Voice Therapy: Following the

Evidence Trail
Joseph C. Stemple, Ph.D.
Lisa B. Thomas, M.A., Doctoral Candidate

Voice Therapy Orientations

Hygienic
Symptomatic
Physiologic
Eclectic

Hygienic Voice Therapy

Discover the behavioral causes of the voice

disorder & modify/eliminate of the causes to
improve the voice
Organized and promoted by every text related to
voice disorders
There is often a behavioral cause for a voice
disorder; discover, modify/eliminate it and the
voice improves

Symptomatic Voice Therapy

Modification of deviant vocal symptoms such

as breathiness, inappropriate pitch, loudness,
hard glottal attacks, and so on
Organized and promoted by Daniel Boone in his
text The Voice and Voice Therapy (1971)
If the voice component is inappropriate, modify
that component with voice facilitating techniques

Physiologic Voice Therapy

Based on expanded knowledge of vocal

function as evaluated through objective voice
assessment and measurement
Strives to improve the relationship or balance
among voice respiratory support, laryngeal
muscle strength, control and stamina, and
and supraglottic modification of the laryngeal
tone

Physiologic Voice Therapy

Presented

by Colton and Casper (1990) and

Stemple, Glaze, and Gerdeman (1993)
Concentrates on the modification of the
underlying physiology of the voice producing
mechanisms: respiration, phonation, resonance

Eclectic Voice Therapy

Combination of any and all of the previous

orientations to affect positive vocal change
Voice pathologists should be aware of all
management approaches and use those which
are most effective not only for the patient, but
for the therapist as well

What do we mean by
following the evidence trail?

Many voice therapy interventions have become

standard practice with limited supporting data
Clinical/medical/surgical practices have outpaced the scientific evidence to support them
Why?
Patients continue to show up at our doors
We will continue to treat them with techniques
that APEAR to work

Is Research Support Necessary in

Clinical Practice?

How do we know that what we do in therapy actually

does what it is meant to do?
How do we know that therapy success was the
technique and not the therapist?
How many techniques and approaches do we use
from habit or because they seem to work?
How many of us blindly follow the latest therapy fad
without the benefit of good data?

Research Support cont

Outcomes data should serve as the foundation of

clinical practice in voice pathology.
Why?
Concerns revolve around objective
accountability
Research funding has centered on the form and
quality of clinical outcome studies
NIH Roadmap

History of Outcomes Research

in Voice

Earliest reports 1940s

Case Studies, Anecdotal reports

1980s and early 1990s

Instrumentation advances
Dramatic increase in number of outcome studies
Primarily survey and retrospective studies. Some
group studies & SS designs emerge.
Lack of control and research rigor

History of Outcomes Research

in Voice

Studies of the 1990s and 2000s

Instrumentation advances
Increased rigor in designs
Lines of research developing
Ex: LSVT, Ramig et al. (1995)

Decisions Regarding the

Content of the Review
Voice Therapy
for Functional
Voice D/O

Hygienic

Symptomatic

Physiologic

Review Process Phase 1

Medline, CINAHL, PsychINFO, ASHA

journals (1980 present)
Search terms: voice therapy, efficacy, outcomes,
voice disorders
Total # citations = 124
41 inappropriate population (SD, IPD)
46 not related to treatment efficacy, outcomes
7 non-English
30 studies for review

Review Process Phase 2

Historical search from pertinent readings 38

additional studies

Review Process Phase 3

Review, categorization, and rating of studies

Butler and Darrah (2001) 5 level rating system

Hygiene Therapy: Evidence

Direct treatment of voice appears superior to vocal

hygiene training

Verdolini-Marston et al. (1995)

Carding & Horsley (1992)
Carding et al (1999)
Roy et al. (2001)
Holmberg et al. (2001)
Pasa et al. (2007) contradictory results (VH = increase in
knowledge, decrease in self-reported symptoms, however, no
significant change in direct measures of MPFR or MPT)

Hygiene Evidence
Group hygiene training yields change in
knowledge but no change in behavior

Knowledge
Nilson and
Schneiderman (1983)
Aaron and Madison
(1991)
Pasa et al. (2007)

Behavior
Broaddus-Lawrence et
al. (2000)
Timmermans et al.
(2004, 2005)
Chan (1994)

