Vocal Function Exercises Laryngeal Adduction Exercises Angie Predmore Robyn Renwick

Purpose To improve vocal quality Increase muscle activity

Laryngeal Adduction Exercises Pushing/pulling Holding breath Glottal attack Pseudo supraglottic swallow 3

Who? used with patients with poor vocal fold adduction (hypo- adduction) laryngeal trauma (may result in recurrent laryngeal nerve paralysis) neurological diseases PD, MS, closed head injury, stroke, congenital conditions such as sulcus vocalis (vocal fold furrow) should not be used in patients with voice problems due to vocal fold inflammation or mass lesions on the folds (i.e. nodules, polyps) Pushing and pulling exercises should not be used with patients that have uncontrolled high blood pressure (Ramig & Verdolini, 1998)

Purpose Voice quality Facilitate improved vocal fold closure during voice production Helps to treat breathiness, low intensity, hoarseness, or overall vocal quality Conditions such as vocal fold bowing and vocal fold weakness or paralysis (Logemann, 1998)

Purpose Swallowing safety / airway protection Increase muscle activity in the larynx Basic to good laryngeal closure during swallowing A sequence of these exercises should be completed before actual swallowing therapy if laryngeal incompetence can’t be managed quickly by postural assists or teaching the patient to voluntarily close their airway (Logemann, 1998)

Method Two sets of exercises The series of exercises should be completed five to ten time per day for five minutes Each exercise should be repeated 5 times before moving on to the next exercise in the set The whole series of exercises should be repeated three times (Logemann, 1998)

Set 1 Exercise 1: Be seated. Hold your breath as tightly as possible while pushing down or pulling up on your chair with both hands for 5 sec. (Logemann, 1998)

Set 1 Exercise 2: Be seated. Bear down against a chair with only one hand. Produce clear voice simultaneously. (Logemann, 1998)

Ah.. Ah..ah..ah..ah.. Set 1 Exercise 3: Repeat ‘ah’ 5 times with a hard glottal attack on each vowel. Ah.. Ah..ah..ah..ah.. (Logemann, 1998)

Set 1 Patients should practice this series every day for one week. A follow-up swallow evaluation should be completed to assess improvements in airway protection from the larynx. The SLP and patient can also monitor improvements in laryngeal function by listening to clarity and vocal quality. If no improvements are noted, the exercises should be changed to those in Set 2. This prevents monotony and introduces exercises in a hierarchy (Logemann, 1998)

Set 2 The series of exercises should be completed five to ten time per day for five minutes Each exercise should be repeated 5 times before moving on to the next exercise in the set The whole series of exercises should be repeated three times (Logemann, 1998)

Set 2 Exercise 1: Pull up on chair with both hands while prolonging phonation. (Logemann, 1998)

Set 2 Exercise 2: Begin phonation of ‘ah’ with a hard glottal attack and sustain phonation with a clear, smooth vocal quality for 5-10 seconds (Logemann, 1998)

Set 2 Exercise 3: Pseudo-supraglottic swallow Take a breath, hold it, and cough as strongly as possible (Logemann, 1998)

Recovery Improvement should be seen within 2 weeks Occasionally it will take 6-8 months with some patients to attain adequate airway protection or vocal quality these are often those who have had more serious conditions (i.e. extended supraglottic laryngectomy) (Logemann, 1998)

Cautions Stemple, Glaze & Klaben (2000) suggested that the effectiveness of these exercises depends on the degree of vocal fold gap prognosis for improvement is most favorable if a light touch closure is evident during the videostroboscopic evaluation Patient should be monitored closely for signs of hyperfunction (Miller, 2004) (Stemple, Glaze & Klaben, 2000; Miller, 2004)

Efficacy There is very little research about the use and efficacy of laryngeal adduction exercises. Since there are extremely few efficacy studies concerning vocal fold adduction exercises, few SLPs currently use the pushing and pulling type of exercises. Yamaguchi et al. (1990) Silverman Voice Treatment (LSVT)

Yamaguchi et al. (1990) Cases of glottal incompetence Treated by the pushing exercises technique. Three patients that had paralysis of the vocal folds or sulcus vocalis All three individuals improved following voice treatment. Two improved 20 dB (statistically significant increase in intensity), and one improved 7 dB (clinically significant increase in intensity).

