AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

Voice therapy encompasses a myriad of techniques employed in the management schema for patients with voice disorders. These techniques may seek to eliminate potentially harmful vocal behaviors, alter the manner of voice production, and/or enhance vocal fold tissue healing following injury. Emerging data suggest that voice therapy is an effective and appropriate method of therapy either in itself or as a compliment to other treatment modalities (eg, surgery, medications).

The particular therapeutic regimen employed for a particular patient is highly variable and based on several key issues including: (1) vocal fold tissue health, (2) vocal demands of the patient, (3) baseline phonatory behaviors, and (4) patient compliance. Once these 4 factors have been evaluated, a customized voice therapy program is developed and contoured to address the vocal complaints and the demands of the patient. For example, a voice therapy program for a 70-year-old housewife is likely to vary significantly from that for a 30-year-old attorney, even in the presence of similar laryngeal appearance.

Simplistically, voice disorders may be divided into the following 3 categories: hyperfunctional, hypofunctional, and dysfunctional. In each of these cases, a vocal fold lesion and/or neurological abnormality may contribute to the voice disorder.      

Hyperfunctional voice disorders, regardless of the presence of a vocal fold lesion, involve increased laryngeal and/or supralaryngeal muscle tension. The goal of therapy for these disorders is to decrease laryngeal and supralaryngeal muscle tension during voice production in an attempt to improve vocal efficiency. A benign vocal fold lesion may likely accompany hyperfunctional voice disorders. Therapy must not only target improved vocal efficiency but also enhanced resolution of the lesion. Evidence is emerging that "exercise" in the broad sense may alter wound healing events and facilitate lesion resolution. Therefore, customized therapies must be designed to treat patients who present with benign vocal fold lesions (eg, nodules, polyps) because these lesions are likely the manifestation of the wound healing response to phonotrauma.

In contrast, hypofunctional voice disorders (eg, unilateral vocal fold paralysis, parkinsonian dysphonia) typically respond to behavioral voice therapy techniques that improve glottal closure or augment vocal tract dynamics to enhance vocal output.¹

Voice therapy is also widely believed to be effective with patients who do not fall into either of the above categories. These patients have a dysfunctional voice disorder (eg, psychogenic dysphonias, conversion dysphonia, puberphonia) in that they are capable of producing a normal voice but do not use the vocal mechanism in a functionally appropriate manner. In addition, several populations of patients may benefit from voice therapy. As described in the following section, a unique form of voice therapy called "respiratory retraining" has been shown to be effective in the management of patients with a condition referred to as paradoxical vocal fold movement disorders. In this condition, the vocal folds inappropriately close during breathing, causing shortness of breath and/or cough. In addition, voice therapy may be beneficial in the transgender population in which the voice must be manipulated to correspond with the patient's gender identity. 

ACCURATE DIAGNOSIS

Section 3 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

A prerequisite to voice therapy is a referral from a voice care team, which typically involves an otolaryngologist and speech pathologist. This referral should evolve from a complete evaluation of the vocal mechanism including rigid and/or flexible laryngeal endoscopy. Stroboscopy may also be indicated for many patients to visualize vibratory motion. This thorough evaluation process permits for the customization of a voice therapy program based on vocal physiology. 

VOICE THERAPY

Section 4 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

Historically, voice therapy involved resting the voice.  The role of voice rest in voice therapy is controversial.  Although many clinicians still recommend decreasing the amount of voice use, the role of complete/silent voice rest is limited.  Furthermore, for many patients, voice rest is not feasible.  For example, 4 weeks of voice rest for an elementary school teacher is often unreasonable. If an inefficient or traumatic manner of speaking is the cause of voice problems, the voice may improve temporarily following voice rest; however, the problems typically return upon resumption of voice use. In addition, teachers and others who use their voices professionally may suffer serious job-related consequences as a result of being placed on long-term voice rest.

