Final revisions to

Integration of Singing into Voice Therapy

Martin L. Spencer, M.A. CCC-SLP               August 26, 2009 (Revision)

Dick,

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. . . interdisciplinary management of speakers and singers.”1

SINGER PATHOLOGY (possible new sub-heading)

The author has observed that typical contributing factors to pathologic occurrence in singers include:

Excessive predominance of high-pitched chest register phonation. Consistent mismatch of tessitura, fach, or voice part with innate physiologic

capacity. Sustained excessive loudness or voce piena, and lack of awareness to "mark" or

rest when vocally fatigued. Lack of vocal warm-up before rehearsals or performances. Insufficient amplification or feedback monitoring in enhanced acoustic

environments. Poor vocal hygiene via factors such as smoking, excessive alcohol intake,

excessive social voice usage, physical deconditioning, poor hydration, and unattended reflux or allergy control. 

Ignoring early warning signals of vocal injury: (moved section)1) loss of phonatory ease thereby incurring compensatory strain; 2) delayed or disrupted tonal onset;3) diminished breath control;  4) loss of intensity, or inability to vary intensity;5) curtailment of pitch range, loss of register, or atypical change in voice

category;6) loss of smooth passaggio transition;7) persistently undesirable quality such as voice breaks, burring or

diplophonia;

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8) Atypical delay of vocal recovery after performance, or excessive warm-up times.

Increased awareness and correction of these pathologic triggers is a basic component of voice rehabilitation. Voice therapy also typically utilizes regulatory programs such as Vocal Function Exercises (Stemple), Resonant Voice Therapy variants (Verdolini-Madsen) or Hybrid Voice therapy (Spencer). 2 This article posits that singing-based exercise will be is of additional rehabilitative value. Its range of repair includes behavioral voice dysfunction (muscle tension  dysphonia), neuropathy, atrophy, lesioning resolution, and phonosurgical recovery.3 4 5

In the sense that singing heightens speech, singing also heightens voice therapy. Rationale for the inclusion of singing into voice therapy may touch upon numerous bases:

Optimized alignment of respiration, phonation and resonance via tonal sustain. Accurate targeting of pitch zones of therapeutic interest including register

exploration and passaggio development. Conditioning of extrinsic and intrinsic laryngeal musculature. Systematic sustain of vocal fold oscillation may decrease stiffness associated with

scarring and fibrosis, and may encourage optimal phenotypic expression of new vocal fold tissue.6 7 (This new hypothesis provides significant support for therapy after phonosurgery, and therapeutic dissolution of fibrous lesions such as singer’s nodules.)

Musical notation provides objective documentation of changing vocal capacity across treatment; a desirable feature within a contemporary professional climate of “evidence-based practice.”

Exercise variations are limitless in number, fun, and can be tailored to changing phases of recovery.

ORIGINS OF VOICE THERAPY

Speech pathology is a recent profession. The earliest related 20th century writings primarily concern identification and treatment of stuttering and lisping . . . and Freud figured prominently.8  In 1939, Charles Van Riper produced a seminal text in which voice disorders were realized as a distinct diagnostic classification.9 The modern era of voice rehabilitation started in the 1930s and 1940s through humanists such as Emil Froschels, Nathan Weiss, Friedrich Brodnitz, and G. Paul Moore. There were several voice therapy texts in the 1960s and 1970s but the one to really take hold was by Daniel Boone (the 8th edition will be released in 2009)10 "Clinical voice pathology" coalesced as a more distinct branch of speech pathology in the early 1980's, spurred by the practical application of stroboscopy as a diagnostic tool and the concomitant identification of the uniqueness of lamina propria anatomy and physiology by figures such as Minoru Hirano and Diane Bless.

As clinical voice pathology has gained a significant threshold only in the last thirty years, its corpus has developed via globalized scientific method, thereby constraining subjective influence and seeking to consolidate theory.

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EXERCISE OVERVIEW

It is best to model each exercise prior to patient iteration; the better the model, the greater the expectation for positive change. Breathe deeply and freely before each task, a patient will instinctively mimic this preparation. The author regards each breath as an opportunity for calmed inspiration and structured preparation for vocalization. (Note to singing teachers: do not permit the metronomic demands of rapid 4/4 exercises to habituate tensions associated with “catch breaths” or “breath stacking.”)

Each exercise should be sequentially transposed upwards or downwards by semi-tones so that a completed series taxes a patient’s usable compass. The gist of such therapy is to preserve vocal quality as pitch borders are gently extended upwards and downwards. Start each series with a lower mid-range pitch that elicits optimal voicing characteristics. Make notes of pitch versus quality correlations when either parameter is challenged by the pathology. (Treatment notes are used throughout medicine to document patient condition upon each encounter.)

