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206 The Voice and Voice Therapy
●
One vocal fold is normally “stuck” in a paramedian position off midline; phonation is
breathy, rough, and short in duration. Dysphagia is not uncommon.
Symptoms or findings that would indicate a diagnosis of UVFP:
●
Fits medical history of tracheostomy and reconstructive laryngeal surgery.
●
Elevated airflow on phonatory function analysis.
●
Breathy and hoarse vocal quality and reduced pitch range.
Symptoms or findings that would not indicate a diagnosis of UVFP:
●
Although it is compromised, Susan has control of respiratory-phonatory valving for
speech tasks.
●
There is no diplophonia.
●
There is no vocal improvement with facilitation techniques of half-swallow boom, head
turn, and digital manipulation.
Is it paradoxical vocal fold movement (PVFM)?
●
PVFM is an insidious laryngeal manifestation often mistaken for uncontrolled asthma.
●
Vocal folds close when they should open and open when they should close.
●
PVFM is tricky to diagnose because causes and presentation are so diverse.
●
Susan’s pulmonologist suspected PVFM because of the capricious nature of the SOB.
Symptoms or findings that would indicate a diagnosis of PVFM:
●
SOB appeared to be associated with PVFM precipitators.
●
Asthma had been ruled out.
●
Previous medical testing revealed normal lower airway function.
●
Susan reported some anxiety and depression.
Symptoms or findings that would not indicate a diagnosis of PVFM:
●
Susan performed vocal and speech tasks while experiencing SOB. In our clinical
experience, a person with PVFM is normally not able to perform those tasks.
●
SOB resolves with rest.
●
It is too early to extrapolate limited observations of psychosocial disorders in PVFM to
the larger population.
Endoscopic Evaluation
The patient was seated in the exam chair in the clinic and positioned for a flexible endoscopic
examination using halogen light source. The Pentax Medical distal chip video laryngoscope was
passed along the floor of the left nasal cavity. Nasoendoscopy revealed a subglottal anterior laryngeal web, most likely a result of the reconstructive surgery performed 10 years earlier. The web
was attached to the inferior and medial aspect of the anterior commissure bilaterally, ceasing about
CHAPTER 6 Evaluation of the Voice 207
one-third of the distance from the anterior commissure, where the distance between the folds
abducting becomes too great.
Summary
The subglottal laryngeal web is consistent with the subject’s medical history, symptoms, complaints,
and clinical assessment. The web served to block incoming and outgoing air and to inhibit normal
vocal fold vibration. The airway was estimated to be two-thirds to three-quarters occluded by the
web. The web was associated with Susan’s complaints of elevated pitch for speaking and sustained
vowels, and reduced pitch range. It also contributed to the backpressure or buildup of subglottal
air that might account for feelings of “spasms.” The increased tissue at the glottis interfered with
TVF vibration and resulted in elevated measures of jitter and shimmer.
Recommendations
The patient and her mother were apprised of the findings, and Susan was referred to the local
medical center for surgery to remove the web. She was encouraged to follow all recommendations
by the surgical otolaryngologist. She was scheduled to return to this clinic after intervention for
a brief reassessment followed by vocal hygiene counseling and any voice facilitating approaches
deemed necessary.
Summary
The voice evaluation is the time when the clinician first meets the voice patient, providing opportunity for observation and testing. The evaluation begins when the patient is observed in the
waiting room and continues as part of each therapy session, particularly as the clinician continually searches with the patient for new vocal behaviors. The clinician must continue to evaluate
and observe the patient’s respiratory, phonatory, and resonance functions. Whenever possible,
these functions should be quantified with instrumentation. Auditory-perceptual judgments are
also extremely valuable in describing the patient’s voice disorder and the manner in which it is
produced. The patient’s perception of voice handicap is also important to assess. The patient’s
voice data are used for comparison purposes, to quantify vocal changes during the first visit,
through subsequent therapy sessions, and in the final outcome session. Patient performance, both
as observed and as measured, is offered to the patient as continuing feedback, which helps the
patient become aware of voice performance. The evaluation enables the voice clinician to decide
on which management steps to take for the patient, and to refer the patient to professionals in
other disciplines when necessary. If voice therapy is indicated, the evaluation helps the clinician
to develop a therapy plan and to predict the patient’s prognosis.
