Voice Therapy:

Does Science Support the Art?

Lisa B. Thomas and Joseph C. Stemple

Lexington, Kentucky

Three primary orientations to the treatment of ftinctional voice disorders have emerged in the
lit- erature. Hygienic aJaproaches focus on the elimination of behaviors considered to be
harmful to the vocal mechanism. 5ymptomatic 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, plionation, and
resonance.With the va- riety of approaches now available, selection of appropriate and effective
techniques can be chal- lenging for clinicians.The purposes of tliis 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 ftiture
study.

Introduction
Over the years, a number of teclmiques have emerged
for the treatment of ftmctional voice disorders. Some
methods have emerged from otir sister field, the vocal
arts, others kom the scientific study of voice production,
and still oUiers from the modification of basic vegetative
tinctions.What is more, some methods have approached
voice treatment holistically by modifying the fiill speech
production system, whereas others have treated via pa-
tient education or tlirougli the retraining of a specific
voice parameter. The result has been the emergence of
a broaci, and ever expanding, inventory of voice thera-
py methods.Tlus growth, although exciting, has posed a
iuñque challenge to clinicians. The voice clinician of to-
day must not only be knowledgeable of available meth-
C‹›i›ii›iti11icntiue Dis‹›i-‹ters Reulc›ii›
Yc›ltln1e I, Nttmber 1,p|›. 49-77
Cripyriglit O 2(Jf)7 Plural Publishing, Inc.
ods, but lie or she must also •r reciate the evidence-base
behind each.Tits 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 tlus re-
view is to provide clinicians with an overview of voice
therapy methods across a variety of treatment orienta-
tions an‹t establish the level of evidence si: rr orting each
metliocl. In 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
49
 50 COMMUNICATIVE DISORDERS MVIEW,VOL. 1, NO.1
1940s Jroescliels, 1943; Peaclier & Holinger, 1947). It
was not, however, until the 1970s that consistent calls for
outcomes research iii the fielcl were expressed. In 1971,
G. Paul Moore, speech scientist and speech-language pa-
thologist, considered the voice therapy literature and de-
termined that the field of voice therapy suffered from a
lack sufficient scientific support. Furthermore, lie con-
cluded that many methods used in voice therapy were
chosen, not because of scientific evidence, btit because
of clinician preference.As a result, Moore proposed that
voice therapy remained primarily an art, without suffi-
cient scientific foundations. Since Moore’s reflection on
the literature, a number of other authors have echoed
lits call for empirical support of therapeutic methods
Jillman, Gress, Hargrave, Walsh, R Bunting, 1990; John-
son, 1985; Pannbacker, 1998; Perkins, 1985; Ramig
&Ver- dolini, 1998; Reed, 1980). As a result of these calls,
the field has seen a slow, but steady, emergence of the
scien- tific evidence that Moore desired.
Voice therapy outcomes research has evolved
though three main stages. Early articles on the benefit
of voice therapy came in the form of descriptive case
series reports, expert opitiions, and anecdotal cotn-
ments (Hillman et a1., 1990). Although, capable of pro-
viding information on therapy with individual subjects,
these models did not allow for generalization to the larg-
er population of voice Uierapy subjects. During tlus pe-
riod, the lack of objective measures made more detailed,
scientific sttidy of the voice challenging Jeecl, 1980).
The 1980s brought great advancements in acoustic
and visual perceptual measures of the voice and ush-
ered in a new phase of voice research, the
instrumental stage. In 1985,Jo1inson responded to recent
instrumen- tal advances of the period by stating, “the
profession is at the threshold of being able to validate
years of clini- cal 1••actice in voice disorders with
efficieiit data collec- tion teclmiqties" (p. 129). .|olinSon
wa5 proven correct in lits prediction, as the 1990s
brought about a dramatic increase in outcomes snidies
using data collected from the instrumental assessment
of voice (Pannbaker, 1998). However, many of the studies
conducted during tliis pe-
riod contained metliodologic flaws and a lack of rigor in
their design; other studies failed to provide information
related to the Duration of treatment, frequency of treat-
ment, and subject characteristics. In addition, many
stud- ies relied tipon survey research and retrospective
anal- yses; few sureties met the rigorous randomized,
control criteria required for ptire efficacy research
Jannback- er, 1998). The studies of tliis perioci,
although capable of producing data on client
improvement with therapy, lacked the proper controls
to demonstrate a cause-ef- fect relationship between
the therapy method and voice change (Bassiotmy,
1998). Extraneous variables were
able to exert influence in Uie stiidies, limiting conclu-
sions regarding the pure causal effects of the treatment
method.
Voice therapy outcomes research needed to con-
front the final stage in its evolution—the cidoption of
rigorous experimental designs, including randomizecl
control trials or well-controlled witlfin-subject designs
Qelnman & Orlikoff, 1998; Hegde, 1985). Stich designs
woiild allow researchers to rule out extraneoiis vari-
ables and propose caiise-effect determinations.A review
of studies conducted in recent years demonstrates the
emergence of these rigorous designs @assiotiny, 1998;
Laukkanen, Syrja, Laitala, R Leino, 2004; MacKenzie, Mil-
lar, Wilson, Sellars, R Deary, 2001; Pedersen, Beranova, R
Moller, 2004; Rattenbury, Carling, R Finn, 2004; Roy et
al., 2001, 2002, 2003; Stemple, Lee, D'Amico, R Pickup,
1994;Verdolini,Titze, R Fennell, 1994;Verdolini-Marston,
Sandage, R Titze, 1994;Verdolini-Marston,Titze, & Druck-
er, 1990).
The Challenges of Outcomes Research
The slow progression of treatment outcomes re-
searchover the decades is perhaps understandable con-
sidering the complexities of tliis type of research. Vari-
ous factors have limited tlus form of research in voice,
including the etlucal considerations of delayecl or no-
treatment experimental designs, the lack of suflicient
numbers of subjects for large group studies, the lack of
controlled methods of voice therapy (the artistic nature
of voice therapy), and the variability of patient etiologies
in group snidies Jannbacker, 1998; Reed, 1980).
Despite the limiting factors noted above, a ntunber
of studies have emerged that demonstrate the influence
of voice therapy in general in the treatment of voice dis-
orders in adults Wlocli, Gould A Hirano, 1981; Deal, Mc-
Clair, R Siiddertli, 1976; Holmberg, Hillman, Hammar-
berg, Sodersten, & Doyle, 2001; Lancer, Syder, .{ones, R
LeBotitillier,1988; MacKenzie et al., 2001; McCrory, 2000;
McFarlane R Patterson, 1990; Murry R Woodson, 1992;
Paniibacker, 1999; Peaclier R Holinger, 1947; Ramig R
Verctolini, 1998); fundings regarding treatmei:t outcomes
in clñldren have been less clear Jaliane R Mayo, 1989;
Kay, 1982; Lee R Son, 2005; Sander, 1989; Shearer, 1972;
Tooliill, 1975) Although these studies provide critical
information regarding the contribution of the therapy
process in recovery, clinicians rely uJaon information re-
lated to the outcomes offered by sf›ecific methods of
treatment. Stich studies have been less common in the
literature.
The purpose of this article is to present a critical
review of outcomes research related to specific treat-

ment methods for functional voice disorders. Studies
discussing specific treatment methods within the three
primary orientations to voice therapy—hygienic, symp-
tomatic, ancl physiologic—are reviewed. Each study is
examined to determine the level of evidence it provides
in support of the given method. Conclusions regarding
areas of strength and areas for funire development are
presented.
At the time of tliis review, more tlian 30 years have
passed since Moore’s (1971) commentary on the state
of the voice therapy literature. Have the years produced
the evidence that Moore so desired? Has the field re-
mained primarily an art form, or has it progressed to be-
ing an art form undergirded by science? The following
review responcis to those questions.
Defining Functional Voice Disorders
The definition of voice disorders has broadened over
the years. Early works defined voice disorders as any de-
viation of pitch, loudness, quality, or tempo from age,
gender, or cultural, expectations (Boone, 1971;Van Riper
R Irwin, 1958). More current definitions, however, have
shifted from a focus on the voice signal to a focus on the
individual. One sticli definition by Stemple et al. (2000)
states “a voice disorder exists when either the stnicture
or fiinction, or both, of the laryngeal mechanism no lon-
ger meet the voicing requirements established for the
mechanism by the speaker"(p. 2).Tlus more recent defi-
nition broadened the scope of the term“voice disorder"
by including individuals such as tlle professional voice
tiser who, by clinical standards, falls with the range of
normal, yet who reports failure of the voice to meet per-
sonal requirements.
The term “/i/iiciion‹sf voice disorder"' may be more
ctifficult to define. Some have used the term /inciion-
at to refer to voice disorders that occtir in the absence
of identifiable laryngeal pathology Jo one R McFarlane,
1988; Van Riper & Irwin, 1958). Other schemes have re-
served the term/oacftonaf for descriptions of voice dis-
orders with a psychological origin (Boone, 1971). Finally,
some authors have described as/srtcIiottaf those voice
disorclers related to inappropriate tise, or functioning, of
the vocal mechanism (Stemple et al., 2000). In tlus final
scheme, the term/uiiciioitof disorder may include be-
nign mucosal disease wliicli evolved secondary to fiinc-
tional behaviors. Functional voice disorders as defined iii
tlus final scheme focus on the physiologic aspects of the
laryngeal system, rather than on the strucniral causes or
consequences of inappropriate use.T1iis latter definition
is the perspective of choice for tliis article.
VOICE TI-IERAPY 51
Orientations to Voice Therapy
Over the years, a variety of approaches have emerged
for the treatment of fiinctional voice disorders. Occa-
sional attempts have been made to categorize these ap-
proaches according to their theoretical foundations. In
1980,Reedreviewed the prevailing philosophies of voice
therapy.At that time, perspectives varied from hygienic
and symptomatic management to holistic, physiologic
management. Stemple’s (2003) discussion of voice ther-
apy demonstrates that the basic plfilosoplñes of therapy
have undergone little change in the past 25 years. Stem-
ple classified voice therapy approaches as belonging to
one of four major categories: hygienic, symptomatic, psy-
cliogenic, and physiologic. Certainly, most wotild agree
that divisions such as those above are, perhaps, more ac-
ademic than practical. However, classifications do offer
a usenil vehicle for comparing and evaluating various
methodologies. Thus, tlus evidence review follows the
basic orientations proposed by Reed and Stemple and
will includes hygienic, symptomatic, and physiologic ap-
proaches to voice therapy.
Hygienic Voice Therapy
Hygienic methods for voice improvement have been
described in many classic voice therapy texts (Andrews,
2002; Boone, 1971; Case, 1996; Colton R Casper, 1996;
Deem R Miller, 2000; Hicks & Bless, 2000; Stemple, 1993;
Stemple et al., 2000;West, Kennedy, & Carr, 1947;Van Rip-
er & Irwin, 1958). Foundational to the hygienic orienta-
tion of therapy are two beliefs:(1) many functional voice
disorders are initiated and maintained by behaviors that
bring harm to the laryngeal stnichires;(2) elimination of
liarmnil and traumatic behaviors will lead to improve‹l
vocal performance. Hygienic approaches to voice thera-
py, therefore, foctis on the identification and subsequent
elimination of poor vocal behaviors followed by the de-
velopment of proper vocal behaviors.
Within UKs orientation, vocal hygiene management
has been characterized in a number of ways. Some au-
thors have considered vocal hygiene as one component
of a larger and more comprehensive voice tlierapyproto-
col(Andrews, 2002; Boone, 1971; Colton R Casper ,
1996; Deem R Miller, 2000; Hicks & Bless, 2000; Stemple
et al., 2000;West et al., 1947;Van Riper R Irwin, 1958).
Others have argued that vocalhygiene may, at times, stand
alone as the sole method of ad‹Jressing voice Jaroblenis
(An- drews, 2002; Colton R CasJaer, 1996). Colton and
Casper pointed out that either perspective may be
appropriate for adoption by clinicians. They stated,
"vocal hygiene may constitute the entire rehabilitation
program, or it
52 COMMUNICATIVE DISORDERS REVIEW,VOL. 1, NO.1
may be one part of the program”(p. 300). Over the years,
vocal hygiene has been a mainstay in vocal rehabilitation
programs (Mueller R Larson, 1992).
Symptomatic Voice therapy
Symptomatic voice therapy is based upon the con-
cept of symptom modification.Voice therapy under tliis
model focuses on the remediation of aberrant vocal
sym}›toms in the areas of pitch, loudness, and quality.Al-
thoighsymptomatic methods can be identified in early
speech correction texts (Van leper R Irwin, 1958;West
et a1., 194a, tlus particular orientation to voice therapy
1971 seminal text, Tle Voice and Voice Tiierafiy. Symp-
tomatic voice therapy was based upon the belief that
modification and correction of vocal, respiratory, and
resonance symptoms woul‹1 lead to improvement in the
voice condition.
Boone’s (1971) symptomatic approach involved the
use of facilitating techniques to bring about the client's
best voice. In lits original presentation of symptomat-
ic therapy, Boone proposed 20 facilitating methods ca-
pable of modifying vocal symptoms. Methods ranged
from techniques such ss yawn-sigh and ci›ewing aimed
at relaxing the vocal mechanism to techniques such as
flusi›ing aimed at increasing vocal fold contact during
plionation.
Physiologic Voice Merapy
Recent years have brought a shift away from targeted
treatment of symptoms to holistic consideration of the
voice. Foundational to physiologic voice therapy is the
belief that voice disorders are best treated by modifying
the underlying physiology of voice pro‹tuction (Stemple,
2000; Stemple et a1., 2000). Due to the foctis on physiol-
ogy, individuals subscribing to tlus form of therapy often
discuss treatment methods using anatomic or physiolog-
ic terms. One description of the physiologic approach
by Stemple, Lee, D’Amico, anal Pickup (1994) demon-
strates this fact. Stemple and colleagues suggest that the
physiologic approach to voice therapy involves three
key compoi:ents: (I) improving the balance among the
primary voice production systems of respiration, plio-
nation, and resonance, (2) improving the strength, bal-
ance, tone, and stamina of the laryngeal muscles, and (3)
c1eveloJ›ing a healthy mricosal covering of the true vo-
cal folds.Thus, the physiologic approach draws tipon the
clinician’s understanding of normal voice production to
transition the voice to its most appropriate form.
Reviewing the Evidence
Leveb of Evidence
Recent decades have brought an increasect interest
in treatment outcomes research in a variety of profes-
sions. As a result, a number of authors have developed
methods by wliicli the rigor an‹J quality of treatment
outcomes studies can be rated Qtitler & Darrali, 2001;
Gtiyatt, Vist, Falck-Ytter, Kunz, Magrini, & Sclitinemann,
2006; Robey R Schtiltz, 1998). For tliis review, the au-
thors have chosen to follow Butler and Darrali’s five-lev-
el classification scheme. In their examination of tlier•ry
iterative, eve sri‹iies irc ii‹ie‹i iiiose «esigns exiuuit-
ing the strongest level of experimental support for the
therapeutic method uncter investigation, whereas Level
V studies demonstrated the lowest level of support. Lev-
elI designs included the randomized control trial, the all-
or-none case series, and the N-of-1 randomized control
(single-subject design). Level11 designs included nonran-
domized control trials, prospective cohort studies with
concurrent controls, analytic siirveys,ABABA single sub-
ject design, alternating treatments single subject design,
and the multiple baseline across participants single sub-
ject design. Level III classification was reserved for case-
control snidies, cohort stuclies with historical controls,
and ABA single subject designs. Level IV studies included
before and after case series without controls and the AB
single subject design. Finally, LevelV evidence included
nonempirical works such as: descriptive case series/case
reports, anecdotal reports, statements of expert opinion,
theory based on physiologic, bench, or animal research,
and/or common sense principles (see Table 1).
Method of Review
For the purpose of tliis review, the authors conduct-
ed searches of the following on-line databases: Med-
line, PsyclñNFO, Ctimtilative Index of Nursing and Al-
lied Health Literature (CINAHL), and the archives of the
American Speech-Language-Hearing Association. On-liije
searches were limited to the period between 1980 and
March 2006. Database searches were followed by a thor-
oughhistorical search tising previously published criti-
cal reviews and meta-analyses. No year of publication re-
strictions were placed on the historical search. Sn«1ies
were chosen for review if the following criteria were
met: (1) the snidy examined the benefit of a treatment
method included within one of the aforementioned
treatment orientations; (2) the study focused on treat-
ment of disorders of a functional nature; and (3) the arti-
 YOICETHERAPY 53

Table 1. Categorizing Levels of Evidence

Randomized control trial N-of-1 randomized control trial

All-or-none case series
II Nonrandomized control trial ABABA design
Prospective cohort study with Alternating treatments design
concurrent control group Multiple baseline across participants
III Case control stuffy ABA design
Cohort study with historical control
group