Hygiene: Evidence

Hydration reduces phonatory effort

Verdolini et al. (1994)
Verdolini-Marston et al. (1990, 1994)
Solomon and DiMattia (2003)
Fisher et al. (2001)
Hydration increases vocal endurance
Yiu and Chan (2003)

Hygiene
Conclusions & Implications

Few large scale studies support the therapeutic

benefit of general hygiene education
Growing support for use of hydration
Hygiene should be used only as an adjunct to
direct forms of treatment.
Future work
Monitor / quantify compliance
Increase number of studies on disordered
populations

Symptomatic Therapy: Evidence

Primarily case reports and anecdotal evidence

Few group studies
Majority of methods have Level IV and V
evidence
Many methods have no published evidence

Symptomatic: Evidence

Evidence supports use of biofeedback

EMG

Acoustic / Aerodyanamic

Prosek et al (1978); Stemple et al. (1980); Andrews

et al. (1986)
Yamaguchi et al. (1986); Laukkanen et al. (2004)

Laryngeal Function

DAnontio (1987); Rattenbury et al. (2004)

Symptomatic Therapy
Conclusions & Implications

One line of promising work - Biofeedback

Future Directions
Potential examination of theoretical bases of the
methods
More rigorous research designs

Physiologic Therapy: Evidence

Evidence
Physiologic / theoretical evidence
Clinical evidence
Majority, well-controlled group studies

Physiologic: Clinical Evidence

Lines of research for 4 methods

Accent Method
Smith & Thyme (1976); Kotby et al. (1991);
Fex et al. (1994); Bassiouny (2001)
Vocal Function Exercises
Stemple et al. (1994); Sabol et al. (1995); Roy
et al. (2001), Gillivan-Murphy et al. (2006),
Bell et al. (2007)

Physiologic: Evidence

Resonant Voice Therapy

Verdolini-Marston et al. (1995); Chen et al.
(2003); Roy et al. (2003); Bell et al. (2007)
Manual Laryngeal Musculoskeletal Reduction
Technique
Roy and Leeper (1993); Roy et al. (1997); Van
Lierde et al. (2004)

Physiologic Therapy
Conclusions and Implications

Orientation came to forefront at time of efficacy

emphasis
Evidence supports a shift from symptomatic Tx
to physiologic Tx

Conclusions & Implications

Orientations
Physiologic methods possess strongest support
Efficacy of hygiene training inconclusive
Lack of evidence for symptomatic therapy

Future Directions / Questions

Should symptomatic be examined or revised?
Determine ways of examining hygiene more fully
Consider / replicate model lines of research in voice

Does Science Support the Art of

Voice Therapy?

Historically an art form

Shift to science base in 1990s 2000s.
Instrumentation
Societal focus on outcomes research
Current Tx models have scientific support

Full Review Published In:

Thomas, L.B., & Stemple, J.C. (2007). Voice
therapy: Does science support the art?
Communicative Disorders Review, 1, 51-79.

Designing the
Vocal Hygiene
Protocol

Vocal Hygiene

Evidence suggests:
VH does not stand alone as a treatment for voice
disorders
Best used as a complement to other therapies
May insulate patient from further voice deterioration

Vocal Hygiene

May exert influence due to:

Elimination of poor vocal habits which contributed

to / perpetuated the disorder
Lays the foundation for progress

Maintaining the health of the vocal fold cover

Hydration
Reduction of acidic irritants or other irritants of the

mucosal cover

Vocal Hygiene: A Typical Protocol

Vocal hygiene counseling involves:

identifying the abusive behaviors
describing the physiologic effects of those behaviors
on the voice production mechanisms
defining the specific occurrences
modifying or eliminating the behavior

Vocal Hygiene: Components of a

Standard Protocol

Water intake considerations

Manage intake of dehydrating substances

Multiple forms: beverages, OTC meds, prescription

meds, etc.

Deal with chronic throat clearing / coughing

Substitute behaviors

Components of a Standard Protocol

Strategic management of acoustic environment

Diligent reflux management

Symptomatic, Asymptomatic cases

Vocal warm-ups as needed

Vocal Hygiene: Final Thoughts

Vocal rest vs. Modified vocal rest

Dictating vs. strategizing
The KEY is patient education and patient
understanding

Planning
Physiologic Voice
Therapy Protocols

Research Support for Physiologic

Voice Therapy

What are physiologic voice therapies exactly?

