Semi-Occluded Vocal Tract Exercises for Voice Therapy (and - PowerPoint Presentation

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Semi-Occluded Vocal Tract Exercises for Voice Therapy (and singing)

AKA – Why we Trill, Hum, use straws etc.

Liz Savina, Redcliffe HospitalFor Qld Voice Special Interest GroupMay 2014 Slide2

OverviewDefinition & brief background of physics

What major therapy “programs” use itDiscuss some recent studies that show the effects of different parameters/ on different populations. DemonstrationsTherapy hierarchiesCase examplesSlide3

3 Major Ways of Doing SOVT (Andrade 2014)

Constant frontal narrowing of the vocal tract (nasals/glides and hand-over-mouth); Lengthening (and narrowing) the vocal tract through means of a tube (Lax-Vox/Straw).Adding a 2ndry source of vibration into the vocal tract (lip and tongue-trills, Tube into water/fricatives).

Been used in various forms for over 100 years (Conroy et al. 2014) Slide4

My burning questionsIs it guaranteed to work??Which types are best for building up vocalis (muscle within vocal cords) and closing glottic

gaps versus Improving retraction/deconstriction, preventing overclosureSlide5

Why/How Does SOVT Work?Potentially decreases the aerodynamic power necessary for phonation & optimises closure of the vocal folds

– neither breathy or pressed (Andrade et al. 2014) Slide6

An entire conference on SOVT!Slide7

A little bit of the physicsSOVT (at the lips) works by…….

Raising the mean supraglottal and intraglottal pressuresImpedance matching by vocal fold adduction and epilarynx tube narrowing can then make the voice more efficient and more economical (in terms of tissue collision).(Titze 2006) Decrease in phonation threshold pressure Reduced minimum pressure at which the VC will vibrate

Decreased phonatory effortDecreased strain(Conroy et al 2014, Guzman et al., 2013), The vocal fold adduction appears to be a reflex reaction. Slide8

A little bit of physicsL

owering of the first vocal tract formant (F1) allowing the fundamental frequency (F0) of speech to be closer to F1, Increasing inertive reactance of the vocal tract and producing a more efficient vocal fold vibration pattern -> easier voicing

http://www2.psychology.uiowa.edu/faculty/mcmurray/speechglossary/Slide9

Some SOVTWiden the pharynx in relation to the

epilarynx -> a clustering of the 3rd, 4th, & 5th formants (Andrade 2014) – “Singer’s Formant” Slide10

Marco Guzman, et al Resonance Tube and Straw Phonation 523.e27Slide11

SOVT is used in

Stemple’s Vocal Function Exercises (nasals & Finnish bilabial fricative) Verdolini-Abbots – LMRVT – core part of her Voice Therapy Spectrum – using MLaxVox (9mm id, 25cm (Andrade) or 35 cm (Stemple) tube in 1-5cm of water (aim for 3-5cm - Stemple)

Finnish Resonance Tube (soft silicone or glass tube 25-27 cm & 9 mm id in 2-5cm of water or free air) ~40 year hx (Paes)Slide12

SOVT is used in

Accent Method (voiced fricatives)Estill Siren on “ng”, sireningTitze’s Straw exercise (small diameter for men, larger diameter for women – Titze Brisbane 2013)Glide loaded sentence of CAPE-V – We were away a year ago

& S/Z ratioSlide13

Lax Vox – Stemple

20111 of the Big 3 things for future voice therapy. Slide14

Lax Vox indicated for:

Stemple (2011) Holistic therapy for various functional and organic voice disorders:Muscle tension dysphoniaVocal fold nodules and polyps

Habitual and psychogenic dysphonias-aphonias (by masking proprioceptive feedback) Vocal fold paralysis (RLN and SLN)PresbyphoniaPuberphonia

• Pre

and postoperative

phonosurgerySlide15

Lax Vox in Singing and Theatre voice Stemple (2011)

Daily voice care for all groups of voice usersPrevention of voice problems for vocal athletesDeveloping vocal muscles with several exercises (glissando, staccato, Messa di Voce, etc.)

