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Voice Therapy:
Does Science Support the Art?

Lisa B. Thomas and Joseph C. Stemple

University of Kentucky
Lexington, Kentucky

Three primary orientations to the treatment of functional voice disorders have emerged in the lit eratura.
Hygienic approaches focus on the elimination of behaviors considerad to be harmful to the vocal mechanism.
Symptomatic approaches target the direct modification of aberrant features of pitch, loudness, and quality.
Finally, physiologic methods approach treatment holistically, as they work to retrain and rebalance the
subsystems of respiration,phonation, and resonance.With the va- riety of approaches now available, selection
of appropriate and effective techniques can be chal- lenging for clinicians.The purposes of tliis review are to:
(1) describe various hygienic, symptomatic, and physiologic approaches to voice treatment, (2) investígate the
evidence base behind the thera- peutic approaches, (3) draw conclusions regarding the relative strength of
hygienic, symptomatic, and physiologic tlierapies, and (4) suggest directions for futura study.

Introduction a daunting task to the clinician who is attempting to stay

abreast of developments across tire breadth of the field.
Therefore, the purpose of tliis review is to provide clinicians
Over the years, a number of techniques have emerged for witli an overview of voice therapy methods across a variety of
the treatment of functional voice disorders. Sorne methods have treatment orientations and establish the level of evidence
emerged from our sister field, the vocal arts, others from the supporting each method. In so doing, the review will assist
scientific study of voice production, and still others from the clinicians in preparing appropriate and effective treatment
modification of basic vegetative functions.What is more, some programs for the individuáis whom they serve.
methods have approached voice treatment holistically by
modifying tire full speech production system, whereas others
have treated via pa- tient education or through the retraining of
Evolution of Research
a specific voice parameter. The result has been the emergence
of a broad, and ever expanding, inventory of voice therapy
methods.This growth, although exciting, has posed a unique The first attempts to examine the effects of voice therapy
challenge to clinicians.The voice clinician of to- day must not methods can be identified as far back as the
only be knowledgeable of available methods, but he or she
must also appreciate the evidence-base behind each.This can be
1940s (Froeschels, 1943; Peacher & Holinger, 1947). It was
not,however,until the 1970s tliat consistent calis for outcomes
Communicattve Disorders Review
researcli in tlie field were expressed. In 1971, G. Paúl Moore,
Volume 1, Number l,pp. 49-77 Copyright
© 2007 Plural Publisliing, Inc. speech scientist and speech-language pa- thologist, considered
the voice therapy literatura and de- termined that the field of
voice therapy suffered from a lack sufficient scientiñc support.
4
Furthermore, he con- cluded that many methods used in voice 9
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50 COMMUNICATTVE DISORDERS REVIEXYVOL. 1, NO. 1