Before and after case series without AB design

control group
V Descriptive Research/Noueinpitical
Descriptive case sei ir.s/case reports
Aiieci:totes
£:xpert opiiiioii
Tkeoi-ies hasecl oii pm) siology, hence, or ai’tininl i-eseai-ch
Common sens/first priticiples
Sout-ce: Modified with permission from“Effects t›f a netirodevelopmental treatment (NDT) f‹›r
cerebral palsy:An AACPDM eviclence report,' by C. Butler and.I. Darrah, 201a1, Dc•uc•lofin1‹•ntol
7ffc•rfic/ate cnñ Colt:I Nc•tti'o/«›w: 45, p. 781.

cle was published in English. Selected studies were rated

according to the five-level classification system of Butler
and Darrah (2001).
Scope and Intention of the Review
The intention of the review is to offer a broad over-
view of the current voice therapy evidence base. The
scope of the review was guided by, and in some re r
ects limited by, the literahire itself. Inherent in the voice
lit- erature are the widely recognized variables of
nomencla-
ture and study design. Fortimately, in the area of voice,
the majoriq of therapy approaches extend beyond no-
menclature limitations, as they are applicable across a
wide range of vocal pathologies. Concerns regarding de-
sign variability are of greater note.The studies presented
below vary significantly in their subject selection, ther-
apy implementation, treatment course, outcomes mea-
sures, and so forth. Consistent with these limitations, the
authors have chosen to include all pertinent snidies, re-
gardless of variability in subject demograplucs, subject
etiology, manner of service provision, or treatment in-
tent (i.e., prevention vs. rehabilitation). Finally, the liter-
anire review demonstrated that few authors have con-
sidere‹t treatment efficiency in their snidies.Although a
vitally important feature in today’s clinical marketplace,
the literature at lland did not lend itself to conclusions
regarding efficiency, and thus tlus aspect of outcomes is
not considered in the rating of studies.
Studies within each of the three primary voice thera-
py orientations are presented in the following discussion.
The authors’ conclusions regarding the overall status
of research within each orientation also are presented.
Evidence for Hygienic
Voice Therapy Methods
Despite the fact that hygienic methods have been a
mainstay of therapy from the earliest clays of voice ther-
apy to the present, few smites have systematically in-
vestigated the effects of vocal hygiene therapy ‹slope as
a means of managing fiinctional voice disorders. More
common in the literatiu-e have been studies using vocal
hygiene training as a control against wliicli other direct
therapy methods are measure‹t.Valuable information re-
garding the influence of vocal hygiene can be derived
from tlus research model. In fact, many of the studies clis-
ctissed below that contribute to our knowleclge of the
effect of vocal hygiene training have fol1owe‹J the “vocal
hygiene as control" model.
Studies were selected for inclusion in the vocal
hygiene review if the following criteria were met: (1)
54 COMMUNICATIVE DISORDERS RSVIEW,YOL. 1, NO.1

The study examineci vocal hygiene training in isolation,

conficlential and resonant voice therapies. Participants
or the sttidy used vocal hygiene training as a control
were 18 college-aged females with confirmed vocal nod-
against wliicli other methods could be examined. (2) At
ules. Results demonstrated that the treatment grotip out-
some phase in the study, the vocal hygiene component
performed the vocal hygiene control group on all mea-
of therapy was completed in isolation without concur-
sured parameters—auditory perceptual voice ratings,
rent direct therapy. Studies examining hygiene methods
laryngeal a}ipearance, and self-perceived vocal effort. In-
only in association with a concurrent direct treatment
terestingly, after the 2-week study period, individuals in
component were not included, as such studies did not
the vocal hygiene group demonstrated a ctegree of re-
offer specific information related to the contribution of
gression on measures of self-perceived vocal effort.The
vocal hygiene to therapy progress. (3)The vocal hygiene
findings siiggested that vocal hygiene alone was not suf-
protocol included one or more of the following stan-
ficient for altering the course of the voice disorder {Lev-
dard hygiene objectives: vocal hygiene education, elimi-
el II).
nation of vocal abuses and misuses, reduction of loud-
Holmberg, Hillman, Hammarberg, Sodersten, and
ness, reduction of the amount of talking, or hydration
Doyle (2001) studied the influence of a five-}iliase voice
...•.. p rn ..•.
uierapy prograrii oii tire voices or i i woiiieii iiiagnoseii
A number of studies identified for review discussed
with vocal notliiles. All subjects received vocal hygiene
the benefit of broad-based vocal hygiene education pro-
as the initial phase of the program. Participant response
grams (Aaron R Madison, 1991; Bloch & Gotild, 1974;
to therapy was monitored tlirougli periodic perceptii-
Broaddtis-Lawrence, Treole, McCabe, Allen, R Toppin,
al ratings of voice, acoustic analysis, and laryngeal vid-
2000; Chan, 1994; Holmberg, Hillman, Hammarberg, Sod-
ersten, R Doyle, 2001; Nilson & Schneiderman, 1983; eostroboscopy examinations. The authors fotind no sig-
Roy et al., 2001, 2002; Scluieider, 1993). OUier snidies, nificant changes in the measured parameters following
however, provided data on a single aspect of vocal hy- completion of the vocalliygiene phase.The authors con-
giene, such as hydration (Solomon R DiMattia, 2000;Ver- cluded that vocal hygiene training alone was not a ben-
dolini, Titze, & Fennell., 1994; Verdolini-Marston et a1., eficial treatment for vocal nodiiles (Level. IV).
1994; Verdolini-Marston et al., 1990;Yiu R Chan, 2003). Two separate randomized control trials joy et
The review first examines studies related to genetal hy- al., 2001, 2002) examined the vocal hygiene approach
giene approaches.The section concludes with findings against other forms of direct treatment. In a 2001 stiidy,
related to specific hygiene targets. Roy et a1. examined the effects of vocal hygiene verses
the Vocal Function Exercise protocol of Stemple (1993).
Sixty teachers with current or past complaints of voice
General Vocal Myglene Training problems were enrolled in Uie stiidy. Subjects were di-
vided into a Vocal Function Exercise group, a vocal hy-
Individual Vocal Hygiene Training. Individual- giene group, and a no-treatment contro1group.T1ieVoice
ized management of vocal hygiene often involves the
Handicap Index ; Jacobson et a1., 1997) and a foir-
tise of behavior modification approaches to alter meth-
item questionnaire addressing subject compliance and
ods of voice use.The methods generally involve a period
subject perception of improvement were ii5ect for pre-
of patient education, followed by a period of awareness
and post-training comparisons. Both the vocal hygiene
training and abuse irlentification. The hygiene program
group and the Vocal Function Exercise grotip attei:ded
concludes with the modification stage, where clients
Join therapy sessions over a 6-week period. Significant
are asked to reduce the occurrence of inappropriate
improvement in VHI scores was observed only in the
behav- iors (Andrews, 2001). Several studies have
Vocal Function Exercise group. No significant changes
examined tlus model of vocal hygiene management.
were observed for the vocal hygiene and control groups.
In 1974, Bloch and Gotilcl examined the use of voice
The authors concluded that the use of vocal hygiene
therapy in the managemei:t of grarniloma. The authors
training alone as a form of voice therapy should be ex-
presented the case of a 42-year-old male with recurrent
amined nirtlier (beret J.
graniiloma. following 4 months of therapy aimed pri-
In a second study, Roy et a1. (2002) examined the
marily at vocal hygiene, the granuloma was resolved, and
influence of two forms of vocal hygiene management
the patient evidenced improvement on acoustic and
for loudness reduction—conventional didactic vocal hy-
aerodynamic measures. The case presentation provided
giene training and voice amplification via a portable am-
early evideiice as to the influence of vocal hygiene man-
agement in the poJaulation of patients with grantiloma plification system. Fifty teachers with a history of voice
(Zere/). concerns were randomly assigned to a vocal hygiene
group, an amplification group, or a no-treatment con-
In 1995, Verdolini-Marston, Burke, Lessac, and Cald-
trol group. Subjects in the treatment groups met with a
well used a vocal hygiene control group in a study
speech-langiiage pathologist on four occasions over a 1
of
 VOICE THERAPY 55

week period.The VHI (Jacobson ct a1., 1997), self-ratings

dren were capable of increasing knowledge regarding
of voice severity and acoustic measures were used to
vocal abuse {Leuel. IV).
document change over the course of the study.The vocal
Aaron and Madison (1991) conducted a separate-
hygiene grotip saw no significant changes in pre- to post-
sample, pretest-post-test study to examine the impact of
training measures, whereas the amplification group ex-
vocal hygiene education on a group of 36 high school
hibited significant gains on all three outcome measures.
clieerleaders. Participants were randomly assigned to
Between-group comparisons revealed no significant dif-
one of two experimental groups. Members of Grotip I
ferences in outcomes between the vocal hygiene and
completed a pretest of their knowleclge of voice produc-
amplification gr r s, suggesting no clear dominance of
tion and tise. Both groups then participated in a perio‹l
one form of treatment over the other. However, respons-
of vocal hygiene training. At the close of training, par-
es on a post-treatment questionnaire suggested that sub-
ticipants in Group H completed the post-test of voice
jects in the amplification group were more compliant
knowledge.The results demonstratect an increase in the
and experienced greater clarity of voice and greater
mean score on tests of voice knowledge following train-
ease of phonation than the vocalhygiene training group.
ing (i = 9.98;p <0.05).The authors concluded that train-
.*:. .ate-r ..r.dirig siiggestc‹i sorrc enema or airip men-
rig prugraiiis sucii as the onc tiscci in Lite sniciy may De
tion over traditional hygiene methods. Both treatment
beneficial in increasing knowletlge of the voice and its
groups saw greater gains than the no-treatment control
potential abuses (Zeref .
group {level. I).
Although the above stiidies by Nilson and Schneider-
Finally, a 1993 article by Schneider provides infor-
man (1983) and Aaron and Madison (1991) examined
mation regarding the long-terrii benefit of vocal hygiene
changes in bnowIe‹:tge with grotip-based vocal hygiene
training. The author followed a 27-year-old female with
eclucation, Chan (1994) studied changes in heiiaoioz
vocal nodules for seven assessments over a 2-year pe-
with hygiene training. Chan targeted a group f 25 fe-
riod. Initial assessment data included a notation of pa-
male kindergarten teachers without voice complaints.
tient symptoms, acoustic measurement, laryngeal ex-
!•! 1ects were divided into control and experimeiital
amination, and auditory-percephial ratings of the voice.
groups based upon the schools in wluch they worked.
Therapy involved 12 weekly individual therapy sessions
Subjects participated in a 90-minute vocalhygiene work-
focused on vocal hygiene training. A review of the pa-
shop. Acoustic, spectral, and electroglottograpliic mea-
tient’s symptoms across the span of the study revealed
surements were taken prior to and following training. In
improvement on ratings of laryngeal appearance and
addition, subjects maintained daily records of the nim-
voice quality over time. Furthermore, the subject’s de-
ber of vocal abuses. The results clemonstrated a signifi-
scription of vocal symptoms suggested progress over
cant reduction in the number of daily vocal abuses as
time.Acoustic measures,1iowever, did not correlate with
well as significant improvements in acoustic and elec-
the above trends in other domains of assessment. The
troglottograpliic voice measures for the experimental
results demonstrated long term progress on several do-
grotip. No such changes were observed in the control
mains of voice assessment with the use of vocal hygiene
group. The author concluded that vocal hygiene educa-
training alone (Zeuef ).
tion training was beneficial for the population of te.icli-
ers (Zeref II).
Group Hygiene Training. Several authors have ex-
Broaddus-Lawrence et a1. (2000) presented fotir, 60-
amined the benefit of group vocal hygiene training as a
minute vocal hygiene classes to a grou}i of 11 untrained
means of preventing or managing voice disorders. Much
adtilt singers. The authors obtained pre- and post-train-
of the research in tits area has been conducted on popu-
ing recordings of the number of vocal abuses and the
lations known to be at risk for vocal abuse— school-age
number of appropriate voice uses. In addition, subjects
children, teachers, and Jarofessional voice users.
provided self-ratings of sJ›eec1i and singing quality, their
Nilsou and Sclineiderman (1983) provided a fotir-
ability to use of the information gained its training, and
session voice abuse prevention J9fOgfam to second and
the overall value of the hygiene training. The authors
third-grade students and their teachers. S•*>l t°C t kIlOWl- identifiect no significant differences in the number of vo-
edge and awareness of vocal abuse patterns were tested cal abuses demonstrated by subjects following training.
Jarior to, immediately following, and 5 months following hi addition, the authors fotind no significant increases
participation in the program. Results demonstrated that in the number of positive, or ocally hygienic, behaviors
subject knowledge of vocal abuse significantly increased displayed by the singers. Finally, subject self-ratings of
in the pre-treatment to immediate post-treatment time voice quality and voice use patterns revealecl no signifi-
period; a decline in knowledge was observed at the 5- cant changes in these areas as a result of hygiene train-
month follow-up session. The authors concluded that ing. Interestingly, despite the lack of statistically signifi-
prevention programs aimed at elementary school clul- cant changes in the measured variables, subjects in the
snidy reported that the hygiene training was satisfying
and helpful ‹feael. IV).
Timmermans, DeBodt, Wuyts, and Van de Heyning
(2004) examined the influence of vocal hygiene educa-
tion and voice training on the voices of 46 students con-
sidere‹t to be ñittire professional voice users. One-half of
the students received 1 school year of vocal hygiene edu-
cation and 18 months of direct voice tmining;tlie remain-
der of students received no form of training. Although
the experimental group demonstrated positive changes
in the acoustic aspects of voice following the hygiene
training, a daily habits questionnaire showed no change
in vocally abusive behaviors with education.The authors
concluded that vocal hygiene training failed to bring
a0oi:I •.--si•-ci -•*ar•g-•s in ciaii-/ -z car iiabits (? •reG ? ,.
In a similar 2005 stndy,Timmermans, De Bodt,Wiyts,
and Van de Heyning enrolled 23 subjects from a school
for audiovisual communication. Subjects received 18
months of voice training, consisting of vocal hygiene ed-
ucation and vocal retraining.The vocal hygiene compo-
nent of the program consisted of 30 hotirs of
didactic training over a 3-month period, wlierea5 the
vocal train- ing component consisted of 30liours of
small group tech nical voice training per year. Results
demonstrated signif- icant improvements in acoustic
measures of voice and voice quality. However, subjects
failed to make changes in vocal hygiene habits following
education.The authors concluded that group hygiene
education programs such as the one provided in the shidy
were not sticcessf\il in altering subject behavior {Level
IV).
Specific Vocal Mygiene Targets
In addition to the generalvocalliygienetraining
stzid- ies noted above, some aiithors have examined the
ben- efit of specific components of vocal hygiene.
Several of these targeted vocal hygiene areas are
reviewed below.
Hydration. Hydration and lubrication of the larynx
has been considered in the literahire for many years. In
an early article on the issue by hint (1974), lie noted
"considering certain singers' throats over a period of
years, I have often noted that those wlficli are well lubri-
cated survive longer" (p. 287). In the article, Punt went
on to review systemic, local, and atmospheric methods
of enhancing vocal fold lubrication. Since that time, sev-
eral studies have examined the influence of hydration
on voice production (Solomon R DiMattia, 2000; Verdo-
lint et al., 1994; Verdolini-Marston et al., 1994; Verdolini-
Marston et al., 1990; Yin R Chan, 2003). These stiidies
focused primarily on the systemic and environmental
manipulations of hydration.
In the first of these snidies, Verdolini-Marston, Titze,
and Drucker (1990) used a 3 X 3 factorial design to ex-
amine the influence of hydration on the i»lionationpres-
stire tloesliolds JPTs) of six healthy adults. Subjects
were exposett to tluee conditions—dry, wet, and con-
trol. Under dry conditions, subjects were placed in an
area of 30 to 35a litunidity for 4 hours and given three
teaspoons of a decongestant (drying) medication. Sub-
jects in wet conditions were placed in an area with 85
to 100*J› litimidiry, given two teaspoons of a miicolytic
agent along with water upon request. For the control
condition, no manipulations of humidity were made by
investigators, no medications were taken, ancl water in-
take was not controlled. Phonation pressure thresholds
were taken at low, medium, and lugli pitches at the
close of each condition. Results suggested that PPTs were
low- est (ciesireci ciirectiorij for tire "wet," or iiyciratea
condi- tion. Tile authors concluded that hydration had a
posi- tive infliience on the phonation pressure
tloesliold of subjects by altering the viscoelastic
properties of the vo- cal folds {Level I).
in a 1994 follow-up snidy, Verdolini, Titze, and Fen-
nell set forth to replicate the above snidy tising a dou-
ble-blind, placebo-controlled, counterbalanced sttidy.
Twelve nonsmoking adults were each exposed to three
condiuons—wet,dry, and control. Measurements of
pho- nation tluesllold pressure and perceived
phonatory ef- fort were taken prior to and following
each of the above conditions. Results suggested that
phonation pressure thresholds decreased with an
increase in hydration and vice versa.Thus, an inverse
relationship between hydra- tion and phonation
pressure tloesliold was identified. Furthermore,
subject ratings of perceived plionatory ef- fort
increased following the dehydration ("dry") condi-
tion. Ratings of effort did not change with the hydration
("wet") or control conditions. The authors concluded
that hydration does play a role in voice production by
altering the pres5tire required to initiate phonation (Ker-
el I).
A similar hydration study was conducted using indi-
viduals with voice disorders.Verdolini-Marston, bandage,
andTitze (1994) used a double-blind, placebo-controlled,
subject crossover design to determine if there was a
ben- efit of hydration over a placebo in the
management of vocal nodiiles. 5ublects were six adults
with the cliagno-
sis of vocal nodules or vocal polyps.The hydration con-
dition included a 2-liotir exposure to a lugli humidity en-
vironment, the intake of eight glasses of water, and the
intake of one teaspoon of a mucolytic agent three times
over the course of the day. Placebo conditions included
2 hours in a room with filtered air and candles, eight sets
of finger exercises, and one teaspoon of an herbal medi-
cine thee times per day. The authors identified statis-
tically significant pre- to post-treatment differences for
the hydration grotip in the areas of perceived phonatory
effort, appearance of the vocal folds, and s1 er. No

