We are pleased to welcome Gayla S. Skadden, MA, CCC-SLP, as our
guest host for the SLP chat tonight, Monday, January 24, 2005. 
She will be addressing the topic of Care of the Professional Voice.

Gayla S. Skadden, MA,<cc>C-SLP, is currently a voice therapist with the
Philadelphia ENT Associates working with Drs. Robert T. Sataloff, Yolanda
Heman-Ackah, Karen Lyons, and Stephen Goldstein. She has her Bachelor of
Music degree in Vocal Performance with an emphasis in commercial music from
Millikin University in Decatur, IL and her Master of Arts in Communication
Disorders, Speech-Language Pathology from the University of Northern Colorado
in Greeley, CO. Ms. Skadden also completed the Summer Vocology Institute with
Ingo Titze in conjunction with the University of Iowa at the National Center
for Voice and Speech in Denver, CO. As a singer and violinist, Ms. Skadden
has always had a love of the performing arts and became a speech-language
pathologist with the goal of wanting to further the study, habilitation,
and rehabilitation of the voice, emphasizing the professional voice. Prior
to working with Dr. Sataloff in Philadelphia, Ms. Skadden has been a voice
therapist in North Carolina, Colorado, and most recently in Los Angeles for
Cedars-Sinai Medical Center.

Our guest host has provided us with resources/handouts which may be found
below the chat transcript.

