A Voice Rehabilitation Protocol With the Semioccluded

Ventilation Mask in Subjects With Symptoms of Vocal

Fatigue and Phonatory Effort
*Marco Guzman, †Carlos Calvache, ‡Fernanda Pacheco, §Nicole Ugalde, ║Vasti Ortiz, ¶Juan Del Lago, and
#
Marcelo Bobadilla, *, and zx║{#Santiago, Chile, and yBogota, Colombia

Summary: Purpose. The present study was designed to assess the efficacy of a six-session physiologic voice
therapy program with the semioccluded ventilation mask (SOVM) in a group of subjects with voice complaints
(vocal effort and fatigue).
Methods. Thirty-four participants with functional dysphonia were randomly assigned to one of two treatment
groups: (1) voice treatment with physiologic voice therapy plus vocal hygiene program (n = 17), and (2) vocal hygiene
program only (n = 17). Laryngoscopic assessment was performed in all subjects to confirm laryngeal diagnosis. Before
and after voice therapy, participants underwent aerodynamic assessment. The Voice Handicap Index (VHI), Vocal
Tract Discomfort Scale (VTDS), and self-assessment of resonant voice were also performed. The treatment included
six voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks
performed with the SOVM. Comparison for all variables was performed between experimental group and control
group.
Results. Statistical analysis showed significant improvements for experimental group for VHI (decrease), VTDS
(decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental group
was observed in subglottic pressure and phonation threshold pressure.
Conclusion. Physiologic voice therapy based on the SOVM with connected speech exercises seems to be an
effective tool to improve voice in subjects diagnosed with voice complaints. Apparently, improvements are
reflected in both subjective and objective outcomes. A reduction in phonatory effort and perceptual aspects of
vocal fatigue are the main subjective improvements. A decrease in air pressure-related variables seems to be the
most important objective change after voice therapy.
Key Words: Semioccluded ventilation mask−Semioccluded vocal tract exercises−Vocal effort−Vocal fatigue
−Voice therapy.

INTRODUCTION pain, dryness, and tightness in the laryngeal area.2-4 These

In a recent publication by Hunter et al1 aimed at reviewing symptoms increase across the speaking day and improve
the use of the terms vocal fatigue, vocal effort, vocal load, after a period of rest.3 Most common aspects related to per-
and vocal loading, it was proposed that vocal effort could formance in patients with vocal fatigue include difficulty in
be defined as: “The perceived exertion of a vocalist to a per- voice projection (weak voice), reduced pitch range, reduced
ceived communication scenario (vocal demand)”.1 Also, vocal flexibility, reduced control, and deterioration in voice
authors suggested that a good definition for vocal fatigue quality or hoarseness.3,5,6 To date, no reliable and consistent
could be: “A quantifiable decline in function (performance objective acoustic markers of vocal fatigue have been
or perceptual) that influences vocal task performance and is found.7-11 Results from aerodynamic and laryngoscopic
individual specific”.1 Hence, it seems that vocal fatigue has examinations are slightly more encouraging, but are not
at least two main components, being one of them a group of specific or reliable enough to be considered markers of vocal
subjective sensations associated to vocal discomfort. Com- fatigue.12-15 Due to the fact that vocal fatigue can be present
monly reported vocal fatigue symptoms include soreness, with a normal laryngeal examination and a perceptually
normal voice, the patient
s report of subjective sensations
Accepted for publication October 13, 2020. of vocal discomfort is still the main assessment aspect to
Funding: This research was supported by grants from CONICYT (grant FONDE- diagnose vocal fatigue in clinic.
CYT 11180291).
From the *Department of Communication Sciences and Disorders, Universidad de Semioccluded vocal tract exercises (SOVTEs) have been
los Andes, Chile; yDepartment of Communication Sciences and Disorders, Corpora- attributed to an increased vocal efficiency and economy,
cion Universitaria Iberoamericana, Vocology Center, Bogota, Colombia; zClinica
Las Condes, Santiago, Chile; xClinica Bicentenario, Santiago, Chile; ║Department of which in turn, promote a decrease in discomfort associated
Communication Sciences and Disorders, Universidad de Chile, Santiago, Chile; to voice disorders.16,17 Also, previous studies have demon-
{Department of Otolaryngology, Clínica Universidad de los Andes, Santiago, Chile;
and the #Department of Communication Sciences and Disorders, Universidad de los strated that SOVTEs are effective tools to treat voice disor-
Andes, Santiago, Chile. ders using a physiologic approach.18-21 Most common
Address correspondence and reprint requests to Marco Guzmán, Department of
Communication Sciences and Disorders, Universidad de los Andes, Avenida Monse- SOVTEs are tube phonation either with the free end in air


