Vocal Function ExercisesLaryngeal Adduction ExercisesAngie PredmoreRobyn Renwick

Purpose

•To improve vocal quality

•Increase muscle activity

Laryngeal Adduction ExercisesPushing/pulling Holding breathGlottal attack Pseudo supraglottic swallow

Who?• used with patients with poor vocal fold adduction

(hypo-adduction)• laryngeal trauma (may result in recurrent

laryngeal nerve paralysis)• neurological diseases

▫ PD, MS, closed head injury, stroke, congenital conditions such as sulcus vocalis (vocal fold furrow)

• should not be used in patients with voice problems due to vocal fold inflammation or mass lesions on the folds (i.e. nodules, polyps)

• Pushing and pulling exercises should not be used with patients that have uncontrolled high blood pressure (Ramig & Verdolini, 1998)

Purpose

•Voice quality▫Facilitate improved vocal fold closure

during voice production▫Helps to treat breathiness, low intensity,

hoarseness, or overall vocal quality ▫Conditions such as vocal fold bowing and

vocal fold weakness or paralysis

(Logemann, 1998)

Purpose•Swallowing safety / airway protection• Increase muscle activity in the larynx•Basic to good laryngeal closure during

swallowing•A sequence of these exercises should be

completed before actual swallowing therapy▫ if laryngeal incompetence can’t be managed

quickly by postural assists or teaching the patient to voluntarily close their airway

(Logemann, 1998)

Method

•Two sets of exercises•The series of exercises should be

completed five to ten time per day for five minutes

•Each exercise should be repeated 5 times before moving on to the next exercise in the set

•The whole series of exercises should be repeated three times

(Logemann, 1998)

Set 1

Exercise 1:Be seated. Hold your breath as tightly as possible while pushing down or pulling up on your chair with both hands for 5 sec.

(Logemann, 1998)

Set 1

Exercise 2:Be seated.Bear down against a chair with only one hand. Produce clear voice simultaneously.

(Logemann, 1998)

Set 1

Exercise 3:Repeat ‘ah’ 5 times with a hard glottal attack on each vowel.

(Logemann, 1998)

Set 1• Patients should practice this series every day for

one week. • A follow-up swallow evaluation should be

completed to assess improvements in airway protection from the larynx.

• The SLP and patient can also monitor improvements in laryngeal function by listening to clarity and vocal quality.

• If no improvements are noted, the exercises should be changed to those in Set 2. ▫This prevents monotony and introduces

exercises in a hierarchy(Logemann, 1998)

Set 2

•The series of exercises should be completed five to ten time per day for five minutes

•Each exercise should be repeated 5 times before moving on to the next exercise in the set

•The whole series of exercises should be repeated three times

(Logemann, 1998)

Set 2

Exercise 1:Pull up on chair with both hands while prolonging phonation.

(Logemann, 1998)

Set 2

Exercise 2:Begin phonation of ‘ah’ with a hard glottal attack and sustain phonation with a clear, smooth vocal quality for 5-10 seconds

(Logemann, 1998)

Set 2

Exercise 3:Pseudo-supraglottic swallowTake a breath, hold it, and cough as strongly as possible

(Logemann, 1998)

Recovery

•Improvement should be seen within 2 weeks

•Occasionally it will take 6-8 months with some patients to attain adequate airway protection or vocal quality ▫these are often those who have had more

serious conditions (i.e. extended supraglottic laryngectomy)

(Logemann, 1998)

Cautions

•Stemple, Glaze & Klaben (2000) suggested that the effectiveness of these exercises depends on the degree of vocal fold gap ▫prognosis for improvement is most

favorable if a light touch closure is evident during the videostroboscopic evaluation

•Patient should be monitored closely for signs of hyperfunction (Miller, 2004)

(Stemple, Glaze & Klaben, 2000; Miller, 2004)

Efficacy

•There is very little research about the use and efficacy of laryngeal adduction exercises.

•Since there are extremely few efficacy studies concerning vocal fold adduction exercises, few SLPs currently use the pushing and pulling type of exercises.▫Yamaguchi et al. (1990) ▫Silverman Voice Treatment (LSVT)

Yamaguchi et al. (1990)• Cases of glottal incompetence • Treated by the pushing exercises technique. • Three patients that had paralysis of the vocal

folds or sulcus vocalis• All three individuals improved following voice

treatment. ▫Two improved 20 dB (statistically significant

increase in intensity), and one improved 7 dB (clinically significant increase in intensity).

LSVT

•The Lee Silverman Voice Treatment (LSVT) program utilizes intensive high phonatory effort exercises in order to increase vocal fold adduction.

•It has been documented to have short and long term effectiveness for those with idiopathic Parkinson’s Disease.

(Ramig, 1998)

Vocal Function Exercises“Knoll”

Who?• Beneficial to treat

▫ Hyperfunction Too much laryngeal activity

▫ Hypofunction Too little laryngeal activity

• Prevention▫ Hyperfunction▫ Vocal symptoms

• Research has demonstrated improvements for▫ Vocal nodules▫ Singers▫ Aging voice

Philosophy

•The laryngeal mechanism, like other muscle systems, may become imbalanced and/or strained.

