Voice Treatment

1. Explain and demonstrate pharyngeal tongue positioning and effects on voice. Check posturing.
2. Begin practice with the whispered production of alveolar consonants, such as /t/,/d/,/s/,and /z/. Whisper a rapid series of "ta" or "da", etc. sounds 10 per breath for several minutes. Analysis with the patient what has just been done, for example, "What does the front-of-the-mouth feel like?" Other consonants that lead themselves to frontal practice are /w/,/p/,/f/,/v/, and /l/. High vowel which could help here are /i/,/I/,and /e/.
3. After some success with whispered production, add voice lightly. Use oral readings which are loaded with tongue-tip consonants and front vowels. Practice contrasting new front resonance with old posterior resonance. Analyze the difference of the 'feeling" with the patient.

Decreasing loudness

1. Audiological evaluation
2. For ages three to ten: We ask the child to develop awareness of five different voices
   1. Presented as a whisper
   2. Presented as a quiet voice
   3. Present a normal voice to talk to family
   4. Present a voice that can get attention across the room
   5. Present a yelling voice to call someone outside
3. For patients over ten, we might discuss an inappropriately loud voice. Using audiotape recording of clinician's appropriate loudness to patient inappropriate loudness level
4. Focus on making the patient aware of the problem. Once aware, demonstrate how the loud voice may be perceived by others. Negative interpretations are usually sufficient to motivate him to learn to speak at a normal level
5. Practice using quiet voice using the Visi-pitch for feedback. Provide practice drills for appropriate vocal loudness.

For an increase in loudness:

1. Determine if softness in not attributed to hearing loss, general physical weakness, or severe personality problems.
2. Discuss with the patient the soft voice. Focus on making the patient aware of the problem. Once aware, demonstrate how the soft voice may be perceived by others.
3. Try to achieve a pitch level at which the patient is able with some ease to produce a louder level. Use the Visi-Pitch to help the patient associate changes in pitch with relative changes in intensity. Practice sustaining a /a/ at that level for five seconds, concentrating on good vocal quality. Then take a deep breath and repeat the same pitch at a maximum loudness level. After some practice, ask the patient to sing /a/, up the scale for one octave, at one vocal production per breath; then have him or her to go down the scale, one note per breath, until reaching the starting pitch.
4. Explore the best pitch, the one that produces the best loudness and quality.
5. Respiration training may be necessary
6. Pushing approach may be necessary
7. For patients who appear to resist increasing the loudness, it might be necessary to introduce loud noise. The Lombard effect lends itself well therapeutically.

1. Obtain baseline data of how well the patient can make pitch discriminations. Using instruments and voice, ask the patient if the stimuli are the same or different. If the patient is unable to discriminate between one whole note and its flat or sharp, the indication is that the patient's pitch discrimination is not normal, but not necessarily that pitch discrimination therapy is needed. If patient is unable to discriminate notes that are more than a third apart, some discrimination training is necessary if the patent is ever going to match target model voice.
2. Pitch discrimination training should begin at the patient's baseline. The clinician should provide a variety of pitch stimuli and continue the practice until patient is able to discriminate one full musical note apart.
3. Tonal memory therapy also begins at baseline. That is, if the patient can remember a two-tone sequence. The therapy should begin by presenting two tone-note sequence and asking the patient to identify which note varies between the two presented. When the patient can hear a four-note melody, tonal memory is probably good enough to recall various voice model presentations.
4. When the patient is able to demonstrate a consistent ability to hear his or her "good" voice, ear training can be discontinued.

1. By evaluating the patient, identify the offensive vocal act. Then determine its baseline rate of occurrence.
2. Children with vocal abuse must become aware of its impact on the voice. Using story or picture cards, makes the child aware cognitively of the vocal abuse or misuse.
3. Discuss identified vocal abuse with the patient, emphasizing the need to reduce its frequency. Assign the task of counting the number of times each day they find themselves engaged in that particular abuse.
4. Ask patient to plot daily vocal abuse on a graph and bring it to each therapy sessions. Through awareness, vocal abuse should subside.

1. Demonstration of hard glottal attacks and easy glottal attacks should be provided for the patient
2. With children we demonstrate the child's vocal attack by letting them hear their voice versus normal peer voice. Then practice using the word in the initial position of the sound /h/. When the /h/ words are produced correctly, introduce other words beginning with unvoiced consonants for similar practice. Then use words beginning with vowels.
3. Use the whisper-fountain technique. The patient's task is to whisper very lightly the initial vowel of monosyllabic words, prolonging it by gradually increasing the loudness of the whisper until phonation has begun, finally, the whole word is used. The whisper blends into soft phonation.
4. The yawn-sigh approach is effective in eliminating hard glottal attack.
5. The chewing approach almost always reduces the glottal stroke.
6. Use various instruments to provide feedback, such as Visi-pitch, The Voice Monitor, etc.
7. Once the patient is able to produce easier glottal attack, make an audio recording of phonation. Ask the patient to listen from baseline to now. The patient should think of the difference in both the sound and the contrasting feeling between the two models.