~or Alvaro
n del Portillo 12455, Santiago, Chile E-mail: guzmann.marcoa@gmail.com or in water, lip trills, tongue trills, lip buzz, Y-buzz among
Journal of Voice, Vol. 37, No. 1, pp. 60−67
0892-1997 others.18,19 They only allow performing a single-phoneme
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved. task such as [u:], connected speech or singing is not possible.
https://doi.org/10.1016/j.jvoice.2020.10.011
Marco Guzman, et al A Voice Rehabilitation Protocol With the Semioccluded Ventilation Mask in Subjec 61

To overcome this limitation, a semioccluded ventilation present program focuses on the same principles as other
mask (SOVM) (a mask usually used for cardiopulmonary physiologic programs using SOVTEs, we expected a posi-
resuscitation) was first proposed by Borragan et al22 in tive impact in voice of subjects on objective and subjective
1999. The SOVM, which is considered a type of SOVTE, vocal features. We hypothesized that the present program
creates a more distal occlusion allowing connected speech would be able to promote a higher self-perception of reso-
and singing tasks during voice therapy and training. nant voice production and lower handicap in voice-related
To date, five studies have explored the effects of the aspects. Also, lower PTP was expected after voice therapy.
SOVM as a training and therapeutic tool. In a Canine lar-
ynx model by Mills et al23 aerodynamic data were collected
for two tube extensions (15 and 30 cm), and two tube diame- METHODS
ters (6.5 and 17 mm) both with and without the SOVM. Participants
Results were compared between groups and between condi- Inclusion criteria for all participants were (1) age within the
tions within each group. Authors reported that SOVM leads range of 20-50 years, (2) laryngoscopic diagnosis of muscle
to the same decrease in phonation threshold flow and pho- tension dysphonia with absence of organic lesions or other
nation threshold pressure (PTP) that have been previously tissue changes, (3) history of voice problems for at least
observed during tube phonation. Fantini et al24 in a study one year, (4) no current or previous voice therapy, (5) no
aimed at investigating the immediate effects of a SOVM in history of smoking, and (6) self-reported sensation of muscle
a group of contemporary commercial music singers found tension, vocal effort, and vocal fatigue. This study was
significant improvements in acoustic and subjective self- reviewed and approved by the Institutional Review Board
assessed measures after SOVM exercises. Acoustic changes of Universidad de los Andes and Coporaci
on Universitaria
after the warm-up exercises included jitter, shimmer, and Iberoamericana. Informed consent was obtained from all
singing power ratio in the experimental group. Frisancho participants. Forty participants were initially enrolled in
et al25 conducted a study aimed to explore the immediate this study. Six subjects were excluded because laryngoscopic
effects of the SOVM in subjects with functional dysphonia diagnosis did not meet inclusion criteria. Subjects laryngo-
and subjects with normal voice. It was suggested that imme- scopically diagnosed with functional dysphonia (nonorganic
diate positive effect could be produced by connected speech dysphonia) (n = 34), were randomly assigned (block ran-
phonatory tasks using the SOVM in both dysphonic sub- domization was used) to one of two treatment groups before
jects and subjects with normal voice. Authors concluded starting voice therapy procedures: (1) voice treatment with
that SOVM exercises with connected speech seem to pro- physiologic voice therapy plus vocal hygiene program
mote an easy voice production and a more efficient phona- (n = 17; experimental group), and (2) vocal hygiene pro-
tion. Awan et al26 in a recent study designed to examine the gram only (n = 17; control group). Mean age in the experi-
effects of the SOVM in subjects with normal voice and dys- mental group was 29 years, range 22-43. Mean age in the
phonic, reported that beneficial changes in both aerody- control group was 24 years, range 20-41. All subjects com-
namic and acoustic variables may be observed in both pleted the whole treatment program.
groups after using the SOVM.26
A SOVM connected to a flexible tube with its end is sub- Laryngoscopic assessment
merged into the water is another way to perform connected Before voice therapy, all participants underwent laryngo-
speech or singing using a mask. This combination (mask scopic and aerodynamic, assessment, as well as providing a
and tube in water) allows producing phonation while doing self-assessment of their voice. First, they were asked to
water bubbling (water resistance therapy). There is only one undergo rigid videostroboscopy (Digital tele-endoscope
published study exploring the immediate effects of a SOVM Olympus WA96100A; Olympus, Center Valley, PA) to con-
combined with water resistance therapy exercises (ie, semi- firm laryngosopic diagnosis. Laryngoscopic examinations
occluded water resistance ventilation mask) on objective were performed by one experienced ENT clinician who is
(voice range and multiparametric voice quality indices) and co-author of the present study. Topical anesthesia was used
subjective (auditory-perceptual and self-report) vocal out- during endoscopic procedure.
comes in individuals with normal voices.27 Authors con-
cluded that both the innovative water resistance ventilation
mask and the traditional water resistance exercises seem to Aerodynamic assessment
be effective vocal warm-up exercises for musical theater stu- Aerodynamic data were collected with a PG-100 portable
dents. All aforementioned investigations have explored only device (Glottal Enterprises, Syracuse, NY). Participants
the immediate effects of the SOVM. To the best of our from both groups were asked to engage in the same two
knowledge, to date, there are no studies exploring the possi- assessment phonatory tasks before and after treatment: (1)
ble therapeutic effectiveness of the SOVM in subjects diag- repetition of the syllable [pa:] (speaking voice quality) at
nosed with voice disorders. The present study was designed comfortable loudness level and (2) repetition of the syllable
to assess the effectiveness of a physiologic voice therapy pro- [pa:] (speaking voice quality) at the softest possible voice
gram with the SOVM in a group of subjects with voice com- without reaching whisper. The first phonatory task was per-
plaints (vocal effort and fatigue). Based on the fact that the formed to estimate the subglottic pressure (Psub) from the
62 Journal of Voice, Vol. 37, No. 1, 2023