such pre- to postcondition differences were i‹tentified
in the i»1acebo group. Furthermore, no statistically signif-
icant pre- to postcondition differences were observed in
either group for phonation tloesliold pressure, auditory
i»erceptiial ratings of voice, and the acoustic measures
of jitter and signal-to-noise ratio.The authors concluded
that the sttidy provided early evidence in support of the
use of hydration as a form of treating vocal nodules and
Jaolyps (Level 1).
Solomon and DiMattia (2000) studied the impact of
hydration on the phonation tloesliold pressures of fotir
women dtuing periods of prolonged reading. Subjects
participated in a single subject ABAC design, where one
treatment condition was considered "liigh hydration"
anti cite coiiciiiioii *was consiciere‹i "row iiy‹iraiion." i iie
liigh hydration condition delayed the onset of elevat-
ed phonation threshold pressures in thee of four sub-
jects. Interestingly, the opposing dehydration condition
did not province increases in phonation threshold pres-
sures.The authors concluded that hydration maybe able
to reduce vocal fatigue secondary to prolonged talking
{Leuel. 11).
Finally, Yin and Chan (2003) studied the impact of
hydration and periodic voice rest on 20 nonprofession-
a1 Karoke singers. Subjects were randomly assigned to
a hydration + voice rest experimental grotip or a non-
hydration, nonvoice rest control. Subjects in the experi-
mental group received 100 ml of water and 1 minute of
voice rest following each song, whereas control subjects
clid not receive water or voice rests. Resiilts demonstrat-
ed that subjects in the experimental group were able
to sing significantly longer than subjects in the control
group @ <0.001). Furthermore, subjects who received
the hydration treatment saw no changes in acoustic or
percepnial measures from the pre- to postsinging condi-
tioi:s. Subjects in the experimental grotip experienced
mild acoustic changes following singing. In noting one
limitation of the snidy, the authors reported that neither
hydration nor vocal rest could be causally linked to the
improvements in the experimental group due to the
combination of the two measures in the study. However,
the authors concluded that hydration, when provided
along with periodic vocal rest, was beneficial in reduc-
ing the vocal fatigue of singers {Level 1).
Silent Cough. Several authors have reported the use
of the "silent cough" as a substitute behavior for cough-
ing and tlooat clearing behavior (Deem & Miller, 2000;
McFarlane, 1988; Zwittman R Calcaterra, 1973). Silent
cough has been characterized as a cough produced with
excessive airflow and limited sound production seem
R Miller). Zwittman and Calcaterra sugge5ted that use of
the modified form of coughing wotild permit only light
closure of the true vocal folds without associated clo-
YOICE THJiRAPY 57
siire of the false vocal folds hiring the cough response.
They proposed that such a closure pattern would re-
sult in less tension with the larynx during coughing.
Zwittman and Calcaterra proctuced the only article in
the literature reviewing the use of the silent cough. To
demonstrate the benefit of the method, the authors con-
sidered the cases of four individuals with voice prob-
lems related to coughing histories. The authors found
improvement in qualitative measures of voice quality
and laryngeal appearance for all subjects after initiation
of the silent cough. The authors concluded that the si-
lent cough method should be considered for inclusion
in therapy protocols for individuals with cluonic cough-
ing or tlooat clearing (beret ).
Voice Rest/Modified Voice Rest. The debate
over the use of absolute voice rest in the treatment of
functional voice disorders has ensued for some time.
Myerson (1958) was one of the first to question the
broad-based tise of absolute voice rest in the dysplionic
population, pointing out that some disorders will re-
spond to a rest protocol whereas others will not. Myer-
son suggested that vocal rest was appropriate only for
‹sci/ie cases of edema and swelling, as rest wotild have
no impact upon the fibrotic tissue changes present in
chronic pathologies.
Myerson’s conclusions are paralleled by many in the
field today.At present, absolute voice rest is felt by most
voice care professionals to be an essential component
of the treatment pzog;rzm only in cases of aciite laryn-
geal trauma or laryngeal surgery Boone, 1971; Deem R
Miller, 2000; Hicks R Bless, 2000; Prater, 1991; Sataloff,
1987).
Programs of modified voice rest, or voice conserva-
tion, have gained popularity in recent years. Such pro-
grams call for a reduction in the amount of voice use
as well as a modification in the style of voice tise (e.g.,
reduced loudness) for a specified period of time. Some
data regarding the influence of modified voice rest pro-
grams has emerged. Koufmann and Blalock (1989) com-
pleted a retrospective examination of postoperative
voice reduction programs in 127 patients. A portion of
subjects had engagecl in programs of absolute voice rest,
whereas others had used programs of voice conserva-
tion such as that described above. Outcomes suggested
that voice conservation programs were as beneficial as
absolute voice rest programs in controlling postopera-
tive dysphonia (Zeref . Van der Merwe (2004) devel-
oped a formal program of voice conservation called the
Voice Use Reduction Program.Two case stuclies present-
ed by Van der Merwe ctemonstrated improvement in vo-
cal fold appearance, improvement in voice quality and
reduction in vocal fatigue after the period of reduced
voice use {level V).
 Others have recommende‹t the tise of a whisper or a
quiet whisper as a means of voice rest. However, uncer-
tainty regarding the glottic configuration used in whis-
pered phonation has made endorsement of these meth-
ods difficult. Brodnitz (1958) suggested that whispered
phonation may be harmful to the vocal folds, as it was
produced by compression of the medial vocal fold
edges. Others, however, have reached different
conclusions re- garding glottal posture during the wlñsper
and have pro- posed that the whisper may be a safe
form of voice rest Jufnagle, 1993;Hufnag1e R
Hufnagle, 1983; Monoson R Zemlin, 1984). Several
snidies (Monoson R Zemlin. 1984; Rubin, Praneetvatakul,
Glierson, Moyer, R Sataloff, 2006; Solomon,
McCall,Trosset, R Gray, 1989) have elucidated tire
cortrocers / o/ v erriorisfiatirig tiiai a entire iorni or the
whisper does not exist. The studies fotinct that the
whisper may be produced in several manners. Different
methods of whisper production were associated with
different glottal configurations and, therefore, different
degrees of vocal risk. The above studies, although con-
ducted primarily to describe the physiologic basis of the
whisper, have elticiclated its therapeutic tise (Level V).
Thus, use of the whisper as a form of vocal rest has
not been confirmed or rejected in the literatiire.The lit-
erature suggests that a client’s manner of producing the
whisper likely determines whether the behavior will be
beneficial or harmful to the user.
Conclusions and Implications
A review of group studies investigating the use of
individual, didactic vocal hygiene training with persons
with voice disorders raises questions regarding the suf-
ficiency of hygiene training alone for management of
voice disorders. Studies conducted to date point to a su-
periority of clirect treatments over hygiene approaches
for treating voice disorders and call into question the de-
gree of change possible with vocal hygiene alone Hol-
mberg et a1., 2001; Roy et al., 2001;Verdolini-Marston et
a1., 1995).
Studies examining the potential for group-t›aseA hy-
giene training for altering vocal behaviors have raised
questions regarcling the effects of tliis form of treatment.
Snidies have demonstrated changes in knowledge lea-
e/ following traitfing (Aaron R Madison, 1991; Nilson &
Scli eiderman, 1983); however, these changes have not
consistently translated into changes in heiiaviot- (Broad-
dus-Lawrence et al., 2000; Chan, 1994; Timmermans ct
al., 2004, 2005).As a result, the benefit of gr r hygiene
training for preventing and managing voice disorders
has not yet been clearly demonstrated.
One s}aecific hygiene target that has yielded consis-
tent and promising results is the area of hydration. Sev-
eral well-controlled studies have identified reductions
in phonation threshold }aressure (Solomon & DiMattia,
2003;Verdolini et al.,1994;Verdo1ini-Marston et a1., 1990)
as well as improvement in vocal endurance Citi R
Chan, 2003) following hydration conditions.
Uiiforninately, on- ly one study has demonstrated the
benefit of hydration in subjects with diagnosed voice
disorders Jerdolini- Marston et al., 1994). Nonetheless,
the aforementioned hydration studies provide early
evidence to suggest that increased hydration may yield
reduced }ilionatory effort along with enhanced vocal
endurance, important con- siderations for the
treatment of voice disorders. Large- scale, controlled
studies examining the effects of hydra- tion protocols on
clinical populations are still needed.
A review of the above studies suggests that vocal hy-
giene training iacits atiequatc scientific evicience to sup-
port its use as a primary mode of voice treatment. Acldi-
tional work must be done before vocal hygiene methods
can be considered an effective form of voice manage-
ment. Until such research has been produced, vocal hy-
giene should be considered only as one part of a larger,
more comprehensive voice program.
In order to ensure the adeqrtacy of fiitiire
hygiene studies, research in the area of vocal hygiene
should con- sider the following design priorities. (1)
Designs shoiild allow for the consideration of hygiene
apart from other direct treatment influences. Studies
using a hygiene on- ly control group would be of benefit,
as would studies tising a hygiene only piiase of
treatment. (2) Hygiene protocols sliotild be clearly and
operationally defined; each component of the hygiene
protocol should be not- ed.Attention to such details
wotild allow for comparison of hygiene protocols across
studies and wotild elucidate key components of the
hygiene protocol. (3) Studies should consider the
impact of hygiene training on ac- nial subject behavior
and voice production.The investi- gation of slNs in
knowledge, although important, does not provide the
clinical information needed by profes- sionals within
the fielcl. (4) Changes in subject behavior and the degree
of subject compliance should be quan- tifiable. Without
adequate measurement of subject be- havior, few
conclusions regarding treatment outcomes can be
drawn. The use of quantifiable programs sticli as that
proposed by van de Merwe (2004) wotild help in the
monitoring of key hygiene factors. f5) Promising
methods of vocal hygiene management mtist be evalu-
ated in disor‹1ered populations.Although some methods
have been exa ed in this way, others have not. Once a
method has been found to be influential within the nor-
mal population, researchers must look for creative, yet
rigoroiis, ways of examining its benefit in a disordered
population.
Indeed, research has yet to paint a clear picnire re-
garding the influence of vocal hygiene treatment mod-
els on voice disorders.As research rigor within the field

advances, perhaps the place of vocal hygiene in the
treatment program will become clearer. Until that time,
hygiene methods should be viewed as an adjunct to
comprehensive models of symptomatic or physiologic
treatment.
Evidence for Symptomatic
Voice Therapy Methods
Symptomatic voice therapy, as originally defined by
Boone (1971), involves therapy aimed at the modifica-
tion of vocal symptoms. In 1us original presentation of
the treatment approach, Boone identified 20 techniqiies
capable of modifying aberrant vocalsymptoms (seeTable
2). In recent years, additional facilitating methods have
been added to the list of symptomatic methods (Boone
R McFarlane, 1988;Boone, McFarlane, &Von Berg, 2005).
For the purpose of tliis review, a therapy method was
considered ”symptomatic” if it aligned closely with
one of the tra‹Jitiona1 facilitating methods listed in Table
2, pc ñ it focused on the modification of an isolated vocal
symptom for correction of voice.
Interestingly, many outcomes snidies related to
symptomatic treatment have failed to isolate a specific
facilitating method for investigation. The studies have,
rather, examined comprehensive symptomatic programs
composed of a variety of facilitating methods. As a re-
salt, few studies share data on a single technique. For the
purpose of tlus review, snidies examining the effects of
specific facilitating methods are prioritized and are pre-
sented first. The section concludes with a brief review
of studies examining coinptei›ensive symptomat‘ic pro-
grams that have incorporated more than one facilitating
technique into the protocol.
facilitating Methods
Pushing. The ptislfing approach was first presented
by Froeschels (1944) as a means of managing weakness
of the son palate. Froeschels, Kastein, and Weis (1952)
built upon tliis early work and siiggested use of the
method for individuals with inadequate glottic closure.
The puslfing method was based tipon the premise that
the rapid and voluntary contraction of one set of mum
c1e5 would result in the contraction of other groups of
muscles (Froescliels et al., 1955).The authors suggested
that quick, intentional movements of the arms would
enhance contraction of the laryngeal mtisculatiire, and
thereby, increase vocal fold closure. Boone (1971) pro-
posed a slightly different rationale for the puslfing meth-
od. He noted the tendency for the larynx to undergo re-
flexive closure during moments of heavy exertion. From
VOICfi TI-IERAPY 59
tliis principle, lie concluded that heavy exertion cotild
be used to bring about improved vocal fold closure for
voicing.
The pushing method calls for clients to sustain plio-
nationwlfile engaging ineffortfulptisl rig.The combined
effort is purported to yield an increase in glottic closure
and an increase in loudness. Once basic phonation is en-
hanced with pushing, the client is trained to monitor the
improved voice tlirougli the aiiclitory channel.When the
client appears able to monitor productions, the Jatislñng
action is slowly faded.The improved voice is generalized
to corinected speech Boone, 1971).
Over the years, only two articles have been produced
discussing the clinical benefit of the pushing method.
iii i955, Froesclieis er at. fiisciis-seri ciiificai cxpcricnccs
with the pushing method, reporting sticcessñil tise of
the method with a variety of neurologic as well as non-
neurologic diagnoses. In the article, the authors shared
the case studies of five individuals i inadequate vocal
fold closure who had been treated with the method.All
cases responded to the method and demonstrated Zinc-
tional gains with treatment {Level ).
A second article by Yamaguclii et a1. (1993) dis-
cussed the effect of the ptislñng method on vocal loid-
ness.Yamaguc1ii and colleagues shared the case studies
of thee inctividuals, two with vocal fold paralysis and
one with sulcus vocalis. The individuals participated in
20- to30-minute therapy sessions where the pushing ap-
proachwas trained. Sessions were conducted once per
week until a training effect was:ippreciated.At the close
of therapy, all subjects demonstrated an increase in vo-
callotidness levels, although the degree of change varied
from 7 to 22 dB and the ability of subjects to generalize
the increased loudness varied. In addition, some cases
exhibited signs of vocal fold inflammation and extrane-
ous compensatory movements within the larynx follow-
ing training.The auUiors suggested that the study pvoviR-
ed early evi‹1ence iii support of pushing for disorders of
vocal fold approximation btit cautioned that users must
be aware of limitations regarding generalization and po-
tential laryngeal compensation. {Leuel V).
Humming. The humming metliocl, as ctescribed by
Colton and Casper (1990), involves the use of a lium to
traineasy,relaxedplionation.Tlieteclmiqueis basedu}aon
the premise that humming affords the client increased
proprioceptive feedback from oronasal resonances and
decreased feedback from laryngeal resonances. The re-
sult of such a shift slioulcl be a more relaxed mariner
of production (Colton R Casper, 1990).Yin and Ho (2002)
examined the humming method of voice treatment.
Eight subjects with liyperftinctional voice disorders
were matched with eight normal controls. Each partici-
pant underwent two, 45-minute training sessions using
 Table 2. Facilitating Approaches Used in Symptomatic Therapy

Altering tongue position X

Auditory feedback X
Change of loudness X
Chant talk X
Chewing •i»proach X
Confidential voice*
Digital manipulation X
.far training X
F.liii i a.y.tion. of n.b srs x
Elimination of hard glottal attack X
Establishing new }aitch
Explanation of the problem X
Feedback X
Glottal fry K
Half-swallow, boom X
Heacl positioning x
Hierarchy analysis
Inhalation phonation x
Laryiigeal massage* X
Masking x
Nasal glide stimulation X
Negative practice X
O{aen mouth approach X
Pitch iriflections X
Place the voice/Focus X
Pushing aJaproacli X
Redirected phonation X
Relaxation X
Respiration training X
Target voice models X
Tongue lirotrtlsion X
Voice rest X
Yawn-sigh a}aproach X

