ARTICLE IN PRESS

Efficacy of Water Resistance Therapy in Subjects

Diagnosed With Behavioral Dysphonia: A Randomized
Controlled Trial
*,†,*Marco Guzman, *,†Rodrigo Jara, ‡Christian Olavarria, *Paloma Caceres, *Geordette Escuti,
*Fernanda Medina, *Laura Medina, *Sofia Madrid, §Daniel Muñoz, and ‖Anne-Maria Laukkanen, *†‡§Santiago,
Chile, and ‖Tampere, Finland

Summary: Purpose. The purpose of the present study was to determine the efficacy of water resistance therapy
(WRT) in a long-term period of voice treatment in subjects diagnosed with voice disorders.
Methods. Twenty participants, with behavioral dysphonia, were randomly assigned to one of two treatment groups:
(1) voice treatment with WRT, and (2) voice treatment with tube phonation with the distal end in air (TPA). Before
and after voice therapy, participants underwent aerodynamic, electroglottographic, acoustic, and auditory-perceptual
assessments. The Voice Handicap Index and self-assessment of resonant voice quality were also performed. The treat-
ment included eight voice therapy sessions. For the WRT group, the exercises consisted of a sequence of five phonatory
tasks performed with a drinking straw submerged 5 cm into water. For the TPA, the exercises consisted of the same
phonatory tasks, and all of them were performed into the same straw but the distal end was in air.
Results. Wilcoxon test showed significant improvements for both groups for Voice Handicap Index (decrease), sub-
glottic pressure (decrease), phonation threshold pressure (decrease), and self-perception of resonant voice quality (increase).
Improvement in auditory-perceptual assessment was found only for the TPA group. No significant differences were
found for any acoustic or electroglottographic variables. No significant differences were found between WRT and TPA
groups for any variable.
Conclusions. WRT and TPA may improve voice function and self-perceived voice quality in individuals with be-
havioral dysphonia. No differences between these therapy protocols should be expected.
Key Words: Tube phonation–Semi-occluded vocal tract–Voice therapy–Subglottic pressure–Phonation threshold pressure.

INTRODUCTION occluded vocal tract exercises (SOVTE). This group of exercises

Physiological approach of voice therapy is commonly used by includes phonation on voiced fricatives, nasals, lip and tongue
speech-language pathologists in treating patients with a wide trills, hand over mouth, and phonation into different tubes with
variety of voice disorders. Stemple1 defined this approach of voice the distal end either freely in the air or submerged into a recip-
therapy as “programs aimed to modify the physiology of the vocal ient filled with water.
mechanism.” According to Stemple, this approach involves three Several studies have been carried out to investigate the phys-
main components: “1) to improve the balance between the primary iological aspects of SOVTE. Some of them have focused on the
voice production sub-systems (respiration, phonation, and res- glottal source,5–24 others on vocal tract configuration,22,25–29 and
onance), simultaneously, as opposed to working on each also an important number of investigations have explored aero-
component individually (as symptomatic approach does), 2) to dynamic variables.29–33 Some effects regarding the glottal source,
improve the strength, balance, tone, and stamina of laryngeal related to the increased inertive reactance in the vocal tract, have
muscles, and 3) to develop a healthy mucosal covering of vocal been reported in modeling studies.9,34,35 Specifically, earlier mod-
folds.”2 Examples of physiological voice therapy programs include eling investigations support the idea that this increment positively
resonant voice therapy (RVT),3 the accent method of voice therapy affects the vocal fold vibration,5,8,34,35 changing the glottal flow
(AM),4 and vocal function exercises (VFE).1 amplitude and pulse shape.6,7,35,36 According to Titze, strength-
ening of the higher harmonics and an increase in the overall sound
pressure level are caused by an increased skewing of the glottal
Semi-occluded vocal tract exercises flow waveform (faster cessation of the flow) when inertive re-
A common aspect in physiological voice therapy programs men- actance is increased.5–8 Additionally, the phonation threshold
tioned above is that all of them take advantage of semi- pressure (PTP) (the minimum subglottal pressure required to ini-
Accepted for publication September 8, 2016.
tiate and sustain phonation) is reduced by increased vocal tract
From the *Department of Communication Sciences, University of Chile, Santiago, Chile; inertance.8,35,36 Low values of this variable suggest an easy pho-
†Department of Otolaryngology, Las Condes Clinic, Santiago, Chile; ‡University of Chile
Hospital, Santiago, Chile; §Department of Otolaryngology, University of Chile, Santiago,
nation (low phonatory effort).
Chile; and the ‖School of Education, Speech and Voice Research Laboratory, University A considerable number of studies have explored the possible
of Tampere, Tampere, Finland.
Address correspondence and reprint requests to Marco Guzman, Department of
effect of SOVTE on vocal fold adduction through electro-
Communication Sciences, University of Chile, Santiago, Chile; Department of glottographic contact quotient (CQEGG).10–19 Andrade et al18 as
Otolaryngology, Las Condes Clinic, Santiago, Chile. E-mail: guzmann.marcoa@gmail.com,
mguzman@med.uchile.cl
well as Guzman et al19 compared the CQEGG among different
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ SOVTEs. The latter found that different SOVTEs differen-
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
tially affect vocal fold adduction in both subjects with dysphonia
http://dx.doi.org/10.1016/j.jvoice.2016.09.005 and subjects with normal voice. Lip and tongue trills produced
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016

