Voice Therapy

Author Credentials 

Judith M. Wingate, PhD
Jacksonville University
2800 University Blvd N
Jacksonville, FL 32211
Email: jwingat2@ju.edu

Christine M. Sapienza, PhD
Jacksonville University
2800 University Blvd N
Jacksonville, FL 32211
Email: csapien@ju.edu

Module Summary

Voice problems are frequently encountered in an otolaryngology practice, with professional speakers representing a large percentage of the caseload. A recommended treatment method is voice therapy. A certified speech pathologist with special training in voice disorders is the best trained professional to complete voice therapy. Many approaches to voice therapy are available. Optimal therapy design fits an individual patient’s needs. Expected outcomes include reductions in laryngeal irritation, decreased use of compensatory strategies, improved dynamic range or pitch and loudness, reduced vocal fatigue, and improved endurance for voicing.

Module Learning Objectives 
  1. Identify the basic principles of voice therapy.
  2. Describe the role of voice therapy in a model of vocal recovery.
  3. State the appropriate referral process to voice rehabilitation specialists.
  4. Describe the relationship between the evaluation and treatment processes involved in voice care.

Incidence

Learning Objectives 
  1. Identify the incidence of voice disorders in the general population of the United States.
  2. Identify the incidence of voice disorders in professional voice users.
  3. Identify the incidence of voice disorders in teachers.
  4. Identify the incidence of voice disorders in children.
References 
  1. Araujo-Pernambuco L, Espelt A, Balata P, Lima K. Prevalence of voice disorders in the elderly: a systematic review of population-based studies. European Archive of Oto Rhino Laryngol. 2015; 272: 2601-2609. [EBM Level 1]
  2. Bhattacharyya N. The prevalence of pediatric voice and swallowing problems in the United States. Laryngoscope. 2015; 125:746-50. [EBM Level 4]
  3. Cutiva C, Vogel I, Burdorf, A. Voice disorders in teachers and their associations with work-related factors: a systematic review. J Comm Dis. 2013; 46:143-155. [EBM Level 1]
  4. Duff M, Proctor A, Yairi E. Prevalence of voice disorders in African American and European American preschoolers. J Voice. 2004; 18: 348-353. [EBM Level 4]
  5. Hartley N, Breen E, Thibeault S. Epidemiology of vocal health in young adults attending college in the United States. J Speech Lang Hear Res. 2016; 59:973-993.[EBM Level 3]
  6. Kallvik E, Lindstrom E, Homqvist S, Lindman J, Simberg S. Prevalence of hoarseness in school-aged children. J Voice. 2015; 29:260.e1-19. [EBM Level 3]
  7. Roy N, Merrill R, Thibeault S, Parsa R, Gray S, Smith E. Prevalence of Voice Disorders in teachers and the general population. J Speech Lang Hear Res. 2004; 47: 281-29 [EBM Level 4]
  8. Roy N, Merrill R, Gray S, Smith, E. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005; 115:1988-1995 [EMB Level 4]

Patient Evaluation

Learning Objectives 
  1. Review the details of the laryngoscopic examination and the use of laryngostroboscopy for diagnosis of laryngeal disorders.
  2. Review the candidates (lesion types) for voice therapy.
  3. Identify the types of postsurgical patients who would benefit from voice therapy.
  4. Understand that patients needing voice therapy should be assessed by a speech pathologist with special expertise in treating the voice.
    1. Identify the minimum standards for a practicing speech pathologist/voice specialist.
    2. Diagram the relationship between the otolaryngologist and voice specialist.
    3. Identify the resource for locating a voice specialist for referral.
  5. Discuss at least five distinct etiologic factors that may be associated with a patient’s voice problem.
    1. Describe the deviant voice characteristics of functional voice disorders.
    2. Describe the deviant voice characteristics of organic voice disorders.
    3. Describe the deviant voice characteristics of neurological voice disorders.
  6. Review the relationship between vocal use, vocal demand, and the occurrence of voice disorders.
  7. Identify who should be involved with evaluation of a pediatric voice disorder.
  8. Diagram the perceptual, acoustic, and aerodynamic tasks that are relevant to include in the evaluation of a voice disorder.
  9. Identify two voice quality indexes that are used to determine patient perception of the voice disorder and functional impact.
References 
  1. Demerci S, Tuzuner A, et al. Rigid or flexible laryngoscope: the preference of children. Int J Ped Otorhinolarngol. 2015;79:1330-1332 [EBM Level 3]
  2. Hanschmann H, Lohmann A, Berger R. Comparison of subjective assessment of voice disorders and objective voice measurement. Folia Phoniatr Logop. 2011;63:83-7. [EMB Level 4]
  3. Hengen J, Peterson M, McAllister A. Patient characteristics and intervention effect as measured by Voice Handicap Index. Logoped Phoniatr Vocol. 2017;31:262.e13-262.e22 [EBM Level 2]
  4. Kelchner L, Brehm S, de Alarcon A, Weinrich B. Update on pediatric voice and airway disorders: assessment and care. Curr Opin Otolaryngol Head Neck Surg. 2012;20:160-164. [EMB Level 5]
  5. Merati, AL, Keppel K, Braun NM, Blumin JH, Kerschner JE. Pediatric voice-related quality of life: findings in healthy children and in common laryngeal disorders. Annals Otol Rhinol Laryngol. 2008;117:259-62.
  6. Romak JJ, Orbelo DM, Maraqos NE, Ekbom DC. Correlation of the Voice Handicap Index-10 and Voice-Related Qualify of Life (V-RGOL) in patients with dysphonia. J Voice. 2014;28:237-40. [EBM Level 3]
  7. Roy N, Barkmeier-Kraemer J, Eadie T, Sivasankar MP, Mehta D, Paul D, Hillman R. Evidence-based clinical voice assessment: a systematic review. Am J Speech Language Pathology. 2013;22:212-226. [EBM Level 1]
  8. Shrivastav R & Wingate J. Perceptual attributes and assessment of the singer’s voice. In Benninger MS, Murry T, Johns MM (eds). The performer’s voice. 2016;179-192. [EBM Level 5]

