Voice Therapy: Following the Evidence Trail

1
Voice Therapy Following the Evidence Trail

• Joseph C. Stemple, Ph.D.
• Lisa B. Thomas, M.A., Doctoral Candidate

2
(No Transcript)
3
(No Transcript)
4
Voice Therapy Orientations

• Hygienic
• Symptomatic
• Physiologic
• Eclectic

5
Hygienic Voice Therapy

• Discover the behavioral causes of the voice
  disorder modify/eliminate of the causes to
  improve the voice
  
• Organized and promoted by every text related to
  voice disorders
  
• There is often a behavioral cause for a voice
  disorder discover, modify/eliminate it and the
  voice improves

6
Symptomatic Voice Therapy

• Modification of deviant vocal symptoms such as
  breathiness, inappropriate pitch, loudness, hard
  glottal attacks, and so on
  
• Organized and promoted by Daniel Boone in his
  text The Voice and Voice Therapy (1971)
  
• If the voice component is inappropriate, modify
  that component with voice facilitating techniques

7
Physiologic Voice Therapy

• Based on expanded knowledge of vocal function as
  evaluated through objective voice assessment and
  measurement
  
• Strives to improve the relationship or balance
  among voice respiratory support, laryngeal muscle
  strength, control and stamina, and and
  supraglottic modification of the laryngeal tone

8
Physiologic Voice Therapy

• Presented by Colton and Casper (1990) and
  Stemple, Glaze, and Gerdeman (1993)
  
• Concentrates on the modification of the
  underlying physiology of the voice producing
  mechanisms respiration, phonation, resonance

9
Eclectic Voice Therapy

• Combination of any and all of the previous
  orientations to affect positive vocal change
  
• Voice pathologists should be aware of all
  management approaches and use those which are
  most effective not only for the patient, but for
  the therapist as well

10
What do we mean by following the evidence
trail?

• Many voice therapy interventions have become
  standard practice with limited supporting data
  
• Clinical/medical/surgical practices have
  out-paced the scientific evidence to support them
  Why?
  
• Patients continue to show up at our doors
• We will continue to treat them with techniques
  that APEAR to work

11
Is Research Support Necessary in Clinical
Practice?

• How do we know that what we do in therapy
  actually does what it is meant to do?
  
• How do we know that therapy success was the
  technique and not the therapist?
  
• How many techniques and approaches do we use from
  habit or because they seem to work?
  
• How many of us blindly follow the latest therapy
  fad without the benefit of good data?

12
Research Support cont

• Outcomes data should serve as the foundation of
  clinical practice in voice pathology.
  
• Why?
• Concerns revolve around objective accountability
• Research funding has centered on the form and
  quality of clinical outcome studies
  
• NIH Roadmap

13
History of Outcomes Research in Voice

• Earliest reports 1940s
• Case Studies, Anecdotal reports
• 1980s and early 1990s
• Instrumentation advances
• Dramatic increase in number of outcome studies
• Primarily survey and retrospective studies. Some
  group studies SS designs emerge.
  
• Lack of control and research rigor

14
History of Outcomes Research in Voice

• Studies of the 1990s and 2000s
• Instrumentation advances
• Increased rigor in designs
• Lines of research developing
• Ex LSVT, Ramig et al. (1995)

15
Decisions Regarding the Content of the Review
16
Review Process Phase 1

• Medline, CINAHL, PsychINFO, ASHA journals (1980
  present)
  
• Search terms voice therapy, efficacy, outcomes,
  voice disorders
  
• Total citations 124
• 41 inappropriate population (SD, IPD)
• 46 not related to treatment efficacy, outcomes
• 7 non-English
• 30 studies for review

17
Review Process Phase 2

• Historical search from pertinent readings 38
  additional studies
  
• Review Process Phase 3
• Review, categorization, and rating of studies
• Butler and Darrah (2001) 5 level rating system

18
Hygiene Therapy Evidence

• Direct treatment of voice appears superior to
  vocal hygiene training
  
• Verdolini-Marston et al. (1995)
• Carding Horsley (1992)
• Carding et al (1999)
• Roy et al. (2001)
• Holmberg et al. (2001)
• Pasa et al. (2007) contradictory results (VH
  increase in knowledge, decrease in self-reported
  symptoms, however, no significant change in
  direct measures of MPFR or MPT)

19
Hygiene Evidence
Group hygiene training yields change in knowledge
but no change in behavior

• Knowledge
• Nilson and Schneiderman (1983)
• Aaron and Madison (1991)
• Pasa et al. (2007)

• Behavior
• Broaddus-Lawrence et al. (2000)
• Timmermans et al. (2004, 2005)
• Chan (1994)

20
Hygiene Evidence

• Hydration reduces phonatory effort
• Verdolini et al. (1994)
• Verdolini-Marston et al. (1990, 1994)
• Solomon and DiMattia (2003)
• Fisher et al. (2001)
• Hydration increases vocal endurance
• Yiu and Chan (2003)

21
HygieneConclusions Implications

• Few large scale studies support the therapeutic
  benefit of general hygiene education
  
• Growing support for use of hydration
• Hygiene should be used only as an adjunct to
  direct forms of treatment.
  
