The Role of Speech-Language Pathologists in Voice Therapy

According to the National Institute on Deafness and Other Communication Disorders (part of the National Institutes of Health), about 7.5 million Americans have difficulty using their voices.

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.

Understanding Voice Disorders: Causes, Signs and Symptoms

Voice disorders encompass a wide range of voice problems due to an equally wide range of causes and circumstances.

Although the root of the problem is often different, the goal of voice therapy is the same: to identify the voice disorder and implement techniques designed to improve, restore, or preserve a resonant and healthy voice.

Causes of Voice Disorders

A wide array of circumstances can lead to loss of voice quality or a total loss of voice. For example, voice problems may be due to:

• Misuse of the voice (frequently screaming or raising the voice)
• Environmental factors like allergies
• Pharmacological side effects
• Viruses
• Bacterial infections
• Neurological disorders
• Issues like vocal cord nodules
• Vocal fold surgery

One of the most frequent causes of a loss of voice quality is laryngitis, although inflammation of the vocal cords due to allergies, viruses, and gastroesophageal reflux are also common.

Swelling of the vocal cords, and lesions and cysts in the larynx often cause hoarseness, as do vocal fold paralysis, vocal fold nodules, and vocal fold granulomas.

Neuromuscular disorders and diseases are also known to affect voice quality. This includes things like dysphonia, Parkinson’s disease, strokes, laryngeal cancer, and cerebral vascular accidents.

Even individuals with poor voice habits, such as teachers who must often raise their voice to be heard or sports fans who cheer loudly, can suffer from lasting voice quality issues due to damage to the vocal cords. Misuse of the voice can have long-lasting effects, including hoarseness, laryngitis, and even vocal paralysis.

Signs and Symptoms of Voice Disorders

The signs and symptoms of voice disorders vary from patient to patient, so voice therapy programs must be tailored to a patient’s specific needs.

Symptoms may range from a persistent feeling that something is caught in the throat, to a strained feeling in the neck and throat, to a scratchy or hoarse voice. Some patients may experience voice issues that worsen as the day progresses, eventually leading to a near loss of voice by the end of the day, while others have difficulty raising or projecting their voice.

For individuals who rely heavily on their voice for their career, such as singers, motivational speakers, clergymen, broadcasters, and actors, they may use voice therapy as a preventive measure, with the ultimate goal of preserving their voice from damage.

Treating Voice Disorders: The Role of the Speech-Language Pathologist in Voice Therapy

Voice therapy is an approach used by speech-language pathologists to help patients find relief from symptoms and achieve the best possible voice. Voice therapy consists of an assessment, followed by the implementation of two techniques: voice therapy and vocal hygiene.

Assessment

The first step of voice therapy is to assess the patient’s voice production and voice quality and structure the therapeutic program accordingly. Often, SLPs consult with otolaryngologists and neurologists to ensure a proper diagnosis.

If a voice disorder is suspected, SLPs first perform a screening. This generally involves evaluating vocal characteristics related to respiration, phonation, and resonance, as well as vocal range and flexibility.

If deviations from a normal voice are detected, SLPs suggest further evaluation through a comprehensive assessment. There are several standardized and non-standardized measures that SLPs use, and diagnostic therapy is often performed as part of the comprehensive assessment process.

SLPs look at a variety of factors when making an assessment, such as:

• Any impairments in the patient’s body structure and function that could affect sound production and verbal/nonverbal communication
• Any deficits, health conditions, or medications that can affect the voice
• The patient’s limitations (if any) in terms of activity or participation in interpersonal interactions
• The existence of any environmental or personal factors that may present obstacles to successful communication

A comprehensive assessment to identify voice disorders includes:

• Case history
  • Patient’s description of voice problem, including onset and symptoms
  • Medical status and history
  • Previous voice treatments
  • Daily habits related to vocal hygiene
• Self-Assessment: The patient’s assessment of how the voice problems affect:
  • The ability to communicate in social, work settings, and everyday activities
  • Emotions and self-image
• Oral-Peripheral Examination: Assessment of:
  • Structural and motor-based deficits that could affect communication
  • Symmetry and movement of the face, head, neck, and respiratory system
  • Sensation of the face and mouth
  • Taste and smell
  • Laryngeal sensations (burning, pain, tickling, dryness, etc.)
• Assessment of Respiration
  • Respiratory pattern
  • Coordination of respiration with phonation
  • Maximum phonation time
• Auditory-Perceptual Assessment
  • Voice quality (strain, pitch, loudness, overall sensitivity
  • Resonance
  • Phonation
  • Rate
• Instrumental Assessment, such as laryngeal imaging
• Acoustic Assessment
• Air Flow Assessment

