Voice Therapy: Does Science Support the Art? Lisa B. Thomas and Joseph C. Stemple University of Kentucky Lexington, Kentucky ‘Three primary orientations to the treatment of functional voice disorders have emerged in the lit erature. Hygienic approaches focus on the elimination of behaviors considered to be harmful to the vocal mechanism, Symptomatic approaches target the direct modification of aberrant features of pitch, loudness, and quality Finally, physiologic methods approach treatment holistically as they ‘work to retrain and rebalance the subsystems of respiration, phonation, and resonance. With the va- riety of approaches now available, selection of appropriate and effective techniques can be chal- lenging for cinicians-The purposes of this review are to:(1) describe various hygienic, symptomatic, and physiologic approaches to voice treatment, (2) investigate the evidence base behind the thera. peutic approaches, (3) draw conclusions regarding the relative strength of hygienic, symptomatic, and physiologic therapies,and (4) suggest directions for furure study, Introduction ‘Over the years,a number of techniques have emerged for the treatment of functional voice disorders, Some ‘methods have emerged from our sister feld, the vocal arts, others from the scientific study of Voice production, and still others from the modification of basic vegetative functions What is more, ome methods have approached voice treatment holistically by modifying the full speech production system, whereas others have treated via pa: tient education or through the retraining of a specific voice parameter The result has been the emergence of 4 broad, and ever expanding, inventory of voice thera- ‘PY methods. This growth, although exciting, has posed a ‘unique challenge to clinicians.The voice clinician of to- day must not only be knowledgeable of available meth Communicative Disorders Reve ‘Volume 1,Number 1, pp.49-77 Copyright © 2007 Pra Publishing, Ine ‘ods, but he or she must aso appreciate the evidence-base behind each.This can be a daunting task to the clinician ‘who is attempting to stay abreast of developments across the breadth of the field Therefore, the purpose of this re- view is to provide clinicians with an overview of voice therapy methods across a variety of treatment orienta: tions and establish the level of evidence supporting each method. Ta so doing, the review will assist clinicians in preparing appropriate and effective treatment programs {for the individuals whom they serve, Evolution of Research ‘The first attempts to examine the effects of voice therapy methods can be identified as far back as the 950 _ COMMUNICATIVE DISORDERS REVIEW.VOL, 1,NO.1 1940s Croeschels, 1943; Feacher & Holinger, 1947). It ‘was not, however,untl the 1970s that consistent calls for ‘outcomes research inthe field were expressed. In 1971, Paul Moore, speech scientist and speech language pa. thologist, considered the voice therapy literature and de- termined that the field of voice therapy sulfered froma Jack sufficient scientific support. Furthermore, he con: cluded that many methods used in voice therapy were chosen, not because of scientific evidence, ut because of clinician preference.As 2 result, Moore proposed that voice therapy remained primarily an art, without suff- In 1952, Froeschels agnin presented the chewing method and shared its benefi in. eases of mutational voice, hyperfunctional voice, and “deaf” voice. Again, he conciuded that the chewing method was beneficial in ‘returning the voice to norma in all three cases (Level ¥). Finally, Brodnitz. and Froeschels (1954) examined the use of chewing in six individuals with vocal nod- ules. Voice quality and vocal fold appearance were con- sidered prior to and following therapy with the chewing ‘method According to the authors, five ofthe six cases of noglules Were corrected with the use of the method.The authors concluded thatthe technique was successil in treating nodules, it reduced pitch and muscle tension during voice production. Since early descriptions ofthe chewing method, variations of the chewing approach have appeared in other classic voice texts (Boone, 1971; Colton & Casper, 1990;Van Riper & Iewin, 1958); how. ever, outcomes studies related to the chewing method hhave not been produced inthe literature since the afore- ‘mentioned works of the 1940s and 1950s (LeveV). ‘Yawn-Sigh. The yawnsigh approach was presented as one of Boone's (1971) original 20 facilitating meth. ous. According to Boone, production of a yawn Worked to open and relax the pharyngeal cavity. Boone hypoth sized that performing a yawn just prior to phonation ‘would yield phonation inthe context ofa relaxed vocal tract Tins the yawensigh method took advantage of a vegetative function to bring about a more relaxed man: ner of voice production. VOICETHERAPY 61 ‘One of the first discussions of the yawnsigh meth- od in the literature was by Brewer and McCall (1974). ‘The authors reviewed three symptomatic voice therapy ‘methods via the presentation of case studies. One case study involved use of the yawnsigh method with an in dividual with ventcicular phonation. Laryngeal exami- pation verified that the yawn-sigh maneuver eliminaced ventricular fold closure; however, the corrected man- net voice production was not generalized to connect ed speech (Level V). Interestingly, McFarlane (1988) also ‘considered the yawn-sigh as one clement of a treatment ‘program for ventricular phonation. McFarlane reported elimination of the ventricular voice following 25 treat: _ment sessions where a combination of yawn-sigh and in- Inalation phonation was applied (Level V) A third examination of the yawnsigh approach was completed in 1993 when Boone and McFarlane exam- ined the physiologic underpinnings of the approach, Fight adults without histories of voice disorders were asked to produce a yawn followed by a sigh. Measure- ‘ments of acoustic output and pharyngeal dimensions ‘were taken during the productions.,The authors ident fied a lowering of the larynx in the neck as well asa wid- ening of the pharynx during the yawn-sigh maneuver. No changes in fundamental frequency were observed however,a lowering of the second formant and a depres sion of the third formant were observed in most cases, The authors concluded by theoretical implication that the yawnsigh would be useful for cases of vocal hyper- function, as it moved the vocal tract into a more relaxed position (Level ¥) Most recently, Xu, Ikeda, and Komiyama (1991) ex- amined a related approach termed the yawn breathing pattern, Ninety-one subjects with varying voice diagno- ses were enrolled in the study. Subjects engaged in 10 ‘outpatient treatment sessions where they received train. ing in how to use a yawning breath pattern to facilitate ‘normal voice production. Subjects were given visual bio- feedback regarding their respiratory kinematics during their yawning breaths. According to the authors, 94% of ‘cases Were able to successfully perform the yawning ma- neuver at the close of therapy: However, subject selfrat- ings of improvement in voice with treatment suggest ced that only 37% reported satisfactory improvement and 57% reported fir improvement following treatment. The authors identified that those subjects reporting satisfac- ‘ory improvement also demonstrated improvement in laryngeal condition as well as improvement on acoustic and aucltory-perceptual measures of voice. Subjects re- porting lower degrees of satisfaction with the treatment method did not demonstrate similar degrees of change fon the above measures. The authors concluded that use of the yawning method along with visual feedback on62 _ COMMUNICATIVE DISORDERS REVIEW.VOL,1,NO.1 respiratory patterns is an appropriate method of voice treatment (Level IV), Feedback. The use of feedback in various forms for the correction of voice problems has been proposed for some time (Boone, 1971:Van Riper & Irwin, 1958). Eaaly uses of feedback were rudimentary, requing the pa- tient to cup his or hands to the ears to enhance auditory ‘monitoring of the tone (Van Riper & Irwin, 1958).Since that time, however, technologie advances have allowed for additional methods of auditory and visual feedback Several studies have examined the benefit of feedback for enhancing progress in therapy. [Atleast four studies have examined the use of sur- {ace electromyography (EMG) 382 form of feedback for ‘vocal hyperfunction (Andrews, Warner, & Stewart, 1986; Prosek, Montgomery, Walden, & Schwartz, 1978; Stem ple, Weiler Whitehead, & Koray, 1980; iu, Verdolini, & CChow,2005).Prosek et al 1978) used EMG with a group ‘of subjects of varying diagnoses, including: vocal nod: ules, spasmodic dysphonia, contact ulcer, traumatic la yngitis, and laryngeal carcinoma ¢postumor removal) ‘Three of sx subjects using EMG biofeedback saw reduc- tion in EMG activity after 14, 30-minute treatment ses- sions.The other three individuals receiving biofeedback did not demonstrate changes. The authors concluded that EMG may facilitate motor relearaing in some, but snot all, cases of vocal hypesfunction (Level IV) Stemple etal, (1980) enrolled 21 normal subjects and seven subjects with vocal nodules ina study of EMG biofeedback. Baseline measures of all subjects indicated higher levels of muscle activity at rest and during voice production for subjects in the vocal nodule group. Sub- jects diagnosed with vocal nodiles underwent cight, 45-minute treatment sessions using EMG biofeedback. At the close of therapy, subjects with nodules demon- strated a significant reduction in tension during voice production (F = 2.32; p <0.05) and at rest (F = 5.67; <0.001), Furthermore, 86% of subjects saw improve ment in auditory perceptual ratings Voice, while five of six saw improvement on laryngeal examination post therapy-The authors concluded that EMG was an appro- priate biofeedback method for the treatment of voice disorders Level IV) Andrews, Warner, and Stewart (1986) compared the effects of surice EMG and progressive relaxation on in- viduals with hyperfunctional voice disorders. Ten fe- ‘males wit hyperfunctional dysphonia were divided in- to five matched pairs. Individuals within the pairs were alternately assigned to receive ether the EMG treatment ot the progressive relaxation treatment. Electromyo- graphic treatment involved the placement of a surfice electrode in the region ofthe cricothyroid muscle. Sub jects monitored the degree of muscle tension by obser vation of needle movement on the EMG unit. The pro- sressive relaxation treatment began with the creation of 4 calm attitude and progressed to the point of selfxelax- ation. The numberof treatment sessions ranged fom 4 to 15, Results showed that both EMG and progressive relaxation reduced the degree of muscle tension in the Jaryngeal region duiring phonation, Furthermore, both treatment methods yielded improvements in voice qual ty,vocal control and selfrated severity. No significant dit ferences were found between the two treatment meth ‘ods.The authors concluded the surface EMG was useftl in the management of vocal hyperfunction (Level I. Most recently Yiu, Verdolini, and Chow (2005) at- tempted to refine the field's knowledge in the area of EMG. Specifically the authors set forth 0 determine ‘which type of surface EMG biofeedback—concustent or terminal—was most advantageous in producing re- loxed laryngeal musculature. Twenty-two subjects Were divided into a concurrent feedback group and a termi- nal feedback group. Subjects in the concurrent feedback. group received realtime displays of musele activity from the thyrohyoid area and the orofacial region (control) uring speech production. Subjects inthe terminal feed- back group received feedback from the aforementioned sites only upon completion ofan utterance. Results dem onstrated no clear difference between the two types of EMG feedback. Furthermore, the authors found no evi dence of reduced musce activation in the laryngeal area With eitber feedback types. In an interesting, and unan- ticipated finding, the authors identified a reduction in muscle activity atthe oroficial control site The authors hhypothesized that the high degree of focused attention oon the laryngeal site during biofeedback training may have limited motor learning in that area, although allow. ing for incidental learning in other areas.The study sug gested that continued work must be done to examine ‘the motor learning effects of biofeedback approaches Gevel 1D, Other authors have examined the use of acoustic and aerodynamic feedback for voice management. Yarna- such et al, 1986) conducted an early study examining the use of visual feedback of airflow and acoustic da ta in the management of vocal nodules Twenty females ‘with vocal nodiles obtained visual feedback of airflow fate, pitch, and intensity from the phonolaryngosraph, ‘The usefulness of the approach was determined by pre- to posttreatment comparisons of laryngeal appearance. Findings demonstrated that nodules were reduced or eliminated in 65% of cases ater 3 10 4 months of bio feedback training, The authors conctuded that visual feedback would be an appropriate nonsurgical interven tion for vocal nodules (Level). More recently, Laukkanen, Sra, Latala, and Leino (2004) conducted a randomized control trial compar. ing therapies using visual feedback of spectral data toconventional therapies without feedback. Twelve act ing students were divided into experimental (biofeed back) and control (traditional) groups and monitored for their ability to acquire a targeted manner of voice production labeled a"ringing" voice. Subjects in the con trol group were provided with a verbal description and ‘model of the target voice; subjects in the experimen: tal group received the aforementioned guidance along With visual feedback of longterm average spectrum da- ‘a, Both groups saw improvement in voice quality as well as enhancement of spectral energy atthe 3 t0 5 kftz range. Fundamental frequency (,) changes varied across groups, with the biofeedback group seeing an in- crease in F, and controls seeing a decrease. Finally, the biofeedback group saw sigaificanly greater ceductions in the relative dB than did the control group. The au- thors concluded that the study provided support or the use of biofeedback as an adjunct to conventional forms of treatment (Level Tn a 1988 study, Bastian provided one of the earl- st cals for the use of laryngeal videostroboscopy as 2 therapeutic feedback tool Ar least two studies have ex- amined the benefit of realtime laryngeal visual feedback on therapy outcomes. In 1987, D'Antonio, Lotz, Chait, and Netsell presented the case of a 22-year old female status—post a crushing injury of the larynx. The sub- ject received traditional therapy along with visual feed- back of laryngeal function and subglotic air pressure Pre and posttreatment comparisons after four sessions demonstrated voice, aerodynamic, and laryngeal ratings near the range of normal. Onemonth follow-up exam- nations demonstrated the maintenance of improvement Jn aerodynamic and laryngeal measures. The study pro vided early information related to the successful incor poration of visual feedback of laryngeal function into the treatment setting Level). Ramtenbury, Carding, and Finn (2004) also examined the therapeutic benefit of realtime visual feedback of the laryngeal structures. The authors completed a pro spective randomized control tril on 50 consecutive subjects with muscle tension dysphonia, Subjects were randomly assigned to a traditional therapy group of 2 transnasil exible laryngoscopy (TFL) assisted group. Subjects in the traditional therapy group received vo- cal hygiene training as wel as direct therapy using a va- riety of symptomatic therapy methods. Subjects in the TELassisted group received the above noted protocol along with visual feedback of the larynx. Auditory per- ceptual ratings of the voice jter, shimmer, and patient seifratings of vocal performance were monitored along with the amount of time spent in therapy. Results ind cated that both groups stw significant improvement in auditory perceptual selfsated,and acoustic measures of ‘voice; however, subjects inthe TRLassisted group spent, VOICETHERAPY 63 on average, two hours less in therapy than the tradition- al group (p <0.01.). The authors concluded that visual feedback with the use ofthe flexible scope during treat ‘ment may be a beneficial component of therapy, as it -may serve to reduce the degree of time required for sue: cessful management of the condition (Level 1). Change of Loudness. Boone (1971) proposed change-of loudness 2s one of his original facilitating ‘methods. In his original presentation of the approach, he suggested that the method could be used for disor. ders of increased or decreased loudness. Boone's meth- ‘od began with an awareness phase, where attention Was, drawn to the deviance of the patient's loudness level. ‘An expioration/manipuiation phase followed, where desired loudness was determined and then generalized. Since Boone's inital proposal of this technique, other ‘methods of altering vocal loudness feature have been proposed (Holbrook, Rolnick, & Bailey, 1974; Lodge ‘iVarnall, 1981; Roy et al, 2002) Information related to ‘the methods is presented below. Holbrook et al. (1974) examined the benefit of a de- vice for reducing loudiness.The authors fitted 32 patients with vocal pathologies and histories of vocal abuse with vocal intensity controllers (VIC). The devices provided auditory feedback to patients at moments when voice production exceeded desired loudness levels.The mean therapy course with the VIC was 5.3 weeks, with a range from 2 to 12 weeks. Eleven of the 32 subjects saw com plete resolution of laryngeal pathologies, whereas an ad- ditional eight of the 32 subjects saw significant reduc: tion in lesion size on laryngeal exam. Only three subjects saw no change in loudness with the approach. Remain- ing subjects either left the study before completion or ‘were diagnosed with hyperfunction only, making track: ing of lesion size inappropriate. The authors conciuded. that feedback devices such as the VIC were helpful in re- clucing loudness levels