• Future work
• Monitor / quantify compliance
• Increase number of studies on disordered
  populations
  

22
Symptomatic Therapy Evidence

• Primarily case reports and anecdotal evidence
• Few group studies
• Majority of methods have Level IV and V evidence
• Many methods have no published evidence

23
Symptomatic Evidence

• Evidence supports use of biofeedback
• EMG
• Prosek et al (1978) Stemple et al. (1980)
  Andrews et al. (1986)
  
• Acoustic / Aerodyanamic
• Yamaguchi et al. (1986) Laukkanen et al. (2004)
  
  
• Laryngeal Function
• DAnontio (1987) Rattenbury et al. (2004)

24
Symptomatic TherapyConclusions Implications

• One line of promising work - Biofeedback
• Future Directions
• Potential examination of theoretical bases of the
  methods
  
• More rigorous research designs

25
Physiologic Therapy Evidence

• Evidence
• Physiologic / theoretical evidence
• Clinical evidence
• Majority, well-controlled group studies

26
Physiologic Clinical Evidence

• Lines of research for 4 methods
• Accent Method
• Smith Thyme (1976) Kotby et al. (1991) Fex et
  al. (1994) Bassiouny (2001)
  
• Vocal Function Exercises
• Stemple et al. (1994) Sabol et al. (1995) Roy
  et al. (2001), Gillivan-Murphy et al. (2006),
  Bell et al. (2007)
  

27
Physiologic Evidence

• Resonant Voice Therapy
• Verdolini-Marston et al. (1995) Chen et al.
  (2003) Roy et al. (2003) Bell et al. (2007)
  
• Manual Laryngeal Musculoskeletal Reduction
  Technique
  
• Roy and Leeper (1993) Roy et al. (1997) Van
  Lierde et al. (2004)

28
Physiologic TherapyConclusions and Implications

• Orientation came to forefront at time of efficacy
  emphasis
  
• Evidence supports a shift from symptomatic Tx to
  physiologic Tx
  

29
Conclusions Implications

• Orientations
• Physiologic methods possess strongest support
• Efficacy of hygiene training inconclusive
• Lack of evidence for symptomatic therapy
• Future Directions / Questions
• Should symptomatic be examined or revised?
• Determine ways of examining hygiene more fully
• Consider / replicate model lines of research in
  voice

30
Does Science Support the Art of Voice Therapy?

• Historically an art form
• Shift to science base in 1990s 2000s.
• Instrumentation
• Societal focus on outcomes research
• Current Tx models have scientific support

31
Full Review Published In
Thomas, L.B., Stemple, J.C. (2007). Voice
therapy Does science support the art?
Communicative Disorders Review, 1, 51-79.
32
Designing the Vocal Hygiene Protocol
33
Vocal Hygiene

• Evidence suggests
• VH does not stand alone as a treatment for voice
  disorders
  
• Best used as a complement to other therapies
• May insulate patient from further voice
  deterioration
  

34
Vocal Hygiene

• May exert influence due to
• Elimination of poor vocal habits which
  contributed to / perpetuated the disorder
  
• Lays the foundation for progress
• Maintaining the health of the vocal fold cover
• Hydration
• Reduction of acidic irritants or other irritants
  of the mucosal cover

35
Vocal Hygiene A Typical Protocol

• Vocal hygiene counseling involves
• identifying the abusive behaviors
• describing the physiologic effects of those
  behaviors on the voice production mechanisms
  
• defining the specific occurrences
• modifying or eliminating the behavior

36
Vocal Hygiene Components of a Standard Protocol

• Water intake considerations
• Manage intake of dehydrating substances
• Multiple forms beverages, OTC meds, prescription
  meds, etc.
  