Glottal closure deficienciesWarming up and cooling downFinding and developing the optimal voice (primal sound)Balancing the glottal attackFacilitating the lowered larynx

Developing

registers and smoothing the

passaggioSlide16

Lax Vox ReferenceDenizoglu I,

SihvoM. Lax Vox Voice Therapy Technique. CurrPractORL 2010, 6(2):284-295 (unable to find on Medline Ovid or Ebsco or Pubmed or even Google!)Slide17

SOVT researched in:Teachers (RVT and Finnish Tube)Elderly (Finnish Tube)Actors and singers (RVT)“Behavioural” voice problems

Benign vocal lesionsHaven’t yet found research on Unilateral Vocal Fold ParalysisSlide18

Some Recent Studies

http://fraukruse.wordpress.com/2013/03/07/lax-vox-voice-therapy/Slide19

Some Recent StudiesImmediate effects normal speakerstrained/untrained instructed/non-instructed dyshphonic/ hyperfunctional populations (tubes)

Effect of 6 week programme on “elderly” (tube in water)24 Hours of RV

http://fraukruse.wordpress.com/2013/03/07/lax-vox-voice-therapy/Slide20

Summary of Articles will followSlide21

Andrade et al 2014 Electroglottographic Study of Seven Semi-Occluded

Exercises:…….Journal of VoiceSlide22

Andrade 2014 SOVTE

LaxVox (9mm id, 25cm –? Water depth)Straw (12.5 cm in length & 4 mm in diameter)Lip-trillTongue-trillHand-over-mouth

Humming Tongue-trill with hand-over-mouth.Slide23

Procedure Andrade 2014N = 23 healthy volunteers

SP demonstrated and provided teaching on error until subjects produced correctlyAsked to do same pitch for all activities. Electroglottographic & Acoustic measuresSlide24

F1 – F0 Andrade 2014 Slide25

Steady

(single source) Hand-over-mouthHumming Straw

with lower CQr & F1 - F0

difference

Easiest Phonation

Fluctuating

(dual source)

Tongue-trill

Lip-trill

LaxVox

with

larger

CQr

&

F1 - F0 difference

More effortful phonation but ? gives massage effect

SOVT

Andrade

et al. 2014Slide26

Massaging the Vocal Tract

Note the bouncing of the pharyngeal walls – easier to see in the second half of clip when the pitch is held constant. Slide27

Tongue Trill + Hand Over Mouth Andrade 2014

Exhibited mixed effects in both the exercise groupsSlide28

Costa et al., 2011. Immediate effects of the phonation into a straw exerciseSlide29

Costa et al 2011N = 48, 23 with benign lesions (nodules, cysts, polyps, and Reinke’s edema ), 25 without.

Rigid plastic straw 8.7 cm long & 1.5 mm diamExaminer demonstrated then participants did 1 minute of straw phonation at self selected mid range frequency and intensity.

Videolaryngoscopy, vocal self Ax, acoustic and auditory perception AxSlide30

Costa et al 2011Significant improvement on vocal self Ax in patients with benign vocal lesions (p=0. 015) but no change in patients without lesions.

No statistically significant differences before and after the exercise and between the groups, in the videolaryngoscopy, acoustic and auditory-perception assessmentsSlide31

Gaskill, C. S., & Quinney, D. M. (2012). The effect of resonance tubes on glottal contact quotient with and without task instruction: a comparison of trained and untrained voices. Journal of VoiceSlide32

Gaskill & Quinney 2012

Two groups of male participants, 10 with no vocal training 10 with classical vocal training, No instruction/practice: told keep pitch and loudness consistent

Instruction/practice: got to practice until found best pitch and loudness and had sense of oral resonanceSlide33

Gaskill & Quinney 2012

Procedure12 reps of a vowel-like phonation for at least 5 seconds.Narrow glass tube, 8 mm ID and 50 cm Some participants needed to be cued to not produce a humming or nasalized sound, but to allow all of the sound to go through the tube instead of coming through the nose.Slide34

Gaskill & Quinney 2012 Conclusions

Resonance tube can cause immediate and measurable changes in glottal CQ These changes remain highly variable and do not always fit with theoretical predictionsdoes need an

individualized approach that could include trying multiple tube lengths and diameters as well as extended and systematic practice with larger variations in pitch than those exhibited in this studySlide35