in persons with voice disorders evel 19) Lodge and Yarnall (1981) used an ABAB reversal teaching/research design to examine the use ofa strue- tured program of cueing and reinforcement for the man- agement of loudness. The subject was a 24-yearcld fe- ‘male with moderate mental impairment. The authors demonstrated the successful use of the behavioral ap- proach in reducing the patient's loudness to target ev cls.The subject was able to maintain the reduced louc: ness levels during three followup sessions. The authors concluded that the structured use of positive and neg tive reinforcement was successfl as a treatment meth ‘od but cautioned that generalization from the single case study would be inappropriate (Level V). anally, Roy et a. (2002) examined the use of voice amplification devices for the management of loudness64 _ COMMUNICATIVE DISORDERS REVIEW, VOL. 1,NO.1 ‘concerns, Fity teachers were randomly asigned to et ther a vocal hygiene group, a voice amplification group, ‘ora control group. Subjects in the treatment groups par ticipated in four treatment sessions over a Gweek pe- riod. At the lose of intervention only the amplification group saw significant improvements on the VE, self ings of severity, and acoustic measures. Vocal hygiene and no-treatment control groups filed to demonstrate significant improvements on any of the measured vari ables. Finally, on a posttreatment questionnaire regard: ing the benefit of treatment, the amplification group consistently reported greater levels of perceived bene- fit than the vocal hygiene group. The authors conclud- ed that voice amplification devices were beneficial in bringing about improvement in the voice by reducing vocal loudness (eve! Inhalation Phonation. Inhalation phonation was originally proposed by Boone (1966) as a means of fa Cilttin true vocal fold phonation in cases of functional aphonia. The approach called for patients to produce a soft tone on inhalation. Once capable of producing the inhaled tone consistent the client was asked to pro- duce a matching tone on exhalation The voicing on ex- hhaation was then generalized to other speech contexts, Boone's (1966) use ofthe method was based upon cater work inthe Held of radiology that demonstrated the mechanics of inhalation phonation, During inhals- tion phonation, the false vocal folds take on a retract ced posture. As a result, the false folds become incapable ‘of contributing to inhaled voice production. Boone held that voicing on inhalation could, therefore, be used to bring about contact ofthe true vocal folds without asso ciated contact of the false vocal folds. Research on the inhalation phonation method has been limited. In Boone's (1966) original presentation ‘of the method he reported on use of the method with two cases of functional aphonia.The inhalation method elicited voicing in both cases, and individvals retuned to normal functioning following a minimal number of treatment sessions (Level ¥). McFarlane (1988) report éd on the use of inhalation phonation in combination ‘ith the yawnsigh method forthe management ventric ‘lar phonation. MeFarlane presented the case of a 70- yearold male who retuened to true vocal fold phons: tion after 25 treatment sessions employing the above methods (Level V) Maryn, DeBodt,and Van Cauwenberg (2003) also included inhalation phonation in their arti- cle discussing treatment options for ventricular phona tion. The authors presented the cases of three individ- vals with ventricular phonation of varying etiologies. Interestingly inhalation phonation and other facilitating ‘methods were only successful in estoring trae fold pho- nation in one ofthe three eases The authors concluded ‘that behavioral interventions, such as inhalation phona- tion, were only successful in cases where the ventricu- Jar phonation was functional, and not compensatory, in nature (Leve! ¥V). Digital Manipulation/Digital Pressure. Boone 1971) presented digital manipulation as @ method for lowering pitch. According to Boone, the application of, digital pressure to the thyroid cartilage would tit the cartilage posterioriy, and thereby, shorten the true vo- cal folds-The shortened and thickened vocal folds would yield a lower pitch production, Limited attention has been given to the technique in the literature. Furthermore, most authors discussing the ‘method have used digital manipulation in combination with other techniques. Such protocols have made it dif ficult to determine the contribution that digital manip lation offered in the patient's outcome. Despite this limi tation, two articles discussing digital manipulation are reviewed briefly. McFarlane (1988) reported using digital pressure as fone component of @ treatment program to lower the pitch of a male with mutational falsetto voice-The treat- ‘ment protocol established normal pitch, and therapy was ‘completed in five sessions (Level V). Maryn et al 2003) used digital manipulation for management of ventricular phonation. The method, when combined with a series Of other methods, eliminated ventricular phonation in ‘only one of three cases. The authors concluded that be- havioral methods, such as digital manipulation, may be ‘of benefit only in cases of noncompensatory ventricular voicing (Level ¥). Relaxation. Litersture in the field has consistently demonstrated the relationship between hyperfunctional patterns of voice use and the development of voice dis- anders (Boone, 1971; Boone & McFarlane, 1988; Boone, McFarlane, & Von Berg, 2005; Murph, 1964; Van Riper & Irwin, 1958).As a result, the application of relaxation rethods tothe treatment voice disorders has been sug- gested for many years. Such relaxation techniques can be considered as filling into two categories One group- ing of relaxation methods targets direct relaxation of the body structures. The target of direct relaxation proce: dures may be the whole body or simply the upper bod, head, and neck. Techniques such as Jacobson's (1942) progressive relaxation and Boone's (1971) head rotation may be considered as direct relaxation methods. Other ‘methods achieve relaxation indirectly Techniques such as the yawnsigh, chewing, and chant talking can be con- sidered inthis grouping. In this section ofthe paper, the effets of direct relaxation treatments are reviewed. Direct relaxation although often mentioned as one component of a comprehensive voice treatment pro-gram, has rarely been considered for its pure contribu. tion to vocal rehabilitation. Only three studies addressing. direct relaxation could be found in the voice literature, Gray, England, and Mahoney (1986) examined a method of relaxation termed reciprocal inhibition. The authors presented the cise report of a 27-year-old female who resented with hoarseness following removal of vocal nodules. In the therapeutic sequence, the subject was ‘made aware of increased bodily tension and then trained to selectively reduce areas of tension. Once able to en- sage in thorough relaxation, the client practiced using, the relaxation methods in situations of increasing stress. At the close of 3 weeks of treatment using the method, the patient reported an increased ability to handle stress {ul situations without accumulation of tension. in add tion, a follow-up examination of the laryngeal structures atthe close of therapy revealed a reduction in swelling. of the vocal folds:The authors conctuded that the meth- ‘od was beneficial in reducing the patient's hoarseness and reducing vocal fold swelling (Level V). In that same year, Andrews, Warner, and Stewart (1986) examined the benefit of progressive relaxation for the treatment of hyperfunctional voice disorders. Ten subjects were enrolled in the study; five groups of ‘matched pairs were created. Subjects were alternately assigned to receive either progressive relaxation train- ing or EMG biofeedback therapy for the voice condition, Results demonstrated that subjects in both groups saw reduced muscle tension in the laryngeal region follow- ing therapy. Furthermore, voice quality, selfrated voice severity, and vocal control improved following treat- ‘ment in both groups. The authors found no significant differences between the two treatment orientations The group concluded that progressive relaxation and EMG biofeedback were successful methods for reducing ten- sion in patients with hyperfunction (Levet ID. Blood (1994) used a single subject interaction de- sign with multiple baselines across subjects to examine the contribution of relaxation to improvement in voice therapy. Two subjects with bilateral nodules were used in the study.A core program of voice therapy consisting, of abuse reduction, respicition training, and easy vocal onset was instituted. After a period of time, relaxation, training was added to the core program. Results dem- onstrated resolution of nodules as well as improvement jn multiple voice parameters. However, the study dem- onstrated that the relaxation training component did not contribute independently to the subjects’ outcomes, ‘Thus, the authors concluded that relaxation traning was ‘not a beneficial means of