<Robin> Welcome! We are chatting tonight about Care of the Professional Voice with guest host
          Gayla S. Skadden, MA, CCC-SLP.
<Gayla Skadden,<CCC-SLP> Hello everyone.  Thanks for having me.
<Gayla Skadden, CCC-SLP> I thought a definition of what a professional voice user is might be in order first.
<Gayla Skadden, CCC-SLP> Professional voice users are, generically, anyone who uses their voice as a primary
          tool in how they make their living.
<Gayla Skadden, CCC-SLP> Examples would include singers, actors, teachers and coaches, clergy, politicians,
          telemarketers or phone technical support, and public speakers (i.e., in business presentations,
          motivational speaking, etc.).
<Gayla Skadden, CCC-SLP> Some will delineate the category of professional voice user even farther by adding
          the term "elite voice users", meaning singers, actors, or voice over actors.
<cc> How about considering the speech pathologist as a professional voice user?
<Gayla Skadden, CCC-SLP> Yes, absolutely the SLP is a prime example of a professional voice user.
<evelyn_w> I agree, I come home some days with a sore throat.
<Gayla Skadden, CCC-SLP> Although not required, many SLPs who work with professional voice find it useful to
          have some background in singing or acting because study of how to use their voice is innate in those
<Robin> Gayla, please tell us about your background in singing.
<Gayla Skadden, CCC-SLP> I have a bachelor's degree in vocal performance from Millikin University and taught
          singing voice for 10 years prior to becoming an SLP.
<Robin> Gayla, lets start with what brings a client to you, ie, complaints, symptoms, and how you evaluate.
<Gayla Skadden, CCC-SLP> Evaluation of the voice in our office includes a full ENT evaluation including
          videostroboscopic exam and if warranted, evaluation by an SLP and Singing Voice Specialist (SVS).
<Gayla Skadden, CCC-SLP> Complaints vary from vocal fatigue to hoarseness to pain with speech or singing
          to loss of range in singing to loss of vocal loudness.
<Gayla Skadden, CCC-SLP> Many of the vocal problems we see can have similar symptoms and very different
<Robin> What type of objective measures do you take?
<Gayla Skadden, CCC-SLP> For objectives, we use MultiSpeech/CSL for acoustic measurements and a couple of
          different items for airflow measurements.
<Robin> Gayla, do you qualify as both the SLP AND Singing Voice Specialist (SVS)?
<Gayla Skadden, CCC-SLP> Yes, I work as both an SLP and SVS, but in our office they operate as separate
          entities, so I will see a patient either for speech or singing, but not both.
<Robin><Arliene>, you had a question for Gayla about the roles of the SLP and SSS
<Robin> Gayla, what if someone needs both speech and singing intervention?
<Gayla Skadden, CCC-SLP> Actually, most of our patients receive both speech and singing, if we feel after
          the evaluation that they can benefit from both.  Singing is such a good way to access better
          breathing and often more relaxed production, that even non-singers can benefit.  Although singing
          uses the same mechanism, it is different enough in thought process to sometimes bypass the frequent
          compensatory tension that may occur with speech as that person's default setting.
<Arliene> Gayla..since you work in a multidimensional office, can you explain how you balance the role of
          the voice speech pathologist and the singing coach ???
<Gayla Skadden, CCC-SLP> In my former workplace, I did both singing and speech in a single session.  But,
          it can be wonderful to have input from strictly a speech or strictly a singing side because you
          have more than one pair of eyes to evaluate the patient and more techniques to try.
<tmgirl> Yes, please I'm double majoring at the undergrad level in both music and communicative disorders.
<cherm29> I'm currently a student in the CSUN Distance program and am interested in specializing in voice
<Arliene> tmgirl...are the demands complementary or both too demanding on your voice???
<tmgirl> Well, so far complementary!
<tmgirl> Arliene, at least most of the course material is very similar so far.
<Arliene> In terms of vocal hygiene, clearly the speech pathologist should take the main role, but what
          happens with singing parameters, and advice for performing??
<Gayla Skadden, CCC-SLP> Advice for performing can come from either the SLP or the SVS, but it generally
          falls to the SVS in the performance setting.  Things like using a vocal monitoring system on stage,
          taking vocal breaks between musical sets, not drinking alcohol during a gig, etc.
<ener> Gayle, backing up to pre-evaluation, how do you get your referrals?  Who refers to you?  Have you
          developed a niche in your area by local ENTs, voice teachers and area conservatories?
<Robin> Gayla is currently is currently a voice therapist with the Philadelphia ENT Associates working with
          Drs. Robert T. Sataloff, Yolanda Heman-Ackah, Karen Lyons, and Stephen Goldstein.
<Gayla Skadden, CCC-SLP> Referrals come with the teritory in our office because I work in the office with
          4 ENTs who specialize in voice.  We do occasionally get outside referrals just to the SLPs, but our
          office policy is that  one of our doctors has to evaluate them prior to any therapy intervention.
<ener> You have quite a group there!   Great colleagues in this specialty area!
<tmgirl> How does one come by a job working specifically with professional voice users?
<Robin> good question