Guzman et al 2013 Laryngeal and Pharyngeal Activity During

Semioccluded Vocal Tract Postures in Subjects Diagnosed With Hyperfunctional Dysphonia

8 SOVT exercises: Slide36

SOVT postures Guzman et al 2013

N=20 hyperfunctional dysphonia8 SOVT exercises: Blinded laryngologists rated 3 endoscopic variables using a five-point Likert scalevertical laryngeal position (VLP), pharyngeal constriction, and laryngeal compressionSlide37

SOVT postures in hyperfunctional dysphonia Guzman et al 2013

All semioccluded techniques produced a lower larynxnarrower aryepiglottic opening and a wider pharynx

Compared to resting positionVLP, A-P constriction,& pharyngeal width changed differently throughout the 8 semi-occluded postures.Most prominent changes were obtained with a tube into the water and narrow tube into the air Slide38

Lower Laryngeal Position

Straw exercises: Before (left), during (middle), after (right)Findings:Lower laryngeal position both during and afterHigher velum position both during and afterHypopharynx much wider during(Different Guzman et al., 2013, pg 523.e24 Figure 6)Slide39

Paes, et al. (2013). Immediate effects of the Finnish resonance tube method on

behavioral dysphonia. J Voice, 27(6), 717-722. doi: 10.1016/j.jvoice.2013.04.007Slide40

Paes 2012 25 female teachers minimum 5-year history of dysphonia & no prior speech therapy. Subjects produced 3 sets of 10 sustained phonations with a 1-minute rest between phonations

27-cm

glass tube immersed in

at least/up to

2 cm of water

. Slide41

Results – Paes 201268% of the teachers reported

increased phonatory comfort 52% reported improved voice quality after performing the exercises. Perceptual analysis: improved voice on counting numbers but not on “ah”

Spectrogram: decreased instability, subharmonics, noise in high frequencies, and the tendency for reduced low frequency noise on. Mean fundamental frequency decreased.Slide42

Dos Santos, et. al.(2014). Verifying the effectiveness of using resonance tubes in voice therapy with elderly people

. Slide43

Resonance Tubes in the “Elderly”Dos Santos et al 2014

Resonance Tube Group: Improvement in Grade, Asthenia, Strain, Instability on GRBASI No change in breathiness90% self-reported improvementImproved Vital CapacityImproved spirometrySlide44

Resonance Tubes in the “Elderly”Dos Santos et al 2014

N= 42 elderly in long term care residential between ages of 62-93 years 30 femalesx6 1 hour weekly sessions of resonance tube, compared to vocal hygiene ed sessions. Glass tubes (8 mm to 9 mm ID and 24 cm to 25 cm length in 2-5cm of water).

RT Therapy Rx: instructed to emit continuous sounds, nonsensical words, and to hum the tune of “Happy Birthday to You.” Rest periods of up to two minutes between emissions. Slide45

Verdolini, 2012. Vocal exercise may attenuate acute vocal fold inflammationSlide46

Resonant voice for treatment of vocal fold inflammation Verdolini 2012

N=3 healthy malesUsed Resonant VoiceProspective, Randomized and double blind 1-hour vocal loading procedure, followed by randomization to aTalking as normal condition, Vocal rest

condition, RV exercise condition Treatments were monitored in clinic for 4 hours and continued extra-clinically until the next morning. Slide47

Resonant voice for treatment of vocal fold inflammation Verdolini 2012

Results Complete data sets were obtained for 3 inflammatory biomarkers--IL-1beta, IL-6, MMP-8Results were poorest at 24-hour follow-up in the talking as normal conditionSharply improved in the voice rest condition

Were the best in the RV conditionSlide48

SummarySOVT exercises can optimise the closure of the vocal folds, open the pharynx widerThese effects tend to occur immediatelyThey are not guaranteed to do so, so still need to be individually checked – person doing should feel a more “open throat”, less effortful voicing and sound should improve( that’s up to our subjective judgement)

If SOVT improves the vocal tract configuration, evidence shows this can then be carried over to vowels and other speech sounds.