Symptomatic Voice Therapy

Major focus area

Speech Therapy -> Voice

Short description

Symptomatic voice therapy is an approach where the SLP identifies a voice therapy facilitating technique which, when used by a particular patient, enables him/her to easily produce a good voice. The focus of symptomatic voice therapy is direct modification of specific vocal symptoms: pitch, loudness, resonance, or respiration. Facilitating techniques include but are not limited to: chewing exercises, circumlaryngeal massage, ear training, elimination of abuses, establishing new pitch, respiration training, target voice models, voice rest, and yawn-sign approach (Stemple, et al., 2000; Drudge & Philips 1976; Russell 2010; Pannbacker 1998).

Long description

Symptomatic voice therapy is an approach where the SLP identifies a voice therapy facilitating technique which, when used by a particular patient, enables him/her to easily produce a good voice. The focus of symptomatic voice therapy is direct modification of specific vocal symptoms: pitch, loudness, resonance, or respiration. Facilitating techniques include but are not limited to: chewing exercises, circumlaryngeal massage, elimination of abuses, establishing new pitch, relaxation, respiration training, and yawn-sign approach (Stemple, et al., 2000; Drudge & Philips 1976; Russell 2010; Pannbacker 1998).

Chewing Exercises: Better vocal fold approximation and optimum muscular adjustment of the vocal folds are specific physiologic improvements that result from this technique. The muscular adjustments that are facilitated by the chewing approach usually result not only in a reduction of hard glottal attack but also in simultaneous improvements in loudness, pitch, and vocal quality.

Method: Advise the patient that you understand that he or she may feel awkward or silly when first trying the technique but that the technique is, nonetheless, very useful. Have the patient sit facing a mirror. Ask the patient to pretend he or she is chewing a chunk of cotton candy. Tell the patient to chew in a relaxed, open-mouthed, exaggerated manner and to pretend to move the cotton candy around in the mouth with exaggerated movements of the tongue. Do not rush this stage of the technique and do not proceed until the patient is capable of producing a natural and exaggerated manner of chewing. While the patient is engaged in exaggerated chewing, ask him or her to start phonating softly. It may be necessary to model this for the patient. After the patient has become adept at using a relaxed method of chewing and phonating, ask him or her to inhale deeply and to chew and phonate the outgoing air stream. Encourage the patient to let the vocal pitch vary erratically. It is important for the patient to practice chewing and phonating until a relaxed voice is produced. Next, the patient should be told to simultaneously chew, phonate, and articulate brief two- or three-word combinations that begin with vowels (e.g., "I am in", "I am over", "I am up"). When the patient begins to demonstrate relaxed phonation with short phrases, additional stimulus materials should be introduced. Practice drills should progress to include chewing sentences at various pitch and loudness levels. Daily practice with the chewing technique should continue until the patient begins to demonstrate diminished laryngeal dysfunction in conversational speech.

Circumlaryngeal massage: A "hands-on" approach in which patients are trained to massage their neck area while observing different changes in their voice quality. The purpose of this technique is to eliminate pain while speaking, relax muscles in the laryngeal area, and reduce tension in the upper body – all helping to decrease pain and allowing the larynx to relax into a more comfortable position (Russell, 2010). Indications: It is used in patients who report neck tension, upper body tension, stiffness, or tenderness along with vocal symptoms. It is also used for muscle tension dysphonia (functional dysphonia).

Elimination of abuses, hard glottal attach: Patient is taught to produce a soft glottal attach or an easy onset by initiating phonation with the sound /h/, utilizing vowels, vowel-consonant combinations, and progressing through words, phrases, paragraph reading, and conversation. The /h/ is extinguished as soon as possible in the process.

Establishing new pitch: There is great controversy among speech pathologists regarding whether a patient's vocal pitch should be changed when the lowered vocal pitch is due to increased loading of the vocal folds by mass lesions that are secondary to vocal abase. Often, a patient's vocal pitch is not actually lowered, but is perceived as lowered because of alterations in loudness, vocal effort, and vocal quality Unless a patient is phonating in the range of vocal fry or is phonating at a pitch that makes gender identification difficult, it is probably best not to work directly on changing vocal pitch. Raising the patient's habitual pitch level can be very risky in patients with lesions due to vocal abuse. If the habitual pitch is accidentally raised too high, laryngeal tension will be increased at a time when increased tension could further irritate already sensitive vocal folds. If, after extensive consideration, it is deemed necessary to use techniques to normalize vocal pitch, the following procedures should be used:

Instruments:
1. A pitch pipe can be used to provide a pitch for the patient to model.
2. Specialized instrumentation such as a Visi-Pitch, Tunemaster III, or a Tonar II can be used to monitor the patient's pitch level.

Method:
1. The patient should be instructed to attempt to sustain the vowel /a/ at the optimal pitch level.
2. As the patient becomes more skilled at pitch control, a progression from other vowels to single words phrases, sentences, and monologue should be used until the new vocal pitch level becomes habitual.

Respiration training: Therapy approach for breath support focuses on coordinating breathing with vocalization.

Indications: Talking with decreased breath support. Professional speakers who may require greater breath support during presentation than during normal conversational speech. Patients with excessive cough, Paradoxical vocal fold motion disorder, vocal spasm or laryngeal irritation.

Method:
1. Ear training: Ask the patient to read a paragraph and tape-record sample of his/her voice and use it to monitor the patient’s respiration strategy
2. Ask the patient to say as many numbers as possible on one normal expiration and to stop before any force or strain is evident.
3. Give the patient a paragraph with phrase markers, and ask the patient to read it aloud with normal inhalation occurring at each phrase marker.
4. The discussion between the clinician and the patient should be audio-taped. Then, monitor the tape for inappropriate breathing patterns.
5. The patient is asked to monitor his or her voice daily during non-therapy conversational times.

Yawn-sigh technique: The yawn serves to expand the pharynx and to stretch and then relax the extrinsic laryngeal muscles, thus lowering the larynx in the neck to a more neutral position and permit a more forward placement of the tongue in the oral cavity.

Method: Patients are asked to initiate the first half of a yawn behavior. The subsequent sigh should then be more relaxed with less tension noted in the phonation of the tone. From the sigh phonation, the patient is taught to appreciate the sensation of laryngeal relaxation. The yawn-sigh technique is then paired with vowels and then gradually expanded into words, phrases, paragraph readings, and conversational speech.