• Deal with chronic throat clearing / coughing
• Substitute behaviors

37
Components of a Standard Protocol

• Strategic management of acoustic environment
• Diligent reflux management
• Symptomatic, Asymptomatic cases
• Vocal warm-ups as needed

38
Vocal Hygiene Final Thoughts

• Vocal rest vs. Modified vocal rest
• Dictating vs. strategizing
• The KEY is patient education and patient
  understanding

39
Planning Physiologic Voice Therapy Protocols
40
Research Support for Physiologic Voice Therapy

• What are physiologic voice therapies exactly?
• Good question (Probably just an academic term)
• Seems to relate to a therapy program involving
  exercises or vocal maneuvers that attend to all
  three subsystems of voice production at once,
  respiration, phonation, and resonance

41
Research Support for Physiologic Voice Therapy
cont

• These therapy programs are most often described
  as physiologic approaches to voice therapy
  
• Accent Method
• Lee Silverman Voice Therapy
• Resonant Voice Therapy (LMRVT)
• Vocal Function Exercises

42
Why is Treating the Physiology Critical?

• Diagnosis Symptoms, pattern of production,
  etc.
  
• Example Nodules
• Example Paralysis
• Individualized responses to pathology

• Universal Goal Restore to normal physiology,
  normal efficiency
  
• Treatment Need holistic method to restore normal
  physiology
  
• Implication Some physiologic therapies
  applicable across a broad range of pathologies
  

43
Vocal Function Exercises

• A series of systematic voice manipulations,
  similar in theory to physical therapy for the
  vocal folds, designed to strengthen and
  coordinate the laryngeal musculature, and to
  improve the efficiency of the relationship among
  airflow, vocal fold vibration, and supraglottic
  treatment of phonation

44
Vocal Function Exercises cont

• Long sustained tones
• Maximal pitch glides
• Efficient posturing of the voice producing
  mechanism to permit maximum output with minimal
  effort

45
Genesis of VFE

• Bertram Briess
• Robert Stimpert
• Jan Barnes

46
Vocal Function Exercises Primary Research Support

• Stemple J, Lee L, DAmico B, Pickup B (1994)
  Efficacy of Vocal Function Exercises as a method
  of improving voice production. J Voice, 8
  271-278.
• Double-blind, placebo-controlled study
• 35 females ages 21-25 with normal voice
• Pre and post-test acoustic, aerodynamic, and
  videostroboscopic measures
  
• Performed VFE 2x each 2x per day for 4 weeks

47
Stemple et al., 1994, cont

• Results
• Maximized use of phonation flow volume
• Decreased airflow rates
• Increased maximum phonation time
• Increased frequency range
• Improved the symmetry of vibration
• Average VFE phonation times increased with
  plateau at 2 weeks
  

48
Vocal Function Exercise Research Support cont

• Sabol J, Lee L, Stemple J (1995) The value of
  Vocal Function Exercises in the practice regimen
  of singers. J Voice, 9 27-36.
  
• 20 university graduate level opera majors ranging
  in age from 26-39 years (men) and 21-43 years
  (women)
  
• Pre and post-test acoustic, aerodynamic, and
  videostroboscopic measures as well as perceptual
  questionnaire
  
• Performed VFE 2x each 2x per day for 4 weeks
  along with regular singing activities
  

49
Sabol et al., 1995, cont

• Results
• Decreased airflow rates at both high and low
  pitches (intensity and pitch were held steady for
  pre and post-test)
  
• Increased MPT at all pitch levels
• Reported improvement in dynamic range control
• Average VFE times increased with plateau at 3
  weeks
  

50
Vocal Function Exercise Research Support cont

• Roy N, Gray S, Ebert M, Dove H, Corbin-Lewis K,
  Stemple J (2001) An evaluation of the effects of
  two treatments for teachers with voice disorders
  A randomized clinical trial. JSHR, 44 286-296.
• Assessed the functional effects of Vocal Hygiene
  and VFE on 58 school teachers with self-reported
  voice problems
  
• Subjects were randomly assigned to VFE, VH and
  control groups
  
• Treatment phase lasted for 6 weeks
• Pre and post Voice Handicap Index (VHI) were
  completed by all subjects
  

51
Vocal Function Exercise Research Support cont

• Results
• Control group worse
• Vocal Hygiene group no change
• VFE group significant improvement

52
Strategies for Physiologic Voice Therapy

• Vocal Function Exercises
• a series of systematic voice manipulations,
  similar in theory to physical therapy for the
  vocal folds, designed to strengthen and
  coordinate the laryngeal musculature, and to
  improve the efficiency of the relationship among
  airflow, vocal fold vibration, and supraglottic
  treatment of phonation

53
Strategies for Physiologic Voice Therapy

• What is made of multiple cartilages, muscles, and
  connective tissue and is a jointed system which
  may become injured, weakened, or imbalanced in
  its function?

