The voice therapy program includes a technical skills component.
A few techniques most effectively target a specific type of voice disorder - for instance, the Lee Silverman Voice Therapy approach is developed specifically for use with Parkinson's patients, while confidential voice is used mainly for individuals who have an injury to the vocal fold mucosa. In general, however, there is no single correct set of techniques for a specific voice problem. This is because most voice problems are made up of more than one feature and have more than one single cause. In addition, most techniques achieve improved voice by targeting improved balance of all of the components of voice production; they just use slightly different means of obtaining that balance. Different therapists have different approaches, all with many commonalities. One technique may work best for one therapist or patient, and another approach works best for others. Voice therapy is an interaction of the therapist and the patient. Most (but not all) of these exercises begin by eliciting the correct voice production technique using the most facilitating sounds and combinations of sounds. Then, as the patient becomes able to produce voice in this optimal way, the technique is carried over into words, phrases and sentences until integrated into conversational speech.
In alphabetical order, some of these techniques:
- Accent Method
- Confidential Voice
- Digital Laryngeal Manipulation
- Lee Silverman Voice Treatment (LSVT)
- Resonant Voice
- Vocal Function Exercises
Accent Method: This program uses rhythmic exercises to facilitate the coordination of minimally-constricted vocal fold vibration with appropriate air pressure and air flow. The Accent Method is a holistic approach that addresses pitch, loudness and timbre simultaneously, rather than focusing separately upon each of these vocal parameters. Rhythmic contraction of the muscles involved in breathing are coordinated with production of increasingly complex utterances. The consonants in these utterances are used as accents within the rhythm. Initially, rhythmic whole body movements are used to facilitate clear and easy voice production. Rhythmic variation in pitch and loudness are incorporated to gain increased vocal flexibility.
Confidential Voice: Confidential voice is designed as a temporary style of voice production used to help facilitate mucosal repair. It is often used in acute (short-term) voice problems and after surgery. It is part of a modified voice rest program and can be used as the only type of voice production for one to two weeks, or as part of a longer-term program that alternates periods of voice rest with more demanding voice use. Confidential voice is a light voice. It is an easy, breathy, low airflow style of phonation. It is a softly-produced voice, and therefore not functional for many communicative needs. Although the voice is soft, it is not a breathy whisper. Low-effort is critical to the success of this style of phonation. However, low-effort does not imply low pitch or low (pharyngeal) tone focus. Importantly, the normal pitch of the voice is maintained, and even a slightly increased pitch contour (mildly "sing-song") is encouraged to prevent "monotone", which can force the laryngeal muscles into a "locked-in", inflexible setting that can be contrary to facilitating mucosal repair.
Digital Laryngeal Manipulation: Also called laryngeal massage, the focus of this technique is to decrease excessive contraction of the muscles of the larynx (see muscle tension dysphonia). This is achieved through pressing on selected areas of the neck (focal palpation), circumlaryngeal massage, and manually repositioning the larynx. Using the thumb and forefinger, moderate pressure is applied in small circles, from front to back, targeting selected areas of the larynx and neck. Often, excessive muscle contraction causes the larynx to be positioned too high in the neck, pulled up towards the base of tongue. Speaking in this position for extended periods of time can cause neck discomfort and even focal pain or tenderness.
Laryngeal massage will therefore often focus initially upon the contracted thyrohyoid space (the area between the larynx and the hyoid bone) to release the excessive contraction and allow the larynx to descend. Gentle manual repositioning of the larynx during phonation can sometimes prevent habituated patterns of excessive contraction. Vocal exercises are incorporated during the massage to facilitate clear and easy voice production without excessive muscle contraction. The patient is then encouraged to focus upon auditory and vibrotactile feedback to encourage maintenance of easy voice production in the absence of manual manipulation.
Lee Silverman Voice Treatment (LSVT): This is an intensive program, with attendance required four days/week for four consecutive weeks. The focus of LSVT is the use of "loud" voice, emphasizing both the production and the habituation of loud voice. This program was developed and has been tested mainly on patients with Parkinson's disease. However, many clinicians have found it helpful with patients who have other types of diseases or voice problems that cause problems with loudness level and/or clarity of articulation.
Resonant Voice: This approach focuses upon achieving a specific configuration of the vocal folds and muscles immediately above the vocal folds (termed the epilaryngeal area) by training the patient to respond to sensations of vibration in the face (similar to the "buzz" that you would feel when humming). Resonant voice techniques aim to increase the power and clarity of the voice while decreasing the vibratory forces that can contribute to mucosal trauma. The goal is to create an optimal pressure balance between the lung pressure below the vocal folds, the air pressure in the vocal tract above the glottis, and the vocal fold resistance to the airflow. This technique is commonly used in cases of primary or secondary muscle tension dysphonia in which the vocal folds are either squeezed together with too much force, or held stiffly apart and prevented from contacting together or vibrating fully. Resonant voice production may decrease the excessive or uncoordinated muscle contractions, allows the vocal folds to vibrate more freely, and therefore improve vocal fold contact and vocal quality.
Vocal Function Exercises: This approach is a three-component program of warm up, pitch glides (high to low and low to high) and sustained vowel phonation at selected pitches. These exercises are performed a specific number of times during the day. Like any type of exercise, they can be done incorrectly or correctly. Producing them with a resonant voice (also called "flow" mode of phonation) rather than excessive effort, is key to these exercises. These exercises are based upon the hypothesis that their systematic practice will increase the bulk and strength of the thyroarytenoid muscle (the body of the vocal folds) and improve coordination of the multiple muscles of the larynx that must be co-activated for speech.