Change in Levator Veli Palatini Muscle Activity of Normal Speakers in

Association With Elevation of the Velum Using an Experimental Palatal

Lift Prosthesis
TAKASHI TACHIMURA, D.D.S., PH.D.
KANJI NOHARA, D.D.S.
YOSHINORI FUJITA, D.D.S.
HISANAGA HARA, D.D.S., PH.D.
TAKESHI WADA, D.D.S., PH.D.

Objective: The purpose of this study was to examine whether mechanical

elevation of the velum can directly affect the levator veli palatini muscle (LVP)
activity using normal speakers as subjects.
Design: Each subject was instructed to produce /mu/, /u/, /pu/, /su/, and /tsu/
in a speech task and to blow with maximum possible effort. Smoothed elec-
tromyographic activity of the LVP was recorded with an experimental palatal
lift prosthesis (PLP) both in place and removed.
Participants: Four normal speakers were used as subjects.
Results: LVP activity for all tasks was significantly smaller (p , .001; Stu-
dent’s t test) with the PLP in place than without the PLP for all subjects. An
analysis of variance (p , .001) clarified that activity ranges of the LVP were
significantly different between the removal and placement conditions for all
the subjects.
Conclusion: The result was similar to that previously obtained for patients
with velopharyngeal incompetence wearing a PLP. It is possible that the de-
crease in the LVP activity in association with placement of a PLP is caused by
the direct effect of mechanical elevation, which decreases the distance the
velopharyngeal mechanisms must travel for complete closure of the velophar-
ynx.

KEY WORDS: levator veli palatini, palatal lift, velopharynx, velum

Speech appliances, including a palatal lift prosthesis (PLP),
have been reported to stimulate velopharyngeal function in
association with speech therapy for patients with velopharyn-
geal incompetence (Shelton et al., 1968; Weiss, 1971; Wong
and Weiss, 1972; Mazaheri and Mazaheri, 1976; McGrath and
Anderson, 1990; Tachimura et al., 1995, 1999, 2000). It was
reported that, for some wearers, the velopharyngeal function
could be improved to the point that the appliance could be
discarded (Blakeley, 1960; Blakeley and Porter, 1971; Shelton
et al., 1971a, 1971b). Most studies focusing on the clinical
effects of a speech appliance reported clinical success records
Dr. Tachimura is Associate Professor and Vice Chair, Dr. Nohara and Dr.
Fujita are postgraduate students, Dr. Hara is Assistant Professor, and Dr. Wada
is Professor and Chair; Division for Oral and Facial Disorders, Graduate School
of Dentistry, Osaka University, Osaka, Japan.
Presented at the 54th Annual Meeting of American Cleft Palate–Craniofacial
Association, New Orleans, 1998.
This research was supported by grants-in-aid from the Japanese Ministry of
Education (Grant 10838019 and 12671879).
Submitted February 2000; Accepted October 2000.
Reprint requests: Dr. Takashi Tachimura, Division for Oral and Facial Dis-
orders, Graduate School of Dentistry, Osaka University, 1-8, Yamada-Oka, Su-
ita, Osaka, 565-0871 Japan. E-mail tatimura@dent.osaka-u.ac.jp.
as percentages but did not report on the physiological causes
of the effect.
Kuehn and Moon (1994, 1995) reported that for normal
speakers, the difference between levator activity for speech
and possible maximum levator activity in a nonspeech activity
is greater than that for speakers with hypernasality. They de-
fined the differences as reserve capacity for normal speech. In
fact, speakers with hypernasality used approximately the same
level of activity in the top of their activity range for both task
types. On the basis of these results, they recommended that a
strategy to extend the reserve capacity be employed to improve
velopharyngeal function. As one of those strategies Kuehn
(1991) proposed continuous positive air pressure (CPAP) ther-
apy, which could strengthen the levator veli palatini muscle.
Tachimura et al. (1999, 2000) reported that placement of
speech appliances decreased the levator activity of wearers of
a PLP or a speech bulb both for blowing and speech. De-
creased levator activity in association with prosthesis place-
ment could be interpreted as a relational increase in reserve
capacity. They speculated that the clinical effect of a speech
appliance might be caused by an increase in reserve capacity
for velopharyngeal function in association with a decrease in
levator activity. However, it is not clear what variables are

