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A Holistic Approach to Voice Therapy

Article in Seminars in Speech and Language · June 2005

DOI: 10.1055/s-2005-871209 · Source: PubMed

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A Holistic Approach to Voice Therapy
Joseph C. Stemple, Ph.D.1

ABSTRACT

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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.

KEYWORDS: voice therapy, holistic health, Vocal Function Exercises

Learning Outcomes: As a result of this activity, the participant will be able to (1) define several orientations to
voice therapy; (2) describe the concept of a holistic approach to voice therapy; and (3) apply Vocal Function
Exercises to client management and to personal vocal health.

INTRODUCTION TO VOICE THERAPY pitch appropriate to the age and sex, (4) a slight
Historically, care of the voice by speech- vibrato, and (5) a graceful and constant inflec-
language pathologists began in the 1930s as tion of pitch and force which follows the mean-
an outgrowth of techniques used to enhance the ing of what is spoken.1,2
normal voice. From texts and techniques bor- This goal became the definition of what
rowed from elocution, oral interpretation, and would be expected in normal voice production.
public speaking, the early goal of therapy was to Many therapy techniques used to train this
develop and improve voice characterized by (1) ideal voice have evolved since these early begin-
adequate loudness, (2) clearness of tone, (3) a nings, including therapies designed to enhance

Subclinical Communication Problems; Editors in Chief, Audrey L. Holland, Ph.D., and Nan Bernstein. Ratner, Ed.D.;
Guest Editor, Lisa K. Breakey, M.A. Seminars in Speech and Language, volume 26, number 2, 2005. Address for
correspondence and reprint requests: Joseph C. Stemple, Ph.D., 369 West First Street #408, Dayton, OH 45402,
E-mail: [email protected]. 1Blaine Block Institute for Voice Analysis and Rehabilitation, Dayton, Ohio. Copyright #
2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0734-
0478,p;2005,26,02,131,137,ftx,en;ssl00235x.
131
132 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 2 2005

vocal hygiene, therapy that identifies and modi- and spiritual. When one part is not working
fies vocal symptoms, therapy that attends to the at its best, it impacts all of the other parts of
psychogenic aspects of the voice disorder, and that person. Furthermore, this whole person,
therapy that explores the underlying physiology including all of the parts, is constantly inter-
of the voice disorder and modifies that physiol- acting with everything in the surrounding en-
ogy through direct voice exercises.3 vironment.4
In short, hygienic voice therapy focuses on In addition to these concepts, holistic
identifying and then modifying or eliminating health focuses on a wellness continuum and
inappropriate vocal hygiene behaviors such as not on disorders or disabilities. This may be
shouting, talking loudly over noise, singing out demonstrated by using a wellness line. The line
of range, screaming, coughing, throat clearing, represents all possible degrees of health. The far

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and poor hydration. Symptomatic voice therapy left end of the line represents premature death.
focuses on modification of deviant vocal symp- On the far right end is the highest possible level
toms such as pitch, loudness, breathiness, hard of wellness or maximum well-being. The center
glottal attacks, and glottal fry. The focus of point of the line represents a lack of apparent
psychogenic voice therapy is on the client’s disease. This places all levels of illness on the
emotional and psychosocial status that led to left half of the wellness continuum. The right
and maintained the voice disorder. The phys- half shows that even when no illness seems
iologic orientation of voice therapy focuses on to be present, there is still much room for
directly modifying and improving the balance improvement.4
of laryngeal muscle activity to the supportive Holistic health is an ongoing process. As a
airflow, as well as the correct focus of the lifestyle, it includes a personal commitment to
laryngeal tone. Most voice treatment is eclectic, be moving toward the right end of the wellness
using some combination of all of the orienta- continuum. No matter what their current status
tions.3 It is important to note that all of these of health, people can improve their level of
therapy techniques are equally effective for the well-being. Even when there are temporary
normal as well as the disordered voice. setbacks, movement is always headed toward
wellness.4

