Alexa: [00:00:00] Muscle tension dysphonia is commonly diagnosed in the voice clinic. But what actually is it? Why do voice professionals experience it? And what are some of the signs that we can keep an ear out for in ourselves, and in our clients. Who better to get the answers from than Dr. Lori Sonnenberg, a speech language pathologist and a muscle tension dysphonia specialist? 

Lori is here to help us understand what the diagnosis and treatment protocol is for muscle tension dysphonia, and she helps us to understand some of the audible signs that we might be able to pick out in a singer.  

We also discussed one of Lori's favourite topics, understanding if something could be muscular or mucosal. And Lori helps us to understand how we, as voice teachers, can continue to work with a student who we suspect has MTD or has actually been diagnosed with MTD. 

Alexa: Over to you, Lori! 

Lori, as somebody who works with the voice, do [00:01:00] you find it easy or difficult to turn off your work ears and put on your leisure ears? Do you find yourself kind of watching TV or films and sneakily picking up on tension or perhaps a vocal challenge that somebody might be experiencing? 

Lori: Yes, sometimes. Sometimes I try, like most of us, I think, would agree to, you know, to turn that, assessment type listening off and really just think about who I'm listening to, what it is that they're trying to express, and just try to enjoy what they're trying to create in the moment. And that helps a lot to turn that off. 

Uh, my young daughter used to talk about when we would watch The Voice together as a family, and she would say, Mom, you're making that face again. [00:02:00] And I would say, what face? What face? What are you talking about? She's like, no, that one, you know, that where you're, you know, so apparently there are things like that sneaking out on my face and my expressions that I don't realize. 

But no, I, and I try to be really selective about what I listen to and who I go to see live and if I come to see someone live, it's because I really, really like them and I want to enjoy what's happening.  

Alexa: , I'll be looking out for that facial expression throughout our chat in case I feel like I'm talking in a particular MTD way. 

Lori: No, not at all. Not at all.  

Alexa: But that's what we're here to talk about, muscle tension dysphonia. So what exactly is muscle tension dysphonia? How would you describe that term? And what's the difference between primary and secondary MTD?  

Lori: So when someone comes to me with a diagnosis of muscle tension dysphonia, which [00:03:00] happens on an hourly basis, because it gets diagnosed so much in the voice clinic, um, I like to talk about it in the sense of the use of the mechanism, not the mechanism itself. 

So when someone comes to me and says, I've been diagnosed with this, what does this mean? I don't understand, uh, because they say nothing's wrong with my larynx or my vocal folds. Everything looks healthy, but I know something's not. Right. Usually, that's the story. And so, you know, muscle tension dysphonia to me means that there is some problem with the use of the mechanism, not the mechanism itself. 

Yeah, , so meaning that the technical approach or the strategy that's being used for speech or singing is not resulting in easy, healthy, efficient, and usually normal vocal fold movement and [00:04:00] positioning. Now, that's just from the person who's doing the therapeutic and treatment side of things and my own diagnostic assessment. 

People usually come to me having already seen a physician that has diagnosed it. And so I'm the one that's stuck with the job of explaining and reassuring and educating and helping them to understand it, hopefully through a little different lens because people come to that conversation with all kinds of, Concerns and fears and thoughts about it. 

Primary MTD, can I say MTD, is that okay to just use that acronym? 

Alexa: Yeah, We'll probably refer to it as MTD from here on out, so yeah.  

Lori: Okay, yeah, that's easier, I think. So, primary MTD is when it stands alone, meaning that the professional who has [00:05:00] assessed the person and the voice can't find anything physically or organically wrong with the parts. 

So then primary, meaning that it stands alone and it's not in response to some other. issue, like other diagnosis. Secondary means usually that the muscle tension that is being used or the patterns, I like to say muscle tension patterns that are present for that individual are Often in, uh, they come as a result of a response to something else that's going on, like a pathology or injury or even some other type of condition pretty much any difficulty that's happening vocally, any diagnosis, in my opinion, almost always has some sort of overlay with muscle [00:06:00] tension just because we, when there's an imbalance in the system, we use more effort. 

 So when effort levels go up, then we work harder, we use and recruit from muscle groups that You know, we don't really want involved. And so that's the way that I like to educate people about it. And the other thing I want to make sure I mention is that muscle tension dysphonia, MTD, is also used a lot in the voice clinics as a part of differential diagnosis scenarios. Do you know what I mean by that?  

