Voice Therapy

Methods

Khalid H Al Malki, MD, PhD

Lecture Objectives:
To explore …
* Anatomy,
* Physiology,
* Assessment,
* Management,
* Prognosis
* Referrals
of Voice Disorders.

Khalid H Al Malki, MD, PhD

Management of Voice Disorders:
 Voice therapy.

 Phonosurgery.

 Drugs.

 Technical aid devices.

Khalid H Al Malki, MD, PhD

Voice Therapy

Khalid H Al Malki, MD, PhD

Behavior re-adjustment voice
therapy (BRAT):
Entails 2 main tasks:

A. Vocal hygiene advice (Chapter 7).

B. Voice Therapy (Chapter 8).

M N Kotby Khalid H Al Malki, MD, PhD

A. Vocal hygiene advice:

 To provide a “larynx friendly” environment.

 Addresses diet, lifestyle, and vocal demands.

 The patient has to learn his/her limits and

operate within them.

 The concept of “vocal finances”.

Khalid H Al Malki, MD, PhD

 ‫ﻧﺼﺎﺋﺢ ﺍﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ ﺍﻟﺼﻮﺕ‪:‬‬
‫ﺃﻭﻻ‪ :‬ﻻﺗﻔﻌﻝ ﻣﺎﻳﺅﺫﻯ ﺻﻭﺗﻙ ﻭﺗﺟﻧﺏ ﺍﻵﺗﻲ‪:‬‬
‫‪‬ﺍﻟﺻﺭﺍﺥ ﻭﺍﻟﻛﻼﻡ ﺑﺻﻭﺕ ﻋﺎﻝ‪.‬‬
‫‪‬ﺍﻟﻛﻼﻡ ﻣﻥ ﻣﺳﺎﻓﺎﺕ ﺑﻌﻳﺩﺓ‪.‬‬
‫‪‬ﺍﻟﻛﻼﻡ ﻓﻲ ﺍﻟﺿﻭﺿﺎء‪.‬‬
‫‪‬ﺍﻟﻛﻼﻡ ﻟﻌﺩﺩ ﻛﺑﻳﺭ ﻣﻥ ﺍﻟﻣﺳﺗﻣﻌﻳﻥ ﻣﻊ ﻋﺩﻡ ﺍﺳﺗﺧﺩﺍﻡ ﻣﻛﺑﺭ ﻟﻠﺻﻭﺕ‪.‬‬
‫‪‬ﻛﺛﺭﺓ ﺍﻟﻛﻼﻡ ﻓﻲ ﻭﺟﻭﺩ ﺍﻟﺗﻬﺎﺏ ﺑﺎﻟﺣﻧﺟﺭﺓ‪.‬‬
‫‪‬ﻛﺛﺭﺓ ﺍﻟﻧﺣﻧﺣﺔ ﻭﺍﻟﻛﺣﺔ ﺍﻟﺷﺩﻳﺩﺓ‪.‬‬
‫‪‬ﺍﻟﺿﺣﻙ ﻭﺍﻟﺑﻛﺎء ﺑﺻﻭﺕ ﻋﺎﻝ‪.‬‬
‫‪‬ﺍﻟﻛﻼﻡ ﺑﺳﺭﻋﺔ ﻭﺑﺩﻭﻥ ﺃﺧﺫ ﺍﻟﻧﻔﺱ ﺍﻟﻛﺎﻓﻰ‪.‬‬
‫‪‬ﺍﻟﺗﺩﺧﻳﻥ ﺃﻭ ﻣﺧﺎﻟﻁﺔ ﺍﻟﻣﺩﺧﻧﻳﻥ‪.‬‬
‫‪‬ﺗﻧﺎﻭﻝ ﺍﻟﻛﺣﻭﻟﻳﺎﺕ‪.‬‬
‫‪‬ﺗﻧﺎﻭﻝ ﺍﻷﻛﻼﺕ ﺍﻟﺣﺭﺍﻗﺔ‪.‬‬
‫‪‬ﺍﻹﻛﺛﺎﺭ ﻣﻥ ﺍﻟﻣﺷﺭﻭﺑﺎﺕ ﺍﻟﺗﻲ ﺗﺣﺗﻭﻱ ﻋﻠﻰ ﺍﻟﻛﺎﻓﻳﻳﻥ‪ ،‬ﻣﺛﻝ ﺍﻟﺷﺎﻱ ﻭﺍﻟﻘﻬﻭﺓ ﻭﺍﻟﻛﻭﻻ‪.‬‬

