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Voice Therapy
 Symptomatic voice therapy is an approach to work directly on single voice
components, such as pitch, loudness, resonance, or respiration
 Physiologic and holistic voice therapy is an approach to balance the three
subsystems of voice production at once. Examples of physiologic voice therapy
include Vocal Function Exercises, Resonant Voice Therapy, and the Accent
Method of Voice Therapy.
The general goal of voice therapy:
 To rehabilitate the patient's voice to a level of function that enables the patient to
fulfill his or her daily voice and/or speech communication needs.
 To help a client produce a voice of the best possible pitch, loudness, and quality in
relation to the individual's age and gender[1].
 To reduce or eliminate the voice disorder
 To prevent recurrence of the voice disorder
Elements and goals of Voice Therapy
1) To educate the patient about the anatomy and physiology of the vocal system and
how vocal pathology affect the voice production.
2) To modify or eliminate inappropriate hygienic behaviors  Hygienic voice
therapy
3) To modify air pressures and airflow in an attempt to bring about efficient voice
production without unnecessary strain  Symptomatic voice therapy
4) To improve voice production through better vocal folds approximation 
Symptomatic voice therapy
5) To modify functional hypernasality or hyponasality secondary to organic
pathology  Symptomatic voice therapy
6) To reduce laryngeal area muscles tension and effort (vocal hyperfunction) 
Symptomatic voice therapy (Chewing exercise, Yawn-sigh technique, EMG
biofeedback, and Manual Circumlaryngeal Therapy (Digital Massage)).
7) Home practice

Hygienic voice therapy

 To modify or eliminate inappropriate hygienic behaviors
 Hygienic voice therapy is considered as the first step in voice therapy programs.
 These are some examples of poor vocal hygiene behaviors 
o shouting,
o talking loudly over noise,
o screaming,
o background vocal noises,
o coughing,

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o throat clearing,
o poor hydration,
o taking excessive coffee, alcohol, and smoking
o Poor vocal hygiene may also include the habitual use of voice
components in an inappropriate manner[2], which is called functional
vocal behaviors.

 The procedures of the four steps of Vocal Hygiene Therapy:

1. Identify the trauma behavior: 
 The clinician will provide the patient with a behavioral chart to record
all inappropriate hygienic behaviors
 Provide life-style modifications list that help the patient reduce laryngeal
irritation
2. Describe the effects: To educate the patient about the anatomy and physiology
of the vocal system and how vocal pathology affects the voice production.
3. Define specific occurrences
4. Modify the behavior.
5. Hydration
6. Use a warm mist humidifier in your room
7. Build in periods of voice rest
8. Consider amplification
9. Breathe correctly when speaking

Symptomatic Voice Therapy

Techniques
Techniques to reduce laryngeal area muscles
tension and effort:
1) Circumlaryngeal Massage Technique:[3]
 Circumlaryngeal massage is a "hands-on" approach in which patients are trained to
massage their neck area while observing different changes in their voice quality.
 The purpose of this technique is to eliminate pain while speaking, relax muscles in
the laryngeal area, and reduce tension in the upper body – all helping to decrease
pain and allowing the larynx to relax into a more comfortable position.

Indications:
 It is used in patients who report neck tension, upper body tension, stiffness, or
tenderness along with vocal symptoms.
 It is also used for muscle tension dysphonia (functional dysphonia)