the lowest CQEGG values, whereas straw submerged 10 cm below al dysphonia, normal without voice training, normal with voice
water presented the greatest CQEGG.19 Low CQEGG values during training, and vocal fold paralysis).37
tongue and lip trills have also been reported by Andrade et al18
and Gaskill and Erickson.10 Evidence about efficacy of physiological approach of
The impact of SOVTE on vocal fold vibration and glottal area voice therapy
variables has also been observed by high speed digital imaging Multiple earlier studies have demonstrated the efficacy of phys-
during tube phonation.20–22 Additionally, an investigation (a double- iological approach of voice rehabilitation programs.38–63 VFEs have
case study) using computerized tomography (CT) was carried been examined with both normal and voice disordered
out to observe whether there are systematic changes in the vocal populations,38–56 as well as RVT57–59 and AM.60–63 However, there
fold adjustment during and after tube phonation.23 Muscle ac- are few studies exploring the efficacy of alternative voice reha-
tivity has also been assessed using electromyography.24 Findings bilitation programs based on SOVTE, such as phonation into
from electromyography showed that the ratio of thyroaryte- different tubes with the distal end either freely in the air or sub-
noid muscle activity versus cricothyroid muscle activity increased merged into a recipient with water. An investigation on the effect
during phonation into a tube.24 of drinking straw phonation in air plus bilabial consonant /ß:/ in
Vocal tract shape changes during SOVTE have been inves- a group of acting students diagnosed with muscle tension dys-
tigated through CT,17,25,29 magnetic resonance imaging,26 and with phonia showed that after a 6-week therapeutic period, significant
flexible laryngeal endoscopy as it comes to hypopharyngeal and positive changes were observed by spectral analysis and laryn-
laryngeal changes.27 In a single case CT study with a vocally goscopic assessment.64 In a recent randomized controlled trial,
normal subject, Vampola et al25 found that the most dominant Kapsner-Smith et al65 demonstrated that a 6-week therapeutic
modification during tube phonation was the expansion of the cross- program, based on flow-resistant tube exercises (stirring straw pho-
sectional area of the oropharynx and oral cavity. A higher velum nation), caused significantly more improvement in Voice Handicap
position was also reported. When comparing the pre- and posttube Index (VHI) scores than in the scores of the control condition (no-
phonation, the authors showed that the total volume of the vocal treatment group).65 Furthermore, flow-resistant tube therapy resulted
tract was considerably larger after phonation into the tube. The in significant decrease in roughness (from the Consensus Auditory-
volume of the valleculae and piriform sinuses also increased.25 Perceptual Evaluation of Voice (CAPE-V) scale) relative to the
Similar results have been demonstrated by Laukkanen et al26 and control group. To the best of our knowledge, only two longitu-
Guzman et al17 in vocally normal subjects. The latter also showed dinal studies have been carried out using phonation into tubes
that the vertical laryngeal position was lower during phonation submerged in water (water resistance therapy [WRT]) in sub-
into a tube compared with vowel phonation, and that the changes jects with behavioral dysphonia.66,67 In a controlled study conducted
were more prominent during phonation into a narrow straw (stir- by Simberg et al,66 participants from experimental group under-
ring straw) compared with phonation into the traditional Finnish went a 7-week therapy period with WRT. Perceptual assessment
glass tube. Wistbacka et al28 showed in a recent investigation with and results from a questionnaire of the occurrence of vocal symp-
a dual-channel electroglottograph that phonation into a tube sub- toms revealed significant positive changes in the treatment group
merged into water caused a lower vertical laryngeal position, compared with the control group.67
whereas it rose during phonation with the distal tube end in air.
Moreover, in a recent investigation with CT on voice patients, Tube in air versus tube into water
the total volume of the vocal tract increased during tube pho- From the physical point of view, one of the main differences
nation compared with the conditions pre- and postexercises.29 between tube phonation with the free end in air and tube sub-
Various earlier studies have addressed the effect of different merged into water is the degree of resistance that they offer to
SOVTEs on air pressure measures.17,30–33,37 Maxfield et al32 mea- the airflow, being greater when tube is placed in water. Andrade
sured the intraoral pressure (Poral) produced by 13 semi- et al33 showed that when tubes are submerged into water, back
occlusions. The highest values of oral pressure were evidenced pressure (analogous to Poral) needs to overcome the pressure
for a straw submerged in water, for lip trills, and for a stirring generated by the water depth before flow can start.33 Another
straw with the free end in air. Radolf et al30 showed that com- difference between tube phonation in air and into water is due
pared with vowel phonation, the Poral increased in phonation to the water bubbles produced during the latter (WRT). There-
into a resonance tube and stirring straw, most when the reso- fore, tube phonation in water generates a pulsating oral pressure
nance tube was 10 cm in water. Subglottic pressure (Psub) also at the frequency of 15–40 Hz,30,31 which may cause a massage-
tended to increase relatively more than Poral, and thus transglottic like effect on the laryngeal and pharyngeal tissues.
pressure (Ptrans) was higher during tube and straw phonation Although the two physical differences between tube in air and
compared with vowel phonation. In a recent investigation, it was tube in water are well supported by evidence, there is no evi-
found that all exercises with phonation into tubes in air and sub- dence on the possible long-term effects of these two therapeutic
merged in water had a significant effect on Psub, Poral, and approaches and the possible differences in the effects. It seems
Ptrans.37 Phonation into a flexible silicon tube (LaxVox-like tube) important to investigate whether these approaches would result
submerged 10 cm in water and phonation into a stirring straw in different therapeutic outcomes. The investigation is moti-
in air resulted in the highest values of Psub and Poral com- vated by the fact that these two approaches are practical and easy
pared with baseline. Moreover, most variables behaved in a similar to use in voice therapy, and therefore they have become increas-
way regardless of the vocal status of the participants (function- ingly popular worldwide. Therefore, the present study aimed to
 ARTICLE IN PRESS
Marco Guzman, et al Efficacy of Water Resistance Therapy for Behavioral Dysphonia 3

determine the efficacy of WRT and tube phonation in air during Participants performed different phonatory tasks according to
a long-term period of voice treatment in subjects diagnosed with the protocol used in PAS for aerodynamic and electroglottographic
behavioral dysphonia. assessments. In the present study, only two protocols were used:
“comfortable sustained phonation with EGG” and “voice effi-
METHODS ciency.” During “comfortable sustained phonation protocol,”
subjects were required to produce a sustained vowel [a:]. During
Participants
“voice efficiency protocol,” an estimate of the Psub was re-
Twenty-eight participants were initially enrolled in this study. All
corded from the Poral during the occlusion of the voiceless
participants were randomly assigned to one of two treatment groups
consonant [p:] during the repetition of the syllable [pa:]. A thin
before starting voice therapy procedures: (1) voice treatment with
plastic and flexible tube inserted into the mouth was used to
WRT, and (2) voice treatment with tube phonation with the distal
capture Poral. During “voice efficiency protocol,” PTP was also
end in air (TPA). Subjects were distributed equally among groups
obtained. For that purpose, participants were asked to produce
(n = 14 for each group). The mean age in the WRT group was 28
repetition of the syllable [pa:] as softly as possible but without
years, with a range of 20–35. The mean age in the TPA group was
entering into whisper. All phonatory tasks were demonstrated
27 years, with a range of 18–33. The inclusion criteria for all par-
by researchers, and a brief practice was conducted before ob-
ticipants were (1) age within the range of 18–50 years, (2)
taining voice recordings that best represented the target
laryngoscopic diagnosis of hyperfunctional dysphonia (with the
productions. For PTP, a longer practice was performed. Three
absence of organic lesions), and (3) no current or previous voice
repetitions were made for all phonatory tasks.
therapy. Laryngeal evidence for hyperfunction was the presence
All samples were analyzed with real-time aerodynamic and
of compression of the glottis or supraglottic structures during pho-
EGG analysis software. A criterion level of 25% from the peak-
nation. Moreover, all subjects reported sensation of muscle tension
to-peak amplitude of the EGG signal was used for CQEGG analysis.
and effort during phonation. Even though 28 participants were ini-
Only the most stable sections from the middle part of the samples
tially enrolled, only 20 participants completed the entire therapeutic
were included in the EGG and aerodynamic analyses. Once the
procedure (10 participants in each group).
stable sections were selected, the following variables were
Participants from all groups were native speakers of Spanish.
obtained:
This study was reviewed and approved by the University of Chile,
Faculty of Medicine Review Board. Informed consent was ob-
(1) comfortable sustained phonation protocol: mean EGG
tained from all the participants. Assessment and therapy sessions
contact quotient (CQ) (%) and mean glottal airflow (L/s)
were carried out in the voice research laboratory at the Univer-
(2) voice efficiency protocol: mean Psub (cm H2O), glottal
sity of Chile.
resistance (cm H2O/L/s), and PTP (cm H2O)