* Considered a form of physiologic v‹›ice therapy in this review

the humming technique. Auditory perceptual measures
of roughness and breatliiness were taken along with
various acoustic measures one week before the onset of
therapy, the day of Uierapy initiation, and one week fol-
lowing the final session. Both the dysplionic group and
the normal control group demonstrated improvements
in roiighness ratings and increases in fundamental fre-
quency following the humming training. In addition, the
dysplionic group, wlñcli began treatment as significantly
different from controls on rouglmess cuff breatliiness
parameters, concluded Uierapy with significant differ-
ences only on ratings of rouglmess. The authors con-

chided that humming was an appropriate method of re-
ducing vocal liyperfiinction and bringing abotit desired
changes in voice production (Level III).
Chewing. The chewing approach was originally de-
scribed by Froescliels (19(3, 1952). According to Froe-
scliels (1943) voice production in humans likely began
as an adjunct to the chewing process. Froescliels pro-
posed that the use of chewing motions during voice
production woiild return the client to the most natriral
and basic mode of voice production and distance the
client from any aberrant patterns of production. Froe-
scheds’ method required that the patient begin with a
period of isolated chewing motions. Such motions were
eventually during connected speech. In one of lbs early
presentations of the method, Froescliels (1943) illustrat-
ed the use of the chewing method with five individuals
with voice disorders. Cases included persons with the
organic pathologies of vocal fold paresis, cyst, and pzp-
illoma as well as persons with functional disorders of
a liypo- or hyperfiinctional nature. Froescliels reported
resolution of voice symptoms in all five of the cases fol-
lowing tise of the chewing method (here/).
In 1952, Froescliels again presented the chewing
method and shared its benefit in cases of mutational
voice, hyperftmctional voice, and "deâf” voice. Again, lie
concluded that the chewing method was beneficial in
retnrning the voice to normal in all three cases {Level ) .
Finally, Brodnitz and Froeschels (1954) examined
the use of chewing in six individiials witll vocal nod-
ules. Voice quality and vocal fold appearance were con-
siclered prior to and following therapy with the
chewing method.According to the authors, five of the
six cases of nodules were corrected with the use of the
method.The authors concluded that the technique was
successfiil in treating nodules, as it reduced pitch and
muscle tension during voice production. Since early
descriptions of the chewing method, variations of the
chewing approach have appeared in other classic voice
texts Boone, 1971; Colton R Casper, 1990; Van Riper R
Irwin, 1958); how- ever, outcomes studies related to the
chewing method have not been producecl iñ the literanire
since the afore- mentioned works of the 1940s and 1950s
(here/ F).
Yawn-Sigh. The yawn-sigh approach was presented
as one of Boone’s (1971) original 20 facilitating metlv
ods.According to Boone, production of a yawn worked
to open and relax the pliaryngeal cavity. Boone hypoth-
esized that performing a yawn just prior to phonation
would yield phonation in the context of a relaxed vocal
tract. Thus, the yawn-sigh method took advantage of a
vegetative function to bring about a more relaxed man-
ner of voice production.
VOICE THERAPY 61
One of the first discussions of the yawn-sigh meth-
od in the literature was by Brewer and McCall
(1974). The authors reviewed three sym}›tomatic voice
therapy metliocts via the presentation of case studies.
One case study involved use of the yawn-sigh method
with an in- dividual with ventricular phonation.
Laryngeal exami- nation verified that the yawn-sigh
maneuver eliminated ventricular fold closure; however,
the corrected man- ner voice production was not
generalized to connect- ed speech (Zeref F).
Interestingly, McFarlane (1988) also considerecl the
yawn-sigh as one element of a treatment program for
ventricular phonation. McFarlane re}iorted elimination
of the ventricular voice Motoring 25 treat- ment
sessions where a combination of yawn-sigh and in-
halation phonation was applied {Level V)
A third examination of the yawn-sigh approach was
completed in 1993 when Boone and McFarlane exam-
ined the physiologic underpinnings of the approach.
Eight adults without histories of voice disorders were
asked to produce a yawn followecl by a sigh. Measure-
ments of acoustic output and pliaryngeal dimensions
were taken during the productions.The authors identi-
fied a lowering of the larynx in the neck as well as a
wid- ening of the pliarynx during the yawn-sigh
maneuver. No changes in nindamental 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 yawn-sigh would be usefiil for
cases of vocal liyper- ftinction, as it moved the vocal
tract into a more relaxed position (Zeref V).
Most recently, Xu, Ikeda, and Komiyama (1991) ex-
amined a related approach termed the yawn breathing
pattern. Ninery-one subjects with varying voice diagno-
ses were enrolled in the smdy. 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"ñ of cases were able to successfully perform the
yawning ma- neuver at the close of therapy. However,
subject self-rat- ings of improvement in voice with
treatment suggest- ed that only 37"fi reported
satisfactory improvement and 57’ñ reported fair
improvement following treatment.The authors identified
that those subjects reporting satisfac- tory improvement
also demonstrated improvement in laryngeal condition
as well as improvement on acoustic and auditory-
perceptual measures of voice. Subjects re- porting lower
degrees of satisfaction with the treatment method did
not demonstrate similar degrees of change on the above
measures.The authors concluded that use of the
yawning method along with visual feedback on
62 COMMUMCATIVE DISORDERS REVIEW,VOL. 1, NO. 1
respiratory patterns is an appropriate method of voice
treatment (Zerc/ . a calm attitude and progressed to the point of self-relax-
Feedback. The tise of feedback in various forms for
the correction of voice problems has been proposed for
some time Boone, 1971;Van Riper & Irwin, 1958).
Early tises of feedback were nidimentary, requiring the
pa- tient to cup lits or hands to the ears to enhance
auclitory monitoring of the tone Jan Riper & Irwin,
1958). Since that time, however, teclmologic advances
have allowed for adclitional methods of auditory and
visual feedback. Several studies have examined the
benefit of feedback for enhancing progress in therapy.
At least fotir stuclies have examined the tise of sur-
face electrom yograpliy ( EMG) as a form of feedback for
vocal liyperfiinction (Andrews,Warner, R Stewart, 1986;
Prosek, Montgomery, Walden, R Schwartz, 1978; Stem-
ple,Weiler, Wluteliead, R Komray, 1980;Yiu,Verdolini, R
Chow, 2005).Prosek et al.(1978) used EMG with a grotip
of subjects of varying diagnoses, including: vocal nod-
ules, spasmodic dysphonia, contact tilcer, traumatic far-
yngitis, and laryngeal carcinoma (post-tiimor removal).
Three of six subjects using EMG biofeedback saw reduc-
tion in EMG activity after 14, 30-minute treatment ses-
sions.The other thee individuals receiving biofeedback
did not demonstrate changes. The authors concluded
that EMG may facilitate motor relearning in some, but
not all, cases of vocal hyperfunction {Level .
Stemple et al. (1980) enrolled 21 normal subjects
and seven subjects with vocal nodules in a study of EMG
biofeectback. Baseline measures of all subjects indicated
luglier levels of muscle activity at rest and during voice
production for subjects in the vocal nodule group. Sub-
jects diagnosed with vocal nodules tmderwent eight,
45-minute treatment sessions using EMG biofeedback.
At the close of therapy, subjects with nodules demon-
strated a significant reduction in tension during voice
proctuction (N = 2.32;p <0.05) and at rest (I = 5.67;p
<0.001). Furthermore, 86a of subjects saw improve-
ment in auditory perceptual ratings voice, while five of
six saw improvement on laryngeal eaamination post-
therapy.The authors concluded that EMG was an appro-
priate biofeedback meHiod for the treatment of voice
clisorders tlevel IV).
Andrews,Warner, and Stewart (1986) compared the
effects of surface EMG and progressive relaxation on in-
clividtials with liyperfunctional voice disorders. Ten fe-
males with liyperfunctional dysphonia were divided in-
to five matched pairs. Individuals with the pairs were
alternately assigned to receive either the EMG treatment
or the progressive relaxation treatment. Electromyo-
graphic treatment involvect the placement of a surface
electrode in the region of the cricothyroid muscle. Sub-
jects monitored the degree of muscle tension by obser-
vation of needle movement on the EMG unit.The pro-
gressive relaxation treatment began with the creation of
ation. The number of treatment sessions ranged from 4
to 15. Results showed that both EMG and progressive
relaxation reduced the degree of muscle tension in the
laryngeal region during phonation. Furthermore, both
treatment methods yielded improvements in voice quali-
ty, vocal control, and self-rated severity. No significant dif-
ferences were found between the two treatment meth-
ods.The authors concluded the surface EMG was useñil
in the management of vocal liyperfiinction (Zeref NJ.
Most recently, Yiti, Ver‹1olini, and Chow (2005) at-
tempted to refine the field’s knowledge in the area of
EMG. Specifically, the authors set forth to determine
WiiiCii U/pié iii 3iiiiiiiié mvic u1‹iiCcuL*i‹ii(—iit•H1iitil’l’Ciii
or terminal—was most advantageoiis in producing re-
laxed laryngeal musciilattire.Twenty-two subjects were
divided into a concurrent feedback group and a termi-
nal feedback group. Subjects in the concurrent feedback
group received real time displays of muscle activity from
the th roli oid area anci the orofacial region (control)
during speech production. Subjects in the terminal feed-
back group received feedback from the aforementioned
sites only upon completion of an utterance. Results dem-
onstrated no clear difference between the two types of
EMG feedback. Furthermore, the authors found no evi-
dence of reduced muscle activation in the laryngeal area
with either feedback types. In an interesting, and unan-
ticipated finding, the authors identified a reduction in
muscle activity at the orofacial control site. The authors
hypothesized that the liigh degree of focused attention
on the laryngeal site during biofeedback training may
have limited motor learning in that area, although allow-
ing for incidental learning in other areas.The snidy sug-
gested that continuect work must be done to examine
the motor learning effects of biofeectback approaches
{Level II).
Other authors have examined the tise of acoustic
and aerodynamic feedback for voice management.Yama-
gticlii 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 nodules obtained visual feedback of airflow
rate, pitch, and intei:sity from the pliOnolaryngogr•P
The usefulness of the approach was determined by pre-
to post-treatment comparisons of laryngeal appearance.
Findings demonstrated that nodules were reduced or
eliminated in 65% of cases after 3 to 4 months of bio-
feedback training. The authors concluded that visual
feedback would be an appropriate nonsurgical interven-
tion for vocal nodriles {Level IV).
More recently, Laukkanen, Syrja, Laitala, and Leino
(2004) conducted a randomized control trial compar-
ing therapies using visual feedback of spectral data to
 VOICE THERAPY 6

