Anatomy, Biomechanics, Biology:

A “Spectrum” of Voice Therapies

Kittie Verdolini Abbott, PhD, CCC-SLP
Santiago, Chile 2014

Communication Science and Disorders

School of Health and Rehabilitation Sciences
 Discussion in three parts
• (1) Developmental
anatomy

• (2) Basic science

relevant to “indirect
therapy”

• (3) Basic science

relevant to “direct”
therapy (“spectrum” of
voice therapies)
 Starting point
• Phonotrauma
– Nodules
– Polyps
– Etc.
– Most common
pathologies to affect
voice (see, for example,
powerpoints for AIV)
 WARNING:
The most boring part of the course follows here
• Depending on who you are.
• This information is necessary.
• I will do my best to be entertaining.
 Development
• Anecdotally, it
Image from http://supermon.files.wordpress.com/2010/01/baby.jpg

appears infants have

a relatively reduced
risk of phonotrauma
(<1-2 years).
 Development
• That is:
(Approximate percents)

– Infants: Relatively low risk

16
14
– Children: Increased risk 12
10
8 males

– Adults 6 females

4
• Males low risk 2
0
• Females higher risk 0 to 2 2 to 3 3 to 13 15 to 60 60 to 90

– Elderly: Low risk

 Why?
• Partly due to anatomic and biologic factors?
 Macrostructure
• Few clearly
relevant data….

http://dessertdarling.com/wp-content/uploads/2012/02/sadface3.jpg
 Macrostructure
• Neonate compared to • Possibile implications:
adult Interactions between
– Short pharynx “source” and “filter” may
– High cricoid cartilage (C4) vary over time (details
– Compact hyolaryngeal region (C1) unclear)
– Epiglottis approximated to soft palate
(allowing for simultaneous suction • Relevance for
and respiration) phonotrauma?
• Development notrauma???
– 2 years: Laryngeal confines descend
to C5
– 15 years: Laryngeal confines descend
to final position (C6-7); hyoid bone
and thyroid cartilage separate
• Isaacson, 1996
 Macrostructure

Adult vocal folds: Long

Neonate vocal folds: Short (Immagini dal dr. Christopher Hartnick)
 Macrostructure
• Possible implication
– Short folds  high Fo
in the neonate

– High frequency should

increase the risk of
phonotrauma
 Microstructure
• Data are a little
more clear

http://3.bp.blogspot.com/-vpsc13PCfc0/TaLCGaq2SjI/AAAAAAAACTA/hw2MDzTk6mg/s1600/smiley-
face.jpg
Microstructure
• Epithelium (cells)

• Lamina propria
– Cells and extracellular matrix
– Phonotrauma develops here
(alterations in ECM)
• Muscle

• (Basal membrane)
• (Gray, 1994)
 Microstructure
• Nodules (for ex.)
– Thickening and
interruption of the basal
membrane

– Migration of Collagen I,
IV, towards the
superficial lamina
propria

– Increased fibronectin
(images from Gray, 1997)
 Microstructure
• Neonate v. adult
– Neonatal phonation produces
hyaluronic acid in the vocal
folds (Sato et al., 2001).
– The neonate has about 51%
of the collagen adults have
(Hammond et al., 2000)
– The neonate has about 23%
of the elastin adults have
(Hammond et al., 1998)
– Image from Gray, 1996
• Possible implications:
Maybe the neonate has:
– Decent shock absorption
in the vocal folds
– Reduced fibers that
constitute a substantial
aspect of common
phonotraumatic lesions
– Together, perhaps these
factors reduce the risk
of phonotrauma in
neonates?
 Microstructure
• In adults the lamina
propria has 3
differentiated layers:
– Superficial LP: (note:
epithelium + SLP =
mucosa; “floppy”)
– Intermediate and deep
lamina propria
(ligament; white;
“tougher”)
 Microstructure
• Differentiated lamina
propria not present at
birth
• Trilaminar structure
develops gradually over
17 years
– Monolayer 
– Bilaminar structure 
– Trilaminar structure
• Hartnick CJ et al. Development and maturation of the
pediatric human vocal fold lamina propria. Laryngoscope.
2005 Jan; 115(1):4-15. Immagine prossime pagine da
Hartnick, c.p.
2 day 2 month

