence of distinction:– Declarative learningimpaired in amnesia(damage to hippocampusand amygdala)– Procedural learning sparedin amnesia (does notdepend on hippocampusand amygdala) E.g. Milner, 1962

Model of motor learning Implication: “Booklearning” and “motorlearning” depend ondifferentneuroanatomicalsubstrates– Declarative memorydepends onhippocampus andamygdala– Procedural memorydoes not depend onhippocampus andamygdala

Model of motor learning Further implication: Motorlearning can and doesoccur without consciousmemory of priortraining—i.e. withoutconscious support ofwhat has been learned What are further cognitivecharacteristics of thesystem that learns motorthings? Note: Notions of anentirely “clean distinction”between declarative andprocedural learning hasbeen challenged; forsimplification we will setthose aside today andconsider characteristics ofthe “procedural” systemwhich is certainly involvedin motor learning.

Model of motor learning Declarative lIntentionalSmall capacityFlexibleSlow serial processingPhylogenetically andontogenetically new– Vanishing, unstable– Attention-dependent– Repetition-dependent Procedural perceptualIncidentalUnlimited capacityStereotypicFast parallel proc-gPhylogenetically andontogenetically old– Stable over time– Attention-dependent– Repetition-dependent(massive, for habitformation)––Note: Data largely from verbal“priming” studiesReview by Verdolini (1997)

Summary for procedural (motor)learning Attention: Direct togestures’ effects, notbiomechanics Intention: Intention toachieve goal; perceptualimaging of target Metaphoric images(associationalprocessing): Don’t work Consciousness:Conscious, intellectualpractice not helpful inlong term; proceduralpractice is helpful– Review in Titze &Verdolini Abbott, 2012

Structuring practice Observational learning– Watching others perform atask may enhance learning– E.g. juggling; signlanguage; dance; surgery(Adams & Creamer, 1962;Hayes et al., 2008;Steffens, 2007; Gray et al.,1991; Custers et al., 1999)– Key appears to be learnerhas active response toobservations (Schmidt &Lee, ploads/2009/02/surgery 468x399.jpg

Structuring practice Mirror neuronsimplicated? E.g. Rizzolatti &Craighero, pg

Structuring practice Manipulations enhancingimmediate performanceoften harm learning–––––Frequent augmented feedback oftenincreases performance, decreaseslearningConcurrent augmented feedback oftenincreases performance, decreaseslearningBlocked practice often increasesperformance, decreases learning(See also Part/whole practice)Non-variable practice often increasesperformance, decreases generalizedlearning Manipulations harmingimmediate performanceoften enhance learning–––––Infrequent augmented feedback oftendecreases performance, enhanceslearningTerminal augmented feedback oftendecreases performance, enhanceslearningRandom practice often decreasesperformance, enhances learning(See also Part/whole practice)Variable practice often decreasesperformance, enhances generalizedlearning– Review by Verdolini & Lee(2002)

Structuring practice More on augmentedfeedback– AF about biomechanics Knowledge of Performance(not so helpful; seepreceding informationabout internal focus ofattention)– AF about results Knowledge of Results (KR)(helpful for learning)

Structuring practice KR timing– KR delay interval too briefharms learning (0 v. 3.2sec; Swinnen ta l., 1990)– Subject’s evaluation of ownperformance during the KRinterval may be helpful(Hogan & Yanowitz, 1978)

Interpretation Could a single factorexplain many of thevariables discussed? Desirable difficulties(Bjork, 1998)

Other: Structuring practice Interpretation– Introducing “desirabledifficulties” (increasinglearner effort) duringpractice decreasesperformance butenhances learning(Bjork, 1998)– Caution is that if taskis already inherentlyeffortful, at least someof typical laws ofpractice reverse—souse frequent feedbackand blocked practiceto optimize learning– (Review by Wulf &Shea, 2002)

Other: Structuring practice Implications for voice training models?

The effect of training manipulations on theoutcome of Lessac-Madsen Resonant VoiceTherapyK. Verdolini, C. Rosen, M .Dietrich, N. Li, L. Scheffel, R.Branski, & R. HersanUniversity of PittsburghUniversity of Pittsburgh Voice CenterData presented at 34th Symposium, Care of the Professional Voice, 2005

Acknowledgements Liz Grillo, M.A., CCC-SLPElaine Rubenstein, Ph.D.Jackie Gartner-Schmidt, Ph.D., CCC-SLPClark Rosen, M.D.Jody Kreiman, Ph.D.NIDCD DC005643

Gap in the data “How” people acquir

Summary: Vocal fold posturing yielding best vocal economy: barely separated vocal folds ( 0.6-0.7 mm), for conditions tested Precisely replicated results for independent human study Generally similar results expected for other fundamental frequencies, possibly with sl