therapy were chosen, not because of scientiñc evidence, but rule out extraneous variables and propose cause-effect
because of clinician preference.As a result, Moore proposed determinations.A review of studies conducted in recent years
that voice therapy remained primarily an art, without sufficient demonstrates the emergence of these rigorous designs
scientiñc foundations. Since Moore’s reflection on the (Bassiouny, 1998; Laukkanen, Syrja, Laitala, & Leino, 2004;
literatura, a number of other authors have echoed his cali for MacKenzie, Millar, Wilson, Sellars, & Deary, 2001; Pedersen,
empirical support of therapeutic methods (Hillman, Gress, Beranova, & Moller, 2004; Rattenbury, Carding, & Finn, 2004;
Hargrave, Walsh, & Bunting, 1990; John- son, Roy et al., 2001, 2002, 2003; Stemple, Lee, D’Amico, &
1985;Pannbacker, 1998; Perkins, 1985;Ramig &Ver- dolini, Pickup, 1994;Verdolini,Titze, & Fennell, 1994;Verdolini-
1998; Reed, 1980). As a result of these calis, the field has seen Marston, Sandage, &Titze, 1994;Verdolini-Marston,Titze, &
a slow, but steady, emergence of die scien- tific evidence that Druck- er, 1990).
Moore desired.
Voice therapy outcomes research has evolved through
three main stages. Early articles on the benefit of voice therapy The Challenges of Outcomes Research
carne in the form of descriptive case seríes reports, expert
opinions, and anecdotal com- ments (Hillman et al., 1990). The slow progression of treatment outcomes research over
Although, capable of pro- viding information on therapy with tlie decades is perhaps understandable con- sidering the
individual subjects, tírese models did not allow for complexities of tliis type of research. Vari- ous factors have
generalization to the larg- er population of voice therapy limited tliis form of research in voice, including the etliical
subjects. During tliis pe- riod.the lack of objective measures considerations of delayed or no- treatment experimental
made more detailed, scientiñc study of the voice challenging designs, the lack of sufficient numbers of subjects for large
(Reed, 1980). group studies, the lack of controlled methods of voice therapy
The 1980s brought great advancements in acoustic and (the artistic natura of voice therapy), and the variability of
visual perceptual measures of the voice and ush- ered in a new patient etiologies in group studies (Pannbacker, 1998; Reed,
phase of voice research, tbe instrumental stage. In 1985, 1980).
Johnson responded to recent instrumental advances of the Despite the limiting factors noted above, a number of
period by stating, “the profession is at the threshold of being studies have emerged tliat demónstrate the influence of voice
able to validate years of clini- cal practice in voice disorders therapy in general in the treatment of voice disorders in adults
with efficient data collec- tion techniques” (p. 129). Johnson (Bloch, Gould & Hirano, 1981; Deal, Mc- Clain, & Suddertli,
was proven correct in liis prediction, as the 1990s brought 1976; Holmberg, Hillman, Hammar- berg, Sodersten, & Doyle,
about a dramatic increase in outcomes studies using data 2001; Lancer, Syder, Jones, & LeBoutillier, 1988;MacKenzie
collected from the instrumental assessment of voice et al., 2001;McCrory, 2000; McFarlane & Watterson, 1990;
(Pannbaker, 1998). However.many of the studies conducted Murry & Woodson, 1992; Pannbacker, 1999; Peacher &
during tliis period contained nrethodologic flaws and a lack of Holinger, 1947; Ramig & Verdolini, 1998);findings regarding
rigor in their design; other studies failed to provide information treatment outcomes in children have been less clear (Kahane &
related to the duration of treatment, frequency of treat- ment, Mayo, 1989; Kay, 1982; Lee & Son, 2005; Sander, 1989;
and subject characteristics. In addition, many studies relied Shearer, 1972; Toohill, 1975) Although these studies provide
upon survey research and retrospectivé anal- yses; few studies critical information regarding the contribution of the therapy
met the rigorous randomized, control criteria required for pura process in recovery, clinicians rely upon information related to
efficacy research (Pannbacker, 1998). The studies of tliis the outcomes offered by specific methods of treatment. Such
period, although capable of producing data on client studies have been less common in the literatura.
improvement with therapy, lacked the proper controls to The purpose of this article is to present a critical review of
demónstrate a cause-ef- fect relationship between the therapy outcomes research related to specific treat-
metlrod and voice change (Bassiouny, 1998). Extraneous
variables were able to exert influence in the studies, limiting
conclu- sions regarding the puré causal effects of the treatment
method.
Voice therapy outcomes research needed to con- front tlie
final stage in its evolution—the adoption of rigorous
experimental designs, including randomized control triáis or
well-controlled witliin-subject designs (Belirman & Orlikoff,
1998; Hegde, 1985). Such designs would allow researchers to
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VOICE THJERAPY 51
ment methods for functional voice disorders. Studies discussing philosopliies of therapy have undergone little change in the past
specific treatment methods within the three primary 25 years. Stemple classified voice therapy approaches as
orientations to voice therapy—hygienic, symptomatic, and belonging to one of four maior categories: hygienic,
physiologic—are reviewed. Each study is examined to symptomatic, psy- cliogenic, and physiologic. Certainly, most
determine the level of evidence it provides in support of the would agree that divisions such as those above are, perhaps,