3 year 7 year
13 year old
 Microstructure
• Possible implication:
Maybe the development of
an underlying ligament
creates a harder striking
surface, and thus increases
the risk of phonotrauma
with age?
• (But if that’s the case, why
do men have a reduced risk
http://learnchinesesoftware.org/wp-content/uploads/2010/10/woman-thinking.jpg
of phonotrauma? Maybe
due to a sharp increase in
hyaluronic acid at puberty
in males…)
 Microstructure
• Neonate v. adult
– Fibroblasts: Cells that, in
adults, produce fibers in
the lamina propria.
– Inactive in the
production of these
fibers in the neonate
(Hirano et al., 1999).
• Possible implication:
Maybe neonates don’t
have the machinery
required for the production
of fibers that constitute
phonotrauma?
• Are we doing any better?
Summary macro- and
microstructure
C/w reduced risk of C/w risk of
phonotrauma in increased risk of
infants compared phonotrauma in
to children neonates
compared to
children
Soft striking High Fo
surfaces (ligament
lacking)

Little capacity to
produce fibers that
constitute
phonotrauma
 However…..
• The situation is probably
more complex……

• Biomechanically:
– Maybe the infant’s scream
is different than the adult’s
yell.
– Maybe it is relevant that
the infant actually uses
voice much less than the
adult.
 Note
• Much of what we know • Problems:
about vocal fold – Prolonged tissue fixation
microstructure is derived – Prolonged pre-mortem
from cadaver tissues intubation
– Tissue dessication

• New functional
approaches are under
development (e.g.,
Optical Coherence
Tomography; Hartnick,
p.c.)
 Transitioning to next topics
• Voice therapy
– Indirect therapy
(aka “vocal
hygiene”)

– Direct therapy
(voice training)
 Biomechanics and biology
• Indirect therapy
(first)

• Direct therapy
(second)
 Indirect therapy (general)
• Typically lots of do’s and
don’ts (lots)
– Don’t clear your throat
– Don’t cough
– Sip lots of water
– Don’t use glottal stops
– Don’t talk loudly
– Don’t talk over noise
– Don’t call over a distance
– Don’t smoke
– Relax
– Etc. (64 recs in studies by Roy et
al., 2000s)

University of Pittsburgh
 Why do something so annoying?
• Clinicians without lots
of confidence in voice
knowledge/skills love it

• Hand people a list; go

over list; go home

University of Pittsburgh
 Data (most studies on teachers)
• Support • Examples
– Not much (non- – Pasa et al., 2006; Ilomaki
randomized studies, few et al., 2008; Niebudek-
control groups, Bogusz et al., 2008
questionable statistics or
lack thereof, etc.)

University of Pittsburgh
 Data
• “Oops” factor • (Which study gets the
– Randomized, controlled crown for design and
studies: VH instructions approach to analysis? And
(6 wk) failed to produce tentative conclusions to this
changes in Voice point?)
Handicap Index or self-
perceived voice –
although no-tx controls
got worse (Roy et al.,
2001; 2002)

University of Pittsburgh
 Question
• Why are results from VH
programs generally
underwhelming?

• Could they be improved to

improve outcomes?