449
450 Cleft Palate–Craniofacial Journal, September 2001, Vol. 38 No. 5

involved in the change in levator activity in association with

prosthesis placement.
It is possible that when the velum is elevated by a PLP or
a pharyngeal bulb inserted into the velopharynx, the velopha-
ryngeal port size is decreased and the velopharyngeal mech-
anisms do not need to travel as far, compared with a no-pros-
thesis condition. Therefore, it may be hypothesized that the
decreased activity may be caused directly by mechanical ele-
vation of the velum. On the other hand, however, Tachimura
et al. (1995, 1997) reported that a decrease in levator activity
might be caused by prevention of air flow into the nasal cavity
through the velopharynx (Tachimura et al., 1995) or an oro-
nasal fistula (Tachimura et al., 1997). When the velum is main-
tained at the level of the palatal plane, which is the level of
velopharyngeal closure, it is likely that inward movement of
the lateral pharyngeal wall plays a major role in closing the
velopharyngeal gap left after the velum is elevated. That is, it
is still unclear whether the decrease in levator activity in the
placement condition is caused by the direct effect of mechan-
ical elevation or by other variables such as aerodynamic
changes in association with placement. When it is clarified that
the decrease in levator activity (increase in reserve capacity)
is attributed to mechanical elevation of the velum, one phys-
iological concept of fabrication of a PLP will be obtained.
The study of normal speakers enables examination of the
effect of mechanical elevation on velopharyngeal function
without the influence of aerodynamic variables because normal
speakers can achieve complete closure of the velopharynx dur-
ing the production of obstruent sounds and blowing regardless
of whether an experimental PLP is in place. The purpose of
this study was to examine whether a change in levator activity
in association with placement of a PLP is caused directly by
mechanical elevation of the velum for normal speakers.

METHOD

Subjects

Four normal male speakers (age range 22 to 43 years) with

normal articulation and resonance and no hypernasality or hy-
ponasality participated. Their velopharyngeal function was
also shown to be within normal limits during blowing and
speech using nasometry (nasalance score range 10.5 to 12.8)
and nasoendoscopy.
Palatal Lift Prosthesis
A customized experimental PLP was constructed for each
subject. The length, width, and angle of the velum section of
the PLP were adjusted so that the widest possible velum sec-
tion, measured between bilateral levator dimples, could elevate
the velum to the level of the palatal plane. As a result, the
dorsum of the velum could contact the posterior pharyngeal
wall at the level of the palatal plane. Two gaps were left un-
closed bilaterally on either side of the contact site between the
velum dorsum and posterior pharyngeal wall to prevent hy-
FIGURE 1 An experimental palatal lift prosthesis. A. Horizontal view.
B. Lateral view. C. Intraoral finding with a palatal lift prosthesis in place.
ponasality and nasal obstruction. The target configuration of
the velum section of the PLP was confirmed using flexible
fiberoptic nasoendoscopy and lateral cephalogram (Figs. 1 and
2).
With the PLP in place, the subject showed no resonance
changes, including hyponasality, for nasal sounds and did not
complain of nasal airway obstruction during respiration. In ad-
dition, two experienced speech pathologists rated oral and na-
sal resonance balance to be within normal limits with no ob-
served differences when the prosthesis was removed.