given method. Conclusions regarding areas of strength and more ac- ademic than practical. However, elassiñeations do
areas for future development are presented. offer a useful veliicle for comparing and evaluating various
At the time of tliis review, more tlian 30 years have passed metliodologies. Thus, tliis evidence review follows the basic
since Moore’s (1971) commentary on the state of tlie voice orientations proposed by Reed and Stemple and will ineludes
therapy literature. Have the years produced the evidence that hygienic, symptomatic, and physiologic approaches to voice
Moore so desired? Has the field re- mained primarily an art therapy.
form, or has it progressed to be- ing an art form undergirded by
science? The following review responds to tliose questions.
Hygienic Voice Therapy
Hygienic methods for voice improvement have been
Defining Functional Voice Disorders described in many elassie voice therapy texts (Andrews, 2002;
Boone, 1971; Case, 1996; Colton & Casper, 1996; Deem &
The definition of voice disorders has broadened over the Miller, 2000; Hicks & Bless, 2000; Stemple, 1993; Stemple et
years. Early works defined voice disorders as any de- viation of al., 2000; West, Kennedy, & Carr, 1947; Van Riper & Irwin,
pitch, loudness, quality, or tempo from age, gender, or cultural, 1958). Foundational to the hygienic orienta- tion of therapy are
expectations (Boone, 1971;Van Riper & Irwin, 1958). More two beliefs: (1) many functional voice disorders are initiated
current definitions, however, have shifted from a focus on the and maintained by behaviors that bring harm to the laryngeal
voice signal to a focus on the individual. One such definition by structures; (2) elimination of harmful and traumatic behaviors
Stemple et al. (2000) states “a voice disorder exists when either will lead to improved vocal performance. Hygienic approaches
the structure or function, or botli, of the laryngeal mechanism to voice therapy, therefore, focus on tlie identification and
no lon- ger meet the voicing requirements established for the subsequent elimination of poor vocal behaviors followed by the
mechanism by the speaker” (p. 2).This more recent definition development of proper vocal behaviors.
broadened the scope of the term “voice disorder” by including Within tliis orientation, vocal hygiene management has
individuáis such as the professional voice user who, by clinical been characterized in a number of ways. Some authors have
standards, falls within the range of normal, yet who reports considered vocal hygiene as one component of a larger and
failure of the voice to meet personal requirements. more comprehensive voice therapy proto-
The term 'functional voice disorder” may be more difficult col(Andrews,2002;Boone, 1971;Colton & Casper, 1996; Deem
to define. Some have used the term functional to refer to voice & Miller, 2000; Hicks & Bless, 2000; Stemple et al.,
disorders that occur in the absence of identifiable laryngeal 2000;West et al., 1947;Van Riper & Irwin, 1958). Others have
pathology (Boone & McFarlane, 1988;Van Riper & Irwin, argued that vocal hygiene may, at times, stand alone as the solé
1958). Otlier schemes have re- served the termfunctional for method of addressing voice problems (Andrews, 2002; Colton
descriptions of voice disorders with a psychological origüi & Casper, 1996). Colton and Casper pointed out that either
(Boone, 1971).Finally, some authors have described as perspective may be appropriate for adoption by clinicians. They
functional those voice disorders related to inappropriate use, or stated, “vocal hygiene may constitute the entire rehabilitation
functioning, of the vocal mechanism (Stemple et al., 2000). In program, or it may be one part of the program” (p. 300). Over
tliis final scheme, the term functional disorder may inelude be- tlie years, vocal hygiene has been a mainstay in vocal
nign mucosal disease wliich evolved secondary to functional rehabilitation programs (Mueller & Larson, 1992).
behaviors. Functional voice disorders as defined m tliis final
scheme focus on the physiologic aspeets of tíie laryngeal Symptomatic Volee Tberapy
system, rather than on the structural causes or consequences of
inappropriate use.Tliis latter definition is the perspective of Symptomatic voice therapy is based upon the con- cept of
choice for tliis article. symptom modiñeation. Voice therapy under this model focuses
Orientations to Voice Therapy on the remediation of aberrant vocal symptoms in the areas of
pitch, loudness, and quality.Al- though symptomatic methods
can be identified in early speech correction texts (Van Riper &
Over the years, a variety of approaches have emerged for
Irwin, 1958; West et al., 1947), tliis particular orientation to
the treatment of functional voice disorders. Occa- sional
voice therapy carne to the forefront after being introduced in
attempts have been made to categorize these approaches
Boone’s 1971 seminal text, The Voice and Voice Therapy.
according to their theoretical foundations. In 1980,Reed
Symptomatic voice therapy was based upon the belief that
reviewed the prevailing philosopliies of voice therapy. At that
modiñeation and correction of vocal, respiratory, and resonance
time, perspectives varied from hygienic and symptomatic
symptoms would lead to improvement in the voice condition.
management to holistic, physiologic management. Stemple’s
Boone’s (1971) symptomatic approach involved the use of
(2005) discussion of voice therapy demonstrates that the basic
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52 COMMUNICATIVE DISORDERS REVIEW; VOL. 1, NO. 1