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2) Chewing exercises:
 Better vocal fold approximation and optimum muscular adjustment of the vocal
folds are specific physiologic improvements that result from this technique[4].
 The muscular adjustments that are facilitated by the chewing approach usually
result not only in a reduction of hard glottal attack but also in simultaneous
improvements in loudness, pitch, and vocal quality.
Procedures:
Advise the patient that you understand that he or she may feel awkward or silly when
first trying the technique but that the technique is, nonetheless, very useful.
 Have the patient sit facing a mirror. Ask the patient to pretend he or she is chewing
a chunk of cotton candy.
 Tell the patient to chew in a relaxed, open-mouthed, exaggerated manner and to
pretend to move the cotton candy around in the mouth with exaggerated
movements of the tongue.
 Do not rush this stage of the technique and do not proceed until the patient is
capable of producing a natural and exaggerated manner of chewing.
 While the patient is engaged in exaggerated chewing, ask him or her to start
phonating softly. It may be necessary to model this for the patient.
 After the patient has become adept at using a relaxed method of chewing and
phonating, ask him or her to inhale deeply and to chew and phonate the outgoing
air stream. Encourage the patient to let the vocal pitch vary erratically. It is
important for the patient to practice chewing and phonating until a relaxed voice is
produced.
 Next, the patient should be told to simultaneously chew, phonate, and articulate
brief two- or three-word combinations that begin with vowels (e.g., "I am in," "I
am over," "I am up").
 When the patient begins to demonstrate relaxed phonation with short phrases,
additional stimulus materials should be introduced.
 Practice drills should progress to include chewing sentences at various pitch and
loudness levels.
 Daily practice with the chewing technique should continue until the patient begins
to demonstrate diminished laryngeal dysfunction in conversational speech.

3) Yawn-sigh approach:
 The yawn serves to expand the pharynx and to stretch and then relax the extrinsic
laryngeal muscles, thus lowering the larynx in the neck to a more neutral position
and permit a more forward placement of the tongue in the oral cavity.

Procedures:
 Patients are asked to initiate the first half of a yawn behavior.
 The subsequent sigh should then be more relaxed with less tension noted in the
phonation of the tone.
 From the sigh phonation, the patient is taught to appreciate the sensation of
laryngeal relaxation.
 The yawn-sigh technique is then paired with vowels and then gradually expanded
into words, phrases, paragraph readings, and conversational speech.
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4) Biofeedback training:
 The basis of biofeedback is that self- control of physiological functions is possible
with continuous, immediate information about the internal bodily state.
 Electromyographic biofeedback has been used successfully in the rehabilitation
treatment of a wide range of neuromuscular disorders.
 EMG biofeedback training permits patients to monitor electrical activities of their
muscles and to exert some control over these areas.
 This form of biofeedback training has permitted patients to view the tension of the
extrinsic laryngeal muscles and to reduce or increase these tension levels utilizing
auditory and visual feed-back

Techniques to modify airflow (Respiratory

retraining):
1) Therapy approach for Breath support:
 Respiratory Retraining focuses on coordinating breathing with vocalization.
 It is often used in conjunction with the treatment of reflux.
Indications:
1. Talking with decreased breath support
2. Professional speakers who may require greater breath support during
presentation than during normal conversational speech
3. Patients with excessive cough,
4. Paradoxical vocal fold motion disorder,
5. vocal spasm or laryngeal irritation.

Procedures:[5]
1) Ear training: Ask the patient to read a paragraph and tape-record sample of his/her
voice and use it to monitor the patient’s respiration strategy
2) Ask the patient to say as many numbers as possible on one normal expiration and
to stop before any force or strain is evident.
3) Give the patient a paragraph with phrase markers, and ask the patient to read it
aloud with normal inhalation occurring at each phrase marker.
4) The discussion between the clinician and the patient should be audio-taped. Then,
monitor the tape for inappropriate breathing patterns.
5) The patient is asked to monitor his or her voice daily during non-therapy
conversational times.
2) Abdominal/Diaphragmatic Breathing PatternsError! Bookmark not
defined.
 Although the diaphragm is always active during respiration in normally healthy
individuals, some use a greater amount of thoracic or chest breathings during
respiration.
 Chest breathing patterns may be adequate for voice support, although a more
efficient means of breathing for speech can be achieved when the

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abdominal/diaphragmatic movements predominate over other respiratory chest

wall movements.
 The most efficient method of air intake for the support of voice is through the
downward contraction of the bottom the diaphragm
 When the diaphragm contracts downward, the abdomen is forced outward, and the
cavity expands to its maximum extent.
 This expansion permits a greater flow of file air into the lungs. The air may then be
used to better support your voice.
 This technique is simply used to introduce the patient to proper abdominal
movement during respiration.