In contrast, contemporary voice therapy typically includes several aspects, including the following: (1) educating the patient on normal and abnormal vocal physiology, (2) identifying and minimizing vocally traumatic behaviors, and (3) direct voice work. A comprehensive approach including all 3 components is likely to yield superior outcomes. In addition, as current literature suggests, components of motivational interviewing are likely to increase the success of voice therapy intervention.²

Historically, voice therapy has been divided into 2 categories: indirect and direct therapeutic techniques. A review of each is provided below.   

Indirect voice therapy

Indirect voice therapy is primarily educational. Traditionally, the initial sessions of therapy includes an overview of the following issues:

• Normal vocal anatomy and physiology
• Voice care/vocal hygiene
• • Minimize shouting/yelling.
  • Minimize whispering.
  • Minimize caffeine and alcohol, as they are diuretics.
  • Minimize coughing and throat clearing.
  • Minimize grunting or vocalization during exercise.
  • Do not compete vocally with noisy environments.
  • Eliminate tobacco use and exposure to second-hand smoke.
  • Conserve the voice during periods of excessive fatigue and stress.
  • Eat a well-balanced diet.
  • Keep hydrated by drinking at least 8 glasses of water per day and 1 additional glass for every serving of caffeine or alcohol consumed. For additional hydration because of environmental dryness, humidifiers, steam inhalers, or both are often recommended.
  • Increase awareness of potentially traumatic vocal behaviors, and implement a lifestyle plan that minimizes these behaviors. For example, a teacher may need to alter the teaching schedule to minimize vocal demands. This could be as simple as including more films in the lesson plan, selecting a student to teach the class for a day, or changing the teaching format from lectures to small-group discussions.
  • Minimize laryngopharyngeal reflux through behavioral and/or dietary modifications.

Direct voice therapy

Direct voice therapy involves alteration of a patient's speaking technique in an attempt to increase vocal efficiency and improve voice quality. In addition, as mentioned previously, specific vocal exercises may be prescribed to enhance vocal fold tissue health. Direct voice therapy typically requires 1-2 therapy sessions per week for approximately 6-8 weeks. Exceptions exist, including voice therapy prior to phonosurgery, which is usually limited to several sessions before surgery and resumption of therapy approximately 1-2 weeks after surgery.

A brief synopsis of the most common systematic approaches is provided below. A properly trained voice clinician may use many different voice therapy techniques, merging indirect and direct voice therapy to contour the program that is most likely to yield the highest level of success. In addition, great skill and training are required to use a combination of voice therapy techniques to achieve maximum voice rehabilitation. The types of therapies listed below are not all-inclusive, nor are the descriptions instruction manuals for the inexperienced clinician. Rather, each therapy is a synopsis of the therapeutic model behind that therapy type.

Confidential voice therapy

Confidential voice therapy involves reducing overall loudness of the voice while increasing breathing in order to reduce the vocal fold collision force and to reduce supralaryngeal and laryngeal muscle tension. Usually, confidential voice therapy is indicated following acute vocal fold injury. It is also useful for several weeks following surgery prior to gradually and safely introducing increased loudness.

Resonant voice therapy

Resonant voice therapy involves training the patient to increase intraoral air pressure and is associated with vibratory sensations in nasal and facial bones. It is often used for organic lesions, functional dysphonias, mild vocal fold atrophy, and even vocal fold paralysis. This training is easily achieved by humming the consonant /m/. Resonant voice is produced with vocal folds in a slightly abducted or barely adducted position. This laryngeal posture is favorable for patients who present with laryngeal hyperfunction, hyperadduction (ie, pressed voice), or both. This vocal fold positioning appears to produce the clearest and most prominent voice with little effort and decreased risk of injury.

Vocal function exercises

Vocal function exercises (VFEs) are based on the principle of systematic exercise to increase bulk, strength, and coordination of laryngeal musculature and are used for hyperfunctional and hypofunctional voice disorders. There are 3 steps to the program. Each step is to be completed twice, and the entire program is to be done twice a day. Steps include (1) vocal warmup, (2) pitch glides (high-to-low and low-to-high), and (3) prolonged humming of /o/ at selected pitches. Doing these exercises correctly, using a resonant voice without strain, is imperative.