FIGURE 2 Cephalogram showing palatal lift prosthesis (PLP) in place
(A) and nasoendoscopic findings in both PLP-in (B) and PLP-out (C) con-
ditions. Note that the velum is elevated up to the level of the palatal plane
(A) and two openings for respiration are visible in either side of the contact
between the velum and the posterior pharyngeal wall (C).
Tasks
Each subject was instructed to perform speech and blowing
tasks in two conditions (PLP-in versus PLP-out). The speech
tasks were productions of /mu/, /u/, /pu/, /su/, and /tsu/. Each
speech sample was repeated 10 times in separated, isolated
utterances.
The blowing task was performed using a blowing tube made
of two polyethylene tubes with a 2-mm inner diameter and 3-
mm outer diameter. One tube, 30 cm in length, was adhered
to another shorter tube 10 cm in length with the side walls of
the respective tubes. Kuehn and Moon (1994) and Goto (1977)
reported that for normal speakers, levator activity increases in
relation to oral air pressure during blowing. In this study, to
avoid any influence of oral air pressure change on levator ac-
tivity, oral air pressure during blowing was required to be
maintained at the same level across the two prosthesis condi-
tions. One of the tubes was connected to a pressure transducer
to allow the speakers to monitor the blowing intensity. The
other tube prevented the buildup of air pressure in the oral
cavity during the blowing task. It was thought that, without
the second tube, subjects might try to maintain oral air pressure
by impounding air with a tight closure between the elevated
Tachimura et al., LEVATOR VELI PALATINI ACTIVITY 451
tongue and the velum, leading to inaccurate representations of
levator muscle activity.
In each of the two placement conditions (PLP- in and PLP-
out), subjects were instructed to blow at the same effort level
(i.e., blowing intensity). The effort level was determined prior
to electrode insertion. Each subject was instructed to blow
through the blowing tube as long and hard as possible without
a PLP. The resulting level of air pressure was determined as
the target level for the blowing task.
A 3-minute rest period interval was taken between the blow-
ing task and speech tasks so as to prevent any influence of
order effect on levator activity. Similarly, a 5-minute rest was
taken between the PLP-in and PLP-out conditions.
Electromyography
Levator electromyographic (EMG) activity was collected in
a similar way to the authors’ previous studies (Tachimura et
al., 1995, 1999, 2000). The electrode insertion site in the ve-
lum was anesthetized using a cotton swab dipped in 4% li-
docaine topical anesthetic. Before insertion of the electrodes,
the insertion site was determined with PLP in place so that the
velum section of the PLP would not cover it. Stainless steel
wires (80 3 1023 mm in diameter) were inserted perorally in
a superior, posterior, and lateral direction. The two electrodes
were placed approximately 5 mm apart and 10 mm deep in
each subject’s left levator muscle.
EMG signals were amplified (AB651J, Nihon Kohden, To-
kyo, Japan), high-pass filtered at 30 Hz, rectified, and
smoothed with a time constant of 30 milliseconds through a
second amplifier (EI600G, Nihon). For the blowing task, oral
air pressure was measured by a pressure transducer and an
associated amplifier (AP620G, Nihon Kohden).
All physiologic signals were stored on datacorder tape using
a data recorder (KS-616, Sony, Tokyo, Japan).
Data Analysis
EMG activity was measured using a laboratory computer
and commercial analysis software. Procedures used for mea-
surement of the EMG activity for speech tasks and blowing
tasks were similar to those that the authors have used for pre-
vious studies (Tachimura et al., 1999, 2000). For speech tasks,
the peak of the smoothed EMG curve associated with each
speech sample was recorded. For the blowing task, EMG ac-
tivity was measured at 0.2-second intervals within the duration
when the pressure wave was stabilized (Fig. 3).
RESULTS
Figure 4 shows the mean and standard deviation of the le-
vator activity for each subject in each condition. The EMG
activity was expressed as a percentage relative to the maxi-
mum value of EMG activity observed throughout the experi-
ment. The range of levator activity for speech generally tended
to be near the lower end of the operating range, compared with
452 Cleft Palate–Craniofacial Journal, September 2001, Vol. 38 No. 5

FIGURE 3 Measurement of levator EMG activity during speech and

blowing. Left: The peak of the smoothed EMG trace in each production
was measured. Right: Raw EMG activity from the levator veli palatini
muscle, rectified and smoothed EMG activity, and oral air pressure trace
recorded during blowing task. Measurement of EMG activity was per-
formed at 0.2-second intervals from the time that the pressure wave sta-
bilized.

