Speech Therapy -> Voice


Voice therapy is an approach used by speech-language pathologists to help patients find relief from symptoms and achieve the best possible voice.

Skilled interventions

  • Confidential Voice Therapy

    Confidential voice therapy involves the SLP teaching the patient how to lower the volume of the voice while using an easy, breathy voice quality, as if speaking “confidentially” to someone. It is most commonly used as an effective means of significantly reducing the pressure on the vocal folds during phonation for a limited period, after which a patient may return to a more functional volume of speech.

    This type of voice therapy is indicated following an acute vocal fold injury or as a method of gradually resuming voice use following surgery. In confidential voice therapy, patients are trained to produce a soft, breathy voice without full vocal fold closure.  It is considered as the First-Line Voice Therapy Regimen During Early Recovery Period. The main goal, in fact, of this technique is to allow patients to speak while vocal fold health improves. The patient should use the confidential voice in all speaking situations. Then, when the vocal folds have healed, other regimens can be used to bring the voice back to its full strength, tone, and color. Whispered voice is not desirable.

    Indications: Vocal cord injury, vocal muscle tension. Method: Patients typically use the confidential voice for about two to three weeks; after this period of time, symptoms such as pain, fatigue, and substantial hoarseness should improve, allowing more intense therapeutic regimens to be started (Stemple, et al., 2000; Pannbacker 1998).

  • Hygienic Voice Therapy

    Hygienic voice therapy is an approach targeting vocal behaviors in the patient’s habitual speech patterns that are the case of the voice disorder. Once the SLP identifies the poor vocal hygiene habits the patient is instructed on how to modify or eliminate the behavior leading to improved voice production. Poor vocal hygiene behaviors include shouting, talking loudly over noise, screaming, vocal noises, coughing, throat clearing, and poor hydration. Poor vocal hygiene may also include the habitual use of voice components in an inappropriate manner.

    For example: use of an inappropriate pitch our loudness, reduced respiratory support, poor phonatory habits (glottal attacks/glottal fry) or inappropriate resonance are simply functional vocal behaviors(Stemple, et al., 2000; Pannbacker, 1998).

  • Lee Silverman Voice Treatment

    Lee Silverman Voice Treatment is specifically designed for patients with Parkinson's disease, the Lee Silverman voice treatment advocates increasing the effort with which patients speak – thereby "pushing" the voice and making it stronger. In essence, patients are trained to exhale higher volumes of air out of their lungs, more forcefully – while simultaneously closing their vocal folds more completely. The result is a louder and stronger voice. Indications: This regimen was specifically designed to treat voice disorders caused by Parkinson's disease, but is also being increasingly used to treat vocal symptoms in other types of neurological disorders (Stemple, et al., 2000; Pannbacker 1998).

  • Physiologic Voice Therapy

    Physiologic voice therapy is a holistic approach and includes voice therapy programs that directly alter or modify the physiology of the vocal mechanism. The focus is to balance the three subsystems of voice production at once (Stemple, et al., 2000; Pannbacker, 1998).

    • Accent Method of Voice Therapy

      The accent method of voice therapy focuses on improving breathing technique to increase voice clarity. Specifically, patients are taught to use accentuated and rhythmic movements in both their pronunciations and in related body movements. Proponents of the therapy suggest that it helps relax the vocal muscles while also helping to synchronize voice production with a recognizable rhythm produced by another part of the body.

      While vocal therapists practice the accent method with some degree of variation, in general treatment takes the form of a therapist asking questions to a patient in a particular rhythm – and the patient responding in that same pattern. Accent voice therapy helps patients adjust the timing and rhythm with which they breathe and accent words.

      Some form of additional stimulus may be used, such as a body movement or a drum or tambourine, to help patients form a series of exaggerated syllables or words. These exercises progress to longer phrases and eventually sentences. Throughout the exercises, the accentuated rhythm used during speaking is maintained, while the body movements and other external stimulus that were used initially are reduced or eliminated (Stemple, et al., 2000; Pannbacker 1998).

    • Vocal Function Exercises

      Vocal function exercises: This is a program of systematic exercises that strengthen and rebalance the subsystems involved in voice production (respiration, phonation, and resonance).

      Vocal function exercises:
      1. Sustain /i/ vowel for as long as possible. The goal is for /i/ to equal the longest /s/ that the patient is able to sustain. This is produced softly but not breath and the voice must be engaged. This is considered the warm up.
      2. Say the word “knoll” glide from the lowest note to the highest note with no voice breaks. Glides improve muscular control and flexibility and are considered a stretching exercise.
      3. Say the word “knoll” from the highest note to lowest note with no voice breaks and no growl. This is considered a contracting exercise.
      4. Sustain musical notes C,D,E,F, and G as long as possible on the word “knoll” minus the “kn”. The “oll” at different notes is considered a low impact adductory power exercise. Exercises include maximum vowel prolongations and pitch glides using specific pitch and phonetic contexts. Vocal functional exercise is necessary to regain the balance among airflow, to this laryngeal muscle activity, to the supraglottic placement of the tone.

