Voice Therapy

Symptomatic Voice Therapy
-Treat the symptoms
– Focuses on the premise that most voice disorders are based on misuse of pitch, loudness, respiration, therefore, Boone developed his “facilitating approaches”

Psychodynamic Voice Therapy
– Treat the person
– Focuses on treating the underlying psychological components (self esteem, emotional problems, interpersonal relationships)

Etiologic Voice Therapy
– Treat the causes
– Focuses on treating the causes of the voice problem (i.e. misuse/abuse/overuse/hygiene)

Physiologic Voice Therapy
– Treat the system
-Focuses on directly modifying the function of the laryngeal musculature and respiratory support to alter the patient’s current use of these subsystems
– Based on exercise physiology (warmup, cool down and repetitive trials)

Eclectic/Holistic Voice Therapy
– Treat it all
– Utilization of many different approaches to find the most individualized treatment for your patient.
– This is what most therapists do

Long Term Goals of Voice Therapy
– To optimize function of the larynx
– To eliminate pathology
– To produce optimal voice quality
– To rebalance the sub-systems of respiration, phonation and resonance

Patient Education and Counseling
– Goal: Help pt. understand how voice is created and what their particular problem is
– How:
– Instruction in A&P of vocal mechanism
– Discuss role of 3 subsystems (respiration-power for voice, phonation- source for voice, resonance- modifier for voice)

Vocal Hygiene Counseling
– Goal: Create the best possible environment to achieve vocal fold health
– How:
– Hydration- Reduces friction of VF, helps VF vibrate w/ least amt. of effort, helps protect VF from injury, helps to reverse existing injury)
– Lubrication- use personal steam inhaler, shower steaming, room air humidifier (helps protect the VF during phonation)
– Vocal Rest- complete or modified

Elimination of Vocal Misuse/Abuse
Goal: Eliminate contributing and maintaining factors to allow for healing and improve overall vocal quality
-Identify instances of misuse
-Identify instances of abuse
-Educate patient on the effects of their specific types of misuse/abuse (Smoking, alcohol consumption, caffeine consumption, yelling, screaming, consistent use of a loud voice, hard glottal attack, habitual throat clearing, coughing)
-Create guidelines specific to that patient
-Discuss ways to achieve success
-Discuss ways to modify their environment

Management of GERD and LPR
Goal: Reduce/eliminate episodes of GERD/LPR to prevent vocal fold damage/irritation
-Educate your patient about GERD/LPR
-Discuss medical management and compliance with medication
-Review Do’s and Don’ts
-Strategize difficult scenarios to improve compliance and success

Tension Reduction Exercises
-Goal: Reduce laryngeal & extra-laryngeal tension because excessive tension reduces vibration and increases duration and force of adduction
-Describe and demonstrate stretches for neck, shoulders, back, jaw, tongue, lips, soft palate, respiratory muscles
-Progressive muscle relaxation techniques
•Guided contraction followed by relaxation
-Relaxation Response Breathing (Dr. Benson)

Vocal Warm-Ups
•Goal: To relax laryngeal musculature and balance use of the 3 sub-systems
-Often referred to as “Throat Openers”
-Lip Trills
-Musical Scales
•Create regimen for each patient as therapy progresses
-Focus on the exercises that bring about best vocal quality with least effort
-Begin instruction in self-awareness, self-analysis, internal biofeedback

Frontal Tonal Exercises
•Goal: To improve tonal focus thereby reducing impact on vocal folds. Takes focus away from the vocal folds.
-Sounds, phrases, words, sentences with nasal laden sounds
-Sensing vibration in face/nose/lips/anterior palate
-Laryngeal tonal focus v. Orofacial tonal focus

Lower Thoracic Abdominal Breathing/ Respiratory Training
•Goal: Establish efficient and adequate breath support for voice utilizing appropriate musculature
-Exercises focusing on using the lower thoracic abdomen (i.e. diaphragm) v. strap/shoulder muscles for breathing
-Relaxed breathing
-Breath is the “power”
-Unimpeded airflow for optimal voice production
-Reduce speech on residual

Easy Onset Phonation
•Goal: To eliminate hard glottal attacks during speech production as these can injure the vocal fold mucosa
-“Ease” into vowel initiated words
-Add an aspirate quality
-Practice throughout hierarchy

Chant Talk
•What is it?
-“Singing monotone”
-Smooth and connected – legato
-Elevated pitch, prolonged vowels, lack of syllable stress, reduced glottal attack
-To reduce laryngeal strain
-To improve breath support
•In therapy, progress to alternating chant talk with regular voice (20 seconds each) to encourage carry-over
•Record the patient and discuss the acoustic/perceptual differences between the two methods
•Reduce the chanting

Chewing Technique
•What is it?
-Increased mouth opening via exaggerated chewing action (both horizontal and vertical)
-To reduce laryngeal hyperfunction
-To reduce tension in the articulators
•In therapy, have patient engage in exaggerated open-mouth chewing (imagine several crackers or huge gum ball), followed by light voicing of nonsense words while chewing, followed by counting, then words, phrases, and sentences, with progressive decline in chewing action
-Use mirror feedback
•By the end, patient is told to “think chewing”

Confidential Voice
•What is it?
-Use of a soft and breathy voice with reduced rate and reduced vocal fold adduction (think Marilyn Monroe or telling someone a secret)
•Light voice – NOT whispering
-Reduces glottal strain
•In therapy, demonstrate confidential voice. Describe and explain the benefits. Then assign reading tasks and spontaneous speech tasks, and ultimately voice use with confidential voice

Digital Manipulation
•What is it?
-Applying pressure to the thyroid cartilage
•Goals (3 distinctly different goals for different patients):
-Reducing excessive tension (and concomitant laryngeal elevation)
-Reducing pitch (puperphonia)
-Reducing breathiness due to unilateral vocal fold paralysis or paresis

Circumferential Laryngeal Massage
•What is it?
-Massaging the larynx via gentle external manipulation
-To reduce laryngeal and extralaryngeal tensions
-To lower the position of the larynx
•Initially developed by Aronson

Inflection Training/ Increasing Vocal Melody
•What is it?
-Exercises aimed at increasing the amount of pitch variability in speech
-Decrease monotone pitch
-Decrease glottal fry
-Decrease voiced and voiceless pitch breaks
-Decrease oral and pharyngeal tightness
•In therapy, discuss the purpose of intonation when communicating (different meanings), and importance of holding the listener’s interest. Practice short phrases and discuss changes in meaning, practice with rote phrases, counting exercises, gradually moving towards conversational speech.

Vocal Function Exercises
-To improve vocal fold strength and flexibility
-To rebalance the sub-systems
•What is it?
-Systematic glides and sustained vowels

Lessac-Based Resonant Voice Therapy
•Developed by Kitty Verdolini and based on Dr. Arthur Lessac’s voice work in the theatre arts
•For patients with many types of conditions: vocal fold lesions, paresis/paralysis, bowing, and functional voice problems
•Goal: to achieve the “cleanest” possible voice with the least amount of effort and impact between the vocal folds.
•Systematic program once per week for 8 weeks
•Each session involves work on “basic resonant voice training gesture,” a specific type of humming and then application to functional phrases

Lee Silverman Voice Therapy
•Developed by Dr. Lorraine Ramig
•For persons with voice and speech problems secondary to Parkinson’s disease
•Also used for patients with other neurological disorders which result in weak vocal folds
•Very specific, intensive treatment that emphasizes “think loud!”
•Four days per week for four weeks
•Practice loud sounds and functional phrases
•Patients are taught to “recalibrate” a new loudness
•Has the greatest number of efficacy studies of all types of voice therapies.