the blowing tasks. For all subjects, the maximum EMG activity
was observed in the condition of blowing at maximum inten-
sity level without the PLP. The EMG activity range for speech
was less than 50% of the maximum activity, regardless of
whether the PLP was in place or removed.
A one-way analysis of variance revealed that levator activity
was significantly (F[1508] 5 35.45, p , .001) lower in the
PLP-in condition in comparison with the PLP-out condition.
As shown in Table 1, this effect was observed for all sub-
jects irrespective of the task (Student’s t test, p , .001).
FIGURE 4 Mean and standard deviation of levator veli palatini EMG
DISCUSSION activity (percent peak levator EMG) for speech tasks and blowing at pos-
sible maximum intensity with and without the palatal lift prosthesis (PLP).
There are several reports regarding the use of a speech ap- Open and closed circles represent mean values for PLP-out and PLP-in
pliance, including the palatal lift prosthesis, to improve velo- conditions, respectively. Note that standard deviation is expressed with one
direction bar for ease in viewing. TT, IY, NK, OT 5 initials of subjects’
pharyngeal function for speakers with velopharyngeal incom- names.
petence. Most studies reported the percentage of patients who
were able to eliminate the prosthesis and maintain acceptable
speech, but two studies (Tachimura et al., 1999, 2000) exam- tasks. On the basis of the results of their own studies (Table
ined the physiological changes in velopharyngeal function in 2) and those of Kuehn and Moon (1994, 1995), they speculated
association with placement of a speech appliance as observed that reserve capacity can be extended by decreased EMG ac-
in levator veli palatini muscle activity. Kuehn and Moon tivity in the placement condition relative to the removal con-
(1994, 1995) proposed the concept of reserve capacity defined dition. However, it has not been clarified which variables,
as the difference in levator activity between blowing at max-
imum intensity and speech. That is, in case of greater reserve
capacity, levator muscle activity for speech is maintained at TABLE 1 Levator Veli Palatini Muscle Activity for Each
lower levels in comparison with maximal activity. Therefore, Experimental Condition†‡
with a greater reserve capacity, the muscles related to velo- PLP Out PLP In
Sub-
pharyngeal function might not encounter fatigue, which would ject Tasks Mean 6 SD N Mean 6 SD N t Value
otherwise prevent the velopharyngeal muscle from maintain-
TT Speech 36.25 6 11.98 59 27.32 6 7.84 60 4.801*
ing tight velopharyngeal closure during connected speech, Blowing 90.65 6 7.66 15 69.27 6 9.24 15 6.897*
blowing, or both. Kuehn and Moon (1994, 1995) recommend- IY Speech 27.84 6 10.95 60 16.14 6 7.45 60 6.842*
ed that strengthening of the levator muscle might extend re- Blowing 78.19 6 11.55 11 51.43 6 7.75 11 6.387*
NK Speech 22.31 6 5.69 60 16.28 6 8.13 60 4.711*
serve capacity, enabling the velopharyngeal musculature to Blowing 82.85 6 9.54 15 60.5 6 7.76 15 7.028*
maintain tight velopharyngeal closure without fatigue. Kuehn OT Speech 21.17 6 7.60 60 13.27 6 6.19 60 6.220*
(1991) reported CPAP therapy as one such strategy. Blowing 72.83 6 12.78 15 53.93 6 8.93 14 4.644*
Tachimura et al. (1999, 2000) reported that placement of a † The levator veli palatini muscle activity was expressed as a percentage relative to the
maximum value of EMG activity observed throughout the experiment.
speech appliance decreased levator EMG activity in compari- ‡ PLP 5 palatal lift prothesis; N 5 number of tokens measured.
son with a no-prosthesis condition for both speech and blowing * p , .001.