Once the assessment is complete, SLPs are able to:

• Diagnose a voice disorder
• Provide a clinical description and assessment of the severity of the disorder
• Make a prognosis and recommend interventions
• Identify appropriate treatments or management options
• Refer the patient to other professionals, if needed

An important part of the initial assessment and the continued assessment as the voice therapy progresses includes evaluating:

• Format: The structure of the treatment session
• Provider: The person offering the treatment (volunteer, caregiver)
• Dosage: The frequency, intensity and duration of the services
• Setting: Where the treatment is performed

An important part of an SLP’s job description involves observing and analyzing the patient’s progress and adding or removing therapeutic techniques as necessary. Depending on the cause of the vocal issues, this may include frequent visits to an otolaryngologist to observe the progress the voice therapy is having on the larynx.

Vocal Hygiene

SLPs encourage patient to make changes in their lifestyles and develop a healthier regimen to achieve and maintain a healthy voice. This often includes:

• Adhering to a period of vocal rest or relaxation
• Avoiding screaming, shouting, or making other loud noises
• Avoiding throat clearing or coughing
• Limiting the use of air conditioning in the summer and using humidifiers in the winter to prevent dryness of the throat
• Maintaining adequate hydration (drinking 6-8 glasses of water per day)
• Maintaining good nutrition
• Minimizing alcohol consumption
• Minimizing exposure to second-hand cigarette smoke or other noxious chemicals
• Not smoking

Vocal Therapy

Vocal therapy involves changing the biomechanics of voice production. The goal of voice therapy is to improve vocal function and quality and implement exercises aimed at achieving vocal cord strength, endurance, and flexibility and the balance of respiration, phonation, and resonation.

Most voice therapy programs consist of 4-10 sessions over a period of 6-8 weeks, although the length of therapy ultimately depends on the diagnosis, compliance with the therapeutic program (Is the patient performing the required exercises at home and following vocal hygiene guidelines?), and the underlying causes and conditions.

SLPs specializing in voice therapy use a number of voice therapy techniques, categorized as either:

Physiologic Voice Therapy – Physiologic voice therapy is a holistic approach to treatment that strives to balance the three systems of voice production: respiration, phonation, and resonance.

Types of physiologic voice therapy include:

• Accent Method
• Cup Bubble/Lax Vox
• Expiratory Muscle Strength Training
• Lee Silverman Voice Treatment
• Manual Circumlaryngeal Techniques
• Phonation Resistance Training Exercise
• Resonant Voice Therapy
• Stretch and Flow Phonation
• Vocal Function Exercises

Symptomatic Voice Therapy – The focus of symptomatic voice therapy is on modifying deviant vocal symptoms, such as a pitch that is too high or low or a voice that is too soft or loud.

Symptomatic voice therapy utilizes direct symptom modification using a variety of techniques that include:

• Amplification
• Auditory Masking
• Biofeedback
• Chant Speech
• Confidential Voice
• Glottal Fry
• Inhalation Phonation
• Semi-Occluded Vocal Tract Exercises (straw phonation, lip trill)
• Posture
• Relaxation
• Twang Therapy
• Yawn-Sigh

Additional Resources for Speech-Language Pathologist Specializing in Voice Therapy

The National Institute on Deafness and Other Communication Disorders, the Voice Foundation, and, of course, The American Speech-Language Hearing Association (ASHA) all serve as excellent resources for further reading on voice therapy.

Additionally, groundbreaking research and therapy is taking place in this area of focus, much of which is being led by top universities and medical centers:

• John Hopkins Voice Center
• University of Pittsburgh Medical Center Voice Center
• Los Angeles Voice Doctor
• Professional Voice Center of Cincinnati

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