1. Lecture 11 Voice Therapy Part 3: Physiologic and Eclectic Voice Therapy Approaches
CD661OL 2014

2. Physiologic Voice Therapy
Organized and promoted by Colton and Casper (1990) and Stemple, Glaze, and Gerdeman (1993)
Aim: modification of the underlying physiology of the voice producing mechanisms: respiration, phonation, resonance
Weakness: does not account for behavior
2. Physiologic voice therapy techniques have become some of the most commonly used therapy techniques to remediate voice problems. The primary aim of these techniques is to modify the underlying physiology of the voice producing mechanisms; respiration, phonation and resonance. It’s only weakness it that it des not account for behavior. Thus, you will have vocal hygiene goals as well.

3. Physiologic Voice Therapy (Stemple, 2000;2014)
Based on our expanded knowledge of vocal function as evaluated through objective voice assessment
Improves balance amongst respiratory support, laryngeal muscle strength, control and stamina and supraglottic modification of the laryngeal tone
Promotes a healthy vocal fold cover
Balances the subsystems to correct disturbances in function
3. Physiologic voice therapies voice have directly alter or modify the physiology of the vocal mechanism. The therapies focus on balancing all of the 3 subsystems involved in voice production; respiration, phonation and resonance. Any disturbance in the physiologic balance of these 3 systems can lead to a voice problem.

4. Physiologic Voice Therapy (Stemple, 2000;2014)
Possible areas of disturbance:
*Respiratory volume, power, air pressure and airflow
*Vocal fold tone, mass, stiffness, flexibility and approximation
*Coupling of supraglottic resonators and placement of laryngeal tone
Cause of disturbance may be mechanical, neurological, or psychological
Management involves direct modification of the inappropriate physiologic activity thru exercise and manipulation
4. Inherent to the physiologic is a holistic approach. These therapies strive to balance the 3 subsystems as opposed to working directly on only single voice components such as pitch or loudness. Any of one of the 3 areas may become unbalanced. Possible areas of disturbance are listed on this slide.

5. Physiologic Voice Therapy Techniques
Vocal Function Exercises (Stemple, 1994 ;2000; Sabol et al., 1995; Pasa et al., 2007; Gorman et al., 2008; Saunder et al., 2010)
Lessac Masden Resonant Voice Therapy (Verdolini et al., 1995;1998;Smith etal., Shen et al., 2007; Schindler et al., 2008)
Accent Method (Smith and Thyme, 1979; Kotby, 1991;1995; 1998; Fex et al., 1994; Bassiouony et al, 1998
Flow Phonation (Gauffin et al., 1989; Sundberg et al., 1993;1994)
Lee Silverman Voice Therapy (Ramig et al., 2001a ;2001b; 2004; Fox et l., 2002; Spielman et al., 2007; Sapir et al.,2006; 2007;2011)
Semi-Occluded Vocal Tract Exercises (Laukannen et al, 2008; ;Titze, 2006; 2007;2009;Nix et al., 2007; Simberg et al., 2007;Sampaio et al., 2008; Guzman et al., 2013)
5. Six commonly used physiologic voice therapy techniques.

6. Strategies for Physiologic Voice Therapy (Stemple).
Vocal Function Exercises
a series of systematic voice manipulations, similar in theory to physical therapy for the vocal folds, designed to strengthen and balance the laryngeal musculature, and to improve the efficiency of the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation
6. Vocal Function exercises were developed by Joseph Stemple and are useful for both hyperfunction disorders, such as phonotrauma and functional disorders, and hypofunctional disorders such as presbylaryngis, vocal fold paresis and unilateral VF paralysis.

7. Vocal Function Exercises
Rationale:
Recalibrates laryngeal mechanics, strengthens laryngeal musculature, restores balance amongst phonatory systems, may improve glottic closure
Protocol: All tasks involve a frontal tone focus
Warm up task – sustained ‘ee’ on pitch w/ extreme frontal focus F4 ♀ F3 ♂
Expansion exercise - pitch glides up on ‘oh’ ‘ol’ or ‘nol’
Contraction exercise – pitch glides down on ‘oh’ ‘ol’ or ‘nol
Power exercises – sustained phonation on five pitches, usually C, D, E, F and G
Application to Hypofunctional Disorders: effective for presbyphonia, paresis and bowing (Stemple, 1994;2000; Sabol et al., 1995; Pasa et al., 2007; Gorman et al., 2008; Saunder et al., 2010).
Application to Phonotrauma and Functional Disorders: decreases medial compression, effective for vocal fatigue
(Roy et al, 2001; Gillivan-Murphy et al., 2006)
7. The physiological rationale is that the exercises recalibrate the laryngeal mechanics and strengthen laryngeal musculature. They may improve glottic closure in cases of hypofunction and decrease medial compression in cases of hyperfunction. Systematic exercise protocol restores balance, laryngeal strength and creates ease of phonation. Frontal tone focus is required and care to avoid hard glottal onsets and absence of muscle tension are essential.