Accent method voice therapy

Accent method voice therapy can be used for hyperfunctional and hypofunctional voice disorders. It takes a more holistic approach in that it involves whole body movements in order to improve vocal function. Those who support this method report increased pulmonary output, reduced laryngeal muscle tension, and a normalized vibratory pattern of vocal folds during phonation. This therapy is performed by vocalizing rhythmic consonant sounds (called accents), usually in combination with body movements and with stressing respiratory support for each accent. Increasingly complex accents are introduced until carryover to the conversation level is achieved.

Digital laryngeal manipulation

In most cases of vocal hyperfunction, the larynx is in an elevated position. Patients often report generalized neck pain, and, on palpation, focal areas of tenderness can be noted in the area of the thyrohyoid musculature, along the superior ridge of thyroid cartilage, and along the inferior border of hyoid bone. Patients may present with a significantly decreased thyrohyoid space.

The goal of digital laryngeal manipulation is to lower the larynx and to decrease supralaryngeal muscle tension. This is achieved by placing the thumb and forefinger in the thyrohyoid space and massaging in small circles, starting at the anterior aspect of thyroid cartilage and moving posteriorly. Special attention should be paid to any areas of more intense focal pain.

This technique may yield only temporary improvement in voice, but it gives patients some biofeedback and a technique that they can use themselves. Digital laryngeal manipulation is indicated in any laryngeal condition involving excess muscle tension (eg, muscle tension dysphonia), but it may also be effective for patients with organic lesions who have developed compensatory excessive muscle tension due to glottal incompetence.

Lee Silverman voice treatment

Lee Silverman voice treatment (LSVT) is the most researched voice therapy protocol.³ LSVT was developed to address hypokinetic dysphonia associated with Parkinson disease (PD). LSVT is a very systematic approach to voice therapy and is prescribed for 4 consecutive weeks at 4 sessions a week for optimal results. The primary goal of treatment is to increase overall loudness with little or no attention paid to other communication deficits commonly associated with PD (eg, dysarthria).

Within each of these more systematic treatment protocols, 4 major aspects of voice production must be addressed if they are problematic. SLPs must recognize and rehabilitate any of the following: (1) aberrant respiratory patterns, (2) pitch variation, (3) oral muscle tension, and (4) abnormalities of onset of voicing. In many cases, the patient must be trained in proper abdominal breathing. Ideally, little clavicular movement should occur on inhalation; instead, abdominal motion should be used to facilitate adequate and efficient breaths. On exhalation, abdominal contraction is optimal to facilitate adequate subglottal pressure in order to minimize laryngeal constriction.

Voice therapy must also address the pitch of the voice. Often, patients must become reacquainted with their natural pitch. A patient speaking at an unhealthy pitch is placing unnecessary strain on the vocal musculature; this can either cause or worsen the problem. Patients who are unable to hear or feel appropriate pitch of their voice may benefit from some sort of biofeedback therapy. This can be as simple as recording the patient's voice and replaying it so that the patient can listen to the degree of vocal dysfunction, or it can consist of more complex computer-based systems that can provide a means of visual feedback with regard to pitch or numerous other voicing parameters.

Identifying any excess muscle tension in the oral cavity is also vital. Excessive buccal, lingual, and mandibular tension is not necessary and can have a negative effect on voice by increasing laryngeal height and by encouraging laryngeal hyperfunction. Patients must become aware of this tension and must be given exercises to alleviate it.

The act of initiating the voice can be potentially harmful. Many patients present with a hard glottal onset, which involves an abrupt attack of vowel sounds that use high subglottic pressure. Initiating sound with such a high intraglottic contact force can lead to increased laryngeal hyperfunction and often vocal fold pathology.

Respiratory retraining

Respiratory retraining focuses on coordinating breathing with vocalization. This technique has been shown to be useful for patients with excessive cough, paradoxical vocal fold motion disorder, vocal spasm, or laryngeal irritation. It is often used in conjunction with the treatment of reflux.

