Voice Therapy Techniques

(New Yorl eye and ear infirmary of Mount Sinai)

A few techniques most effectively target a specific type of voice
disorder - for instance, the Lee Silverman Voice Therapy approach is
developed specifically for use with Parkinson's patients, while
confidential voice is used mainly for individuals who have an injury to
the vocal fold mucosa. In general, however, there is no single correct set
of techniques for a specific voice problem. This is because most voice
problems are made up of more than one feature and have more than one
single cause. In addition, most techniques achieve improved voice by
targeting improved balance of all of the components of voice
production; they just use slightly different means of obtaining that
balance. Different therapists have different approaches, all with many
commonalities. One technique may work best for one therapist or
patient, and another approach works best for others. Voice therapy is an
interaction of the therapist and the patient. Most (but not all) of these
exercises begin by eliciting the correct voice production technique using
the most facilitating sounds and combinations of sounds. Then, as the
patient becomes able to produce voice in this optimal way, the technique
is carried over into words, phrases and sentences until integrated into
conversational speech

In alphabetical order, some of these techniques:

 Accent Method
 Confidential Voice 
 Digital Laryngeal Manipulation 
 Lee Silverman Voice Treatment (LSVT)
 Resonant Voice 
 Vocal Function Exercises
Accent Method: This program uses rhythmic exercises to facilitate the
coordination of minimally-constricted vocal fold vibration with
appropriate air pressure and air flow. The Accent Method is a holistic
approach that addresses pitch, loudness and timbre simultaneously,
rather than focusing separately upon each of these vocal parameters.
Rhythmic contraction of the muscles involved in breathing are
coordinated with production of increasingly complex utterances. The
consonants in these utterances are used as accents within the rhythm.
Initially, rhythmic whole body movements are used to facilitate clear
and easy voice production. Rhythmic variation in pitch and loudness are
incorporated to gain increased vocal flexibility.
Confidential Voice: Confidential voice is designed as a temporary style
of voice production used to help facilitate mucosal repair. It is often used
in acute (short-term) voice problems and after surgery. It is part of a
modified voice rest program and can be used as the only type of voice
production for one to two weeks, or as part of a longer-term program
that alternates periods of voice rest with more demanding voice use.
Confidential voice is a light voice. It is an easy, breathy, low airflow
style of phonation. It is a softly-produced voice, and therefore not
functional for many communicative needs. Although the voice is soft, it
is not a breathy whisper. Low-effort is critical to the success of this style
of phonation. However, low-effort does not imply low pitch or low
(pharyngeal) tone focus. Importantly, the normal pitch of the voice is
maintained, and even a slightly increased pitch contour (mildly "sing-
song") is encouraged to prevent "monotone", which can force the
laryngeal muscles into a "locked-in", inflexible setting that can be
contrary to facilitating mucosal repair.
Digital Laryngeal Manipulation: Also called laryngeal massage, the
focus of this technique is to decrease excessive contraction of the
muscles of the larynx (see muscle tension dysphonia). This is achieved
through pressing on selected areas of the neck (focal palpation),
circumlaryngeal massage, and manually repositioning the larynx. Using
the thumb and forefinger, moderate pressure is applied in small circles,
from front to back, targeting selected areas of the larynx and neck.
Often, excessive muscle contraction causes the larynx to be positioned
too high in the neck, pulled up towards the base of tongue. Speaking in
this position for extended periods of time can cause neck discomfort and
even focal pain or tenderness.
Laryngeal massage will therefore often focus initially upon the
contracted thyrohyoid space (the area between the larynx and the hyoid
bone) to release the excessive contraction and allow the larynx to
descend. Gentle manual repositioning of the larynx during phonation can
sometimes prevent habituated patterns of excessive contraction. Vocal
exercises are incorporated during the massage to facilitate clear and easy
voice production without excessive muscle contraction. The patient is
then encouraged to focus upon auditory and vibrotactile feedback to
encourage maintenance of easy voice production in the absence of
manual manipulation.
Lee Silverman Voice Treatment (LSVT): This is an intensive program,
with attendance required four days/week for four consecutive weeks.
The focus of LSVT is the use of "loud" voice, emphasizing both the
production and the habituation of loud voice. This program was
developed and has been tested mainly on patients with Parkinson's
disease. However, many clinicians have found it helpful with patients
who have other types of diseases or voice problems that cause problems
with loudness level and/or clarity of articulation.
Resonant Voice: This approach focuses upon achieving a specific
configuration of the vocal folds and muscles immediately above the
vocal folds (termed the epilaryngeal area) by training the patient to
respond to sensations of vibration in the face (similar to the "buzz" that
you would feel when humming). Resonant voice techniques aim to
increase the power and clarity of the voice while decreasing the
vibratory forces that can contribute to mucosal trauma.  The goal is to
create an optimal pressure balance between the lung pressure below the
vocal folds, the air pressure in the vocal tract above the glottis, and the
vocal fold resistance to the airflow. This technique is commonly used in
cases of primary or secondary muscle tension dysphonia in which the
vocal folds are either squeezed together with too much force, or held
stiffly apart and prevented from contacting together or vibrating fully.
Resonant voice production may decrease the excessive or uncoordinated
muscle contractions, allows the vocal folds to vibrate more freely, and
therefore improve vocal fold contact and vocal quality.
Vocal Function Exercises: This approach is a three-component
program of warm up, pitch glides (high to low and low to high) and
sustained vowel phonation at selected pitches. These exercises are
performed a specific number of times during the day. Like any type of
exercise, they can be done incorrectly or correctly. Producing them with
a resonant voice (also called "flow" mode of phonation) rather than
excessive effort, is key to these exercises. These exercises are based
upon the hypothesis that their systematic practice will increase the bulk
and strength of the thyroarytenoid muscle (the body of the vocal folds)
and improve coordination of the multiple muscles of the larynx that must
be co-activated for speech
ASHA.