HOLISTIC HEALTH
In global terms, holistic health is an approach to HOLISTIC VOICE THERAPY
life. Rather than focusing on illness or specific It is interesting that from both the historical
parts of the body, this ancient approach to perspective and from the present-day culture of
health considers the whole person and includes self-improvement, voice improvement is not
analysis of physical, nutritional, environmental, only for the disordered voice, but also for those
emotional, social, spiritual, and lifestyle values. who want to enhance their vocal performance
The goal is to achieve maximum well-being, and image. It is well understood that people are
where everything functions to the very best judged by the way they sound. Voice is often a
level possible. With holistic health, people delicate indicator of physical, emotional, and
accept responsibility for their own level of social status. Personality, attitude, and even
well-being, and make choices every day to subtle changes in mood and intent are reflected
take charge of their own health.4 in voice. Voice is an important part of the image
Holistic health is based on the concept that that each individual projects.
a whole is made up of interdependent parts. From the holistic health perspective, voice
The earth is made of interacting systems, such is one part of the physical, emotional, and life-
as air, land, water, plants, and animals. For life style status of an individual. On the wellness
to be sustained, these systems cannot be sepa- continuum, normal voice would represent the
rated, for what happens to one also affects the middle of the wellness line. The disordered
other systems. In the same way, an individual is voice would be located to the left of the midline,
a whole made up of interdependent parts, while the outstanding voice such as that of the
which are the physical, mental, emotional, opera singer or the great actor occupies the far
HOLISTIC APPROACH TO VOICE THERAPY/STEMPLE 133

right of the line. A large area of improvement is causes may be mechanical, neurologic, or psy-
possible from the midpoint to the far right. chological.3 Whatever the cause, one manage-
Therefore, many of the management approaches ment approach is direct modification of the
designed to improve the disordered voice may inappropriate physiologic activity through direct
also be used to enhance the normal voice. exercise and manipulation. When all three sub-
One of these management approaches, systems of voice are addressed in one exercise,
Vocal Function Exercises (VFE), directly fits then this is considered holistic voice therapy.
the concept of a holistic approach to voice Examples of holistic voice therapy include
therapy. These concepts comprise several hol- VFE,3,5 Resonant Voice Therapy,12 the Accent
istic health ideals, including: Method of Voice Therapy,13,14 and the Lee
Silverman Voice Treatment (CM).15

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1. Vocal wellness is a continuum including the In a double-blind, placebo-controlled
disordered voice, the normal voice, and the study, Stemple and colleagues5 demonstrated
super normal voice. No matter what their that VFE were effective in enhancing voice
current status of vocal health, people can production in young female adults without
improve their level of voice production if vocal pathology. The primary physiologic ef-
they make a personal commitment to be fects were reflected in increased phonation
moving toward the right end of the wellness volumes at all pitch levels, decreased airflow
continuum. Research demonstrates that rates, and subsequent increase in maximum
VFE both improve the disordered voice phonation times. Frequency ranges were ex-
and enhance the normal voice.5,6 tended significantly in the downward direction.
2. By choosing to follow this management Sabol and associates,6 experimenting with
approach, people accept responsibility for the value of VFE in the practice regimen of
maintaining and enhancing their vocal singers, used opera graduate-level students as
health. subjects. Once again, the results demonstrated
3. Voice is made of interdependent parts: res- significant improvement in physiologic mea-
piration, phonation, and resonance. A rela- surements of voice production including in-
tive dynamic equilibrium among these parts creased airflow volume, decreased airflow
must be maintained for voice to be normal or rates, and increased maximum phonation time
enhanced. even in this group of superior voice users.
Roy et al16 studied the efficacy of VFE
with a pathologic subject population. Teachers
VOCAL FUNCTION EXERCISES who reported experiencing voice disorders were
Normal voice production depends on a relative randomly assigned to three groups: VFE, vocal
balance among three subsystems: airflow, sup- hygiene, and control groups. For 6 weeks, the
plied by the respiratory system; laryngeal experimental groups followed their respective
muscle strength, balance, coordination, and therapy programs, monitored by licensed
stamina; and coordination among these and speech-language pathologists who were trained
the supraglottic resonators (pharynx, oral cav- by the experimenters in the two approaches.
ity, nasal cavity). Because of their interdepen- Pre- and post-testing of all three groups using
dence, a disturbance in one of these subsystems the Voice Handicap Index17 revealed signifi-
will affect the other two, causing a physiologic cant improvement in the VFE group, no im-
imbalance, which may be perceived as an in- provement in the vocal hygiene group, while
effective voice or as a voice disorder.3,7–10 the control group rated themselves worse.
Disturbances may be in respiratory volume, For the purpose of discussion, it is useful to
power, pressure, and flow. Disturbances may consider that the laryngeal mechanism is simi-
also manifest in vocal fold tone, mass, stiffness, lar to other muscle systems and may become
flexibility, and approximation. Finally, the cou- strained and imbalanced through many etiolo-
pling of the supraglottic resonators and the gic factors.18 Indeed, the analogy that we often
placement of the laryngeal tone may cause or draw with clients is a comparison of the reha-
be implicated in a voice disorder.11 The overall bilitation of the knee to rehabilitation of the
134 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 2 2005