Alexa: Could you explain that a little bit more?  

Lori: Yeah. So, there are certain voice conditions or other diagnoses that can mimic diagnostic criteria for muscle tension dysphonia or MTD. For example, uh, I would say that probably one of the most common is, , laryngeal dystonia or spasmodic dysphonia is the the former term that we use for that diagnosis, and that [00:07:00] can affect speech or singing. 

And so a lot of times doctors will send patients to me and they say, you know, we're not exactly sure if this is a, a neuro, some sort of atypical neurological thing that's going on, like a dystonia. Or if it's really a muscle tension dysphonia situation. And so, uh, then we have to go to work in the treatment setting, sort of peeling back the layers and trying to better understand how the voice is functioning. And you have to spend time with the voice to figure that out.  

Alexa: And could you just define for us what dystonia is compared to dysphonia?  

Lori: Yes, dystonia is when there are involuntary, uh, muscle spasms in the mechanism somewhere. And, um, I mean, usually the sort of clear [00:08:00] cut types of dystonia that affect the voice are, it's a movement disorder. But it's involuntary, and so the vocal folds, the muscles of the vocal folds will spasm involuntarily, and that creates disruption and distortion in the vibration, uh, and the sound, and so dysphonia just means abnormal voicing.  

Alexa: So when somebody goes to a clinician, an ENT, gets a scope and they come away with that diagnosis of muscle tension dysphonia in the absence of another pathology, what is it that the ENT might be seeing then? 

Lori: That's a great question. Uh, historically we use About four different, like, diagnostic criteria, visually. The first one being well, the first one that comes to mind is [00:09:00] false vocal fold contraction. Uh, and so that usually, that's thinking, like, from the sides. And those false vocal folds sit a little slightly higher than the true vocal folds. 

And so they will, We'll see like compression and squeezing and constriction there. So they look for things like that. Uh, then there's the narrowing and squeezing from front to back, like anterior posterior narrowing. Then another very, very common, and this is probably what comes to me the most, because I've got doctors here that are really savvy at, diagnosing this is a posterior glottal gap. 

So in the, the posterior commissure, those vocal folds, like the heels of the arytenoids don't snap together from front, all the way from front to back. And then another criteria sometimes is like a raised larynx position. [00:10:00] Now, with all that said, all of those things can be observed during normal voicing and singing without there being any issue. 

So you can see that's where the contradictions start to kind of come in and the confusion and a lot of times probably is the reason for, uh, MTD being probably the most common diagnosis to come out of a voice clinic because they might see a little bit of one of those. But nothing else than say, oh, well, you know what, this is probably MTD. 

Alexa: So how can we actually distinguish then between MTD and another scenario, maybe like a hormonal situation like premenstrual voice syndrome, or maybe in a teenage female who, where it's quite common for there to be that posterior glottic chink, or maybe a sign of aging voice? [00:11:00]  

Lori: Yes. Uh, well, that is a tough question. I think the, the best way to answer that is to say that, there have to be other parts of the diagnostic process and the assessment. 

And that's where careful like interviewing and history taking and really learning about what that person is experiencing in their day to day and week to week life as a singer. So like listening, observing, finding patterns. I talk about that a lot. Like, are there any patterns that you notice? 

Now, are you talking about when we're looking at the vocal folds or just when we're listening and working with a singer?  

Alexa: Yeah, let's say when we're working and listening to a singer because I understand , in the scope from what people like Kerrie Obert said, you wouldn't necessarily get someone to do a twang sound or a purposeful APN with the tongue or things like that [00:12:00] if you would, if you were doing a diagnostic for this sort of thing. 

Lori: The best way I think I can say this is that , there are going to be overlays with symptoms. And also knowing how to ask about those things specifically. So with premenstrual syndrome which just means that there's some water retention and swelling in the, in the folds during a particular time of hormone fluctuation, uh, you can find those patterns and ask about, you know, , So that get details from the person about when and how and what. You can also, , talk to them about day to day variability and just understanding the ebb and flow of that. , aging voice changes, aging related changes to me are very, very different. , spectrum of what someone would complain about probably, dehydration or other changes. , [00:13:00] again, I think that's where you have to peel back the layers as you discuss it and perhaps experiment and do some trials. 

The way I talk about it with my singers is I'll say, you know what, we've got some data to tip to. Compile. Let's get some data here and I'll give them a, a little trial to say, let's do an experiment and find out how you respond if we do this for five to seven days, you know, and that's a good little way sometimes to suss out those patterns and figure out if we can relate it to something very specific. 