Treatment

Learning Objectives 
  1. List the goals of voice therapy.
    1. Discuss the benefits of voice therapy.
    2. Discuss the patient expectations of voice therapy.
    3. Discuss the role of patient compliance with regard to the success or failure of therapy.
  2. Review the many approaches to therapy available for voice problems.
    1. Identify the most common types of voice therapy utilized in practice.
      1. Define hygienic voice therapy.
      2. Define symptomatic voice therapy.
      3. Define psychogenic voice therapy.
      4. Define physiologic voice therapy.
        1. Review specifically vocal function exercises as a prescribed vocal exercise program.
        2. Review specifically resonant voice therapy.
        3. Review specifically the Lee Silverman Voice Therapy (LSVT) as a program designed for patients with Parkinson’s disease.
        4. Review specifically semi-occluded vocal tract exercises.
  3. Review respiratory muscle training as a new modality for training the muscles of respiration.
  4. Recognize that elements of all types of therapy may be combined to best fit patient’s’ needs.
  5. Describe how age, cognitive level, and linguistic level of the child needs to be considered in designing a voice therapy program.
References 
  1. Abbott, KV. Some guiding principles in emerging models of voice therapy for children. Seminars in Speech & Language. 2013;34:80-93. [EBM Level 5]
  2. Baker S, Davenport P, Sapienza C. Examination of strength Training and Detraining Effects in Expiratory Muscles. J Speech Lang Hearing Res. 2005;48:1235-1333.[EBM Level 2]
  3. Baker S, Sapienza C, Davenport P, et al. Inspiratory muscle strength training: a case of bilateral abductor vocal fold paralysis. J Voice. 2003;17:384-94. [EBM Level 4]
  4. Chen SH, Hsiao TY, Hsiao LC, Chung YM, Chiang SC. Outcome of resonant voice therapy for female teachers with voice disorders: perceptual, physiological, acoustic, aerodynamic, and functional measurements. J Voice. 2007;21:415-425. [EBM Level 2]
  5. El Sharkawi A, Ramig L, Logemann JA, et al. Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study. J Neurol Neurosurg Psychiatry. 2002;72:31-36. [EBM Level 4]
  6. Franca, MC, Bass-Ringdahl S. A clinical demonstration of the application of audiovisual biofeedback in the treatment of puberphonia. Intl J Pediatric Otorhinolarynogolgoy. 2015;79(6):912-920. [EBM Level 5]
  7. Gartner-Schmidt J, Gherson S, Hapner E, Muckala J, Roth D, Schneider S, Gillispie A. The development of a conversational training therapy: a concept paper. J Voice. 2016;40(5):563-573. [EBM Level 5]
  8. Gartner-Schmidt J, Roth DF, Zullo TG, Rosen CA. Quantifying component parts of indirect and direct voice therapy related to different voice disorders. J Voice. 2013; 27:210-216. [EBM Level 4]
  9. Guzman M, Castro C, Testart A, Munoz D, Gerhard J. Laryngeal and pharyngeal activity during semioccluded vocal tract postures in subjects diagnosed with hyperfunctional dysphonia. J Voice. 2013;27:709-16. [EBM Level 4]
  10. Hartley N, Braden M, Thibeault SL. Practice patterns of speech-language pathologists in pediatric vocal health. Am J Speech Lang Path. 2017;26:281-300. [EBM Level 3]
  11. Hoffman-Ruddy B, Lehman J, Crandell C, et al. Laryngostroboscopic, acoustic, and environmental characteristics of high-risk vocal performers. J Voice. 2001;15:543-52. [EBM Level 3]
  12. Hooper CR. Treatment of voice disorders in children. Lang Speech Hear Serv Sch. 2004;25:320-326. [EMB Level 5]
  13. John A, Enderby P, Hughes A. Comparing outcomes of voice therapy: a benchmarking study using the therapy outcome measure. J Voice. 2005;19:114-123.[EBM Level 4]
  14. Kaneko M, Hirano S, Tateya I, Kishimoto Y, Hiwatashi N, Fujiu-Kurachi M, Ito J. Multidimensional analysis on the effect of vocal function exercises on aged vocal fold atrophy. J Voice. 2015;29:638-644. [EBM Level 2]
  15. Kapsner-Smith MR, Hunter EJ, Kirkham K, Cox K, Titze IR. A randomized controlled trial of two semi-occluded vocal tract voice therapy protocols. J Speech Language Hearing Res. 2015;58:535-549. [EBM Level 1]
  16. Kim J, Sapienza C. Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial. J Rehab Res Dev. 2005;42:211-224. [EBM Level 5]
  17. King DL, Hoffman-Ruddy B. A model for treating voice disorders in school-age children within a video gaming environment. J Voice. 2012:26(5):656-663. [EBM Level 4]
  18. Laciuga H, Rosenbek J, Davenport P, Sapienza C. Functional outcomes associated with expiratory muscle strength training: narrative review. JRRD. 2014;51:535-546 [EBM Level 1]
  19. Lee E, Son Y. Muscle tension dyshonia in children; voice characteristics and outcome of voice therapy. Inter J Pediatric Otorhinolayrngol. 2005;69:9-917. [EBM Level 3]
  20. Portone C, Johns MM, Hapner ER. A review of patient adherence to the recommendation for voice therapy. J Voice. 2008;22:192-196. {EBM Level 3]
  21. Ramig L, Sapir S, Fox C, et al. Changes in vocal loudness following intensive voice treatment (LSVT) in individuals with Parkinson’s disease: a comparison with untreated patients and normal age-matched controls. Mov Disord. 2001;16:79-83. [EBM Level 2]
  22. Sapienza C, Brown J, Martin D, et al. Inspiratory pressure threshold training for glottal airway limitation in laryngeal papilloma. J Voice. 1999;13:382-88. [EBM Level 4]
  23. Sauder C, Roy N, Tanner K, Houtz DR, Smith ME. Vocal function exercises for presbylaryngis; a multidimensional assessment of treatment outcomes. Ann Otol Rhinol Laryngol. 2010;119:460-7. [EBM Level 4]
  24. Smith BE, Kempster GB, Sims HS. Patient factors related to voice therapy attendance and outcomes. J Voice. 2010;24:694-701.[EBM Level 3]
  25. Steen IN, MacKenzie K, Carding PN, Webb A, Deary IJ, Wilson JA. Optimising outcome assessment of voice interventions, II. Sensitivity to change of self reported and observer-rated measures. J Laryngology and Otology. 2008;122:46-51. [EBM Level 2]
  26. Teixeira LC, Behlau M. Comparison between vocal function exercises and voice amplification. J Voice. 2015;29(6):718-726. [EBM Level 2]
  27. Van Lierde KM, Claeys S, DeBodt M, Van Cauwenberge P. Long-term outcome of hyperfunctional voice disorders based on a multiparameter approach. J Voice. 2007;179-188. [EBM Level 4]
  28. Wingate J, Brown WS, Davenport P, Shrivastav R, and Sapienza C. Treatment outcomes for professional voice users. J Voice. 2007;21(4):433-449. [EBM Level 2]
  29. Yiu EM, Lo MC, Barrett EA. A systematic review of resonant voice therapy. Int J Speech Lang Pathol. 2017;19:17-29. [EBM Level 1]
  30. Ziegler A, Verdolini Abbott K, Johns M, Klein A, Hapner E. Preliminary data on two voice therapy interventions in the treatment of presbyphonia. Laryngoscope. 2014;124:1869-1876.

