Presentation on theme: "Semi-Occluded Vocal Tract Exercises for Voice Therapy (and singing) AKA – Why we Trill, Hum, use straws etc. Liz Savina, Redcliffe Hospital For Qld Voice."— Presentation transcript:
1Semi-Occluded Vocal Tract Exercises for Voice Therapy (and singing) AKA – Why we Trill, Hum, use straws etc.Liz Savina, Redcliffe HospitalFor Qld Voice Special Interest GroupMay 2014
2Overview Definition & brief background of physics What major therapy “programs” use itDiscuss some recent studies that show the effects of different parameters/ on different populations.DemonstrationsTherapy hierarchiesCase examples
33 Major Ways of Doing SOVT (Andrade 2014) Constant frontal narrowing of the vocal tract (nasals/glides and hand-over-mouth);Lengthening (and narrowing) the vocal tract through means of a tube (Lax-Vox/Straw).Adding a 2ndry source of vibration into the vocal tract (lip and tongue-trills, Tube into water/fricatives).Been used in various forms for over 100 years (Conroy et al. 2014)
4My burning questions Is it guaranteed to work?? Which types are best forbuilding up vocalis (muscle within vocal cords) and closing glottic gaps versusImproving retraction/deconstriction, preventing overclosure
5Why/How Does SOVT Work?Potentially decreases the aerodynamic power necessary for phonation & optimises closure of the vocal folds – neither breathy or pressed (Andrade et al )
7A little bit of the physics SOVT (at the lips) works by…….Raising the mean supraglottal and intraglottal pressuresImpedance matching by vocal fold adduction and epilarynx tube narrowing can then make the voice more efficient and more economical (in terms of tissue collision).(Titze 2006)Decrease in phonation threshold pressure Reduced minimum pressure at which the VC will vibrateDecreased phonatory effortDecreased strain(Conroy et al 2014, Guzman et al., 2013),The vocal fold adduction appears to be a reflex reaction.
8A little bit of physicsLowering of the first vocal tract formant (F1) allowing the fundamental frequency (F0) of speech to be closer to F1, Increasing inertive reactance of the vocal tract and producing a more efficient vocal fold vibration pattern -> easier voicing
9Some SOVTWiden the pharynx in relation to the epilarynx -> a clustering of the 3rd, 4th, & 5th formants (Andrade 2014) – “Singer’s Formant”
10Marco Guzman, et al Resonance Tube and Straw Phonation 523.e27
11SOVT is used inStemple’s Vocal Function Exercises (nasals & Finnish bilabial fricative)Verdolini-Abbots – LMRVT – core part of her Voice Therapy Spectrum – using MLaxVox (9mm id, 25cm (Andrade) or 35 cm (Stemple) tube in 1-5cm of water (aim for 3-5cm - Stemple)Finnish Resonance Tube (soft silicone or glass tube cm & 9 mm id in 2-5cm of water or free air) ~40 year hx (Paes)
12SOVT is used in Accent Method (voiced fricatives) Estill Siren on “ng”, sireningTitze’s Straw exercise (small diameter for men, larger diameter for women – Titze Brisbane 2013)Glide loaded sentence of CAPE-V – We were away a year ago& S/Z ratio
13Lax Vox – Stemple 2011 1 of the Big 3 things for future voice therapy.
14Lax Vox indicated for: Stemple (2011) Holistic therapy for various functional and organic voice disorders:Muscle tension dysphoniaVocal fold nodules and polypsHabitual and psychogenic dysphonias-aphonias (by masking proprioceptive feedback)Vocal fold paralysis (RLN and SLN)PresbyphoniaPuberphonia• Pre and postoperative phonosurgery
15Lax Vox in Singing and Theatre voice Stemple (2011) Daily voice care for all groups of voice usersPrevention of voice problems for vocal athletesDeveloping vocal muscles with several exercises (glissando, staccato, Messa di Voce, etc.)Glottal closure deficienciesWarming up and cooling downFinding and developing the optimal voice (primal sound)Balancing the glottal attackFacilitating the lowered larynxDeveloping registers and smoothing the passaggioI find it interesting the Stemple has come out in such strong support of it, given he had his own SOVT exercises.