voice. Both the knee and the larynx are com- The exercises are simple to teach and, as
prised of muscle, cartilage, and connective tis- the research has demonstrated, may improve
sue. When the knee is injured, rehabilitation both the disordered and the normal voice. The
includes a short period of immobilization for exercise program is concrete, similar in concept
the purpose of reducing the effects of the acute to physical therapy, and improvement of vocal
injury. The immobilization is followed by as- efficiency may be objectively plotted on a graph.
sisted ambulation and then the primary reha- The program begins by describing the relation-
bilitation begins in the form of systematic ship of the three subsystems to the client. The
exercise. This exercise is designed to strengthen client is then taught a series of four exercises to
and balance all of the supportive knee muscles be practiced at home, two times each, twice per
for the purpose of returning the knee to as close day, preferably morning and evening. These

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to its normal functioning as possible. exercises include:
Rehabilitation of voice may also involve a
short period of voice rest following acute injury 1. Sustain the /i/ vowel for as long as possible
or after surgery to permit healing of the mucosa on a musical note (F) above middle (C) for
to occur. The client may then begin conserva- females and boys, (F) below middle (C) for
tive voice use and follow through with all of the adult males. (Notes may be modified up
management approaches that seem necessary. or down to fit the needs of the client.
Full voice use is then resumed quickly and the Seldom are they modified by more than
therapy program often is successful in returning two notes in either direction.)
the client to normal voice production. We
would suggest, however, that on many occa- Goal: Based on airflow volume. (In our clinic the
sions clients are not fully rehabilitated because goal is based on reaching 80 to 100 mL/
one of the important rehabilitation steps was sec of airflow. So, if the flow volume is
neglected. That step is the systematic exercise equal to 4000 mL, then the goal is 40 to
program that is often necessary to regain the 45 seconds. When airflow measures are
balance among airflow, laryngeal muscle activ- not available, the goal is equal to the
ity, and the supraglottic placement of the tone. longest /s/ that the client is able to sustain.
Bertram Briess19,20 first described a series Placement of the tone should be in an
of laryngeal muscle exercises. Briess suggested extreme forward focus, almost, but not
that there is a direct relationship between the quite, nasal. All exercises are produced as
condition of the laryngeal musculature and the softly as possible, but not breathy. The
quality of voice and for the voice to be most voice must be ‘‘engaged.’’ This is consid-
effective, the intrinsic muscles of the larynx ered a warm-up exercise.)
must be in a dynamic equilibrium. Briess’s 2. Glide from your lowest note to your highest
exercises concentrated on restoring the balance note on the word ‘‘knoll.’’
in the laryngeal musculature and decreasing
tension of the hyperfunctioning muscles. Un- Goal: No voice breaks. The glide requires the
fortunately, many assumptions Briess made use of all laryngeal muscles. It stretches
regarding laryngeal muscle function were in- the vocal folds and encourages a system-
correct and his therapy methods were not atic, slow engagement of the cricothyroid
widely followed. The concept of direct exercise muscles. The word ‘‘knoll’’ encourages a
to strengthen voice production persisted. forward placement of the tone as well as
Barnes21 described a modification of Briess’ an expanded open pharynx. The client’s
work that she termed ‘‘Briess Exercises.’’ These lips are to be rounded and a sympathetic
exercises were modified and expanded by vibration should be felt on the lips. (May
Stemple22 into Vocal Function Exercises also use a lip trill, tongue trill, or the
(VFE). The exercise program strives to balance word ‘‘whoop.’’) Voice breaks will typi-
the subsystems of voice production whether the cally occur in the transitions between low
disorder is one of vocal hyperfunction or and high registers. When breaks occur,
hypofunction. the client is encouraged to continue the
HOLISTIC APPROACH TO VOICE THERAPY/STEMPLE 135

