A Holistic Approach to Voice Therapy

Transcription

1 A Holistic Approach to Voice Therapy Joseph C. Stemple, Ph.D. 1 ABSTRACT 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 Historically, care of the voice by speechlanguage pathologists began in the 1930s as an outgrowth of techniques used to enhance the normal voice. From texts and techniques borrowed from elocution, oral interpretation, and public speaking, the early goal of therapy was to develop and improve voice characterized by (1) adequate loudness, (2) clearness of tone, (3) a pitch appropriate to the age and sex, (4) a slight vibrato, and (5) a graceful and constant inflection of pitch and force which follows the meaning of what is spoken. 1,2 This goal became the definition of what would be expected in normal voice production. Many therapy techniques used to train this ideal voice have evolved since these early beginnings, 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, Address for correspondence and reprint requests: Joseph C. Stemple, Ph.D., 369 West First Street #408, Dayton, OH 45402, jstemple@dhns.net. 1 Blaine 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) ,p;2005,26,02,131,137,ftx,en;ssl00235x. 131

2 132 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER vocal hygiene, therapy that identifies and modifies vocal symptoms, therapy that attends to the psychogenic aspects of the voice disorder, and therapy that explores the underlying physiology of the voice disorder and modifies that physiology through direct voice exercises. 3 In short, hygienic voice therapy focuses on identifying and then modifying or eliminating inappropriate vocal hygiene behaviors such as shouting, talking loudly over noise, singing out of range, screaming, coughing, throat clearing, and poor hydration. Symptomatic voice therapy focuses on modification of deviant vocal symptoms such as pitch, loudness, breathiness, hard glottal attacks, and glottal fry. The focus of psychogenic voice therapy is on the client s emotional and psychosocial status that led to and maintained the voice disorder. The physiologic orientation of voice therapy focuses on directly modifying and improving the balance of laryngeal muscle activity to the supportive airflow, as well as the correct focus of the laryngeal tone. Most voice treatment is eclectic, using some combination of all of the orientations. 3 It is important to note that all of these therapy techniques are equally effective for the normal as well as the disordered voice. HOLISTIC HEALTH In global terms, holistic health is an approach to life. Rather than focusing on illness or specific parts of the body, this ancient approach to health considers the whole person and includes analysis of physical, nutritional, environmental, emotional, social, spiritual, and lifestyle values. The goal is to achieve maximum well-being, where everything functions to the very best level possible. With holistic health, people accept responsibility for their own level of well-being, and make choices every day to take charge of their own health. 4 Holistic health is based on the concept that a whole is made up of interdependent parts. The earth is made of interacting systems, such as air, land, water, plants, and animals. For life to be sustained, these systems cannot be separated, for what happens to one also affects the other systems. In the same way, an individual is a whole made up of interdependent parts, which are the physical, mental, emotional, and spiritual. When one part is not working at its best, it impacts all of the other parts of that person. Furthermore, this whole person, including all of the parts, is constantly interacting with everything in the surrounding environment. 4 In addition to these concepts, holistic health focuses on a wellness continuum and not on disorders or disabilities. This may be demonstrated by using a wellness line. The line represents all possible degrees of health. The far left end of the line represents premature death. On the far right end is the highest possible level of wellness or maximum well-being. The center point of the line represents a lack of apparent disease. This places all levels of illness on the left half of the wellness continuum. The right half shows that even when no illness seems to be present, there is still much room for improvement. 4 Holistic health is an ongoing process. As a lifestyle, it includes a personal commitment to be moving toward the right end of the wellness continuum. No matter what their current status of health, people can improve their level of well-being. Even when there are temporary setbacks, movement is always headed toward wellness. 4 HOLISTIC VOICE THERAPY It is interesting that from both the historical perspective and from the present-day culture of self-improvement, voice improvement is not only for the disordered voice, but also for those who want to enhance their vocal performance and image. It is well understood that people are judged by the way they sound. Voice is often a delicate indicator of physical, emotional, and social status. Personality, attitude, and even subtle changes in mood and intent are reflected in voice. Voice is an important part of the image that each individual projects. From the holistic health perspective, voice is one part of the physical, emotional, and lifestyle status of an individual. On the wellness continuum, normal voice would represent the middle of the wellness line. The disordered voice would be located to the left of the midline, while the outstanding voice such as that of the opera singer or the great actor occupies the far