facilitating techniques to bring about the client’s best voice. In included nonempirical works such as: descriptive case
his original presentation of symptomatic therapy, Boone series/case reports, anecdotal reports, statements of expert
proposed 20 facilitating methods ca- pable of modifying vocal opinión, tlieory based on physiologic, bench, or animal
symptoms. Methods ranged from techniques such as yawn-sigb research, and/or common sense principies (seeTable 1).
and chewing aimed at relaxing the vocal mechanism to
techniques such as pusbing aimed at increasing vocal fold
contact during phonation. Method of Review

For the purpose of tliis review, the authors conduct- ed

Physiologic Voice Tberapy searches of the following on-line databases: Med- line,
PsychINFO, Cumulative Index of Nursing and Al- lied Healtli
Recent years have brought a shift away from targeted
Literature (CINAHL), and the archives of the American
treatment of symptoms to holistic consideration of the voice.
Speech-Language-Hearing Association. On-line searches were
Foundational to physiologic voice therapy is the belief that
limited to the period between 1980 and March 2006. Database
voice disorders are best treated by modifying the underlying searches were followed by a thor- ougli historical search using
physiology of voice production (Stemple, 2000; Stemple et al., previously published criti- cal reviews and meta-analyses. No
2000). Due to the focus on physiology, individuáis subscribing year of publication re- strictions were placed on the historical
to tliis form of therapy often discuss treatment methods using search. Studies were chosen for review if the following criteria
anatomic or physiologic terrns. One description of the were met: (1) the study examined the benefit of a treatment
physiologic approach by Stemple, Lee, D’Amico, and Pickup method included within one of the aforementioned treatment
(1994) demonstrares this fact. Stemple and colleagues suggest orientations; (2) the study focused on treatment of disorders of
that the physiologic approach to voice therapy involves three a functional nature; and (3) the arti-
key components: (1) improving tíie balance among the primary
voice production systems of respiration, phonation, and
resonance, (2) improving the strength, balance, tone, and
stamina of the laryngeal muscles, and (3) developing a healthy
mucosal covering of the tme vocal folds.Thus, the physiologic
approach draws upon the clinician’s understanding of normal
voice production to transition the voice toits most appropriate
form.