And to me, that's just an important part of my job as the, uh, SLP is. You know, the doctors kind of depend on me to finish that diagnostic process with the singer if there are any questions.  

Alexa: This reminds me of what you were saying with your work with vocal health education when you were talking about knowing your baseline. 

Lori: [00:14:00] Oh, absolutely.  

Alexa: Knowing your day to day voice so that you are tapping into your awareness a little bit more of when things are off. And I know I am one of those people who every month when the period is due, I'm there with. With the range being a bit of a cow and if it's not bad enough having a hot water bottle and no motivation, it's the voice is not necessarily my friend either at that time. 

So having a little voice diary and knowing what your day to day is like, the patterns just start to come up and you start to notice little things in other areas that you may not have been aware of either.  

Lori: Yes, that day to day. Well, I refer to it as self monitoring, and that is probably, uh, it's probably the number one thing that we can all do as protectors and keepers of our own vocal health. 

Because if we don't If we don't do the work to understand those [00:15:00] variations, uh, then we don't know how to respond to them. And that requires trial and error and, uh, experimenting for your own body. You know, for example I like many of us, I am a, have high vocal demand on a daily basis, and I know that there are sacrifices I have to make outside of my work to maintain the voicing I need to do my job. 

And that's many of us are in that situation, right? And finding that perfect little recipe of what's too much and what's not enough, and how much warm up do I need, and how much cool down, and How much downtime do I need during the day to balance all of that? I'm an example of someone who I don't, my voice and my body respond better to staying on vocally during the workday. 

Rather than letting down for too long, I'm [00:16:00] better off to stay warm and to reset a lot and just keep going. Uh, and then do my cool down and then turn it off at the end of the day. My body and my voice respond better to that, but that's kind of unique. But I only know that because I've done that work. about myself. do you have a way of testing for yourself every day to monitor baseline?  

Alexa: So I do the famous swell test that you speak about and also Dr. Bastian has mentioned in his videos as well. I will monitor around the time of the menstrual cycle because I know that's when my voice tends to misbehave. I am the worst at hydration with many singers I, I know and I do notice if I am under, I do notice that my voice is not as well equipped with what it needs to do. [00:17:00] But I know how long it takes for me to warm up my voice. I'm pretty good after maybe six, seven, 10 minutes. And my cool down, I take a little bit longer with my cool down and I tend to do it over the process of the evening. 

So I might start in the car journey on the way home doing some gentle glides or some descending sirens and then I'll do it again later on as long as my husband doesn't go. What the heck is that noise?  

Lori: When my daughter was very young and as young children do they keep Uh, journals about things that they think about in their lives, you know, especially little girls. 

And I discovered a journal page once where she was jotting down things, top three things I love and top three things I hate. And I made the top three things she hated in that my mom's vocal warmups.  

Alexa: Oh, I mean, yeah, we're an [00:18:00] annoying bunch.  

Lori: We are. She tested me one time to see how long I could go in the car while we were driving somewhere without vocalizing. 

Yeah, yeah.  

I didn't make it very far.  

Alexa: But it's, I think that's the thing, we're so tuned into our voices that any opportunity that we have to just test it, how's it doing today? Like, I'll just find myself starting a siren and my husband will go, no. 

Lori: So, I'm thinking of something related to our topic today, which, so we're thinking of self monitoring and testing and figuring out for yourself what works, how much, how little, what warmups get me there quickest. 

And so someone, a singer who's been given this diagnosis of muscle tension dysphonia, uh, sometimes causes, uh, fear and concern and they sort of take on [00:19:00] the term and the label become a part of their psyche and their identity. And so then there's this instinctual need to protect and, and, and put the voice in a little box and keep it safe. 

And it also makes it difficult sometimes to face what we might learn in the testing. because we don't want to look at it. And so that's where some of the language things become important in the way that we communicate with singers about this thing called tension. Because we all sing with tension all the time, every day. 

Alexa: And we need it.  

Lori: It's impossible to the right. And there's good tension. There's, you know, there are unwanted things and, bad things, but then there are they're good [00:20:00] things, so we need tension to do it well and so That, that testing is important, but it can also cause anxiety and concern in people. 