Laryngoscopic assessment Audio recordings and acoustical analysis

Before voice therapy, all participants underwent laryngo- After aerodynamic and EGG assessments, participants were re-
scopic, aerodynamic, electroglottographic, acoustic, and perceptual corded when reading a 242-word phonetically balanced text,
assessments of voice. First, they were asked to undergo rigid which took approximately 90 seconds. A Focusrite Scarlett 8i-6
videostroboscopy (Digital Videostroboscopy System RLS 9100- USB audio interface (Focusrite Audio Engineering, High
B; KayPENTAX, Lincoln Park, NJ) to confirm medical diagnosis. Wycombe, UK) and a Rode condenser-omnidirectional micro-
Laryngoscopic examinations were performed by one experi- phone, Model NT2-A (Rode, Long Beach, CA) were used to
enced laryngologist at the University of Chile Hospital and who capture the audio signals. The microphone was positioned 30 cm
is a coauthor of the present study (C.O.). No topical anesthesia from the mouth of the participants, who remained standing. Re-
was used during endoscopic procedure. cordings took place in an acoustically treated room, and the
samples were recorded digitally at a sampling rate of 44.1 kHz
Aerodynamic and electroglottographic assessments and with 16 bits. The recording of voice signals was made using
Aerodynamic and electroglottographic (EGG) signals were cap- the software Pro Tools 9.0 (Avid Corporation, Burbank, CA).
tured simultaneously during all phonatory tasks. Aerodynamic Acoustical analysis with long-term average spectrum (LTAS)
data were collected with the Phonatory Aerodynamic System was performed. The acoustical variables in this study were (1)
(PAS; KayPENTAX, Model 4500). EGG data were obtained with the sound level difference between the F1 and F0 regions
an electroglottograph (KayPENTAX, Model 6103). Both aero- (L1−L0), that is, the level difference between 300–800 Hz and
dynamic and EGG systems were connected to an interface 50–300 Hz; and 2) the alpha ratio, which is the sound level dif-
(Computerized Speech Lab, Model 4500, KayPENTAX), which ference between 50–1000 Hz and 1000–5000 Hz. L1−L0 has been
in turn was connected to a desktop computer running a real- associated with the degree of vocal fold adduction. Hypoadducted
time aerodynamic and EGG analysis software (KayPENTAX, vocal folds present a strong L0 (sound level of F0) and low L1
Model 6600, version 3.4). All samples were digitally recorded (sound level of F1), whereas a weak L0 and strong L1 are present
at a sampling rate of 22.1 KHz with 16 bits/sample quantiza- in voices with higher vocal fold adduction.68 Alpha ratio is a
tion. Calibration of the airflow rate and pressure was performed measure that represents overall spectral slope.69 This spectral vari-
before every recording session according to the manufactur- able has been found to depend on phonation type (degree of vocal
er’s instructions. fold adduction), being higher in hyperfunctional voices.70 The
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016

LTAS spectra for each subject were obtained by the Praat soft- included aspects related to sensory-motor learning principles
ware, version 5.3.60 (Institute of Phonetic Sciences of the applied to voice rehabilitation and use of SOVTE.
University of Amsterdam, The Netherlands). For each sample, All therapy sessions included three sections: (1) introduction (3
a bandwidth of 100 Hz and Hanning window were used. Before minutes), where the clinician asked about home practice and any
performing LTAS analysis, unvoiced sounds and pauses were voice issue that happened during the previous week; (2) core (24
eliminated from the samples by the Praat software using the pitch- minutes), where the participants demonstrated exercises that had
corrected LTAS version with standard settings. been practiced during the previous week and rehearsed new pho-
natory tasks planned for the session; and (3) end of practice (3
Auditory-perceptual evaluation minutes), where the clinician instructed the home practice that the
All recorded audio samples from the phonetically balanced text patient should perform every day until the next therapy session.
were perceptually assessed by three blinded judges (speech- The first therapy session also included instruction about vocal
language pathologists with at least 10 years of experience in voice hygiene habits (hydration, avoidance of high loudness speech, and
clinic). Additionally, 20% of samples were randomly repeated avoidance of laryngeal irritants) for both groups.
in order to determine whether judges were consistent in their For the WRT group, the exercises consisted of a sequence of
perceptions (intra-rater reliability analysis). They were not aware five phonatory tasks performed into a commercial plastic drink-
of these repetitions. Perceptual assessment was performed on ing straw (5 mm in inner diameter and 25.8 cm in length)
a 100-mm visual analog scale. Only one perceptual variable was submerged 5 cm into water. The main reason for choosing this
assessed, resonant voice quality. This variable was defined as a type of tubes is the fact that they are easily available and af-
voice that sounds as being produced easily and with forward fordable for clinicians and patients in several countries. Phonatory
placement (0 = not resonant at all, 100 = very resonant). Forward tasks included (1) sustained vowel-like sound, (2) ascending and
placement is an auditory perception of well projected and bright descending glissandos throughout a comfortable vocal range, (3)
voice. Raters could replay each sample as many times as they intensity and pitch accents, (4) messa di voce, and (5) singing
wanted before making their decision and moving on to the next the melody of the song “happy birthday” into the straw. These
sample. The evaluation was performed in a quiet room at the phonatory tasks were sequentially included in the treatment period
voice research laboratory using high-quality headphones (Bose during the eight sessions. Participants were asked to feel vibra-
AE2, Bose Corporation Framingham, MA). None of the listen- tory sensations on the alveolar ridge, and face and head areas,
ers reported any hearing problems. and to feel ease of phonation. Participants from this group were
also encouraged to feel a massage-like sensation produced by
water bubbling during all phonatory tasks with WRT. Before and
Questionnaire application
during practice, the clinicians provided individual demonstra-
All participants were asked to complete the Spanish adaptation
tions and verbal descriptions of each phonatory task.
and validation of the VHI-30.71,72 This self-administrated ques-
For the TPA group, the exercises consisted of the same five
tionnaire is a health status instrument designed to assess the voice
phonatory tasks performed into the same kind of a plastic drink-
handicap resulting from voice problems. The VHI has impor-
ing straw as was used in the exercise group, but in the control
tant psychometric properties of reliability and validity.71 It contains
group the distal end of the straw was held in air. Moreover, lip
30 items chosen to address the functional, physical, and emo-
buzz ([ß:]) was also included in the first session for the control
tional impact of voice problems. Each item is individually scored
group to help the subjects recognize vibratory sensations.
on a 5-point Likert scale anchored by “never” (score of 0) and
For a home exercise program, the subjects from both groups
“always” (score of 4).71
were required to complete 6–8 times daily, during 5–10 minutes
each time. At the end of each session, the subjects were given
Self-assessment of voice quality on a paper sheet detailed instructions for the home exercise
Before aerodynamic, electroglottographic, and acoustics record- program. The instructions included all phonatory tasks learned
ings, all participants were required to self-assess their voice during the session.
quality. Perceptual assessment was performed on a 100-mm visual
analog scale. Only one perceptual variable was assessed (reso-
nant voice quality), defined as a voice that feels easy and with Posttherapy assessment
sensation of vibration on the front part of face and mouth (0 = not Once the eight-session voice therapy period was accom-
resonant at all, 100 = very resonant). plished, each participant underwent the same assessment
procedure as had been performed for the pretherapy assess-
ment. The procedure included aerodynamic, EGG, acoustic,
Voice therapy procedures
auditory-perceptual assessment, and self-assessment of voice.
The treatment period included eight voice therapy sessions within
Posttesting was performed exactly 1 week after completion of
8 weeks, with a frequency of one therapy session per week. Each
voice therapy.
session lasted for 30 minutes. Therapy sessions were adminis-
trated by four trained speech-language pathologists. To standardize
the therapeutic performance, all clinicians participated in a 20- Statistical analysis
hour training period (conducted by the first author of the present All statistical analyses were made using Stata 13.1 (StataCorp
study) prior to performing the therapy. This training period LP, College Station, TX). A P value <0.05 was considered
 ARTICLE IN PRESS
Marco Guzman, et al Efficacy of Water Resistance Therapy for Behavioral Dysphonia 5