16Lax Vox ReferenceDenizoglu I, SihvoM. Lax Vox Voice Therapy Technique. CurrPractORL 2010, 6(2): (unable to find on Medline Ovid or Ebsco or Pubmed or even Google!)
17SOVT researched in: Teachers (RVT and Finnish Tube) Elderly (Finnish Tube)Actors and singers (RVT)“Behavioural” voice problemsBenign vocal lesionsHaven’t yet found research on Unilateral Vocal Fold Paralysis
19Some Recent Studies Immediate effects normal speakerstrained/untrained instructed/non-instructeddyshphonic/ hyperfunctional populations (tubes)Effect of 6 week programme on “elderly” (tube in water)24 Hours of RV
21Andrade et al 2014 Electroglottographic Study of Seven Semi-Occluded Exercises:…….Journal of Voice
22Andrade 2014 SOVTE LaxVox (9mm id, 25cm –? Water depth) Straw (12.5 cm in length & 4 mm in diameter)Lip-trillTongue-trillHand-over-mouthHummingTongue-trill with hand-over-mouth.? Give demonstrations of each here?
23Procedure Andrade 2014 N = 23 healthy volunteers SP demonstrated and provided teaching on error until subjects produced correctlyAsked to do same pitch for all activities. Electroglottographic & Acoustic measures
24F1 – F Andrade 2014Use of SOVT significantly reduced the difference between The first formant and the Fundamental Frequency compared to a comfortable phonation of “ah”You can see that for males and females there were different effects of the various SOVT, with the females gaining a greater reduction on Formant 1-Fundamental frequency. However there was a difference in the effect of the combination of tongue trill and handover mouth between males and females, suggesting the addition of the second source of vibration, while significant for both, might be more significant for females. LaxVox in males had the least reduction in F1-f0, while Tongue Trill in females had the least reduction in F1-F0
25SOVTAndrade et al. 2014 Fluctuating (dual source) Tongue-trill Lip-trillLaxVoxwith larger CQr &F1 - F0 differenceMore effortful phonation but ? gives massage effectSteady(single source)Hand-over-mouthHummingStrawwith lower CQr & F1 - F0 differenceEasiest PhonationAndrade proposed SOVT exercises should be separated into two groups. Those with a steady/single source of vibration – either narrowing or lengthening the vocal tract (with narrowing). These tend to lead to the easiest ohonation.
26Massaging the Vocal Tract Note the bouncing of the pharyngeal walls – easier to see in the second half of clip when the pitch is held constant.
27Tongue Trill + Hand Over Mouth Andrade 2014 Exhibited mixed effects in both the exercise groups
28Costa et al., 2011. Immediate effects of the phonation into a straw exercise
29Costa et al 2011N = 48, 23 with benign lesions (nodules, cysts, polyps, and Reinke’s edema ), 25 without.Rigid plastic straw 8.7 cm long & 1.5 mm diamExaminer demonstrated then participants did 1 minute of straw phonation at self selected mid range frequency and intensity.Videolaryngoscopy, vocal self Ax, acoustic and auditory perception Ax
30Costa et al 2011Significant improvement on vocal self Ax in patients with benign vocal lesions (p=0. 015) but no change in patients without lesions.No statistically significant differences before and after the exercise and between the groups, in the videolaryngoscopy, acoustic and auditory-perception assessments
31Gaskill, C. S. , & Quinney, D. M. (2012) Gaskill, C. S., & Quinney, D. M. (2012). The effect of resonance tubes on glottal contact quotient with and without task instruction: a comparison of trained and untrained voices. Journal of Voice
32Gaskill & Quinney 2012 Two groups of male participants, 10 with no vocal training10 with classical vocal training,No instruction/practice: told keep pitch and loudness consistentInstruction/practice: got to practice until found best pitch and loudness and had sense of oral resonance
33Gaskill & Quinney 2012 Procedure 12 reps of a vowel-like phonation for at least 5 seconds.Narrow glass tube, 8 mm ID and 50 cmSome participants needed to be cued to not produce a humming or nasalized sound, but to allow all of the sound to go through the tube instead of coming through the nose.