– Reduce number of parameters

addressed (see compliance
literature; only so many cards to
play)

– Personalize and target programs

University of Pittsburgh
 Stated differently:
• Can we create an
indirect voice therapy
approach that is “lean
and mean”

– Limit the number of

things we ask people to
do
– Target recommendations
to the individual
 Specifically
• We might consider targeting
only a few parameters to
potentially address in a
voice hygiene program…….
 And further
• We might tailor our
recommendations to
each individual patient.

spendamillion.com
 Any difference in the results?
• Randomized controlled • Healthy teachers
(N=31 for full study, 3
groups) VHI Scores comparison-Pittsburgh

– Student teachers at start of teaching 25

received (a) 2 hr of limited-

20
parameter, personalized VH program,
(b) VH + 2 hr voice training, or (c) 15 BL

VHI
nothing 1-m/o
10 2-m/o
– Healthy teachers: All VH and VH+VT
subjects had (equivalently) improved 5
VHI at 1- and 2-mo follow-up (all
0
control subjects got worse) Control VH+RVT VH
– Subjects with voice problems: Groups

Required VH + voice training to do

better than controls (data not shown;
Nanjundeswaran et al., 2012)

University of Pittsburgh
 So what are these “limited parameters?”

• HYDRATION • Lean and mean VH

– Enough water? (Rule of thumb 2 qt/day;
more with sweating & diuretics) program (details in
– Dry airway (mouth breathing, drying
drugs, alcohol, caffeine) “Step by Step” lecture)
• INFLAMMATION CONTROL
– Laryngopharyngeal reflux (reduce spices,
acidic foods; don’t lie down or exercise
after eating; take prescribed drugs
– Smoking, environmental pollution

• YELLING AND SCREAMING

– Alternate personal expression; learn how
to yell safely (see voice training)

University of Pittsburgh
 Tentative conclusions VH
• Tentative conclusion:
– For prevention of voice
problems in
occupational users,
targeted, personalized
VH programs may be
sufficient to reduce risk
– For treatment of voice
problems, heavier guns
may be required (e.g.
voice training)

University of Pittsburgh
 Dehydration
(systemic or superficial) (bad)
• Increases Ps required to
oscillate the vocal folds
for voice production
Fisher et al., 2001; Jiang et al., 2000; Titze, 1988; Verdolini-Marston et al.,
1990; Verdolini et al., 1994; Verdolini et al., 2002

• May increase the risk of

phonotrauma
Titze, 1981

http://web.hcsps.sa.edu.au/projects/deserts/projects/group13/namib%20desert%
201.jpg
 Hydration
(systemic or superficial)(good)
• Reduces the Ps required
to oscillate the vocal
folds for voice
production
• Jiang et al., 2000; Verdolini-Marston et al., 1990; Verdolini et al., 1994

• May diminish the

severity of
phonotraumatic lesions
• Verdolini-Marston et al., 1994

http://lomophilly.files.wordpress.com/2009/09/water-drop-a.jpg
 Inflammation (bad)
Laryngopharyngeal reflux
• LPR may increase the risk of
phonotraumatic lesions and
other conditions affecting
voice (e.g., cancer, paralysis,
etc.).

• According to retrospective
data, effective treatment of
LPR may improve vocal fold
pathologies and voice.
(Koufman, 1991; Shaw et al., 1996, 1997)
 Inflammation(bad)
LPR
• However……
– If we want to
scare ourselves
(next page)…

http://images.icanhascheezburger.com/completestore/2009/4/5/1288346177681
08870.jpg
Laryngoscope. 2006 Jan;116(1):144-8. Links
Empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review.
Karkos PD, Wilson JA.
Department of Otolaryngology, The Freeman Hospital, Newcastle upon Tyne, UK.
OBJECTIVE: The objective of this study was to define the outcome of empiric treatment of suspected
laryngopharyngeal reflux (LPR) symptoms with proton pump inhibitors (PPIs). DESIGN: The authors
conducted a systematic review of the English and foreign literature. Studies that used PPIs as an empiric
treatment modality for suspected LPR, whether alone or in combination with other acid suppressants and/or
placebo, were included. Studies that did not include PPIs as a treatment option were excluded. MAIN
OUTCOME MEASURES: A lack of common outcome measures was evident in the uncontrolled studies. In the
randomized, controlled trials, outcome measures included symptom questionnaires and videolaryngoscopy.
Only one study used computerized voice analysis. RESULTS: Fourteen uncontrolled studies together with one
unblinded, nonrandomized study with a control group of healthy volunteers and six double-blind, placebo-
controlled randomized trials were identified from 1994 to 2004. Selection bias, blinding of the results, and
lack of common outcome measures were some of the problems preventing a formal metaanalysis. Although
uncontrolled series reported positive results, randomized, controlled trials demonstrated no statistically
significant differences for changes in severity or frequency of symptoms associated with suspected reflux
between PPIs and placebo. CONCLUSIONS: Recommendations for empiric treatment of suspected LPR with
PPIs, by far the most common ear, nose and throat practice in the United Kingdom, are based on poor levels
of evidence from uncontrolled studies. The few randomized, controlled trials have failed to demonstrate
superiority of PPIs over placebo for treatment of suspected LPR.
 Inflammation (male)
Smoking and other
• Exogenous inflammation of
any type can affect voice
and increase the risk of
phonotrauma.