Procedures:
 The patient is asked to lie down in a supine position.
 Then, a book may be placed on the abdomen while the patient is asked to observe
the natural movement of the abdomen during breathing. As the patient inhales, the
book will rise. The opposite movement will be observed during exhalation.
 The patient is asked to breathe in this manner with out phonation and then
gradually introduce the voice component (vowels, words, phrases, paragraph
reading, and conversational speech.)

3) Lee Silverman Voice TreatmentError! Bookmark not defined.

 Specifically designed for patients with Parkinson's disease, the Lee Silverman
voice treatment advocates increasing the effort with which patients speak – thereby
"pushing" the voice and making it stronger.
 In essence, patients are trained to exhale higher volumes of air out of their lungs,
more forcefully – while simultaneously closing their vocal folds more completely.
The result is a louder and stronger voice.

Indications:
 This regimen was specifically designed to treat voice disorders caused by
Parkinson's disease, but is also being increasingly used to treat vocal symptoms in
other types of neurological disorders.

4) Confidential Voice Therapy:

Goals:
 In confidential voice therapy, patients are trained to produce a soft, breathy voice
without full vocal fold closure.
 It is considered as the First-Line Voice Therapy Regimen During Early Recovery
Period
 The main goal, in fact, of this technique is to allow patients to speak while vocal
fold health improves.
 The patient should use the confidential voice in all speaking situations.
 Then, when the vocal folds have healed, other regimens can be used to bring the
voice back to its full strength, tone, and color.
 Whispered voice is not desirable
Indications:
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 Vocal cord injury

 Vocal muscle tension
Procedures:
 Patients typically use the confidential voice for about two to three weeks; after this
period of time, symptoms such as pain, fatigue, and substantial hoarseness should
improve, allowing more intense therapeutic regimens to be started.

Technique to modify vocal pitch:

5) Therapy approach for vocal pitch:
 There is great controversy among speech pathologists regarding whether a patient's
vocal pitch should be changed when the lowered vocal pitch is due to increased
loading of the vocal folds by mass lesions that are secondary to vocal abase.
 Often, a patient's vocal pitch is not actually lowered, but is perceived as lowered
because of alterations in loudness, vocal effort, and vocal quality
 Unless a patient is phonating in the range of vocal fry or is phonating at a pitch that
makes gender identification difficult, it is probably best not to work directly on
changing vocal pitch.
 Raising the patient's habitual pitch level can be very risky in patients with lesions
due to vocal abuse.
 If the habitual pitch is accidentally raised too high, laryngeal tension will be
increased at a time when increased tension could further irritate already sensitive
vocal folds
 If, after extensive consideration, it is deemed necessary to use techniques to
normalize vocal pitch, the following procedures should be used:

Insturments:
1) A pitch pipe can be used to provide a pitch for the patient to model.
2) Specialized instrumentation such as a Visi-Pitch, Tunemaster III, or a Tonar II can
be used to monitor the patient's pitch level.

Procedures:
1) The patient should be instructed to attempt to sustain the vowel /a/ at the
optimal pitch level.
2) As the patient becomes more skilled at pitch control, a progression from other
vowels to single words phrases, sentences, and monologue should be used until
the new vocal pitch level becomes habitual.

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Physiologic and holistic Voice

Therapy Techniques
6) Vocal Functional Exercises:Error! Bookmark not defined.
 This is a program of systematic exercises that strengthen and rebalance the
subsystems involved in voice production (respiration, phonation, and resonance).
 Exercises include maximum vowel prolongations and pitch glides using specific
pitch and phonetic contexts.
 Vocal functional exercise is necessary to regain the balance among airflow, to this
laryngeal muscle activity, to the supraglottic placement of the tone.
Indications:
 Vocal fold lesions
 Muscle tension dysphonia
 Hypophonia (weak voice)

Procedures:
At home, the patient is taught these four exercises two times each, twice per day,
preferably morning and evening.