‫‪Khalid H Al Malki, MD, PhD‬‬

 ‫ﻧﺼﺎﺋﺢ ﺍﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ ﺍﻟﺼﻮﺕ‪:‬‬
‫ﺛﺎﻧﻳﺎ‪ :‬ﺍﻓﻌﻝ ﻣﺎ ﻳﺣﺎﻓﻅ ﻋﻠﻰ ﺻﺣﺔ ﻭﺳﻼﻣﺔ ﺻﻭﺗﻙ‪:‬‬
‫‪‬ﺷﺭﺏ ﻛﻣﻳﺔ ﻛﺑﻳﺭﺓ ﻣﻥ ﺍﻟﺳﻭﺍﺋﻝ ﺑﻣﻌﺩﻝ ﺛﻼﺛﺔ ﻟﺗﺭﺍﺕ ﻳﻭﻣﻳﺎ‪.‬‬
‫‪‬ﺍﺳﺗﻌﻣﺎﻝ ﻣﺭﻁﺑﺎﺕ ﺍﻟﺟﻭ ﻋﻧﺩ ﺍﻟﺣﺎﺟﺔ‪.‬‬
‫‪‬ﺍﺳﺗﺧﺩﺍﻡ ﺍﺷﺎﺭﺍﺕ ﻣﻥ ﺃﺟﻝ ﻟﻔﺕ ﻧﻅﺭ ﻣﻥ ﻫﻭ ﻋﻠﻰ ﺑﻌﺩ‪ ،‬ﺑﺩﻻً ﻣﻥ ﺍﺳﺗﺧﺩﺍﻡ ﺍﻟﺻﻭﺕ ﺍﻟﻌﺎﻟﻰ‪.‬‬
‫‪‬ﺗﻘﻠﻳﻝ ﺍﻟﺿﻭﺿﺎء ﻓﻰ ﺍﻟﺑﻳﺋﺔ ﺍﻟﻣﺣﻳﻁﺔ ﻗﺩﺭ ﺍﻻﻣﻛﺎﻥ ﻗﺑﻝ ﺗﺑﺎﺩﻝ ﺍﻟﺣﺩﻳﺙ‪ ،‬ﺃﻭ ﺃﻥ ﺗﻛﻭﻥ ﻗﺭﻳﺑﺎ‬
‫ﻣﻣﻥ ﺗﺗﺣﺩﺙ ﻣﻌﻪ‪.‬‬
‫‪‬ﻋﻼﺝ ﻧﺯﻻﺕ ﺍﻟﺑﺭﺩ ﻭﺍﻟﺳﻌﺎﻝ‪.‬‬
‫‪‬ﺍﺳﺗﺧﺩﺍﻡ ﻁﺑﻘﺔ ﺍﻟﺻﻭﺕ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻭﻋﺩﻡ ﺍﻟﺗﻛﻠﻑ ﻓﻲ ﺇﺧﺭﺍﺝ ﺍﻟﺻﻭﺕ‪.‬‬
‫‪‬ﺍﺳﺗﺧﺩﺍﻡ ﻣﻛﺑﺭ ﻟﻠﺻﻭﺕ ﻟﻠﺣﺩﻳﺙ ﻓﻲ ﻣﻛﺎﻥ ﻣﻔﺗﻭﺡ‪.‬‬
‫‪‬ﻣﻧﺢ ﺍﻟﺻﻭﺕ ﻓﺗﺭﺍﺕ ﻣﻥ ﺍﻟﺭﺍﺣﺔ ﻗﺩﺭ ﺍﻷﻣﻛﺎﻥ ﻋﻠﻰ ﻣﺩﺍﺭ ﺍﻟﻳﻭﻡ‪ ،‬ﻭﺧﺻﻭﺻﺎ ﻋﻧﺩ ﺍﻟﺗﻌﺭﺽ‬
‫ﻟﻧﺯﻟﺔ ﺑﺭﺩ ﺃﻭ ﺍﺭﻫﺎﻕ‪.‬‬
‫‪‬ﺍﻻﻋﺗﺩﺍﻝ ﻓﻲ ﻣﺩﺓ ﺍﺳﺗﻌﻣﺎﻝ ﺍﻟﺻﻭﺕ ﻭﺷﺩﺗﻪ‪.‬‬
‫‪‬ﺍﻟﻣﺑﺎﺩﺭﺓ ﺑﺎﺳﺗﺷﺎﺭﺓ ﻁﺑﻳﺏ ﺍﻟﺗﺧﺎﻁﺏ ﻭﺍﻟﺻﻭﺕ ﻋﻧﺩ ﺍﺳﺗﻣﺭﺍﺭ ﺍﻟﺑﺣﺔ ﻷﻛﺛﺭ ﻣﻥ ﺃﺳﺑﻭﻋﻳﻥ‪.‬‬

