Presented By
Fahad Masood
Senior lecturer
BS/HS-BSMA-242
BS/HS-BSMA-242
Vocal Function
Exercises
Laryngeal
Adduction
Exercises
In this topic we will
study about vocal
exercices
Purpose
• To improve vocal quality
• Increase muscle activity
Who?
• used with patients with poor vocal fold adduction (hypo-
adduction)
• laryngeal trauma, (may result in recurrent laryngeal nerve
paralysis)
• neurological diseases :
▫ Parkinsons Disease , Multiple scleorosis, closed head injury,
stroke, congenital conditions such as sulcus vocalis (vocal
fold furrow)
(Ramig & Verdolini, 1998)
Purpose
• Voice quality
▫ Facilitate improved vocal fold closure during voice
production.
▫ Helps to treat breathiness, low intensity,
hoarseness, or overall vocal quality.
▫ Conditions such as vocal fold bowing and vocal
fold weakness or paralysis.
(Logemann, 1998)
• should not be used in patients with voice problems
due to vocal fold inflammation or mass lesions on the
folds (i.e. nodules, polyps)
• Pushing and pulling exercises should not be used
with patients that have uncontrolled high blood
pressure
Purpose
• Swallowing safety / airway protection.
• Increase muscle activity in the larynx.
• Basic to good laryngeal closure during
swallowing.
• A sequence of these exercises should be
completed before actual swallowing therapy
▫ if laryngeal incompetence can’t be managed
quickly by postural assists or teaching the patient
to voluntarily close their airway
(Logemann, 1998)
Method
• Two sets of exercises
• The series of exercises should be completed five
to ten time per day for five minutes
• Each exercise should be repeated 5 times before
moving on to the next exercise in the set
• The whole series of exercises should be repeated
three times
(Logemann, 1998)
Set 1
Exercise 1:
Be seated.
Hold your breath as tightly as possible while
pushing down or pulling up on your chair with
both hands for 5 sec.
(Logemann, 1998)
Set 1
Exercise 2:
Be seated.
Bear down against a chair with only one hand.
Produce clear voice simultaneously.
(Logemann, 1998)
Set 1
Exercise 3:
Repeat ‘ah’ 5 times with a hard glottal attack on
each vowel.
Ah.. Ah..ah..ah..ah..
(Logemann, 1998)
Set 1
• Patients should practice this series every day for one
week.
• A follow-up swallow evaluation should be completed to
assess improvements in airway protection from the
larynx.
• The SLP and patient can also monitor improvements in
laryngeal function by listening to clarity and vocal quality.
• If no improvements are noted, the exercises should be
changed to those in Set 2.
▫ This prevents monotony and introduces exercises in a
hierarchy
(Logemann, 1998)
Set 2
• The series of exercises should be completed five
to ten time per day for five minutes.
• Each exercise should be repeated 5 times before
moving on to the next exercise in the set .
• The whole series of exercises should be repeated
three times.
(Logemann, 1998)
Set 2
Exercise 1:
Pull up on chair with both hands while
prolonging phonation.
(Logemann, 1998)
Set 2
Exercise 2:
Begin phonation of ‘ah’ with a hard glottal attack
and sustain phonation with a clear, smooth vocal
quality for 5-10 seconds
(Logemann, 1998)
Set 2
Exercise 3:
Pseudo-supraglottic swallow.
Take a breath, hold it, and cough as strongly as
possible.
(Logemann, 1998)
Recovery
• Improvement should be seen within 2 weeks
• Occasionally it will take 6-8 months with some
patients to attain adequate airway protection or
vocal quality .
▫ these are often those who have had more serious
conditions (i.e. extended supraglottic
laryngectomy)
(Logemann, 1998)
Efficacy
• There is very little research about the use and
efficacy of laryngeal adduction exercises.
• Since there are extremely few efficacy studies
concerning vocal fold adduction exercises, few
SLPs currently use the pushing and pulling type
of exercises.
▫ Yamaguchi et al. (1990)
▫ Silverman Voice Treatment (LSVT)
Yamaguchi et al. (1990)
• Cases of glottal incompetence
• Treated by the pushing exercises technique.
• Three patients that had paralysis of the vocal folds or
sulcus vocalis
• All three individuals improved following voice treatment.
▫ Two improved 20 dB (statistically significant increase
in intensity), and one improved 7 dB (clinically
significant increase in intensity).
LSVT
• The Lee Silverman Voice Treatment (LSVT)
program utilizes intensive high phonatory effort
exercises in order to increase vocal fold
adduction.
• It has been documented to have short and long
term effectiveness for those with idiopathic
Parkinson’s Disease.
(Ramig, 1998)
Vocal Function Exercises
“Knoll”
Who?
• Beneficial to treat
▫ Hyperfunction
Too much laryngeal activity
▫ Hypofunction
Too little laryngeal activity
• Prevention
▫ Hyperfunction
▫ Vocal symptoms
• Research has demonstrated improvements for
▫ Vocal nodules
▫ Singers
▫ Aging voice
Philosophy
• The laryngeal mechanism, like other muscle
systems, may become imbalanced and/or
strained.
• VFE treat in a holistic manner.
