1. CD661OL 2014
Lecture 9
Voice Therapy Part 2: Symptomatic Voice Therapy, Breathing and Relaxation Exercises, and Vocal Hygiene
1. Lecture 9 Voice Therapy Part 2 Symptomatic Voice Therapy, Breathing Exercises, Relaxation Exercises and Vocal Hygiene

2. Symptomatic Voice Therapy
Developed by Boone
Consists of facilitating techniques
Focus : Modification of deviant vocal symptoms such as breathiness, inappropriate pitch, loudness, inadequate respiration, and hard glottal attacks, etc. will improve the voice.
2. There are many symptomatic voice tx techniques that are very helpful. It’s rare that I don’t use at least 1 of them in the curse of tx, but it’s also rare that it’s the only approach I use. Recall that the weakness of this approach is that the symptom may not be the cause of the disorder.

3. Symptomatic Voice Therapy
Facilitating Techniques
Laryngeal massage (digital manipulation)
Yawn –sigh
Chewing
Easy onset and linking for elimination of glottal attacks
Tongue stretches and supraglottic relaxation exercises
Push – Pull exercises
Chanting
Breathing exercises
Altering habitual pitch and loudness
3. This slide shows a number of tx techniques that may facilitate improved vocal quality. I will provide descriptions and brief video examples of laryngeal massage, yawn sigh, easy onset and linking, tongue and supraglottic relaxation exs., chanting, push-pull exs. and breathing exs. However, altering habitual pitch and loudness are often better addressed through the physiological tx techniques and will be discussed in Lecture 11 Voice Therapy Part 3.

4. Symptomatic Voice Therapy Techniques – Most Common
Techniques to decrease extralaryngeal or supraglottic muscle tension
Techniques to decrease hard glottal attacks
Techniques to increase glottic closure
4. This slide lists three of the most common symptom areas treated with facilitating techniques.
(Boone et al., 2010 )

5. Hard Glottal Attacks
Hard glottal attack - a forceful adduction of the VFs at the beginning of sound production that results in excessive medial compression of the VFs after which the VFs are blow open rather forcefully.
Causes increased laryngeal muscle tension
Pervasive use of hard glottal attacks is higher in muscle tension dysphonia and phonotrauma patients than people w/o a voice disorder (Andrade et al., 2000).
Several tx approaches address hard glottal attacks
5. Hard glottal attacks must be eliminated or decreased in cases of phonotrauma due to the increased medial compression that results from the production of hard glottal attacks. An example of what a hard glottal attack sounds like is provided in the video on easy onset and linking.

6. Voice Treatment : Use of Pre-phonatory Glottal Airflow to Eliminate Hard Glottal Attacks
Easy onset / linking – trains continuous airflow,; links vowels & consonants; eliminate glottal attacks
Yawn-sigh - lowers larynx, relaxes larynopharynx, releases supraglottic squeezing
Chewing technique –Speaking while chewing. disengages laryngeal tension.
Chant talk technique : trains continuous air flow
6. This slide lists four techniques to eliminate or decrease hard glottal attacks. Easy onset and linking and yawn sigh are probably the most commonly used.
Boone et al., 2011

7. Easy Onset and Linking
Easy onset teaches onset of phonation for vowels
heat eat, hold old, hot odd, high eye
Linking teaches easy vowel onset via linkage of the vowel to the preceding consonant
‘red apples’ pronounce as redapples with no glottal attack on the vowel
7. Easy onset involves a soft or slightly aspirated attack on vowel onset. One way to teach this is to train word pairs with /h/ and vowel initial onsets such as ‘heat, eat.’ The idea is to produce ‘eat’ with a soft attack and sometimes training / ‘h’ initial words increases the patient’s awareness of allowing greater airflow and decreased vocal effort. That said, this technique can be difficult for individuals w/ pervasive use of hard attacks. What I find much more effective is ‘linking’. Linking involves launching the vowel off the preceding consonant such as in the example ‘red apples’. This technique encourages continuous airflow and is much easier to learn. I also feel it’s more effective and easier to generalize because when we talk it’s a fairly continuous connected stream of speech so learning to link is highly applicable and easy to learn and generalizes faster than working on single vowel initial words.

8. Yawn – Sigh Technique Can be used with and without the sigh
Instruct patient to:
* relax jaw and gradually open mouth, slowly widening the mouth position
* allow air to flow in and feel posterior oral pharynx widen and stretch as they continue to breathe in
*hold stretch for a moment at top of inhalation and then exhale with or without a sigh
* have zero tolerance for neck, shoulder or facial tension, head must be sitting atop neck, neck and head should not jut forward
8. Yawn sigh is great for lowering the larynx, stretching and relaxing the laryngopharyngeal muscles, opening the supraglottic area and teaching connection of breath with phonation to eliminate hard attacks when used with the ‘sigh’ component.

