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

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

Liz Savina, Redcliffe Hospital

For Qld Voice Special Interest Group May 2014

Overview

 Definition & brief background of physics  What major therapy “programs” use it  Discuss some recent studies that show the effects of different parameters/ on different populations.  Demonstrations  Therapy hierarchies  Case examples

3 Major Ways of Doing SOVT

(Andrade 2014) 1. Constant frontal narrowing of the vocal tract (nasals/ glides and hand-over-mouth); 2. Lengthening (and narrowing) the vocal tract through means of a tube (Lax-Vox/Straw).

• 3. 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)

My burning questions

• • Is 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 overclosure

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)

An entire conference on SOVT!

A little bit of the physics

-

SOVT (at the lips) works by…….

Raising the mean supraglottal and intraglottal pressures

-

Impedance 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 effort

–

Decreased strain

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

A little bit of physics

Lowering 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/

•

Some SOVT

Widen the pharynx in relation to the epilarynx -> a clustering of the 3rd, 4th, & 5 th formants ( Andrade 2014) –

“Singer’s Formant”

Marco Guzman, et al Resonance Tube and Straw Phonation 523.e27

SOVT is used in

 Stemple’s Vocal Function Exercises (nasals & Finnish bilabial fricative)  Verdolini-Abbots – LMRVT – core part of her Voice Therapy Spectrum – using M  LaxVox (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)

SOVT is used in

• • • • Accent Method (voiced fricatives) Estill Siren on “ng”, sirening Titze’s Straw exercise for men, larger diameter for women – Titze Brisbane 2013) (small diameter Glide loaded sentence of CAPE-V

We were away a year ago

–

& S/Z ratio

Lax Vox

– Stemple 2011 1 of the Big 3 things for future voice therapy .

Lax Vox indicated for:

Stemple (2011) 

Holistic therapy for various functional and

organic voice disorders:  Muscle tension dysphonia  Vocal fold nodules and polyps  Habitual and psychogenic dysphonias-aphonias (by masking proprioceptive feedback)  Vocal fold paralysis (RLN and SLN)  Presbyphonia  Puberphonia • Pre and postoperative phonosurgery

Lax Vox in Singing and Theatre voice

Stemple (2011)  Daily voice care for all groups of voice users  Prevention of voice problems for vocal athletes  Developing vocal muscles with several exercises (glissando, staccato, Messa di Voce, etc.)  Glottal closure deficiencies  Warming up and cooling down  Finding and developing the optimal voice (primal sound)  Balancing the glottal attack  Facilitating the lowered larynx  Developing registers and smoothing the passaggio

Lax Vox Reference

Denizoglu 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!)

SOVT researched in:

• • • • • • Teachers (RVT and Finnish Tube) Elderly (Finnish Tube) Actors and singers (RVT) “Behavioural” voice problems Benign vocal lesions Haven’t yet found research on Unilateral Vocal Fold Paralysis

Some Recent Studies

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

Some Recent Studies

• • • Immediate effects – normal speakers – trained/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/

Summary of Articles will follow

Andrade et al 2014

Electroglottographic Study of Seven Semi-Occluded

Exercises:…….Journal of Voice

Andrade 2014 SOVTE

1. LaxVox ( 9mm id, 25cm –? Water depth) 2. Straw ( 12.5 cm in length & 4 mm in diameter) 3. Lip-trill 4. Tongue-trill 5. Hand-over-mouth 6. Humming 7. Tongue-trill with hand-over-mouth.

Procedure

Andrade 2014  N = 23 healthy volunteers  SP demonstrated and provided teaching on error until subjects produced correctly  Asked to do same pitch for all activities.

Electroglottographic & Acoustic measures

F1 – F0

Andrade 2014

• • • Steady (single source) Hand-over-mouth Humming Straw with lower CQr & F1 - F0 difference Easiest Phonation

SOVT

Andrade et al. 2014 • Fluctuating (dual source) Tongue-trill • • Lip-trill LaxVox with larger CQr & F1 - F0 difference More effortful phonation but ? gives massage effect

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 .

Tongue Trill + Hand Over Mouth

Andrade 2014 Exhibited mixed effects in both the exercise groups

Costa et al., 2011. Immediate effects of

the phonation into a straw exercise

Costa et al 2011

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

 Rigid plastic straw 8.7 cm long & 1.5 mm diam  Examiner 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 Ax

Costa et al 2011

• •

Significant 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 assessments

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 Voice

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 resonance

Gaskill & Quinney 2012 Procedure

 12 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.

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 predictions  does need an individualized approach that could include trying multiple tube lengths and diameters as well in pitch as extended and systematic practice with larger variations than those exhibited in this study

Guzman et al 2013 Laryngeal and

Pharyngeal Activity During Semioccluded Vocal Tract Postures in Subjects Diagnosed With Hyperfunctional Dysphonia

 8 SOVT exercises:

SOVT postures

Guzman et al 2013  N=20 hyperfunctional dysphonia  8 SOVT exercises:  Blinded laryngologists rated 3 endoscopic variables using a five-point Likert scale  vertical laryngeal position (VLP), pharyngeal constriction, and laryngeal compression

SOVT postures in hyperfunctional dysphonia

Guzman et al 2013  All semioccluded techniques produced  a lower larynx  narrower aryepiglottic opening  and a wider pharynx

Compared to resting position

 VLP, 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

Lower Laryngeal Position

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

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.2013.04.007

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 .

Results – Paes 2012

• • • • • 68% 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.

Dos Santos, et. al.(2014). Verifying

the effectiveness of using resonance tubes in voice therapy with elderly people

.

Resonance Tubes in the “Elderly”

Dos Santos et al 2014 Resonance Tube Group:  Improvement in Grade, Asthenia, Strain, Instability on GRBASI  No change in breathiness  90% self-reported improvement  Improved Vital Capacity  Improved spirometry

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 females x6 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.

Verdolini, 2012.

Vocal exercise may attenuate acute vocal fold inflammation

Resonant voice for treatment of vocal fold inflammation

Verdolini 2012  N=3 healthy males  Used Resonant Voice  Prospective, Randomized and double blind  by randomization to a  1-hour vocal loading procedure, followed Talking 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.

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-8  Results were poorest at 24-hour follow-up in the talking as normal condition  Sharply improved in the voice rest condition  Were the best in the RV condition

Summary

• • • • SOVT exercises can optimise the closure of the vocal folds, open the pharynx wider These effects tend to occur immediately They 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.