conventional therapies without feedback. Twelve act-

on average, two hours less in therapy than the tradition-
ing students were divided into experimental (biofeed-
al group (p <0.01.).The authors concluded that visual
back) and control (traditional) groups and monitored
feedback with the use of the flexible scope during treat-
for their ability to acqture a targeted manner of voice
ment may be a beneficial component of therapy, as
production labeled a “ringing”voice. Subjects in the
it may serve to reduce the degree of time required for
con- trol group were provided with a verbal description
suc- cessltil management of the condition (beret .
and model of the target voice; subjects in the
experimen- tal group received the aforementioned
Change of Loudness. Boone (1971) proposed
guidance along with visual feedback of long-term
change of loudness as one of lits original facilitating
average spectnim da- ta. Both groups saw improvement
methods. In his original presentation of the approach,
in voice quality as well as enhancement of spectral
he suggested tllat the method could be used for disor-
energy at the 3 to 5 kHz range. Fundamental frequency
ders of increased or decreased loudness. Boone’s meth-
changes varied across groups, with the biofeedback group
od began with an awareness phase, where attention was
seeing an in- crease in F, and controls seeing a decrease.
drawn to the deviance of the patient’s loudness level.
Finally, the uioieecliiacii groiip saw sibiiiricaiitiy greater
ixn cxpioraiion/manipulation piiasc foiioweci, wiiere
reciuctiuns in the relative dB than did the control group.
desired loudness was determined and then generalized.
The au- thors concluded that the study provided support
Since Boone’s initial proposal of this tecluiiqiie, other
for the use of biofeedback as an adjunct to conventional
methods of altering vocal loudness feanire have been
forms of treatment {Leuel I).
proposed olbrook, Rolnick, R Bailey, 1974; Lodge
In a 1988 study, Bastion provided one of the earli-
RYarnall, 1981; Roy et a1., 2002). Information related to
est calls for the use of laryngeal videostroboscopy as a
the methods is presented below.
therapeutic feedback tool. At least two studies have ex-
Holbrook et a1. (1974) examined the benefit of a de-
amined the benefit of real-time laryngeal visual feedback
vice for reducing loudness.The authors fitted 32 patients
on therapy outcomes. In 1987, D'Antonio, Lotz, Chait,
with vocal pathologies and histories of vocal abtise with
and Netsell presented the case of a 22-year-old female
vocal intensity controllers QC). The devices provided
status—post a crushing injury of the laryrix. The sub-
auditory feedback to patients at moments when voice
ject received traditional therapy along with visual feed-
production exceeded desired loudness levels.The mean
back of laryngeal function and subglottic air pressure.
therapy course with the VIC was 5.3 weeks, with a
Pre and post-treatment comparisons after fotir sessions
range from 2 to 12 weeks. Eleven of the 32 subjects saw
demonstrated voice, aerodynamic, and laryngeal ratings
com- plete resolution of laryngeal pathologies, whereas an
near the range of normal. One-month follow-up exami-
ad- ditional eight of the 32 subjects saw significant
nations demonstrated the maintenance of improvement
reduc- tion in lesion size on laryngeal exam. Only three
in aerodynamic and laryngeal measures. The stiidy pro-
stiblects
vided early information related to the successful incor-
saw no change in loudness with the approach. Remain-
poration of visual feedback of laryngeal fiinction into
ing subjects either left the study before completion or
the treatment setting (beret .
were diagnosed with liyperfiinction only, making track-
Rattenbury, Carding, and Finn (2004) also examined
ing of lesion size inappropriate.The authors concluded
the therapeutic benefit of real-time visual feectback of
that feedback devices such as the VIC were helpful in
the laryngeal strictures. The authors completed a pro-
re- ducing loudness levels in persons with voice
spective randomized control trial on 50 consecutive
disorders level IV).
subjects with muscle tension dysphonia. Subjects were
Lodge and Yarnall (1981) used an ABAB reversal
randomly assigned to a traditional therapy grotip or a
transnasal flexible laryngoscopy (TFL) assisted group. teaching/research design to examine the use of a striic-
Subjects in the traditional therapy group received vo- mred program of cueing and reinforcement for the man-
cal hygiene training as well as direct therapy using a va- agement of loudness. The subject was a 24-year-old fe-
riety of symptomatic therapy methods. Subjects in the male with moclerate mental impairment. The authors
TFL-assisted group received the above noted protocol demonstrated the successfiil use of the behavioral ap-
along with visual feedback of the larynx. Auditory per- proachin reducing the patient’s loudness to target lev-
ceptual ratings of the voice, jitter, shimmer, and patient els.The subject was able to maintain the reduced loud-
self-ratings of vocal performance were monitored along ness levels during three follow-tip sessions.The authors
with the amount of time spent in therapy. Results indi- concluded that the stnictured use of positive and nega-
cated that both groups saw significant improvement in tive reinforcement was successfiil as a treatment meth-
auditory perceptiial, self-rated, and acoustic measures of od btit cautioned that generalization from the single
voice; however, subjects in the TFL-assisted grotip spent, case study would be inappropriate {level V).
Finally, Roy et a1. (2002) examined the tise of voice
amplification devices for the management of loudness
concerns. Fifty teachers were randomly assigned to ei-
that behavioral interventions, such as inhalation phona-
ther a vocal hygiene group, a voice amplification grotip,
tion, were only successful in cases where the ventricu-
or a control group. Subjects in the treatment groups par-
lar phonation was n.inctional, and not compensatory, iii
ticipated in four treatment sessions over a Gweek pe-
nature (Seve/).
riod.At the close of intervention, only the amplification
group saw significant improvements on the VHI, self-rat-
Digital Manipulation/Digital Pressure. Boone
ings of severity, and acoustic measures. Vocal hygiene
(1971) presented digital manipulation as a method for
anct no-treatment control groups failed to demonstrate
lowering pitch. According to Boone, the application of
significant improvements on any of the measured vari-
digital pressure to the thyroid cartilage would tilt the
ables. Finally, on a post-treatment questionnaire regard-
cartilage posteriorly, and thereby, shorten the true vo-
ing the benefit of treatment, the amplification group
cal folds.The shortened and tluckened vocal folds wotild
consistently reported greater levels of perceived bene-
yield a lower pitch production.
fit than the vocal hygiene group. The authors conclud-
Limited attention has been given to the teclmiqtie in
ed that voice amplification devices were beneficial in
the literanire. Fiuthermore, most authors discussing the
arM.ging a or:I ..pr ;•g,•rrg • i: I ir. i.G - . /qi« - p/• h er.ii
ins unet ii‹i”fc ttsc vi cii@ic‹ti mining ciiaviGii ui pwi up u iAcioi i
cirig vocal loudness (Level I) .
with other tecluiiqiies. Such protocols have made it dif-
ficult to ctetermine the contribution that digital manipu-
Inhalation Phonation. Inhalation phonation was
lation offered in the patient’s outcome. Despite tlus limi-
originally proposed by Boone (1966) as a means of fa-
tation, two articles discussing digital manipulation are
cilitating true vocal fold phonation in cases of functional
reviewed briefly.
aplionia. The approach called for patients to produce a
McFarlane (1988) reported using digital pressure as
soft tone on inhalation. Once capable of producing the
one component of a treatment program to lower the
inhaled tone consistently, the client was asked to pro-
pitch of a male with mutational falsetto voice.The treat-
duce a matching tone on exhalation.The voicing on ex-
ment protocol established normal pitch, and therapy was
lialation was then generalized to other speech contexts.
completed in five sessions (beret F). Maryn et a1.
Boone’s (1966) use of the method was based upon
(2003) used digital manipulation for management of
earlier work in the field of radiology that demonstrated
ventricular phonation. The method, when combined
the mechanics of inhalation phonation. During inhala-
with a series of other methods, eliminated ventricular
tion phonation, Use false vocal folds take on a retract-
phonation in only one of thee cases.The authors
ed posture.As a result, the false folds become incapable
concluded that be- havioral methods, such as digital
of contributing to inhaled voice production. Boone held
manipulation, may be of benefit only in cases of
that voicing on inhalation could, therefore, be used to
noncompensatory ventricular voicing Level V).
bring about contact of the true vocal folds without asso-
ciated contact of the false vocal folds.
Relaxation. Literanire in the field has consistently
Research on the inhalation phonation method has
demonstrated the relationship between liyperfimctional
been limitect. In Boone’s (1966) original presentation
patterns of voice tise and the development of voice dis-
of the method he reported on rise of the method with
orders Boone, 1971; Boone R McFarlane, 1988; Boone,
two cases of fiuictional aplionia.The inhalation method
McFarlane, R Von Berg, 2005; Murphy, 1964; Van Riper
elicited voicing in both cases, and individuals returned
R IrWin, 1958).As a result, the application of relaxation
to normal ñinctioning following a minimal number of
methods to the treatment voice disorders has been sug-
treatment sessions (Zere/ F). McFarlane (1988) report-
gested for many years. Such relaxation techniques can
ed on the use of inhalation phonation in combination
be considere‹t as falling into two categories. One group-
with the yawn-sigh method for the management ventric-
ular phonation. McFarlane presented the case of a 70- ing of relaxation methods targets direct relaxation of the
year old male who returned to true vocal fold phona- body strictures. The target of direct relaxation proce-
tion after 25 treatment sessions employing the above clues may be the whole body or simply the upper body,
methods JevelV). Maryn, DeBodt, and Van Catiwenberg head, and neck. Techniques such as Jacobson’s (1942)
(2003) also included inhalation phonation in their arti- progressive relaxation and Boone’s (1971) head rotation
cle discussing treatment options loz ventricular phona- may be considered as direct relaxation methods. Other
tion. The authors presented the cases of three individ- methods achieve relaxation iiirfirectly.Techniques sticli
uals with ventricular phonation of varying etiologies. as the yawn-sigh, chewing, and chant talking can be con-
Interestingly, inhalation phonation and other facilitating sidered in this grouping. In tlus section of the paper; the
methods were only successnil in restoring true fold pho- effects of dii’eCt refm‹sfiOt? treatments are reviewed.
nation in one of the thee cases.The authors concluded 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 thee studies
addressing direct relaxation cotild be found in the
voice literanire. Gray, England, and Mahoney (1986)
examined a method of relaxation termed reciprocal
inhibition. The authors presented the case report of a
27-year-old female who presented 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- gage 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- Nett
sitiiatioris wifiioiii accuiiiiiiaiioii Ol tension. in ati‹ii- tion,
a follow-tip examination of the laryngeal strictures at the
close of therapy revealed a reduction in swelling of the
vocal folds.The authors concluded that the meflv 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 liyperfiinctional 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 sublects in both groups saw
reduced muscle tension in the laryngeal region follow-
ing therapy. Furthermore, voice quality, self-rated voice
severity, and vocal control proved 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 liyperfiinction level II
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, respiration 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 norlules as well as improvement
in multiple voice parameters. However, the study dem-
onstraterl that the relaxation training component did
not contribute independently to the subjects’ outcomes.
Thus, the authors concluded that relaxation training was
not a beneficial means of managing vocal nodules {Lev-
el II).
Place the Voice. According to Boone (1988) many in-
dividuals with voice disorders maintain an inappropriate
mental focus on the laryngeal region.As a result, lie pro-
posed that individuals with vocal hyperfunction should
be tmined to shift the vocal tone away from the neck and
into the midface region. Boone proposed that training be-
gin by tising 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 faded.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 Uie physiology of the voice place-
ment approach. The authors used voice placement to
treat an individual with vocal fold edema and inappro-
priate patterns of muscle tension. Fiberoptic laryngos-
copy performed wlule the patient performed the voice
placement teclmiqtie confirmed the method’s ability to
reduce tension patterns in the larynx. Following treat-
ment, the patient demonstrated reduced glottic and su-
praglottic tension during voice production.The authors
concluded that the method was successñil in altering
laryngeal fiinction and achieving the desired pattern of
voice use {Level V). tn 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
lugl£iglited the importance of pitch modification in the
therapeutic process Boone, 1971; Murphy, 1964). Preva-
lent at the time of the writings was the concept of opti-
mum pitch. Leaders in the 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 tlus premise, Boone presented a treatment
protocol for establislfing a new pitch.
The rationale behind direct pitch modification i»ro-
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 Boone, 1988). Seconct, pitch modification in cas-
es of mass lesions of the vocalfolds has been challenged.
In 1971, Boone stated,"problems of mass and size of the
vocal fol‹Js resulting in inappropriate voice pitch levels
are sometimes helped by direct attempts to change the
pitch level"(p. 127). £ew in the field today would
ascribe to sticli a statement. Prevalent in the field
today is the belief that pitch disnirbances related to
“mass and size” changes of the vocal folds should not
be dit-cctly man- aged in therapy.These disturbances,
rather, should be al-
 lower 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 tise with cases of fiinctional
pitch disorders.
Despite the method’s popularity for many years, arti-
cles related to the effects of behavioral methods of pitch
alteration have been limited. In fact, only two articles dix
cussing the development of a new pitch cotild be iden-
tified in the literatiire.' In 1970, Fisher and Logemann
demonstrated successftil elevation of pitch in a 19-year-
old actress with vocal nodules. The subject tmderwent
18 months of voice therapy to raise her pitch from 190
Hz to 250 Hz. At the close of therapy, the authors re-
ported ftinctional improvement in the subject’s voice.
Furthermore, instnimental measures suggested changes
in vibratory patterns of the folds following therapy.The
subject demonstrated a post-treatment increase of the
open quotient and reduction of the speed quotient.Ac-
cording to the authors, these changes indicated reduced
perio‹Js 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
(1988) also used pitch elevation with an individual witll
vocal nodules. In the case report, McFarlane suggested
that pitch elevation was successful in clearing the vocal
tone. The pitch teclmique, when employed with other
techniques to relax and refoctis the voice, was siccess-
fii1 in eliminating the subject’s vocal nodules (level V).
Redirected Phonation. Boone (1966) described a
method by which vegetative functions, such as throat
clearing, cotiglNg, and laughing, could be tised to fa-
cilitate voicing at the level of the tnie vocal folds. In lbs
original presentation of the method, Boone used light
coughs to elicit vocal fold contact. The coughs were
then modified and extended into sustained phonation.
Although not presented as one of lits original facilitating
methods, Boone added redirected phonation in a later
edition of 1us classic teat Boone et a1., 2005)
A search of the literatiire suggested that Boone’s ini-
tial presentation of redirected phonation in 1966 serves
as the only consideration of the method in the literature.
In the article, Boone presented the case reports of two in-
dividuals with ñinctional aplionia. Both individuals were
treated wifli a combination of redirected phonation
ight cougl g) and inhalation phonation.The teclmiques
were sticcessfiil in restoring the inctividuals to normal
voicing in a minimal number of sessions tlevel V).
'Use of digital pressure to lower pitch in cases of mutational voice is presented separately in tlus paper.
Symptomatic Methods—
Comprehensive Programs
In the past few decades, a number of authors con-
sidering the influence of voice therapy have employed
symptomatic methods in their investigations Qlocli,
Gould, & Hirano, 1981; Dnidge & Phillips, 1981; McCro-
ry, 2001; Mtirry RWoodson, 1992).These studies, though
not capable of yielding information on specific methods,
do shed light on protocols that adhere to symptomatic
models of treatment.
Dnidge and Phillips (1976) employed yawn-sigh,
pitch alteration, easy voice onset, and other symptom-
atic methods in their snidy of the role of shaping in
voice therapy. Tile authors conciuueci inal me facuiiai-
ing 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 V).Bloch, Gould, and Hirano (1981) used methods
stich as pitch elevation, reduction of hard glottal attack,
and respiration training for the treatment of 17 individ-
uals with vocal fold grarruloma. Pre- to post-treatment
comparisons suggested that granitloma were eliminated
in 9 of 17 patients and reduced in size in 4 of 17 patients.
The authors concluded that symptomatic voice therapy
was useful in treating many cases of vocal fold granulo-
ma (Level IV). Murry and Woodson (1992) tised symp-
tomatic methods such as reduction of hard glottal attack,
relaxation, and altering tongue position in their exami-
nation of various management styles for vocal nodules.
Again, the voice therapy methods used by the authors
were successful in improving the voice of subjects {I.ei›-
el ) . Finally, McCrory (2001) conducted a retrospective
audit of 26 patients with vocal nodules. Subjects were
treated with methods such as chewing, yawn-sigh, voice
placement, and pitch alteration. Following treatment,
70a of subjects saw a reduction or elimination of no‹l-
ules, whereas 90%› were rated by speech-language pa-
thologists as having voices that fell witlfin the normal
or mildly dysplionic ranges. {Level V). Tints, these smd-
ies demonstrate the potential benefit of a symptomatic
protocol in the treatment of voice conditions; however,
the lack of rigorous, well-controlled group designs limits
widespread generalization of findings.
A review of symptomatic therapies reveals concerns
related to the strength of research witlfin tits orienta-
tion. The majority of studies discussed above demon-
strated a lack of rigor in their research design.As a result,
many of the facilitating methods witlfin the symptomat-
ic model have been supported only by Level IV or Level
V evidence.Although the studies provide early evidence
for the tise of a method, firm efficacy conclusions can
not be derived from these studies. Second, few of the
above stiidies examined the influence of specific symp-
tomatic teclmiques. Authors reported on the effects of
comprelensiue 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
iiaiiniiiCPv iiiiiiiigii iTiiiiii ié g iiii Siiiufc:S. i-l’iiiillSi2ib
lines of research have emerged suggesting the benefit
of various forms of biofeedback for relaxing the larynge-
al mtisculature. 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
futiire development of even more sophisticated biofeed-
back methods.
If symptomatic methods are to be considered as po-
tential tools of therapy in the ñiture, research in tlus area
must advance on two fronts. First, the theoretical foun-
dations of symptomatic methods must be examined. As
sophisticated instnimentation was not available at the
time of symptomatic therapy’s emergence, the physio-
logic underpinnings of many symptomatic methods have
not been demonstrated. Researchers should employ the
advanced instnimentation now available in the field
to examine the physiology beliirid these conventional
methods. Secondly, the symptomatic methods must be
examined more Billy 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 sticli approaches have ris-
en to the surface as primary protocols under the physi-
ologic umbrella: Confidential Voice Therapy (Colton R
Casper, 1990),Vocal Function Exercises (Stemple, 1993),
the Accent Method (Smith & Thyme, 1976), Manual La-
ryngeal Musculoskeletal Reduction (Aronson, 1990; Roy,
1993; Roy & Leeper, 1993), Resonant VoiceTlierapy
Jes- sac, 1965; Roy,Weinrich, Gray,Tanner, Stemple, &
Sapien- za, 2003;Verdo1ini, 2000), and Lee
SilvermanVoice Treat-
ment Jamig, Countryman, Thompson, & Horii, 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-
man Voice Treatment, although a well-research proto-
col for treating netirogenic voice anal speech concerns,
does not target the treatment of fiinctional disorders
and does not, therefore, meet the review criteria for tlus
paper. Lee Silverman Voice Treatment is discussed at the
close of the paper as a model of efficacy research with-
in the field.
Articles examining any one or a combination of the
ai›ove live proiocois were inciu‹ie‹i in tire review. Stu‹iies
ex:imiriing procedural modifications of the above meth-
ods were also included as long as the basic foundations
of the method were preserved in the study.
Furthermore, articles examining the theoretical and
physiologic un- derpinnings of the above protocols were
considered as evidence and were, therefore, included in
the review. Ev- idence pertaining to each of the above
five protocols is presented below.
Con dentiaf Voice
Confidential voice therapy was originally presented
by Colton and Casper (1990). In their text, the authors
proposed the technique as a means of reducing glottic
compression in cases of vocal 1iyperñmction.The tech-
nique calls for individuals to speak in a soft, nonwhis-
pered, breatliy tone for all communicative interactions
over a period of several weeks.Fotmdational to the
meth- od is the belief that the confidential tone yields a
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;(3) retraining of pleasing
and rate patterns;
(4) reduction of muscular tension during phonation; and
f5) elimination of strained or tight breathe i»atterns
(Casper, 2000). It should be noted that the confidential
voice protocol exists within a larger, more comprehen-
sive treatment program that includes vocalliygiene man-
agement and resonant voice training (Casper, 199a.
Early in therapy, the confidential voice is trained and
clients are instructed to rise 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 discontintiation of the confiden-