8. Semi-Occluded Vocal Tract Exercises – Straw / tube Phonation in water
Rationale –
Facilitates impedance matching
Increases VT inertance
Generates a ‘back pressure’
Necessitates greater respiratory drive
May increase Bernoulli & increase VF closure for paralysis, paresis and VF bowing
Lowers larynx nnd decreases throat tension
Trains frontal tone focus
(Titze, 2006; Laukannen et al., 2012; 2012; Henrich et al., 2012; Guzman et al., 2013)
8. Impedance is the effective resistance of an alternating current, or in this case the resistance of the vibrated air flow (AC airflow), arising from the combined effects of resistance and reactance (nonresistive component in an AC circuit, again think AC flow).
Or stated another way, it’s ‘the measure of the opposition that a circuit (the vocal tract) presents to a current (the vibrated airflow).’ When we use semi occluded vocal tract exercises we are ‘matching impedance.’ For example, we vary the diameter of the straw / tube according to whether the disorder is hyper or hypo functional. For hypofunctional disorders, we use a wider diameter straw (Boba or smoothie straw) because it matches the incomplete VF closure. For hyperfunctional disorders we use a regular drinking straw or narrower straw because many of our hyperfunctional clients have hyperadduction. Also, these exercises will lower the larynx and decrease laryngeal / pharyngeal muscle tension (MT) whether primary MT or secondary MT.

9. Semi-Occluded Vocal Tract Exercises for Hyperfunction
Regular drinking straws or narrow straws
Glides, ‘revving’ and other pitch patterns, including speech patterns
May also use lip or tongue trills, bilabial or labial dental fricatives, ‘oo’ with narrowed lips in place of straw exercises
9. These are the instructions for the exercises for hyperfunctional clients. See video for details.

10. Semi-Occluded Vocal Tract Exercises – Straw Phonation in water for hypofunction
Use a wider diameter straw (smoothie or Boba)
Fill glass with 2 cm of water
Tasks:
pitch glides
‘revving’
‘speech’
10. This exercise is also known as the ‘cup bubble’ exercise and is also sometimes used for hyperfunctional patients to increase airflow and increase awareness of airflow. Cup bubble is also part of some Flow Phonation therapy approaches. For hypofunctional clients, the use of a straw in water necessitates increased respiratory drive and increased respiratory drive may increase the Bernoulli Effect and aid in increased VF approximation. See video for demo.

11. : Resonant Voice Techniques
Resonant Voice Techniques (Verdolini-Marston et al. 1995) – Used for hyperfunctional or hypofunctional disorders
Goal: decrease hyperfunction, decrease VF medial compression; increases loudness/ability to project
Consists of ‘frontal tone placement,’ uses syllables, words, sentences etc with /m,n,j,r,z/ then generalizes technique to conversation.
11. Resonant Voice Therapy approaches are by far the most common physiologic voice therapy approach and are of benefit to both hypofunctional and hyperfunctional disorders. I use them regularly. Resonant voice therapy has been shown to decrease medial compression, distribute the force of impact more evenly across the entire VF rather than having the bulk of the force directed at the juncture of the anterior 1/3 and posterior 2/3’s of the VFs. The VFs are ‘lightly adducted.’ Resonant voice also increase loudness by increasing the intensity of the middle and upper vocal harmonics by 6-12 dB. This results in a brighter, richer, more resonant voice that projects well without vocal effort.