TABLE 1.
Results (Median and Interquartile Range) From Experimental Group for VHI, Auditory-Perceptual Assessment, and Self-
Perceived Voice Quality (Wilcoxon Test)
Variable Pre Post P Value
Total VHI 33.00 (25.00–47.00) 20.50 (14.00–25.00) 0.0018
VHI functional 9.00 (5.00–16.00) 6.00 (4.00–6.00) 0.0101
VHI physical 15.50 (10.00–19.00) 11.50 (5.00–15.00) 0.0056
VHI emotional 9.50 (5.00–13.00) 3.00 (2.00–6.00) 0.0128
Self-assessment 43.00 (38.00–74.00) 75.50 (72.00–89.00) 0.0002
Auditory-perceptual assessment 61.25 (49.00–66.50) 58.25 (51.50–68.00) 0.0602
Abbreviation: VHI, Voice Handicap Index.

statistically significant, and all P values were two-sided. De- we obtained adequate and significant (P < 0.05) final consis-
scriptive statistics were calculated for the variables, including tency for auditory-perceptual assessment. The ICC prevoice
median and interquartile range. Variables were compared between therapy was 0.68 (P = 0.038), and the ICC postvoice therapy was
control group and experimental group and before-after treat- 0.87 (P = 0.008).
ment using the Wilcoxon test. Spearman’s rank correlation
coefficient with Bonferroni-adjusted significance level was used Wilcoxon test results
to assess correlation between variables. Intraclass correlation co- Tables 1 and 2 show results from the WRT and TPA groups, re-
efficient (ICC) was also used to assess reliability of the listening spectively, for VHI, auditory-perceptual assessment, and self-
evaluation. perceived voice quality. Significant improvements (P < 0.05) were
observed for both groups when pre- and postvoice therapy con-
RESULTS ditions were compared for the total score of VHI (decrease) and
Reliability analysis self-perception of resonant voice quality (increase). Improve-
Intra-rater reliability analysis for auditory-perceptual evalua- ment in auditory-perceptual assessment was found only for the
tion demonstrated good agreement for each judge (Judge 1: 0.75, TPA group. No significant differences were found when com-
P = 0.031; Judge 2: 0.65, P = 0.049; Judge 3: 0.84, P = 0.001). paring the WRT and TPA groups.
Initially, poor agreement was obtained between judges (inter- Tables 3 and 4 display the results for the WRT and TPA groups,
rater analysis). This was due to dissimilar evaluation by one of respectively, for aerodynamic and EGG variables. Significant
the judges, so with this outlying judge removed from the analysis changes (P < 0.05) were observed in both groups when pre- and

TABLE 2.
Results (Median and Interquartile Range) From Control Group for VHI, Auditory-Perceptual Assessment, and Self-
Perceived Voice Quality (Wilcoxon Test)
Variable Pre Post P Value
Total VHI 33.50 (18.00–44.00) 22.50 (9.00–37.00) 0.0463
VHI functional 7.00 (4.00–10.00) 6.50 (2.00–9.00) 0.1811
VHI physical 17.00 (10.00–24.00) 11.00 (5.00–17.00) 0.0217
VHI emotional 4.50 (3.00–13.00) 4.50 (2.00–7.00) 0.5731
Self-assessment 44.00 (29.00–58.00) 70.00 (61.00–79.00) 0.0093
Auditory-perceptual assessment 37.75 (20.50–53.00) 53.50 (33.00–60.00) 0.0125
Abbreviation: VHI, Voice Handicap Index.

TABLE 3.
Results (Median and Interquartile Range) From Experimental Group for Aerodynamic and EGG Variables (Wilcoxon Test)
Variables Pre Post P Value
Glottal airflow (L/s) 0.15 (0.10–0.20) 0.15 (0.11–0.17) 0.7213
EGG CQ (%) 57.38 (48.36–62.19) 56.80 (52.80–61.23) 0.7713
Subglottic pressure (cm H2O) 8.81 (7.83–9.87) 8.41 (6.61–8.73) 0.0218
Glottal resistance (cm H2O/L/s) 55.44 (47.60–132.70) 53.86 (39.22–96.13) 0.1141
PTP (cm H2O) 5.76 (5.33–6.16) 4.40 (4.29–5.34) 0.0051
Abbreviations: CQ, contact quotient; EGG, electroglottographic; PTP, phonation threshold pressure.
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 4.
Results (Median and Interquartile Range) From Control Group for Aerodynamic and EGG Variables (Wilcoxon Test)
Variables Pre Post P Value
Glottal airflow (L/s) 0.18 (0.15–0.30) 0.17 (0.12–0.25) 0.1394
EGG CQ (%) 55.30 (52.66–56.82) 53.75 (49.20–56.74) 0.5751
Subglottic pressure (cm H2O) 10.23 (9.62–11.42) 8.58 (7.84–9.41) 0.0218
Glottal resistance (cm H2O/L/s) 55.76 (46.17–66.75) 44.62 (36.83–52.59) 0.0926
PTP (cm H2O) 6.10 (5.77–6.82) 4.83 (4.15–5.44) 0.0051
Abbreviations: CQ, contact quotient; EGG, electroglottographic; PTP, phonation threshold pressure.

postvoice therapy conditions were compared for Psub (de- subscale (rho = −0.856; P = 0.001) for the TPA group before
crease) and PTP (decrease). No significant differences were found therapy. These results suggest that the more Psub was needed
between the WRT and TPA groups. to initiate phonation the less voice problems the subjects re-
The results from the acoustical analysis are shown in Tables 5 ported. This paradoxical negative correlation is likely due to the
and 6. No significant changes were found when comparing pre- small sample size. It may also reflect a difficulty to find the softest
and postvoice therapy conditions for both groups. possible tone in the first recording.

Correlation analysis DISCUSSION

Correlation analysis revealed some results of clinical rele- The present study assessed the effects of an 8-week voice therapy
vance. A strong linear negative correlation was found between period with WRT as a primary treatment for patients diag-
VHI total score and self-perceived voice quality for the TPA group nosed with behavioral dysphonia. The results appear to support
both before therapy (rho = −0.765; P = 0.009) and after therapy the role of WRT (one representative of physiological approach
(rho = −0.666; P = 0.035). The VHI emotional subscale and self- in voice treatment) as a potentially effective treatment for sub-
perceived voice quality (rho = −0.689; P = 0.027) also correlated jects with functional voice disorders. Effectiveness of WRT was
negatively both before (rho = −0.802; P = 0.005) and after therapy compared to voice therapy with phonation into a tube with the
for the TPA group. Furthermore, there was a negative correla- distal end in air. Data showed significant improvements for both
tion between the VHI functional subscale and self-perceived voice treatment protocols when pre- and postvoice therapy condi-
quality (rho = −0.754; P = 0.011) for the TPA group before tions were compared for VHI (decrease), Psub (decrease), PTP
therapy. These three correlations suggest that the more voice prob- (decrease), and self-perception of resonant voice quality (in-
lems the subjects reported, the less ease and less vibratory crease). No significant differences were found for any acoustic,
sensations they experienced during voice production. More- electroglottographic, or auditory-perceptual variable. Addition-
over, PTP also showed a strong negative correlation with self- ally, no significant differences were found when comparing the
perceived voice quality (rho = −0.754; P = 0.041) for the TPA WRT and TPA groups for any variable.
group before therapy, suggesting that the less Psub was needed A significant reduction of the total VHI score was observed
to barely initiate phonation the less effort and more vibratory for both groups after voice therapy. Moreover, the scores of each
sensations were perceived during phonation. Additionally, and individual subscale (functional, physical, and emotional) sig-
contrary to what could be expected, PTP correlated negatively nificantly improved (decrease) after therapy for the WRT group.
with the VHI total score (rho = −0.840; P = 0.002), VHI func- No improvements were observed for the functional and emo-
tional subscale (rho = −0.650; P = 0.028), and VHI organic tional subscales for the TPA group. From our data, it seems that