• E.g., smoke, environmental

pollution, chemical
exposures, allergies, various
medications….
• E.g., Richter et al.

http://i.treehugger.com/images/2007-2-28/smoking.jpg
Uncontrolled yelling and screaming
(bad)
• The threshold for
phonotrauma is person-
specific.

• However, uncontrolled
yelling and screaming are
contraindicated without
training by a qualified
person (e.g., using the
epiglottis as a noise source;
Ufema; Montequin; http://thepeoplebrand.com/blog/wp-content/uploads/2007/03/holler2.jpg

Raphael).
 Direct therapy: Voice training
• Starting point: Can
we identify an ideal
biomechanical set-
up to optimize voice
in general?
• thefitnessexperts.co.uk
 Biomechanics
• Biomechanical “set-up”: • “Optimizing voice:”
Here = adduction – Intense (clear) (dB)
– Limited risk of damage
(impact stress, SI)
– Limited effort (subglottic
pressure, Ps)
– Image from www.scientificamerican.com

emedicine.medscape.com
 Biomechanics
• Specific questions:
http://www.hellowood.com/images/Steps3WR.jpg

– First:
• What adduction will maximize
vocal intensity (dB)?
• What adduction will minimize
risk of VF damage (SI)?
• What adduction will optimize
the relationship between
intensity (large) and impact
stress (SI) small?
– Second:
• What will the identified
adductions do for vocal effort
(Ps)?
 Biomechanics
• Approach:
– Simulation
– Excised larynx
– Human data
Berry et al., 2001

http://www.ust.ucla.edu/ustweb/Homepage_imgs/ucla_04.jpg
 Biomechanics
• Metods:
(excised larynx)

Image from Jiang, J.J, Zhang, Yu, & Ford, C.N. (2003).
Nonlinear dynamics of phonations in excised larynx
experiments. J. Acoust. Soc. Am. 114, 2198.
 Biomechanics
• Results:
Acoustic output
(excised larynx)
 Biomechanics
IMPORTANT!!
• Results:
Acoustic output with
simulations adding
vocal tract (/a/, /i/,
/u/)
 Biomechanics
IMPORTANT!!
• Results:
• Vocal fold impact
stress
 Biomechanics
IMPORTANT!!
• Results:
• “Vocal economy”
(output/impact)
 Biomechanics
• Summary: • Adduction that optimizes vocal
economy = ~0.6-0.7 mm between
vocal processes, for the
conditions evaluated (Fo 155; PS
ca. 10-16 cm H20).

• Data precisely replicated in an

independent human experiment
(Fo ~ 195 Hz; in Berry et al.,
2001).