3 HOLISTIC APPROACH TO VOICE THERAPY/STEMPLE 133 right of the line. A large area of improvement is possible from the midpoint to the far right. Therefore, many of the management approaches designed to improve the disordered voice may also be used to enhance the normal voice. One of these management approaches, Vocal Function Exercises (VFE), directly fits the concept of a holistic approach to voice therapy. These concepts comprise several holistic health ideals, including: 1. Vocal wellness is a continuum including the disordered voice, the normal voice, and the super normal voice. No matter what their current status of vocal health, people can improve their level of voice production if they make a personal commitment to be moving toward the right end of the wellness continuum. Research demonstrates that VFE both improve the disordered voice and enhance the normal voice. 5,6 2. By choosing to follow this management approach, people accept responsibility for maintaining and enhancing their vocal health. 3. Voice is made of interdependent parts: respiration, phonation, and resonance. A relative dynamic equilibrium among these parts must be maintained for voice to be normal or enhanced. VOCAL FUNCTION EXERCISES Normal voice production depends on a relative balance among three subsystems: airflow, supplied by the respiratory system; laryngeal muscle strength, balance, coordination, and stamina; and coordination among these and the supraglottic resonators (pharynx, oral cavity, nasal cavity). Because of their interdependence, a disturbance in one of these subsystems will affect the other two, causing a physiologic imbalance, which may be perceived as an ineffective voice or as a voice disorder. 3,7 10 Disturbances may be in respiratory volume, power, pressure, and flow. Disturbances may also manifest in vocal fold tone, mass, stiffness, flexibility, and approximation. Finally, the coupling of the supraglottic resonators and the placement of the laryngeal tone may cause or be implicated in a voice disorder. 11 The overall causes may be mechanical, neurologic, or psychological. 3 Whatever the cause, one management approach is direct modification of the inappropriate physiologic activity through direct exercise and manipulation. When all three subsystems of voice are addressed in one exercise, then this is considered holistic voice therapy. Examples of holistic voice therapy include VFE, 3,5 Resonant Voice Therapy, 12 the Accent Method of Voice Therapy, 13,14 and the Lee Silverman Voice Treatment (CM). 15 In a double-blind, placebo-controlled study, Stemple and colleagues 5 demonstrated that VFE were effective in enhancing voice production in young female adults without vocal pathology. The primary physiologic effects were reflected in increased phonation volumes at all pitch levels, decreased airflow rates, and subsequent increase in maximum phonation times. Frequency ranges were extended significantly in the downward direction. Sabol and associates, 6 experimenting with the value of VFE in the practice regimen of singers, used opera graduate-level students as subjects. Once again, the results demonstrated significant improvement in physiologic measurements of voice production including increased airflow volume, decreased airflow rates, and increased maximum phonation time even in this group of superior voice users. Roy et al 16 studied the efficacy of VFE with a pathologic subject population. Teachers who reported experiencing voice disorders were randomly assigned to three groups: VFE, vocal hygiene, and control groups. For 6 weeks, the experimental groups followed their respective therapy programs, monitored by licensed speech-language pathologists who were trained by the experimenters in the two approaches. Pre- and post-testing of all three groups using the Voice Handicap Index 17 revealed significant improvement in the VFE group, no improvement in the vocal hygiene group, while the control group rated themselves worse. For the purpose of discussion, it is useful to consider that the laryngeal mechanism is similar to other muscle systems and may become strained and imbalanced through many etiologic factors. 18 Indeed, the analogy that we often draw with clients is a comparison of the rehabilitation of the knee to rehabilitation of the