      Indications: Vocal fold lesions, Muscle tension dysphonia, Hypophonia (weak voice).

  • Psychogenic Voice Therapy

    Psychogenic voice therapy is an approach that focuses on identification and modification of the emotional and psychosocial disturbances associated with the onset and maintenance of the voice problem. When the psychogenic causes are resolved, the voice disorder dissipates. SLP must have developed superior interview and counseling skills, as well as the skill to know when the emotional or psychosocial problem is in need of more intensive evaluation and therapy by other professionals (Stemple, et al., 2000).

  • Resonant Voice Therapy

    Resonant voice therapy: Resonant voice (or voice with forward focus) refers to a voice that resonates or echoes within the face or facial bones. Resonant voice therapy is a tool that voice therapists use to help patients feel the vibrations of their voices along the lips, tongue, and nose, and then use those sensations to help better project their voices.

    Intended endpoint: This approach aims to produce voice with the vocal folds lightly touching rather than closed tightly – achieving sound volume through resonance. The use of humming or chanting is an integral part of this approach.

    Application group: Resonant voice therapy is now used by vocal therapists to treat a number of voice disorders, such as muscular tension dysphonia and vocal fold lesions (Stemple, et al., 2000; Pannbacker, 1998).

  • Symptomatic Voice Therapy

    Symptomatic voice therapy is an approach where the SLP identifies a voice therapy facilitating technique which, when used by a particular patient, enables him/her to easily produce a good voice. The focus of symptomatic voice therapy is direct modification of specific vocal symptoms: pitch, loudness, resonance, or respiration. Facilitating techniques include but are not limited to: chewing exercises, circumlaryngeal massage, elimination of abuses, establishing new pitch, relaxation, respiration training, and yawn-sign approach (Stemple, et al., 2000; Drudge & Philips 1976; Russell 2010; Pannbacker 1998).

    Chewing Exercises: Better vocal fold approximation and optimum muscular adjustment of the vocal folds are specific physiologic improvements that result from this technique. The muscular adjustments that are facilitated by the chewing approach usually result not only in a reduction of hard glottal attack but also in simultaneous improvements in loudness, pitch, and vocal quality.

    Method: Advise the patient that you understand that he or she may feel awkward or silly when first trying the technique but that the technique is, nonetheless, very useful. Have the patient sit facing a mirror. Ask the patient to pretend he or she is chewing a chunk of cotton candy. Tell the patient to chew in a relaxed, open-mouthed, exaggerated manner and to pretend to move the cotton candy around in the mouth with exaggerated movements of the tongue. Do not rush this stage of the technique and do not proceed until the patient is capable of producing a natural and exaggerated manner of chewing. While the patient is engaged in exaggerated chewing, ask him or her to start phonating softly. It may be necessary to model this for the patient. After the patient has become adept at using a relaxed method of chewing and phonating, ask him or her to inhale deeply and to chew and phonate the outgoing air stream. Encourage the patient to let the vocal pitch vary erratically. It is important for the patient to practice chewing and phonating until a relaxed voice is produced. Next, the patient should be told to simultaneously chew, phonate, and articulate brief two- or three-word combinations that begin with vowels (e.g., "I am in", "I am over", "I am up"). When the patient begins to demonstrate relaxed phonation with short phrases, additional stimulus materials should be introduced. Practice drills should progress to include chewing sentences at various pitch and loudness levels. Daily practice with the chewing technique should continue until the patient begins to demonstrate diminished laryngeal dysfunction in conversational speech.

    Circumlaryngeal massage: A "hands-on" approach in which patients are trained to massage their neck area while observing different changes in their voice quality. The purpose of this technique is to eliminate pain while speaking, relax muscles in the laryngeal area, and reduce tension in the upper body – all helping to decrease pain and allowing the larynx to relax into a more comfortable position (Russell, 2010). Indications: It is used in patients who report neck tension, upper body tension, stiffness, or tenderness along with vocal symptoms. It is also used for muscle tension dysphonia (functional dysphonia).

    Elimination of abuses, hard glottal attach: Patient is taught to produce a soft glottal attach or an easy onset by initiating phonation with the sound /h/, utilizing vowels, vowel-consonant combinations, and progressing through words, phrases, paragraph reading, and conversation. The /h/ is extinguished as soon as possible in the process.

    Establishing new pitch: There is great controversy among speech pathologists regarding whether a patient's vocal pitch should be changed when the lowered vocal pitch is due to increased loading of the vocal folds by mass lesions that are secondary to vocal abase. Often, a patient's vocal pitch is not actually lowered, but is perceived as lowered because of alterations in loudness, vocal effort, and vocal quality Unless a patient is phonating in the range of vocal fry or is phonating at a pitch that makes gender identification difficult, it is probably best not to work directly on changing vocal pitch. Raising the patient's habitual pitch level can be very risky in patients with lesions due to vocal abuse. If the habitual pitch is accidentally raised too high, laryngeal tension will be increased at a time when increased tension could further irritate already sensitive vocal folds. If, after extensive consideration, it is deemed necessary to use techniques to normalize vocal pitch, the following procedures should be used:

    1. A pitch pipe can be used to provide a pitch for the patient to model.
    2. Specialized instrumentation such as a Visi-Pitch, Tunemaster III, or a Tonar II can be used to monitor the patient's pitch level.