208 The Voice and Voice Therapy
GUIDED READING
Read the following article:
Lee, L., Stemple, J. C., Glaze, L., & Kelchner, L. N. (2004). Quick screen for voice and
supplementary documents for identifying pediatric voice disorders. Language, Speech,
and Hearing Services in Schools, 35(4), 308–320.
Compile a list of the voice and resonance behaviors that are important to collect and assess in a
child-related screening instrument. Create a miniversion of your own quick screen instrument.
Read the following reports.
American Speech-Language-Hearing Association. (2004d). Vocal tract visualization and
imaging [Position statement]. https://www.asha.org/policy/ps2004-00121/
American Speech-Language-Hearing Association. (2004e). Vocal tract visualization and
imaging [Technical report]. https://www.asha.org/practice-portal/clinical-topics/voicedisorders/vocal-tract-visualization-and-imaging/
Describe the roles and responsibilities of the SLP with respect to vocal tract visualization.
PREPARING FOR THE PRAXIS
Directions: Please read the case studies and answer the five questions that follow.
1. See Case Study 1, Mrs. V. The numeric value of 93 mm on the CAPE-V for vocal
strain translates to:
A. Severely deviant
B. Moderately deviant
C. Mildly deviant
D. Within normal limits
2. In Case Study 1, Mrs. V revealed a speaking fundamental frequency (SFF) ranging
from 125 to 135 Hz as measured instrumentally. If digitized instrumentation had
not been available, SFF could easily be measured on an electronic keyboard or smart
device app. In this case, the closest musical note to her pitch would be (hint: see
Table6–5):
A. B
2
B. F
3
C. A
3
D. C
4
CHAPTER 6 Evaluation of the Voice 209
3. The throat clearing demonstrated by Samir in Case Study 2 is most likely secondary to:
A. Sensation of globus due to thickened mucus and the presence of vocal nodules
B. Behaviors he has adopted from his brother
C. Laryngopharyngeal reflux
D. A polyp
4. The maximum phonation time demonstrated by Samir in Case Study 2 is:
A. Below the mean MPT for normal speakers his age
B. Consistent with the mean MPT for normal speakers his age
C. Within the range of MPT for normal speakers his age
D. Above the mean MPT for normal speakers his age
5. An Individualized Education Program (IEP) is warranted for Samir because:
A. His hoarse voice interferes with his ability to participate in daily educational
interactions.
B. He has been diagnosed with vocal nodules.
C. He speaks in a rough and low voice.
D. He is in need of a “just right voice” book.
CHAPTER 7
VOICE FACILITATING
APPROACHES
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Identify the rationales and procedural approaches for the voice facilitating
approaches (VFAs) of Auditory Feedback, Change of Loudness, Chewing, and
Confidential Voice. Cite at least one evidence-based practice article that supports
the target VFA.
●
Describe the rationales and procedural approaches for the VFAs of Counseling,
Digital Manipulation, Elimination of Abuses, Establishing a New Pitch, and Focus.
Cite at least one evidence-based practice article that supports the target VFA.
●
Explain the rationales and procedural approaches for the VFAs of Glottal Fry, Head
Positioning, Hierarchy Analysis, Inhalation Phonation, and Laryngeal Massage.
Cite at least one evidence-based practice article that supports the target VFA.
●
Describe the rationales and procedural approaches for the VFAs of Masking, Nasal-
Glides, Open-Mouth Approach, Pitch Inflections, and Redirected Phonation. Cite
at least one evidence-based practice article that supports the target VFA.
●
Identify the rationales and procedural approaches for the VFAs of Relaxation,
Respiration Training, Tongue Protrusion /i/, Visual Feedback, and Yawn-Sigh. Cite
at least one evidence-based practice article that supports the target VFA.
211
212 The Voice and Voice Therapy
oice therapy is highly individualized, depending on the cause of the problem, its
maintaining factors, the motivation of the patient, and the availability of appropriate
V
of professionals other than the speech-language pathologist (SLP), such as an otolaryngologist
(ear, nose, throat [ENT] physician) who may successfully treat papilloma or laryngeal cancer.