• We expect results generally

similar for other F0, possibly with
slight shifts in the curves (Berry,
p.c.).
http://www.stammeringlife.com/Images/Vocal%20Folds%20(vf)%20Opening%20and%20Closi
ng.JPG
 Biomechanics
• Problem: We wanted: • Choose 2 out of 3???
– Strong output (√)
– Limited SI (√)
– Limited effort…(?)
Or in local terms…..
 Biomechanics
• Nope.
drspeech.com

• PL > k B c w
T
– Titze, 1988

– k = constant
– T = vocal fold thickness
– B = damping coefficient
(~viscosity)
– c = speed of mucosal wave
– w = prephonatory width at vocal
processes
 Biomechanics
• Summary: • Barely touching or
barely separated vocal
folds represent a
biomechanical objective
for many people,
including those with
voice disorders
– Strong output
– Relatively minimal
impact stress
http://www.stammeringlife.com/Images/Vocal%20Folds%20(vf)%20Opening%20and%20Closi
ng.JPG

– Minimal phonatory
effort (respiratory)
 Biomechanics
• As chance would • Singer and actors
have it… produce what some call
“resonant voice” with
this very posture!
– Peterson et al., 1994
– Verdolini et al., 1998

http://api.ning.com/files/vlzj-gWGwag4ns0bp0kF-GRoztWyRSrxo78oTwyb9rO3-
28SsjXn5aOOtT9C0j*clTfJTE8-SiaRPWY0pByJ7xMTTK-adcrj/singer.jpg
 Biomechanics
• Resonant voice • “Easy” voice produced with
perceptible anterior oral
vibrations.
• Physiologically we have
large-amplitude, low-
impact vocal fold
oscillations.
• Verdolini-Marston et al., 1995;
Verdolini, 2000; Peterson et
al., 1994; Verdolini et al., 1998;
video
 Biomechanics
• Link between
perception and
biomechanics
Complete VF closure
Incomplete VF closure
 Biomechanics
• Summary to this • Barely touching or barely
separated vocal folds appear
point: to optimize the relation
between voice output
intensity (strong) and vocal
fold impact stress (small). This
configuration also helps to
minimize vocal (respiratory)
effort.

• This set up corresponds

perceptually to “resonant
http://www.stammeringlife.com/Images/Vocal%20Folds%20(vf)%20Opening%20and%20Closi
voice” (anterior oral
ng.JPG
vibrations; easy voice) – with
fairly large VF vibrations and
low inter-VF impact.
 First link to a biomechanical
“spectrum” of voice therapies.

theblackbat.com
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE,
RESONANT VOICE, “VOCAL
FUNCTION EXERCISES,”
ACCENT METHOD, LSVT
1 2
3 4
5
3 = FLOW VOICE

4 = YAWN/SIGH, FALSETTO

5 = BREATHY VOICE
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE,
1
RESONANT VOICE, “VOCAL
FUNCTION EXERCISES,”
ACCENT METHOD, LSVT
2
3
4
3 = FLOW VOICE 5

4 = YAWN/SIGH; FALSETTO

5 = BREATHY VOICE
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE,
RESONANT VOICE, “VOCAL
FUNCTION EXERCISES,” 2 3
ACCENT METHOD, LSVT 1 4
5

3 = FLOW VOICE

4 = YAWN/SIGH; FALSETTO

5 = BREATHY VOICE
 QUESTION
• Based on this • Discussion
information alone,
which therapy would
you choose for
which patients?
– #2: “Ideal” therapies
– #3-5: Other
therapies
Additionally, there is a “new black” in
voice science….
• The new “buzz:”
“SEMI-OCCLUDED
VOCAL TRACT”

• (SOVT)
 Biomechanics/SOVT
• Partial occlusion of
vocal tract --
anywhere:
– Epilarynx
– Tongue
– Lips
– Soft palate
– Vocal tract extension
with straw
 Biomechanics/SOVT
• Centuries of examples in
classical singing

• Contemporary examples in
theatre training (e.g.,
Lessac, inverted
megaphone)

• Contemporary examples in
SLP (e.g., Vocal Function http://www.google.com/imgres?imgurl=http://cache2.allpostersimages.com/p/LRG/8/855/7JRY000Z/pos

Exercises, LMRVT, Accent ters/barraud-francis-his-masters-voice.jpg&imgrefurl=http://www.allposters.com/-sp/His-Masters-Voice-