4 134 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER voice. Both the knee and the larynx are comprised of muscle, cartilage, and connective tissue. When the knee is injured, rehabilitation includes a short period of immobilization for the purpose of reducing the effects of the acute injury. The immobilization is followed by assisted ambulation and then the primary rehabilitation begins in the form of systematic exercise. This exercise is designed to strengthen and balance all of the supportive knee muscles for the purpose of returning the knee to as close to its normal functioning as possible. Rehabilitation of voice may also involve a short period of voice rest following acute injury or after surgery to permit healing of the mucosa to occur. The client may then begin conservative voice use and follow through with all of the management approaches that seem necessary. Full voice use is then resumed quickly and the therapy program often is successful in returning the client to normal voice production. We would suggest, however, that on many occasions clients are not fully rehabilitated because one of the important rehabilitation steps was neglected. That step is the systematic exercise program that is often necessary to regain the balance among airflow, laryngeal muscle activity, and the supraglottic placement of the tone. Bertram Briess 19,20 first described a series of laryngeal muscle exercises. Briess suggested that there is a direct relationship between the condition of the laryngeal musculature and the quality of voice and for the voice to be most effective, the intrinsic muscles of the larynx must be in a dynamic equilibrium. Briess s exercises concentrated on restoring the balance in the laryngeal musculature and decreasing tension of the hyperfunctioning muscles. Unfortunately, many assumptions Briess made regarding laryngeal muscle function were incorrect and his therapy methods were not widely followed. The concept of direct exercise to strengthen voice production persisted. Barnes 21 described a modification of Briess work that she termed Briess Exercises. These exercises were modified and expanded by Stemple 22 into Vocal Function Exercises (VFE). The exercise program strives to balance the subsystems of voice production whether the disorder is one of vocal hyperfunction or hypofunction. The exercises are simple to teach and, as the research has demonstrated, may improve both the disordered and the normal voice. The exercise program is concrete, similar in concept to physical therapy, and improvement of vocal efficiency may be objectively plotted on a graph. The program begins by describing the relationship of the three subsystems to the client. The client is then taught a series of four exercises to be practiced at home, two times each, twice per day, preferably morning and evening. These exercises include: 1. Sustain the /i/ vowel for as long as possible on a musical note (F) above middle (C) for females and boys, (F) below middle (C) for adult males. (Notes may be modified up or down to fit the needs of the client. Seldom are they modified by more than two notes in either direction.) Goal: Based on airflow volume. (In our clinic the goal is based on reaching 80 to 100 ml/ sec of airflow. So, if the flow volume is equal to 4000 ml, then the goal is 40 to 45 seconds. When airflow measures are not available, the goal is equal to the longest /s/ that the client is able to sustain. Placement of the tone should be in an extreme forward focus, almost, but not quite, nasal. All exercises are produced as softly as possible, but not breathy. The voice must be engaged. This is considered a warm-up exercise.) 2. Glide from your lowest note to your highest note on the word knoll. Goal: No voice breaks. The glide requires the use of all laryngeal muscles. It stretches the vocal folds and encourages a systematic, slow engagement of the cricothyroid muscles. The word knoll encourages a forward placement of the tone as well as an expanded open pharynx. The client s lips are to be rounded and a sympathetic vibration should be felt on the lips. (May also use a lip trill, tongue trill, or the word whoop. ) Voice breaks will typically occur in the transitions between low and high registers. When breaks occur, the client is encouraged to continue the

5 HOLISTIC APPROACH TO VOICE THERAPY/STEMPLE 135 glide without hesitation. When the voice breaks at the top of the current range and the client typically has more range, the glide may be continued without voice as the folds will continue to stretch. Glides improve muscular control and flexibility. This is considered a stretching exercise. 3. Glide from your highest note to your lowest note on the word knoll. Goal: No voice breaks. The client is instructed to feel a half-yawn in the throat throughout this exercise. By keeping the pharynx open and focusing the sympathetic vibration at the lips, the downward glide encourages a slow, systematic engagement of the thyroarytenoid muscles without the presence of a back-focused growl. In fact, no growl is permitted. (May also use a lip trill, tongue trill, or the word boom. ) This is considered a contracting exercise. 4. Sustain the musical notes (C-D-E-F-G) for as long as possible on the word knoll minus the kn. (Middle C for females and boys, octave below middle C for males.) Goal: Remains the same as for exercise number 1. The oll is once again produced with an open pharynx and constricted, sympathetically vibrating lips. The shape of the pharynx to the lips is likened to an inverted megaphone. The fourth exercise may be tailored to the client s present vocal ability. Although the basic range of middle C, an octave lower for males, is appropriate for most voices, the exercises may be customized up or down to fit the current vocal condition or a particular voice type. Seldom, however, is the exercise shifted more than two notes in either direction. This is considered a low-impact adductory power exercise. Quality of the tone is also monitored for voice breaks, wavering, and breathiness. Quality improves as times increase and pathologies begin to resolve. All exercises are done as softly as possible. It is much more difficult to produce soft tones; therefore, the vocal subsystems will receive a better workout than if louder tones were produced. Extreme care is taken to teach the production of a forward tone that lacks tension. In addition, attention is paid to the glottal onset of the tone. The client is asked to breathe in deeply with attention paid to training abdominal breathing, posturing the vowel momentarily, and then initiating the exercise gesture without a forceful glottal attack or an aspirate breathy attack. It is explained to the client that maximum phonation times increase as the efficiency of the vocal fold vibration improves. Times do not increase with improved lung capacity. Indeed, even aerobic exercise does not improve lung capacity, but rather the efficiency of oxygen exchange with the circulatory system does, thus giving the sense of more air. The musical notes are matched to the notes produced by an inexpensive pitch pipe that the client purchases for use at home. He or she might be given a tape recording of live voice doing the exercises that could be used for home practice as well. Many clients find the taperecorded voice easier to match than the pitch pipe. We have found that individuals who complain of tone deafness can often be taught to approximate the correct notes with practice and guidance from the voice pathologist. Finally, clients are given a graph on which to mark their sustained times, which is a means of plotting progress. Progress is monitored over time and, because of normal daily variability, clients are encouraged not to compare today to tomorrow and so on. Rather, weekly comparisons are encouraged. Estimated time of completion for the program is 6 to 8 weeks. Some individuals experience minor laryngeal aching for the first day or two of the program similar to muscle aching that might occur with any new muscular exercise. As this discomfort will soon subside, they are encouraged to continue the program through the discomfort should it occur. When the client has reached the predetermined therapy goal, and voice quality and other vocal symptoms have improved, then a tapering maintenance program is recommended. Although some individuals who use their voices professionally may choose to remain in peak vocal condition, many of our