TABLE 5.
Results (Median and Interquartile Range) From Experimental Group for Acoustic Variables (Wilcoxon Test)
Variable Pre Post P Value
Alpha ratio −12.52 (−16.13–11.20) −13.71 (−15.64–12.46) 0.5751
L1−L0 −0.08 (−3.53 2.97) −1.19 (−4.22 3.89) 0.6012

TABLE 6.
Results (Median and Interquartile Range) From Control Group for Acoustic Variables (Wilcoxon Test)
Variable Pre Post P Value
Alpha ratio −14.83 (−16.57–9.78) −16.01 (−17.87–13.45) 0.0745
L1−L0 −2.65 (−4.38 0.23) −2.74 (−4.58 3.46) 0.7213
 ARTICLE IN PRESS
Marco Guzman, et al Efficacy of Water Resistance Therapy for Behavioral Dysphonia 7

WRT had a wider positive impact than therapy with tube in air, Furthermore, correlation analysis from our data interestingly dem-
regarding the areas that could be affected by voice disorders (func- onstrated associations between PTP and the VHI total score, VHI
tional, physical, and emotional). Several earlier studies using functional subscale, and VHI physical subscale. The greatest value
physiological programs for voice rehabilitation have used VHI was found in the latter. Because VHI physical subscale is related
as an outcome.39,47,55,58,59,65 A recent investigation conducted by to the degree of physical vocal discomfort (eg, “I use a great
Kapsner-Smith et al demonstrated a significant reduction of the deal of effort to speak,” “I feel as though I have to strain to
VHI total score after voice therapy for both treatment groups produce voice,” “my voice sounds creaky and dry,” my voice
(VFE and phonation into a thin straw with the free end in air) “gives out” on me in the middle of speaking”), it is reasonable
compared with the non-treatment group.65 A positive effect of to find an association between these variables.
VFE on VHI has also been observed, in various other studies, PTP is expected to decrease during SOVTE, as it has been
eg, in patients with aging voice, 47,55 teachers with voice found to decrease due to the increased vocal tract inertance.8,35
complaints,39 and subjects diagnosed with behavioral dysphonia.56 In a modeling study with excised larynges, PTP was assessed
Additionally, two studies have reported positive outcomes for by Conroy et al75 during nine conditions: control, two tube di-
VHI after voice treatment with RVT.58,59 Roy et al58 observed ameters, three tube lengths, and three levels of flow input. A
that following a 6-week period, both the RVT and the use of elec- significant decrease in PTP was detected for the longest tube and
tric voice amplification resulted in a significant reduction of the the narrower tubes. Similarly, PTP was found to decrease for a
mean VHI scores. Similar results of RVT were shown by Chen glass resonance tube in a study applying a physical model of
et al59 in a group of female teachers with voice disorders. Other human voice production.31 To the best of our knowledge, no
studies exploring the effectiveness of physiological voice therapy studies have been conducted to assess PTP after a long-term period
programs (VFE,40,47 RVT,57,58,73 and AM63) have also demon- of voice therapy with tube phonation. Only one investigation has
strated some self-reported improvements using different scales used PTP as an outcome to observe changes after a physiolog-
than VHI. Gillivan-Murphy et al40 in a study performed with ical voice therapy program.59 Chen et al59 reported a significant
primary and secondary school teachers reported improvements reduction of PTP after an 8-week period of voice treatment with
in the Voice Symptom Severity Scale in subjects from the ex- RVT in teachers with voice disorders. Additionally, some in-
perimental group treated with VFE. The Voice Symptom Severity vestigations have been carried out to observe PTP after voice
Scale is a 30-item patient-derived inventory of voice symp- exercises as vocal warm-up. Theoretically, vocal warm-up should
toms with three content domains and a total score.74 Evidence increase blood flow to the vocal fold muscles, thus decreasing
supports the idea that physiological voice therapy programs such muscle viscosity, and this in turn should decrease the PTP. Nev-
as VFE, RVT, AM, and tube phonation protocols positively affect ertheless, no consistent results have been found. In some cases,
self-assessment outcomes. findings are even contrary to what is expected from the theo-
In the present study, visual analog scale assessing the self- retical point of view. Vintturi et al76 and Motel et al77 found a
perceived resonant voice quality also showed a significant significant increase of PTP after vocal warm-up, whereas other
improvement (increment) for both groups after 8 weeks of voice studies have reported a high variability among participants or
therapy. Patients felt their voice production easier (less effort) no effect.78,79 Only one study, conducted by McHenry and
and involving more vibratory sensations in the front part of face Johnson,80 reported a decrease of PTP after vocal warm-up. During
and mouth. No significant differences were found when com- SOVTE, a decreased PTP could be explained as a result of in-
paring both groups. Interestingly, correlation analysis from our creased vocal tract reactance. After SOVTE, ie, after the semi-
data showed a strong negative correlation between self-perceived occlusion has been removed from the vocal tract, the effect is
voice quality and VHI total score, and some of the subscales for supposed to remain due to a better phonation balance (neither
the TPA group. Perceived phonatory effort has also been as- breathy nor pressed phonation) or an improved impedance match
sessed in earlier works where subjects have been treated with between the larynx and the vocal tract, eg, in terms of a slightly
physiological voice therapy programs. Sauder et al47 reported less narrowed epilarynx.9
self-perceived phonatory effort after a 6-week treatment period Another aerodynamic measure that exhibited changes when
in a group of subjects with aging voice. Furthermore, in an in- comparing pre- and postvoice therapy conditions in the present
vestigation where RVT was administered to patients diagnosed study was Psub. It decreased in both groups significantly. Likely,
with vocal nodules, Verdolini-Marston et al57 found a decrease this reduction also reflects (as PTP did) the lower phonatory effort
in self-perceived phonatory effort after 2 weeks of voice treat- perceived by subjects in their voice production. Two previous
ment. Likely the patients of the present investigation and those therapeutic investigations performed using physiological ap-
from the above-mentioned earlier studies learned to produce a proaches (AM) reported changes in Psub after a long-term
more resonant voice after the treatment period. Nevertheless, it treatment period.61,63 Kotby and Fex61 observed a decrease in Psub
is also possible that they just learned to pay attention to some after a 20-week period of voice treatment with AM in a group
sensations associated with voice production. That as such may of subjects diagnosed with a wide variety of voice disorders.
also be seen as a positive outcome. Similar findings were reported by Bassiouny.63 Only one pre-
As perceived phonatory effort has been associated with the vious study has shown opposite results (increment of Psub);
PTP (the Psub required to barely initiate and sustain phonation),34,35 however, they are expected taking into account the population
this parameter would be expected to decrease after voice therapy. included (elderly men).43 The authors suggested that this in-
Our data showed a significant decrease in PTP for both groups. crease was a result of improved glottal closure.43
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016