Posters_i385238_.htm&usg=__F8dS9ZcjmFMQ9dQ63RSgVLVVNX0=&h=300&w=400&sz=23&hl=en&start=
0&zoom=1&tbnid=-c-

Method) JVxJw9sqVIM:&tbnh=120&tbnw=161&ei=wx8WTpSUPLPKiAK4x6CKDw&prev=/search%3Fq%3Dvoice%26
um%3D1%26hl%3Den%26rlz%3D1T4RNRM_enUS430%26biw%3D1280%26bih%3D551%26tbm%3Disch&u
m=1&itbs=1&iact=rc&dur=121&page=1&ndsp=24&ved=1t:429,r:4,s:0&tx=52&ty=59
 Biomechanics/SOVT
• What does the SOVT kth.se; ncvs.org

get us? Various

manipulations of the
vocal tract, including
SOVT, can amplify VF
output.
– E.g., epilaryngeal narrowing
enhances acoustic energy in
the 3 kHz range (singer’s
formant; Sundberg, 1977).
 Biomechanics/SOVT
• Source-filter theory of
Speech Production:

– Source + Filter = Output

(Fant, 1960)

haskins.yale.edu
 Biomechanics/SOVT
• Non-linear dynamic
model: Challenges the
classic “source-filter”
model.

• Source  Filter = Output

• That is, source and filter

influence each other (e.g.,
Titze, 2011)
 Biomechanics/SOVT
IMPORTANT!!
• Specifically: SOVT • Facilitates VF oscillation (in
produces 3 important some cases increases
oscillation amplitude)
results for the vocal
folds and for phonatory
respiration • Abducts the VF

• Reduces phonatory Ps (Titze

& Verdolini Abbott, 2012)
 Biomechanics/SOVT
• Facilitation of VF oscillation • Increase in acoustic output
(in some cases increasing (stronger voice)
amplitude) 

• VF abduction • Reduces VF impact stress

(safer voice)
• Reduction of phonatory Ps
 • Reduces respiratory effort
in phonation
 Biomechanics/SOVT
Stated differently
• Should augment • Should further increase
benefits of barely acoustic output (dB)
ad/abducted vocal
folds: • Should further decrease
the risk of phonotrauma
(SI)

• Should further decrease

respiratory effort (Ps)
 Important work on SOVT by
Chilean scientist and colleagues!
 Important work on SOVT by
Chilean scientist and colleagues!
• Guzman, M, Higueras, D., Fincheira, C., Muñoz, D., Guajardo, C., & Dowdall, J.
(2013). Immediate acoustic effects of straw phonation exercises in subjects with
dysphonic voices. Logoped Phoniatr Vocol, 38(1), 35-45.

• Guzman, M, Rubin, A., Muñoz, D., & Jackson-Menaldi, C. (2013). Changes in glottal
contact quotient during resonance tube phonation and phonation with vibrato. J
Voice, 27(3), 305-311.
• Guzman, M., Laukkanen, A.M., Krupa, P., Horáček, J., Švec, J.G., & Geneid A. (2013).
Vocal tract and glottal function during and after vocal exercising with resonance
tube and straw. J Voice, 27(4),523.e19-34.

• Guzman, M., Castro, C., Testart, A., Muñoz, D., & Gerhard, J. (2013). Laryngeal and
pharyngeal activity during semioccluded vocal tract postures in subjects diagnosed
with hyperfunctional dysphonia. J Voice, 27(6):709-716.
 Transition to biology
topwomensmagazines.com

• Why is this question so ehow.com

interesting? keetsa.com

– SOVT  VF abduction can be

considered a biological
prevention factor (reduction
in SI)
– SOVT  Large-amplitude VF
vibrations could be a
biological treatment factor
(for existing injury) (next
pages)
– SOVT  reduced phonatory
Ps helps to minimize
phonatory effort
 Biology
• Prevention factor
– The primary factor in
phonotrauma pathogensis is
thought to be inter-vocal fold
impact stress (Titze, 1994)