‫‪Khalid H Al Malki, MD, PhD‬‬

A. Vocal hygiene advice:

 Vocal hygiene advices in the first and second

sessions of voice therapy.

 If difficulty with compliance to these advices,

prognosis in voice therapy is guarded.

Khalid H Al Malki, MD, PhD

B. Voice therapy:
 The patient is most important member of the
team – the patient must be motivated to
participate.

 Voice therapy should be tailored to

accommodate the patient’s professional, career,
and daily goals.

 The concept of “Trial Therapy”.

Khalid H Al Malki, MD, PhD

B. Voice therapy (cont):
 It is the patient’s responsibility to:
 attend sessions.
 complete home practice.
 work to carry over efficient voice use in
everyday life.
 Patient education (anatomy, physiology,
causes, treatment options, …..).
 Realistic patient expectations.

Khalid H Al Malki, MD, PhD

B. Voice therapy (cont):

 Voice therapy is not “cookbook care.”

Each patient presents with individual needs.

 Some therapies work better with some

patients than others.

Khalid H Al Malki, MD, PhD

B. Voice therapy (cont):
 Not all patients are appropriate patients for
voice therapy.

 Voice therapy begins with an accurate

diagnosis and referral from an otolaryngologist.

 The ENT diagnoses the voice disorder, and

the SLP evaluates the vocal behavior while
determining stimulability for improvement.

Khalid H Al Malki, MD, PhD

B. Voice therapy (cont):
Causes of failure of voice therapy:
1. Inappropriate referral from ENT.
2. Not stimulable for a better voice.
3. Decreased motivation for change (i.e.,
wants a “quick fix”).
4. Non-compliant to vocal hygiene advices.
5. Will not accept responsibility.

Khalid H Al Malki, MD, PhD

B. Voice therapy (cont):
Causes of failure of voice therapy (cont.):
6. Hearing loss.
7. Possible concomitant emotional or
psychological problems.
8. Accurate referral to an inexperienced
speech-language pathologist.

Khalid H Al Malki, MD, PhD

Voice therapy methods:

I. Specific methods.

II. Diverse methods.

III. Holistic methods.

M N Kotby Khalid H Al Malki, MD, PhD

Voice therapy methods:
I. Specific methods:
1. Paralytic dysphonia (pushing technique).

2. Mutational dysphonia (finger manipulation and

pressure).

3. Psychogenic aphonia (cough, hum,

masking..).

M N Kotby Khalid H Al Malki, MD, PhD

Voice therapy methods (cont.)
II. Diverse methods:

1. Relaxation. 5. Head rolling.

2. Altering tongue position. 6. Laryngeal massage.
3. Pitch inflection. 7. Inhalation phonation.
4. Yawn-sigh. 8. Chant talk.