managing vocal nodules (Lev- el). Place the Voice. According to Boone (1988) many in- dividuals with voice disorders maintain an inappropriate VoICETHERAPY 65, -mental focus on the laryngeal region. As a result, he pro- posed that individuals with vocal hyperfunction should be trained to shift the vocal tone away from the neck and into the midéace region. Boone proposed that training be- sin by using nasal sounds to enhance the patient's aware- ness of resonance in the facial area, Once the patient ap- ‘preciated facial resonance, nasal sounds were fied. The patient was trained to maintain the midfacial focus in a ‘variety of more challenging speech contexts, Brewer and McCall (1974) considered the clini cal benefit as well as the physiology of the voice place ‘ment approach. The authors used voice placement to treat an individual with vocal fold eclema and inappro: priate patterns of muscle tension. Fiberoptic laryngos: copy performed while the patient performed the voice placement technique confirmed the method's ability to reduce tension patterns in the larynx. Following treat- ment, the patient demonstrated seduced glottic and su- ‘praglottic tension during voice production. The authors concluded that the method was successful in altering laryngeal function and achieving the desired pattern of voice use (Level V). In another case report, McFarlane (1988) discussed use of voice placement as one part of a comprehensive treatment protocol for a teacher with vocal nodules. After 24 treatment sessions, the nodules ‘were resolved, and the subject was dismissed from ther- apy (Level V). Establishing a New Pitch. Early texts in the field highlighted the importance of pitch modification in the therapeutic process (Boone, 1971; Murphy 1964). Prev lent at the time of the writings was the concept of opti ‘mum pitch, Leaders inthe field held that each individual possessed an optimum pitch level at which voice should be produced. If habitual patterns of voice use did not fall at the optimum pitch level, it was suggested that efforts be taken to bring the pitch to the target level. Following this premise, Boone presented a treatment protocol for ‘establishing a new pitch. ‘The rationale behind direct pitch modification pro- tocols has been questioned over the years for several reasons. First, since early writings on the topic of pitch, the concept of optimum pitch has been largely dis missed Gone, 1988). Second, pitch modification in cas 5 of mass lesions of the vocal folds has been challenged. In 1971, Boone stated,"problems of mass and size ofthe ‘vocal folds resuiting in inappropriate voice pitch levels + are sometimes helped by direct attempts to change the pitch level"(p. 127). Few in the field today would ascribe to such a statement, Prevalent in the field today is the belief that pitch disturbances related to “mass and size” changes of the vocal folds should not be directly man- aged in therapy These disturbances, rather, should be al-66 _ COMMUNICATIVE DISORDERS REVIEW.VOL. 1,NO. 1 lowed to normalize as other aspects of voicing are man- aged and as the vocal folds undergo healing (Stemple et al, 2000). Direct pitch modification attempts, therefore, should be reserved only for use with cases of functional pitch disorders. Despite the method's popularity for many years, arti- ‘les related to the effects of behavioral methods of pitch alteration have been limited. Infact, only two articles dis- ‘cussing the development of a new pitch could be iden- tified in the literature.’ In 1970, Fisher and Logemann, demonstrated successful elevation of pitch in a 19-year- cold actress with vocal nodules. The subject underwent 18 months of voice therapy to raise her pitch from 190 Hz to 250 Hz. At the close of therapy, the authors re ported functional improvement in the subject's voice. Furthermore, instrumental measures suggested changes in vibratory patterns of the folds following therapy The subject demonstrated a posttreatment increase of the ‘open quotient and reduction of the speed quotient.Ac- cording to the authors, these changes indicated reduced petiods of vocal fold contact during the vibratory cycle and suggested the potential for improved healing of the vocal folds with the elevated pitch (Level V). McFarlane (1.988) also used pitch elevation with an individual with vocal nodules. In the case report, McFarlane suggested ‘that pitch elevation was successful in clearing the vocal tone. The pitch technique, when employed with other techniques to relax and refocus the voice, was success- {ulin eliminating the subject's vocal nodules (Level V). Redirected Phonation. Boone (1966) described a method by which vegetative functions, such as throat clearing, coughing, and laughing, could be used to fe clitate voicing at the level of the true vocal folds. In his original presentation of the method, Boone used light coughs to elicit vocal fold contact. The coughs were then modifed and extended into sustained phonation, Although not presented 2s one of his original facilitating methods, Boone added redirected phonation in a later edition of his classic text Boone eta, 2005) ‘A search ofthe literature suggested that Boone’ ink tial presentation of redirected phonation in 1966 serves 2s the only consderition ofthe method in the literature. In the article, Boone presented the case reports of two in dividvals with functional aphonia. Both individuals were treated with a combination of redirected phonation ight coughing) and inhalation phonation The techniques were successful in restoring the individuals to normal voicing {na minimal number of sessions (Level ¥). Symptomatic Methods— Comprebensive Programs In the past few decades, a number of authors con- sidering the influence of voice therapy have employed symptomatic methods in’ their investigations Bloch, Gonld, & Hirano, 1981; Drudge & Phillips, 1981; MeCro- 1%, 2001; Murry & Woodson, 1992) These studies, though, ‘ot capable of yielding information on specific methods, do shed light on protocols that adhere to symptomatic ‘mociels of treatment. Drudge and Philips (1976) employed yawnsigh, pitch alteration, easy voice onset, and other symptom atic methods in their study of the role of shaping in voice therapy. The authors conciuded that the facilitat- {ng methods Were beneficial in eliciting and shaping the target voice but noted that shaping and ongoing analy- sis of client behavior was critical in determining success Level ¥).Bloch, Gould, and Hirano (1981) used methods such as pitch elevation, reduction of hard glottal attack, and respiration training for the treatment of 17 individ vals with vocal fold granuloma. Pre- to posttreatment ‘comparisons suggested that granuloma were eliminated in 9 of 17 patients and reduced in size in 4 of 17 patients. ‘The authors conchuded that symptomatic voice therapy ‘was useful in treating many cases of vocal fold granulo: ma (Level IV). Murry and Woodson (1992) used symp- tomatic methods such as reduction of hard glottal attack, ‘relaxation, and altering tongue position in their exami: ination of various management styles for vocal nodules. Again, the voice therapy methods used by the authors ‘Were successful in improving the voice of subjects (Lev lV). Finally, McCrory (2001) conducted a retrospective audit of 26 patients with vocal nodules. Subjects were treated with methods such as chewing, yawnssigh, voice placement, and pitch alteration. Following treatment, 70% of subjects saw a recuction or elimination of nod: ules, whereas 90% were rated by speech-language pa- thologists as having voices that fll within the normal ‘or mildly dysphonic ranges. (Level ¥).Thus, these stud ies demonstrate the potential benefit of a symptomatic ‘protocol inthe treatment of voice conditions; however, the lack of rigorous, wellcontrolled group designs limits ‘Widespread generalization of findings. Conclusions and Implications A review of symptomatic therapies reveals concerns related to the strength of research within this orienta tion. The majority of studies discussed above demon ‘Use of ital pressure to lower pitch in cases of mutational voice Is presented separately in this paperstrated lack of rigor in their research design.As a result, ‘many of the facilitating methods within the symptomat™ Jicmodel have been supported only by Level IV or Level Vevidence Although the studies provide eatly evidence for the use of a method, firm efficacy conclusions can. not be derived from these studies. Second, few of the above studies examined the influence of specific symp. tomatic techniques, Authors reported on the effects of comprebensive voice therapy protocols, but examina tions of specific components of those protocols were few. Finally the literature search demonstrated that no published evidence exists for many of the traditional ‘symptomatic methods proposed by Boone and others, At present, only one symptomatic method has been examined through multiple group studies. Promising lines of research have emerged suggesting the benefit of various forms of biofeedback for relaxing the larynge- al musculature. Systems offering