– A primary factor determining

SI is VF adduction (e.g., Jiang
& Titze, 1994; Berry et al.,
2001)

– Thus, a reduction in SI with

SOVT should help to reduce
the risk of – i.e., prevent --
phonotrauma.
 Biology
• Treatment factor:
newdentalimplants.org

– Some forms of tissue

mobilization – as for
example with large-
amplitude, low-impact
VF oscillations in RV
(using SOVT) can have
anti-inflammatory
effects.
– Shown for example in
the periodontic
literature.
 Biology
• “Cyclic Tensile Strain”
significantly reduced
concentrations of several
pro-inflammatory mediators
in periodontic tissue (PGE-2,
IL-1, IL-6, IL-8, MMP-1,
MMP-3, MMP-9, and IL-1β).
• Agarwal et al., 2003; Long et al., 2001;
image from Hunt, 1984 )
 Biology
• Proposed
mechanism is
the“NF-κB signal
transduction
pathway.”
Branski dissertation
 Biology
• Important for us:
– Anti-inflammatory benefits
of tissue mobilization
appear related to cellular
deformation occurring with
tissue elongation.

– …as for example with

large-amplitude VF
vibrations (at high pitches
in particular) with resonant icky.blogspot.com

voice and SOVT.

 Biology
Note
•
• Modulation of inflammatory (Agarwal et al. 2003; Charon, Luger, Mergenhagen, &
Oppenheimer, 1982; Clark, 1988; Cockbill, 2002; Ghosh
& Karin, 2002; Karin & Lin, 2002; Kirsner & Eaglstien,
mediators is not only 1993; Long, Buckley, Liu, Kapur, & Agarwal, 2002; Long,
Hu, Piesco, Buckley, & Agarwal, 2001; Viatour, Merville,
important in the acute Bours, & Chariot, 2005; Witte & Barbul, 1997).

phase of wound healing;

• Such modulation is also

important for the long-term
results of wound healing,
which are driven by events
in the acute phase 
 Biology
Wound healing phases (overlapping)
• Inflammation (a few
days)

• Protein synthesis (a few

weeks)

• Tissue remodeling (up

to a year or more)
 Biology
• Test of potential value
of tissue mobilization
(voicing) in acutely
injured vocal folds

• First, methodological
study
 Biology
• Initial study: we were 140
Interleukin-1beta (pg/mg protein)

able to capture 120

100
80

apparent variations in
60
40
20
0

concentrations of Pre 10 Min.

Time
20 Min

inflammatory mediators 2
Tumor Necrosis Factor-alpha (pg/mg protein)

pre- and post-injur from 1.5

concentrations in 0.5

laryngeal secretions.
Pre 10 Min. 20 Min.
Time

Matrix Metalloproteinase-8 (pg/mg protein)

30
25

Verdolini et al., 2003 20

15
10
5
0
Pre 10 Min 20 Min
Time
 Biology
IL-1beta

• Scream study
14.00

12.00

10.00

Normalized Value
8.00 IL-1beta baseline
IL-1beta post-loading
IL-1 beta 4-hr post-treatment
6.00
IL-1beta 24-hr post-treatment

4.00

2.00

0.00
Spontaneous Speech Voice Rest Resonant Voice
Treatment Condition

IL-6

70.00

60.00

50.00

Normalized Value
40.00 IL-6 baseline
IL-6 post-loading
IL-6 4-hr poast-treatment
30.00
IL-6 24-hr post-treatment

20.00

10.00

0.00
Spontaneous Speech Voice Rest Resonant Voice
Treatment Condition

MMP-8

16.00

14.00

12.00

Normalized Value
10.00
MMP-8 baseline
MMP-8 post-loading

Verdolini Abbott et al., 2012

8.00
MMP-8 4-hr post-treatment
MMP-8 24-hr post-treatment
6.00

4.00

2.00

0.00
Spontaneous Speech Voice Rest Resonant Voice
Treatment Condition
 o IL-1β IL-6

SS Rest RV SS Rest RV

N 1 1 1 2 1 2

Post 1.21 (0.00) 1.93 (0.00) 1.51 (0.00) 2.65 (1.33) 10.62 (0.00) 8.31 (1.24)