INDICATIONS FOR BEHAVIORAL VOICE THERAPY

Section 5 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

Functional voice disorders

Functional voice disorders are characterized by the presence of vocal symptoms without anatomical laryngeal abnormality. Muscle tension dysphonia (MTD) is the most common disorder in this category. Most literature suggests that a course of indirect and direct voice therapy is very effective in decreasing laryngeal hyperfunction associated with MTD (see Voice Therapy for therapeutic techniques for MTD).

During evaluation, it is often helpful to determine if the patient is able to improve voice quality with trials of direct voice therapy techniques. This is a strong indicator of future voice therapy success. However, the longer the patient has had dysphonia, the more guarded the prognosis for success with therapy. Psychogenic dysphonias, such as conversion dysphonia, also fall into the category of functional voice disorders. Combinatory therapy with a trained SLP and a mental health specialist is believed to treat these disorders effectively.

Organic vocal fold disorders

Organic vocal fold disorders include, but are not limited to, vocal fold nodules, cysts, and polyps. Vocal nodules are small, commonly bilateral lesions of the superficial layer of lamina propria, usually located at the junction of the anterior third and posterior two thirds of membranous vocal fold. Voice therapy is usually the sole treatment indicated for vocal nodules if they are not long-standing in duration and not extremely fibrotic in nature.

Cysts and polyps are also lesions of the superficial layer of the lamina propria. Phonomicrosurgery and voice therapy are usually indicated in the treatment of cysts and polyps. Voice therapy is indicated prior to and following surgery and can improve the outcome. In these cases, voice therapy combined with surgery is thought to decrease the likelihood of lesion recurrence due to poor vocal technique and vocal misuse.

Neurological voice disorders

Neurological voice disorders can often affect a patient's voice. The most common disorders resulting in dysphonia include PD, essential tremor (ET), and spasmodic dysphonia (SD). LSVT has been demonstrated to be effective for treating the communication disorder associated with PD. Treatment is intensive, requiring 4 sessions a week for 4 weeks. The purpose of treatment is to increase loudness, and in addition to improved voice, patients may develop increased respiratory output, decreased glottal incompetence, improved articulatory precision and mobility, and improved overall intelligibility. In follow-up studies, LSVT has been shown to be effective without continued treatment for 3-5 years.

Spasmodic dysphonia is a focal dystonia affecting the laryngeal musculature, most commonly treated with localized injections of botulinum toxin A (BOTOX®). These injections temporarily weaken the muscles, thereby decreasing dystonic laryngeal muscle activity. The duration of weakness varies from patient to patient and often from injection to injection. Murry and Woodson (1995) suggested that behavioral voice therapy used in combination with BOTOX® injection therapy increases the effectiveness and duration of the BOTOX® therapy.⁴

Unfortunately, there is little literature concerning the efficacy of voice therapy with other neurological disorders. Patients with vocal tremor are often referred for voice therapy. Patients need to be informed that while speech language pathology may improve voice, tremor or other neurological symptoms are not commonly resolved with voice therapy alone; therefore, medical treatment may be indicated. Voice therapy may help the patient compensate for the neurologic problem and improve other components of voice that are not directly affected by the disorder.

Vocal fold immobility

Success of voice therapy in patients with unilateral vocal fold immobility is dependent on the position of the paralyzed vocal fold, the remaining vocal fold bulk, the tension present in the immobilized fold, the duration of the disorder, and surgical correction if performed. Patients with a paralyzed vocal fold in a medial position are more likely to have successful therapy than are patients with an immobile vocal fold in a lateral position.

Historically, voice therapy for vocal fold paralysis involved rigorous pushing/pulling exercises, which actually induced laryngeal hyperfunction. Resultant hyperfunction is often more detrimental to the patient's voice than the paralysis itself. These types of pushing/pulling exercises have no role in modern voice therapy. Vocal function exercises, resonant voice therapy, challenge therapy (modified LSVT), postural/position alterations, or a combination of these are indicated. In cases in which the paralyzed vocal fold is extremely lateral (>3 cm), voice therapy usually follows surgical correction.