Good question (Probably just an academic term)
Seems to relate to a therapy program involving
exercises or vocal maneuvers that attend to all three
subsystems of voice production at once, respiration,
phonation, and resonance

Research Support for Physiologic

Voice Therapy cont

These therapy programs are most often

described as physiologic approaches to voice
therapy:
Accent Method
Lee Silverman Voice Therapy
Resonant Voice Therapy (LMRVT)
Vocal Function Exercises

Why is Treating the Physiology

Critical?

Diagnosis = Symptoms,
pattern of production,
etc.

Example: Nodules
Example: Paralysis

Individualized responses
to pathology

Universal Goal: Restore

to normal physiology,
normal efficiency
Treatment: Need holistic
method to restore
normal physiology
Implication: Some
physiologic therapies
applicable across a broad
range of pathologies

Vocal Function Exercises

A series of systematic voice manipulations, similar in

theory to physical therapy for the vocal folds,
designed to strengthen and coordinate the laryngeal
musculature, and to improve the efficiency of the
relationship among airflow, vocal fold vibration, and
supraglottic treatment of phonation

Vocal Function Exercises cont

Long sustained tones

Maximal pitch glides
Efficient posturing of the voice producing
mechanism to permit maximum output with
minimal effort

Genesis of VFE

Bertram Briess
Robert Stimpert
Jan Barnes

Vocal Function Exercises

Primary Research Support

Stemple J, Lee L, DAmico B, Pickup B (1994) Efficacy of

Vocal Function Exercises as a method of improving voice
production. J Voice, 8: 271-278.

Double-blind, placebo-controlled study

35 females ages 21-25 with normal voice
Pre and post-test acoustic, aerodynamic, and
videostroboscopic measures
Performed VFE 2x each 2x per day for 4 weeks

Stemple et al., 1994, cont

Results:
Maximized use of phonation flow volume
Decreased airflow rates
Increased maximum phonation time
Increased frequency range
Improved the symmetry of vibration
Average VFE phonation times increased with

plateau at 2 weeks

Vocal Function Exercise Research

Support cont

Sabol J, Lee L, Stemple J (1995) The value of Vocal

Function Exercises in the practice regimen of singers. J
Voice, 9: 27-36.
20 university graduate level opera majors ranging in age
from 26-39 years (men) and 21-43 years (women)
Pre and post-test acoustic, aerodynamic, and
videostroboscopic measures as well as perceptual
questionnaire
Performed VFE 2x each 2x per day for 4 weeks along
with regular singing activities

Sabol et al., 1995, cont

Results:
Decreased

airflow rates at both high and low

pitches (intensity and pitch were held steady
for pre and post-test)
Increased MPT at all pitch levels
Reported improvement in dynamic range
control
Average VFE times increased with plateau at
3 weeks

Vocal Function Exercise Research

Support cont

Roy N, Gray S, Ebert M, Dove H, Corbin-Lewis K, Stemple J

(2001) An evaluation of the effects of two treatments for
teachers with voice disorders: A randomized clinical trial. JSHR,
44: 286-296.
Assessed the functional effects of Vocal Hygiene and VFE
on 58 school teachers with self-reported voice problems
Subjects were randomly assigned to VFE, VH and control
groups
Treatment phase lasted for 6 weeks
Pre and post Voice Handicap Index (VHI) were completed
by all subjects

Vocal Function Exercise Research

Support cont
Results:
Control

group worse
Vocal Hygiene group no change
VFE group significant improvement

Strategies for
Physiologic Voice Therapy

Vocal Function Exercises

a series of systematic voice manipulations, similar

in theory to physical therapy for the vocal folds,
designed to strengthen and coordinate the
laryngeal musculature, and to improve the
efficiency of the relationship among airflow,
vocal fold vibration, and supraglottic treatment
of phonation

Strategies for
Physiologic Voice Therapy

What is made of multiple cartilages, muscles,

and connective tissue and is a jointed system
which may become injured, weakened, or
imbalanced in its function?