9. Chant Talk Trains continuous airflow
Initially performed using /m, n/ initial cv forms
Care must be taken in modeling to demonstrate continuous airflow
Start at cv level, move to words, short phrases and then sentences.
Once continuous flow is maintained move to productions w/ natural speech inflections while maintaining air flow.
9. Chant talk is often used as a task in Resonant Voice Therapy which is a physiological technique. Chant talk encourages continuous airflow, connection of speech to the breath stream and the sensation of letting the voice ‘float on the air.’ It’s great for decreasing hard attacks and decreasing vocal effort.

10. Primary Muscle Tension Dysphonia & Secondary Muscle Tension
Assessment via laryngeal, neck and jaw palpation and endoscopy will inform
where muscle tension is located
whether intrinsic or extrinsic or both
Possible Treatment Techniques:
Laryngeal massage Easy onset
Tongue stretches * Resonant Voice
Neck stretches * Semi-occluded VT exs.
Jaw massage * Flow phonation
Supraglottic relaxation exs.
Yawn sigh
10. Primary muscle tension dysphonia is commonly treated with a combination of symptomatic and physiologic voice therapy approaches. Physiologic techniques are marked w/ an asterisk. Please note that these same techniques may be used for secondary muscle tension as well. Secondary muscle tension as a negative compensation due to incomplete glottic closure due to phonotrauma or organic lesions or hypofunction (RLN and SLN paralyses, paresis, presbylaryngis, Parkinson’s and dysarthrias). MUST also be treated and eliminated.

11. Address Extralaryngeal Muscle Tension via
Laryngeal massage
Jaw tension – massage
Tongue – relaxation stretches
Neck – relaxation stretches
Shoulders – relaxation stretches
Progressive relaxation
Ragdoll exercise
11. These are techniques to eliminate extralaryngeal muscle tension. What you use will depend where the muscle tension occurs.
(Colton et al., 2011)

12. Circumlaryngeal Massage (a. k
Circumlaryngeal Massage (a.k.a digital manipulation) see Stemple et al. page 54-55
1. Locate hyoid bone – massage at point of major horns
2. Locate superior cornu of TC - massage
3. Locate thyrohyoid space and massage within it
3. Massage within suprahyoid area
4. Massage along anterior border f sternocleidomastoid muscle
12. Circumlaryngeal massage and digital manipulation are useful and efficacious for the treatment of laryngeal muscle tension. This slide provides simple instructions for a basic laryngeal massage. For instruction for full laryngeal massage see
Of course, we want to teach the client to perform the massage on themselves daily as needed during the course of therapy.
Stemple et al., 2014; Roy and Bless, 1998; Aronson 1997

13. Jaw Massage Techniques
Have pt. massage from top to bottom of masseter muscle with heel of the hand. Tell patient to unhinge jaw and make sure teeth are not touching.
Have pt. massage from top to bottom of masseter muscle with finger tips
Have pt massage from bottom to top of masseter muscle with fingertips while slowly opening mouth as they massage upward.
13. Jaw tension translates quite easily to laryngeal tension. You can assess for jaw tension via palpation but also watch your client speak. Note degree of mouth opening. Does your patient appear to ‘set’ their jaw when they speak? Sometimes simply asking them to relax or ‘unhinge’ their jaw during therapy tasks will result in a noticeable change in vocal quality. This slide provides you with 3 jaw massage techniques to teach your client.

14. Exercises to decrease neck and shoulder tension – see video on Moodle
Head tilt to left towards shoulder, repeat on right
Head turn (rotate) to right, hold, breathe in and turn head a little more
Shoulder rolls front and back
Shoulder ‘crunches’
Torso, shoulder and back stretches
Ragdoll
14. Many times our clients present with mild to severe neck/shoulder tension. This must be addressed as neck and shoulder tension and neck posture can adversely affect laryngeal position and function. See video for demos. Whenever a pt. reports daily pain in neck, upper back or shoulders, a referral to a physical therapist should be made. Daily pain in these areas due to muscle tension is NOT normal. Consult with patient’s ENT or PCP for referral to PT.

15. Endoscopic evidence of laryngeal muscle tension
A-P compression and FVF medialization are indicative of supraglottic tension. Persons w/ phonotrauma lesions and MTD have a significantly greater occurrence of both than those w/o a voice problem (Stager, 2000).
Supralottic squeezing – always a sign of tension.
15. Endoscopic evaluation via nasendoscope or oral scope may reveal intrinsic laryngeal muscle tension in the form of A-P compression, medial-lateral and / or FVF compression and supraglottic squeezing. This tension must be addressed in therapy and eliminated.

16. Decrease intrinsic or supraglottic tension via (see handout on Moodle and video demo)
Yawns – lowers larynx, opens supraglottic area abducts VFs
Tongue stretches – relaxes base of tongue, opens supraglottic area
Slurping spaghetti – round lips and inhale air through rounded lips. This lowers larynx and opens supraglottic area and abducts VFs
Silent laughter – abducts false vocal folds
16. All the techniques listed on this slide decrease intrinsic/supraglottic constriction and throat tension. Tongue stretches provide a twofold benefit; they decrease base of tongue (BOT) tension and open the supraglottic area. Tongue stretches must be done slowly and correctly to obtain maximum benefit, i.e. release of muscle tension. See video for instructions.