1. A tape recording should be made while patient is searching for his optimal and habitual pitches and then played back.
2. Using a loop tape, have the patient extend an /a/ at the desired pitch for about five seconds.
3. Use the Visi-Pitch for baseline data and feedback
4. The Tunemaster III and the Tonar II are instruments for monitoring practice in establishing a new pitch.
5. Once the new pitch is established, work on single words, preferably those beginning with a vowel, repeating each word in a pitch monotone.
6. Once the patient does well at the single-word level, introduce phrases and short sentences. When success is achieved at the sentence level, assign the patient a reading passage.
7. After reading well in monotone, the patient may try using the new pitch in some real-life conversations.
8. Record new pitch and use as therapy model.

Velopharyngeal closure:

1. Use panensoscope with television monitor to provide information on how the velopharyngeal closure mechanism works, and how one can distinguish the velum from the posterior and lateral pharyngeal walls.
2. Patient is asked to place panensoscope into the mouth and slide it back to the superior surface of the tongue.
3. Patient is asked to visualize the closure on the TV monitor. Various vowel and consonant combinations are used to produce closure.
4. Patient is to focus on "what it feels like" after production when they have produced the target pattern.
5. Patient should practice the procedure once effective closure is obtained. If closure is not obtained, stop this procedure.

Relaxation:

1. Patient is introduced to the electromyography (EMG) apparatus. When he or she is in a relaxed state, the feedback will report reduced digital counts.
2. Specific operation procedures are followed according to the specification listed by the manufacturer of the feedback unit.
3. The clinician obtains baseline data.
4. Patient is to imagine various scenes representing tension and relaxation. Fluctuation in feedback should occur.
5. The clinician obtains another baseline while the patient is in relaxed state.
6. Following baseline, the patient may then receive various kinds of training instructions.
7. One variation in feedback levels are demonstrated under various conditions, the clinician may wish to give quantification feedback to patient.

1. Explain vocal rest to patient, insisting that he or she not even whisper
2. The patient should be counseled about no coughing, throat clearing, or laughing
3. Situational vocal rest is a option which can be used for certain patients.

1. With children use pictures and narratives for explanation.
2. With teen-agers and adults explain that a yawn represents a prolonged inspiration with maximum widening of the supraglottal airway, then demonstrate a yawn.
3. After the patient has yawned, ask them to exhale gently with light phonation.
4. Once yawn-phonation is achieved, instruct the patient to say words beginning with /h/ or with open-mouthed vowels, one word per yawn in the beginning, followed eventually by four or five words in one exhalation.
5. Demonstrate the sigh phase of the exercise, the prolonged, easy, open-mouthed exhalation after the yawn. Then omit the yawn entirely, demonstrating a quick, normal, open-mouthed inhalation followed by the prolonged open-mouthed sigh,
6. After the patient can produce a relaxed sigh, have him or her say the word "hah" after beginning the sigh. Follow this with a series of words beginning with the glottal /h/. Additional words for practice after the sigh should begin with middle and low vowels
7. Finally, one the yawn-sigh approach is well developed, have the patient think of the relaxed oral feeling it provides.

1. Explain to patient that he is speaking with unnecessary tension.
2. With both clinician and patient facing a mirror, ask patient to pretend to
   open mouth wide as if biting a handful of crackers.
3. Establish a natural exaggerated motion of chewing.
4. Demonstrate chewing and add a very soft phonation. Have patient imitate
   you (i.e., "yam-yam").

   ***For the method to be effective, the natural movements of the tongue as experienced
   when actually chewing food should be maintained.

5. Introduce some actual words and phrases, such as "lampshade"; "peaches and
   cream"; "candy chunks".
6. Once chewing method well established, ask patient to count from 1 to 10 using same
   technique. If patient's ability decreases, go back to earlier level.
7. Introduce connected speech. Provide verbal materal to say or passages to read
   aloud.
8. The last practice step is to use the approach during conversational speech. If any
   difficulty experienced, return to the highest successful level and guide forward from
   there.
9. After several weeks of practice, teach patient how to diminish the exaggerated
   chewing to a more normal jaw movement. The patient MUST retain the same feeling
   and the same sound in his voice.