feedback on laryngeal function, acoustic/aerodynamic output, and muscle ef- fort appear to have a positive treatment effect. Recent advances in instrumentation will, perhaps, allow for the future development of even more sophisticated biofeed- back methods. If symptomatic methods are to be considered as po- tential tools of therapy in the future, research in this area ‘nist advance on two fronts, First, the theoretical foun- dations of symptomatic methods rmust be examined. As| sophisticated instrumentation was not available at the time of symptomatic therapy’s emergence, the physio- Iogic underpinnings of many symptomatic methods have ‘not been demonstrated. Researchers should employ the advanced instrumentation now available in the field to examine the physiology behind these conventional ‘methods. Secondly, the symptomatic methods must be examined more fully for their clinical contributions. Fu- ture studies must advance beyond previous work by iso- lating specific facilitating methods for examination and employing more rigorous group research designs. Evidence for Physiologic Voice Therapy Methods As previously noted, recent years have seen a shift toward the use of physiologic methods for managing functional voice disorders.Six such approaches have ris en to the surface a primary protocols under the physi ‘logic umbrella: Confidential Voice Therapy (Colton & ‘Casper, 1990), Vocal Function Exercises (Stemple, 1993), the Accent Method (Smith & Thyme, 1976), Manna La- ryngeal Musculoskeletal Reduction (Aronson, 1990; Roy, 1993;Roy & Leeper, 1993), Resonant Voice Therapy CLes- sac, 1965;Roy, Weinrich, Gray. Tanner, Stemple, :Sapien- 2a, 2003;Verdolini, 2000), and Lee Silverman Voice Treat VOICETHERAPY 67 ‘ment (Ramnig, Countryman, Thompson, & Hori, 1995) Each method approaches the voice condition in a ho- listic manner with the aim of altering the overall physi ology of voice production, Five of the above methods are applicable for use with functional voice disorders and are discussed in the section that follows, Lee Silver. san Voice Treatment, although a wellresearch proto- col for treating neurogenic voice and speech concerns, does not target the treatment of functional disorders and does not, therefore, meet the review critera for this paper Lee Silverman Voice Treatment is discussed at the Clase ofthe paper as a model of efficacy research with- inthe field Articles examining any one or a comibination of the above ive protocols were inciuied in the review. Studies examining procedural modifications ofthe above meth- ods were aso included as long as the basic foundations ofthe method were preserved inthe study Furthermore, articles examining the theoretical and physiologic un. derpinnings of the above protocols were considered as ‘evidence and were, therefor, included inthe review. E¥- idence pertaining to each of the above five protocols is presented below. Confidential Voice Confidential voice therapy was originally presented by Colton and Casper (1990). In their text, the authors proposed the technique as a means of reducitig glottic ‘compression in cases of vocal hyperfunction. The tech- nique calls for individuals to speak in a soft, nonwhis- pered, breathy tone for all communicative interactions over a period of several weeks. Foundational to the meth: dis the belief that the confidential tone yieldsa slightly opened glottic posture during voicing, and thereby, re- duces vocal fold collision forces during phonation. Re- ported benefits of the confidential voice therapy meth- ‘od include: (1) reduction of the collision impact of the vocal folds during voice production; 2) reduction of vo- cal intensity; @) retraining of phrasing and rate patterns; @ reduction of muscular tension during phonation; and (©) elimination of strained or tight breathing patterns (Casper, 2000). It should be noted that the confidential voice protocol exists within a larger, more comprehen- sive treatment program that includes vocal hygiene man agement and resonant voice training (Casper, 1997) arly in therapy, the confidential voice is trained and clients are instructed to use the voice for all communi- cative interactions for approximately 4 weeks, Midway through the therapy experience, clients are trained in the use of a resonant voice pattern, the pattern that is to be assumed following discontinuation of the confiden- tial voice. Therapy concludes with gradual fading of the68 _ COMMUNICATIVE DISORDERS REVIEW,VOL. confidential voice and gradual incorporation of the reso- nant voice into daily conversations (Casper, 1997). Casper (2000) and Colton and Casper (1996) spoke to the theoretical model underlying confidential voice therapy. The authors provided summaries of fiberoptic and aerodynamic studies conducted on subjects during, production of the confidential voice, Studies identified the presence of incomplete glottic closure along with aerodynamic changes indicative of the desired glottic closure pattern during production of the target voice, ‘The authors concluded that the findings supported the use of confidential for therapy for cases of vocal hyper- function, The authors noted, however, that the same studies identified glottic closure patterns indicative of hhyperfunetion in some subjects (Casper, 2000; Colton & Casper, 1996). Thus, glottic closure patterns in confiden: tial voice production may vary from subject to subject, being appropriate in some subjects and inappropriate in others Only one study examining the effects of confidential voice therapy was identified during the literature search, 4.1995 study by Verdolini-Marston, Burke, Lessac, Glaze, and Caldwell compared the use of confidential voice therapy and resonant voice therapy to 4 vocal hygiene control group. Subjects in treatment groups participat- ed in 2 weeks of treatment, whereas control subjects received a brief educational session regarding vocal hy- giene. Subject compliance with recommenced treatment protocols was monitored as well. Pre and posttreatment ‘measures of laryngeal appearance, auditory perceptu- al aspects of voice, and selfperceived vocal effort were used for determining the effects of the various treat- ‘ment methods.The authors found that treatment groups ‘outperformed the control group on all measured pasa: eters, Furthermore, the study found no relationship be ‘owen the type of therapy and the likelihood of benefit ‘rom therapy Interestingly, outcomes from therapy were related more closely with compliance than with type of ‘therapy. The above findings suggested that confidential voice was superior to an isolated vocal hygiene training program and potentially equitable with resonant voice ‘methods in improving the voice (Level ID, Vocal Function Exercises Vocal Function Exercises CVFE,Stemple, 1993) sefers toa series of exercises aimed at restoring proper balance among the speech subsystems of respiration, phonation, and resonance. The exercises were founded upon the ‘work of Breiss (1957, 1959), Breiss held that imbalances ‘within the intrinsic laryngeal musculature were primary contributors to Voice disorders and that therapy efforts should be aimed at correcting laryngeal imbalances. Fol lowing this premise, Stemple (1993) created a series of exercises for “restrengthening and balancing the laryn- geal musculature, improving vocal fold flexibility and ‘movement, and rebalancing airflow to muscular activity" (p.7).A description of Stemple's protocol follows. According to Stemple (1993), patients are trained in a series of four, welldefined vocal exercises which are practiced twice each, two times per day. The first exercise in the sequence serves as a vocal ‘warm-up exercise. The patient engages the laryngeal system to produce and sustain /i/ at a predetermined pitch. The second exercise, stretching exercise, requires that the patient slowiy glide upward through the ‘pitch range. The third exercise encourages contraction of the system by requiring the patient to glide downward through the range. The final exercise has the patient sustain five, se- {quential notes as long as possible. The final exercise acts as an adductory strengthening exercise. All exercises are performed with a frontal tone focus and a low loud- ness level. The production precautions ensure that the exercises are produced in a safe manner and ina way that allows for maximum laryngeal benefit. Typically pa- tients continue performing the exercise regime for 6 to 8 weeks, although variations from that time frame are permitted, Since the inception of VFEs in the 1990s, three group studies have examined their effect on normal and disor- dered populations. In 2 double lind placebo controlled study, Stemple, Lee, D'Amico, and Pickup (1994) exam- ined the use of VFEs with a group of 35 adult females ‘with no history of voice disorders. Subjects were ran- domly divided into three groups. Subjects in the experi- ‘mental treatment group engaged in a 4-week VEE pro ‘gram. Subjects in the control group were offered vocal hygiene training only. Subjects in the placebo group par- ated in a protocol of daily reading and chanting, a