tial voice.Therapy concludes with gradual fading of the
 confidential voice and gradual incorporation of the reso-
nant voice into fiai1y conversations (Casper, 199a.
Casper (2000) and Colton and Casper (1996) spoke
to the theoretical model underlying confidential voice
therapy. The authors provided summaries of fiberoptic
and aerodynamic snidies conducted on subjects during
production of the confidential voice. Snidies identified
the presence of incomplete glottic closure along with
aerodynamic changes indicative of the desired glottic
closure pattern during prodiiction of the target voice.
The authors concluded that the findings supported the
use of confidential for therapy for cases of vocal 1iyper-
function. The authors noted, however, that the same
studies identified glottic closure patterns indicative of
iiyperiiuiciioii iii sortie siibjects Clasper, zu0o; cotton &
fiasper, 1996).Thus, glottic closure patterns in confiden-
tial voice procluction may vary from subject to subject,
being appropriate in some subjects and inappropriate
in others.
Only one snidy examining the effects of confidential
voice therapy was identified during the literature search.
A 1995 stiidy by Verdolini-Mafston, Burke, Lessac, Glaze,
and Caldwell compared the use of confidential voice
therapy and resonant voice therapy to a vocal hygiene
control group. Subjects in treatment groups participat-
ed in 2 weeks of treatment, whereas control sublects
received a brief educational session regarding vocal hy-
giene.Subject compliance with recommended treatment
protocols was monitored as well. Pre and post-treatment
‹ measures of laryngeal appearance, auditory perceptu-
al aspects of voice, and self-perceived 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 param-
eters. Furthermore, the study found no relationslup be-
tween the type of therapy and the likelihood of benefit
from therapy. Interestingly, outcomes front 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 I
Vocal function E:xercises
Vocal Function Exercises (VFE; Stemple, 1993) refers
to a 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 musculahire were primary
contributors to voice disorders and that therapy efforts
should be aimed at correcting laryngeal imbalances. Fol-
lowing tliis premise, Stemple (1993) created a series of
exercises for “restrengtliening and balancing the laryn-
geal musculature, i»roving vocal fold flexibility and
movement, and rebalancing airflow to mtisctilar activity”
(p. .A description of Stemple’s protocol follows.
According to Stemple (1993), patients are trained
in a series of four, well-defined vocal exercises wliicli
are practiced twice each, two times per day. The first
exercise in the sequence serves as a vocal “warm-tir”
exercise. The patient engages the laryngeal system to
produce and sustain /i/ at a predetermined pitch. The
second exercise, a stretching exercise, requires that the
patient slowly glide upward though the pitch range.
The third exercise encourages contraction of the system
by requiring the patient to glide downward through the
range.Tire ñnai exercise iias tire patient sustain nve, se-
quential notes as long as Jaossib1e.The final exercise acts
as an addtictory 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 in a 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 ofVFEs in the 1990s, thee
group snidies have examined their effect on normal and
disor- dered populations. In a double-blind placebo
controlled study, Stemple, Lee, D’Amico, and Pickup
(1994) exam- ined the use of VFEs with a group of 35
adtilt females with no history of voice disorders.
Subjects were ran- domly divided into three groups.
Subjects in the experi- mental treatment grotip engaged
in a 4-week VFE pro- gram. Subjects in the control
grotip were offered vocal hygiene training only. Subjects
in the placebo group par- ticipated in a protocol of daily
reading and chanting, a practice not believed to have a
significant influence on voice production methods.At
the close of 4 weeks, sub- jects in the experimental
group demonstrated significant changes in flow rate,
plionatory volume, maximum pho- nation time, and fre
uenc range. No significant chang- es were observed in
the control or placebo groups.The authors concludecl
that the VFE program had a positive effect on the voice
prodriction systems of healthy aclult females (tenet 1).
In 1995, Sabol, Lee, and Stemple examined the tise
of VFEs with singers. T\venty healthy singers were di-
vided into an experimental treatment group and a con-
trol group. Subjects in the treatment group completed
the VFE protocol for 28 days; controls did not engage in
the prescribed exercise routine. Pre- to post-treatment
comparisons of acoustic, aerodynamic, and stroboscopic
measures demonstrated significant increases in pliona-
tory volumes and maximum phonation times in the ex-
perimental group at all pitches. Furthermore, the experi-
mental group evidenced a decreased flow rate during
strings of rhytlunic, punctuated fricative-vowel
productions at liigh pitches. Finally, subjects in the ex-
produc- tions. Finally, once the respiratory-phonatory
perimental groti}i reported an improved sense of breath
control following training. The authors concluded that connec- tion is well established, the enhanced respiratory-
pliona- tory pattern is generalized to connected speech
the tise of the VFE program resulted in more efficient
Harris, 2000).
patterns of voice production in the group of singers
Kotby, Slmomoto, and Hirano (1993) examined the
{level II).
theoretical underpinnings of theAccent Method bystudy-
Roy, Gray, Simon, Dove, Corbin-Lewis, and Stemple
(2001) conducted a randomized control trial comparing
ing the method’s ability to alter airflow rates through the
glottis. The authors examined three subjects with vary-
the use ofVFEs to vocal hygiene treatment and a no-treat-
ing degrees of experience with the Accent Method. One
ment control condition. Subjects included 60 teachers
stib lect had used the method for 16 years, whereas an-
with self-reported current and/or historical voice diffi-
culty.The VHI Jacobson et al.,199a and a four-question other had tised the method loz 10 months. One subject
had no previous training with the method.Aerodynam-
teacher questionnaire were tised for pre- to post-treat-
ic measures revealed increases in airflow rates with use
significant reductions in the degree of voice handicap as
Furthermore, the degree of airflow rate enhancement
measured by the VHI. No significant changes in the VHI
were observed for the hygiene or control groups. Fur- varied with level of experience. Finally, the aforemen-
thermore, the VFE grotip demonstrated lugher ratings of tioned increases in airflow rate were accompanied by
voice improvement than the vocal hygiene grotip. This, increases in SPL and fundamental frequency, a finding
the first study to examine VFE use outside the normal that provided additional support for the method’s
population, supported the program’s utility in improv- ability to enhance vocal otitptit (Zeref .
ing fiinctional voice outcomes. No direct measures of At least four group studies have examined the treat-
voice were used in this study; therefore, conclusions re- ment effects of the Accent Method. Smith and Thyme
garding the protocol’s ability to alter voice production (1976) conducted the first sticli study. Tlfirty nonvoice
cannot be made {teuel I). disordered college-aged students received 10 consecu-
tive training sessions with the Accent Method. Pre- and
post-treatment measures demonstrated spectrographic
Accent Method changes in the desired direction after training. Specifical-
ly, spectrographic analysis revealed increases in the dura-
The Accent Method of voice therapy was originally
tion of the fundamental as well as increases in the cltira-
presented by Svend Smith in the first half of the 20th
tion of sotmd energies above 1000 Hz. Furthermore, the
century Harris, 2000). The method tises abdoininodia-
intensity of sounds below 1000 Hz was significantly in-
ploagmatic breathing and accenhiated vowel produc-
creased.The authors concluded that the Accent Method
tions to optimize the respiratory-phonatory connection
was successful in augmenting vocal output {level IV).
and bring about proper patterns of vocal fold closure
In 1991, Kotby, El-Sady,Abou-Rass, and Hegazi exam-
(Kotby, Sliiromoto, & Hirano, 1993).
ined the effects of the Accent Method on a disordered
The Accent Method was originally based tipon the
population.The authors enrolled 28 subjects with a va-
myoelastic aerodynamic theory of vocal fold vibration
riety of voice disorders. Disorders included dysplionias
proposed by van den Berg in 1958 (Harris, 2000). van
of a ninctional nature as well as dysplionias secondary
den Berg’s theory discussed the contribution of the ex-
to vocal fold lesions and vocal fold immobility. Subjects
haled airstream on the closing phase of the vocal fold
engaged in three, 20-minute sessions per week. Twenty
vibratory cycle. Specifically, van den Berg’s theory held
training sessions were completed with each subject. Pa-
that the hillier the rate of airflow throiigh the glottis,
tient interviews, auditory perceptual voice ratings, stro-
the greater the medial pulling force on the vocal fold
boscopic ratings, and aerodynamic measures were taken
edge.Advocates of the Accent Method proposed that in-
after sessions 10 and 20. The findings demonstrated a
dividuals can be trained to control the rate of exhaled
positive sly in voice performance in 89.3•/» of the sub-
air though the glottis and, thereby, indirectly control the
jects. Specifically, auditory perceptual ratings of grade,
closing of the glottis during voicing.With the recent revi-
strain, and leakage demonstrated significant changes in
sions of van den Berg’s model byTitze (1994), advocates
the desired directions. Furthermore, stroboscopic exam-
of the Accent Method have also pointed to the method’s
ination revealed a recltiction in nodule size in 6 of 6 sub-
ability to narrow the vocal tract to create the back pres-
jects diagnosed with nodules. Finally, the aeroclynanuc
sure needed to assist in vocal fold closure Harris).
measures of maximum phonation time, maximum flow
The Accent Method protocol begins with training
rate, subglottic pressure, and glottic efficiency all dem-
the abdominodiapliragmatic breath. Once established,
onstrated significant changes in the desired direction.
the abdominodiaphragmatic breath is tised to produce
The authors field that the results supported the use of
the Accent Method for fiinctional and organic voice dis-
orders {Level IV).
Fex, Fex, Sliiromoto, 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-
ers collected pre- and post-treatment perceptual and
acoustic measures. Results demonstrated significant (p
<0.05) changes toward normal on the acoustic measiires
of pitch perturbation quotient, amplinide pertiirbation
quotient, normalized noise energy, and ftmdamental fre-
quency. In addition, fatings by subjects and speeclvlan-
gtiage pathologists lent subjective support to the ther-
apy’s benefit. The findings supported the method’s use p,
¿¿J,, p,;p,pt¿q gJ d gp dp qy p;pp (¿pg.q¿ yy,
In 1998, Bassiotiny conducted the most rigorous ex-
amination of tlieAccent Method to date.The author con-
ducted a double-blind randomized control trial with 42
subjects of varying diagnoses. Subjects were randomly
assigned to a vocal hygiene + Accent Method group or
a vocalhygiene only (control) group. Subjects in the Ac-
cent Method grotip received 20 minutes of therapy, two
times per week. A total of 20 sessions were completed.
Controlsubjectsreceivedvocalliygienetraining one time
per week.A total of 10 sessions were completed. Subjec-
tive ratings and objective measures were taken prior to
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-
pert 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 exlfibited significant improve-
ment on all stroboscopic parameters examined by judg
es; such changes were not observed in the hygiene only
grotip. Finally, the Accent Method group demonstrated
significantly greater gains than controls on the following
objective measures: SPL range, subglottic pressure, glot-
tal efficiency, glottal resistance, slimmer, and harmonics-
to-noise ratio. Interestingly, neither grotip demonstrated
significant pre- to post-treatment change in inverse fil-
tering parameters.The findings pointed to the benefit of
the Accent Method as 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 I).
Manual Laryngeal Musculoskeletal
Reduction Technique (MLMRT)
Methods of manually managing liyperfunctional
patterns of voice use were first discussed by Aronson
(1990). In lbs classic text Clinical Voice E isorders ,AroR-
son described a method by which the extrinsic larynge-
al mtisctilattire could be systematically manipulated and
massaged to reduce muscle tension and eliminate inap-
propriate patterns of muscle engagement for voicing.
The teclmiqtie as described byAronson and others joy,
1993; Roy,Bless, Heisey, R Ford,1997; Roy & Leeper 1993;
Van Lierde, DeLay, Clement, DeBodt, &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,
Edit Nifii"ñ isk iii"igñ@ii S ii 3”/SkiiiTiñk ii iTi‹tSS fiber ‹twit iRñ-
nipulation of the laryngeal complex. Massage begins su-
periorly at the level of the liyoid bone and progresses
inferiorly to the thyroid cartilage. Slowly the laryngeal
musculature relaaes, and the larynx is guided lower in
the neck. During the period of massage, the patient is cm-
rected to gradually begin voicing. Vocal attempts begin
with humming and vowel prolongation and slowly ad-
vance toward conversation as the degree of tension al-
lows.The session closes with a review of therapy results
and a discussion regarding life events potentially con-
tributing to the condition.
In 1993, Roy provided an early discussion regarding
the clinical utility of the manual laryngeal musculoskele-
tal reduction technique (MLMR .He presented the case
review of a 61-year-old male with ventricular phonation
following prolonged intubation.The patient underwent
eight sessions of MLMRT over a 2 month period. Prior to
treatment, auditory perceptual ratings of voice indicat-
ed a severe deficit. Post-treatment ratings were witlfin
the normal range. Furthermore, acoustic measures ttin-
damental frequency, jitter, slimmer, and signal-to-noise
ratio demonstrated marked changes in the normal direc-
tion following treatment. Finally, stroboscoJaic examina-
tions revealed a post-treatment reduction in ventricular
fold motion along with a corresponding increase in vo-
cal fold visibility.The author proposed the case as initial
evidence for the tise of MLMRT with the population of
persons with ventricular phonation (level V).
In the same year, Roy and Leeper (1993) conduct-
ed the first formal snidy examining the manual meth-
od.The researchers enrolled 17 subjects with functional
voice disorders of varying duration in a single session of
MLMRT therapy. Subjects experienced a significant re-
duction in severity ratings of voice (p <0.0001) at the
conclusion of a single session. In addition, the single see
sion brought about significant movement in fire normal
direction on the acoustic measures of jitter, s1 er, and
signal-to-noise ratio. Finally, 93% of subjects were able to
maintain tlus 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 (Zeref .
In 1997, Roy, Bless, Heisy, and Ford btñlt upon the
earlier study to examine the short and long-term effects
of MLMRT.Twenty-five subjects with ftmctional dyspho-
nia were enrolled in the snidy. Subjects engaged in a sin-
gle session where MLMRT was tised. Measures of voice
were taken prior to treatment, at the close of the
sin- gle treatment session, and at distant time post-
treatment (range of follow-tip 3.6 to 5.5 months).At the
close of a single treatment session, subjects experienced
a signifi- cant reduction in voice severity ratings @
<0.0001). In acldition, the subjects demonstrated
significant improve-
iiéie fiu.uuu ij wn ciié fiiiiiiis lii iFiéii3tiic:S iii i tiiiua-
mental frequency, jitter, slummer, and signal-to-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-
gree of relapse. The authors concluded that short-term
outcomes from MLMRT appeared stronger than long-
term outcomes and proposed that the method would
be usef\il in the acute management of ftmctional disor-
ders (Level IV).
A final published snidy of MLMRT 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 dysplionia. Each of the subjects had failed to clemon-
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 (Hirano, 1981). Pre- to post-treatment changes in
the acoustics of voice were quantified tising the Dysplio-
nia Severity Index PSI;Wuyts et al., 2000). Pre- to post-
treatment comparisons demonstrated improvements on
the GRBAS scale and the DSI for all subjects. Specifically,
subjects demonstrated a reduction in strain, elevation of
the Ugliest possible frequency, and movement of funda-
mental frequency, jitter, and shimmer toward the normal
range.The authors concluded that the M£MkT was ben-
eficial in managing cases of muscle tension dysplionia
(Zeref .
tesonarzt Voice beraf:›y
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- irt,g of tire Human Voice (1965),1ñgh1ighted 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. Lea
sae held that production of the well-placed voice would
yield optimal ninctioning of respiratory, plionatory, 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 mariner of pro-
duction.Titze (2003) states,“resonant voice engages the
vocal tract for maximum transfer of power from glottis
to lips, and ultimately all the way to the listener”(p.
292). The efficiency of the resonant voice appears to
stem from patterns of voice production with the
larynx.Ac- cording to Titze, when energy is properfy
converted at die ievei oi tire vocai ioicis, tile giotiai
sonnet wave has the potential to be propagated over
long distances. Vi- brations of the glottal tone can
extend into the facial re- gions, and a resonant voice
results. These propositions have been supported by the
work of Berry et al. (2001) and Verdolini, Druker,
Palmer, and Samawi (1998) that demonstrated that the
glottic configuration observed in the resonant voice was,
in fact, the glottic configuration known to produce
maximum transfer of sotmd through the vocal tract.
Verdolini (2000) described the goals and sequence
of RVT. Hygiene goals are addressed throughout the
course of therapy and foctis primarily on hydration and
the management of any associated reflux concerns.The
nenromuscular direct training stage of therapy consists
of two co< r onents. First, inappropriate patterns of
mis-
cle use are deactivated. Second, easy phonation, charac-
terized by vibratory sensations near the alveolar ridge, is
established.
At least thee published studies have examined the
effects of RVT. A 1995 stiidy by Verdolini-Marston et al.
compared RVT to other forms of voice management.
Eighteen college-aged females with the diagnosis of vo-
cal nodules participated in the sttidy. Subjects were di-
vided into two treatment groups PVT, confidentialvoice
therapy) and a vocal hygiene control group.At the close
of just 2 weeks of treatment, participants in the treat-
ment groups exhibited greater gains on all parameters
those in the control group. Results demonstrated the
benefit of RVT and confidential voice therapy over vocal
hygiene training alone {Leael 11).
In 2003, Roy,Weinrich, Gray, Tanner, Stemple, and Sa-
pienza examined a modification of the traditional Reso-
nant Voice Therapy approach. The stiidy examined the
effects of various voice treatment metliocls on a sam-
ple of 64 teachers with a self-reported history of voice
difficulty. Subjects were ranclomly assigned to one of
three treatment methods: resonant therapy, respiratory
muscle training, and amplification. Subjects completed
the VHI Qacobson et al., 1997) as well as voice sever-
iry rating prior to and at the close of treatment. Results
showed significant reductions in perceived handicap as
determined by the VHI for both the resonant therapy Q
<0.007) and amplification groups Q <0.002). Significant
changes on the VHI were not observed in the respirato-
ry muscle trairiing group. Furthermore, resonant voice
training and amplification groups exhibited significant
reductions in voice severity ratings. Again, significant
changes were not observed with the respiratory muscle
training grotip. A follow-tip 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 tliera oup. The stirsup-
as amplification in the treatment of voice disorders (Zen
el 1).
In that same year, Chen, Huang, and Chang (2003)
examined the effect of Resonant Voice Therapy on 21
female subjects with hyperfiinctional dysphonia.Video-
stroboscopic, auditory perceptual, acoustic, and aero-
dynamic assessments were conducted prior to and fol-
lowing eight treatment sessions. Results demonstrated
significant changes on laryngeal videostroboscopy and
auditory percepnial measures of voice. Furthermore,
significant changes in the desired direction were not-
ed on tests of shimmer, intraoral pressure, and speaking
frequency range. The authors concluded that Resonant
Voice Therapy was a usenil mechanism for treating the
liyperftinctional voice {Level .
Conclusions and Implications
A review of the above studies demonstrates sup-
port for physiologic approaches along both theoretical
and clinical lines.The development of specialized instni-
mentation for viewing and measuring voice production
has allowed the physiologic approaches to be examined
from a physiologic, or theoretical, standpoint. Research-
ers have confirmed the physiology belfind a number
of physiologic methods and arrived at conclusions re-
garding the potential benefit of the methods. Physiology
studies, although not tnie treatment outcomes snidies,
do provide evidence in siipport of the theory behind
the methods. Second, the majority of fire physiologic ap-
proaches have been supported tlirougli stringent clini-
cal research. Most method5 have been investigated using
at least one well-controlled g;roup study; others possess
lines of clinical research that have developed over a
number of years.
Of the methods presented above, four emerge with
a strong evidence base. Vocal Function Exercises, Reso-
nant Voice Therapy, the Accent Method, and the Manual
Laryngeal Musculoskeletal Reduction Technique appear
promising for use in treatment of functional voice disor-
ders. Contintiecl research examining the benefit of the
metliocts with varying populations of patients wotild 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 of the two areas has yielded an improved
research foundation for the field of voice therapy.
Conclusions and Future Directions
The above review provides vital iriformation 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, well-controlled group stiidies 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 stucty, have not consistently emerged as influ-
ential in the treatment of voice disorders. In addition, the
majority of facilitating methods under the symptomat-
ic model have not received sufficient research attention
to 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 said of the statiis of voice therapy
in the earliest days of the 21st cenhiry? A review of the
literature demonstrates reason for optimism. Since 1990,
researchers 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 ftiture of outcomes research. First, with
the emer- gence of physiologic methods and the
developing base of evidence supporting physiologic