1. Ask patient to phonate and to extend phonation by "hanging on to an ah". Apply
   slight finger pressure to cartilage.
2. Ask patient to maintain the lower pitch even when your fingers are removed.
3. Continue procedure until patient is able to retain lower pitch.
4. Instruct patient how to place fingers on external larynx and feel upward and
   downward movement of the larynx. Ask patient to phonate at optimum level
   previously established.

1. Develop patient's general awareness of hierarchial behaviors to be studied.
2. Identify situations in which patient feels most comfortable. Develop hierarchy of
   situations in which patient experiences variation of voice.
3. Have patient sequence voice situations from normal to most dysphonic.
4. Begin therapy with "good" end of hierarchial sequence. Have the patient recall the
   feeling of the good voice with patient experience in the situation rated best.
5. Progress thru hierarchy as patient is able to be successful in each situation.
6. After patient is conditioned to a more favorable optimum behavior, have patient
   practice his optimum response outside the clinic under good conditions and gradually
   progress toward more adverse situations.

1. Once patient is able to produce the target phonations free, ask him to voice deliberately an
   old phonation pattern.
2. Make an audio tape of target phonation and old phonation patterns and have patient
   critique differences.
3. Have patient identify the situation in which he is best able to produce new voice.
4. Make specific plans to use old voice pattern deliberately. Then analyze contrasting
   vocal behaviors.

1. Have patient view self in a mirror to observe presence or absence of open mouth behavior.
2. The clinician should point out any areas of tension or restriction.
3. Develop an awareness of oral openness during listening tasks. Patient should listen or
   read with teeth slightly apart.
4. To establish oral openness, ask patient to drop head toward his chest and let his lips
   part and jaw drop open.
5. Have patient practice some relaxed /a/s.
6. Have patient develop conscious awareness of the feeling of open versus tight, closed
   mouth by keeping a journal of each time he becomes aware of the mouth being closed
   unnecessarily.
7. Once oral openness is achieved, establish carry-over between orality and the
   speech-voicing task itself.

1. Listen with patient to recorded samples of patient's voice and sample of voices with
   excellent pitch variation.
2. Discuss differences with patient to increase awareness of lack of pitch variation.
3. Begin working on downward and upward inflectional shifts of the same word.
4. Have patient practice introducting pitch shifts within specific words.
5. Record patient's oral reading and conversation from time to time.
6. Critically analyze these productions with regard to pirch variability.

1. Demonstrate pushing method by raising patient's fists to about shoulder height, and
   then pushing his arms down suddenly in a rapid, uninterrupted motion. (Or have
   patient push his body off seat of chair.)
2. After patient can perform above well, have patient push and phonate simultaneously.
3. Have patient practice phonation at same loudness level without pushing.
4. Carry-over increased loudness without pushing to conversational tasks.

1. Use any method of relaxation. Jacobson's classical method of differential relaxation is
   particularly useful.

1. Begin with simple explanation of phonatory physiology, emphasizing that outgoing air
   stream vibrates vocal cords.
2. Demonstate slightly exaggerated breath, as used in sighing.
3. Demonstrate the quick inhalation and prolonged exhalation needed for normal
   speaking tasks.
4. Practice extending an even phonation for as long as possible without any noticeable
   phonation break or change of quality.
5. Progressively increase the extension time to 8, 12, 15, then 20 seconds.
6. Present reading materials designed to develop breath control.

1. Discuss various ways of production of voice.
2. Explain that the goal of treatment is to produce voicing with the least amoung of
   effort.
3. Review phonation of patient as detected during evaluation.
4. Experiment with various pitches, body positions, etc. to find patient's optimum pitch
   level.
5. Tape record this search. Once target phonation is determined, it may be played back
   as a model.
6. Have patient listen to own model recording and attempt to modify voice to match that
   phonation.
7. Once target phonation achieved, introduce oral reading.
8. Continue to present various tasks until spontaneous conversation reached using
   optimum voice production.

"Functional voice problems usually respond to the same techniques of voice treatment as dysphonias related to cord thickening, vocal nodules, polyps, contact ulcers, etc.. A differential treatment approach is not needed for each voice disorder. Rather, our treatment might be more effective and relevant if, after analyzing the voice disorder along the dimensions of pitch, loudness, and quality, we then applied a therapy appropriate to those dimensions."

"The voice therapist must continually search for the patient's best and most appropriate voice production. The selection of what to do in voice treatment is related to what the patient is doing and what we can give him to do to produce a "good" voice."            Boone, 1971

Christy Lake & Kimberli Moore, 1997