On the other hand, using the case of unilateral vocal fold paralysis as an example, the patient
is managed by both the SLP and the ENT physician, who will see the patient at different times
during the recovery process. Many voice problems are managed by the SLP-voice clinician alone.
For example, the voice clinician may help the patient with functional aphonia regain voice with
voice therapy and then provide the follow-up that may be required to maintain normal voice.
and maintaining factors that were identified at the time of the initial diagnostic evaluation. Even
during voice therapy, there must be a continuous search for a possible change in the maintenance
factors of the voice problem, which could then dictate a different management or therapy offering.
their problems are organic, neurogenic, or functional, our VFAs may not be differentiated according
to such causal factors. If the patient is exhibiting a problem in breath control, for example, the
cause of the problem may get primary attention, but the techniques for using more efficient breath
for voice are selected from a pool of approaches for improving breath control.
many therapy approaches are designed to take the work out of speaking (Alegria et al., 2020b;
Mansuri et al., 2018). A voice therapy approach for a particular person with vocal hyperfunction
would be selected from an array of such approaches, with the selection again related to causal and
maintaining factors. A young man who exhibits hard glottal attack might profit from learning to
reduce his rate of speech, opening his mouth a bit more, learning more of a legato (smooth, easy
flow) style of voicing, and practicing vocal chanting. His voice clinician would select the therapy
approaches that help facilitate this easy, smooth style of voicing.
diagnostic–evaluation data could be fed into a software program that would automatically tell the
voice clinician which therapy methods to use with a recommended sequence of application. Such
a cookbook approach to voice therapy is not possible. Rather, the SLP uses the presenting data
and observations for decisions regarding management, selecting a particular approach for a trial
beginning (known as a diagnostic probe). The patient’s response to the probe and its effect on
voice determine if that therapy approach will be used or eliminated in therapy or if the approach
can be combined with other approaches. Rarely is a particular voice therapy technique applied in
isolation (Angadi & Stemple, 2012). For example, if a louder voice produces a clearer voice with
less roughness, combining work on increasing respiratory volume, extending expiratory durations,
improving patient posture, and increasing mouth opening could be combined with increasing
loudness in a treatment session.
management and treatment. Some voice problems may require only the management
What is offered for management and therapy (and by whom) is dictated by the presenting causal
While many of the management strategies differ among voice patients according to whether
Perhaps the most observed voice problems are related to vocal hyperfunction, for which
The authors were once approached by a computer scientist who suggested that the voice
Patient Compliance and Emerging Technologies in Voice Intervention
Adherence to voice therapy is crucial for the successful treatment of voice disorders, yet it often
presents significant challenges. Several factors influence adherence, including patient motivation,
CHAPTER 7 Voice Facilitating Approaches 213
the complexity of therapy protocols, and the perceived effectiveness of the therapy. Adherence to
voice therapy varies widely, often impacted by the severity of the voice disorder and the patient’s
personal circumstances. High dropout rates are common, often due to the time-intensive nature
of therapy and the slow progress perceived by patients (Cutchin et al., 2023; Rubino & Abbott,
2024; Torbes et al., 2020; White & Chandran, 2023). Motivation plays a critical role in adherence.
Patients who understand the importance of therapy and see tangible benefits are more likely to
stick with the program. However, those who do not perceive immediate improvements are prone
to drop out (Rubino & Abbott, 2024). The complexity of therapy exercises and the required
duration can be daunting for many patients. Simplifying exercises and providing clear, manageable
goals can improve adherence (Rubino & Abbott, 2024). A strong therapeutic alliance between
the patient and the therapist can enhance adherence. Trust and open communication encourage
patients to continue with therapy despite challenges (Gillespie & Gartner-Schmidt, 2018). Interventions such as patient education, motivational interviewing, and personalized therapy plans
tailored to individual needs and preferences have shown promise in reducing dropout rates and
improving adherence (Chopra et al., 2023; Rubino & Abbott, 2024).