Consistent with the WHO (2001) framework, intervention is designed to

  capitalize on strengths and address weaknesses related to
underlying structures and functions that affect voice production;
 facilitate the individual's activities and participation by assisting
the person in acquiring new communication skills and strategies;
and
 modify contextual factors to reduce barriers and enhance
facilitators of successful communication and participation, and to
provide appropriate accommodations and other supports, as well as
training in how to use them.

See the ASHA resource titled Person-Centered Focus on Function:

Voice [PDF] for an example of functional goals consistent with ICF.

Collaborating With Other Professionals

In the case of medically related voice disorders (e.g., vocal polyps, vocal
cysts, spasmodic dysphonia), SLPs often team with otolaryngologists
and other medical professionals (e.g., pulmonologists,
gastroenterologists, neurologists, allergists, endocrinologists, and
occupational medicine physicians) and, if appropriate, develop treatment
plans to support the medical plan and to optimize outcomes.

Some individuals develop voice disorders in the absence of structural

pathology (e.g., functional aphonia, muscle tension dysphonia, and
mutational/functional falsetto) and may benefit from support in addition
to what can be provided by the SLP.

Counseling, direct manipulation of the voice, and use of interview

questions can be used to probe possible factors contributing to the voice
problem. SLPs refer the individual to appropriate health care
professionals (e.g., psychologists) to address issues outside the SLP's
scope of practice (ASHA, 2016b). SLPs often engage in collaborative
approaches throughout the course of assessment and subsequent
treatment.

Treatment Approaches
Norms within different settings are considered when determining vocal
needs and establishing goals. For example, vocal norms and needs
within the workplace may be different from those within the community
(e.g., home and social settings).
SLPs often incorporate aspects of more than one therapeutic approach in
developing a treatment plan. 
Approaches can be direct or indirect.

 Direct approaches focus on manipulating the voice-producing

mechanisms (e.g., phonation, respiration, and musculoskeletal
function) in order to modify vocal behaviors and establishing healthy
voice production (Colton & Casper, 1996; Stemple, 2000).
 Indirect approaches modify the cognitive, behavioral,
psychological, and physical environments in which voicing occurs
(Roy, et al., 2001; Thomas & Stemple, 2007). Indirect approaches
include the following two components:
o Patient education—discussing normal physiology of voice
production and the impact of voice disorders on function;
providing information about the impact of vocal misuse and
strategies for maintaining vocal health (vocal hygiene)
o Counseling—identifying and implementing strategies such as
stress management to modify psychosocial factors that
negatively affect vocal health (Van Stan, Roy, Awan, Stemple,
& Hillman, 2015)

A therapeutic plan typically involves the use of at least one of the direct
approaches and one or more of the indirect approaches based on the
patient's condition and goals.
Some clinicians concentrate on directly modifying the specific
symptoms of the inappropriate voice, whereas others take a more holistic
approach, with the goal of balancing the physiologic subsystems of
voice production—respiration, phonation, and resonance.
Many clinicians begin by
  identifying behaviors that are contributing to the voice problems,
including unhealthy vocal hygiene practices (e.g., shouting, talking
loudly over noise, coughing, throat clearing, and poor hydration) and
 implementing healthy vocal hygiene practices (e.g., drinking plenty
of water and talking at a moderate volume) and practices to reduce
vocally traumatic behaviors (e.g., voice conservation).