• “Physical therapy” for the voice
(Stemple, Glaze, & Gerdeman-Klaben, 2000)
Purpose
• Increase the bulk, strength, and coordinated
interaction of muscles
• Improved glottal efficiency
• Improved vocal quality
▫ Easy onset
▫ Frontal focus
▫ Respiratory support
▫ Balance respiration, phonation, & resonance
(Stemple, 2000; “Vocal function exercises”, n.d.)
Method
• Set of 4 exercises
• Completed 2x each, 2x daily
▫ 1x in the morning, 1x in the afternoon
• Complete as softly as possible to .
▫ Purpose: increase muscular and respiratory effort
to maintain phonation.
(Andrews, 2006)
Step 1: Warm-Up
• Sustain the vowel /i/ for as long as possible
▫ on a musical note F
above middle C for women and children
below middle C for men.
May be modified based on patient’s vocal range.
• Goal
▫ Dependent on patient’s airflow volume.
▫ Targeted volume is 80-100 mL/s of airflow.
Flow volume, mL H2O/100 mL H2O = _______
seconds
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Step 2: Stretching
• Say “Knoll” and glide from lowest note
to highest note in vocal range.
• Goal
▫ Complete without voice breaks.
▫ Use of the word “knoll” encourages a forward vocal
focus and an open pharynx.
▫ Lips should be rounded and the patient should feel
vibration on the lips.
▫ During this exercise, vocal folds are stretched and
muscle control and flexibility is improved.
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Step 3: Contraction
• Say “Knoll” and glide from highest note to
lowest note in vocal range.
• Goal:
▫ Complete without voice breaks.
▫ Encourages a forward focus and an open
pharynx.
▫ Complements the previous stretching exercise
by contracting the laryngeal muscles.
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Step 4:
Adductory Power Exercise
• Voice “Oll” (“knoll” without “kn”) as long as
possible on musical notes C, D, E, F, and G
▫ above middle C for women and children
▫ below middle C for men
modify based on patient’s vocal range).
• Goal
▫ dependent on patient’s airflow volume.
▫ The goal is the same as the first exercise with a
targeted volume is 80-100 mL/s of airflow.
(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)
Recovery
• Patients track progress on a graph
▫ Sustained times
▫ Daily variation is expected
• Improvement typically seen within 6-8 weeks
(Stemple, Glaze, and Klaben, 2000)
Maintenance
Once goals have been met and vocal quality has
improved, the following weekly program is
recommended:
Full program 2 times each, 2 times per day
Full program 2 times each, 1 time per day (morning)
Full program 1 time each, 1 time per day (morning)
Exercise #4, 2 times each, 1 time per day (morning)
Exercise #4, 1 time each, 1 time per day (morning)
Exercise #4, 1 time each, 3 times per week (morning)
Exercise #4, 1 time each, 1 time per week (morning)
(Stemple, Glaze & Klaben, 2000)
Efficacy
Voice Therapy: Clinical Studies (Stemple, 2000)
Provides a variety of cases in which he has used VFE
• Hyperfunction • Hypofunction
▫ 9 year old ▫ 71 year old
▫ 21 year old ▫ 36 year old
▫ Improved vocal quality ▫ Improved efficiency of
Easy onset, respiratory breath support for
support, frontal focus phonation
Balance among respiration,
phonation, resonance • Treatment of vocal nodules
▫ 26 year old
• Prevention of hyperfunction
▫ Improved vocal quality
▫ 53 year old
Overall improvement in
▫ Avoid hyperfunction as a vocal folds
new, higher pitch is learned Frontal focus
Increased MPT
Prevention of Vocal Symptoms
• Pasa, Oates, & Dacakis (2007)
▫ 37 primary school teachers
▫ Ages: 21 to 55
▫ Results
Decrease in vocal symptoms.
Improved vocal quality.
Increased maximum phonation times.
Singers
• Wrycza-Sabol, Lee, and Stemple (1995)
▫ 20 healthy graduate-level voice majors
▫ Ages 21 to 55
▫ Results:
Improved glottal efficiency
Increased airflow rates
Imporved phonation volumes
Increased MPTs
Aging Voice
• Gorman, Weinrich, Lee, and Stemple (2008)
▫ 19 male participants
▫ Ages 60 to 78
▫ Results:
Continuous improvements in MPT
Improved glottal closure
References
• Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through geriatrics.
Thomson: Canada.
• Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic changes as a result
of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903.
• Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing
disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX.
• Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North
American, 37, 105-119.
• Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene
training and vocal function exercises in preventing voice disorders in primary school
teachers. Logopedics Phoniatrics Vocology 32, 128-140.
• Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech,
Language, and Hearing Research, 41, 101-116.
• Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada.
• Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice pathology:
Theory and management. Singular: Canada.
• Vocal function exercises. In Vocology. Retrieved July 13, 2009, from
http://ncvs.org/museum-archive/vocologyguide.pdf
• Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function exercises in
the practice of regimen of singers. Journal of Voice, 9(1), 27-36.
• Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990). Pushing
exercise program to correct glottal incompetence. Annual Bulletin of the Research
Institute of Logopedics, 24, 223-234.