34Gaskill & Quinney 2012 Conclusions Resonance tube can cause immediate and measurable changes in glottal CQThese changes remain highly variable and do not always fit with theoretical predictionsdoes need an individualized approach that could include trying multiple tube lengths and diameters as well as extended and systematic practice with larger variations in pitch than those exhibited in this study
35Guzman et al 2013 Laryngeal and Pharyngeal Activity During Semioccluded Vocal Tract Postures in Subjects Diagnosed With Hyperfunctional Dysphonia8 SOVT exercises:
36SOVT postures Guzman et al 2013 N=20 hyperfunctional dysphonia8 SOVT exercises:Blinded laryngologists rated 3 endoscopic variables using a five-point Likert scalevertical laryngeal position (VLP), pharyngeal constriction, and laryngeal compression
37SOVT postures in hyperfunctional dysphonia Guzman et al 2013 All semioccluded techniques produceda lower larynxnarrower aryepiglottic openingand a wider pharynxCompared to resting positionVLP, A-P constriction,& pharyngeal width changed differently throughout the 8 semi-occluded postures.Most prominent changes were obtained with a tube into the water and narrow tube into the air
38Lower Laryngeal Position Straw exercises: Before (left), during (middle), after (right)Findings:Lower laryngeal position both during and afterHigher velum position both during and afterHypopharynx much wider during(Different Guzman et al., 2013, pg 523.e24 Figure 6)
39Paes, et al. (2013). Immediate effects of the Finnish resonance tube method on behavioral dysphonia. J Voice, 27(6), doi: /j.jvoice
40Paes 201225 female teachers minimum 5-year history of dysphonia & no prior speech therapy.Subjects produced 3 sets of 10 sustained phonations with a 1-minute rest between phonations27-cm glass tube immersed in at least/up to 2 cm of water.
41Results – Paes 201268% of the teachers reported increased phonatory comfort52% reported improved voice quality after performing the exercises.Perceptual analysis: improved voice on counting numbers but not on “ah”Spectrogram: decreased instability, subharmonics, noise in high frequencies, and the tendency for reduced low frequency noise on.Mean fundamental frequency decreased.
42Dos Santos, et. al.(2014). Verifying the effectiveness of using resonance tubes in voice therapy with elderly people.
43Resonance Tubes in the “Elderly” Dos Santos et al 2014 Resonance Tube Group:Improvement in Grade, Asthenia, Strain, Instability on GRBASINo change in breathiness90% self-reported improvementImproved Vital CapacityImproved spirometry
44Resonance Tubes in the “Elderly” Dos Santos et al 2014 N= 42 elderly in long term care residential between ages of years30 femalesx6 1 hour weekly sessions of resonance tube, compared to vocal hygiene ed sessions.Glass tubes (8 mm to 9 mm ID and 24 cm to 25 cm length in 2-5cm of water).RT Therapy Rx: instructed to emit continuous sounds, nonsensical words, and to hum the tune of “Happy Birthday to You.”Rest periods of up to two minutes between emissions.
45Verdolini, 2012. Vocal exercise may attenuate acute vocal fold inflammation
46Resonant voice for treatment of vocal fold inflammation Verdolini 2012 N=3 healthy malesUsed Resonant VoiceProspective, Randomized and double blind1-hour vocal loading procedure, followed by randomization to aTalking as normal condition, Vocal rest condition, RV exercise conditionTreatments were monitored in clinic for 4 hours and continued extra-clinically until the next morning.
47Resonant voice for treatment of vocal fold inflammation Verdolini 2012 ResultsComplete data sets were obtained for 3 inflammatory biomarkers--IL-1beta, IL-6, MMP-8Results were poorest at 24-hour follow-up in the talking as normal conditionSharply improved in the voice rest conditionWere the best in the RV condition
48SummarySOVT exercises can optimise the closure of the vocal folds, open the pharynx widerThese effects tend to occur immediatelyThey are not guaranteed to do so, so still need to be individually checked – person doing should feel a more “open throat”, less effortful voicing and sound should improve( that’s up to our subjective judgement)If SOVT improves the vocal tract configuration, evidence shows this can then be carried over to vowels and other speech sounds.