    1. The patient should be instructed to attempt to sustain the vowel /a/ at the optimal pitch level.
    2. As the patient becomes more skilled at pitch control, a progression from other vowels to single words phrases, sentences, and monologue should be used until the new vocal pitch level becomes habitual.

    Respiration training: Therapy approach for breath support focuses on coordinating breathing with vocalization.

    Indications: Talking with decreased breath support. Professional speakers who may require greater breath support during presentation than during normal conversational speech. Patients with excessive cough, Paradoxical vocal fold motion disorder, vocal spasm or laryngeal irritation.

    1. Ear training: Ask the patient to read a paragraph and tape-record sample of his/her voice and use it to monitor the patient’s respiration strategy
    2. Ask the patient to say as many numbers as possible on one normal expiration and to stop before any force or strain is evident.
    3. Give the patient a paragraph with phrase markers, and ask the patient to read it aloud with normal inhalation occurring at each phrase marker.
    4. The discussion between the clinician and the patient should be audio-taped. Then, monitor the tape for inappropriate breathing patterns.
    5. The patient is asked to monitor his or her voice daily during non-therapy conversational times.

    Yawn-sigh technique: The yawn serves to expand the pharynx and to stretch and then relax the extrinsic laryngeal muscles, thus lowering the larynx in the neck to a more neutral position and permit a more forward placement of the tongue in the oral cavity.

    Method: Patients are asked to initiate the first half of a yawn behavior. The subsequent sigh should then be more relaxed with less tension noted in the phonation of the tone. From the sigh phonation, the patient is taught to appreciate the sensation of laryngeal relaxation. The yawn-sigh technique is then paired with vowels and then gradually expanded into words, phrases, paragraph readings, and conversational speech.

Reference links

  • The Role of Speech-Language Pathologists In Voice Therapy 1
    Author: SpeechPathologyGraduatePrograms.org - The inability to use our voices effectively has the potential to have a major impact on personal relationships, careers, and the overall quality of our lives. Although many think that voice therapy is reserved for singers, actors, and broadcasters, in reality, virtually everyone can benefit from voice therapy to heal, manage, or prevent voice disorders at some point. Speech-language pathologists (SLPs) specializing in voice therapy are involved in the diagnosis, assessment, planning, and treatment of individuals with voice disorders. These healthcare providers are trained to evaluate voice use and vocal function to determine the causes of voice loss and the best treatments for improving and maintaining voice production. To fully understand the role of SLPs in voice therapy, it’s important to first understand what voice disorders are, how they develop, and their underlying causes.
  • Bilingual Service Delivery 1
    Author: ASHA - Information and resources regarding bilingual service delivery by SLPs (from ASHA)
  • A Holistic Approach to Voice Therapy 0
    Author: Joseph C Stemple - Therapy approaches designed to improve the disordered voice may be equally effective when used to enhance the normal voice. A holistic approach to voice therapy is based on a continuum of voice wellness from the disordered voice to the elite voice of the healthy performer. Individuals take charge of the wellness of their voices by following good principles of vocal hygiene and exercising the vocal mechanism in a healthful manner. All voices may be improved on this continuum toward the ideal. When voice therapy techniques attend to the three subsystems of voice production, respiration, and phonation and resonance, the techniques fall into the category of holistic voice therapies. Vocal Function Exercises is one holistic voice therapy approach that has been found to be effective in improving those with voice disorders and enhancing the normal voice. This article introduces the concept of holistic voice therapy and describes the specific Vocal Function Exercise Program.
  • Voice Therapy 0
    Author: DukeHealth - Anyone can develop a voice problem at any stage of life. People who use their voices professionally -- such as teachers, coaches, clergy members, performers, and telemarketers -- may be more likely to have voice problems. Voice therapy can improve your voice’s health, function, quality, and stamina. That's why it's often described as "physical therapy for your voice." You may be referred for voice therapy after a joint voice evaluation by a laryngologist -- an ear, nose, and throat (ENT) doctor with advanced training in voice disorders -- and a voice-specialized speech pathologist.
  • Bilingual (Spanish/English) Evaluation Resources 1
    Author: Bilinguistics - Dozens of speech, language, fluency, and other evaluation resources for bilingual evaluations

Activity List(s)

Visual Schedule Cards

Related Disorder(s)

  • Voice disorders - Voice disorders are medical conditions involving abnormal pitch, loudness or quality of the sound produced by the larynx and thereby affecting speech production.

Goal Bank

  • Marci will implement 3 healthy vocal hygiene practices during daily tasks over a 2 week period. 0
  • Maria will demonstrate healthy vocal quality in the context of her daily work and social activities during continuous voice use for at least 15 minute monologues after 4 weeks. 0