Strategies for
Physiologic Voice Therapy

Your Knee

Strategies for
Physiologic Voice Therapy

Rehabilitation for injuries of the knee

rest to reduce edema
appropriate supports, casts, bracings, and wraps
as needed
ambulatory devices
systematic exercise
continuation of previous activities

Strategies for
Physiologic Voice Therapy

Your Larynx

Strategies for
Physiologic Voice Therapy

Rehabilitation for Injuries of the Larynx

sometimes voice rest

vocal hygiene counseling

modify symptoms

continuation of previous voicing activities

Strategies for
Physiologic Voice Therapy

MISSING ELEMENT

Direct Systematic Exercises

Restrengthening and coordinating the laryngeal

musculature

Enhancing the relationship of the three

subsystems of voice production

Four Steps

Warm up

Stretching Exercise

Contracting Exercise

Adductory Strengthening Exercise

Resonance

Phonation

Respiration

Vocal Function Exercises

1.

(warm-up) Sustain the vowel /i/ for as long as

possible on the musical note (F)
Goal = __ sec (F above middle (C) for
females F below middle (C) for males)

Vocal Function Exercises

Posture

Breathing

Placement

Onset

Vocal Function Exercises

2.

(stretching) Glide from your lowest note to

your highest note on the word knoll,
whoop, tongue trill, lip trill
Goal = no voice breaks

ol
Pharynx

Lip
Buzz
Lips

Vocal Function Exercises

3.

(contracting) Glide from a comfortable

high note to your lowest note on the
word knoll, boom, tongue trill, lip
trill
Goal = no voice breaks

Vocal Function Exercises

4.

(power) Sustain the musical notes (C-D-EF-G) for as long as possible on the word
old without the /d/.
Goal = __ sec. (middle (C) females, octave
below middle (C) males

Pitch Modifications

GABCDEFGABC

GABCDEFGABC

GABCDEFGABC

Vocal Function Exercises

notes are matched to a pitch pipe, tape recorder, key

board, piano

daily record is charted by the patient

estimated time of completion 8-10 weeks

some patients experience minor laryngeal aching the first

few days of exercise

Vocal Function Exercises

all exercises are done 2 x each, 2 x per day
all exercises are done as softly as possible, but engaged
quality of tone is monitored for breaks, wavering, and

breathiness
extreme care is taken to teach the production in a
forward tone focus without tension
attention is paid to the glottal onset of the tone to
assure an easy onset without breathiness
appropriate breathing technique is assured

Explanation to the Patient

Admit that it seems silly

Compare it to workout program, physical

therapy, weight lifting, etc.

Stress the necessity of systematic exercise

without breaks

Explain that the times do not increase due to

increased lung capacity

Advantages for the Patient

Easily understood, reasonable model

Systematic, permits plotting of progress

Patient must attend to the voice at least 2

times per day

Involves doing something positive as

opposed to the dont dos

Vocal Function Exercises

Maintenance Schedule
Full program 2 x each 2 x per day
Full program 2 x each 1 x per day
Full program 1 x each 1 x per day
2 x each 1 x per day
Exercise 4
1 x each 1 x per day
Exercise 4
1 x each 3 x per week
Exercise 4
1 x each 1 x per week
Exercise 4

Each taper involves approximately 1 week

Future Research

Clinical populations
Measurement strategies
Study the underlying physiologic principles of
the training modalities

Resonant Voice Therapy

Lessac (1965)

The well-placed voice yields optimal functioning of

respiratory, phonatory, and resonance systems

Titze (2003)

RV maximum transfer of power through the vocal tract from

glottis to lips and ultimately to the listener
Proper energy conversion at the vocal folds results in
excellent propagation of sound -- vibrations of the glottal
tone can extend into the facial regions

Resonant Voice Therapy

RV produced with vocal folds barely separated

Berry (2001)
Glottic configuration observed in RV produces
maximum transfer of sound through vocal tract
Implications: Glottal configuration for RV is most
efficient use of the system

Resonant Voice Therapy

Voice production involving oral vibratory

sensations, usually on the anterior alveolar ridge
or higher in the face
In the context of easy phonation
Where resonant voice is a continuum of oral
sensations and easy phonation builds from basic
speech gestures through conversational speech

Resonant Voice Therapy

Training methodologies are experiential,

focusing on the processing of sensory
information
The training model assumes similar approaches
for voice restoration and enhancing the normal
voice (excellence training)

Resonant Voice Therapy

Fundamental perceptual target is focused, oral vibratory

sensations in the context of easy phonation.
The singular training focus (resonance) is expected to
affect multiple levels of physiology (breathing and
laryngeal).
Large numbers of repetitions are used, in varying
speech contexts.
Training is strongly goal (results) driven, involving a
dogged insistence upon the greatest possible precision
in the achievement of the perceptual tasks.