And so that's why I'm all about, you know, if you've listened to some of my education stuff on this, that on self monitoring is that the best we can think we can do is talk about it and make sure that we're saying it out loud, like this is going to happen. It's going to happen. And it's not. You know, like overdoing it and having tired muscles and overworked systems and those things are going to happen and learning to go with that ebb and flow is an important part, not only of just general vocal health, but also managing a muscle tension dysphonia diagnosis. But you've got to get really comfortable with, [00:21:00] uh, assessing your own voice as you experience it. 

Alexa: With that word, tension, it is like a taboo word to use in vocal education because it has so many meanings. I know this is probably quite a hard question to answer, but how much tension determines a problem? When does it become muscle tension dysphonia?  

Lori: I really don't know that there's an accurate answer to that because every single voice, every single individual, every human body requires such a delicate balance of all the things that go, all those mysterious systems that go into voice production. 

And you know, even when we study [00:22:00] SOVTs and, uh, and subsystem balance, we know that there are certain exercises that are helpful for establishing that balance, but we still can't figure out all the tiny little nuances of that because it's just impossible because everyone's so different in the way that we, um, the way that we produce voice. 

And so, , I think that there are probably less true cases of muscle tension dysphonia than we think there are, because in the absence of a better term to give it, and finding new language and new terminology of ways to talk about it, I think would be really helpful in those diagnostic situations and so, Uh, I'm getting off track just a little bit with your question, but, uh, you know, the, the reality is that a lot of [00:23:00] cases and situations where a singer is told that they have muscle tension dysphonia, it's really just a coordination issue in the larynx.  

Alexa: Which could then, I guess, be sorted through a technical avenue.  

Lori: Exactly. Exactly. And, and in fact, in my work, and I think a lot of other, uh, singing voice specialist type SLP's as I think of myself as a singing specialist first, almost always that hat is on first and so in my therapeutic work with people in treatment, more often than not, the thing that tips the scales for them in vocal exercise and voice therapy work is in fact really just a coordination issue with vocal registers and, or adduction in my, um, I talk a lot about how I think adduction is [00:24:00] a missing piece in all of this, and you've heard me talk about that probably, and so that coordination, uh, that, is necessary for all the other systems to fall into place. 

And sometimes it's just the most subtle of adjustment somewhere in something. And then everything just feels so different. And that to me is a really important thing to celebrate in voice work is that the voice is really responsive and it often does not take much to, to shift that trajectory. 

It, I mean, sometimes just minutes. And you can expose a singer to a different way to make sound that's much more efficient, probably would not be categorized in that muscle tension dysphonia. Uh, you know, column [00:25:00] and it really wasn't that difficult to change. And that's tough because I do think that, uh, it's, it just comes down to it sometimes being poorly understood, that coordination piece, because we focus so much on removing tension. 

We've got to remove that tension from you. Don't tense your tongue, don't tense your jaw, and if you use that word with a singer, they're going to own that. Nothing is worse than saying to someone who maybe did not think that they didn't feel tense. But then you say to them as the teacher or the therapist or the physician you've got some tongue tension in there. 

Well, then guess what happens? They get tongue tension because we've planted that seed. No, I'm [00:26:00] not saying that we don't, we can't use those terms in our teaching. And I mean, we have to have ways to do that. But that's why I think finding new language. And that's why I like the word patterns. I use the word strategy a lot. 

Have you thought about that much? Is that something that's come your way in other conversations?  

Alexa: Definitely. Yeah, I think the word, some teachers talk about not using the word don't, because, don't can sometimes lead that person into that thing. I think for me, it's awareness. So I might say, watch yourself in the mirror. What do you notice? And some people might need a little bit more guidance of a particular area, but I am very conscious about being too leading in what I'm kind of considering to be a potential issue for them and what they actually experience as the issue. So a lot of awareness and sometimes , Oh my gosh, my shoulders work by my ears. 

And I'd be like, [00:27:00] okay, so what happens if we circle them or we put them down? I mean, I'm not saying that I don't slip into some of those, um, unhelpful languages sometimes, because I think when you're in the moment. It just slips out at times and we can't berate ourselves.  

Lori: No, it does.  

Yeah, you're right. It does. And but, you know, a lot of times I'll let the person in front of me lead the way with that. And so if they are using that language about themselves, I'll acknowledge that and say, well, yeah, you know, you per, perhaps, I, I think that's a, you know, maybe that's a good possibility that you're dealing with some tension, some unwanted tension in parts of your tongue that, you know, the tongue is such a, you know, a massive, uh, organ. 

