Our guest host for tonight's chat on November 6, 2000 is Mrs. Helene Fisher, MA, CCC_SLP,
from Nova Southeastern University's Communication Sciences and Disorders
Department.  Mrs. Fisher, a SLP.D candidate, is a Program Instructor specializing in the
areas of voice and resonance disorders.  Tonight she will chat about voice and resonance

<Robin> Hi Mrs. Fisher
<Adrienne> I'm glad you could join us!!
<Helene Fisher, NS> Thanks for having me
<Robin> Mrs. Fisher is an expert in voice and resonance.....thank you for
    joining us tonight
<Adrienne> Do you deal with improving voice or changing dialects or...?
<Helene Fisher NSU> I focus on respiration, phonation and
    resonatory systems as they pertain to voice
<Robin> Mrs. Fisher, did you teach your voice class tonight?
<Helene Fisher NSU> Yes. I just got back. We discussed neurogenic voice
<Visconti79> do MRIs help assist when identifying where brain damage
    might be or SLP-CCCs can not gain access to it?
<Visconti79> what happens if there is weak lung capacity
<Helene Fisher NSU> Let's address the Parkinson's question. Rigidity of the
    vocal cords are part of the problem.
<Adrienne> ok
<Anonymous3118> Interesting, I've never heard of the cords becoming rigid
    with Parkinson's!
<Visconti79> why is that?
<Helene Fisher NSU> MRI's may identify lesions, especially space occupying
    lesions in the brain, however, there are times when the MRI's do not detect
    the lesion. In Parkinson's, the lesion is thought to be in the
<Helene Fisher NSU> substantia nigra, one of the nuclei in the basal ganglia
<Adrienne> I know the rest of their body is pretty rigid, so it makes sense now
<Visconti79> how come some lesions can not be detected on an MRI scan?
<Visconti79> that is what surrounds the lobes of the brain right?
<Helene Fisher NSU> There is a reduction in elasticity and bowing of the vf's.
    However, when appealing to the pyramidal tract
<Helene Fisher NSU> as opposed to the extrapyramidal tract, e.g. by having
    the patient increase their vocal effort, the coordination amongst
<Helene Fisher NSU> respiration, phonation and resonation improves
<Robin> do you use the LSVT in your clinic for increasing vocal effort?
<Visconti79> if the vocal cords become rigid is there a case of polyps
<Visconti79> because the patient might be tempted to strain them to make
<Adrienne> good hypothesis Visconti
<Visconti79> thank you
<Helene Fisher NSU> Polyps may be associated with hyperfunctional
    behaviors (and allergies,etc) however, the laryngeal tends to be
    hypofunctional in PD
<Helene Fisher NSU> so that I would think that polyps would be unlikely.
<Visconti79> what is the LSVT?
<Robin> Lee Silverman Voice Treatment, a voice program for Parkinsons
<Visconti79> so speech would tend to sounds slurry or other characteristics?
<Helene Fisher NSU> I use neurophysiological rationales similar to that of
<Helene Fisher NSU> I don't believe that Ramig et al explain LSVT as
    appealing to the pyramidal tracts  as a form of compensation for
    extrapyramidal tract deficits, however their techniques seem to reflect that
<Helene Fisher NSU> The concept of appealing to the conscious (pyramidal)
    vs unconscious (extrapy) system is also used by PT's and OT's. E.g. if the pt
    has difficulty initiating gait, transfers, etc, have the pt conscious
<Visconti79> initiating gait?
<Helene Fisher NSU> consciously say out loud, eg. "I will start walking on the
    count of 3, 1,2 , 3."
<Helene Fisher NSU> The pt then starts to walk with little or no difficulty
<Robin> what other types of neurogenic voice disorders are there?
<Helene Fisher NSU> Spasmodic Dysphonia, upper motor neuron, lower
    motor neuron paralyses
<Adrienne> what's the difference between upper and lower?
