Dr Joseph Stemple Vocal Function Exercises
Su Mcdowall
Voice quality can also be affected when psychological stressors lead to habitual, maladaptive aphonia or dysphonia. The resulting voice disorders are referred to as psychogenic voice disorders or psychogenic conversion aphonia/dysphonia (Stemple et al., 2010). These voice disorders are rare. Speech-language pathologists (SLPs) may refer individuals suspected of having a psychogenic voice disorder to other appropriate professionals (e.g., psychologist and/or psychiatrist) for diagnosis and may collaborate in subsequent behavioral treatment.
The complementary relationships among these organic, functional, and psychogenic influences ensure that many voice disorders will have contributions from more than one etiologic factor (Stemple et al., 2014; Verdolini et al., 2006). For example, vocal fold nodules may result from behavioral voice misuse (functional etiology). However, the voice misuse results in repeated trauma to the vocal folds, which may then lead to structural (organic) changes to the vocal fold tissue.
SLPs may also be involved in the assessment and treatment of disorders that affect the laryngeal mechanism (i.e., the aerodigestive tract) and that are not classified as voice disorders, such as the following:
Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth and/or gender identity. Voice disorders were reported to be significantly more prevalent in male children than in female children (Carding et al., 2006; Martins et al., 2015). In adulthood, however, prevalence was higher in female adults than in male adults, with a reported ratio of 1.5:1.0 (Martins et al., 2015; Roy et al., 2005).
Although female adults more frequently received diagnoses of dysphonia with no specific cause noted, male adults were more frequently diagnosed with chronic laryngitis (Cohen et al., 2012). Also, after the age of 40 years, male adults had higher prevalence rates of laryngeal cancer than female adults (Cohen et al., 2012).
Teachers were estimated to be two to three times more likely than the general population to develop a voice disorder (Martins et al., 2014). Certain factors, such as number of classes per week, noise generated outside of the school setting, and volume of voice while lecturing, were indicated to increase the risk of teachers developing a voice disorder (Byeon, 2019).
According to a claims-based study, almost 30% of dysphonia claims were individuals in the service industry. Those in the service industry were estimated to be 2.6 times more likely to develop benign laryngeal growth and individuals in the manufacturing industry were estimated to be 1.4 times more likely to develop malignant laryngeal growth compared to the general population (Benninger et al., 2017).
A disturbance in one of these subsystems or in the physiological balance among the systems may lead to or contribute to a voice disorder. Disruptions can be due to organic, functional, and/or psychogenic causes.
Making modifications to pitch without the guidance of a skilled service provider is not recommended and may result in vocal misuse. However, voice services may be provided to assist with appropriate pitch modifications.
Recognizing associations among these factors, along with patient history, may help in identifying the possible causes of the voice disorder. Even when an obvious cause is identified and treated, the voice problem may persist. For example, an upper respiratory infection could be the cause of the dysphonia, but poor or inefficient compensatory techniques may cause dysphonia to persist, even when the infection has been successfully treated.
Screening may be conducted if a voice disorder is suspected. It may be triggered by concerns from individuals, parents, teachers, or health care providers. When deviations from normal voice are detected during screening, further evaluation is warranted.
Rate of speech may be indirectly impacted by voice disorders. For instance, a patient with a voice disorder may deliberately slow rate of speech to compensate for a voice disorder and increase intelligibility. For reasons such as these, an SLP may consider assessment of rate of speech (e.g., via diadochokinetic rate assessment).
Physicians are the only professionals qualified and licensed to render medical diagnoses related to the identification of laryngeal pathology as it affects voice. Imaging should be viewed and interpreted by an otolaryngologist with training in this procedure when it is used for medical diagnostic purposes.
Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving. The ASHA Practice Portal page on Head and Neck Cancer addresses intervention aimed at acquisition of alaryngeal speech sufficient to allow for functional oral communication.
Voice use within different settings should be considered when determining vocal needs and establishing goals. For example, vocal needs within the workplace may be different from those within the community (e.g., home and social settings).