TABLE 2 Levator Veli Palatini Muscle Activity During Blowing
and Speech Tasks for Patients With Velopharyngeal
Incompetence in PLP-in and PLP-out Conditions†
PLP Out PLP In
Task Mean SD N Mean SD
Blowing
Low 62.3 14.5 32 42.9 17.8
Comfortable 68.5 12.9 32 52.4 12.2
High 85.5 11.2 28 60.4 12.4
Speech 57.7 31.1 65 25.0 23.5
Modified from Tachimura et al. (1999) and Tachimura et al. (2000).
† PLP 5 palatal lift prothesis; N 5 number of tokens.
* p , .0001.
changed in association with prosthesis placement, are involved
in the decrease in levator activity.
It has been reported that levator muscle activity is influenced
by several variables including intraoral or intranasal air pres-
sure and air flow (Kuehn et al., 1993; Kuehn and Moon, 1994,
1995; Tachimura et al., 1995, 1997, 1999), gravity (Moon and
Canady, 1995) or positioning of the velum (Kuehn et al., 1982;
Moon et al., 1994). Tachimura et al. (1995, 1997) reported that
levator activity can be decreased by means of preventing air
emission into the nasal cavity during speech with a speech
appliance. These results may imply that change in an aero-
dynamic variable associated with placement of a speech ap-
pliance is involved in levator activity change. On the other
hand, when a speech appliance is in place for speakers with
velopharyngeal inadequacy, resonance can be changed from
hypernasal to normal. That is, resonance change in association
with prosthesis placement might also be involved in the reg-
ulation of velopharyngeal function.
In this study, it can be supposed that there was no change
in resonance or aerodynamic variables even in the placement
condition because all subjects were normal speakers. That is,
decreased levator activity for the normal speakers was not
caused by changes in resonance or aerodynamic variables but
directly as a result of placement of a PLP.
No subject showed nasal escape of air during blowing with
a PLP in place. Therefore, there was no apparent change in
tightness of the velopharyngeal seal between the two condi-
tions. Two hypotheses can be offered to explain why tightness
of the velopharynx is maintained with decreased levator activ-
ity: (1) movement of velopharyngeal structures other than the
velum (e.g., lateral pharyngeal wall) compensated for de-
creased velar movement so that the levator muscle did not have
to contact as forcefully, (2) with decreased velopharyngeal port
size in association with elevation of the velum, there was no
need for the velopharyngeal mechanisms, including the levator
muscle, to close the velopharynx with as much force. That is,
the oppositional load force of the velum can be overcome suf-
ficiently with a decreased level of levator muscle activity. A
PLP elevates the velum to the level of the palatal plane so that
the velum need not elevate any more for velopharyngeal clo-
sure. Therefore, inward movement of lateral pharyngeal walls
may assume a major role in velopharyngeal closure. There are
Tachimura et al., LEVATOR VELI PALATINI ACTIVITY 453
some studies on the contribution of the lateral pharyngeal wall
to velopharyngeal closure (Astley, 1958; Igresias et al., 1980)
and other articles focusing on the synchronization of velar and
pharyngeal wall movement (Zwitman et al., 1974; Skolnick
N t Value and McCall, 1972; Witzel and Posnick, 1989). It is likely that
the lateral pharyngeal walls and the velum work synchronously
36 4.909* to achieve velopharyngeal closure for speech but that individ-
32 5.432* uals differ in their relative contribution of the velum and pha-
28 7.865* ryngeal walls to closure.
65 6.780*
It is possible that lateral wall movement is increased to com-
pensate for decreased velar movement if the velar movement
to close the velopharynx is externally inhibited in the condition
of continuous contraction of the levator veli palatini muscle.
However, a PLP does not inhibit velar movement but supports
velar elevation because the direction of the external elevation
force applied by a PLP is the same of that for the velar move-
ment. In fact, there was still a large amount of levator EMG
activity even when a PLP was in place. That is, it is possible
that motor control features for the levator muscle action are
regulated so that the velopharyngeal mechanisms can fulfill
the targeted aim of action effectively and appropriately. There-
fore, decreased levels of levator activity may not be caused by
compensation with increased inward movement of the lateral
pharyngeal walls but indicate an absence of need for the ve-
lopharyngeal mechanisms to move as hard as without the ap-
pliance to achieve complete closure of the velopharynx.
Lateral pharyngeal wall movement was not examined in
this study. Therefore, it is not clear whether lateral pharyngeal
wall movement can be altered in association with elevation of
the velum to attain tight closure of the velopharynx to com-
pensate for less movement of the elevated velum. Moreover,
it is not clear either whether the levator muscle or other mus-
cles such as the superior constrictor can contribute to move-
ment of the lateral pharyngeal walls or how activity of other
muscles than the levator muscle may change in association
with a change in velar position. Anatomically, the levator mus-
cle is positioned to influence the lateral walls of the pharynx
by its action on the torus tubarius, whereas the superior con-
strictor is too low to contribute to velopharyngeal closure
(Dickson and Maue-Dickson, 1980). Kuehn et al. (1982) ex-
amined the relationship between velar position and activity of
the levator veli palatini muscle, the palatoglossus muscle, and
the palatopharyngeus muscle. They found activity in the su-
perior constrictor but on a more inconsistent basis. From these
studies, it may be said that the levator muscle may take a role
of inward movement of the lateral pharyngeal wall, but this is
not conclusive.
Moon and Canady (1995) reported that levator activity can
vary depending on the direction of gravitational forces on the
velum. That is, when a subject is seated in the upright position,
levator muscle activity is greater than that observed in a re-
clined position. Their study may imply that the magnitude of
the load borne by the levator muscle can vary according to the
direction of the applied load. A load applied in a direction
opposite the direction of velar elevation may require greater
levator muscle activity than in the unloaded condition. On the
454 Cleft Palate–Craniofacial Journal, September 2001, Vol. 38 No. 5
other hand, if the velum is provided with support in the direc-
tion of the velar movement (i.e., unloaded), the levator muscle
may be required to exert less effort than in the condition of
no external support.
When a PLP is in place to elevate the velum, it is possible
that for subjects with velopharyngeal incompetence, the leva-
tor muscle bears less load than without it. So it is possible that
the decreased levator activity shown by speakers with a cleft
palate with velopharyngeal incompetence results from a de-
crease in magnitude of the load borne by the levator muscle
because of mechanical elevation of the velum. However, for
subjects with velopharyngeal incompetence with a speech ap-
pliance in place, aerodynamic and resonance variables may
also be changed as well. In addition, for such speakers, a
change in tactile sensation of the velopharynx in association
with prosthesis placement might also be involved in the change
in levator activity. Future study is warranted to examine how
these variables can be involved in the change in levator activity
for subjects with velopharyngeal incompetence in association
with placement of a speech aid prosthesis.
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