Resonant Voice Therapy

Primary Clinical Support

4 clinical studies
Verdolini-Marston et al., 1995
Roy et al., 2003
Chen et al., 2003

Basic RVT Training Maneuvers

Stretches and Breathing Warm-Ups

Shoulders
Neck
Jaw
Floor of Mouth
Lips
Tongue
Pharynx

Basic Training Gesture for RT

(This is Step 1 for all stages of RT)

Holm-molm-molm-molm-molm..As a sigh
Extreme forward focus is required with
appropriate breath support
Make the connection from the abdominal
muscles to the lips
Patient should feel very relaxed at the end of this
gesture

RT Hierarchy: Stage 1 All Voiced

molm-molm-molm.. (sustained pitch) ____
note
- vary the rate only
- discover the vibrations; experiment with broad and
narrow vibrations;
- eventually focus on the narrow vibration; like a
narrow beam of light
- increase the ease of production by reducing the
effort by 1/2 and 1/2 again
- increase lift (as if pitch were increasing)
1.

RT Hierarchy: Stage 1 All Voiced

2. molm-molm-molm..
slow-fast-slow
soft-loud-soft on ____ note

3. molm-molm-molm.. as speech
use non-linguistic phrase
vary the rate, pitch, and loudness
make the connection from the abdominal muscles

to the lips

RT Hierarchy: Stage 1 All Voiced

4. Chant the following voiced phrases on the
musical note ___
Mary made me mad.
My mother made marmalade.
My merry mom made marmalade.
My mom may marry Marv.
My merry mom may marry Marv.
Marv

made my mother merry.

5. Over-inflect these phrases as speech

RT Hierarchy: STAGE 2
Voice-Voiceless Contrasts
Basic Training Gesture
1. mamapapa.. vary the rate on ___ note
2. mamapapa..

slow-fast-slow
soft-loud-soft on ___ note

3. mamapapa.. As speech

use non-linguistic phrases

vary the rate, pitch, and loudness
make the connection from the abdominal muscles to the
lips

RT Hierarchy: STAGE 2
Voice-Voiceless Contrasts
4. Chant the following voiced/voiceless phrases on the
musical note ___

Mom may put Paul on the moon.

Mom told Tom to copy my manner.
My manner made Pete and Paul mad.
Mom may move Pollys movie to ten.
My movie made Tim and Tom sad.

5. Over-inflect these phrases as speech

RT Hierarchy: STAGE 3 ANY PHRASE

Basic Training Gesture
Produce the following phrases in sequence as
follows:
First, chant the phrase on the note___, (no breath)
Then over-inflect it with extreme forward focus, and
Then finally repeat it as natural speech with a forward
focus.
Note: Each individual phrase should be produced following
this 3-step sequence before moving onto the next phrase.

RT Hierarchy: STAGE 3 ANY PHRASE

-

All the girls were laughing.

Get there before they close.
Did you hear what she said?
Come in and close the door.
Are you going tonight?
Put everything away.
Come whenever you can.
We heard that yesterday.
The player broke his leg.
The children went swimming.

RT Hierarchy Stage 4
Paragraph Reading

read a paragraph with phrase markers

separate each phrase only by the natural
inhalation of air
exaggerate focus and then repeat with a more
normal speech/voice production
repeat the above without phrase markers

RT Hierarchy Stage 5
Controlled Conversation
practice forward speech placement in
conversation
do not permit glottal attacks, glottal fry, etc.