Reviewing the Evidence

Levels of Evidence

Recent decades have brought an increased interest in

treatment outeomes research in a variety of profes- sions.As a
result, a number of authors have developed methods by which
the rigor and quality of treatment outeomes studies can be rated
(Butler & Darrah, 2001; Guyatt, Vist, Falck-Ytter, Kunz,
Magrini, & Schunemann, 2006; Robey & Schultz, 1998). For
this review, the authors have chosen to follow Butler and
Darrah’s five-lev- el classification scheme. In their examination
of therapy literature, Level I studies included those designs
exliibit- ing the strongest level of experimental support for the
therapeutic method under investigation, whereas Level V
studies demonstrated the lowest level of support. Level I
designs included the randomized control trial, the all- or-none
case series, and the N-of-1 randomized control (single-subject
design). Level II designs included nonran- domized control
triáis, prospective cohort studies with concurrent controls,
analytic surveys,ABABA single sub- ject design, alternating
treatments single subject design, and the múltiple baseline
across participants single subject design. Level III classification
was reserved for case- control studies, cohort studies with
historical controls, and ABA single subject designs. Level IV
studies included before and after case series without controls
and theAB single subject design. Finally, Level V evidence
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VOICE TIIERAPY 53

Table 1. Categorizing Levels of Evidence

Level Group Single Subject

I Randomized control trial N-of-1 randomized control trial
All-or-none case series
II Nonrandomized control trial . ABABA design
Prospective cohort study with concurrent control Alternating treatments design
group Múltiple baseline across participants

III Case control study ABA design

Cohort study with historical control group
IV Before and after case series without control group
AB design
V Descriptive Research/Nonempirical
Descriptive case series/case reports
Anecdotes
Expert Opinión
Theories based on physiology, bencb, or animal research .
Common sens /flrstprincipies
Source: Modified with permission from“Effects of a neurodevelopmental treatment (NDT) for cerebral
palsy:AnAACPDM evidence report,”by C.Butler and J.Darrah,2001, Developmental Medicine and CMld
Neurology, 43, p. 781.

ele was published in Englisli. Selected studies were rated according to outeomes is not considerad in the rating of studies.
the five-level classification system of Butler and Darrah (2001). Studies within each of the tliree primary voice therapy
orientations are presented in the following discussion. The authors’
conclusions regarding the overall status of research within each
Scope and Intention of the Review orientation also are presented.

The intention of the review is to offer a broad over- view of the

current voice therapy evidence base. The scope of the review was Evidence for Hygienic
guided by, and in some respeets limited by, the literature itself. Voice Therapy Methods
Inherent in the voice literature are the widely recognized variables of
nomencla- ture and study design. Fortunately, in the area of voice, the Despite the fací that hygienic methods have been a mainstay of
majority of therapy approaches extend beyond no- menclature therapy from the earliest days of voice therapy to the present, few
limitations, as they are applicable across a wide range of vocal studies have systematically in- vestigated the effeets of vocal hygiene
pathologies. Concerns regarding design variability are of greater therapy alone as a means of managing functional voice disorders.
note.The studies presented below vary signfficantly in tlieir subject More common in the literature have been studies using vocal hygiene
selection, therapy implementation, treatment course, outeomes mea- training as a control against which other direct therapy methods are
sures, and so fortli. Consistent with these limitations, the authors have measured. Valuable information regarding the iníluence of vocal
chosen to inelude all pertinent studies, re- gardless of variability in hygiene can be derived from tliis research model. In fací, many of the
subject demographics, subject etiology, manner of service provisión, studies dis- cussed below that contribute to our knowledge of the
or treatment in- tent (i.e., prevention vs. rehabilitation). Finally, the effect of vocal hygiene training have followed the “vocal hygiene as
Eter- ature review demonstrated that few authors have considerad control” model.
treatment efficiency in their studies. Although a vitally important Studies were selected for inclusión in the vocal hygiene review
feature in today’s clinical marketplace, ' the literature at liand did not if the following criteria were met: (1)
lend itself to conclusions regarding efficiency, and thus tliis aspect of