4hr post 3.13 (0.00) 3.54 (0.00) 3.68 (0.00) 3.44 (2.12) 20.94 (0.00) 6.30 (5.96)

24hr post 12.52 (0.00) 1.87 (0.00) 0.45 (0.00) 32.25 (31.61) 9.16 (0.00) 2.72 (2.72)

IL-8 TNF-α

SS Rest RV SS Rest RV

N 1 0 1 1 1 1

Post 4.57 (0.00) Nil 6.22 (0.00) 1.25 (0.00) 1.18 (0.00) 1.26 (0.00)

4hr post 4.18 (0.00) Nil 4.23 (0.00) 0.96 (0.00) 1.22 (0.00) 1.30 (0.00)

24hr post 14.81 (0.00) Nil 2.08 (0.00) 4.69 (0.00) 1.11 (0.00) 1.14 (0.00)

MMP-8 IL-10

SS Rest RV SS Rest RV

N 1 1 1 2 1 1

Post 3.04 (0.00) 3.62 (0.00) 1.21 (0.00) 1.53 (0.44) 2.48 (0.00) 1.16 (0.00)

4hr post 3.33 (0.00) 13.82 (0.00) 1.18 (0.00) 2.85 (1.07) 0.56 (0.00) 1.59 (0.00)

24hr post 13.34 (0.00) 2.00 (0.00) 0.38 (0.00) 2.62 (1.54) 1.38 (0.00) 4.09 (0.00)
 Biology
• Summary on the
possible or likely
biological value of
resonant voice –
which uses a SOVT:
– Small inter-VF impact:
Biological prevention factor

– Large-amplitude vibrations:
Biological treatment factor
 Biology
• The SOVT appears
important for these
effects
– Reduces VF adduction
and therefore VF impact
stress (prevention factor)

– Increases VF vibration
amplitudes (treatment
factor)
 Biology
• Results replicated
in vitro
• Branski et al. (2007;
Best Basic Science
paper, J Voice)
 Biology
• Results replicated
in silico
• Li et al., 2005; Li et al.,
2011
 Biology
• Chronic phase:
• But wait! – Acute healing influences long-
• So far we’ve talked about the term healing (as noted) but also:
acute phase of wound healing
• What about the chronic case, – During the chronic phase of
healing, proteins align according
which is what we typically see to the force vectors applied
clinically? during healing.

– Maybe large-amplitude
vibrations (with resonant voice
and SOCT) help to orient proteins
in a way that allows for
functional VF vibration (and low-
impact aspect of oscillations
helps to minimize new trauma;
data lacking).
 Biomechanics/biology
• Returning to the
previous curves…

• Adding the effect of the

SOVT?
– Output intensity
– VF impact stress
– Vocal economy
– anaconda-snake
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE,
RESONANT VOICE, VOCAL
FUNCTION EXERCISES,
ACCENT METHOD, LSVT
1 <-2
3 4
3 = FLOW VOICE 5

4 = YAWN/SIGH; FALSETTO

5 = BREATHY VOICE
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE,
1
RESONANT VOICE, VOCAL
FUNCTION EXERCISES,
ACCENT METHOD, LSVT
2
3
4
3 = FLOW VOICE 5

4 = YAWN/SIGH; FALSETTO

5 = BREATHY VOICE
LEGEND
(APPROXIMATE VALUES)
1 = PRESSED VOICE

2 = NORMAL VOICE, OCE

NORMALE, RESONANT
VOICE, VOCAL FUNCTION 2 3
EXERCISES, ACCENT 1 4
METHOD, LSVT 5

3 = FLOW VOICE

4 = YAWN/SIGH; FALSETTO

5 = BREATHY VOICE
CLINICAL CONSIDERATIONS?
 Whew
• GLAD THAT’S DONE!

• Next: Perceptual-
motor learning.

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