54
Strategies for Physiologic Voice Therapy

• Your Knee

55
Strategies for Physiologic Voice Therapy

• Rehabilitation for injuries of the knee
• rest to reduce edema
• appropriate supports, casts, bracings, and wraps
  as needed
  
• ambulatory devices
• systematic exercise
• continuation of previous activities

56
Strategies for Physiologic Voice Therapy

• Your Larynx

57
Strategies for Physiologic Voice Therapy

• Rehabilitation for Injuries of the Larynx
• sometimes voice rest
• vocal hygiene counseling
• modify symptoms
• continuation of previous voicing activities

58
Strategies for Physiologic Voice Therapy

• MISSING ELEMENT

59
Direct Systematic Exercises

• Restrengthening and coordinating the laryngeal
  musculature
  
• Enhancing the relationship of the three
  subsystems of voice production
  

60
Four Steps

• Warm up
• Stretching Exercise
• Contracting Exercise
• Adductory Strengthening Exercise

61
Resonance
Phonation
Respiration
62
Vocal Function Exercises

• (warm-up) Sustain the vowel /i/ for as long as
  possible on the musical note (F)
  
• Goal __ sec (F above middle (C) for females
  F below middle (C) for males)
  

63
Vocal Function Exercises

• Posture
• Breathing
• Placement
• Onset

64
Vocal Function Exercises

• (stretching) Glide from your lowest note to your
  highest note on the word knoll, whoop, tongue
  trill, lip trill
  
• Goal no voice breaks

ol
Lip Buzz
Pharynx
Lips
65
Vocal Function Exercises

• (contracting) Glide from a comfortable high note
  to your lowest note on the word knoll, boom,
  tongue trill, lip trill
  
• Goal no voice breaks

66
Vocal Function Exercises

• (power) Sustain the musical notes (C-D-E-F-G) for
  as long as possible on the word old without the
  /d/.
  
• Goal __ sec. (middle (C) females, octave below
  middle (C) males
  

67
Pitch Modifications

• G A B C D E F G A B C
• G A B C D E F G A B C
• G A B C D E F G A B C

68
Vocal Function Exercises

• notes are matched to a pitch pipe, tape recorder,
  key board, piano
  
• daily record is charted by the patient
• estimated time of completion 8-10 weeks
• some patients experience minor laryngeal aching
  the first few days of exercise

69
Vocal Function Exercises

• all exercises are done 2 x each, 2 x per day
• all exercises are done as softly as possible, but
  engaged
  
• quality of tone is monitored for breaks,
  wavering, and breathiness
  
• extreme care is taken to teach the production in
  a forward tone focus without tension
  
• attention is paid to the glottal onset of the
  tone to assure an easy onset without breathiness
  
• appropriate breathing technique is assured

70
Explanation to the Patient

• Admit that it seems silly
• Compare it to workout program, physical therapy,
  weight lifting, etc.
  
• Stress the necessity of systematic exercise
  without breaks
  
• Explain that the times do not increase due to
  increased lung capacity
  

71
Advantages for the Patient

• Easily understood, reasonable model
• Systematic, permits plotting of progress
• Patient must attend to the voice at least 2 times
  per day
  
• Involves doing something positive as opposed to
  the dont dos

72
Vocal Function Exercises

• Maintenance Schedule
• Full program 2 x each 2 x per day
• Full program 2 x each 1 x per day
• Full program 1 x each 1 x per day
• Exercise 4 2 x each 1 x per day
• Exercise 4 1 x each 1 x per day
• Exercise 4 1 x each 3 x per week
• Exercise 4 1 x each 1 x per week

Each taper involves approximately 1 week
73
Future Research

• Clinical populations
• Measurement strategies
• Study the underlying physiologic principles of
  the training modalities
  

74
Resonant Voice Therapy

• Lessac (1965)
• The well-placed voice yields optimal functioning
  of respiratory, phonatory, and resonance systems
  
  
• Titze (2003)
• RV maximum transfer of power through the vocal
  tract from glottis to lips and ultimately to the
  listener
  
• Proper energy conversion at the vocal folds
  results in excellent propagation of sound --
  vibrations of the glottal tone can extend into
  the facial regions

75
Resonant Voice Therapy

• RV produced with vocal folds barely separated
• Berry (2001)
• Glottic configuration observed in RV produces
  maximum transfer of sound through vocal tract
  
• Implications Glottal configuration for RV is
  most efficient use of the system
  

76
Resonant Voice Therapy

• Voice production involving oral vibratory
  sensations, usually on the anterior alveolar
  ridge or higher in the face
  
• In the context of easy phonation
• Where resonant voice is a continuum of oral
  sensations and easy phonation builds from basic
  speech gestures through conversational speech
  

77
Resonant Voice Therapy

• Training methodologies are experiential, focusing
  on the processing of sensory information
  
• The training model assumes similar approaches for
  voice restoration and enhancing the normal voice
  (excellence training)
  

78
Resonant Voice Therapy

• Fundamental perceptual target is focused, oral
  vibratory sensations in the context of easy
  phonation.
  
