Voice Therapy for Presbyphonia

Educational Objectives

The goal of this program is to improve management of presbyphonia using voice therapy. After hearing and assimilating this program, the clinician will be better able to:

1. Create protocols for voice therapy in patients with presbyphonia.

2. Implement strategies to improve outcomes of voice therapy for presbyphonia.

Summary

Presbylaryngis: present in the majority of individuals aged >74 yr; problematic if changes in quality of life occur; patient-reported problems — voice that sounds abnormal, inability to be heard, and voice fatigue; observations by clinicians — hoarseness, increased breathiness, lower volume, poor projection, decreased duration of maximum phonation, low pitch, and tremor; options for treatment — voice therapy; augmentation of vocal folds; regenerative medicine

Voice Therapy

Candidates: patients with improvement in voice after trial therapy and willingness to commit to voice exercises

Common themes and differences in protocols: all protocols include prolonged phonation and phonation up and down range of pitch; programs differ in vowel sounds used; specification of pitch, loudness, and dosing per day; and cognitive load

Voice Therapy Protocol for Presbyphonia at University of California, Los Angeles

Resonance tube phonation in water: straw placed in 1 inch of water and occluded; pressure created at one end of straw by phonation creates pressure along entire length of straw down to vocal fold; closer vocal folds allow greater degree of exercise without trauma to tissue; addition of straw effectively doubles length of vocal tract (produces enhanced harmonics, good feedback to ear, further adduction of vocal folds, and rectangular glottis)

Pitch: should be set between G3 and C4 (196-261 Hz) for adult women; use of musical notes helps patients identify pitch; in ≥95% of adult women, pitch A, A#, or B; for adult men, set pitch between C3 and D#3 (normal range A2 to D#3)

Vocal register: chest register corresponds to “talking” voice (full adduction of muscles to produce voice); mixed register, to “singing” voice; protocol works through entire pitch range in all registers to improve ability of vocal folds to protect airway, communicate, and sing; patients are taught how to use voice in different situations

Resonance: most voice using least effort

Protocol: 2 sets of each exercise performed (first set uses large-diameter straw in 1 inch of water; second uses “hoo” phonation); most resonant pitch held for 2.5 min; steps in speaking range performed from best pitch to top of chest register for women and to top and bottom of chest register for men; steps up singing range and pitch glides are performed; then process repeated on “hoo,” from quiet to loud; position head in the middle (neutral) position

Measuring progress: increase in maximum time of phonation indicates progress and point at which difficulty of exercise should be increased

Steps in speaking range: overlapping series of 3 semitones used at a time (one set on straw; one on “hoo” using lips only); progression from quiet to loud performed only in set using “hoo”

Discontinuing exercises: required if patient reports voice fatigue or soreness during or after exercises, has respiratory tract infection, or is taking high doses of medication that increases risk of bleeding

Response: majority of patients experience immediate reset or improvement in voice

Smartphone applications: Piano; Voice Analyst (records voice, analyzes frequency, and provides visual display as feedback tool for patients at home)

Time for response: 4 to 8 wk required for neuromotor programming; 8 to 26 wk, to develop strength for sustained change in voice; patients hear immediate improvement after first session, and improvement is observed after 5 to 6 wk

Duration of therapy: performing exercises 1 time per day as maintenance therapy is recommended for life

Initial frequency of practice: improvement of ≈70% is found in ≈70% of patients who practice 2 times per day; maximum improvement, in ≈95% of patients who practice 3 times per day

Strategies to increase patient compliance: validate goals;; align with and refer back to laryngologist; demonstrate commitment, candidness, and confidence in interaction with patient

Improvement in voice: characterized by improving resonance; raising pitch is objective cue to reach subjective goal of resonant voice

Diameter of straw: use of large-diameter straw is more effective in patients with weak voice; small-diameter straw, in those with tight vocal folds; in patient with weak voice and excessive squeezing of vocal folds, therapy may start with a small-diameter straw and progress to a large-diameter straw; small-diameter straw is not used in water

Patient with inability to match pitch: therapist should match pitch of patient and walk patient up pitch scale by semitone; “baby scale” is often easier to match than one note; use is effective in 99% of patients; in remaining 1%, set timer for ≈14 min, and practice pitch glides

Patients who have undergone radiation or chemoradiation therapy: protocol useful in patients with fibrosis or scarring; increase use of semitone pitch glides and progressions from quiet to loud

Unilateral weakness: in patients with presbyphonia, one side may be weaker than the other; exercises are effective

Paralysis or paresis: paralysis — injection of vocal fold by laryngologist necessary to prevent maladaptive programming of brain; outcome of voice therapy alone rarely satisfactory; paresis — voice therapy preferred as first-line approach; paralysis (continued) — 10 days after injection, patient referred to speech pathologist to identify need for reset or full protocol

Follow-up visits: 2 to 4 sessions required by majority of patients to learn exercises; options include weekly visits for 8 wk, or frequent visits early on followed by 1 visit monthly

Criteria for discharge or referral back to physician: lack of progress in therapy; noncompliance often related to lack of understanding how to perform exercises, inability to integrate exercises into daily life, or inability to improve voice; patients unable to improve after performing exercises correctly may be referred back to laryngologist for injection of vocal folds; only 2 injections performed; surgery or no intervention are only other options

Readings

Desjardins M et al: A systematic review of voice therapy: what “effectiveness” really implies. J Voice. 2017 May;31(3):392.e13-392.e32; Fabron EMG et al: Voice therapy for the elderly with progression of intensity, frequency, and phonation time: case reports. Codas. 2018 Oct 29;30(6):e20170224; Godoy J et al: Effectiveness of vocal therapy for the elderly when applying conventional and intensive approaches: a randomized clinical trial. J Voice. 2019 Sep;33(5):809.e19-809.e26; Granqvist S et al: Resonance tube phonation in water: High-speed imaging, electroglottographic and oral pressure observations of vocal fold vibrations--a pilot study. Logoped Phoniatr Vocol. 2015 Oct;40(3):113-21; Walton C et al: Perspectives on voice treatment for unilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg. 2018 Jun;26(3):157-161.

Disclosures

Ms. Bolden reported nothing to disclose. The planning committee reported nothing to disclose. 

Acknowledgements

Ms. Bolden was recorded at the 2019 UCLA Speech Pathology and Laryngology Update, held April 5, 2019, in Los Angeles, CA, and presented by the David Geffen School of Medicine at the University of California, Los Angeles. For information on future CME activities from this sponsor, please visit cme.ucla.edu. The Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT532201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.