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Voice Therapy

Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving. A future ASHA Practice Portal page on head and neck cancer will address intervention aimed at the acquisition of alaryngeal speech sufficient to allow for functional oral communication.

Consistent with the WHO (2001) framework, intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect voice production;
  • facilitate the individual’s activities and participation by assisting the person in acquiring new communication skills and strategies; and
  • modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation, and to provide appropriate accommodations and other supports, as well as training in how to use them.

Collaborating With Other Professionals

In the case of medically related voice disorders (e.g., vocal polyps, vocal cysts, spasmodic dysphonia), SLPs often team with otolaryngologists 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.

Some individuals develop voice disorders in the absence of structural pathology (e.g., functional aphonia, muscle tension dysphonia, and mutational/functional falsetto) and may benefit from support in addition to what can be provided by the SLP. Counseling, direct manipulation of the voice, and use of interview questions can be used to probe possible factors contributing to the voice problem. SLPs refer the individual to appropriate health care professionals (e.g., psychologists) to address issues outside the SLP’s scope of practice (ASHA, 2016b). SLPs often engage in collaborative approaches throughout the course of assessment and subsequent treatment.

See the ASHA resources on collaboration and teaming and interprofessional education/interprofessional practice (IPE/IPP).

Treatment Approaches

Norms within different settings are considered when determining vocal needs and establishing goals. For example, vocal norms and needs within the workplace may be different from those within the community (e.g., home and social settings).

SLPs often incorporate aspects of more than one therapeutic approach to developing a treatment plan.

Approaches can be direct or indirect.

  • Direct approaches focus on manipulating the voice-producing mechanisms (e.g., phonation, respiration, and musculoskeletal function) in order to modify vocal behaviors and establishing healthy voice production (Colton & Casper, 1996; Stemple, 2000).
  • Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs (Roy, et al., 2001; Thomas & Stemple, 2007). Indirect approaches include the following two components:
    • Patient education—discussing normal physiology of voice production and the impact of voice disorders on function; providing information about the impact of vocal misuse and strategies for maintaining vocal health (vocal hygiene)
    • Counseling—identifying and implementing strategies such as stress management to modify psychosocial factors that negatively affect vocal health (Van Stan, Roy, Awan, Stemple, & Hillman, 2015)

A therapeutic plan typically involves the use of at least one of the direct approaches and one or more of the indirect approaches based on the patient’s condition and goals. Some clinicians concentrate on directly modifying the specific symptoms of the inappropriate voice, whereas others take a more holistic approach, with the goal of balancing the physiologic subsystems of voice production—respiration, phonation, and resonance.

Many clinicians begin by

  • identifying behaviors that are contributing to the voice problems, including unhealthy vocal hygiene practices (e.g., shouting, talking loudly over noise, coughing, throat clearing, and poor hydration) and
  • implementing healthy vocal hygiene practices (e.g., drinking plenty of water and talking at a moderate volume) and practices to reduce vocally traumatic behaviors (e.g., voice conservation).

Treatment Options

The following subsections offer brief descriptions of general and specific treatments for individuals with voice disorders. They are organized under two broad 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). This list of treatment options is not exhaustive, and 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).

Treatment selection depends on the type and severity of the disorder and the communication needs of the individual. Clinicians are sensitive to cultural, linguistic, and individual variables when selecting appropriate treatment approaches. As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Physiologic Voice Therapy

Physiologic voice therapy is inherently a holistic approach to treatment. 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.

Accent Method

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:

  • Facilitate abdominal breathing by initially placing the patient in a recumbent position.
  • Use rhythmic vocal play with models of accented phonation patterns, which the patient then imitates.
  • Transfer rhythms to articulated speech, initially being given a model and eventually progressing through reading, monologues, and conversational speech.

(See, e.g., Kotby, Shiromoto, & Hirano, 1993; Malki, Nasser, Hassan, & Farahat, 2008.)

Cup Bubble/Lax Vox

Cup bubble, also known as Lax Vox, is an aerodynamic building task aimed at improving the ability to sustain phonation while speaking. It is done by having a patient blow air initially into a cup of water without a voice. Voicing can be added for subsequent trials, and in time, the pitch can be altered across and within trials. Eventually, the cup is removed during voicing, and the phonation continues. These exercises are thought to widen the vocal tract during phonation and reduce tension in the vocal folds. Biofeedback increases the individual’s awareness of his or her healthy voice production (e.g., Denizoglu & Sihvo, 2010; Simberg & Laine, 2007).

Expiratory Muscle Strength Training (EMST)

Expiratory muscle strength training (EMST) improves respiratory strength during phonation. Increase in maximum expiratory pressure (MEP) 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 the physiologic load on the targeted muscles (Pitts et al., 2009).

Lee Silverman Voice Treatment (LSVT®)

Lee Silverman Voice Treatment (LSVT®; Ramig, Bonitati, Lemke, & Horii, 1994) was initially developed for patients with Parkinson disease but can also be used with other populations. It is designed to help maximize phonatory and respiratory function using a set of simple tasks. Individuals are instructed to produce a loud voice with maximum effort and to monitor the loudness of their voices while speaking. The effort that is involved generates improved respiratory support, laryngeal muscle activity, articulation, and even facial expression and animation. Using a sound-level meter, visual biofeedback is provided to demonstrate the effort necessary to increase loudness. LSVT is provided by clinicians who are specifically trained and certified in the administration of this technique.

Five basic principles are followed in LSVT:

  • Individuals should “think loud/think shout.”
  • Speech effort must be high.
  • Treatment must be intensive.
  • Patients must recalibrate their loudness level.
  • Improvements are quantified over time.

Manual Circumlaryngeal Techniques

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:

  • Push-back maneuver—place a forefinger on thyroid cartilage and push back to change the shape of the glottis.
  • Pull-down maneuver—place thumb and forefinger in the thyrohyoid space and pull the larynx downward.
  • Medial compression and downward traction—place thumb and forefinger in the thyrohyoid space, and apply medial compression.

Applying these maneuvers during vocalization allows the individual to hear resulting changes in voice quality (Andrews, 2006; Roy, Bless, Heisey, & Ford, 1997). Care is taken when employing these techniques, as some patients report discomfort.

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