<Adrienne> (besides the obvious)
<Helene Fisher NSU> The pyramidal tract, also known as the corticobulbar
    and corticospinal
<Visconti79> does rigidity lead to vocal paralysis?
<Helene Fisher NSU> tracts, are made up of only two neurons on each side
    of the brain.
<Visconti79> really?
<Helene Fisher NSU> The UMN originates in the cortex. 90% of the fibers
    cross over
<Adrienne> two neurons??
<Helene Fisher NSU> in the brainstem to the opposite (contralateral) side
    where they synapse with another neuron i.e. LMN. The LMN innervates
    the specific muscle.
<Helene Fisher NSU> The other 10% that did not cross over ("decussate")
    synapse on the same (ipsilateral) side with a LMN that
    innervates a muscle on the same side. That's why with aphasic pts, if
    the lesion is in the left hemisphere in the cortex (UMN lesion)
    the effects are on the contralateral side, ie hemiplegia,
    paretic vocal cord, etc all on the contralateral side.
<Helene Fisher NSU> With UMN lesions, the effects are: paresis (not
    paralysis) as
<Helene Fisher NSU> the target muscles still receive innervation from the
    ipsilateral side.
<Visconti79> what determines the type of lesion you are dealing with?
<Helene Fisher NSU> However, with LMN, the effects include paralysis,
    absent reflexes, flaccidity, fasiculations, muscle wasting, etc.
<Adrienne> do lesions caused from car accident cause same things as
    lesions from CVA?
<Adrienne> a lesion is any type of damage, no matter the cause right?
<Lisa13> what about laryngeal nerve paralysis?
<Helene Fisher NSU> Lisa, the vagus nerve , the tenth cranial nerve, crosses
    over in the brainstem then sends off various branches, eg auricular branch,
    pharyngeal branch and to the larynx it sends two branches, ie the RLN
    and SLN
<Helene Fisher NSU> A lesion is an area of damage. That's right.
<Adrienne> ok, does it matter how it happened?
<Helene Fisher NSU> A common LMN disorders is damage to the RLN
    (recurrent laryngeal nerve) because it has such a circuitous route.
<Adrienne> I know "where" it happened is very significant
<Visconti79> how it happened would commonly produce the same outcome I
    would think 
<Helene Fisher NSU> Thoracic, cardiac, thyroid, carotid artey, etc surgeries
    occur very close to the RLN, and the RLN may get cut
    accidentally, thus resulting in a LMN paralysis
<Adrienne> you know how a completely broken bone is different than a
    fractured or splintered bone break?... Would lesions of the brain be
    comparable to that?
<Robin> I was going to mention that...the incidence of laryngeal nerve
    problems after Thyroid surgery
<Visconti79> I think a patient I observed had that occur
<Helene Fisher NSU> Intervention usually is conservative during the first 24
    months as spontaneous regeneration may occur. However, if it
    does not, and therapy cannot achieve VF adduction, then surgical
    intervention may need to occur.
<Adrienne> regeneration of what?
<Helene Fisher NSU> Regeneration of the nerve that was resected (cut)
<Robin> how often does regeneration occur?
<Helene Fisher NSU> I cannot give you stats but it depends if the nerve was
    completely severed vs compressed by surrounding edema (swelling)
<Helene Fisher NSU> Traditional therapy techniques include isometric
    pushing-pulling type exercises, but personally, I do not agree with this.
<Adrienne> or did someone discover that they do?
<Adrienne> is it neurons that can't regenerate then?
<Visconti79> how do you do isometric pushing-pulling
<Helene Fisher NSU> Have pt fill up lungs with air then try to close glottis
    while bearing
<Helene Fisher NSU> down, or lifting/pulling a heavy item. This sustained
    and increased effort and increase vf adduction, but only as a function
    of increasing tension of the supraglottal and surrounding structures
<Helene Fisher NSU> I prefer to do the opposite. that is, discourage
    hyperfunctional attempts to compensate, and try to strengthen the
    intrinsic laryngeal muscles for adduction, tension, shorthening and
    lengthening (LCA's, IA's, CT's and TA's)
<Robin> how would you do that?