7) Resonant Voice TherapyError! Bookmark not defined.

 In brief: Resonant voice (or voice with forward focus) refers to a voice that
resonates or echoes within the face or facial bones. Resonant voice therapy is a tool
that voice therapists use to help patients feel the vibrations of their voices along the
lips, tongue, and nose, and then use those sensations to help better project their
voices. Arthur Lessac, a famous theater coach, first described the resonant voice
therapy approach.

Intended endpoint:
 This approach aims to produce voice with the vocal folds lightly touching rather
than closed tightly – achieving sound volume through resonance.
 The use of humming or chanting is an integral part of this approach

Application group: Resonant voice therapy is now used by vocal therapists to treat a
number of voice disorders, such as muscular tension dysphonia and vocal fold lesions.

8) The Accent MethodError! Bookmark not defined.

In brief: The accent method of voice therapy focuses on improving breathing
technique to increase voice clarity. Specifically, patients are taught to use accentuated
and rhythmic movements in both their pronunciations and in related body movements.
Intended endpoint: Proponents of the therapy suggest that it helps relax the vocal
muscles while also helping to synchronize voice production with a recognizable
rhythm produced by another part of the body.

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While vocal therapists practice the accent method with some degree of variation, in
general treatment takes the form of a therapist asking questions to a patient in a
particular rhythm – and the patient responding in that same pattern.
Accent voice therapy helps patients adjust the timing and rhythm with which they
breathe and accent words.
Some form of additional stimulus may be used, such as a body movement or a drum
or tambourine, to help patients form a series of exaggerated syllables or words.
These exercises progress to longer phrases and eventually sentences. Throughout the
exercises, the accentuated rhythm used during speaking is maintained, while the body
movements and other external stimulus that were used initially are reduced or
eliminated.
Application group: The accent method was developed in Europe to treat many types
of voice disorders. Although some voice therapists in the United States favor its use,
the accent method is more commonly employed in Europe.

Psychogenic Voice Therapy

 Psychogenic voice therapy is based on the assumption of underlying emotional or
psychosocial behavioral causes for the voice disturbance.
 The relationship of emotions to voice production has been well documented in the
literature starting as early as the griddle 1800s to the presents.
 Psychogenic voice therapy focuses on identification and modification of the
emotional and psychosocial disturbances associated with the onset and
maintenance of the voice problem.
 When the psychogenic causes are resolved, the voice disorder dissipates.
 Voice pathologists must develop and possess superior interview and counseling
skills, as well as the skill to know when the emotional or psychosocial problem is
in need of more intensive evaluation and therapy by other professionals.

Work cited
1. Roth, F.P. and C.K. Worthington, Intervention for voice and alaryngeal
speech, in Treatment resource manual for speech-language pathology. 2001,
Singular Thomson Learning: Albany, NY.
2. Stemple, J.C., Glace, L., and Klaben, P.B., Survey of voice management, in
Clinical Voice Pathology: Theory and Management. 2000, Singular Publishing
Group: San Diego, CA. p. 261-273.
3. Voice Therapy: Highlights. In Main Regimens/Techniques. The voice problem
website, 2004.
4. Prater, R.J. and R.W. Swift, Voice therapy management of laryngeal
hyperfunction, in Manual of voice therapy. 1984, Pro.ed: Austin, Texas. p. 116-
117.
5. Stemple, J.C., L. Glace, and P.B. Klaben, Survey of voice management, in
Clinical Voice Pathology: Theory and Management. 2000, Singular Publishing
Group: San Diego, CA. p. 292-294.

Dr.Hani Abdulsattar Shaker

Medical Speech & Swallowing Disorders