1. LMRVT and CBCFT: Step by Step Introduction and Overview
Kittie Verdolini Abbott, PhD, CCC-SLP; 2011
Communication Science and Disorders
School of Health and Rehabilitation Sciences

2. Lessac-Madsen Resonant Voice Therapy
Based on long-term clinical work and basic science studies
First loosely described by Verdolini, in Stemple (2000; 2009)
Includes direct and indirect voice therapy
Direct piece partly adapted from work by Lessac (1967, 1997) and Madsen (unpublished)
LMRVT connotes a specific, programmatic approach to hygiene and resonant voice training

3. Arthur Lessac

4. Mark Madsen

5. The “what” of LMRVT: Direct therapy
Biomechanically:
Barely ad/abducted vocal folds that optimize output intensity and relatively minimize impact intensity (departure from “traditional” thought in voice tx).
Involves large-amplitude, low-impact VF oscillations (proposed biological prevention and healing factors) and low Ps (easy)
Preceding effects enhanced by use of semi-occluded vocal tract in training (SOVT) (e.g., voiced continuant consonants)

6. The “what” of LMRVT: Direct therapy
Perceptually:
Voice with perceptible anterior oral vibrations in the context of easy phonation.
Note 2D continuum; both vibration and ease are required to some degree for a voice to be called “resonant” in LMRVT.
RV =
Vibrations
Ease
Not RV =
No Vibrations
Hard

7. The “what” of LMRVT: Indirect therapy
Lean and mean
Hydration
Exogenous inflammation
Uncontrolled yelling and sceaming
georgeforemancooking.com

8. Casper-Based Confidential Flow Therapy
Developed as comparison therapy in NIH-funded clinical trial on the utility of voice therapy for teachers ( ) (R01 DC ).
Includes direct and indirect therapy.
Indirect therapy identical to LMRVT.
Direct therapy piece intended to be more “traditional” than LMRVT.
susandwyerartworks.com

9. Original idea for comparison tx
Quiet breathy (confidential) voice (that’s traditional!)
Idea was to offset communication impairment with QB/CV by training enhanced articulation (Lessac consonant orchestra).
Developed a program.
revwheeler.wordpress.com

10. Bright idea Then we had a bright idea.
Why not ask someone who actually does this kind of therapy to have a look at this program!!!

11. Janina Casper
atsosxdev.doit.wisc.edu

12. The birth of CBCFT
Dr. Casper took one look at the program (QB/C voice all the way through) and said “THAT WILL NEVER WORK!”
“I never have patients do QB/C voice for more than a week or two!”
marinebuzz.com

13. The birth of CBCFT “Oh yeah, so after that, what do you do?”
“I teach them resonant voice – so they can be heard!!!”
pdxcontemporaryart.com

14. The birth of CBCFT
Oh great.
relationship-economy.com

15. The birth of CBCFT
Well, natural sequence after “QB/C voice might be something like “flow voice” (aka “stretch and flow” ff Ed Stone).
Jackie Gartner-Schmidt to the rescue 
dragoart.com

16. Jackie Gartner-Schmidt (CBCFT)

17. The “what” of CBCFT: 2 stages
Biomechanically:
Stage 1: Widely abducted vocal folds, with small VF oscillations (about 1-2 wk).
Perceptually:
Stage 1: Quiet-breathy (confidential) voice.

18. The “what” of CBCFT Biomechanically:
Stage 2: Slightly greater VF separation than for RV, that nonetheless falls in the range of configurations corresponding to “optimal vocal economy” (output intensity/impact intensity).
VF oscillations potentially a bit smaller than for RV, and impact stress potentially a bit smaller as well.
No explicit use of the semi-occluded vocal tract.

19. LEGEND (APPROX EQUIV) 1 = PRESSED VOICE
2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE 1
<-2 3 4 5

20. LEGEND (APPROX EQUIV) 1 = PRESSED VOICE
2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE 1
2  3 4 5

21. LEGEND (APPROX EQUIV) 1 = PRESSED VOICE
2 = NORMAL VOICE, RESONANT VOICE, VOCAL FUNCTION EXERCISES, ACCENT METHOD, LSVT
3 = FLOW VOICE
4 = YAWN-SIGH/FALSETTO
5 = BREATHY VOICE 2 3 1 4 5

22. The “what” of CBCFT Perceptually:
Stage 2: Easy voice with “air all gone.” (Note again 2D continuum; both ease and “air all gone” are required for some degree for a voice to be truly “flow.”)
FV =
Easy
Air all gone
Not FV =
Hard
Air not all gone
thatgamecompany.com

23. Comparison of the “whats”
LMRVT
RV ~ mm VP separation
RV ~ 120 ml/sec average airflow
Anterior oral vibrations; easy
RV: Basic training with voiced continuant consonants (semi-occluded vocal tract) to enhance resonance
CBCFT
FV ~ 1.0 mm VP separation
FV ~ 180 ml/sec average airflow
Easy, “air all gone”
FV: Basic training with unvoiced continuant consonants to enhance flow

24. Comparison of the “hows”
Identical approaches
Used approach theoretically predicted to optimize learning, and empirically shown to optimize voice learning (sensory processing, variable practice).
That approach produced best VHI results in prior study that held biomechanical and perceptual target of voice training constant (resonant voice), and varied training approach.
Recall prior lecture.