<Gayla Skadden, CCC-SLP> I actually entered my SLP course with the specific intent of working with singers
          because I had come from that background.  It took some extra doing outside of my normal courses to
          be able to consider myself as one who specialized in voice care.
<tmgirl> Could you elaborate please what you mean by "extra doing"?
<Gayla Skadden, CCC-SLP> I took the Vocology Institute in Denver at NCVS as one of the ways to specialize.
<Gayla Skadden, CCC-SLP> The Vocology Institute is in conjunction with University of Iowa and involves
          9 graduate credit hours in 4-5 classes to complete.
<tmgirl> Ah, I see, thanks.
<Robin> Gayla, what types of pathologies are typically seen in your clients and do you find that the
          professional singers have different pathologies than the other clients?
<Gayla Skadden, CCC-SLP> We get a variety of disorders - everything from vocal fold lesions (nodules, cysts,
          polyps) to hyperfunction, to neurological damage and reflux-related problems.
<Gayla Skadden, CCC-SLP> Professional singers and actors don't generally have different pathologies, but
          often catch them more quickly than an average speaker would because they use their voices with such
          range and intensity.  Their treatment can also be slightly different based on their need to get back
          to their performance setting.
<GS> Will you address the reflux-related problems?
<Gayla Skadden, CCC-SLP> Reflux often causes fairly severe swelling on the posterior portion of the larynx
          and vocal folds.  It can also cause abnormal muscle contraction of the larynx and lead to chronic
          muscle tension if untreated.
<Gayla Skadden, CCC-SLP> One reflux episode that hits the larynx can cause vocal fold for a 24 hour period -
          meaning that the person is either singing or talking on edematous vocal folds.
<Arliene> How compliant do you find the professional voice users with the reflux treatment regime...
          as opposed to non-professional voice users, who don't always see the efficacy?
<Robin> good question!
<Gayla Skadden, CCC-SLP> Like any patient, their compliance depends greatly on how motivated they are. 
          Even though one might think a professional singer or actor would see the reason for this treatment
          and be more motivated, they are often not compliant due to their lifestyle and personality traits.
<GS> Another reflux question...what medicine is most widely prescribed for singers?
<Gayla Skadden, CCC-SLP> I think the most widely prescribed medicine in our office is Nexium, but it depends
          upon what works with the patient's tolerance.  One thing to note is that in reflux, the doses that
          are often given by laryngologists for LPR treatment are PPI twice daily and a Zantac at night.
<Gayla Skadden, CCC-SLP> These doses are generally more than most GI doctors prescribe.          
<ener> Gayla, there is so much talk about reflux these days...Do you routinely put just about all of your
          singers on some variation of reflux therapy, no matter what their diagnoses?  Precautionary?
<Gayla Skadden, CCC-SLP> We do not put patients on reflux medicine unless they have an LPR diagnosis
          (showing signs of LPR when viewing the larynx), however, that said, about 90% of singers have reflux
          because they use sustained overinflation or greater than normal inflation of the lungs while singing
          and push on the LES (lower esophageal sphincter).
<cherm29> How interesting! I haven't heard of overinflation of the lungs as a cause.
<Gayla Skadden, CCC-SLP> Overinflation is my term, but Dr. Sataloff regularly explains this to his patients.
<ener> Thanks for addressing my specific question regarding singers and reflux.  Overinflation makes sense. 
          I thought that might be the case.
<tmgirl> Do you find that certain pathologies coincide with certain vocal pedagogy concepts?
<Gayla Skadden, CCC-SLP> I've not necessarily seen any specific voice disorders caused by any one vocal
          pedalogical method.  Almost anything in speech and singing can be done either correctly or
          incorrectly with the potential of causing damage.
<AdrienneFSU> Along the lines of Arliene's question.. I was wondering how you evaluate the patient's
          readiness to make changes?  What do you say to the patient looking for the "magic pill" to heal her
<Gayla Skadden, CCC-SLP> "magic pill" - one every patient hopes to find.  It is sometimes difficult to gauge
          their readiness to do what they need to for their vocal health, but if they can see some benefit in
          the first couple of sessions, they are often good candidates.  The other way is to make them aware
          that therapy involves home practice and ask if they are willing to comply with that.
<Gayla Skadden, CCC-SLP> Body awareness is one of the major factors that determines success in voice therapy
          and if someone is unable to feel a change that is audible, then they are often very difficult patients
          to assist in helping them create healthier voice production.
<AdrienneFSU> thanks
<evelyn_w> I work with several mildly autistic children who speak in a very low voice...how can I teach them to
          speak up and maintain a stable volume?          
<Gayla Skadden, CCC-SLP> For the autistic children, if visual stimuli is appropriate for that child, you might
          try to attach a visual cue to their vocal loudness - something that can be used to cue them while they
          are speaking and that can be easily trained to the caregiver.
<Gayla Skadden, CCC-SLP> If the cue is used often enough, the child will begin to feel and hear what is an