Paradoxical vocal fold movement disorder 

PVFMD is a poorly understood disorder that involves inappropriate closure of the vocal folds during respiration. Patients may report dyspnea, cough, or globus sensation. As described above, a combined modality treatment involving respiratory retraining and reflux therapy appears to be an effective treatment option.

CAVEATS OF VOICE THERAPY

Section 6 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

Voice therapy should only be performed by a licensed speech pathologist with training in voice disorders. Many speech pathologists focus on one area of treatment, such as aphasia, dysarthria, dysphagia, cognition, or voice. Referring a patient to a speech language pathologist (SLP) with little experience or interest in voice is not favorable for therapeutic success. 

Voice therapy is individualized. Every patient presents with a completely different syndrome, regardless of the physiology. Individual therapists may approach the same disorder very differently but still achieve the same level of success. However, not every patient with a voice disorder is successful in therapy. The success of therapy is dependent upon many factors, including patient compliance.  

SUMMARY

Section 7 of 8  

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

Voice therapy is an essential component of treatment for many patients with voice disorders. In many cases, voice therapy is the primary treatment recommended for many patients. This article is far from a comprehensive review of all voice therapy techniques, but rather a cursory outline of some of the more salient issues involved in the therapeutic process. Voice therapy is individualized; the type of therapy can vary greatly from patient to patient and from clinician to clinician with similar levels of success. In conclusion, when performed by a certified speech language pathologist (SLP) with specific training and experience in voice disorders, voice therapy can be effective in helping many patients with voice disorders.  

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Accurate Diagnosis
• Voice Therapy
• Indications for Behavioral Voice Therapy
• Caveats of Voice Therapy
• Summary
• References

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3. Behrman A. Facilitating behavioral change in voice therapy: the relevance of motivational interviewing. Am J Speech Lang Pathol. Aug 2006;15(3):215-25. [Medline].
4. Murry T, Woodson GE. Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy. J Voice. Dec 1995;9(4):460-5. [Medline].
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7. Colton RH, Casper JK. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. 2^nd ed. Baltimore: Williams & Wilkins; 1996.
8. Dromey C, Ramig LO, Johnson AB. Phonatory and articulatory changes associated with increased vocal intensity in Parkinson disease: a case study. J Speech Hear Res. Aug 1995;38(4):751-64. [Medline].
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10. Bassiouny S. Efficacy of the accent method of voice therapy. Folia Phoniatr Logop. 1998;50(3):146-64. [Medline].
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12. Ramig LO, Countryman S, O'Brien C, Hoehn M, Thompson L. Intensive speech treatment for patients with Parkinson's disease: short-and long-term comparison of two techniques. Neurology. Dec 1996;47(6):1496-504. [Medline].
13. Ramig LO, Pawlas AA, Countryman S. The Lee Silverman Voice Treatment: A Practical Guide for Treating the Voice and Speech Disorders in Parkinson Disease. Iowa City: National Centre for Voice and Speech; 1995.
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16. Sapir S, Spielman JL, Ramig LO, Story BH, Fox C. Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson disease: acoustic and perceptual findings. J Speech Lang Hear Res. Aug 2007;50(4):899-912. [Medline].
17. Schindler A, Bottero A, Capaccio P, Ginocchio D, Adorni F, Ottaviani F. Vocal improvement after voice therapy in unilateral vocal fold paralysis. J Voice. Jan 2008;22(1):113-8. [Medline].
18. Speyer R. Effects of Voice Therapy: A Systematic Review. J Voice. May 15 2007;[Medline].
19. Stemple JC. Clinical Voice Pathology. New York: Macmillan; 1984.
20. Stemple JC, Lee L, D'Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice. Sep 1994;8(3):271-8. [Medline].
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Article Last Updated: Jan 17, 2008