Treatment Options

The following subsections offer brief descriptions of general and

specific treatments for individuals with voice disorders. They are
organized under two broad categories: physiologic voice therapy (i.e.,
those treatments that directly modify the physiology of the vocal
mechanism) and symptomatic voice therapy (i.e., those treatments
aimed at modifying deviant vocal symptoms or perceptual voice
components using a variety of facilitating techniques).

This list of treatment options is not exhaustive, and the inclusion of any
specific treatment approach does not imply endorsement by ASHA. For
more information about treatment approaches and their use with various
voice disorders, see Stemple et al. (2010).

Treatment selection depends on the type and severity of the disorder and
the communication needs of the individual. Clinicians are sensitive to
cultural, linguistic, and individual variables when selecting appropriate
treatment approaches. As indicated in the Code of Ethics (ASHA,
2016a), SLPs who serve this population should be specifically educated
and appropriately trained to do so.

Physiologic Voice Therapy

Physiologic voice therapy is inherently a holistic approach to treatment.

Physiologic voice therapy programs strive to balance the three
subsystems of voice production (respiration, phonation, and resonance)
as opposed to working directly on isolated voice symptoms. Most
physiologic approaches may be used with a variety of disorders that
result in hyper- and hypofunctional vocal patterns. Below are some of
the physiologic voice therapy programs, arranged in alphabetical order.

Accent Method

The accent method is designed to increase pulmonary output, improve

glottic efficiency, reduce excessive muscular tension, and normalize the
vibratory pattern during phonation. During therapy, the clinician may do
one or more of the following tasks:

 Facilitate abdominal breathing by initially placing the patient in a

recumbent position.
 Use rhythmic vocal play with models of accented phonation
patterns, which the patient then imitates.
 Transfer rhythms to articulated speech, initially being given a
model and eventually progressing through reading, monologues,
and conversational speech.

Cup Bubble/Lax Vox

Cup bubble, also known as Lax Vox, is an aerodynamic building task

aimed at improving ability to sustain phonation while speaking. It is
done by having a patient blow air initially into a cup of water without
voice. Voicing can be added for subsequent trials, and in time, pitch can
be altered across and within trials. Eventually, the cup is removed during
voicing, and the phonation continues. These exercises are thought to
widen the vocal tract during phonation and reduce tension in the vocal
folds. Biofeedback increases the individual's awareness of his or her
healthy voice production (e.g., Denizoglu & Sihvo, 2010; Simberg &
Laine, 2007).

Expiratory Muscle Strength Training (EMST)

Expiratory muscle strength training (EMST) improves respiratory

strength during phonation. Increase in maximum expiratory pressure
(MEP) can be trained with specific calibrated exercises over time, thus
improving the relationship between respiration, phonation, and
resonance. EMST uses an external device to mechanically overload the
expiratory muscles. The device has a one-way, spring-loaded valve that
blocks the flow of air until the targeted expiratory pressure is produced.
The device can be calibrated to increase or decrease physiologic load on
the targeted muscles (Pitts et al., 2009).

LSVT

Manual Circumlaryngeal Techniques

Manual circumlaryngeal techniques are intended to reduce

musculoskeletal tension and hyperfunction by re-posturing the larynx
during phonation. There are three main manual laryngeal re-posturing
techniques:

 Push-back maneuver—place forefinger on thyroid cartilage and

push back to change shape of glottis.
 Pull-down maneuver—place thumb and forefinger in the
thyrohyoid space and pull the larynx downward.
 Medial compression and downward traction—place thumb and
forefinger in the thyrohyoid space, and apply medial compression.

Applying these maneuvers during vocalization allows the individual to

hear resulting changes in voice quality (Andrews, 2006; Roy, Bless,
Heisey, & Ford, 1997). Care is taken when employing these techniques,
as some patients report discomfort.