• The singular training focus (resonance) is
  expected to affect multiple levels of physiology
  (breathing and laryngeal).
  
• Large numbers of repetitions are used, in varying
  speech contexts.
  
• Training is strongly goal (results) driven,
  involving a dogged insistence upon the greatest
  possible precision in the achievement of the
  perceptual tasks.

79
Resonant Voice TherapyPrimary Clinical Support

• 4 clinical studies
• Verdolini-Marston et al., 1995
• Roy et al., 2003
• Chen et al., 2003

80
Basic RVT Training Maneuvers

• Stretches and Breathing Warm-Ups
• Shoulders
• Neck
• Jaw
• Floor of Mouth
• Lips
• Tongue
• Pharynx

81
Basic Training Gesture for RT (This is Step 1
for all stages of RT)

• Holm-molm-molm-molm-molm..As a sigh
• Extreme forward focus is required with
  appropriate breath support
  
• Make the connection from the abdominal muscles to
  the lips
  
• Patient should feel very relaxed at the end of
  this gesture
  

82
RT Hierarchy Stage 1 All Voiced

• molm-molm-molm.. (sustained pitch) ____ note
•  - vary the rate only
• - discover the vibrations experiment with
  broad and narrow vibrations
  
• - eventually focus on the narrow vibration
  like a narrow beam of light
  
• - increase the ease of production by reducing
  the effort by 1/2 and 1/2 again
  
• - increase lift (as if pitch were
  increasing)

83
RT Hierarchy Stage 1 All Voiced

• 2. molm-molm-molm..
• slow-fast-slow
• soft-loud-soft on ____ note
• 3.  molm-molm-molm.. as speech
• use non-linguistic phrase
• vary the rate, pitch, and loudness
• make the connection from the abdominal muscles to
  the lips
  

84
RT Hierarchy Stage 1 All Voiced

• 4. Chant the following voiced phrases on the
  musical note ___
  
• Mary made me mad.
• My mother made marmalade.
• My merry mom made marmalade.
• My mom may marry Marv.
• My merry mom may marry Marv.
• Marv made my mother merry.
• 5. Over-inflect these phrases as speech

85
RT Hierarchy STAGE 2 Voice-Voiceless
Contrasts

• Basic Training Gesture
• 1. mamapapa.. vary the rate on ___ note
• 2. mamapapa..
• slow-fast-slow
• soft-loud-soft on ___ note
• 3. mamapapa.. As speech
• use non-linguistic phrases
• vary the rate, pitch, and loudness
• make the connection from the abdominal muscles to
  the lips
  

86
RT Hierarchy STAGE 2 Voice-Voiceless Contrasts

• 4. Chant the following voiced/voiceless phrases
  on the musical note ___ 
  
• Mom may put Paul on the moon.
• Mom told Tom to copy my manner.
• My manner made Pete and Paul mad.
• Mom may move Pollys movie to ten.
• My movie made Tim and Tom sad.
•  5. Over-inflect these phrases as speech
•  

87
RT Hierarchy STAGE 3 ANY PHRASE 

• Basic Training Gesture
• Produce the following phrases in sequence as
  follows
  
• First, chant the phrase on the note___, (no
  breath)
  
• Then over-inflect it with extreme forward focus,
  and
  
• Then finally repeat it as natural speech with a
  forward focus.
  
• Note Each individual phrase should be produced
  following this 3-step sequence before moving onto
  the next phrase.
  

88
RT Hierarchy STAGE 3 ANY PHRASE

• - All the girls were laughing.
• - Get there before they close.
• - Did you hear what she said?
• - Come in and close the door.
• - Are you going tonight?
• - Put everything away.
• - Come whenever you can.
• - We heard that yesterday.
• - The player broke his leg.
• - The children went swimming.
•  
•  

89
RT Hierarchy Stage 4 Paragraph Reading

• read a paragraph with phrase markers
• separate each phrase only by the natural
  inhalation of air
  
• exaggerate focus and then repeat with a more
  normal speech/voice production
  
• repeat the above without phrase markers

90
RT Hierarchy Stage 5 Controlled Conversation

• practice forward speech placement in
  conversation
  
• do not permit glottal attacks, glottal fry, etc.