metlio‹Js, does inves- tigation of specific symptomatic
methocls remain neces- sary? Is research time better
spent continuing the lines
 of research into physiologic methods or should the spot-
light return to more conventional models of treatment?
Second, definitive 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 has been inconclusive. Researchers must
employ designs that allow for the investigation of vocal
hygiene’s piire contribution to vocal rehabilitation.The
ethical concerns that arise from the tise of a no-treat-
ment group limit options in tlus 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- r-
••t t•*--rap•/ m--i. o s, speca. ori:parents o vocal hy-
giene mtist be examined for their contribution to the
hygiene model of treatment. Researchers must deter-
mine witch, if any, hygiene targets move the client to-
want the clesired outcomes.
Tlfird, researchers of the funme must consider the
long-term benefits of various therapies.Whereas studies
requiring long-term participant follow-tip are inherent-
ly difficult to design and implement, long-term outcome
data is 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
model in the United States governing rehabilitation ser-
vices requires firm data on treatment duration. Fiinire
researchers must address tliis matter by designing stiid-
res that consider the efficiency variable. By doing so, re-
seerclie can provide clinicians with needed data relat- ed
to the required time frames for therapy.
Finally, researchers must engage in the systematic
and long-term investigation of specific treatment ap-
proaches. In the area of voice treatment, Lee Silverman
Voice Therapy PVT) may serve as a model of such re-
search.Tlus treatment approach was first presented by
Ramig, Countryman, Thompson, and Horii (1995) as a
treatment loz voice disorders associated with Parkin-
son's disease. Since LSVT’s original presentation in the
literature, a number of articles have been produced ex-
amining the effectiveness of the method @aumgart-
ner, Sapir, & Ramig, 2001; Rnmig, Countryman, O’Brien,
Hoelin, RTliompson, 1996; Ramig, Countryman,T1iomp-
son, R Horii, 1995; Ramig R Dromey, 1996; Ramig et al.,
2001; Ramig, Sapir, Fox, & Countryman, 2001; Sapir et
al., 2003; Sapir, Ramig, Hoyr, Countryman, O’Brien, &
Hoehn, 2002; Sliarkawi et al., 2002; Spielman, Borod, &
Ramig, 2003).The line of research for LSVT has included
inves- tigation of the following areas: LSVT’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 eapression, investigation of the long-term
maintenance of skills trained in LSVT, investigation of
the physiology be1 d the method, and consideration of
the method’s effectiveness in various other netirogen-
ic populations.T1itis,tliis base of literature demonstrates
the potential for developing systematic lines of research
for other voice therapy methodologies.
In tociay’s society, science and art are often painted as
dichotomous concepts, unable to coexist in a meaning-
ful way.Yet, in the field of voice, perhaps the two
coexist in a complementary relationship—where the
science of the researcher supports the art of the
clinician.These au- thors would propose that voice
therapy is on the verge of sticli a relationslup—science
supporting art, enhanc- ing the lives of those living with
voice disorders.
Address correspondence to Lisa B.Thomas,
Ph.D., 106C C1iarlesT.Wetlungton Building,
Lexington, KY 40536-0200;Te1eplione: 859-323-
1100 ext. 80524; E-mail: Lisa.ThomasTuky.edu
References
Aaron, V L., R Madison, C. L. (1991). A vocal hygiene program
for high school cheerleaders. Loligunge, Speech, Hunt Heai-
itig Set-vices in Scl.tools, 52, 287—290.
Andrews, M. L. (1993). Intervention with young voice users:A
clinical perspective.Journal off Voice, 7,160-164.
Andrews, M. L. (2002). Voice treottiietit for- cl. il‹tren otid
o‹tolesceiits (2nd ed.). San Diego, CA: Singular Publishing
group.
Andrews, S., Warner, J., R Stewart, R. (1986). EMG biofeedback
and relaxation in the treatment of liypermnctional dye
plionia. Bt-itisla Journ‹s f of Coiiiniunico/*oii £isot i:ters, II,
353-369.
Aronson, A. E. (1990). Cliiiicnl voice i:tisot Hers (3rd ed.). New
York:Thieme Stratton.
Bassiouny, S. (1998). fifficacy of the accent method of voice
therapy. Folia Pl›oiiiatrica ct Lo3opedica, TO, I 46-164.
Bastion, R. W (1988). Factors leading to successml evaluation
and management of patients with voice disorders. Eas
y Nose arid Throat Journal, J7, 411-12, 414-416, 418-420.
Baunigartner, C.A., Sapii; S., R Jlaniig, L. 0.(2001).Voice quality
changes following plionatory-respimtory effort treatment
(LSVT) versiis respiratory effort treatment for individi:mls
with Parkinson’s disease./oiirno/ of Voice, I'm, 105-114.
Belirman, A., R Orlikoff, h. f. (1997). Instrumentation in voice
assessment and treatment:What’s the use? Aniericati/otii-
url of Speech-Lmiguage Pathology, 6 4), 9-16.
Berry, D., Verdolini, K., Montequin, D., I-Iess, M., Chan, R., R Ti-
tze, I. (2001). A quantitative out}aut-cost ratio in voice
pro-
duction. Joornef of Speecl›, Laiiyuage, ‹stir:I IIenriit¿ lle-
seat-cfs, 44, 29-37.
Bloch, C. S., R Gould, W J. (1974). Voice theraJay in lieu of
surgery for contact granuloma: A case report. Jour/taf of
Speech ff nd Hearitig Disoi-dci s, 39, 478-485.
 74 COMMUNICATIVE DISORDEIIS RSVIEW,VOL. 1, NO. 1
Bloch, C. S., Gould, W. J, R Hirano, M. (1981). Effect of voice
tliei’apy on contact granuloma of the vocal fold. Annats of
Otorl›lnolai 2›ngolog y, '30, 48-52.
Blood, G. (1994). Efficacy of a computer-assisted voice treat-
ieit Jarotocol. American/oui-iief of Sfleecl.1-language 7°e-
i/so/oy •, 3, 57-66.
Boone, D. R. (1966).Treatment of functional aphonia in a child
and an adult./ofirnsf of Speech mud He‹s ring Disori:tens,
.31, 69-74.
Boone, D. R. (1971). The voice anlt voice I/›eioy›. Eiiglewood
Cliffs, NJ: Prentice-I-fall.
Boone, D., R. R McFarlane, S. C. (1988). Tt:ie voice ‹em:t voice
tlaerajfy (4th ed.). Englewood Cliffs, NJ: Prenticc-Hall.
Boone, D. R., R McFarlane, S. C. (1993). A critical view of the
yawn-sigh as a voice therapy technique./offiviof of Voice,
7, 75-80.
Boone, D. R., McFarlane, S. C., R Von Berg, S. (2003). Tire voice
and voice tkernfy (7t1i ed.). Boston:Allyii R Bacon.
Breiss, B. (1957).VoiceTherapy:Part I. Identification of specific
laryngeal muscle dysninction by voice testing. Archives of
Otolat gmifology, 6G, 375-382.
Breiss, B. (1959). Voice Therapy: Part II. Essential treatment
phases of specific laryngeal muscle dysfunction. At-chives
of Otolai ytifoloyy, 6•fl, 61-69.
Brewer, D., R McCall, G. (1974).Visible laryngeal changes dur-
ing voice therapy: A fiberoJ›tic study. Aiiiiols of Otoi-kino-
lat yiigology , 83,423-427.
Broaddvis-Lawrence, P., Treole, K., McCabe, R., Allen, R., R Top-
pin, £. (2000). The effects of preventative vocal hygiene
education on the vocal hygiene habits and perceptual
voice characteristics of trnining singers./ooi-i/ef o/ Voice,
74, 58-71.
Brodiutz, £. S. (1958). Vocal rehabilitation in benign lesions of
the vocal cords.Journal of Specify ff 1i‹:I Hearing Disor‹ters,
23,112-117.
Brodnitz, F., R Froeschels, E. (1954). Treatment of nodules of
vocal cords by chewing method. A1'Clyives of Otolai)›tigol-
O 60— 56 .
Butler, C., R Darra1i,J. (2001). Effects of a neuroclevelopinental
treatment (NDT) for cerebral palsy:An AACPDM evidence
re}aort. Develofimental.her/fciite and Gl.tilt:I Neuroloffy, 43,
778-7?0.
Case, J. (1996). Clinical tnotin3enlent of voice ‹Disorder-s (3rd
ed.).Austin,TX: Pro-Ed.
Casper,J.(1997, September). The role of tie cotifu:teiitial voice
in a rofce //Jerry@-oiocof. Paper presented at the Pacific
Voice Conference, San Francisco, CA.
Caspei;J.(2000).Confidential voice. InJ. C.Stemple (Ed.), Voice
there .' Clinical stud:ties (2nd ed., pp. 128-139). San Diego,
CA: Singular Publishing group.
Chan, R. W K. (1994). Does the voice improve with vocal hy-
giene education? A study of some instrumental voice mea-
sures in a group of kindergarten teac1iers,/oui-riff o/Vo/ce,
8, 279-291.
Chen, S. H., FIuang,J., R Chang, W. (2003).The efficacy of reso-
nance method to liyperñinctional dysphonia from physio-
logical, acoustic and aerodynamic aspects:The preliminary
study. Asia Pacific Journal of Speech, Language ‹end Hear-
ii’tg, 8, 200-203.
Colton, R., R Casper,J. (1990). Un terstai’idiiig voice j:u-ohlenis.’
A pt.ysiologicol pet-spective for ‹liagnosis anlt treatment.
Baltimore:Williams R Wilkins.
Colton, R., R Casper,J. (1996). Un‹tei stam:ting voice problems.’
A pl.›ysiological perspective for ‹tioyiiosis ailcl treoniient
(2nd ed.). Baltimore:Williams RWilkins.
D'Antonio, L., Lotz,W., Chait, D. R Netsell, R. (1987). Perceptual-
physiologic approach to evaluation and u-eatment of dys-
phonia. Atitials of Otoloy)›, ñ/›ino/o,g9; cuff Lai ynyoloy)›,
J6, 187-190.
Deal, R. E., McClair, B., R Suddertli, J. F. (1976). Identification,
evaluation, therapy, anal follow-up for children with vocal
noclules in a public school setting./ourno/ of Speecl.› and
Neoririy Dison:ters, 41, 390-397.
Deem, J., R Miller, L. (2000). 3fmsoef o/ voice fi›erepj› (2nd
ed.).Austin,TX: Pro-Ed.
Drudge, M. K. M., R Philips, B. J. (1976). Shaping behavior in
voice thempy. Journal of Syeecâ ai’icl Heai-ing Disot dci’s,
41, 398-411.
Fex, B., Fex, S., Shiromoto, 0., R Hirano, M. (1994). Acoustic
analysis of functional dysphonia before and after voice
therapy (Accent Method).Journal of Voice, 8, 163-167.
Fisher, H., R Logemann,J. (1 -70). Objective evaluation of ther-
apy for vocal nodules:A case report./oornof o/SfleecI.› ctid
Hearitig Disor‹tei’s, 55, 277-285.
Froescliels, E. (1943). Hygiene of the voice. At clives of Otolar-
) iigology, 38, 122-130.
Froescliels, E. (1944). Experience of a bloodless treannent for
recurrens-paralysis.Journal of Lai yisgotog3, 5', 347-358.
Froescliels, E. (1952). Chewing method as thera . At‘clyives Of
-roescliels, E., Kastein, S., R Weiss, D. A. (1955). A method of
tlieraJay for paralytic conditions of the mechaiusms of pho-
nation rcspirntion and glutination.Joitt-iie/ o5 speech i i t
Hearing Disorder s, 20, 565-370.
Gray, B., England, G., R Malioney,J. (1986).Treatment of
benign vocal nodules by reciprocal inñi'bition.
Bel.Savior-'esearck mil Tlaet ‹spy, 3, 187-191.
Guyatt, G.,Vist, G., Falck-Ytter,Y., Kiinz, R., Magrini, N. R
Scliueii- einanii, H. (2006). An emerging consensus on
grading rec- ommendations? (Editorial).dirier*reii Cei-ehral
Palsy four- i’iol Cluh, 7d4(1), A08.
Harris, S.(2000).The Accent Method iii clinical }xuctice. In J. C.
Stemple (Ed.), Voice tl1er‹s p y.- Clinical studies (pp. 62-81).
San Diego, CA: Singular Publishing group›.
Hegde, M. (1983). Treatment procedures in coinillffllication
tisoi-i:ters. San Diego, CA: College-FIill Press.
Hicks, D. M., R Bless, D. M. (2000). Principles of treatment. In
W. S. Brown, B. P.Vinson, R M.A. Crary (Eds.), Oi,geiiic voice
i:tisoi clers. Assessment and, h‘eeriiieitf (pp. 171-191). San
Diego, CA: Singular Publislmg group.
Hillman, R. E., Gress, C. D., Hargrave, J., Walsh, M., & Bunting,
G. (1990). The efficacy of speech-language pathology in-
tervention: Voice disorders. Seminars iii speech niut i iii-
guage, 11(4), 297-310.
Him• no, M. {198 I). Clinical nxainin‹s tioii of voice. New
York: Springer-Verlag.
Holbrook,A., Rolnick, M., & Bailey, C. (1974).Treatment of vo-
cal abuse disorders using a vocal intensity controller.Joni-
tual of Sf›eech arid Hearing Disorder s,3•U, 298-303.
Holmberg, E., I-Iillman, R., Flammarberg, B., Sodersten, M.,
R Doyle, P. (2001). Efficacy of a behaviorally based voice
tlieraJ›y protocol for vocal nodules./oui-tial o/ Voice, 2J,
395-412.
IJufnagle, J. (1993). “Soft whisper” technique. In J. C. Stemple
(Ed.), Voice t ierap) : Clinical stu‹ties tpp. 46-49). San Di-
ego, CA: Singular Publishing group.
Htifnagle,J., R Hufnagle, K.(1983). Is quiet whisper harmnil to
the vocal mechanism? A research note.Per ceftual am:1Mo-
tor Shills, 5.7, 735-737.
Jacobson, B.,Johnson,A.,Grywalski, C., Silb.ergleit,A.,Jacobson,
G., Benninger, M., et al. (1997). The Voice Handicap Index
: Development and validation. American fourt1al of
Sf›eecâ-Language Potl.›olog3, 6.33, 66-70.
Jacobson, E. (1942). VOff inwr relax. New York: McGraw Hill
pqp¿pppn,p.
Jo1inson,T. S.(1985):Voice disorders:The measurement of clini-
cal progress. In.J. Costello (Ed.), Syeecla i:tisorders in at:tults
(pp. 127-152). San Diego, CA: College-Hill Press.
Kahane, J. C., & Mayo, R. (1989).The need for aggressive pur-
suit of healthy childhood voices. language, Speech, and
Neariii,g Setzices in Schools,50, 102-107.
Kay, N. J. (1982). Vocal nodules in children: Etiology and
management. /ournof of Lai2 iigolof y aim:t Otolop , 96, 731
—736.
Kotby, M., El-Sady, S.,Abou-Rass,Y., & Hegazi, M. (1991). Efficacy
of the Accent Method of voice therapy./oui-dial ofVoice,5,
316-320.
Kotby, M. N., Sliirmoto., 0., R Hirano, M. (1993). The Accent
Method of voice therapy: fiffect of accentuations on F„ SPL,
and ecñow.Joui-iial of Voice, 7, 519-325.
Kotifman, J. A., R Blalock, P. D. (1989). Is voice rest never indi-
cated?/ou/ital ofYoice,3, 87-91.
Koufmau, J. A., R Blalock, P. D. (1991). Functional voice dis-
orders. Otolai yngologic Clinics of North America, 2d, 1059-
1073.
Cancer, J.M., Syder, D., Jones, A.S., R LeBoutillier, A. (1988).
The outcome of different management patterns for vocal
cord nodules. journal o/ Lai itigoloy am:I Otolog y, 10y,
423-427.
Laukkaneii, A., $yrja, T., Laitala, M., R Leino, T. (2004). Effect of
two month vocal exercising with and without spectral biO’
feedback on student actors' speaking voice. Logopedicsy
7•ñoniotrics, andf Uoco/o,gy, 2N, -7 •
£ee, fi. K., R Son,Y. I. (2005). Muscle tension dysphonia ii: clip-
dren: Voice characteristics and outcome of voice therapy.
International Journal of Pediatric Otolai yu 010 )!, I ff,
911-9l7•
Lessac, A. (1965). The use anlt trninii’tg of the /sunisii voice:
A new approve/› to the bio‹:tytianiics of voice anti speech.
New York.
Lodge, J., R Yarnall, G. (1981). A case study of vocal volume
reduction./otirna/ of Speech aitr:I Hearing Disoi’ taI’S, 46,
317-320.
MacKeioie, K., Millar,A.,Wilson,J., Sellars, C., R Deary, I. (2001).
Is voice therapy an effective treatment for dysphonia? A
randomized controlled trial. l3ritish Me‹ticol Journal, 323,
658-661.
Maryn,Y., DeBodt, M., RVan Cauweuberge, P. (2003).Veitrici-
lar dysphonia: Clinical aspects and tliernpeutic options. £n-
i yi’igoscope, 113,8f9-866.
McCrory, E. (2001).Voice tliern}ay outcomes in vocal fold mod-
ules: A retrospective audit. litternational,fouri’ial of Lai’i-
go‹spe and Coniniuiiicntion Disoi-hers, 3 I(Suppl.), 19-24.
McFarlane, S. C. (1988). Treatment of benign laryngeal disor-
ders with traditional methods and techniques of voice
therapy. fioi; Nose anlt Ti:iront Joui-i’inl, 67,425-435.
McFarlane, S. C., R Watterson,T. L. (1990).Vocal nodules: Endo-
scopic stiidy of their variations and treatment. Semitinrs in
Monoson, P., & Zem1in,W. R. (1984). Quantitative ytudy of whim
per. Folio Pkoniatrica ,36, 53-65.
Moore, G. P. (1971). Organic voice ‹tisor ters. Englewood
Cliffs, NJ: Prentice-Hall.
Mueller, P. B., ‹'k Larson, G. W (1992). Voice therapy practices
and techniques: A survey of Voice clinicians. ./oorne/ o/
Communication Eisordet-s, *I, 251-260.
Murphy, A. (1-64). Functional voice disorders. In C. Van Riper
(Series Ed.), Foum:tattoos of Speecl.› Pathology Set-ies. En-
glewood Cliffs, NJ: Prentice-Hall.
Murry,T., RWoodson, G. E.(1992).A comparison of three meth-
ods for the management of vocal fold nodules./ournn/ of
Voice, d, 271-276.
Myerson, M. C. (1958). Vocal rest in laryngeal disease. A’nnats
of Otorlaii’iolni2›ngolog3, 67,491-493.
Nilson, H., R Sclineiderman, C. R. (1983). Classroom progmm
for the prevention of vocal abuse and hoarseness in ele-
mentary school cluldreu. Laiiguaye, Speecl. , atlcl He‹s ritiff
Services iii Scl.›ools,14, 114-120.
Pannbacker, M. (1998). Voice treatment tecluiiques: A review
rind recommendations for outcome studies. Americati
Jonr ref of Speech-L‹s nguage Pathology, 7(37, 49-55.
Pannbacker, M. (1999). Treatment of vocal nodules: Options
and outcomes. America it Journal of Speech-Lattguoge Pa-
tholo ,8, 209-217.
Poacher, G., R Holliuger, P. (1947). Contact ulcer of the larynx:
The role of vocal reeducation. Arcl.lives of Otolai3uifoloffy,
Pedersen, M., Beranova, A., R Moller, S. (2004). Dysphoiña:
Medical treatment and a medical voice hygiene •i»r roacli:
A prospective ranctomized pilot stMdy. Eur opemi Archives
of Otorñinoloi yngoloy3›, 261,612-315.
Perkins,W H. (1985).Assessment and treatmcnt of voice disor-
ders: State of the art. lii J. Costello (Ed.), Speech clisorders
» ‹st:tufts (py.79-111). San Diego, CA: College-Hill Press.
Prater, R.J. (1991).Voice therapy:Techniques and applications.
Otolni)›i’igoloyic Clinics of Not-tl.› America, 2d,1075-1092.
Prosek, R., Montgomery A., Walden, B., R Schwartz, D. (1978).
EMG biofeedback in the treatment of liyperfuiictional
voice disorders./oiii-dial of Speech niut Henriii,g Disor‹ters,
‹3, 282-294.
Punt, N.A. (1974). Lubrication of the vocal mechanism. Folia
Pl.1oniotrica 3 287-288.
Ramig, L. 0., Countryman, S., O’Brien, C., Hoelm, M., RThomp-
son, L. (1996). Intensive speech treatment for patients with
Parkinson’s disease: Short- and long-term comparison of
two techniques. Neurology, 47, 1496-1504.
 76 COMMUNICATIVE DISORDERS RSVIEW,VOL. 1, NO. 1
Ramig, L. 0., Countryman, S.,Thompson,ñ Horii. (1995). Com-
parison of two forms of intensive speech treatment for Par-
kiisoi’s disease.Journal ofspeecl.› am:I Hearing Reseni cll,
38,1232-1251.
Ramig, L. 0., R Droniey, C. (1996). Aerodynamic mechanisms
underlying treatment-related changes in vocal intensity in
patients with Parkinson disease. /oorriof of speeci.› aiut
Heat-ing Eesearcly, fi'5, 798-807.
hamig, L. 0., Sapir, S., Countryman, S., Pawlas, A.A., O’Brien, C.,
IJoelin, M., et al. (2001). Intensive oice treatment PVT)
for patients with Parkinson’s disease: A 2-year follow-up.
,journal of Nenrolog)›, Neurosurgei 3›, mm Ps) claims5 , 7i, 495-
498.
Jlamig, L. 0., Sapir, S., Fox, S., R Countryman, S.(2001). Changes
in vocal loudness following intensive voice treatment (lS-
YT) iti individuals with Parkinson’s disease: A comparison
with untrcated patients and normal age-matched controls.
Mouei›ient Diso1’dei’s, Id, 79-85.
Ramig, L. 0., & Vcrdolini, K. (1998). Treattnent efficacy: Voice
disorders. Joitrnnl of Speecl.›, language, art f Neoriii,g fie-
senrcii, d 1, 5101-5116.
Rattenbury, H.J., Carding, P. N., R Finn, P. (2004). Evaluating and
effectiveness and efficacy of voice therapy using a transna-
saI flexible laryngoscopy:A randomized control trial./oui-
mcl of Voice, 18, 522-533.
Reed. C. G. (1980).Voice therapy:A need for research.Journal
of Speect› anlt Hem-ing Disori:ters, 4S,157-169.
Robey, R., R Schultz, M. (1998).A model for conducting clini-
cal-outcome research:An adaptation of the standard proto-
col for use in aphasiology. Apl asiology, 12,787-810.
Roy, N. (1993). Ventricular dysphonia following long-term en-
dotraclieal ii:tubation: A case study. Journal of Otolai)›n-
5oloy›,23,189-193.
Roy, N., Bless, D. M., Heisey, D., R Ford, C. N. (1997). Manual
cir- cunilaryngeal tliernpy for functional dysphonia:An
evalua- tionof short- and long-term treatment
outcomes./ourn‹s/ of Voice, 11,321—331.
Roy, N., Gray, f., Simon, M., Dove, H., Corbin-Lewis, K., R Stein-
ple,J. (2001).An evaluation of the effects of two treatment
a}aproaches for teachers with voice disorders: A prospec-
tive rnndomized clinical trial. OUf'774f O Speech, language,
nmt hem-in( Yesearcla, 44, 286-296.
Roy, N., R Lee}aer, IN.A. (1993). Effects of the manual lwyngeal
musculoskeletal tension reduction technique as a treat-
ment for functional voice disorders: Perceptual and acous-
tic measures.Joornof of Voice, 7, 242-249.
Roy, N.,Weinricli, B., Gray, S.,Tanner, K., Stemp1e,J., R Sapienza,
C. (2003). Three treatments for teachers with voice disor-
ders: A randomized clinical trial. fourisal of Syeecii, Lan-
guage, niiff Hearing Research, 4G, 670-688.
Roy, N., Weinrich, B., Gray, S., Tanner, K., Toldeo, S., Dove, H.,
Corbin-Lewis, K., R Stemple, J. (2002). Voice amplification
verses vocal hygiene instruction for teachers with voice
disorders:A treatment outcomes study.Jonrnef o/ Speech,
laitffuaye, ancl. Ilenriiig Research, d5, 623-638.
Rubin,A. D., Praneetvatakul,V, Gherson, S., Moyer, C.A., R Sata-
loff, R. T. (2006). Laryngeal liyperfunction during whisper-
ing: Reality ot myth? Journal of Voice, 20, 121-127.
Sabol, L., Eee, L., R Stemple,J. C. (1995).The value of vocal func-
tion exercises in the prnctice regime of singers./oi/rnof o#
Koice, 9, 27-36.
Sander, ft. K. (1989).Arguments against the aggressive pursuit
of voice therapy for children. Ioii¿uage, Sf›eect›, and Hear-
ing Services in Scl.tools, 20, 94-101.
Sapir, S., Ramig, L. 0., Hoyt, P., Countryman, S., O’Brien, S., R
FIoelin, M. (2002). Speech loudness and quality 12 months
after intensive voice treanneiit (LSV for Parkinson’s dis-
ease: A comparison with an altcruative speech treatment.
'olia Pl.ioiiiatrica ct Loyopoecll,co,54, 296-303.
Sapir, S. Spielman, J. Ramig, L. 0. I-Iinds, S. L. Cont:trymaii, S.
box, C. ct al. (2003). Effects of intensive voice treatment
(the Lee Silverman Voice Treatment [LSVT]) on atnxic dys-
arthria: A case study. American .fout-nal of Speech-Lmi-
zoepe Pell.›oloev, 1s, 387-399.
Sataloff, R. T. (1997).The professional voice: Part III. Common
diagnoses and treatments./oiirnof o/Koice, 7, 283-292.
Schneider, P. (1993). Tracking changes in dysphonia: A case
study./oarn‹sl of Voice, 7, 179-188.
Sharkawi, A. E., Ramig, L., Logeinann, J.A., Pauloski, B. R., Rade-
maker, A. W., Smith, C. H., et al., (2002). Swallowing and
voice effects of Lee Silverman Voice Treatment (LSVT): A
pilot study./oorn‹sf ofNeurolog)›, 7£, 31-36.
Shearer, W. M. (1972). Diagnosis and treatment of voice disor-
ders in school cluldren. font-nal of Speecl.› arm:I Neerfttg
Disorders, 3.7, 215-221.
Smith, S. R Thyme, K. (1976). Statistic research on changes in
speech due to pedagogic treatment (The Accent Method).
Tolia Piioniatrice, *‹9, 93-103.
Solomon, N. P., R DiMattia, M. S. (2000). Effects of a vocally fa-
tiguing task and systemic hydration on phonation thresh-
old i»ressure.Journal of Voice, 14, 341-362.
Solomon, N. P., McCall, G. N.,Trosset, M.W., R Gmy,W C. (1989).
Laryngeal configuration and constriction during two types
of whispering. Joui-nal of Speech url Heariii$ Research,
32, 161-174.
Spielman, J. L., Boron, J. C., & Ramig, L. 0. (2003). The effects
of intensive voice treatment on facial expressiveness in
Parkinson disease: Preliminary data. Co(iiitiue arid, 6e/ier-
ioral Neui’olog)›, 1‹S, 177-188.
Stemple, J. C. f1993). Voice tker‹s py.’ Clinical stui:ties. St. Louis,
MO: MosbyYear Book.
Ste i» • ,J.C. (Ed.). (2000). Voice tla‹n-af›: Clinical studies (2nd
ed.). San Diego, CA: Singular Publishing group.
Steinp1e,J. C. (2005a.A holistic ap}aroacli to voice therapy. Sem-
i.mars in S]aeecl.› ni’id Lanyunge, 26, 131-137.
Stemple, J., Glaze, L., R Klabeii, B. (2000). 6/iiiicef voice ya-
tlyolOff›.’ Tlaeoi) and:t tnoitagetnettt (3rd eel.). San Diego,
CA: Singular Publislñng group.
Stemp1e,J. C., See, L., D’Amico, B., R Pickup, B. (1994). Efficacy
of vocal function exercises as a method of improving voice
production. font tial of Voice, 8, 271-289.
Stemple, J. C., Weiler, E., Whitehead, W., R Komray, R. (1980).
Electromyograpliic biofeedback training with patients ex-
‘liibiting a liy{aerfunctioual voice disorder. Sai3itigoscope,
F0, 471-476.
Timmermans, B., De Bodt, M. S.,Wuyts, F. L., & Van de Heyning,
P. H. (2004).Training outcome in future professional voice
 VOIC£ THERAPY 77