SLPs often team with otolaryngologists/laryngologists and other medical professionals (e.g., pulmonologists, gastroenterologists, neurologists, allergists, endocrinologists, and occupational medicine physicians) and, if appropriate, develop treatment plans to support the medical plan and to optimize outcomes. Collaboration with otolaryngologists/laryngologists is especially important to rule in or rule out underlying pathologies. SLPs can only diagnose functional abnormalities, and only otolaryngologists can diagnose organic pathologies (e.g., nodules, polyps, tumors).
Use of personal protective equipment (PPE) (i.e., face mask) can potentially cause increased strain on voice and perception of vocal effort (Ribeiro et al., 2020). Please see ASHA's Aerosol Generating Procedures and the Resources section below for further information.
There may be differences between treating voice disorders in adults and pediatrics due to differences in anatomy, etiology, and developmental level. According to Braden (2018), anatomical differences between pediatric and adult voice include the following:
The following subsections offer brief descriptions of general and specific treatments for individuals with voice disorders. They are organized under two categories: physiologic voice therapy (i.e., those treatments that directly modify the physiology of the vocal mechanism) and symptomatic voice therapy (i.e., those treatments aimed at modifying deviant vocal symptoms or perceptual voice components using a variety of facilitating techniques). The inclusion of any specific treatment approach does not imply endorsement by ASHA. For more information about treatment approaches and their use with various voice disorders, see Stemple et al. (2010).
Physiologic voice therapy programs strive to balance the three subsystems of voice production (respiration, phonation, and resonance) as opposed to working directly on isolated voice symptoms. Most physiologic approaches may be used with a variety of disorders that result in hyper- and hypofunctional vocal patterns. Below are some of the physiologic voice therapy programs, arranged in alphabetical order.
The accent method is designed to increase pulmonary output, improve glottic efficiency, reduce excessive muscular tension, and normalize the vibratory pattern during phonation. During therapy, the clinician may do one or more of the following tasks (Kotby et al., 1993; Malki et al., 2008):
CTT focuses exclusively on voice awareness and production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. Grounded in the tenets of motor learning, CTT strives to guide patients in achieving balanced phonation through clinician reinforcement, imitation and modeling in conversational speech. CTT incorporates six interchangeable components (Gartner-Schmidt et al., 2016; Gillespie et al., 2019), as follows:
EMST improves respiratory strength during phonation. Increase in maximum expiratory pressure can be trained with specific calibrated exercises over time, thus improving the relationship between respiration, phonation, and resonance. EMST uses an external device to mechanically overload the expiratory muscles. The device has a one-way, spring-loaded valve that blocks the flow of air until the targeted expiratory pressure is produced. The device can be calibrated to increase or decrease physiologic load on the targeted muscles (Pitts et al., 2009).
Manual circumlaryngeal techniques are intended to reduce musculoskeletal tension and hyperfunction by re-posturing the larynx during phonation. There are three main manual laryngeal re-posturing techniques, as follows:
Applying these maneuvers during vocalization allows the individual to hear resulting changes in voice quality (Andrews, 2006; Roy et al., 1997). Care is taken when employing these techniques, as some patients report discomfort.
Symptomatic voice therapy focuses on the modification of vocal symptoms or perceptual voice components. Symptomatic voice therapy assumes voice improvement through direct symptom modification using a variety of voice facilitating techniques (Boone et al., 2010) that are either direct or indirect. Symptoms to be addressed may include
Auditory masking is used in cases of functional aphonia/dysphonia and often results in changed or normal phonation. Individuals are instructed to talk or read passages aloud while wearing headphones with masking noise input. Using a loud noise background, the individual often produces voice at increased volume (Lombard effect) that can be recorded and used later in treatment as a comparison (e.g., Adams & Lang, 1992; Brumm & Zollinger, 2011).
Biofeedback is the concept that self-control of physiologic functions is possible given external monitoring of internal bodily state. Biofeedback may be kinesthetic, auditory, or visual and is intended to provide clear and reliable information in response to alterations in voice production. Thus, patients may make real-time adjustments regarding vocal pitch, loudness, quality, and effort. Ideally, biofeedback helps increase awareness of physical sensations with respect to respiration, body position, and vibratory sensation. This awareness may help individuals understand physiological processes when generating voice.
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