At our voice clinics, just as in many across the country and around the world, we recognize
the importance of compliance by providing the voice patient with immediate success by applying
what we call diagnostic/stimulability probes or VFAs (described in this chapter). Once normal or
near-normal phonation has been demonstrated, we capitalize on this success by making sure the
client leaves with homework that includes an audio–video recording of the session. That is, if the
aphonic patient has achieved vocal success by engaging in the VFA of focus and pitch shift down,
we make a recording of these approaches in clinic and then instruct the patient to do the same on
their smartphone or tablet.
Video recordings of voice therapy have been shown to increase patient compliance (van Leer &
Connor, 2015). Van Leer (2021) reports that mobile support on a smartphone can help the voice
patients successfully adhere to their voice strategies by providing therapy video and audio examples
and reminder notifications. In addition to video recordings, other researchers advocate virtual
reality approaches to voice intervention that simulate vocally challenging environments (Hapner
& Johns, 2004). By placing themselves in a virtual, vocally challenging environment — such as a
classroom — the voice patient is more likely to generalize the VFAs learned in clinic. The reader
is encouraged to review Mallipeddi and colleagues (2023) for an analysis of how remote patient
monitoring, intervention, virtual reality, and artificial intelligence are shaping the therapeutic
process of speech, language, and voice service delivery to patients.
Voice intervention via telepractice is a viable service delivery model for both adults and
children (American Speech-Language-Hearing Association [ASHA], 2023; Coufal et al., 2017;
Fu et al., 2015; Rangarathnam et al., 2015). Mashima and colleagues (2003) and Tindall and
colleagues (2008) reported that voice intervention via telepractice yielded voice outcomes similar
to conventional voice therapy at a significant financial savings to the voice client. Rangarathnam
and colleagues (2015) compared the results of voice therapy for 14 patients with muscle tension
dysphonia (MTD). Seven were treated on site, and seven were treated remotely. Auditory perceptual and quality of life measures revealed increases for both groups, suggesting that the two
service delivery methods are comparable. Cutchin and colleagues (2023) reviewed attendance,
no-show, and cancellation data over a 3-month span of in-person only visits and a 3-month span
of telepractice visits at a tertiary voice care center. Analysis suggested that the overall course of
therapy showed significantly fewer missed appointments and more attended appointments for the
214 The Voice and Voice Therapy
telepractice condition, leading the authors to suggest that patients participating in voice therapy
via telepractice are more likely to initiate treatment and attend treatments and less likely to cancel
treatments compared with patients receiving services in person. Alegria and colleagues (2020b)
conducted a systematic review about the effectiveness of voice therapy interventions in adults with
vocal fold nodules. Results suggested that regardless of whether patients received in-person therapy
or teletherapy, nearly all vocal parameters of interest were found to improve after treatment. Once
more, the researchers reported that short-term treatment (less than 3 weeks) may be as beneficial
as longer-term voice treatment programs. These findings are consistent with those of Wenke and
colleagues (2023), who looked at the differences between intensive therapy versus weekly therapy
for patients with MTD. Two groups of voice patients received either traditional therapy consisting
of 1 hr of therapy each week for 8 weeks or intensive voice therapy, 1-hr sessions 4 days per week
for 2 weeks. Acoustic measures and patient reports suggested that intensive therapy may produce
benefits that are comparable to traditional therapy schedules.
Voice Facilitating Approaches
In this text, we call our therapy approaches VFAs. That is, the selected therapy technique facilitates
a “target” or a more optimal vocal response by the patient. The VFAs are used with patients who
come to us with various kinds of voice disorders: functional, organic, and neurogenic. Part of voice
therapy is searching with patients to find the VFA(s) that seems to help them produce the desired
vocal response. Many patients with the same voice disorder, such as MTD, may require different
therapy approaches for the same problem. For example, in the same afternoon, we may see a
patient who finds focus, or resonant voice therapy, effective in reducing vocal fold hyperfunction,
while the next patient finds inhalation phonation and pitch shift up the keys to a less effortful
voice. It is important to remember that because a person’s voice problem is often a combination of
behavioral, emotional, physical, and structural issues, no one specific therapy approach is facilitative for all patients with the same voice problem. The experienced voice clinician has many voice
therapy techniques to use for particular voice problems with certain patients.