RT Hierarchy Stage 6 Environmental
Manipulations
simulate actual speaking environments
use tapes of background noise
go to noisy cafeteria

91
RT Hierarchy Stage 7 Emotional Manipulations

• use materials and topics that increasingly engage
  and challenge the patient
  

RT Home Exercises
The critical portion of each exercise for each
week is tape recorded as a home exercise example.
15-20 minute home sessions, two times per day w
ith minis as needed 1. Stretches 2. Basic RV
gesture 3. Selected level of hierarchy
92
ConclusionsPhysiologic Voice Therapy

• Some methods applicable across broad range of
  pathologies
  
• Goal of these methods is to restore normal
  (efficient) laryngeal function
  

93
Strategies for Psychogenic Voice Therapy

• The psychogenic voice disorders include
• conversion aphonia
• conversion dysphonia
• muscle tension dysphonia
• functional falsetto
• juvenile voice
• paradoxical vocal fold movement

94
Strategies for Psychogenic Voice Therapy

• Management stages include
• 1. Medical evaluation
• -rule out organic pathology
• -confirms the psychogenic diagnosis
• 2. Diagnostic voice evaluation
• -develops the history
• -provides impression of patients personality
  and shows how functions socially
  
• -gives physiologic rationale for voice problem
• -prepares the patient for vocal change

95
Strategies for Psychogenic Voice Therapy

• 3. Direct manipulation of the voice
• -begins during the diagnostic evaluation
• -expected result is dramatic change toward
  normal voice production
  
• 4. Counseling
• -determines the psychogenisis of the
  disorder
  
• -determines the need for further professional
  counseling

96
Strategies for Psychogenic Voice Therapy

• Conversion aphonia
• non-speech phonation
• cough
• throat clear
• gargle
• falsetto voice technique
• laryngeal videoendoscopy feedback
• Conversion dysphonia
• same as aphonia

97
Strategies for Psychogenic Voice Therapy

• Functional falsetto
• offer reasonable explanation
• hard glottal attack approach
• desensitization program
• Vocal Function Exercises/Forward Focus

98
Treatment of Glottal Incompetence

• Goal Improved closure, more efficient use of the
  system
  
• Methods Same as those used to enhance the system
  with other behavioral conditions
  
• Working on basic physiologic level rather than
  perceptual ideal

99
Case Study Bilateral True Vocal Fold Bowing and
Sulcus

• 73 year old male
• Active lecturer
• Voice Quality
• Mild to mod dysphonia, weak raspy hoarseness
• Chief complaints
• Voice fatigue
• Laryngeal ache
• Progressive hoarseness
• Lack of clarity in voice
• Inability to project voice

100
TREATMENT

• Vocal Function Exercises 2x ea 2x per day
• Airflow volume 3100 ml
• Goal 3100/80 40 sec
• 2-25-04 Baseline MPT 26.3 sec
• 3-4-04 35.2 sec
• 3-18-04 36.8 sec
• 4-1-04 42.2 sec
• 4-19-04 45.3 sec

101
Therapy Results

• Normal voice quality
• No voice fatigue
• Ability to project voice

102
Case Study Left True Vocal Fold Paralysis

• 70 year old female
• retired teacher/active volunteer
• May 21, 2004 Idiopathic LTVF Paralysis
• Voice Quality moderate dysphonia, high pitch,
  weak breathy hoarseness
  
• Chief Complaints
• Hoarseness
• Inability to project
• Mild aspiration

103
Treatment

• Vocal Function Exercises 2x ea 2x per day
• Airflow Volume 2000 ml / 80 25 sec
• 7-26-04 Baseline MPT 6.8 sec
• 8-2-04 12.0 sec
• 8-16-04 21.7 sec
• 9-16-04 24.2 sec
• 10-14-04 28.3 sec

104
Therapy Results

• Mild dysphonia with occasional pitch breaks
• Ability to project
• No dysphagia

105
So, what type of voice therapy should we be
practicing?

• Evidence-based
• Hygiene - present, may not be effective
• Symptomatic - limited, much more needed
• Physiologic - most studied, effective, needs to
  be done with a wider population
  
• Cart before the horse research
• Understand that there are many therapy approaches
  that are probably, might be, may be equally as
  effective as those presented that have not been
  systematically examined
• Every patient is a potential subject. Lets
  continue to explore

106
(No Transcript)
107
References

• Bassiouny, S. (1998). Efficacy of the accent
  method of voice therapy. Folia Phoniatrica et
  Logopedica, 50, 146-164.
  
