Main Regimens/Techniques

As the practice of voice therapy has advanced, a number of voice therapy regimens (or techniques) have been published which utilize various combinations of the therapy components described in the previous section. The extent to which compelling research evidence supports these different approaches varies.

Each of the regimens described below involves some degree of overlap, and many were actually designed as improvements on past efforts. Furthermore, these regimens may be used by voice therapists in different combinations to achieve optimal results.

A patient's voice therapy program is best designed by a vocal therapist and otolaryngologist working in tandem or with a voice care team. Together, caregivers will help determine which regimens/techniques are best for a patient's voice disorder and specific needs.

In brief: Resonant voice (or voice with forward focus) refers to a voice that resonates or echoes within the face or facial bones. Resonant voice therapy is a tool that voice therapists use to help patients feel the vibrations of their voices along the lips, tongue, and nose, and then use those sensations to help better project their voices. Arthur Lessac, a famous theater coach, first described the resonant voice therapy approach.

Intended endpoint: This approach aims to produce voice with the vocal folds lightly touching rather than closed tightly – achieving sound volume through resonance.

Application group: Resonant voice therapy is now used by vocal therapists to treat a number of voice disorders, such as muscular tension dysphonia and vocal fold lesions.

In brief: In confidential voice therapy, patients are trained to produce a soft, breathy voice without full vocal fold closure.

Intended endpoint: By encouraging this gentle sound, forceful collisions by the vocal folds are prevented and lesions or scarring affecting this structure are not worsened. Some types of lesions may begin to reduce in size as a result of lessened trauma to vocal fold tissues.

Application group: Confidential voice therapy is used in patients who have developed serious vocal symptoms due to vocal fold lesions or muscle tension.

Key Information

"Confidential Voice" Technique Is Not Whispering

It is important to realize that though the confidential voice is soft and breathy, it is not a whisper.

First-Line Voice Therapy Regimen During Early Recovery Period

Confidential voice therapy is often one of the first regimens used for patients whose voice strength is nearly imperceptible. The main goal, in fact, of this technique is to allow patients to speak while vocal fold health improves. Then, when the vocal folds have healed, other regimens can be used to bring the voice back to its full strength, tone, and color. Patients typically use the confidential voice for about two to three weeks; after this period of time, symptoms such as pain, fatigue, and substantial hoarseness should improve, allowing more intense therapeutic regimens to be started.

In brief: Circumlaryngeal massage is a "hands-on" approach in which patients are trained to massage their neck area while observing different changes in their voice quality.

Intended endpoint: 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.

Application group: This technique 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) and in symptomatic patients who sit or stand with rigid postures, regardless of whether any tightness or pain is present in the neck.

Key Information

No patient should attempt to perform circumlaryngeal massage without first being educated on the technique by a voice therapist. It is only after this type of training that patients will know the proper location at which to begin the massage (the hyoid bone – located right above the Adam's Apple) and which muscles to focus on.

In brief: Specifically designed for patients with Parkinson's disease, the Lee Silverman voice treatment advocates increasing the effort with which patients speak – thereby "pushing" the voice and making it stronger.

Intended endpoint: In essence, patients are trained to exhale higher volumes of air out of their lungs, more forcefully – while simultaneously closing their vocal folds more completely. The result is a louder, stronger voice.

Application group: This regimen was specifically designed to treat voice disorders caused by Parkinson's disease, but is also being increasingly used to treat vocal symptoms in other types of neurological disorders.

Key Information

An Extremely Intense Program

The Lee Silverman regimen is extremely intense, even by voice therapy standards. Patients must attend four sessions per week for four weeks with the clear goal of making their voices louder.

Wider Acceptance for Some Patients

Clinical studies have shown that Lee Silverman voice treatment has proven successful in some patients. Given the inability of more traditional vocal therapies to improve the voice in sufferers of Parkinson's disease, Lee Silverman treatment has become more widely accepted.

Requires Specialized Training for Professionals

Only clinicians who have attended training programs specifically designed to teach the Lee Silverman Voice Treatment Program (and have received a certificate of completion) should use this approach.

Red Flag

Due to its emphasis on force and effortful speaking, the Lee Silverman voice treatment is now regarded by some physicians as potentially quite harmful for patients with vocal fold disorders and abnormalities that are caused by vocal misuse, such as vocal fold nodules, polyps, or cysts and vocal fold scarring.