And so we acknowledge that, but then that's an opportunity to shift the conversation a little bit and explain that, maybe there are some things, let's design some exercises to help you not feel that thing you're feeling. that you don't like. [00:28:00]  

Yeah.  

Right? So let's unload and remove this thing that you, that we don't want there. 

And then explain that but we need the tongue. We need your tongue. Your tongue can be can needs to be involved in a certain way. So then once we give you something to remove this thing that you're uncomfortable with, or you don't like, then let's find a new way of making sound and try something different with the tongue. 

Alexa: I think , that's a really good point as well, because for example, somebody who might have a lot of APN as a default, where their tongue is sitting further back in the throat. I might say to them, that could be a really awesome stylistic choice. Because you just have to refer it to Christina Aguilera or whoever and say, let's make sure it's a choice and not a default. 

Lori: Right, but do you know that that narrowing and the configuring that you're talking [00:29:00] about, especially using the back of the tongue, and Kerrie Obert talks about this a lot. You know, it's one of her, , really big focuses and research areas and teaching areas. And I have become a huge fan of using those APN strategies, even just to sometimes distract a singer from the thing that they don't like that they're feeling. 

They'll say, well, let's try it this way and then they're just amazed at how much easier it was, even though the thing that we're actually doing is putting tension somewhere but a good tension. So sometimes distracting in that process as we experiment is a fun way to, to get people out of their, uh, their holding of that tension identity. 

Alexa: That's why I really like Chris Johnson's movement assessment course, because he talks about all [00:30:00] these different things that could point towards a particular avenue we might go down to explore in the technical world. But also they're very distracting so they can actually help to reduce this mental tension, if you like, because the singer is too busy swaying or rolling their shoulders to consider how it feels in their mind to be doing that. 

But what would you say? is a group of people that might be more prone to MTD?  

Lori: I think that is such a, a huge, I can think of so many different ways to answer that question. Um, I think that, that, that you're going to be surprised by this answer maybe. One of the scenarios that I think sometimes results in muscle tension dysphonia down the road for a singer is when some other event [00:31:00] or situation, you know, happens vocally, maybe a period of time where the voice was under Um, A higher load and demand of,, a really important show or something. 

Just any situation where the voice is getting overworked on a regular basis. And those subtle, the more subtle signs of difficulty, of swelling, of transient swelling, or, something that's becoming more chronic gets ignored. And then perhaps the system just starts working harder. to produce the same sound that used to be easier to produce. 

Does that make sense?  

Alexa: Yeah. And what are some of those subtle signs, whether that's vocally, audibly that we can hear or in the physical body that us as teachers, we can look out for ourselves, but also in our students who might be going through, you know, shows, auditions, that sort of thing.  

Lori: Yeah. [00:32:00] Do you mind, can I can I go back and like, add one more thing , before we go to the, the things getting sick, I think it's important to acknowledge like having an illness that where there's voice loss and difficulty, and then, uh, perhaps it lingers. A little bit in the voice, and then the singer just can't quite get back on track. And then a third piece is something that I hear a lot from singers who find themselves in a situation where they suspect or have been told that they're dealing with MTD is when they are saying to a voice teacher. Their voice teacher, who supposedly knows their voice really well. Something's not right. Like something feels off. Like I'm, you know, the singer is saying [00:33:00] to their trusted professional who's guiding them, like, this is not right. And they're saying it to multiple people that hear them sing regularly. But then the person says back, you know, well, I mean, but we don't hear anything wrong. 

It sounds fine. And so then that says to that singer, yeah, you're just. That, that's not important. What you're sensing, what you're feeling is not important. And so when that gets tamped down a lot over time and diminished in situations, then I think the trauma and the tension around that, whether it's mental or physical, it grows over time. 

And I, I just want to get that in there because I hear that story a lot from young singers especially that in colleges and universities that. you know, this is not going well and I don't feel like I'm getting this, but then it [00:34:00] doesn't get acknowledged. And so, so you asked about things that we might hear. The things that stand out the most to me, if I think about the many, many, many, Like thousands of hours probably that I've spent listening to singers who've been diagnosed with MTD. Probably one of the top things is going to be some level of unwanted breathiness. And a lot of times there's a pressing that comes in with that, like a pressed breath. 

It's like you can tell that they're, you can hear that they're working really hard and there's compression and constriction in the sound, but yet the tone is not clear. Does, and does that make sense?  

