I have had inquiries from multiple sources about how I track progress in voice rehabilitation sessions, so I thought it was high-time that I sat down to create a blog post about what types of goals I use in my sessions and how you can tweak them to make it workable for your specific clients. Looking for longe term goal suggestions? Check out Part II of this series.
If you have recently been assigned a voice client, and don’t even know where to start, check out the links at the bottom of the blog for material suggestions you can download instantly to your computer.
I divide my goals up into banks, one for Short Term and one for Long Term. I’ll discuss Long Term goals in part 2 of this blog series. The Short Term goals should be used as a guide as you think critically about how you’re working with your patient to achieve success.
Short Term
(1) Patient/Client will demonstrate an understanding of voice production physiology and controlled voice utilization by describing/listing the phonation process and alternatives or modifications of current use in different environmental contexts with 90% accuracy within 4 weeks. (I measure this by education via video, picture and demonstration with biofeedback, to help the client better understand their own mechanism, so they have better control of their own ability to produce sound. This is also where I like to have the patient claim responsibility for the voice disorder, and stop referring to “the voice” in the third person, like it has power.)
(2a) Patient will confirm implementation of hydration regimen in 3 consecutive sessions/weeks to decrease viscosity of reported throat mucus and irritation – as self-reported by patient with 100% accuracy. (There is not a published study about the specific amount of water best for the body when consumed orally. Limiting alcohol and caffeine are also part of this goal, which you could technically create 2 separate goals for, but make it reasonable for the patient as studies show caffeine doesn’t directly impact acoustic measures, but may be a diuretic and cause relaxation of the upper part of the esophagus, making reflux worse.)
(2b) Patient will confirm implementation of topical hydration regimen in 3 consecutive sessions/weeks to decrease phonation threshold pressure (PTP) by utilizing 0.9% isotonic saline in a nebulizer – as self-reported by patient with 100% accuracy. (There is published data by Kristine Tanner and colleagues (see my blog about “Nebulize on the Rise). Make sure you’re discussing any pulmonology concerns with appropriate physicians before making this recommendation, and ALWAYS keep your nebulizer clean.)
(3) Patient will work towards fostering an appropriate daily amount of vocal use and vocal rest to create an optimal balance of usage to allow for greater periods of time for vocal tissue recovery after use, within 4 weeks as evidenced by patient report and SLP observations with 100% accuracy. (We need to stop calling things “vocal abuse” and really define how we are using the term “misuse” because we don’t know what that really means for each person. This is how the goal USED to read, and I think the update better reflects a person-centered voice approach that doesn’t demonize voice use: “Patient will eliminate vocal overuse to improve health of vocal folds by reducing or eliminating trauma to vocal tissues within 4 weeks as evidenced by patient report and SLP observations with 100% accuracy“)
(4a) Patient will establish volitional control of respiration evidenced by utilization of abdominal breathing during structured tasks within 4 weeks with 100% accuracy independently. (I replaced diaphragmatic with abdominal because we cannot truly isolate the diaphragm when we breathe. For voice to be created, it is equal parts resonance, phonation and respiration and abdominal support is so important to that equation. Exploration of how we breathe can be eye-opening for patients and create a better rapport with voice as well as self awareness)
(4b) Patient will establish improved strength and stamina of respiration evidenced by utilization of respiratory resistance training devices (EMST or IMST) during structured tasks within 4 weeks with 100% accuracy independently. (Utilizing devices that tax the muscles of respiration and build real strength are a great addition to voice therapy protocols. Typically you would specify which one, Expiratory Muscle Strength Training-EMST or Inspiratory Muscle Strength Training-IMST, and then how often to complete. You might try 5 sets of 5 breaths per day, or see about where the person begins to feel fatigue. Again, make sure you’re discussing this protocol with the patient’s treating pulmonologist and cardiologist before beginning treatment, as contraindications can occur.)
(5a) Patient will coordinate vocal subsystems in hierarchical speech tasks by producing sound in an efficient manner yielding improved or normal voice quality and vocal endurance in the presence of existing laryngeal disorder with 90% accuracy independently. (This goal is very important, and the patient must reach this goal before number 7 can be achieved. Vocal Resonance, Flow Phonation and Semi-Occluded Vocal Tract Exercises can all be used to achieve this.)
(5b) Patient will coordinate vocal subsystems in hierarchical speech tasks by producing sound in an efficient manner yielding less or no vocal pain as self-reported by the patient in 5/7 days per week. (Updating this goal to include how a person feels when they make sound because sometimes it is their main complaint, and their voice sounds normophonic. Odynophonia is the word meaning pain with vocalizing, so you can use that.)
(6) Patient will reduce vocal effort and fatigue by utilizing more balanced vocal subsystems as evidenced by a decrease in symptoms and reports of reduced tension and pain in and around laryngeal structures. (We used to palpate patients and rate their tension on a scale, but we know now that there’s no evidence to support that palpation ratings we give correlate with laryngeal findings or diagnoses. We do, however, palpate and use that to predict extrinsic laryngeal muscle tension and use that to guide treatment planning. This is how the goal used to be written in the 2017 version of this blog: “Patient will reduce vocal effort and fatigue by decreasing upper body tension as evidenced by a decrease in symptoms and lack of observable/palpable signs of hyperkinetic muscular behaviors.”)
(7) Patient will implement generalization of voice modification skills with 80% accuracy independently to encourage the use of new vocal skills in varied speaking and/or singing contexts. (This includes in sentences, paragraphs, conversation, with ambient background noise, while being masked with an audio source in headphones, on the phone, at the checkout counter…..Wherever the patient uses the voice, this goal applies. You can add a separate goal for singing, or keep it together. You can separate it out if you like, especially if your client is a child, but for adults this should take usually between 4-6 sessions.)
I hope this was helpful, and stay tuned for the blog post on Long-Term Goals for your Voice Rehabilitation clients! I’d love to hear how you are creating your voice goals, so feel free to comment below!
I have a few sample evaluation templates within these products as well:
- Voice & Upper Airway Disorders Assessment Guide (Adult) (Includes samples of behavioral, acoustic and aerodynamic assessment of voice, chronic cough assessment guide, Inducible laryngeal obstruction (ILO) assessment guide and multiple report examples)
- Voice in a Jiff+: Hospital, Clinic or SNF (Instantly downloadable manual and videos to help assess and treat adult voice disorders)
- Guide for Pediatric Voice Assessment (includes video modeling for evaluation, as well as cards to allow the child more control & autonomy during the assessment.)
- Voice in a Jiff: Pediatric Edition (Instantly downloadable manual and videos to help assess and treat pediatric voice disorders)
- Spasmodic Dysphonia Voice Evaluation Guide (A differential diagnosis tool in English and Spanish for determining if it’s SD, muscle tension dysphonia, or tremor)
**This Blog was originally published in 2017. It has been updated as of Tuesday March 5, 2024.
About the Author: Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She evaluates and rehabilitates voice, upper airway disorders and swallowing at her private practice, ATEMPO Voice Center, and lectures on voice science internationally. She is a classically trained mezzo soprano with a minor in vocal performance from Texas Christian University. She has collaborated on and authored multiple peer reviewed published research articles about her community-based voice specialty clinic. She continues to develop a line of instantly downloadable voice assessment and voice therapy materials on TPT or her ATEMPO voice center website. Follow her on Pinterest, on Instagram or like her on Facebook.