17. Ragdoll Exercise See video on Moodle
This is a great exercise for overall relaxation and for training abdominal and lower back breathing
Have pt. stand with feet about 12 inches and a slight bend in knees
Then have them gradually bend over very, very slowly. Have them think of ‘unstacking’ their vertebrae on at a time starting with the head dropping forward and then the neck vertebrae, the back, then bending at the hip, letting arms and head dangle
Have them breathe and relax & hold the position for 45 seconds
Come up slowly with the thought of restacking each vertebrae one at a time. The head should come up last.
Try this ! It’s really great :>)
17. This exercise is wonderful for overall relaxation and for establishing abdominal and lower back breathing. It must be done very slowly. It can also be performed several times in a row fr maximum effects. Watch the video.

18. Breathing Exercises to Establish Abdominal Breathing (see handout and video on Moodle)
A. Sitting & leaning w/ forward forearms on knees B. Standing w/ arms up and crossed over head C. Pavone Exercise D. Sustained /f/ exercise E. Simple verbal instructions F. Lying flat (prone position)
18. VF vibration requires adequate respiratory drive. Thus, inhalation must be adequate to provide sufficient subglottal and airflow for phonation. Abdominal breathing or lateral thoracic breathing (visible or palpable lateral expansion of the ribs) are best. This slide lists a number of breathing exs. All are demonstrated on the video except breathing lying flat.

19. Sitting and leaning forward w/ forearms on knees
See handout on Moodle
In this position, clavicular or shallow breathing can be eliminated
Allows client to feel abdominal wall and lower back expansion during inhalation
Once abdominal breathing is established in this posture, generalize to sitting upright and to standing
19. The handout and video demo will help you with this exercise. I use this one often and it typically works quite well.

20. Arms Over Head Exercise
See handout and video on Moodle
Encourages abdominal breathing and increased lower lateral rib expansion during inhalation
After abdominal breathing is established, generalize to standing with arms at sides and to sitting
20. Again, watch video and look at handout for instructions.

21. Pavone Exercise See handout and video on Moodle
This breathing exercise teaches abdominal breathing and expanded rib posture during inhalation
Also adjusts overall posture, including shoulder and lower back position
Comes from singing pedagogy and yoga
Especially good for singers, actors, teachers, public speakers etc.
21. This breathing exercise was developed by Dante Pavone, a nationally and internationally known singing teacher. Dante had a Master’s in Music, was a licensed SLP and had a doctorate in Voice Pathology. He developed a series of 3 breathing exercises for developing adequate breath support and control for singing and speaking. The exercises are developed out of his knowledge of anatomy and physiology of the breath mechanism, respiratory function during speech and song and yoga. I’ve shared exercise 1 with you because it’s most applicable to abdominal breathing and breath control during speech. The 2nd and 3rd exercises would be most beneficial to singers and actors and are less relevant to conversational speech.

22. Sustained /f/ exercise
Forces an abdominal inhalation
Have patient take in a comfortable breath
Then, have patient produce a sustained /f/ until they are COMPLETELY empty and out of air
Reflex inhalation will be abdominal and patient can easily feel this
22. This is a great exercise for tricking your patient into producing an abdominal breath. It’s usually one of my last resort exercises. The patient MUST sustain the /f/ until they absolutely cannot sustain any longer. This means they must sustain the /f/ beyond the urge to stop and take a breath in. As soon as they stop the sustain, a rapid, reflexive deep abdominal breath occurs because they are truly out of air.

23. Push – Pull Adduction Exercises
Push – pull exercises are used to increase VF adduction in hypofunctional patients, i.e. pts. with VF paralysis, paresis, bowing, presbylaryngis etc.
Pushing palms of hands together or pulling hands apart with fingers hooked together increases as VF adduction.
Push palms of hands together and produce a short staccato vowel or /m/ initial cv syallable
CAUTION: monitor VERY carefully for excessive neck/laryngeal tension and have no tolerance for either or a secondary problem – muscle tension or nodules – may evolve.
23. Push pull exercises have long been used to improve VF closure for swallowing and voice in cases of hypofunction. However, they must be used with caution as secondary laryngeal and neck muscle tension can result if exercises are performed incorrectly. When only voice is being treated (no swallow issues), patient must be monitored for presence of muscle tension and for adequate breath and respiratory/phonatory coordination. They can be useful for ‘jump starting’ the voice when produced correctly, but can easily cause muscle hyperfunction if performed incorrectly. See video for demonstration.

24. Vocal Hygiene
Identify vocal hygiene risks that are specific to the patient
Do not give them a ‘laundry list’ of items that are not specific to them !
Compliance w/ vocal hygiene program is better when program is specific to patient and they understand ‘why.’
See vocal hygiene handouts on Moodle
24. Research indicates, and my personal experiences has verified, that you must identify and treat the vocal hygiene risks that are specific to the patient for good patient participation and compliance . You must have a good understanding of how various vocal behaviors, particularly high risk vocal behaviors, effect the voice and how they may have caused and / or maintained the patient’s vice problem. The patient needs to understand this as well.