• Bell, S., Kidd, B., Leemkuil, C., Smith, A.,
  McCrae, C. (2007, November). Vocal function
  exercises (VFE) verses resonant voice therapy
  (RVT) in the treatment of hyperfunctional voice
  disorders. Poster presented at the American
  Speech-Language-Hearing Association Annual
  Convention, Boston, MA.
• Broaddus-Lawrence, P., Treole, K., McCaabe, R.,
  Allen, R., Toppin, L. (2000). The effects of
  preventative vocal hygiene education on the vocal
  hygiene habits and perceptual voice
  characteristics of training singers. Journal of
  Voice, 14, 58-71.
• Carding, P., Horsley, I., Docherty, G. (1999).
  A study of the effectiveness of voice therapy in
  the treatment of 45 patients with nonorganic
  dysphonia. Journal of Voice, 13, 72-104.
• Casper, J. (2000). Confidential voice. In J. C.
  Stemple (Ed.), Voice therapy Clinical studies
  (2nd ed., pp. 128-139). San Diego, CA Singular
  Publishing.
• Chan, R. W. K. (1994). Does the voice improve
  with vocal hygiene education? A study of some
  instrumental voice measures in a group of
  kindergarten teachers, Journal of Voice, 8,
  279-291.
• Chen, S. H., Huang, J., Chang, W. (2003). The
  efficacy of resonance method to hyperfunctional
  dysphonia from physiological, acoustic and
  aerodynamic aspects The preliminary study. Asia
  Pacific Journal of Speech, Language and Hearing,
  8, 200-203.

108
References

• D'Antonio, L., Lotz, W., Chait, D. Netsell, R.
  (1987). Perceptual-physiologic approach to
  evaluation and treatment of dysphonia. Annals of
  Otology, Rhinology, and Laryngology, 96,
  187-190.
• Fex, B., Fex, S., Shiromoto, O., Hirano, M.
  (1994). Acoustic analysis of functional dysphonia
  before and after voice therapy (Accent Method).
  Journal of Voice, 8, 163-167.
• Fisher, KV., Ligon, J., Sobecks, J.L. Roxe,
  D.M. Phonatory effects of body fluid removal.
  Journal of Speech, Language, and Hearing
  Research, 44, 354-367.
• Gillivan-Murphy, P., Drinnan, M., ODwyer, T.,
  Ridha, H., Carding, P. (2006). The
  effectiveness of a voice treatment approach for
  teachers with self-reported voice problems.
  Journal of Voice, 20, 423-431.
• Holmberg, E., Hillman, R., Hammarberg, B.,
  Sodersten, M., Doyle, P. (2001). Efficacy of a
  behaviorally based voice therapy protocol for
  vocal nodules. Journal of Voice, 15, 395-412.
• Kotby, M., El-Sady, S., Abou-Rass, Y., Hegazi, M.
  (1991). Efficacy of the Accent Method of voice
  therapy. Journal of Voice, 5, 316-320.
  
• Kotby, M. N., Shirmoto., O., Hirano, M. (1993).
  The Accent Method of voice therapy Effect of
  accentuations on Fo, SPL, and airflow. Journal of
  Voice, 7, 319-325.

109
References

• Laukkanen, A., Syrja, T., Laitala, M., Leino,
  T. (2004). Effect of two month vocal exercising
  with and without spectral biofeedback on student
  actors' speaking voice. Logopedics, Phoniatrics,
  and Vocology, 29, 66-76.
• Nilson, H., and Schneiderman, C. R. (1983).
  Classroom program for the prevention of vocal
  abuse and hoarseness in elementary school
  children. Language, Speech, and Hearing Services
  in Schools, 14, 114-120.
• Pasa, G., Oates, J., Dacakis, G. (2007). The
  relative effectiveness of vocal hygiene training
  and vocal function exercises in preventing voice
  disorders in primary school teachers. Logpedics,
  Phoniatrics, Vocology, 32, 1-13.
• Prosek, R., Montgomery, A., Walden, B.,
  Schwartz, D. (1978). EMG biofeedback in the
  treatment of hyperfunctional voice disorders.
  Journal of Speech and Hearing Disorders, 43,
  282-294.
• Ramig, L. O., Countryman, S., Thompson, and
  Horii. (1995). Comparison of two forms of
  intensive speech treatment for Parkinsons
  disease. Journal of Speech and Hearing Research,
  38, 1232-1251.
• Rattenbury, H. J., Carding, P. N., Finn, P.
  (2004). Evaluating and effectiveness and efficacy
  of voice therapy using a transnasal flexible
  laryngoscopy a randomized control trial. Journal
  of Voice, 18, 522-533.

110
References

• Roy, N. (1993). Ventricular dysphonia following
  long-term endotracheal intubation A case study.
  Journal of Otolaryngology, 23, 189-193.
  