          appropriate loudness.
<Robin> Radio Shack makes an inexpensive sound level meter which may be useful.
<evelyn_w> That's great advice, thank you.
<Robin> Gayla, Lets move on to vocal hygiene or vocal do's and don'ts and perhaps some therapy ideas.
<Gayla Skadden, CCC-SLP> There are many basics in vocal hygiene that are helpful to prevent voice problems for
          someone who talks all day.  Drinking lots of water is one of the best!
<cc> I do that - unknowingly though!
<Gayla Skadden, CCC-SLP> Vocal hygiene is about training good habits and good voice use.  Water, decreased
          caffeine and alcohol, no smoking are some of the most well known.
<Gayla Skadden, CCC-SLP> Taking vocal breaks and being aware of loudness levels on the cell phone and in noisy
          settings are a few others.
<Gayla Skadden, CCC-SLP> Steam is also a favorite for trying to hydrate the vocal fold tissue a bit more directly
          and is especially appropriate in dry climates.
<Gayla Skadden, CCC-SLP> Any specific questions about hygiene?
<AdrienneFSU> Gayla, how do you present these strategies to the patient?  The more specific behavioral plan the
<Gayla Skadden, CCC-SLP> During my evaluation, I very specifically ask them about their habits regarding these
          factors.  I also ask about voice use and sleep patterns.  Once I have found some of the behaviors that
          may need adjusting, I address the reasons behind the need.
<AdrienneFSU> Do you typically explain why each behavior is helpful? Explaining anatomy/physiology?
<AdrienneFSU>I think that explanation helps the patient trust the advice.
<Gayla Skadden, CCC-SLP> I very frequently spend time on explaining the anatomy/physiology of the vocal mechanism
          and breathing mechanism because if people understand the reason behind what you are asking them to do,
          they seem to be more likely to follow it.
<Gayla Skadden, CCC-SLP> I do the same for vocal hygiene and reflux precautions.
<s_louise16> Is it really important to drink 8-10 glasses of water and day and why???
<Gayla Skadden, CCC-SLP> It is very necessary to drink at least 6-8  8 ounce glasses of water per day.  The
          tissue surrounding the vocal fold muscle is very suceptable to dehydration.  That tissue layer is what
          creates our vocal quality.  If it is dehydrated, we're in trouble and our vocal quality can be affected.
<Gayla Skadden, CCC-SLP> Often, patient's will think that drinking just prior to performance or speaking is
          adequate, but water never directly gets to the vocal folds - rather, it must go all the way through the
          body before reaching that all important tissue.
<tmgirl> systemic hydration
<Gayla Skadden, CCC-SLP> Exactly tmgirl!
<GS> Is it true that apple is better than water immediately before a performance?
<Gayla Skadden, CCC-SLP> Hmm, I actually haven't heard that one before and I thought I'd heard all the wives
          tales about vocal hygiene.  No, I can't imagine that an apple would be better.  If nothing else, it is
          giving your system more to digest - not good for reflux.
<Arliene> Any advice for this situation  I have a bunch of Yeshiva kids whose rebbes all hold to the "religious"
          principle that the louder you daven (pray), the more enthusiastic you are....they encourage vocal abuse...
          and I have a lot of them with vocal nodules.
<AdrienneFSU> wow
<Gayla Skadden, CCC-SLP> Yes, we see that too.  The best I have come up with is giving them more twang to their
          voice to help it carry without increasing vocal load.
<s_louise16> How do you teach twang?
<Gayla Skadden, CCC-SLP> I generally have the patient plug their nose and try to create a very nasal sound,
          then let the nose go for an open voice production.  It can be a very effective way to achieve forward
          focus.  Always make sure they are not pushing while nose is pinched.
<s_louise16> So twang and forward resonance are similar?
<Gayla Skadden, CCC-SLP> They can be, but twang keeps more of the "nasality" to "cut through", whereas forward
          resonance can be very rounded and, while carrying well, may not be quite what this population is looking for.
<AdrienneFSU> Can you teach them to project their voice to make it louder?
<Gayla Skadden, CCC-SLP> Projection is okay with adequate breath support, but if they already have a vocal
          pathology, the last thing you want is them trying to use regularly projected voice.
<Robin> Arliene, that is quite a challenge you have!...have you spoken to the rebbes?
<Arliene> I've tried to get the religious ENT doctors to rally to educate the rebbes, since it's a little
          difficult coming directly from me...but this is a long process.  I have gotten away once with a personal
          amplifier..but that's not usually readily accepted.
<Gayla Skadden, CCC-SLP> Amplification is, of course, the best option, but I too have had difficulty getting
          these patients and rebbes to use that.
<Robin> We have been chatting for close to an hour! Thank you, Gayla, for sharing your expertise with us.
<evelyn_w> Thanks for the great chat and Gayla, thank you for answering my question.
<tmgirl> Thanks!
<cherm29> This has all been very interesting, Thank you!
<Arliene> I wanted to thank you for your input....best of luck to all in dealing with voice patients! 
<GS> Thanks!
<Gayla Skadden, CCC-SLP> It's been my pleasure!
<Robin>  Thank you all for coming and participating...excellent questions.


Reflux Precautions

Vocal Hygiene

Voice Enemies and Friends

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