25. In greater detail regarding the “how”
Single training focus
Perceptual (introspective)
Attention to detail, especially around gestures’ effects
Exploratory not prescriptive
Literal training (specificity principle)
Flexible troubleshooting
It’s a “Spa Elf!”

26. Comparison of the “ifs”
Identical approach
Parallel clinician and patient manuals, with patient education (to enhance confidence in treatment).
Same requirements in terms of amount and type of practice.
Written and audio recorded instructions.
Etc.
You might consider return audio records and/or excel file for patient compliance reporting

27. LMRVT and CBCFT (see manuals)
Hygiene
(10-15 min)
Stretches
(5-10 min)
Core
Chant
“VC”
“Mini”
(5 min)
“Messa di voce”
Converse
(5-20 min)
Own Tx
(15-20 min) I
Xxx
(xxx) II
xxx C1
III C2 IV
C1+2 V C3 VI C4
VII C5
VIII C6

28. Claim to use LMRVT or CBCFT
After 2-day training session by Verdolini or designated associate, assuming relatively “mature” clinician with emphasis in voice.
ncvs.org

29. Patient selection Voice problem due to hyper- or hypoadduction
Demonstrates kinesthetic (and preferably auditory-perceptual) discrimination capabilities and willingness (Vocal Function Exercises will get you the same biomechanical and biological targets, with outward focus)
Usually some evidence of improved voice within first session

30. Not appropriate populations
Hemorrhage (strongly contraindicated)
Immediate post-surgical
SD (probably won’t help; but see work by Connie Pike, SLP)
Parkinson’s disease (LSVT is appropriate; although see Florida work)
Gaping wide paralyses or otherwise huge glottal insufficiency (you won’t get anywhere)

31. Other selection criterion
If you’re not already sick of it
thenysehng.blogspot.com

32. Data
R01 DC
Teachers with phonotrauma (most) or other phonogenic voice problem (e.g., MTD; a few) (mostly females)
Subjects run
N=105 randomized (52 CBCFT; 53 LMRVT)
4 wk therapy (2 back-to-back sessions/wk)
Follow-up immediately post tx, 3 mo post tx, and 1 yr post baseline
At 1 yr post baseline, N=40 CBCFT; 42 LMRVT)

33. Primary outcome measure
Voice Handicap Index
scielo.br

35. Question Where have you seen the curves on the preceding pages before?
Discussion.

36. Step by step details Manuals
CBCFT Clinician and Patient Manuals included with the course.
LMRVT Clinician and Patient Manuals (and DVD) available from Plural Publishing, Inc. (
chimneycricket.com

37. Start with intake Brief history (Measures)
Baseline voice self-assessment (key as “anchor” for later daily ratings)
List of likely contributory causes (in Clinician and Patient Manuals
Goals (functional, medical, biomechanical)
Recommendations
Prognosis

38. Set-up for therapy
Brief patient education about voice production, voice disorders
Personalized voice hygiene program
pcna.net

39. Hydration risks (from case history)
Systemic risks
Insufficient intake of hydrating fluid in general (< 1.5 qt/day “rule of thumb”)
Insufficient fluid replacement with perspiration
Consumption of dehydrating beverages (caffeine, alcohol)
Use of diuretics (medically indicated or not, e.g., “water pills”)
Recommendations
1.5-2 qt water/day (clinical “rule of thumb”)
Increase water intake with perspiration
Decrease dehydrating beverages (negotiate!!)
Decrease use of non-essential diuretics (negotiate!)

40. Hydration risks (from case history)
Surface dehydration
Exposure to dry ambient air
Use of medications that dry secretions (decongestants, antihistamines, psychotropic drugs)
Mouth breathing (sleep; sports)
Recommendations
Use direct steam inhalation (5 min/BID, clinical ROT; practice in clinic)
Use ambient humidifiers if necessary ($10-150; hot water; discuss placement)
Discontinue non-essential meds (or seek non-drying alternatives)
Seek medical evaluation and treatment for mouth breathing
Train sports breathing (inhale through nose if possible); post-activity steam
Increase water intake (“cross-talk” between systemic and surface hydration)

41. Exogenous inflammation risks (from case history)
LPR
Smoke exposure (self or others)
Chemical exposure (including workplace; e.g., theatre)
Environmental pollution
Recommendations
Behavioral LPR precautions (see manual; negotiate!)
Reduce or stop smoking (negotiate!)
Address chemical exposures where relevant
Possible use of face mask?

42. Uncontrolled yelling and screaming risks (from case history)
Sports
Work demands
Social
Background noise
Personality, habit (the “Richie” syndrome)
Hearing loss
Recommendations
Advise you will train them in loud voice; tell them to “cool it” for now until you get there in therapy
Hearing loss: Address as appropriate
Background noise: Next page

43. Vocal hygiene: Screaming like crazy (bad)
Specifically: Earplug in one ear in background noise
Increases bone conduction; you hear yourself better and don’t scream
Two earplugs even better than one (hear others’ speech better too)

44. Direct therapy
Manuals and demos