Alexa: Yeah, I'm really self conscious now. I'm like, how am I speaking? Am I breathy? Am I pressed? 

Lori: No! [00:35:00] No, not at all. 

Uh, the other thing is the dreaded cracking. That, you know, that we don't want to hear -onset delays, but especially like little quirky little cracking sorts of things, uh, during in transitional areas so, register transitions or lower, upper passaggio, whatever term you want to use for that, uh, that's common also intonation, like poor intonation, In a, in specific areas of the range is a common thing that I hear and then also a common complaint. 

. And then the other thing, probably the number one thing. That I observe and have observed over the years is something that I've started calling register imbalance or register confusion, vocal registration [00:36:00] confusion. As the singer navigates their range, there's just a lot of confusion about how they want to do that. 

And they feel, they often express that they're, they don't know what to do about that. Or you'll hear in their history that. No, I, you know what, I've always struggled with that. So those to me are kind of the real standout things in a singer. Now if we were talking about muscle tension dysphonia in a non singer, that's a, that's a little different like classification in terms of like what they complain about and what we hear. 

But since we're talking about singing, I choose those things.  

Alexa: So just to clarify and close off this first chapter of our talk, is it quite normal for us to experience some delay at times, some swelling at times, and [00:37:00] there's, there's not cause to necessarily worry so much as long as we're aware of it? 

Or is that a case of we, we have to stop now, we don't do anything and we shush?  

Lori: No, I think that I think you observe, you monitor, if you sense those changes. A little delay, a little lowering of the range that, you know, you're missing a couple of those top notes that are difficult. If you respond to that and make a change, meaning voice rest would be the most obvious one, right? 

To stop and rest for a little while. If the voice recovers pretty quickly, then more than likely you were dealing with some sort of muscular thing, right? And then, but if it takes a little while, maybe it was a swelling thing. If you need a little more vocal rest to get back to baseline, as long as you can figure [00:38:00] out, I know that when it's like this, I need to do this, respond to it, make a choice, rest the voice, and if you can get back to baseline in a relatively short period of time, meaning like, you know, one to two days, I think it's fine. 

I don't think it's anything to, be overly concerned about. Now, if that sort of thing starts happening on a regular basis, then that, to me, is a little bit of a flashing little, maybe a little warning signal that, hmm, this is showing up a lot and that's not great. The other thing is just if it starts to take longer to recover. 

Alexa: And what sort of time frame are we speaking there when it's a red flag for the time?  

Lori: I mean, if you get to where you're needing like four or five. To seven days to recover from overuse or something being [00:39:00] amiss, you know, that's getting kind of long and so if that were to happen several times in a period of a few months, then that would make me start to get perhaps a little suspicious because a lot, the reality is, if you have underlying swelling, like a little bit of swelling that just is part of your equipment, which is I don't know if you noticed, we did a post on our socials, uh, last week we started talking about the imperfect vocal folds and how a lot of us have them and that's okay. 

And we don't need to, you know, be worried about that or upset about that. It's possible to be all right with imperfect vocal folds. So if you've already got some little underlying swelling there. And then your demand goes up, you're going to have a bigger response to that because you already have some underlying swelling. 

So [00:40:00] I think it's just a matter of watching, listening, observing, trying things. And then just to remind everyone because I do think this does not happen like it should or like we want it to. Let me say it that way. Voice change that persists for more than a few weeks. That, then it's time to go get help. 

That's it. It's important to, to say that.  

Alexa: And you mentioned about the muscular impact versus what might be mucosal or what might be actually on the vocal folds. When we talk about immediate vocal fatigue or immediate kind of, Oh, that was hard work. I understand that often gets referred to as being a muscular response. 

Lori: Yes.  

Alexa: And that's something that takes a little bit of time to show up is more of that mucosal Effect. Why is that? Why? Why do we fatigue [00:41:00] quickly with a muscular thing? And why does it take swelling and mucosal things to take a bit more time to show up?  

Lori: I think the best way to answer that, uh, this is one of my favorite topics, by the way. 

Alexa: Oh, great.  

Lori: So I have a lot to say about this topic, but I'll keep it, uh, I'll keep it short and sweet. Think about an injury to any other part of the body. You know, especially like an impact or a an impact injury because swelling is an impact injury, right? It's something is touching. And it's so the swelling is a response to that, trauma because it's a physical change takes a little while for that to plump up, right? 