6 136 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER clients desire to taper the VFE program. The following systematic taper is recommended: Full program two times each, two times per day Full program two times each, one time per day (morning) Full program one time each, one time per day (morning) Exercise number 4, two times, one time per day (morning) Exercise number 4, one time per day (morning) Exercise number 4, one time each, three times per week (morning) Exercise number 4, one time each, one time per week (morning) Each taper should last 1 week. Clients should maintain 85% of their peak time, otherwise they should move up one step in the taper until the 85% criterion is met. CONCLUSION In short, VFE provide a holistic voice treatment program that attends to the three major subsystems of voice production. The program appears to benefit individuals with a wide range of voice disorders and is equally effective in enhancing the normal voice. The program is reasonable to carry out in regard to time and effort. It is similar to other recognizable exercise programs: the concept of physical therapy for the vocal folds is easy to understand and progress may be easily plotted, which is inherently motivating. In balancing the three subsystems of voice production, individuals have established a physiologic system that permits a normal voiceproducing mechanism to be integrated into the other communication modalities necessary for oral human interaction. These interactions offer yet another opportunity for the discussion of holistic health in the realm of effective human communication. REFERENCES 1. West R, Kennedy L, Carr A. The Rehabilitation of Speech. New York: Harper and Brothers; Van Riper C. Voice and Articulation. Englewood Cliffs, NJ: Prentice-Hall; Stemple J. Voice Therapy: Clinical Studies. San Diego, CA: Singular: Thomson Learning; Walter S. Holistic health. In: Allison N, eds. The Illustrated Encyclopedia of Body-Mind Disciplines. New York: Rosen Publishing Group; Stemple J, Lee L, D Amico B, Pickup B. Efficacy of vocal function exercises as a method of improving voice production. J Voice 1994;8: Sabol J, Lee L, Stemple J. The value of vocal function exercises in the practice regimen of singers. J Voice 1995;9: Behrman A, Orlikoff R. Instrumentation in voice assessment and treatment: what s the use? Am J Speech Lang Pathol 1997;6: Hicks D. Functional voice assessment: what to measure and why. In: Cooper J, ed. Assessment of Speech and Voice Production: Research and Clinical Applications. Bethesda, MD: National Institute on Deafness and Other Communicative Disorders; 1991: Titze I. Measurements for assessment of voice disorders. In: Cooper J, ed. Assessment of Speech and Voice Production: Research and Clinical Applications. Bethesda, MD: National Institute on Deafness and Other Communicative Disorders; 1991: Bless D. Assessment of laryngeal function. In: Ford C, Bless D, eds. Phonosurgery. New York: Raven Press; 1991: Titze I. Principles of Voice Production. Englewood Cliffs, NJ: Prentice-Hall; Verdolini K. Resonant voice therapy. In: Stemple J, eds. Voice Therapy: Clinical Studies. 2nd ed. San Diego, CA: Singular Publishing; 2000:46 62; Kotby N. The Accent Method of Voice Therapy. San Diego, CA: Singular Publishing; Harris S. The accent method of voice therapy. In: Stemple J, ed. Voice Therapy: Clinical Studies. 2nd ed. San Diego, CA: Singular Publishing; 2000: Ramig L. Lee Silverman Voice Treatment (LSVT; CM) for individuals with neurological disorders: Parkinson disease. In: Stemple J, ed. Voice Therapy: Clinical Studies. 2nd ed. San Diego, CA: Singular Publishing; 2000: Roy N, Gray S, Simon M, Dove H, Corbin-Lewis K, Stemple J. An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. J Speech Lang Hear Res 2001;44: Jacobson B, Johnson A, Grywalski C, et al. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol 1997;6: Saxon K, Schneider C. Vocal Exercise Physiology. San Diego, CA: Singular Publishing; 1995

7 HOLISTIC APPROACH TO VOICE THERAPY/STEMPLE Briess B. Voice therapy part 1: identification of specific laryngeal muscle dysfunction by voice testing. Arch Otolaryngol 1957;66: Briess B. Voice therapy part II: essential treatment phases of laryngeal muscle dysfunction. Arch Otolaryngol 1959;69: Barnes J. Briess Exercises. Workshop presented at: Southwestern Ohio Speech and Hearing Association; October; Cincinnati, Ohio 22. Stemple J. Clinical Voice Pathology: Theory and Management. 1st ed. Columbus, OH: Charles E. Merrill; 1984