practice not believed to have a significant influence on voice production methods.Ar the close of 4 weeks, sub- Jectsin the experimental group demonstrated significant changes in flow rate, phonatory volume, maximum pho- pation time, and frequency range. No significant chang- es were observed in the control or placebo groups.The authors concluced that the VFE program had a positive cffect on the voice production systems of healthy adult females (Level D. In 1995, Sabol, Lee, and Stemple examined the use of VFEs with singers. Twenty healthy singers were di- vided into an experimental treatment group and a con- ‘tol group. Subjects in the treatment group completed the VFE protocol for 28 days; controls did not engage in the prescribed exercise routine, Pre- to posttreatment ‘comparisons of acoustic,aerodynamic, and stroboscopic ‘measures demonstrated significant increases in phona- tory volumes and maximum phonation times in the ex: perimental group at all pitches. Furthermore, the expertmental group evidenced a decreased flow rate during productions at high pitches. Finally, subjects in the ex: ‘perimental group reported an improved sense of breath control following training. The authors concluded that the use of the VFE program resulted in more efficient pterns of voice production in the group of singers evel . Roy, Gray, Simon, Dove, CorbinLewis, and Stemple (2001) conducted a randomized contro trial comparing the use of VFES to Vocal hygiene treatmentand a no-reat ‘ment control condition. Subjects included 60 teachers with selfreported current and/or historical voice dii- culty‘The VHI Jacobson ea, 1997) and a four question teacher questionnaire were Used for pre- to postereat: ‘ment group comparisons The VEE treatment group sat” significant reductions in the degree of voice handicap as measured by the VI. No significant changes inthe VHI ‘were observed for the hygiene or control groups. Fur thermore the VFE group demonstrated higher ratings of voice improvement than the vocal hygiene group. This, the first study to examine VFE use outside the normal population, supported the program's utiity in improv- ing functional voice outcomes. No direct measures of voice were used in ths study; therefore, conclusions re- garding the protocol’ ability to alter voice production cannot be made (Leve!D. Accent Method ‘The Accent Method of voice therapy was originally presented by Svend Smith in the first half of the 20th ‘century Harris, 2000). The method uses abdominodia- phrigmatic breathing and accentuated vowel produc tons to optimize the respiratory-phonatory connection, and bring about proper patterns of vocal fold closure (Kotby,Shiromoto, & Hirano, 1993) ‘The Accent Method was originally based upon the smyoclastic aerodynamic theory of vocal fold vibration proposed by van den Berg in 1958 CHarcis, 2000), van den Berg's theory discussed the contribution of the ex: hhaled airstream on the closing phase of the vocal fold vibratory cycle. Specifically, van den Berg's theory held that the higher the rate of airflow through the glottis, the greater the medial pulling force on the vocal fold edge. Advocates of the Accent Method proposed that in dividuals can be trained to control the rate of exhaled airthrough the glottis and, thereby, indirectly control the closing ofthe glottis during voicing. With the recent revi sions of van den Berg's model by Titze (1994), advocates (of the Accent Method have also pointed to the method's ability to narrow the vocal tract to create the back pres: sure needled to assist in Vocal fold closure (artis). ‘The Accent Method protocol begins with training the abdominodiaphragmatic breath. Once established, the abdominodiaphragmatic breath is used to produce VOICETHERAPY 69 strings of rhythmic, punctuated fricative-vowel produc- tions. Finaly, once the respiratory-phonatory connec: tion is well established, the enhanced respiratory-phona- tory pattern is generalized to connected speech (Harris, 2000) Kotby, Shiromoto, and Hirano (1993) examined the theoretical underpinnings of theAccent Method by study. ing the method's ability to alter airflow rates through the slottis The authors examined three subjects with vary- ing degrees of experience with the Accent Method. One subject had used the method for 16 years, whereas an other iad used the method for 10 months. One subject, had no previous training with the method, Aerodynam jc measures revealed increases in aicflow rates with use of the Accent Method’s basic accentuated productions. Furthermore, the degree of airflow rate enhancement varied with level of experience. Finally, the aforemen- tioned increases in airflow rate Were accompanied by increases in SPL and fundamental frequency, a finding that provided additional support for the method's ability to enhance vocal output (Level). At least four group studies have examined the treat ment effects of the Accent Method. Smith and Thyme 4976 conducted the first such study. Thirty nonvoice disordered collegeaged students received 10 consect- tive training sessions with the Accent Method. Pre- and posttreatment measures demonstrated spectrographic ‘changes in the desired direction ater training, Specific |y,spectrographic analysis revealed increases in the dura tion of the fundamental as well as increases in the dura- tion of sound energies above 1000 Hz Furthermore, the intensity of sounds below 1000 Hz was significantly in- creased, The authors concluded that the Accent Method. ‘was successful in augmenting vocal output (Level IV). In 1991, Kotby, FkSady,Abou-Rass, and Hegazi exam- ined the effects of the Accent Method on a disordered population. The authors enrolled 28 subjects with a va- riety of voice disorders. Disorders included dysphonias ‘of a functional nature as well as dysphonias secondary to vocal fold lesions and vocal fold immobility Subjects ‘engaged in three, 20-minute sessions per week. Twenty training sessions were completed with each subject. Pa- tient interviews, auditory perceptual voice ratings, stro- boscopic ratings, and aerodynamic measures were taken after sessions 10 and 20, The findings demonstrated a positive shift in voice performance in 89.3% of the sub- jects. Specificaly, auditory perceptual ratings of grade, Strain, and leakage demonstrated significant changes in the desired directions. Furthermore, stroboscopic exam. ination revealed a reduction in nodule size in 6 of 6 sub- jects diagnosed with nodules. Finally, the aerodynamic ‘measures of maximam phonation time, maximum fow rate, subglottic pressure, and glottic efficiency all dem onstrated significant changes in the desired direction. ‘The authors held that the resnits supported the use of70 _ COMMUNICATIVE DISORDERS REVIEW.VOL. 1,NO.1 the Accent Method for functional ancl organic voice dis- orders (Level IV) Fx, Fex, Shiromoto, and Hirano (1994) studied the benefit of the Accent Method for functional voice disor- ders.Ten subjects with functional voice concerns were enrolled in 10, 30-minute therapy sessions.The research- crs collected pre- and postireatment perceptual and acoustic measures, Results demonsteated significant (p <0.05) changes toward normal on the acoustic measures of pitch perturbation quotient, amplitude perturbation, quotient, normalized noise energy, and fundamental fre quency In addition, ratings by subjects and speechJan- ‘guage pathologists lent subjective support to the ther: apy's benefit. The findings supported the method's use ‘with functional disorders of voice. Level IY) In 1998, Bassiouny conducted the most rigorous ex- amination of the Accent Method to date-The author con ducted a double-blind randomized control tial with 42 subjects of varying diagnoses. Subjects were randomly assigned to a vocal hygiene + Accent Method group or vocal hygiene only (control) group. Subjects in the Ac ‘cent Method group received 20 minutes of therapy, wo times per week.A total of 20 sessions were completed. Control subjects received vocal hygiene training one time per week.A total of 10 sessions were completed. Subjec- tive ratings and objective measures were taken prior 10 the initiation of therapy, at the midpoint of therapy, and, at the conclusion of therapy. Results demonstrated that the experimental treatment group exhibited significant. ly greater gains than controls on selected subjective and. objective measures. Auditory perceptual ratings by ex ppert judges demonstrated significantly greater grains on the perceptual parameters of grade, strain, and leakage for the Accent Method group (p < 0.01). Furthermore, the Accent Method group exhibited significant improve ‘ment on all stroboscopic parameters examined by judg- s;such changes were not observed in the hygiene only group. Finally, the Accent Method group demonstrated significantly greater gains than controls on the following, objective measures: SPL range, subglottic pressure, glot- tal efficiency, glotal resistance, shimmer, and harmonics tonnoise ritio. Interestingly neither group demonstrated significant pre- to posttreatment change in inverse fi tering parameters. The findings pointed