Several studies have demonstrated an increase in Psub or Poral where three different semi-occlusions were tested ([ß:], [m:], and
during semi-occluded exercises17,28–33 (especially when the tube phonation into a glass tube in air), most subjects showed a de-
is submerged in different depths of water). Results suggest that crease in glottal resistance, mainly due to increased airflow. The
the increased Psub is a compensation due to the increased Poral, authors suggested that these types of exercises immediately affect
which in turn is caused by the high degree of airflow resis- the control of glottal width.83
tance offered by these semi-occlusions. The main variables that Acoustic findings from the present investigation are concor-
affect the airflow resistance during tube phonation are the di- dant with CQEGG and glottal resistance results. Neither L0−L1
ameter and length of the tube in air,21,29,30,32,81 and the depth of nor alpha ratio showed significant differences in pre-post com-
immersion when the tube is placed into water.29,30,32 Consider- parison. However, there was a small decrease (more negative
ing that an increment in Psub is commonly observed during values) in both parameters after voice therapy in both groups.
SOVTE, it seems paradoxical that after a long-term voice therapy Recall that both L1−L0 and alpha ratio have been found to depend
Psub has been found to be lower compared with pretreatment on phonation type (degree of vocal fold adduction).68,69 More neg-
condition. Nevertheless, it is feasible that a moderate incre- ative values are indicative of a less tight vocal fold adduction.
ment of Psub during SOVTE helps train breathing function during Therefore, taking into account CQEGG, glottal resistance, L1−L0,
a long-term period of voice therapy, resulting in a decreased pho- and alpha ratio, it would be possible to state that both groups
natory effort. Further studies should be performed on this topic. tended to decrease vocal fold adduction, even though no sig-
Glottal airflow rate has been found to change after voice therapy nificant pre-post differences were found. Because subjects from
with some physiological programs. Stemple et al38 reported a the present study were diagnosed with hyperfunctional dyspho-
significant decrease in airflow rate after VFE. Authors sug- nia, it is reasonable to expect a decreasing trend for all the above-
gested that this reduction may be due to improved balance mentioned variables.
between glottal adduction and subglottic pressure. Similar results In the present study, the auditory-perceptual assessment dem-
were provided by Sabol et al45 in a study performed with a group onstrated pre-post improvements only for the TPA group. The
of singers treated with VFE and by Kotby et al after therapy with patients treated with WRT did not show significant differences
AM.60 An increased maximum phonation time reported after when comparing pre and post conditions. It is possible to spec-
VFE38,44,46 and after AM60 could also be a consequence of re- ulate that water bubbling could disturb the auditory monitoring
duction in airflow rate. Findings from the present study did not and thus impair the improvement of voice quality. Further studies
show significant differences in glottal airflow rate for neither are needed on this topic. Other studies on physiological ap-
group. Possibly, this variable was not sensitive enough to the proach of voice therapy have also showed only partially positive
improvement in voice function observed in both the experimen- results in perceptual assessment. In a recent work investigating
tal and control groups. Earlier studies did not find any reduction the therapeutic effect of VFE and stirring straw phonation (com-
in glottal airflow rate either after VFE56 or after RVT.59 The lack pared with a non-treatment group), the auditory-perceptual results
of pre-post differences in glottal airflow rate in our data could using CAPE-V were not totally satisfactory.65 A statistically sig-
be associated with the absence of pre-post differences in auditory- nificant improvement was found only for roughness (decrease)
perceptual analysis for the WRT group. in the stirring straw phonation group. Neither VFE nor stirring
Even though SOVTEs have been found to affect CQEGG during straw groups showed changes in overall severity of perceptual
practicing and in some cases immediately after it,10–19 no sig- voice problem, in strain or in breathiness.65
nificant changes were evidenced in CQEGG after 8-week voice
therapy period in the present study. Previous studies have re-
CONCLUSION
vealed that CQEGG could be dependent on the degree of airflow
WRT and TPA may improve voice function and self-perceived
resistance that SOVTEs offer during exercise. Normally, SOVTEs
voice quality in individuals with behavioral dysphonia. No dif-
with high resistance (eg, tube submerged into water) cause a
ferences between these therapy protocols should be expected.
higher CQEGG compared with that with lower airflow resis-
It seems that the main positive effect of both rehabilitation pro-
tance (eg, Finnish glass tube with the distal end in air).19,33 No
tocols is related to the decrease of phonatory effort, which could
previous studies assessing the effect of tube phonation either in
be evidenced by subjective and objective measures.
air or into water (as long-term therapy programs) on CQEGG have
been carried out, thus no direct comparison can be done. Glottal
resistance was another variable included in the present study, REFERENCES
which could be associated with CQEGG, as both tell about the 1. Stemple JC. Voice Therapy: Clinical Studies. San Diego, CA: Singular
resistance that vocal folds offer to the airflow. No significant pre Publishing Group; 2000.
2. Thomas L, Stemple J. Voice therapy: does science support the art? Commun
post differences were observed in glottal resistance for either Disord Rev. 2007;1:49–77.
group. However, it tended to decrease in both groups (same trend 3. Verdolini K. Resonant voice therapy. In: Verdolini K, ed. National Center
was seen in CQEGG). The absence of change in glottal resis- for Voice and Speech’s Guide to Vocology. Iowa City, IA: National Center
tance was also reported after 20 sessions of therapy with AM.60 for Voice and Speech; 1998.
A decreasing trend in glottal resistance has in turn been re- 4. Kotby N. The Accent Method of Voice Therapy. San Diego, CA: Singular
Publishing; 1995.
ported after short-term exercising with SOVTE.81–83 Laukkanen 5. Rothenberg M. Acoustic interaction between the glottal source and the vocal
et al82 showed a decrease in this variable (due to increased flow tract. In: Stevens KN, Hirano M, eds. Vocal Fold Physiology. Tokyo:
and decreased Psub) after phonation with [ß:]. In another study, University of Tokyo Press; 1981:305–328.
 ARTICLE IN PRESS
Marco Guzman, et al Efficacy of Water Resistance Therapy for Behavioral Dysphonia 9