•VFE treat in a holistic manner.

•“Physical therapy” for the voice

(Stemple, Glaze, & Gerdeman-Klaben, 2000)

Purpose• Increase the bulk, strength, and

coordinated interaction of muscles

• Improved glottal efficiency

• Improved vocal quality▫Easy onset▫Frontal focus▫Respiratory support▫Balance respiration, phonation, & resonance

(Stemple, 2000; “Vocal function exercises”, n.d.)

Method

•Set of 4 exercises•Completed 2x each, 2x daily

▫ 1x in the morning, 1x in the afternoon

•Complete as softly as possible to ▫ Purpose: increase muscular and

respiratory effort to maintain phonation

(Andrews, 2006)

Step 1: Warm-Up

• Sustain the vowel /i/ for as long as possible ▫ on a musical note F

above middle C for women and children below middle C for men.

May be modified based on patient’s vocal range.

• Goal▫ Dependent on patient’s airflow volume.▫ Targeted volume is 80-100 mL/s of airflow.Flow volume, mL H2O/100 mL H2O = _______

seconds (Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 2: Stretching• Say “Knoll” and glide from lowest note

to highest note in vocal range.

• Goal▫ Complete without voice breaks. ▫ Use of the word “knoll” encourages a forward

vocal focus and an open pharynx. ▫ Lips should be rounded and the patient should

feel vibration on the lips. ▫ During this exercise, vocal folds are stretched

and muscle control and flexibility is improved.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 3: Contraction• Say “Knoll” and glide from highest note

to lowest note in vocal range.

• Goal: ▫ Complete without voice breaks. ▫ Encourages a forward focus and an open

pharynx. ▫ Complements the previous stretching

exercise by contracting the laryngeal muscles.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 4: Adductory Power Exercise

• Voice “Oll” (“knoll” without “kn”) as long as possible on musical notes C, D, E, F, and G

▫ above middle C for women and children▫ below middle C for men

modify based on patient’s vocal range). • Goal

▫ dependent on patient’s airflow volume.▫ The goal is the same as the first exercise with

a targeted volume is 80-100 mL/s of airflow.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Recovery

•Patients track progress on a graph▫Sustained times▫Daily variation is expected

•Improvement typically seen within 6-8 weeks

(Stemple, Glaze, and Klaben, 2000)

MaintenanceOnce goals have been met and vocal quality

has improved, the following weekly program is recommended: Full program 2 times each, 2 times per day Full program 2 times each, 1 time per day (morning) Full program 1 time each, 1 time per day (morning) Exercise #4, 2 times each, 1 time per day (morning) Exercise #4, 1 time each, 1 time per day (morning) Exercise #4, 1 time each, 3 times per week (morning) Exercise #4, 1 time each, 1 time per week (morning)

(Stemple, Glaze & Klaben, 2000)

Efficacy Voice Therapy: Clinical Studies (Stemple, 2000)

Provides a variety of cases in which he has used VFE

• Hyperfunction▫ 9 year old▫ 21 year old▫ Improved vocal quality

Easy onset, respiratory support, frontal focus

Balance among respiration, phonation, resonance

• Prevention of hyperfunction▫ 53 year old▫ Avoid hyperfunction as a

new, higher pitch is learned

• Hypofunction▫ 71 year old▫ 36 year old▫ Improved efficiency of

breath support for phonation

• Treatment of vocal nodules▫ 26 year old▫ Improved vocal quality

Overall improvement in vocal folds

Frontal focus Increased MPT

Prevention of Vocal Symptoms

•Pasa, Oates, & Dacakis (2007)▫37 primary school teachers▫Ages: 21 to 55

▫Results Decrease in vocal symptoms Improved vocal quality Increased maximum phonation times

Singers

•Wrycza-Sabol, Lee, and Stemple (1995) ▫ 20 healthy graduate-level voice majors ▫ Ages 21 to 55

▫ Results: Improved glottal efficiency

Increased airflow rates Imporved phonation volumes Increased MPTs

Aging Voice

•Gorman, Weinrich, Lee, and Stemple (2008)▫19 male participants▫Ages 60 to 78

▫Results: Continuous improvements in MPT Improved glottal closure

References• Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through

geriatrics. Thomson: Canada. • Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic

changes as a result of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903.

• Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX.

• Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North American, 37, 105-119.

• Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics Phoniatrics Vocology 32, 128-140.

• Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech, Language, and Hearing Research, 41, 101-116.

• Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada. • Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice

pathology: Theory and management. Singular: Canada. • Vocal function exercises. In Vocology. Retrieved July 13, 2009, from

http://ncvs.org/museum-archive/vocologyguide.pdf• Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function

exercises in the practice of regimen of singers. Journal of Voice, 9(1), 27-36. • Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990).

Pushing exercise program to correct glottal incompetence. Annual Bulletin of the Research Institute of Logopedics, 24, 223-234.