Vocal Function Exercises

Laryngeal Adduction
Exercises
 Purpose

■ To improve vocal quality

■ Increase muscle activity

 Laryngeal Adduction
Exercises
Pushing/pulling Holding breath
Glottal attack Pseudo supraglottic swallow
 Who?
• used with patients with poor vocal fold adduction
(hypo-adduction)
• laryngeal trauma (may result in recurrent laryngeal
nerve paralysis)
• neurological diseases
▫ PD, MS, closed head injury, stroke, congenital
conditions such as sulcus vocalis (vocal fold furrow)
• 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
(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)
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 – Improved vocal quality
hyperfunction ■ Overall improvement in vocal
– 53 year old folds
– Avoid hyperfunction as a ■ Frontal focus
new, higher pitch is ■ 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