to the benefit of te Accent Method 2s a clinical tool for the treatment of voice disorders. However, the authors suggested that the therapeutic method may not be equally effective for all diagnostic categories (Level D. Manual Laryngeal Musculoskeletal Reduction Technique (MLMRT) Methods of manvally managing hyperfunctional patterns of voice use were first discussed by Aronson (1990).1n his classic text Clinica Voice Disorders, Aron- son described a method by which the extrinsic arynge- al musculature could be systematically manipulated and massaged to reduce muscle tension and eliminate inap- propriate patterns of muscle engagement for voicing, ‘The technique as described by Aronson and others (ROY, 1993;Roy Bless, Heisey, & Ford, 1997;Roy & Leeper 1993; Van Lierde, DeLay, Clement, DeBode, & Van Cauwenberg, 2004) differs from the digital manipulation proposed by Boone (1971) as a method for lowering pitch. ‘The MLMRT protocol as originally described by Ar- ‘onson (1990) and as applied by others noted above, be- gins with a thorough evaluation of voice and a period of probing regarding intervening emotional factors. Next, the therapist engages in eystcmatic massage and mz nipolation of the laryngeal complex. Massage begins st- periorly atthe level of the hyoid bone and progresses inferiorly to the thyroid cartilage. Slowly the laryngeal muscolature relaxes, and the larynx is guided lower in the neck. During the period of massage, the patient is d- rected to gradually begin voicing Vocal sttempts begin ‘With humming and vowel prolongation and slowly ad- vance toward conversation as the degree of tension ak lows.The session closes witha review of therapy results and a discussion regarding life events potentially con teibuting to the condition In 1993, Roy provided an early discussion regarding the clinical uty of the manual laryngeal musculoskele tal reduction technique (MLMRT) He presented the case review of a 61-yearcold male with ventricular phonation following prolonged intubation. The patient underwent eight sessions of MLMRT over a 2 month period. Prior to ‘weatment, auditory perceptual ratings of voice indicat: ed a severe deficit. Posttreatment ratings were within, the normal range. Furthermore, acoustic measures fun- damental frequency, tes, shimmer, and signal-to-noise rntio demonstrated marked changes in the normal direc- tion folowing treatment. Finally, stroboscopic examina- tions revealed a posttreatment reduction in ventricular fold motion along with a corresponding increase in vor ‘al fold visibility The author proposed the ease a ini evidence for the use of MLMRT with the population of, persons with ventricular phonation (Level ¥). In the same year, Roy and Leeper (1993) conduct: ed the first formal study examining the manual meth- odThe researchers envolled 17 subjects with fonctional voice disorders of varying duration in single session of MIMRT therapy. Subjects experienced a significant re- duction in severity ratings of voice (@ <0.0001) at the conclusion of single session.In addition, the single ses sion brought about significant movement in the normal direction on the acoustic measures of jter shimmer and signalto-nose ratio. Finally, 93% of subjects were abe to _maintain this improved vocal performance for one week‘without treatment The authors concluded that MLMRT ‘was capable of moving patients toward normalization following a single treatment session (Level I¥) In 1997, Roy, Bless, Heisy, and Ford built upon the earlier study to examine the short and longterm effects of MLMRT. Twenty-five subjects with functional dyspho- nia were enrolled in the study. Subjects engaged in a sin- ale session where MLMRT was used. Measures of voice were taken prior to treatment, at the close of the sin- ale treatment session, and at distant time postéreatment ange of follow-up 3.6 to 5.5 months). At the close of a single treatment session, subjects experienced a signifi- ‘cant reduction in voice severity ratings (p <0.0001). In addition, the subjects demonstrated significant improve. ‘ment (@ <0.0003) on the acoustic measures of funda ‘mental frequency, iter, shimmer, and signalto-noise ra- tio at the close of the treatment session. Interestingly the improved voice was maintained long term for the major. ity of subjects, with only 28% of subjects reporting a de- sree of relapse. The authors concluded that short-term Outcomes from MLMRT appeared stronger than long. term outcomes and proposed that the method would be useful in the acute management of functional disor ders (Level IV). ‘final published study of MEMRT was presented by Van Lierde, De Lay, Clement, De Bodt, and Van Cauwen- berg 2004).The authors studied four professional voice users with histories of moderate to severe muscle ten- sion dysphonia. Each ofthe subjects had fiiled to demon- strate progress with other treatment methods. The sub- jects engaged in 25 treatment sessions where MLMRT ‘was employed. Pre- to post-treatment auditory percep: ‘tual ratings of the voice were made using the GRBAS scale Gitano, 1981). Pre: to posttreatment changes in the acoustics of voice were quantified using the Dyspho- nia Severity Index (DSI; Wuyts et al., 2000). Pre- to post- ‘eaiment comparisons demonstrated improvements on the GRBAS scale and the DSI for all subjects. Specifically, subjects demonstrated a reduction in strain, elevation of the highest possible frequency, andl movement of funda: ‘mental frequency, jitter, and shimmer toward the normal range.The authors concluded that the MLMRT was ben- eficial in managing cases of muscle tension dysphonia Covel), Resonant Voice Therapy ‘The origins of Resonant Voice Therapy (RVT) can. be traced back to models for the training of the sing: ing voice. Arthur Lessac, author of The Use and Train- ing of the Huan Voice (1965), highlighted the impor- tance of tonal quality in optimal voice production. He focused on the use of auditory as well as tactile cues for achieving optimal resonance in the midfacial region. Les VOICETHERAPY 71 sac held that production ofthe wellplaced voice would yield optimal functioning of respiratory, phonatory,and resonance systems Since Lessac's writing, clinicians and researchers in the field of voice disorders have shown, an increased interest in the resonant Voice and the bio dynamics of voice production, Proponents of RVT hold that the resonant manner of voice production is the most efficient manner of pro- duction Titze (2003) states, “resonant voice engages the vocal tract for muximum transfer of power from lots to lips and ultimately al the way tothe stenee”(p.292) The efficiency of the resonant voice appears to stem {rom patterns of voice production within the larynx. Ac cording to Titze, when energy is property converted at the level of the vocai folds, the glotal sound wave nas the potential ro be propagated over long distances. Vi brations ofthe glottal one can extend into the facial r- sions, and a resonant voice results-These propositions have been supported by the work of Berry ct al.(2001) and Verdolini, Druk, Palmer, and Samawi (1998) that demonstrated thatthe glottc configuration observed in the resonant voice was, in fact, the glottic configuration ‘known to produce maximum transfer of sound through the vocal tact. Verdolini 2000) described the goals and sequence of RVI. Hygiene goals are addressed throughout the course of therapy and focus primarily on hydration and the management of any associated refiux concerns The ‘neuromuscular direct traning stage of therapy consists ‘of ewo components. First, inappropriate patterns of mus- cle use are deactivated. Second, easy phonation, charac- terized by vibratory sensations near the alveolar ridae, is established. ‘At least three published studies have examined the fects of RVA 1995 study by VerdoliniMarston et al compared RVT to other forms of voice management. ighteen colegeaged females with the diagnosis of vo- cal nodules participated in the stay. Subjects were dt vided into two treatment groups CRVT, confidential voice therapy) and a vocal hygiene control group.At the close ‘of just 2 weeks of treatment, participants in the teat ‘ment groups exhibited greater gtins on all parameters those in the control group. Results demonstrated the benefit of VT and confidential voice therapy over vocal hygiene training alone (Leve! 1D. In 2003, Roy, Weinsich, Gay. Tanner, temple, and Sa- piienza examined a modification of the traditional Reso: nant Voice Therapy approach.'The study examined the effects of various voice treatment methods on a sim ple of 64 teachers witha seltreported history of voice difficulty Subjects were randomly assigned to one of three treatment methods: resonant therapy, respiratory ‘muscle traning, and amplification, Subjects completed the VHI Gacobson et al, 1997) as well 2s voice sever72 _ COMMUNICATIVE DISORDERS REVIEW.VOL. 1,NO.1 ity rating prior to and at the close of treatment. Results| showed significant reductions in perceived handicap as determined by the VAI for both the resonant therapy (p 0,007) and amplification groups (p <0.002), Significant changes on