RT Hierarchy Stage 6
Environmental Manipulations
simulate actual speaking environments
use tapes of background noise
go to noisy cafeteria

RT Hierarchy Stage 7
Emotional Manipulations

use materials and topics that increasingly

engage and challenge the patient

RT Home Exercises
The critical portion of each exercise for each week is
tape recorded as a home exercise example.
15-20 minute home sessions, two times per day with
minis as needed
1. Stretches
2. Basic RV gesture
3. Selected level of hierarchy

Conclusions
Physiologic Voice Therapy

Some methods applicable across broad range of

pathologies
Goal of these methods is to restore normal
(efficient) laryngeal function

Strategies for
Psychogenic Voice Therapy

The psychogenic voice disorders include:

conversion aphonia
conversion dysphonia
muscle tension dysphonia
functional falsetto
juvenile voice
paradoxical vocal fold movement

Strategies for
Psychogenic Voice Therapy
Management stages include:
1. Medical evaluation
-rule out organic pathology
-confirms the psychogenic diagnosis
2. Diagnostic voice evaluation
-develops the history
-provides impression of patients personality
and shows how functions socially
-gives physiologic rationale for voice problem
-prepares the patient for vocal change

Strategies for
Psychogenic Voice Therapy
3. Direct manipulation of the voice
-begins during the diagnostic evaluation
-expected result is dramatic change toward
normal voice production
4. Counseling
-determines the psychogenisis of the
disorder
-determines the need for further professional
counseling

Strategies for
Psychogenic Voice Therapy

Conversion aphonia

non-speech phonation
cough
throat clear
gargle

falsetto voice technique

laryngeal videoendoscopy feedback

Conversion dysphonia

same as aphonia

Strategies for
Psychogenic Voice Therapy

Functional falsetto
offer reasonable explanation
hard glottal attack approach
desensitization program
Vocal Function Exercises/Forward Focus

Treatment of Glottal Incompetence

Goal: Improved closure, more efficient use of

the system
Methods: Same as those used to enhance the
system with other behavioral conditions

Working on basic physiologic level rather than

perceptual ideal

Case Study: Bilateral True Vocal

Fold Bowing and Sulcus

73 year old male

Active lecturer
Voice Quality:

Mild to mod dysphonia, weak

raspy hoarseness

Chief complaints:

Voice fatigue
Laryngeal ache
Progressive hoarseness
Lack of clarity in voice
Inability to project voice

TREATMENT

Vocal Function Exercises 2x ea 2x per day

Airflow volume 3100 ml
Goal 3100/80 40 sec
2-25-04 Baseline MPT
26.3 sec
3-4-04
35.2 sec
3-18-04
36.8 sec
4-1-04
42.2 sec
4-19-04
45.3 sec

Therapy Results

Normal voice quality

No voice fatigue
Ability to project voice

Case Study: Left True Vocal Fold Paralysis

70 year old female

retired teacher/active
volunteer
May 21, 2004 Idiopathic
LTVF Paralysis
Voice Quality: moderate
dysphonia, high pitch, weak
breathy hoarseness
Chief Complaints:

Hoarseness
Inability to project
Mild aspiration

Treatment

Vocal Function Exercises 2x ea 2x per day

Airflow Volume 2000 ml / 80 = 25 sec
7-26-04 Baseline MPT 6.8 sec
8-2-04
12.0 sec
8-16-04
21.7 sec
9-16-04
24.2 sec
10-14-04
28.3 sec

Therapy Results

Mild dysphonia with

occasional pitch breaks
Ability to project
No dysphagia

So, what type of voice therapy should

we be practicing?

Evidence-based
Hygiene - present, may not be effective
Symptomatic - limited, much more needed
Physiologic - most studied, effective, needs to be done with a
wider population
Cart before the horse research
Understand that there are many therapy approaches that are
probably, might be, may be equally as effective as those
presented that have not been systematically examined
Every patient is a potential subject. Lets continue to
explore