• Roy, N., Bless, D. M., Heisey, D., Ford, C. N.
  (1997). Manual circumlaryngeal therapy for
  functional dysphonia An evaluation of short- and
  long-term treatment outcomes. Journal of Voice,
  11, 321-331.
• Roy, N., Gray, S., Simon, M., Dove, H.,
  Corbin-Lewis, K., Stemple, J. (2001). An
  evaluation of the effects of two treatment
  approaches for teachers with voice disorders A
  prospective randomized clinical trial. Journal of
  Speech, Language, and Hearing Research, 44,
  286-296.
• Roy, N., Leeper, H. A. (1993). Effects of the
  manual laryngeal musculoskeletal tension
  reduction technique as a treatment for functional
  voice disorders Perceptual and acoustic
  measures. Journal of Voice, 7, 242-249.
• Roy, N., Weinrich, B., Gray, S., Tanner, K.,
  Stemple, J., Sapienza, C. (2003). Three
  treatments for teachers with voice disorders A
  randomized clinical trial. Journal of Speech,
  Language, and Hearing Research, 46, 670-688.

111
References

• Roy, N., Weinrich, B., Gray, S., Tanner, K.,
  Toldeo, S., Dove, H., Corbin-Lewis, K.,
  Stemple, J. (2002). Voice amplification verses
  vocal hygiene instruction for teachers with voice
  disorders A treatment outcomes study. Journal of
  Speech, Language, and Hearing Research, 45,
  623-638
• Sabol, L., Lee, L., Stemple, J. C. (1995). The
  value of vocal function exercises in the practice
  regime of singers. Journal of Voice, 9, 27-36
  
• Smith, S. Thyme, K. (1976). Statistic research
  on changes in speech due to pedagogic treatment
  (The Accent Method). Folia phoniatrica, 28,
  93-103.
• Solomon, N. P., DiMattia, M. S. (2000). Effects
  of a vocally fatiguing task and systemic
  hydration on phonation threshold pressure.
  Journal of Voice, 14, 341-362.
• Stemple, J. C. (1993). Voice therapy Clinical
  studies. St. Louis, MO Mosby Year Book.
  
• Stemple, J. C., Lee, L., DAmico, B., Pickup,
  B. (1994). Efficacy of vocal function exercises
  as a method of improving voice production.
  Journal of Voice, 8, 271-289.
• Stemple, J. C., Weiler, E., Whitehead, W.,
  Komray, R. (1980). Electromyographic biofeedback
  training with patients exhibiting a
  hyperfunctional voice disorder. The Laryngoscope,
  90, 471-476.

112
References

• Timmermans, B., De Bodt, M. S., Wuyts, F. L.,
  Van de Heyning, P. H. (2004). Training outcome in
  future professional voice users after 18 months
  of voice training. Folia Phoniatrica et
  Logopaedica, 56, 120-129.
• Timmermans, B., De Bodt, M. S., Wuyts, F. L.,
  Van de Heyning, P. H. (2005). Analysis and
  evaluation of a voice-training program in future
  professional voice users. Journal of Voice, 19,
  202-210.
• Van Lierde, K. M., De Lay, S., Clement, G., De
  Bodt, M., Van Cauwenberge, P. (2004). Outcome
  of laryngeal manual therapy in four Dutch adults
  with persistent moderate-to-severe vocal
  hyperfunction A pilot study. Journal of Voice,
  18, 467-474.
• Verdolini, K., Titze, I. R., Fennell, A.
  (1994). Dependence of phonatory effort on
  hydration level. Journal of Speech and Hearing
  Research, 37, 1001-1007.
• Verdolini-Marston, K., Burke, M. K., Lessac, A.,
  Glaze, L., Caldwell, E. (1995). Preliminary
  study of two method of treatment for laryngeal
  nodules. Journal of Voice, 9, 74-85.

113
References

• Verdolini-Marston, K., Sandage, M., Titze, I.
  R. (1994). Effect of hydration treatments on
  laryngeal nodules and polyps and related voice
  measures. Journal of Voice, 8, 30-47.
• Verdolini-Marston, K., Titze, I. R., Druker,
  D. G. (1990). Changes in phonation threshold
  pressure with induced conditions of hydration.
  Journal of Voice, 4, 142-151.
• Yiu , E. M. L., Chan, R. M. M. (2003). Effect
  of hydration and vocal rest on vocal fatigue in
  amateur karaoke singers. Journal of Voice, 17,
  216-227
• Yiu, E. M. L., Verdolini, K., Chow, L. P. Y.
  (2005). Electromyographic study of motor learning
  for a voice production task. Journal of Speech,
  Language, and Hearing Research, 48, 1254-1268.