Phonation Resistance Training Exercise (PhoRTE)

Phonation Resistance Training Exercise (PhoRTE; Ziegler & Hapner,

2013) was adapted from LSVT and consists of four exercises:

 Producing /a/ with loud maximum sustained phonation

 Producing /a/ with loud ascending and descending pitch glides
over the entire pitch range
  Producing functional phrases using a loud and high (pitched) voice
 Producing the same functional phrases using loud and low
(pitched) voice

Individuals are reminded to maintain a "strong" voice throughout

these treatment exercises. PhoRTE has a less intensive intervention
schedule than LSVT. PhoRTE also differs in that it combines both
loudness and pitch when producing phrases (i.e., loud and low
pitch; loud and high pitch). Use of PhoRTE has been studied in
adults with presbyphonia (aging voice) as a way to improve vocal
outcomes (e.g., decrease phonatory effort) and increase voice-
related quality of life (Ziegler, Verdolini Abbott, Johns, Klein, &
Hapner, 2014).

Resonant Voice Therapy

Resonant voice is defined as voice production involving oral vibratory

sensations, usually on the anterior alveolar ridge or lips or higher in the
face in the context of easy phonation. Resonant voice therapy uses a
continuum of oral sensations and easy phonation, building from basic
speech gestures through conversational speech. The goal is to achieve
the strongest, "cleanest" possible voice with the least effort and impact
between the vocal folds to minimize the likelihood of injury and
maximize the likelihood of vocal health (Stemple et al., 2010). The
program incorporates humming and both voiced and voiceless
productions that are shaped into phrase and conversational productions
(Verdolini, 1998, 2000).

Stretch and Flow Phonation

Stretch and flow phonation —also known as Casper-Stone Flow

Phonation—is a physiological technique used to treat functional
dysphonia or aphonia (Stone & Casteel, 1982). It focuses on airflow
management and is used for individuals with breath-holding tendencies.
Individuals are instructed to focus on a steady outflow of air during
exhalation. Various biofeedback methods are used, including placing a
piece of tissue in front of the mouth or holding one's hand in front of the
mouth to monitor airflow. Voicing is introduced once the individual
masters continuous airflow during exhalation. As such, this technique
produces a breathy voice quality. Eventually, this voice quality is carried
into trials with spoken words and phrases, and the breathiness is
gradually reduced.

Vocal Function Exercises (VFEs)

Vocal function exercises (VFEs) are a series of systematic voice

manipulations designed to facilitate return to healthy voice function by
strengthening and coordinating laryngeal musculature and improving
efficiency of the relationship among airflow, vocal fold vibration, and
supraglottic treatment of phonation (Stemple, 1984). Sounds used in
training are specific, and correct production is encouraged. VFEs consist
of four exercises—warm-up, stretching, contracting, and power
exercises. Exercises are completed twice a day (morning and evening) in
sets of two. Maximum phonation time goals are set on the basis of
individual lung capacity and an airflow rate of 80 ml/sec. Individuals are
advised to use a soft, engaged tone and are trained to use a semi-
occluded vocal tract (lip buzz) without tension during voice productions.

Symptomatic Voice Therapy

The focus of symptomatic voice therapy is on the modification of the

deviant vocal symptoms or perceptual voice components. Deviant
symptoms may include pitch that is too high or low, voice that is too soft
or loud, breathy phonation, or the use of hard glottal attacks or glottal
fry. Symptomatic voice therapy assumes voice improvement through
direct symptom modification using a variety of voice facilitating
techniques (Boone et al., 2010) that are either direct or indirect.

Amplification

Amplification devices such as microphones can be used to amplify the

voice in any situation that requires increased volume (e.g., when
speaking to large groups, or during conversation when the individual's
voice is weak). As such, voice amplification can function as a supportive
tool or as a means of augmentative communication. It can help prevent
vocal hyperfunction as a result of talking at increased volume or for
extended periods of time.

Auditory Masking

Auditory masking is used in cases of functional aphonia/dysphonia and

often results in changed or normal phonation. Individuals are instructed
to talk or read passages aloud while wearing headphones with masking
noise input. Using a loud noise background, the individual often
produces voice at increased volume (Lombard effect) that can be
recorded and used later in treatment as a comparison (e.g., Brumm &
Zollinger, 2011; Adams & Lang, 1992).

Biofeedback

The basis of biofeedback is that self-control of physiologic functions is

possible with continuous, immediate information about internal bodily
state. Biofeedback provides clear and reliable feedback in response to
alterations in voice production, thus facilitating improvements in pitch,
loudness, quality, and effort. It can be kinesthetic, auditory, or visual.
Using biofeedback, individuals are trained to become aware of physical
sensations with respect to respiration, body position, and vibratory
sensation. Awareness helps the individual understand his or her
physiological processes when generating voice. Auditory feedback, such
as real-time amplification auditory modeling is an effective way to
achieve voice improvement.