12. Resonant Voice Techniques: Lessac Masden Resonant Voice Tx
Rationale –
May help with impedance matching in hypofunction (VF paralyis and paresis)
Decreases impact stress for hyperfunctional clients (phonotrauma) and increases intensity / ease of vocal projection
Direct resonatory sensation towards oral cavity, alveolar ridge, cheekbones etc
Begin with humming, cv syllables or chanting
Move towards words, phrases, sentences and conversation
(Peterson et al.,1994; Verdolini-Marston et al., 1995;1998; Titze, 2001; 2004; Smith et al., 2005; Barrichelo et al., 2005;Chen et al., 2007)
12. The Lessac-Marsden Resonant Voice Therapy technique is the most well known resonant voice therapy approach and was developed by Dr. Kitty Verdalini-Marston (voice SLP), Arthur Lessac, a well known acting teacher, and Dr. Mark Madsen, a well known singing teacher. The specific protocol is on Moodle. Also, see the video demo.

13. Accent Method Rationale:
Improves coordination of respiration and phonation
Increases respiratory drive which may increase Bernoulli Effect and increase VF approximation for hypofunction
Decreases medial compression
Teaches flow phonation
Focuses on abdominal breathing, aspirated vocal onset, rhythmic intonation in speech, appropriate pitch and loudness
(Smith and Thyme, 1979; Kotby, 1991;1995; 1998; Fex et al., 1994; Bassiouony et al, 1998)
13. The Accent Method was originally developed by Svend Smith for disorders of both voice and fluency but has become a well known voice therapy technique. It focuses on establishing abdominal breathing, improving coordination of respiration and speech and teaches flow phonation. It is appropriate for both hyper and hypo functional clients.

14. Accent Method Protocol: -Sustained voiceless and voiced consonants
-Sustained vowels
-cv syllables (ha, yay, hay, sa, sho, fa etc)
-Produced with different rhythmic
patterns (short, long, varied)
-Produced while physically ‘moving’ the
body by rocking or can be performed
seated using a drum
14. Here is the basic Accent Method Protocol. See the handout and video on Moodle for full protocol and demos.

15. Lee Silverman Voice Therapy
Developed for patients w/ Parkinson’s
Has been used with patients w/ Cerebral Palsy
Has been used with TBI patients
Has high level of evidence regarding tx efficacy.
Simple and easy to implement
15. Lee Silverman Voice Therapy was developed by Lorraine Ramig for the treatment of voice problems associated with Parkinson’s disease. It’s also been used w/ CP and TBI patients. It’s relatively easy to implement and train. It’s typically delivered in a 4 week period during which the patient comes to therapy 4 days per week. The patient is also required to do very specific homework.

16. Lee Silverman Voice Therapy
The tasks are
Sustained, loud phonation on ‘ah’
Pitch glides up
Pitch glides down
Targeting adequate loudness for functional phrases, sentences, paragraph reading and spontaneous speech.
16. Parkinson’s voice is characterized by monopitch, breathiness and decreased loudness. Loud, sustained phonation on ‘ah ’is the first task and the goal is to sustain ‘ah’ for a given number of seconds at a targeted decibel level, usually between 80 – 90 dB. A good sound level meter or software program that measures intensity is essential for tracking therapy data. Parkinson’s patients do NOT realize they are quiet. In fact, when we get them to produce adequate loudness during speech (67 – 70 db) they often state that they feel like they’re shouting. Therapy involves recalibration of vocal effort and perception in order to be successful.

17. Flow Phonation
Rationale: Increased airflow decreases medial compression of the vocal folds
Focus is on flowing, connected speech & frontal tone focus without constriction, tension or hard glottal attacks
(McCullouh et al., 2012; Gauffin et al., 1989; Sundberg et al., 1993;1994)
Best for hyperfunction but can be used for hypofunction as well.
17. Flow phonation decreases medial compression, decreases laryngeal tension and may eliminate hard glottal attacks when trained properly. The idea of ‘flow phonation’ is really inherent in all the physiologic voice therapy techniques. Whether utilizing resonant voice therapy or vocal function exercises, frontal tone focus and increased airflow resulting in connected, flowing easy speech with no laryngeal tension is the goal.

18. Flow Phonation Protocol: Varies but often includes:
* sustained voiceless & voiced fricatives
* glides and nasal consonant in cv form
* ‘cup bubble’ exercise w/ and w/o voice
* gargle w/ and w/ voice
* blowing – blow an 1 ½” wide x 3” long strip of tissue paper w/o voice and then while producing ‘oo’ and keep tissue paper aloft with breath.
18. Many techniques can be used to achieve flow phonation. Some approaches work better for one person than another. It’s always good to have ‘many tools’ in your tool box ! See handout on Moodle and demo video.