<Helene Fisher NSU> through vocal strengthening ex's e.g. as per Joseph
<Lisa13> thank you Mrs. Fisher for the info on laryngeal nerve paralysis
<Helene Fisher NSU> My pleasure, Lisa
<Visconti79> I have a question
<Helene Fisher NSU> I hope I can answer it, Visconti
<Visconti79> if there are so many speech pathology issues related to
    neurology how come observation in neurological units is not required before
    attaining your CCCs
<Adrienne> AMEN
<Helene Fisher NSU> Actually, I would like to know why dissections of the
    brain and peripheral nervous systems aren't mandatory
<Visconti79> that would be a very interesting addition into a curriculum
<Visconti79> but hands on or observation about any topic at least for me
    serves to be very beneficial
<Adrienne> You don't learn that??
<Adrienne> That's what we are talking about in my neuro class now in
<Helene Fisher NSU> On hospital ward rounds, before technology took off,
    the SLP was vital in diagnosing site of lesion
<Visconti79> really?
<Adrienne> I would love to observe more neuro disorders
<Visconti79> they are so interesting
<Alison> Mrs. Fisher, I have a question about a young boy that I am working
    with.  He is 7 years old and has a voice disorder.  Currently I have him
    working on patterns such as making his voice louder and then softer
<Alison> we also are working on some nursery rhymes with him.  I was
    wondering if you have some suggestions, I know this is not a lot of
    information but I have only been working with him for about three weeks
<Helene Fisher NSU> Well, if you want to play, let's try one...
<Robin> Alison, what is the patients specific problem?
<Alison>  He recently transfered to the school and his
    parents do not think there is a problem, however, they have agreed to let
    myself and my supervisor work with him but they will not take him to a specialist.
<Helene Fisher NSU> Alison, you mentioned the boy with a voice disorder.
    Has he had an ENT eval?
<Visconti79> doesn't the boy need that eval before making intervention
<Helene Fisher NSU> Please remember, we may not treat a voice disorder
    without an ENT's OK
<Visconti79> that is what I thought
<Helene Fisher NSU> Many different voice disorders have the same
    symptoms, eg hoarseness, low volume, low pitch, etc. Some of the causes are
    minor such as  laryngitis, however, serious causes such as papilloma,
    webs, even cancer, have to be ruled out
<Adrienne> ENTs rule those out?
<Helene Fisher NSU> Other professionals, eg ENT's, plastic surgeons,
    prosthodontists rely very heavily on SLP input, especially in the cleft palate
    and craniofacial population
<Helene Fisher NSU> SLP's contribute significantly in decision making in
    terms of whether surgery or prostheses or therapy should be provided.
    Even which surgical technique should be used!
<Visconti79> really?
<Visconti79> I did not realize they can advise on so much
<Helene Fisher NSU> I would say that of all the different disciplines on a
    craniofacial team, SLP is the most important
<Visconti79> it is good to hear that slp-cccs are respected in such a way
<Robin> Do all of your programs have a cleft palate clinic?
<Adrienne> FSU does not
<Adrienne> Gainesville has a phenomenal Clinic for cleft palate
<Robin> Mrs. Fisher, its getting late and I'm sure you've had a long day,
    especially with teaching a class tonight....do you want to wrap things up
<Helene Fisher NSU> OK> Let's wrap things up.
<Helene Fisher NSU> We have a voice/Resonance clinic with regular and
    advanced classes in Vocology. Visit us at www.fgse.nova.edu/csd  Good
    night and thanks!
<Visconti79> thank you
<Adrienne> Thank you so much Mrs. Fisher!!
<Robin> thank you so much for coming tonight Mrs. Fisher
<Helene Fisher NSU> My pleasure. Be well.