LSVT The Lee Silverman Voice Treatment (LSVT) program utilizes intensive high phonatory effort exercises in order to increase vocal fold adduction. It has been documented to have short and long term effectiveness for those with idiopathic Parkinson’s Disease. (Ramig, 1998)

Vocal Function Exercises “Knoll”

Who? Beneficial to treat Prevention Hyperfunction Too much laryngeal activity Hypofunction Too little laryngeal activity Prevention Vocal symptoms Research has demonstrated improvements for Vocal nodules Singers Aging voice

Philosophy The laryngeal mechanism, like other muscle systems, may become imbalanced and/or strained. VFE treat in a holistic manner. “Physical therapy” for the voice (Stemple, Glaze, & Gerdeman-Klaben, 2000) 23

Purpose Increase the bulk, strength, and coordinated interaction of muscles Improved glottal efficiency Improved vocal quality Easy onset Frontal focus Respiratory support Balance respiration, phonation, & resonance (Stemple, 2000; “Vocal function exercises”, n.d.) 24

Method Set of 4 exercises Completed 2x each, 2x daily 1x in the morning, 1x in the afternoon Complete as softly as possible to Purpose: increase muscular and respiratory effort to maintain phonation (Andrews, 2006) 25

Step 1: Warm-Up Sustain the vowel /i/ for as long as possible Goal on a musical note F above middle C for women and children below middle C for men. May be modified based on patient’s vocal range. Goal Dependent on patient’s airflow volume. Targeted volume is 80-100 mL/s of airflow. Flow volume, mL H2O/100 mL H2O = _______ seconds (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 26

Step 2: Stretching Say “Knoll” and glide from lowest note to highest note in vocal range. Goal Complete without voice breaks. Use of the word “knoll” encourages a forward vocal focus and an open pharynx. Lips should be rounded and the patient should feel vibration on the lips. During this exercise, vocal folds are stretched and muscle control and flexibility is improved. (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 27

Step 3: Contraction Say “Knoll” and glide from highest note to lowest note in vocal range. Goal: Complete without voice breaks. Encourages a forward focus and an open pharynx. Complements the previous stretching exercise by contracting the laryngeal muscles. (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 28

Step 4: Adductory Power Exercise Voice “Oll” (“knoll” without “kn”) as long as possible on musical notes C, D, E, F, and G above middle C for women and children below middle C for men modify based on patient’s vocal range). Goal dependent on patient’s airflow volume. The goal is the same as the first exercise with a targeted volume is 80-100 mL/s of airflow. (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 29

Recovery Patients track progress on a graph Sustained times Daily variation is expected Improvement typically seen within 6-8 weeks (Stemple, Glaze, and Klaben, 2000) 30

Maintenance Once goals have been met and vocal quality has improved, the following weekly program is recommended: Full program 2 times each, 2 times per day Full program 2 times each, 1 time per day (morning) Full program 1 time each, 1 time per day (morning) Exercise #4, 2 times each, 1 time per day (morning) Exercise #4, 1 time each, 1 time per day (morning) Exercise #4, 1 time each, 3 times per week (morning) Exercise #4, 1 time each, 1 time per week (morning) (Stemple, Glaze & Klaben, 2000) 31

Efficacy Voice Therapy: Clinical Studies (Stemple, 2000) Provides a variety of cases in which he has used VFE Hyperfunction 9 year old 21 year old Improved vocal quality Easy onset, respiratory support, frontal focus Balance among respiration, phonation, resonance Prevention of hyperfunction 53 year old Avoid hyperfunction as a new, higher pitch is learned Hypofunction 71 year old 36 year old Improved efficiency of breath support for phonation Treatment of vocal nodules 26 year old Improved vocal quality Overall improvement in vocal folds Frontal focus Increased MPT 32

Prevention of Vocal Symptoms Pasa, Oates, & Dacakis (2007) 37 primary school teachers Ages: 21 to 55 Results Decrease in vocal symptoms Improved vocal quality Increased maximum phonation times 33

Singers Wrycza-Sabol, Lee, and Stemple (1995) 20 healthy graduate-level voice majors Ages 21 to 55 Results: Improved glottal efficiency Increased airflow rates Imporved phonation volumes Increased MPTs 34

Aging Voice Gorman, Weinrich, Lee, and Stemple (2008) 19 male participants Ages 60 to 78 Results: Continuous improvements in MPT Improved glottal closure

References Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through geriatrics. Thomson: Canada. Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic changes as a result of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903. Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX. Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North American, 37, 105-119. Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics Phoniatrics Vocology 32, 128-140. Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech, Language, and Hearing Research, 41, 101-116. Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada. Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice pathology: Theory and management. Singular: Canada. Vocal function exercises. In Vocology. Retrieved July 13, 2009, from http://ncvs.org/museum-archive/vocologyguide.pdf Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function exercises in the practice of regimen of singers. Journal of Voice, 9(1), 27-36. Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990). Pushing exercise program to correct glottal incompetence. Annual Bulletin of the Research Institute of Logopedics, 24, 223-234.