In brief: The accent method of voice therapy focuses on improving breathing technique to increase voice clarity. Specifically, patients are taught to use accentuated and rhythmic movements in both their pronunciations and in related body movements.

Intended endpoint: Proponents of the therapy suggest that it helps relax the vocal muscles while also helping to synchronize voice production with a recognizable rhythm produced by another part of the body.

Application group: The accent method was developed in Europe to treat many types of voice disorders. Although some voice therapists in the United States favor its use, the accent method is more commonly employed in Europe.

Key Information

"Follow-the-Leader"

While vocal therapists practice the accent method with some degree of variation, in general treatment takes the form of a therapist asking questions to a patient in a particular rhythm – and the patient responding in that same pattern.

Accent Words – Accent Phrases – Accent Sentences

Accent voice therapy helps patients adjust the timing and rhythm with which they breathe and accent words.

Some form of additional stimulus may be used, such as a body movement or a drum or tambourine, to help patients form a series of exaggerated syllables or words.

These exercises progress to longer phrases and eventually sentences. Throughout the exercises, the accentuated rhythm used during speaking is maintained, while the body movements and other external stimulus that were used initially are reduced or eliminated.

In brief: This is a program of systematic exercises that strengthen and rebalance the subsystems involved in voice production (respiration, phonation, and resonance). Exercises include maximum vowel prolongations and pitch glides using specific pitch and phonetic contexts.

Intended endpoint: Exercises aim to improve the voice through maximizing the different functions that contribute to voice production, including speaking and singing.

Application group: Vocal function exercises have been used to treat a wide variety of voice disorders, including use-related vocal fold lesions, muscle tension dysphonia, and hypophonia (weak voice).

A number of other regimens/techniques are used intermittently by vocal therapists. These are usually tried only after more mainstream techniques have proven to be unsuccessful. However, they may be used immediately in cases where a patient's voice is completely or almost completely absent. These techniques are briefly described below.

Singing therapy focuses on relaxing the muscles of the stomach, chest, and neck, while producing simple song-like phrases or chat-like expressions. The goal of these exercises is to help patients develop confidence in producing a voice that is not "protected" or "forced," but free. While the therapist does not attempt to teach patients how to sing, the therapy emphasizes flexible pitch and loudness. In particular, voice therapists will often encourage patients to use trills (much like a "raspberry") during therapy; these sounds, which are produced through exaggerated movements of the lips or tongue, help relax patients and improve voice clarity.

Phonation on inhalation requires patients to speak while breathing in. The technique has been used to eliminate excessive squeezing of the vocal folds in some patients and as a means of initiating voice in a patient where little or no voice is present. After a patient masters speaking on inhalation, the vocal therapist will ask for vocalization during exhalation as well. Gradually, vocalization while breathing in is curtailed, and the patient begins speaking in a normal pattern.

This therapy is especially effective in patients with complete voice loss (aphonia). The technique attempts to initiate voice production as patients perform other sound-producing activities such as throat-clearing, grunting, coughing, laughing, humming, chewing, or gargling. Vocal therapists then help patients transform any sound elicited through these tasks into words or speech.

The change of sex from female to male does not present concerns about voice, as drugs are available to affect the larynx and cause a permanent lower pitch. Male-to-female sex changes, however, require a voice therapist to attend to softness of the voice, pitch, intonation patterns, length of utterance, linguistic differences, and differences in body language and gestures accompanying speaking. Feminine characteristics in these aspects of voice production are often absent directly after male-to-female sex change operations, and require dedication and many months or years to acquire.

Though this section has described several different approaches to voice therapy, there are many others not represented here. In fact, many voice therapists and otolaryngologists have developed their own versions that build upon the common principles of mainstream voice therapies.

In essence, voice therapy is highly individualized and never completed in a "cookbook" manner. A patient's voice therapy may differ from that described here, as well as in the length and intensity of the voice therapy program.

Fortunately, when supervised and administered by a qualified voice therapist – one who has a thorough understanding of how the voice works – many of the techniques described in this section can successfully restore the normal voice. This is especially true when proper diagnosis is made, and voice therapy can be specified to the exact disorder affecting a patient. A patient's commitment also plays a key role in the success of voice therapy.

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