Unison humming may be used to introduce tasks and dispel patient self-consciousness. Once confidence in exercise shaping is established, gradually “open” the sound to become more acoustically assertive (e.g., /mū/ => /mō/ => /mā/.) Gradually withdraw support until the patient is soloing. Make sure that you are satisfied with quality before advancing in task difficulty; there is little point of voice exploration without a stable base.

Loudness levels depend on the particular treatment agenda: soft for the rehabilitation of hyperfunctional disorders such as muscle tension

dysphonia or “nodules” moderately loud for hypophonias such as presbylaryngis (aging voice) or

Parkinsonism.Increased loudness should primarily be regulated primarily with trans-glottal airflow

rather than hyperadductive pinching of the TVFs. Each voice possesses an upper pitch limit. Exploring this limit, or adjacent range,

may be counterproductive to rehabilitation. Although brief forays are useful for diagnostic or prognostic value, more sustained habilitation is best left to a singing specialist.

An exercise should not promote significant strain if patient capacity has been accurately assessed. Singing exercises should be discontinued if any sensation beyond mild discomfort is experienced . . . with the caveat of non-productive coughing; this adverse reaction has not been remarked upon in the literature but appears to be an inhibitory myogenic feedback mechanism which ceases once a basal threshold of conditioning has been reached.

Once rehabilitation objectives in singers are consolidated, the author turns to traditional scale/arpeggio patterns in tempo rubato which enable slow motion detailing of onset, passaggio transition, and high end muscular release. Ballads or aria snippets are then utilized as wordless vocalizes before the final challenge of conveying sentiment through lyrics. At this point it is the singer’s best interest for clinician and singing teacher to engage in transitional dialogue.

Registration

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Many untutored singers are not familiar with concepts of registration. It is routine for these patients to imagine that they have reached a (conservative) pitch ceiling, when a whole upper range (or less commonly lower range) is obtainable. Vocal fold contact area and wave propagation change with register transitions; ideal objectives when trying to dissipate TVF stiffness or edema.11 12

Impairment of smooth register transfer, or register absence, are cardinal symptoms of pathologic presence. Conversely, return of a functional passaggio or reactivated registers are significant indicators of vocal recovery. It is not necessary to work with equalized register transfer in a non-singing population, however many patients profit from an awareness of register zones. It is common for untutored patients to damp register transfer as they perceive loss of vocal control as undesirable.

Elicitation of different registrations for the same speaking range pitch may be valuable. For example, C4 in many females may be produced in chest or mid registers. The author has observed variations of muscle tension dysphonia which involve rapid switching between registers, or loss of ability to lock into chest register during speech.

Register coordination may be subtle for patients to distinguish, and obvious to the clinician with a singer's ear. Increasing patient awareness of registration may significantly impact quality, intelligibility, strain, and vocal fatigue.    Speaking pitch 

Excessively lowered speaking pitch, yielding a raspy or creaky quality, typically falls below the frequency threshold required for periodic TVF oscillation.11 A surprisingly quick fix to a large number of speaking voice complaints is to simply raise spoken tessitura by several tones and increase transglottal airflow. These adjustments will often stabilize undesirable perturbation (think of raising the idle speed in an engine to smooth erratic combustion). This method is of significant value in treating a common form of muscle tension dysphonia demonstrated in adult females who habitually speak in an excessively low alto range. Increasing patient awareness of pitch and intensity modifications that facilitate more effective communication accelerates therapy objectives.  THE EXERCISES 

The following text outlines a rehabilitative method which places singing exercises within the context of voice therapy.   A. Sustained tone 

This exercise uses sustained speaking range pitches to habituate consistent airflow, tone, and intensity (Figure 1a). Pathologic Voices affected by lesion presence frequently demonstrate decreasing quality proportionate to rising pitch; increased frequency accentuates vibratory irregularity. Functional range may be limited to less than an octave in moderate cases and a perfect fifth in more severe cases. There is significantly less margin of error for optimal quality within these restrictions so pitch targets for therapy must be carefully considered.

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Establish a range of acceptable quality through probes and choose a base pitch as the subject for variation. Each pitch is sustained as a hum which is sensed through buzzing resonance localized above the upper lip. Progressively release the nasalance through opening vowels such as /mū/, /mō/, and /mā/. The logic of this sequence is that acoustic impedance and aerodynamic inertance induced by lip closure may stabilize phonation.13 Consequently, an open-most /mā/ could be regarded as the series endpoint which is most prone to perturbation, a consistently observed pattern in clinical practice.     

The syllabification process  continues through an expanding program such as: Continuant-laden monotone chants in which the nasals are slowly and deliberately

accented; “mmanny-menn-inn-the-mmoonn." (hopefully the gist is clear!) Continuously voiced sentences (for fluid voiced onsets) first with natural prosody,

then with word breaks, and finally with natural phrase breaks. “My-mom-may-marry-Marv," leads to "My . . . mom . . . may . . . marry . . . Marv," which leads to "My-mom, may-marry-Marv."