References

Bassiouny, S. (1998). Efficacy of the accent method of voice therapy. Folia Phoniatrica et
Logopedica, 50, 146-164.
Bell, S., Kidd, B., Leemkuil, C., Smith, A., & McCrae, C. (2007, November). Vocal
function exercises (VFE) verses resonant voice therapy (RVT) in the treatment of
hyperfunctional voice disorders. Poster presented at the American Speech-LanguageHearing Association Annual Convention, Boston, MA.
Broaddus-Lawrence, P., Treole, K., McCaabe, R., Allen, R., & Toppin, L. (2000). The
effects of preventative vocal hygiene education on the vocal hygiene habits and
perceptual voice characteristics of training singers. Journal of Voice, 14, 58-71.
Carding, P., Horsley, I., & Docherty, G. (1999). A study of the effectiveness of voice
therapy in the treatment of 45 patients with nonorganic dysphonia. Journal of Voice, 13,
72-104.
Casper, J. (2000). Confidential voice. In J. C. Stemple (Ed.), Voice therapy: Clinical studies
(2nd ed., pp. 128-139). San Diego, CA: Singular Publishing.
Chan, R. W. K. (1994). Does the voice improve with vocal hygiene education? A study
of some instrumental voice measures in a group of kindergarten teachers, Journal of
Voice, 8, 279-291.
Chen, S. H., Huang, J., & Chang, W. (2003). The efficacy of resonance method to
hyperfunctional dysphonia from physiological, acoustic and aerodynamic aspects: The
preliminary study. Asia Pacific Journal of Speech, Language and Hearing, 8, 200-203.

References

D'Antonio, L., Lotz, W., Chait, D. & Netsell, R. (1987). Perceptualphysiologic approach to evaluation and treatment of dysphonia. Annals of
Otology, Rhinology, and Laryngology, 96, 187-190.
Fex, B., Fex, S., Shiromoto, O., & Hirano, M. (1994). Acoustic analysis of
functional dysphonia before and after voice therapy (Accent Method). Journal
of Voice, 8, 163-167.
Fisher, KV., Ligon, J., Sobecks, J.L. & Roxe, D.M. Phonatory effects of body
fluid removal. Journal of Speech, Language, and Hearing Research, 44, 354-367.
Gillivan-Murphy, P., Drinnan, M., ODwyer, T., Ridha, H., & Carding, P.
(2006). The effectiveness of a voice treatment approach for teachers with selfreported voice problems. Journal of Voice, 20, 423-431.
Holmberg, E., Hillman, R., Hammarberg, B., Sodersten, M., & Doyle, P.
(2001). Efficacy of a behaviorally based voice therapy protocol for vocal
nodules. Journal of Voice, 15, 395-412.
Kotby, M., El-Sady, S., Abou-Rass, Y., Hegazi, M. (1991). Efficacy of the
Accent Method of voice therapy. Journal of Voice, 5, 316-320.
Kotby, M. N., Shirmoto., O., & Hirano, M. (1993). The Accent Method of
voice therapy: Effect of accentuations on Fo, SPL, and airflow. Journal of
Voice, 7, 319-325.

References

Laukkanen, A., Syrja, T., Laitala, M., & Leino, T. (2004). Effect of two month
vocal exercising with and without spectral biofeedback on student actors'
speaking voice. Logopedics, Phoniatrics, and Vocology, 29, 66-76.
Nilson, H., and Schneiderman, C. R. (1983). Classroom program for the
prevention of vocal abuse and hoarseness in elementary school children.
Language, Speech, and Hearing Services in Schools, 14, 114-120.
Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal
hygiene training and vocal function exercises in preventing voice disorders in
primary school teachers. Logpedics, Phoniatrics, Vocology, 32, 1-13.
Prosek, R., Montgomery, A., Walden, B., & Schwartz, D. (1978). EMG
biofeedback in the treatment of hyperfunctional voice disorders. Journal of
Speech and Hearing Disorders, 43, 282-294.
Ramig, L. O., Countryman, S., Thompson, and Horii. (1995). Comparison of
two forms of intensive speech treatment for Parkinsons disease. Journal of
Speech and Hearing Research, 38, 1232-1251.
Rattenbury, H. J., Carding, P. N., & Finn, P. (2004). Evaluating and
effectiveness and efficacy of voice therapy using a transnasal flexible
laryngoscopy: a randomized control trial. Journal of Voice, 18, 522-533.