6. Rothenberg M. Source-tract acoustic interaction and voice quality. In: 29. Guzman M, Miranda G, Olavarria C, et al. Computerized tomography
Lawrence VL, ed. Transcripts of the 12th Symposium Care of Professional measures during and after artificial lengthening of the vocal tract in subjects
Voice, Part I. New York: The Voice Foundation; 1983:25–31. with voice disorders. J Voice. 2016;doi:10.1016/j.jvoice.2016.01.003; in
7. Fant G, Lin Q. Glottal source-vocal tract acoustic interaction. Speech press.
Transmission Lab Quart Prog Status Rep Royal Inst Technol Sthlm Sweden. 30. Radolf V, Laukkanen A-M, Horáček J, et al. Air-pressure, vocal fold
1987;1:13–27. vibration and acoustic characteristics of phonation during vocal exercising.
8. Titze I, Story B. Acoustic interactions of the voice source with the lower Part 1: measurement in vivo. Eng Mech. 2014;21:53–59.
vocal tract. J Acoust Soc Am. 1997;101:2234–2243. 31. Horáček J, Radolf V, Bula V, et al. Air-pressure, vocal folds vibration and
9. Titze I. Voice training and therapy with a semi-occluded vocal tract: rationale acoustic characteristics of phonation during vocal exercising. Part 2:
and scientific underpinnings. J Speech Lang Hear Res. 2006;49:448–459. measurement on a physical model. Eng Mech. 2014;21:193–200.
10. Gaskill C, Erickson M. The effect of a voiced lip trill on estimated glottal 32. Maxfield L, Titze I, Hunter E, et al. Intraoral pressures produced by thirteen
closed quotient. J Voice. 2008;22:634–643. semi-occluded vocal tract gestures. Logoped Phoniatr Vocol. 2015;40:84–
11. Laukkanen A-M. About the so called “resonance tubes” used in Finnish 90.
voice training practice. Scand J Logop Phoniatr. 1992;17:151–161. 33. Andrade P, Wistbacka G, Larsson H, et al. The flow and pressure
12. Gaskill CS, Erickson ML. The effect of an artificially lengthened vocal tract relationships in different tubes commonly used for semi-occluded vocal tract
on estimated glottal contact quotient in untrained male voices. J Voice. exercises. J Voice. 2016;30:36–41.
2010;24:57–71. 34. Story B, Laukkanen A-M, Titze I. Acoustic impedance of an artificially
13. Gaskill C, Quinney D. The effect of resonance tubes on glottal contact lengthened and constricted vocal tract. J Voice. 2000;14:455–469.
quotient with and without task instruction: a comparison of trained and 35. Titze I. The physics of small-amplitude oscillation of the vocal folds. J Acoust
untrained voices. J Voice. 2012;26:e79–e93. Soc Am. 1988;83:1536–1552.
14. Cordeiro GF, Montagnoli AN, Nemr NK, et al. Comparative analysis of 36. Rothenberg M. Cosí fan tutte and what it means or nonlinear source-tract
the closed quotient for lip and tongue trills in relation to the sustained vowel acoustic interaction in the soprano voice and some implications for the
/ε/. J Voice. 2012;26:17–22. definition of vocal efficiency. In: Baer T, Sasaki C, Harris KS, eds. Vocal
15. Hamdan AL, Nassar J, Al Zaghal Z, et al. Glottal contact quotient in Fold Physiology: Laryngeal Function in Phonation and Respiration. San
Mediterranean tongue trill. J Voice. 2012;26:669, e11–e15. Diego, CA: College-Hill Press; 1986:254–263.
16. Guzman M, Rubin A, Muñoz D, et al. Changes in glottal contact quotient 37. Guzmán M, Castro C, Madrid S, et al. Air pressure and contact quotient
during resonance tube phonation and phonation with vibrato. J Voice. measures during different semioccluded postures in subjects with different
2013;27:305–311. voice conditions. J Voice. 2016;doi:10.1016/j.jvoice.2015.09.010; in press.
17. Guzman M, Laukkanen A-M, Krupa P, et al. Vocal tract and glottal function 38. Stemple J, Lee L, D’Amico B, et al. Efficacy of vocal function exercises
during and after vocal exercising with resonance tube and straw. J Voice. as a method of improving voice production. J Voice. 1994;8:271–278.
2013;27:305–311. 39. Roy N, Gray S, Simon M, et al. An evaluation of the effects of two treatment
18. Andrade PA, Wood G, Ratcliffe P, et al. Electroglottographic study of seven approaches for teachers with voice disorders: a prospective randomized
semi-occluded exercises: LaxVox, straw, lip-trill, tongue-trill, humming, clinical trial. J Speech Lang Hear Res. 2001;44:286–296.
hand-over-mouth, and tongue-trill combined with hand-over-mouth. J Voice. 40. Gillivan-Murphy P, Drinnan M, O’Dwyer T, et al. The effectiveness of a
2014;28:589–595. voice treatment approach for teacher with self-reported voice problems. J
19. Guzman M, Calvache C, Romero L, et al. Do different semi-occluded voice Voice. 2006;20:423–431.
exercises affect vocal fold adduction differently in subjects diagnosed with 41. Pasa G, Oates J, Dacakis G. The relative effectiveness of vocal hygiene
hyperfunctional dysphonia? Folia Phoniatr Logop. 2015;67:68–75. training and vocal function exercises in preventing voice disorders in primary
20. Granqvist S, Simberg S, Hertegård S, et al. Resonance tube phonation in school teachers. Logoped Phoniatr Vocol. 2007;32:128–140.
water: high-speed imaging, electroglottographic and oral pressure 42. Ensslen A, Croake D, Stemple J. Does a systematic vocal exercise program
observations of vocal fold vibrations—a pilot study. Logoped Phoniatr Vocol. enhance the physiologic range of voice production in graduate-level opera
2014;28:1–9. singers. 38th Annual Symposium: Care of the Professional voice,
21. Laukkanen A-M, Pulakka H, Alku P, et al. High-speed registration of Philadelphia, PA, 2007.
phonation-related glottal area variation during artificial lengthening of the 43. Gorman S, Weinrich B, Lee L, et al. Aerodynamic changes as a result of
vocal tract. Logoped Phoniatr Vocol. 2007;32:157–164. vocal function exercises in elderly men. Laryngoscope. 2008;118:1900–1903.
22. Guzman M, Laukkanen A-M, Traser L, et al. Effect of water resistance 44. Tanner K, Sauder C, Thibeault S, et al. Vocal fold bowing in elderly male
therapy on vocal fold vibration: a high speed registration study. The Voice monozygotic twins: a case study. J Voice. 2010;24:470–476.
Foundation’s 42nd Annual Symposium: Care of the Professional Voice, 45. Sabol JW, Lee L, Stemple JC. The value of vocal function exercises in the
Philadelphia, 2014. practice regimen of singers. J Voice. 1995;9:27–36.
23. Hampala V, Laukkanen AM, Guzman MA, et al. Vocal fold adjustment 46. Nguyen DD, Kenny DT. Randomized controlled trial of vocal function
caused by phonation into a tube: a double-case study using computed exercises on muscle tension dysphonia in Vietnamese female teachers. J
tomography. J Voice. 2015;29:733–742. Otolaryngol Head Neck Surg. 2009;38:261–278.
24. Laukkanen A-M, Titze IR, Hoffman H, et al. Effects of a semioccluded vocal 47. Sauder C, Roy N, Tanner K, et al. Vocal function exercises for presbylaryngis:
tract on laryngeal muscle activity and glottal adduction in a single female a multidimensional assessment of treatment outcomes. Ann Otol Rhinol
subject. Folia Phoniatr Logop. 2008;60:298–311. Laryngol. 2010;119:460–467.
25. Vampola T, Laukkanen A-M, Horacek J, et al. Vocal tract changes caused 48. Tay EY, Phyland DJ, Oates J. The effect of vocal function exercises on the
by phonation into a tube: a case study using computer tomography and voices of aging community choral singers. J Voice. 2012;26:672, e19–e27.
finite-element modeling. J Acoust Soc Am. 2011;129:310–315. 49. Ziegler A, Verdolini Abbott K, Johns M, et al. Preliminary data on two voice
26. Laukkanen A-M, Horacek J, Krupa P, et al. The effect of phonation into a therapy interventions in the treatment of presbyphonia. Laryngoscope.
straw on the vocal tract adjustments and formant frequencies. A preliminary 2013;124:1869–1876.
MRI study on a single subject completed with acoustic results. Biomed Signal 50. Berg EE, Hapner E, Klein A, et al. Voice therapy improves quality of life
Process Control. 2010;7:50–57. in age-related dysphonia: a case-control study. J Voice. 2008;22:70–74.
27. Guzman M, Castro C, Testart A, et al. Laryngeal and pharyngeal activity 51. Sharma N, De M, Martin T, et al. Laryngeal reconstruction following
during semioccluded vocal tract postures in subjects diagnosed with shrapnel injury in a British soldier: case report. J Laryngol Otol.
hyperfunctional dysphonia. J Voice. 2013;27:709–716. 2009;123:253–256.
28. Wistbacka G, Sundberg J, Simberg S. Vertical laryngeal position and oral 52. Ellis LW, Beltyukova SA. Effects of compliance monitoring of vocal function
pressure variations during resonance tube phonation in water and in air. A exercises on voice outcome measures for normal voice. Percept Mot Skills.
pilot study. Logoped Phoniatr Vocol. 2016;41:117–123. 2011;112:729–736.
 ARTICLE IN PRESS
10 Journal of Voice, Vol. ■■, No. ■■, 2016