19. Therapy Task Sequence Relaxation Exercises Breathing exercises
Voice exercises
19. Voice therapy tasks are always performed in a particular sequence. During the therapy session, we work on all relaxation exercises first. Whether laryngeal, tongue, jaw, or neck and shoulder, we always do relaxation exercises before anything else. Second, we work on establishing or practicing abdominal breathing. Lastly, when the muscles are relaxed and abdominal breathing is established, then we work on whatever voice technique the patient is learning. Thus, your segment your 1 hour treatment session in exactly this manner.

20. Eclectic Voice Therapy – Hyperfunctional Goal: Decrease medial compression of VFs, eliminate muscle tension, increase breath support
Lessac Marsden Resonant Voice Therapy
Semi-Occluded Vocal Tract Exercises
Flow Phonation
Vocal Function Exercises
Accent Method
Laryngeal Massage
Supraglottic relaxation exercises
Jaw, Neck and Shoulder Relaxation Exercises
Breathing
20. We nearly always do eclectic voice therapy. Recall that eclectic voice therapy involves utilizing 2 or more of the therapy philosophies; hygienic, symptomatic, psychogenic and physiologic. Breathing is usually a part of treatment, as are muscle relaxation exercises. Vocal hygiene counseling and goal setting is also almost always a component of the therapy plan. It’s very rare that I use only one therapy approach. This slide shows you typical tx approaches for hyperfunctional clients.

21. Eclectic Voice Therapy – Hypofunctional Goal : improve glottic closure, increase intensity
Semi-Occluded Vocal Tract Exercises in water
Lessac Marsden Resonant Voice Therapy
Vocal Function Exercises
Accent Method
For secondary compensatory muscle tension –
- circumlaryngeal massage
- supraglottic relaxation exercises
Jaw, Tonue, Neck and Shoulder Relaxation Exercises
Breathing
21. This slide summarizes possible tx approaches for hypofunctional clients.

22. Teach Abdominal Breathing
Breathing exercises for abdominal breathing
Be aware of
breath holding
exhalation before phonation
speaking too long on one breath
inadequate breath replenishment
22. Establishing adequate breath support is very important. Be aware of breath holding prior to phonation, exhalation before phonation, speaking too long on one breath and abdominal but inadequate breath replenishment, i.e. not taking enough air on inhalation.
(Colton et al., 2011)

23. Confidential Voice Casper (1993)
‘Breathy Phonatio’n
Used for a short period of time to decrease medial compression and impact stress
Decreases VF trauma
Best used post – surgery or after severe phonotrauma
Is the softest intensity one can produce w/ some voicing (VF vibration) present
It is NOT whispering !
23. Confidential voice is a breathy phonation that still has some VF vibration. It is not a whisper. It is voice one would use to exchange a confidence w/ a friend when one does not desire to be overheard by others nearby. It is used for -6 sessions, after which the patient gradually reduces the breathiness and increases intensity. At this point, the therapist should focus on vocal focus and resonance using a resonant voice or frontal tone focus approach.

24. Confidential Voice Casper (1993)
Rationale: Glottis remains slightly open, decreased close phase of vibration, absence of laryngeal muscle tension.
24. Confidential voice decreases medial compression and impact stress and is often used post-surgically after 7-10 days of complete voice rest (i.e. NO talking).

25. Post-surgical Care (Behrman and Sulica, 2003; Porton-Maira and Johns, 2013)
Pre-surgery – highly rec. short course of voice tx to
Train adequate breath support
Eliminate any extralaryngeal or intrinsic laryngeal muscle tension
Address vocal hygiene issues
Train post-surgical voice therapy technique
Post-surgery - 7 to 10 days voice rest
Review pre-surgery recommendations
After rest: Begin glides and semi-occluded VT exercises
Train Confidential Voice if needed (decr. medial compression, glottis remains slightly open)
Train Resonant Voice Therapy
25. Voice rest after surgery is essential ! Remember that after surgery there is a VF wound that is healing and the VFs must not collide. Also recall that the vocal folds collide on average 125 times/sec for men and 225 times/sec for women. This is why voice post-surgical voice rest is essential. Most ENTs will recommend a short course of pre-surgical voice therapy to decrease muscle tension if present, establish vocal hygiene goals, teach abdominal breathing and teach post-surgical voice techniques. Post-surgery, therapy may consist of confidential voice therapy, limited range pitch ascending and descending glides (1-3-1 which is do-mi-do or 1-5-1, do-so-do) and resonant voice therapy.