1. Vocal Function Exercises Laryngeal Adduction Exercises
Angie Predmore
Robyn Renwick

2. Purpose
To improve vocal quality
Increase muscle activity

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

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

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

10. 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)

11. 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)

12. 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)

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

14. 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)

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

16. 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)

17. 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)

18. 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)

19. 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).

20. 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)

21. Vocal Function Exercises
“Knoll”

22. 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

23. 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

24. 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

25. 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

26. 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 mL/s of airflow.
Flow volume, mL H2O/100 mL H2O = _______ seconds
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 26

27. 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

28. 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

29. 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 mL/s of airflow.
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006) 29

30. 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

31. 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

32. 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

33. 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

34. 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

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

36. 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,
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,
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,
Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech, Language, and Hearing Research, 41,
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
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),
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,