M N Kotby Khalid H Al Malki, MD, PhD

Voice therapy methods (cont.)
III. Holistic methods:
Tackles respiratory, pulmonary, and
articulatory mechanisms.

Accent Method
(Smith & Thyme, 1978; Kotby, 1995).

M N Kotby Khalid H Al Malki, MD, PhD

Indications

Khalid H Al Malki, MD, PhD

Indications:
1- Disorders of Voice.
2- Disorders of Speech:
a- Dysarthria: Correcting defective breathing,
dysprosody, and dysphonia.
b- Stuttering: Improving breath control leading to
better phrasing and rhythms.
3- Disorders of Language:
Correcting dysprosody in selected language disorders
in children and adults.

M N Kotby Khalid H Al Malki, MD, PhD

Indications:
Disorders of Voice:
I. Mainstream of therapy:
1. Non-organic voice disorders.

2. Some benign vocal fold lesions.

3. Some organic voice disorders.

M N Kotby Khalid H Al Malki, MD, PhD

Indications:
Disorders of Voice (Cont.)
II. Complementary line of therapy:
1. Pharmacotherapy.

2. Phonosurgery.

M N Kotby Khalid H Al Malki, MD, PhD

Tecnniques

Khalid H Al Malki, MD, PhD

(1) Accent Method Voice Therapy:

Described earlier.

M N Kotby Khalid H Al Malki, MD, PhD

(2) Confidential Voice Therapy:
It is used to reduce the force of vocal fold collision
and excessive laryngeal hyperfunction during
phonation.

A breathy voice produced, but it is not the final the

therapeutic goal.

It is encouraged for a prescribed period to promote

mucosal healing.

Khalid H Al Malki, MD, PhD

Confidential Voice Therapy:
It is only used for a period of time to promote vocal
fold healing.

Once that period is finished, the voice production is

shaped into a healthy vocal production by other
therapies.

Khalid H Al Malki, MD, PhD

(3) Facilitating Techniques:
Originally described by Boone et al.

These techniques were thought to facilitate a “target”

vocal response by the patient.

There are 25 facilitating techniques in total *

They may be used individually or in any combination

to modify deviant vocal symptoms.

Khalid H Al Malki, MD, PhD

(4) Inspiratory muscle strength
training (IMST):
Described by Christine Sapienza.

She developed a device that consists of a mouthpiece

with a one-way valve. The valve blocks airflow until
the threshold pressure is produced to overcome the
spring force.

Khalid H Al Malki, MD, PhD

Inspiratory muscle strength
training (IMST):

Khalid H Al Malki, MD, PhD

Inspiratory muscle strength
training (IMST):
The patient must generate sufficient inspiratory
pressure using inspiratory musculature to open the
valve and allow the air to flow.

IMST has shown to be successful in a case of a

patient with bilateral abductor vocal fold paralysis
and a patient with paradoxical vocal fold motion.

Khalid H Al Malki, MD, PhD

(5) Lee Silverman Voice Treatment:
LSVT was developed to address the hypokinetic
dysphonia most frequently associated with Parkinson
disease.

LSVT is a systematic voice therapy approach that

focuses on increasing loudness during four sessions
per week for 4 weeks.

Khalid H Al Malki, MD, PhD

Lee Silverman Voice Treatment:
Patients are trained to “recalibrate” their habitual
speaking volume to one louder because the loudness
that they think is normal is, in reality, too quiet.

Having patients use a very loud voice also improves

their articulatory precision and inflection.

The efficacy of this treatment has been well-

researched.

Khalid H Al Malki, MD, PhD

Lee Silverman Voice Treatment:
There is a modified version of LSVT called pitch
limiting voice treatment (PLVT).

It requires patients to voice in a low and loud pitch to

increase loudness and speech intelligibility.

Khalid H Al Malki, MD, PhD

(6) Manual Circumlaryngeal
Techniques:
They are direct hands-on approaches in which the
larynx is repositioned during phonation while
observing changes in voice.

May be useful in hyperfunction (MTD).

Symptoms of excessive laryngeal muscle tension are

usually: neck tenderness, soreness, and tightness.

Focal areas of tenderness are felt and manipulated.