users after 18 months of voice training. Folia Piioniati ica

Verdolini-Marston, K.,Sandage, M., RTitze, I.R. (1994). Effect of
ct Logopac tica,56, 120-129.
hydration treatments on laryngeal nodules anct polyi»s and
Timnierinans, B., De Bodt, M. S.,Wuyts, F. L., RVan de Heyning,
P. H. (20059.Analysis and evaluation of a voice-training pro- related voice measures./oiii-iiof of Voice, 8, 30-47.
grnm in future professional voice users./ourno/ o,/ Voice, Verdolini-Marston, K., R Titze, I. R., R Druckei; D. G. (1990).
7 , 202-210. Changes in phonation threshold pressure with induced
Titze, I. R. (1994). Principles of voice production. Englewood conditions of1iydrntion./ourital of Voice, 4, 142-151.
Cliffs, NJ: Prentice-Hall. West, R., Kennedy, L., R Carr, A. (1947). Tl.›e reh‹s hilitation of
Titze, I. R. (2003). A theoretical study of F,-F, interaction with sfieecl› (flev. ed.). New York: Harper R Brothers.
application to resonant s liCaking and singing voice./oui- Wups, F. L., De Bodt, M. S., Molenberghs, G., Remacle, M., Hey-
not of Voice, 18, 292-298. len, L., Miller, B., et al. (2000). The Dysphonia Severity It-
Toohill, R.J. (1975).The psychosomatic aspect of children with dcx:An objective meastn-e of hoarseness based on a iilti-
vocal nodules. Arcl.lives of Oio/aiyiigofogy , 101, 591-595. parameter a}aproacli./oui-trol off Speech, latiguoge, am:I
van den Berg, J. (1958). Myoelastic-aerodynamic theory of Hearittg Reseat-Cly, 43,796—809.
voice production. Jouviaf of Speech anlt Hearing Re- Xu, J., Ikeda, Y., R Komiyama, S. (1991). Bio-feedback and the
senrcl.1, 1, 227-244.
yawning breath pattern in voice therapy:A clinical trial. Au-
-can Tier Mar-xc, ñ. (2 04). The “Joice Use ñeciuctiori Programs.
American Journal of Speecl.›-Language Pathology, 13, 208-
Yamaguclii, H., Yotsukura, Y., Kondo, R., Hanyuti, Y., I-Ioriguclii,
218.
S., linaizuini, S., R Hirose, H. (1986). Nonsurgical therapy
Van Lierde, K. M., De Lay, S., Clement, G., De Bodt, M., & Van
Cauwenberge, P. (2004). Outcome of laryngeal manual for vocal nodules. Folia Plaoniatrica ,38, 372-373.
therapy in four Dutch adults with persistent moderate-to- Yamaguclii, H., Yotsuktira, H., Watanabe, H., Hirose, I4., Ko-
severe vocal hyperfunction:A pilot study.Journal of Voice, bayaslii, N., R Bless, D. M. (1993). Pushing exercise pro-
28,467-474. gram to correct glottal incompetence./oornof o/ Voice, 7,
Vân Riper, C., & Irwin,J. (19f8). Pofce enrf m-ticulotloii.Engle- 250-256.
wood Cliffs, NJ: Prentice-Hall. Yiu , E. M. L., R Chan, R. M. M. (2003). Effect of hydration and
vocal rest on vocal fatigue in amateur karnoke singers./ooi-
Verdolini, K., Druker, D. G., Palmer, P. M., ‹'k Samawi, H. (1998).
Laryngeal adduction in resonant voice./ourna/ of Voice, nal of Voice, I7, 216-227.
2*, 315-327. Yin. E. M. L., R Ho, E.Y.Y. (2002). Short-term effect of humming
Verdolini, K., R Ramig, L. (2001). Review: Occupational risks on vocal cfvizñtf. Asia Pacific OHt‘ l’t ff l 0
for voice problems. Logopei:tics, Plaoniatrics, and Vocol- 7, 123—137.
op›, *6, 37-46. Yiu, fi. M. L., Verdolini, K., R Chow, L.P.Y. (2005). Electroinyo-
Verdolini, K., Titze, I. R., R Fennell, A. (1994). Dependence of graphic study of motor learning for a voice procluction
phonatory effort on hydration level.Joni nal ofSpeeCl0 O1 s tilsk. journal of Speech, Lati5uage, attr:t Hearing Reseni-cl.›,
Hearing Research, 3.7, 1001-1007. 48,1254-1268.
Verdolini-Marston, K., Burke, M. K., Lessac, A., Glaze, L., & Zwitman, D., R Calcaterra,T. (1973).The “silent cough”method
Caldwell, E. (1995). Preliminary study of two method of for vocal hyperfunction.Journal o/ Speech mid He‹s ring
treatment for laryngea1nodu1es.Journal of Voice,*5, 74-85. Disor‹:ters, 38, 119-125.