Rote sets with jumbled articulatory features: “1, 2, 3 . . . 50” or “January, February, March . . . December.”

Conversational sentence lists of progressively greater length.14

Chanting is valuable for stabilization of undesirable pitch-related voice change, and provides a transitional mode from prosaic therapy tasks to utilitarian speech. It is common in therapy to return to chanting when tasks are inconsistently transferred into speech.

The ultimate goal of rehabilitation is maintenance of newly learned skills in real-life conversation.    B. Major tetrachord 

A major tetrachord is one symmetric half of a major scale, either "doh re mi fa" or "soh la ti doh." This pattern may be hummed or sung on the vowel sequences outlined in exercise A (Figure 1b). Seldom is the tetrachord useful beyond a mezzo piano or mezzo forte dynamic. (Why does music not have a median dynamic between mp and mf? This hypothetical “mezzo mezzo” could provide an ideal dynamic neutrality for therapy.) There is great value in the clinician tightly controlling an innate tendency for patients to progressively push intensity as rising transpositions enter higher pitch range; phonation should proceed from a balance of energized, but not hyperfunctional production.

The author favors tetrachord structure for several reasons: Rising transposition of the semitone interval between the top two pitches permits

creeping exploration of recovery margins. The narrow scalar interval provides an accurate gauge of register boundaries,

which in turn facilitates focus on voice production without the complication of register change. The semitone advancement also ensures accurate documentation of changing patient capacity across time, and is likely more reliable and accurate than a pitch glide. (Descending P5 or octave scales are useful for determining lower boundaries.)

The narrow intervallic range of a P4 permits numerous transpositions within registers of relative strength; typically chest in males, and chest or mid in females.

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The several seconds required for each iteration may comfortably fit within the brief time span dictated by pathology.

Controlled, gentle stretching of the vocal folds may serve to dissipate “nodules”, or teach range extension whilst minimizing habitual strain.

 C. Portamento 

In cases of mild vocal impairment, for diagnosis, or as intended therapeutic benefit is taking place, the clinician may proceed to more extended musical patterns.        A portamento is a smooth glide between two boundary pitches. The movement is primarily activated by continuous differential engagement of the cricothyroid and thyroarytenoid muscles in conjunction with finely tuned respiratory control.9 This physiologic underpinning makes the portamento an ideal vehicle for increased vocal control.         Inhibitory hyperfunction is typically encountered when traditional scales breach outside a central zone of pitch comfort. The subtle onset of associated rigidity may be faint to detection as senses are dulled by habitual acceptance. These tensions may be brought into relief with portamenti particularly in the zona di passaggio or when extending into higher pitch range. Correction requires vigilant monitoring. Vocal freedom may be most fully realized with early recognition and release from these insidious patterns. Mirror usage, finger placement on the sides of the neck, and clinician mimicry greatly increase patient awareness of neck, jaw, tongue or facial tensions which are invariably linked to laryngeal strain.        Two intervals are used in portamento therapy: the perfect fifth and octave (Figures 1c and 1d). Perfect fifth portamenti are useful in the treatment of moderate to severe dysphonias, and in an initial phase of phonosurgical recovery. Treatment of milder dysphonias may utilize octave portamenti which tax greater phonatory and respiratory control, particularly in areas of register transfer.         The author structures each exercise iteration as follows:

Eased, deep, trans-nasal inhalation with diaphragmatic primacy and pharyngeal expansion. The patient should direct awareness to the quality of tonal onset, conceptualized as a “marker.” When the tone is even in timbre and easily produced, move on to rising pitch then proceed to pitch change. If the marker is sub-optimally engaged then the patient should stop and repeat the onset until satisfactory performance is achieved. Accuracy of initial intent is more important than ill founded exercise completion.

The marker glides upwards to a fermata on the upper boundary pitch. The ensuing quality should reference similar characteristics to the starting tone (even if registers are crossed). Once the highest pitch is accepted for quality gently return to the starting tone.

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Changes to bio

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Martin Spencer is a voice pathologist working with two surgical groups, Ohio ENT Surgeons and Central Ohio ENT, in Columbus, Ohio. His scope of activities includes laryngeal evaluation and rehabilitation, with a specialty in professional voice. He is President of the Ohio Voice Association and has organized four state-wide conventions; most recently co-chair of the Midwestern Vocal Perspectives conference entitled “Multidisciplinary Rehabilitation of the Performance Voice.”

He received his vocology track MA from the University of Iowa under the mentorship of Ingo Titze. Recent textbook contributions include “Breath Sensitivity Training” in Workbook of Voice Therapy and “Intervention for Bilateral TVF Nodules in a Praise & Worship Leader” in Voice Therapy: Clinical Studies (3 rd ed. ) Articles include . . . .

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