Khalid H Al Malki, MD, PhD

Manual Circumlaryngeal
Techniques
There are three laryngeal reposturing maneuvers:
(a) “push-back” maneuver,
(b) “pull-down” maneuver, and
(c) medial compression and downward traction.

Khalid H Al Malki, MD, PhD

Manual Circumlaryngeal
Techniques
Moments of voice improvement are identified,
shaped, and reinforced with manual laryngeal
manipulations (i.e., digital cueing).

Then, the digital cues are faded while the patient

learns to rely on vibrotactile, kinesthetic, and
auditory feedback to maintain improved voice.

Khalid H Al Malki, MD, PhD

(7) Circumlaryngeal Massage:
This is elaborated by Morrison and Rammage .

It differs from manual circumlaryngeal techniques

because rather than reposturing the laryngeal
mechanisms, direct massage to the laryngeal area is
done.

Khalid H Al Malki, MD, PhD

Circumlaryngeal Massage:
It is achieved by placing the thumb and forefinger
over the tips of the hyoid bone while using circular
motion to massage inferiorly to the thyrohyoid space
and posterior borders of the thyroid cartilage.

Khalid H Al Malki, MD, PhD

(8) Resonant Voice Therapy:
The Lessac-Madsen resonant voice therapy
(LMRVT) is probably most well-known of this type.

It is initiated by having patients hum on nasal sounds

(m, n, ng) and prolong voiced fricatives (z, v).

Eight weekly therapy sessions are prescribed.

Khalid H Al Malki, MD, PhD

Resonant Voice Therapy:
The target is “barely adducted” or “barely abducted”
vocal fold configuration, facilitated by the use of
“resonant voice,” which is defined as “easy” voice
production with anterior oral vibrations.

May be used with patients who have hyperfunctional

voice disorders (e.g., MTD).

Khalid H Al Malki, MD, PhD

(9) Respiratory Retraining Therapy:
Described by Florence Blager.

It consists of inhaling through the nose with a relaxed

tongue posture and prolonging audible exhalation
through pursed lips or by producing an /s/.

Extra attention is paid to exhalation.

Khalid H Al Malki, MD, PhD

Respiratory Retraining Therapy:
Nasal inhalation encourages wider glottal abduction.

Patients are instructed to pay attention to exhalation

and overall relaxation.

It is mostly used with patients diagnosed with

paradoxical vocal fold movement disorder (PVMD).

Khalid H Al Malki, MD, PhD

(10) Stretch and Flow Phonation:
Developed by Stone and Casteel.

It focuses on airflow management.

Many patients present with breath-holding tendencies

that are either the cause of their voice problems or
maladaptive compensatory responses.

Khalid H Al Malki, MD, PhD

Stretch and Flow Phonation
It has five skill levels. Each skill is used in a
hierarchy of different speaking situations (e.g., from
sustained sounds to repeated words up to
conversational speech).

Used with patients with functional aphonia, MTD,

and in patients who have developed maladaptive
compensatory muscle tension.

Khalid H Al Malki, MD, PhD

(11) Vocal Function Exercises:
Briess developed these techniques. More recently,
Stemple et al. adapted this therapy program into a
series of vocal function exercises (VFEs).

VFEs are a series of systematic vocal manipulations,

similar in theory to physical therapy for the vocal
folds.

Khalid H Al Malki, MD, PhD

Vocal Function Exercises:
There are four steps to the program:
(a) vocal warm-up by sustaining the vowel “ee” for
as long as possible.
(b) stretching of the laryngeal muscles by gliding
from the lowest note to the highest note.
(c) contracting of the laryngeal muscles by gliding
from the highest note to the lowest note.
(d) building muscular power by sustaining musical
notes for as long as possible.

Khalid H Al Malki, MD, PhD

Vocal Function Exercises:
The exercises are performed two times each, and are
repeated twice a day.

The exercises are to be done softly without excess

strain.

VFEs may be used on patients with benign vocal fold

lesions, mild glottal incompetence, and MTD.

Khalid H Al Malki, MD, PhD

Thank You