So think about when you, if you sprain your ankle or you hit it. You know, your toe, you stump your toe when you first look at it, you're not going to see all that swelling. [00:42:00] It's going to take a little bit of time, and you kind of observe it and watch it throughout the day, right, to see what's going to happen. 

And so blood flow is being sent to areas of injury and impact in the body. And so it's just because it's a physical change and it takes a little time for that to build up. Whereas the muscular is an immediate something that we can sense I have a really great blog article about this topic. 

I'm not sure if you've read that, but, uh, it's from a few years ago, and it's one of my favorite resources because this doesn't get written about or talked about very often.  

Alexa: Yeah. No, we'll make sure there's a link to that in the show notes. We can go in and check up on that resource.  

Lori: Yeah. And that again, it's patterns, right? And so in a muscular situation you can, if you suspect that that's what you're dealing with there are three [00:43:00] like self assessment questions that I always encourage singers to ask themselves. What am I feeling? Where am I feeling it? And what can I do right now to change it? And those three questions usually will kind of guide you. And so if you also try something that you know might be helpful in the moment, and you can shift to the way the voice is behaving pretty easily and pretty quickly, it's probably a muscular thing, right? 

You know, sometimes even just stopping, being calm and taking a couple of really nice deep breaths and just releasing the system and giving the central nervous system a little break for a second that alone sometimes can have impact on what's coming out of us vocally.  

Alexa: We've invited a few different manual [00:44:00] therapists, laryngeal massage therapists onto the podcast, Robert Price, Walt Fritz, we've had Stephen King on as well.  

Lori: Yep.  

Alexa: In your view, how impactful and effective is self massage? and self stretch on somebody's MTD?  

Lori: I think it could be very useful and very helpful. I also think that it's one tool in the toolbox. You know, and I like to teach self massage and manual therapy techniques, self stretching, whatever we identify together, oh, this feels useful, this feels helpful. 

I notice a positive shift inside of me when I do that. I like to assign, like to [00:45:00] recommend that singers do those movement and massage and stretch things early in their practice time. And, you know, to begin with movement, stretch, massage, and breath work in the first few minutes and then go into the vocal work. 

And then you might have to come back around, but I like to have people sort of sprinkle it. And now, um, now I'm very passionate about the coordination work and the vocal work and the adduction work and all of that being an important part of the process for people. But I, I love. I love self massage. 

Nothing is more empowering for someone to, to discover that they don't need us as the professional to [00:46:00] get results. We have to teach people to teach themselves.  

Alexa: Yeah.  

Lori: That, that's when I know and feel like I've done a good job in my role and, and as a team member when I've taught someone how to teach themselves. 

Alexa: Aside from self massage then, what else is involved in treating MTD?  

Lori: Well, voice therapy, of course, uh, I'm going to put a big vote for that, uh, uh, and . I think mindfulness work is a really important aspect of treating muscle tension disorders. I mean, really all voice disorders or, voice struggles, uh, but the mindfulness work, the mindset work, uh, is such an important part of the therapy process [00:47:00] because, you know, it's important for the singer to understand that we are going to be able to hold old behaviors and new behaviors at the same time. It's impossible to just set down the old things and pick up the new. Doesn't work like that. And so the mindset work can be really helpful in that process of understanding that I'm still going to feel those things sometimes that I don't like. 

So I, I've, oh, more and more, I find myself needing to support people in that way, in the process, giving them new language, more positive language. Um, I mean, there are a lot of modalities, treatment modalities that singers try. I'm sure we've all heard the stories and finding just that right recipe [00:48:00] for each person, I think is important. 

I mean, some people try acupuncture. Yoga, um, I mean, there are just endless options for us, meditation, which goes in the mindfulness category am I leaving something out? I feel like maybe I'm leaving something out, singing lessons, you know, that are, either a standalone or in supplement to the voice lessons and just making sure that everyone's on the same page. 

I consider, uh, not because I like the language, because it is the language we have, I consider myself, I consider MTD in the singing voice to be my personal primary specialty. And I am pretty open about that in marketing and different things just because it's, it's probably what I spend the majority of my time with, um, during the week and in my caseload. 

Alexa: For singing teachers who [00:49:00] might meet with a singer who has had an MTD diagnosis, how can we best adapt the training to them? And is there anything in our technical work that you think should be avoided for a length of time?  

Lori: We've kind of gotten away from the belief that, that this was something that you were doing, that we were doing wrong as a singer, it isn't advisable. 