the VAT were not observed in the respirato- {Fy muscle training group. Furthermore, resonant voice taining and amplification groups exhibited significant reductions in voice severity ratings. Again, significant changes were not observed with the respiratory muscle ‘raining group. A follow-up questionnaire distributed to subjects showed a slight benefit of amplification over resonant therapy. Subjects in the amplification group re- ported greater voice clarity and ease of voicing than did subjects in the resonant therapy group. The study sup: ported the use of the modified resonant therapy as well 1s amplification in the treatment of voice disorders (Lev- at. Tn that same year, Chen, Huang, and Chang (2003) examined the effect of Resonant Voice Therapy on 21 female subjects with hyperfunctional dysphonia. Video- stroboscopic, auditory pescepteal, acoustic, and aero dynamic assessments were conducted prior to and fol- owing eight treatment sessions, Results demonstrated significant changes on laryngeal videostroboscopy and. auditory percepmual measures of voice. Furthermore, significant changes in the desired direction were not: ced on tests of shimmer, intraoral pressure, and speaking, frequency range. The authors concluded that Resonant ‘Voice Therapy was a useful mechanism for treating the ‘hyperfunctional voice (Level IV) Conclusions and Implications A review of the above suties demonstrates sup- por for physiologic approaches slong both theoretical and cata lines The development of specialized instr mentation fr viewing and measuring voice production has allowed the physiologic approaches to be examined from a psilogic, or theoretical standpoint. Research ers have confirmed the physiology behind a number of physologie methods and arived at conclusions re sucing he potential benefit ofthe methods Physiology Seis, atough aot tre teament outcomes studies, do provide evidence in support ofthe theory behind the methods, Second, the majority ofthe physiologic ap- proaches have been supported through stringent cin cal research Most methods bave ben investigated using at least one wellcontrolled group study, others possess lines of einical research that have developed over 2 umber of yeas. Of the methods presented above four emerge with a strong evidence base. Vocal Function Fxercises, Reso. nant Voice Therapy, the Accent Method, and the Manual Taryngeal Musculoskeletal Relction Technique appear promising for use in treatment of functional voice disor- ders. Continued research examining the benefit of the ‘methods with varying populations of patients would be indicated, Interestingly, physiologic approaches to the manage- ‘ment of voice emerged at a time of increased interest in treatment outcomes research. The simultaneous emer- ‘gence ofthe two areas lias yielded an improved research foundation for the field of voice therapy, Conclusions and Future Directions ‘The above review provides vital information for the voice clinician working in the field today: Evidence ‘suggests that physiologic methods of therapy enjoy ‘greater scientific support than other methods of voice ‘treatment. Multiple, wellcontrolled group studies have ‘emerged demonstrating the positive treatment effects of physiologic approaches. On the other hand, evidence for other forms of therapy has been lacking in strength and consistency. Hygiene methods, although subjected to group study, have not consistently emerged as influ- cential in the treatment of voice disorders. In addition, the majority of facilitating methods under the symptomat- Je model have not received sufficient research attention (o suggest their adequacy in voice treatment. Although patients using these approaches may show clinical im- provements, the question remains as to whether im- provements are secondary to the approach itself or to another confounding factor, such as spontaneous im- provement, the placebo effect, or therapist personality. More evidence is needed, ‘What then can be sad of the status of voice therapy in the earliest days of the 21st century? A review of the literature demonstrates reason for optimism. Since 1990, rescarchers have employed more rigorous research de signs in their work;Level I evidence has emerged for sev- ‘eral treatment methods Furthermore, in recent years,au- thors have become more focused in their investigations, ‘choosing to examine the impact of specific therapeutic ‘methods rather than the impact of general therapy mod- els. The more focused studies have produced valuable information that will assist clinical service providers in treatment planning ‘The research advances of the 1990s and 2000s have brought the field to a new level of knowledge. Yet, a ‘number of questions and considerations remain regard- ing the future of outcomes research. First, with the emer- gence of physiologic methods and the developing base of evidence supporting physiologic methods, does inves: tigation of specific symptomatic methods remain neces sary? Is researc time better spent continuing the linesVOICETHERAPY _73 of esearch into physiologic methods or should the spot. light return to more conventional models of treatment? Second, clefinitive answers must emerge in the area ‘of vocal hygiene. Mueller and Larson (1992) demonstrat: ed that vocal hygiene remains a significant component of voice therapy programs, yet research regarding its ‘contribution fas been inconclusive, Researchers must employ designs that allow for the investigation of vocal ‘hygiene’s pure contcibution to vocal rehabilitation. The ethical concerns that arise from the use of a no-treat- ‘ment group limit options in this area. However, using a vocal hygiene only group as a control or using a vocal hygiene only phase of therapy may be appropriate op: tions for investigating hygiene. Furthermore, as with di- rect therapy methods, specitic components of vocal hy giene must be examined for their contribution to the hygiene model of treatment. Researchers must deter ‘mine which, if any, hygiene targets move the client to- ‘ward the desired outcomes, ‘Third, researchers of the future must consider the JTong-term benetits of various therapies Whereas studies requiring long-term participant follow-up are inherent- ly dificult ro design and implement, longterm outcome datas critical to determining the durability of treatment approaches over time. Fourth, as outcomes research emerges, the issue of efficiency must not be overlooked. The current business ‘mode! in the United States governing rehabilitation ser vices requires firm data on treatment duration, Funure researchers must address this matter by designing stud ies that consider the efficiency variable. By doing soe searchers can provide clinicians with needed data relat- Cd to the required time frames for therapy. Finally, researchers must engage in the systematic and longterm investigation of specific treatment ap- proaches. In the area of voice treatment, Lee Silverman Voice Therapy (SVT) may serve as a model of such re- search. This treatment approach was first presented by Ramig, Countryman, Thompson, and Horii (1995) as a treatment for voice disorders associated with Parkin- son's disease. Since ISVT's original presentation in the literature, a number of articles have been produced ex amining the effectiveness of the method (aumgert- ner, Sapir, & Ramig, 2001; Ramig, Countryman, O'Brien, Hochn, & Thompson, 1996;Ramig, Countryman, Thomp. son, & Hori, 1995; Ramig & Dromey, 1996; Ramig et a., 2001;Ramig, Sapir, Fox, & Countryman, 2001;Sapir eta. 2003; Sapir,Ramig, Hoyt, Countryman, O'Brien, & Hocha, 2002; Sharkawi et al, 2002; Spielman, Borod, & Ramig, 2003).The line of research for LSVT has included inves: tigation of the following areas: ISVT's role in improv- ing voice in patient’s with Parkinson's disease, consid- eration on the method's impact on other elements of speech and expression, investigation of the long-term maintenance of skills trained in ISVT, investigation of the physiology behind the method,and consideration of the method's effectiveness in various other neurogen: ic populations. Thus, this base of literature demonstrates the potential for developing systematic lines of research {or other voice therapy methodologies Intoday’ssociety,science and art are often painted as, dichotomous concepts, unable to coexist in a meaning- ‘ul way-Yer, in the field of voice, pethaps the two coexist ina complementary relationship—where the science of the rescarcher supports the art of the clinician These au thors would propose that Voice therapy is on the verge ‘of such a relationship—science supporting art, enhanc ing the lives of those living with voice disorders. Address correspondence to Lisa B-Thomas, PhD, 106C Charles. Wethington Building, Lexington, KY 40536-0200;Telephone: 859 323 1100 ext. 80524; Email: Lisa Thomas@uky.edu References Aaron, ¥.L, & Madison, C.L.(1991).A vocal hygiene program {or high school cheerleaders. Language, Speech, ad Hear ing Services in Schools,22,287-290. Andrews, M.L_(1993)- Intervention with young Voice Users. 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