Chant Speech

Chant speech is characterized by a rhythmic, prosodic pattern that

serves as a template for spoken utterances. It is used in therapy to help
reduce phonatory effort that results in vocal fatigue and decrease in
phonatory capabilities. Chant speech requires pitch fluctuations and
coordination among respiratory, phonatory, and resonance subsystems.
Speakers habituate to these more efficient vocal patterns. The increased
lung pressure required for these tasks may also decrease reliance on
laryngeal resistance and reduce fatigue (e.g., McCabe & Titze, 2002).

Confidential Voice

Confidential voice is designed to reduce laryngeal

tension/hyperfunction and increase air flow (Casper, 2000). The
individual begins with an easy and breathy vocal quality and builds to
normal voicing without decreasing airflow. This technique is intended to
address excessive vocal tension and to facilitate relaxation in the
muscles of the larynx.

Glottal Fry

Glottal fry is useful for patients with vocal nodules and other problems
associated with hyperfunction (e.g., polyps, functional dysphonia,
spasmodic dysphonia, vocal fold thickening, and ventricular phonation).
Because the vocal folds must be relaxed in order to produce glottal fry,
this technique can be a useful index of vocal fold relaxation (Boone et
al., 2010). Although glottal fry is a powerful facilitative technique to
offload tension in the larynx, it is not a long-term speech quality target.

Inhalation Phonation

Inhalation phonation is a technique used to facilitate true vocal

vibration in the presence of habitual ventricular fold phonation,
functional aphonia, and muscle tension dysphonia. Individuals produce a
high-pitched voice on inhalation. Upon inhalation voicing, the true vocal
folds are in a stretched position, suddenly adducted and in vibration.
Upon exhalation, patients try to achieve a nearly matched voice. This
approach eases the way to gaining true vocal fold vibration.
Semi-Occluded Vocal Tract (SOVT) Exercises

Semi-occluded vocal tract (SOVT) exercises in voice therapy involve

narrowing at any supraglottic point along the vocal tract in order to
maximize interaction between vocal fold vibration (sound production)
and the vocal tract (the sound filter) and to produce resonant voice.

Straw Phonation

Straw phonation is one of the most frequently used methods to create

semi-occlusion in the vocal tract (Titze, 2006). Narrowing the vocal tract
increases air pressure above the vocal folds, keeping them slightly
separated during phonation and reducing the impact collision force. To
accomplish this, the individual semi-occludes the vocal tract by
phonating through a straw or tube. Resistance can be manipulated by
varying the length and diameter of the straw. Individuals practice
sustaining vowels, performing pitch glides, humming songs, and
transitioning to the intonation and stress patterns of speech. Eventually,
use of the straw is reduced and eliminated.

Lip Trill

Semi-occlusion at the level of the lips is accomplished via lip trills. This
technique involves a smooth movement of air through the oral cavity
and over the lips, causing a vibration (lip buzz), similar to blowing
bubbles underwater. Often, the trills are paired with phonation and pitch
changes. The focus is to improve breath support and produce voicing
without tension.

Posture

The patient is instructed in the technique of sitting with upright posture

and with the shoulders in a low, relaxed position to facilitate voice
production with less effort. Collaboration with a physical therapist or
occupational therapist may be necessary with some patients
Relaxation

In cases of vocal hyperfunction, a variety of relaxation techniques may

be useful as a tool to reduce both whole-body and laryngeal area tension.
The goal of these techniques is to reduce effortful phonation. Frequently
used techniques include progressive muscle relaxation (slowly tensing
and then relaxing successive muscle groups), visualization (forming
mental images of a peaceful, calming place or situation), and deep
breathing exercises.

Twang Therapy

Twang therapy is used for individuals with hypophonic voice. It

involves the narrowing of the aryepiglottic sphincter using a "twang"
voice to create a high-intensity voice quality while maintaining low
vocal effort (Lombard & Steinhauer, 2007). The desired outcome is
decreasing phonatory effort and increasing vocal efficiency.

Yawn-Sigh

This facilitating technique uses the natural functions of yawning and

sighing to overcome symptoms of vocal hyperfunction (e.g., elevated
larynx and vocal constriction). The technique is intended to lower the
position of the larynx and subsequently widen the supraglottal space in
order to produce a more relaxed voice and encourage a more natural
pitch.