In addition to the current list of 25 approaches in this edition of The Voice and Voice Therapy,
the SLP should be aware of the many other management and therapy approaches described in
the literature. The reader is encouraged to investigate further Bane and colleagues (2017), Verdolini (2000), Yiu and colleagues (2017), Salturk and colleagues (2019), and Yiu and colleagues
(2017) for resonant voice treatment; Titze (2006) and da Cunha Pereira and colleagues (2018)
for semi-occluded vocal tract (SOVT) (straw) exercises; McCullough and colleagues (2012) and
Rangarathnam and colleagues (2023) for flow phonation exercises; Roy and colleagues (1997)
and Mokhlesin and colleagues (2023) for circumlaryngeal massage; Gartner-Schmidt (2021)
and Gillespie and Gartner-Schmidt (2018) for conversation training therapy; Golan (2013) for
Buteyko breathing; Kotby and colleagues (1991) and Othman and colleagues (2021) for the accent
method; and Stemple and Hapner (2019) and Desjardins and colleagues (2022) for expiratory
muscle strength training. This list is by no means exhaustive. Smartphones and tablet software
applications have made it even easier to use accessible and low-cost clinical tools with our voice
patients (Manfredi et al., 2017). Angadi and Stemple (2012), Olszewski and colleagues (2022)
CHAPTER 7 Voice Facilitating Approaches 215
and van Leer and colleagues (2021) list just a few of these apps, which include virtual keyboards,
pitch matchers, stopwatches, decibel meters, voice recorders, and metronomes.
The VFAs in Table 7‒1 are listed alphabetically. After each approach, a notation (x) indicates
the voice parameters that the particular VFA has the potential to influence. For example, VFA
1, auditory feedback, can have an impact on both vocal loudness and quality, with less influence
on voice pitch. Accordingly, for the three columns in Table 7‒1 (pitch, loudness, and quality),
only the loudness and quality columns are marked with (x). Other techniques, such as yawn-sigh
(VFA 25), influence all three parameters of pitch, loudness, and quality, and each column is
marked with (x). Experienced voice clinicians often combine therapy approaches in their search
with the patient to find the target voice. Each of the 25 VFAs in Table 7‒1 is presented from the
following four perspectives: (a) kinds of problems for which the approach is useful, (b) procedural
aspects of the approach, (c) typical case history showing utilization of the approach, and (d) evaluation of the approach.
Included in this 11th edition of The Voice and Voice Therapy are updated procedural approaches
and evidence-based practice (EBP) summaries that support each VFA. EBP, for the purpose of this
chapter, combines the information gleaned from all levels of evidence, ranging from the expert
opinion of respected authorities to systematic reviews and randomized controlled clinical studies.
Readers are encouraged to investigate these EBP resources further for at least a couple of reasons:
to gain an appreciation of the converging evidence for each of these approaches and to use as
rationales when generating goals and objectives for the VFAs.
1. Auditory Feedback
Kinds of Problems for Which the Approach Is Useful
The shift from analog to digital analysis in the late 1980s and 1990s revolutionized voice analysis
and therapy. This certainly applies to immediate auditory feedback (and visual biofeedback later
in this chapter) afforded by digitized instrumentation. Many voice patients profit from using some
kind of auditory feedback in and out of voice therapy. Patients who displayed a window of voice
improvement during the evaluation session (such as when masking was used as a diagnostic probe
resulting in an immediate improvement in voice) often benefit from the use of auditory feedback
during therapy sessions. Regardless of the causal factor of the disorder (organic, neurogenic, or
functional), the patient’s voice may improve with such feedback.
Auditory feedback is supported by motor planning and programming theory (Callan etal.,
2000; Duffy, 2020). In a nutshell, this theory suggests that humans can alter and adapt motorequivalent voice and speech production through integration of sensory information from peripheral
mechanoreceptors, one of those being acoustic feedback. Different kinds of auditory feedback may
enhance patient response, such as using real-time amplification and letting patients hear themselves on headphones as they are speaking. The slight amplification is thought to bridge the gap
between the disordered kinesthetic model and the correct one while using the auditory feedback
loop. Voice improvement is best secured by listening in real time on amplification equipment
that ensures a speech–voice range focus. Numerous smartphone apps and devices are available for
these purposes.