glide without hesitation. When the voice receive a better workout than if louder tones
breaks at the top of the current range and were produced. Extreme care is taken to teach
the client typically has more range, the the production of a forward tone that lacks
glide may be continued without voice as tension. In addition, attention is paid to the
the folds will continue to stretch. Glides glottal onset of the tone. The client is asked to
improve muscular control and flexibility. breathe in deeply with attention paid to train-
This is considered a stretching exercise. ing abdominal breathing, posturing the vowel
momentarily, and then initiating the exercise
3. Glide from your highest note to your lowest gesture without a forceful glottal attack or an
note on the word ‘‘knoll.’’ aspirate breathy attack. It is explained to the
client that maximum phonation times increase

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Goal: No voice breaks. The client is instructed
to feel a half-yawn in the throat through- as the efficiency of the vocal fold vibration
out this exercise. By keeping the pharynx improves. Times do not increase with improved
open and focusing the sympathetic vibra- ‘‘lung capacity.’’ Indeed, even aerobic exercise
tion at the lips, the downward glide does not improve lung capacity, but rather
encourages a slow, systematic engage- the efficiency of oxygen exchange with the
ment of the thyroarytenoid muscles circulatory system does, thus giving the sense
without the presence of a back-focused of more air.
growl. In fact, no growl is permitted. The musical notes are matched to the notes
(May also use a lip trill, tongue trill, or produced by an inexpensive pitch pipe that the
the word ‘‘boom.’’) This is considered a client purchases for use at home. He or she
contracting exercise. might be given a tape recording of live voice
doing the exercises that could be used for home
4. Sustain the musical notes (C-D-E-F-G) for practice as well. Many clients find the tape-
as long as possible on the word ‘‘knoll’’ recorded voice easier to match than the pitch
minus the ‘‘kn.’’ (Middle C for females and pipe. We have found that individuals who
boys, octave below middle C for males.) complain of ‘‘tone deafness’’ can often be taught
to approximate the correct notes with practice
Goal: Remains the same as for exercise number and guidance from the voice pathologist.
1. The ‘‘oll’’ is once again produced with Finally, clients are given a graph on which
an open pharynx and constricted, sym- to mark their sustained times, which is a means
pathetically vibrating lips. The shape of of plotting progress. Progress is monitored over
the pharynx to the lips is likened to an time and, because of normal daily variability,
inverted megaphone. The fourth exercise clients are encouraged not to compare today to
may be tailored to the client’s present tomorrow and so on. Rather, weekly compar-
vocal ability. Although the basic range isons are encouraged. Estimated time of com-
of middle C, an octave lower for males, is pletion for the program is 6 to 8 weeks. Some
appropriate for most voices, the exercises individuals experience minor laryngeal aching
may be customized up or down to fit the for the first day or two of the program similar to
current vocal condition or a particular muscle aching that might occur with any new
voice type. Seldom, however, is the ex- muscular exercise. As this discomfort will
ercise shifted more than two notes in soon subside, they are encouraged to continue
either direction. This is considered a the program through the discomfort should it
low-impact adductory power exercise. occur.
When the client has reached the predeter-
Quality of the tone is also monitored for mined therapy goal, and voice quality and
voice breaks, wavering, and breathiness. Qual- other vocal symptoms have improved, then a
ity improves as times increase and pathologies tapering maintenance program is recom-
begin to resolve. All exercises are done as softly mended. Although some individuals who use
as possible. It is much more difficult to produce their voices professionally may choose to
soft tones; therefore, the vocal subsystems will remain in peak vocal condition, many of our
136 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 2 2005

clients desire to taper the VFE program. The 2. Van Riper C. Voice and Articulation. Englewood
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*
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*
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