Complications

Learning Objectives 

Describe at least two complications that may result from the voice therapy approaches applicable in these situations.

References 
  1. Bovo R, Trevisi P, Emanuelli E, Martini A. Voice amplification for primary school teachers with voice disorders: a randomized clinical trial. Int J Occup Med Environ Health. 2013;26:363- 372. [EBM Level 1]
  2. Gartner-Schmidt J, Rosen C. Treatment Success for Age-related vocal fold atrophy. Laryngoscope. 2011;121:585-589. [EBM Level 4]
  3. Holmberg E, Hillman RE, Hammarberg B, Sodersten M, Doyle P. Efficacy of a behaviorally based voice treatment protocol for vocal nodules. J Voice. 2001;15:395-412. [EBM Level 2]
  4. Mau T, Jacobson BH, Garrett CG. Factors associated with voice therapy outcomes in the treatment of presbyphonia. Laryngoscope. 2010;120:1181-7. [EBM Level 3]
  5. Zeigler A, Gillespie AI, Abbott KV. Behavioral treatment of voice disorders in teachers. Folia Phoniatr Logop. 2010;62:9-23. [EBM Level 2]

Review

Review Questions 
  1. Name at least five professions in which people are most likely to exhibit voice disorders.
  2. Describe the purpose of voice therapy in a model of vocal recovery.
  3. Describe the referral process to a voice rehabilitation specialist.
  4. Describe two approaches to voice therapy.
Resources 

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  1. Annual Meeting Webcast (AMW):