I think it's really about looking for a little modifications and as a singing teacher, the most, one of the most important things is if the singer also has a voice therapist or SLP or SLT on board keep opening the communication lines and asking, at least extending that open door invitation to say is there anything I should know, uh, from your perspective in the therapy setting and the treatment setting that might help inform us [00:50:00] in the studio and then vice versa. 

So, I often because my my clients ask me to do this, uh, I'm always open to sending an email or a phone call to the person's voice teacher and saying, you know what? We're discovering some really great things in therapy, and I'd like to be able to tell you about those, uh, so that you're aware. 

Because we just want to make sure as professionals, we're not giving. the singer conflicting information. So ask your singers to teach you about what they're learning in voice therapy. Show me some of your exercises. I'd love to understand what it is that you're doing that's working there. 

And then as the teacher, you know, being humble enough and, uh, understanding and supportive enough to say, you know what, let's adjust what we're doing a little bit to maybe match this a little bit better so that we can support you and make you feel like everything is real [00:51:00] balanced and similar for you in different environments. 

Uh, it's very common for singers Who've been diagnosed and are being treated for it to invite a lot of people into the kitchen, a lot of cooks in the kitchen, especially because M T D and the singing voice, uh, can be in long standing. Circumstance for a lot of people. It's not uncommon for me to get contacted by somebody who says, I've had been dealing with this for a decade. 

I've worked with all these different people. Uh, and I'm not feeling resolution. I'm not getting answers. So it's very common to find out that a lot of people are being consulted. And, and I think it's important for us as the teachers and the therapists to ask about that. Because you want to make sure you know, what are they being told by someone else and, doing our [00:52:00] best to understand what that means to them. 

Because we don't, we, all we're going to do is just create more confusion. Yeah. And so, I think aligning. singing in the studio with what is happening therapeutically especially in the early stages of the work and then, uh, just staying in touch with the singer about what, what do you feel like is working? 

What are your favorite things to practice? Let's, let's, let's see if we can work with that.  

Alexa: And, how can we take our curiosity on from this conversation then, Lori? What are some good resources? We've got your blog post. Where else can we look to educate ourselves further on MTD? 

Lori: Oh, well, I do have that one very particular blog post that I've mentioned on identifying the [00:53:00] source of vocal fatigue being muscular or mucosal we educate, you know, our socials. I'm very proud of our social media presence at Sonnenberg Voice and my team member she and I work very closely together to develop that content and choose things that educate , but also help people feel really validated and acknowledged. And so, uh, we will be doing a work, I've, funny enough, as much as I teach on it and talk on it and do the work on a day to day basis, I've never officially offered a workshop on MTD. 

Can you believe that?  

Alexa: Well, now's the time, Lori.  

Lori: So, um, that is coming leading up to our conversation I've spent so much extra time over the last few weeks just, you know, organizing my thoughts about it that I thought, you know what? It's time. It's time to do a real workshop on this. So we're going to do like a deep [00:54:00] dive into MTD maybe in April or May. 

It's probably going to be May.  

Alexa: Okay, well, do make sure you send that over to us and we'll put it out.  

Lori: I will. And on our website, we always usually on the homepage, when there are workshops being offered we try to put notifications on the homepage that link to registration and stuff. So it's very easy to follow. 

There's also a way to uh, if you go to the blog on our website and go all the way to the bottom. Like you just scroll to the bottom. You can subscribe to be on our email list where we're always announcing those things. Anything important that happens. And I promise we're not emailing all the time.  

Alexa: Great. Not Lori pestering us again.  

Lori: No, I'm not one of those. I don't have time for that. So I'm not one of those. You're only going to hear from me when things are important are happening. Uh, the most important thing that I just want to take the opportunity, we just this [00:55:00] week publicly are welcoming two brand new team members to Sonnenberg Voice. 

Alexa: Ah, congratulations.  

Lori: Yes, yes, two, uh, singing specialty SLPs here in the States that are going to be working remotely for the practice and I'm thrilled and so that, that is going out this week too, so.  

Alexa: Oh, wonderful. That's so great to hear and the website, the link will be in the show notes everybody. So go ahead and follow Lori on there and your Instagram as well. Lori Sonnenberg, it's been a real joy. Thank you so much for your time and for keeping us company. It's been a pleasure.  

Lori: Yeah, you as well, Alexa. Thank you so much for the invitation and giving me a few minutes to talk about one of my favorite things.