References

Roy, N. (1993). Ventricular dysphonia following long-term endotracheal

intubation: A case study. Journal of Otolaryngology, 23, 189-193.
Roy, N., Bless, D. M., Heisey, D., & Ford, C. N. (1997). Manual
circumlaryngeal therapy for functional dysphonia: An evaluation of short- and
long-term treatment outcomes. Journal of Voice, 11, 321-331.
Roy, N., Gray, S., Simon, M., Dove, H., Corbin-Lewis, K., & Stemple, J.
(2001). An evaluation of the effects of two treatment approaches for teachers
with voice disorders: A prospective randomized clinical trial. Journal of Speech,
Language, and Hearing Research, 44, 286-296.
Roy, N., & Leeper, H. A. (1993). Effects of the manual laryngeal
musculoskeletal tension reduction technique as a treatment for functional
voice disorders: Perceptual and acoustic measures. Journal of Voice, 7, 242-249.
Roy, N., Weinrich, B., Gray, S., Tanner, K., Stemple, J., & Sapienza, C. (2003).
Three treatments for teachers with voice disorders: A randomized clinical
trial. Journal of Speech, Language, and Hearing Research, 46, 670-688.

References

Roy, N., Weinrich, B., Gray, S., Tanner, K., Toldeo, S., Dove, H., CorbinLewis, K., & Stemple, J. (2002). Voice amplification verses vocal hygiene
instruction for teachers with voice disorders: A treatment outcomes study.
Journal of Speech, Language, and Hearing Research, 45, 623-638
Sabol, L., Lee, L., & Stemple, J. C. (1995). The value of vocal function
exercises in the practice regime of singers. Journal of Voice, 9, 27-36
Smith, S. & Thyme, K. (1976). Statistic research on changes in speech due to
pedagogic treatment (The Accent Method). Folia phoniatrica, 28, 93-103.
Solomon, N. P., & DiMattia, M. S. (2000). Effects of a vocally fatiguing task
and systemic hydration on phonation threshold pressure. Journal of Voice, 14,
341-362.
Stemple, J. C. (1993). Voice therapy: Clinical studies. St. Louis, MO: Mosby Year
Book.
Stemple, J. C., Lee, L., DAmico, B., & Pickup, B. (1994). Efficacy of vocal
function exercises as a method of improving voice production. Journal of Voice,
8, 271-289.
Stemple, J. C., Weiler, E., Whitehead, W., & Komray, R. (1980).
Electromyographic biofeedback training with patients exhibiting a
hyperfunctional voice disorder. The Laryngoscope, 90, 471-476.

References

Timmermans, B., De Bodt, M. S., Wuyts, F. L., & Van de Heyning, P. H.

(2004). Training outcome in future professional voice users after 18 months
of voice training. Folia Phoniatrica et Logopaedica, 56, 120-129.
Timmermans, B., De Bodt, M. S., Wuyts, F. L., & Van de Heyning, P. H.
(2005). Analysis and evaluation of a voice-training program in future
professional voice users. Journal of Voice, 19, 202-210.
Van Lierde, K. M., De Lay, S., Clement, G., De Bodt, M., & Van
Cauwenberge, P. (2004). Outcome of laryngeal manual therapy in four Dutch
adults with persistent moderate-to-severe vocal hyperfunction: A pilot study.
Journal of Voice, 18, 467-474.
Verdolini, K., Titze, I. R., & Fennell, A. (1994). Dependence of phonatory
effort on hydration level. Journal of Speech and Hearing Research, 37, 1001-1007.
Verdolini-Marston, K., Burke, M. K., Lessac, A., Glaze, L., & Caldwell, E.
(1995). Preliminary study of two method of treatment for laryngeal nodules.
Journal of Voice, 9, 74-85.

References

Verdolini-Marston, K., Sandage, M., & Titze, I. R. (1994). Effect

of hydration treatments on laryngeal nodules and polyps and
related voice measures. Journal of Voice, 8, 30-47.
Verdolini-Marston, K., & Titze, I. R., & Druker, D. G. (1990).
Changes in phonation threshold pressure with induced
conditions of hydration. Journal of Voice, 4, 142-151.
Yiu , E. M. L., & Chan, R. M. M. (2003). Effect of hydration and
vocal rest on vocal fatigue in amateur karaoke singers. Journal of
Voice, 17, 216-227
Yiu, E. M. L., Verdolini, K., & Chow, L. P. Y. (2005).
Electromyographic study of motor learning for a voice
production task. Journal of Speech, Language, and Hearing Research,
48, 1254-1268.