Vocal Function Exercise: How to Individualize Treatment

Bob is a 78-year-old referred to the voice clinic with a diagnosis of presbylaryngeus. His chief complaints are voice fatigue, inability to project his voice, and effort to talk. Bob reports a self-imposed social isolation because of these vocal difficulties. Laryngeal vidostroboscopy revealed a moderate-sized spindle-shaped glottal gap, consistent with his diagnosis. It was recommended that he begin voice therapy with therapy focusing on Vocal Function Exercises to rebuild the strength and balance in the laryngeal musculature and to rebalance respiration, phonation, and resonance.

Initially, Bob could not foresee himself benefiting from the VFE program. When the speech-language pathologist began talking about musical notes, Bob exclaimed that he couldn’t sing and thus he could not complete the exercises. Here are some modifications you can make to the voice therapy program to help meet the needs of individual patients:

Solutions for Pitch Matching Problems

Many patients express an inability to sing. Therefore, it is important that patients understand that VFEs are not ‘singing’ exercises, but rather vocal fold ‘muscle strengthening’ exercises. Changing the mindset from singing to muscle workout changes the game for many patients.

Also, not being able to sing does not mean that the patient cannot match pitch either with an instrument (pitch pipe, keyboard, recorded sound) or a live or recorded voice. In fact, in my experience, with a little guidance most people can match pitch and improve this ability throughout the exercise program.

On the rare occasion that you encounter a truly ‘tone deaf’ individual, I suggest that you suspend the use of the selected notes and train patients to produce a low, middle, and higher pitch on which to practice the sustained selected semi-occluded vowels. Radhakrishnan and Scheidt (2012) proved this approach successful with a study where a patient demonstrated improvement on measures of quality of life, perceptual, acoustic, and electroglottographic assessments following six weeks of VFEs.

Once Bob quelled his anxiety about matching pitch, he began to struggle with the semi-occluded mouth posture (/ol-buzz/). He rounded the lips so tightly that he was actually creating the tension we were trying to resolve.

Solutions for Difficulty with the SOVT Posture

Describe to the patient to sense what the throat feels like when they yawn. Have them practice holding the yawn position while sustaining the sound /o/ with a small oral aperture. Encourage them to ‘permit’ the lips to buzz; not to ‘make’ the lips buzz. If the sound doesn’t improve after reasonable practice time, default to a normal /o/ sound and encourage a smaller rounded lip opening.

In studies by Radhakrishnan and Scheidt (2012) and Nguyen and Kenny (2009), the prescribed SOVT posture was modified with the vowel /o/ and the Vietnamese vowel /ô/, thereby lessening the degree of semi-occlusion by an unknown amount. Results of voice change and vocal function of participants in both studies were positive.

Individualized Treatment

Speech-language pathologists are skilled at modifying voice therapy programs to meet the needs of individual patients. We caution that changes to the VFE program can also readily be made if the changes adhere to the goals of the program. In the above case, Bob used ascending pitches instead of matching preselected notes and used the vowel /o/ instead of the prescribed /ol-buzz/. Despite these modifications, his therapy results were positive, though the time from therapy onset to discharge was a bit longer (10-weeks) than would normally be expected (6 -8 weeks).