53. Patel RR, Pickering J, Stemple J, et al. A case report in changes in phonatory method for a functional voice disorder. A follow-up study of seven female
physiology following voice therapy: application of high-speed imaging. J patients] (in Finnish). Helsinki, Finland: University of Helsinki; 1992.
Voice. 2012;26:734–741. 68. Kitzing P. LTAS criteria pertinent to the measurement of voice quality. J
54. Guzman M, Angulo M, Munoz D, et al. Effect on long-term average Phon. 1986;14:477–482.
spectrum of pop singers’ vocal warm-up with vocal function exercises. Int 69. FrØkjaer-Jensen B, Prytz S. Registration of voice quality. Bruel-Kjaer
J Speech Lang Pathol. 2013;15:127–135. technology review. Brüel Kjaer Tech Rev. 1976;3:3–17.
55. Kaneko M, Hirano S, Tateya I, et al. Multidimensional analysis on the effect 70. Laukkanen AM, Ilomäki I, Leppänen K, et al. Acoustic measures and
of vocal function exercises on aged vocal fold atrophy. J Voice. self-reports of vocal fatigue by female teachers. J Voice. 2008;22:283–
2015;29:638–644. 289.
56. Pedrosa V, Pontes A, Pontes P, et al. The effectiveness of the comprehensive 71. Jacobson B, Johnson A, Grywalski C, et al. The Voice Handicap Index (VHI):
voice rehabilitation program compared with the vocal function exercises development and validation. Am J Speech Lang Pathol. 1997;6:66–70.
method in behavioral dysphonia: a randomized clinical trial. J Voice. 72. Núñez-Batalla F, Corte-Santos P, Señaris-González B, et al. Adaptation and
2016;30:377, e11–e19. validation to the Spanish of the Voice Handicap Index (VHI-30) and its
57. Verdolini-Marston K, Burke MK, Lassac A, et al. A preliminary study of shortened version (VHI-10). Acta Otorrinolaringol Esp. 2007;58:386–
two methods of treatment for laryngeal nodules. J Voice. 1995;9:74–85. 392.
58. Roy N, Weinrich B, Gray SD, et al. Three treatments for teachers with voice 73. Law T, Lee KY, Ho FN, et al. The effectiveness of group voice therapy: a
disorders: a randomized clinical trial. J Speech Lang Hear Res. group climate perspective. J Voice. 2012;26:e41–e48.
2003;46:670–688. 74. Deary IJ, Wilson JA, Carding PN, et al. VoiSS: a patient-derived voice
59. Chen SH, Hsiao TY, Hsiao LC, et al. Outcome of resonant voice therapy symptom scale. J Psychosom Res. 2003;54:483–489.
for female teachers with voice disorders: perceptual, physiological, acoustic, 75. Conroy ER, Hennick TM, Awan SN, et al. Effect of variations to a simulated
aerodynamic, and functional measurements. J Voice. 2007;21:415–425. system of straw phonation therapy on aerodynamic parameters using excised
60. Kotby MN, El-Sady SR, Basiouny SE, et al. Efficacy of the accent method canine larynges. J Voice. 2014;28:1–6.
of voice therapy. J Voice. 1991;5:316–320. 76. Vintturi J, Alku P, Lauri ER, et al. Objective analysis of vocal warm-up
61. Kotby MN, Fex B. The accent method: behavior readjustment voice therapy. with special reference to ergonomic factors. J Voice. 2001;15:36–53.
Logoped Phonatr Vocol. 1998;23:39–43. 77. Motel T, Fisher K, Leydon C. Vocal warm-up increases phonation threshold
62. Fex B, Fex S, Shiromoto O, et al. Acoustic analysis of functional dysphonia: pressure in soprano singers at high pitch. J Voice. 2003;17:160–167.
before and after voice therapy (accent method). J Voice. 1994;8:163–167. 78. Elliot N, Sundberg J, Gramming P. What happens during vocal warmup?
63. Bassiouny S. Efficacy of the accent method of voice therapy. Folia Phoniatr J Voice. 1995;9:37–44.
Logop. 1998;50:146–164. 79. Milbrath RL, Solomon NP. Do vocal warm-up exercises alleviate vocal
64. Guzman M, Callejas C, Castro C, et al. Therapeutic effect of semi-occluded fatigue? J Speech Lang Hear Res. 2003;46:422–436.
vocal tract exercises in patients with type I muscle tension dysphonia. Revista 80. McHenry M, Johnson J, Foshea B. The effect of specific versus combined
Logop Foniatr Audiol. 2012;32:139–146. warm-up strategies on the voice. J Voice. 2009;23:572–576.
65. Kapsner-Smith MR, Hunter EJ, Kirkham K, et al. A randomized controlled 81. Smith SL, Titze IR. Characterization of flow-resistant tubes used for
trial of two semi-occluded vocal tract voice therapy protocols. J Speech Lang semi-occluded vocal tract voice training and therapy. J Voice. 2016;doi:10
Hear Res. 2015;58:535–549. .1016/j.jvoice.2016.04.001; in press.
66. Simberg S, Sala E, Tuomainen J, et al. The effectiveness of group therapy 82. Laukkanen A-M, Päivi L, Vilkman E. Vocal exercising and speaking related
for students with mild voice disorders: a controlled clinical trial. J Voice. changes in glottal resistance. Logoped Phoniatr Vocol. 1998;23:85–92.
2006;20:97–109. 83. Laukkanen A-M, Lindholm P, Vilkman E. On the effects of various vocal
67. Tapani M. Resonaattoriputki toiminnallisen ääihäirion hoitmenetelmänä. training methods on glottal resistance and efficiency. A preliminary report.
Seitsemän naispotilaan Seurantatutukimus [Resonance tube as a therapy Folia Phoniatr Logop. 1995;47:324–330.