oral pressure during the occlusion of the consonant [p:]. The (eg, attentional focus, amount of practice, practice distri-
second phonatory tasks were performed to obtain the PTP. bution, practice variability, practice schedule, target com-
For both assessment phonatory tasks, a silicon tube inserted plexity, and feedback type) and (2) use of the SOVM
into the mouth was used to acquire oral pressure. Partici- All therapy sessions for the experimental group included
pants were asked not to touch the tube with the tongue or three sections: (1) introduction (3 minutes), during which
any other oral structure in order to prevent a blockage of the clinician asked about home practice and any voice
the airflow. Three repetitions of the two phonatory tasks issue that happened during the previous week, (2) core
were performed by each subject. F0 was required to be the (24 minutes), during which the participants engaged in exer-
same during pre and post assessments. F0 was auditory-per- cises that they had been practiced during the previous week
ceptually controlled by experimenters and participants using and rehearsed new phonatory tasks planned for the session,
a smartphone piano application. All phonatory tasks were and (3) end of practice (3 minutes), during which the clini-
first performed by researchers for explanatory purposes, cian instructed the home practice that the patient should
and a brief practice was conducted before obtaining voice perform every day until the next therapy session. The first
recordings that best represented the target productions. For therapy session also included instruction about vocal
PTP, a longer practice was performed. hygiene habits (hydration, avoidance of high loudness
speech, and avoidance of laryngeal irritants) for both
groups.
Questionnaire application and self-assessment of
For the experimental group, therapy program consisted
voice quality
of a sequence of seven phonatory tasks performed with the
All participants were asked to complete the Spanish adapta-
SOVM (Figures 1 and 2). Phonatory tasks included: (1)
tion and validation of the Voice Handicap Index (VHI),28,29
sustained vowels, (2) ascending and descending glissandos
and the Vocal Tract Discomfort Scale (VTDS).30 VHI-30 is a
throughout a comfortable vocal range, (3) Mesa di voce
self-administrated questionnaire designed to assess the voice
with vowel [a:], (3) vowel sequence [ieaou] at comfortable
handicap resulting from voice problems. The VHI has strong
pitch and loudness, (4) syllable sequences with different
reliability and validity psychometric measures (Mathieson,
vowels and nasal consonants at comfortable pitch and loud-
1993). It contains 30 items chosen to address the functional,
ness, (5) counting numbers, (6) repeating different words,
physical, and emotional impact of voice problems. Each item
(7) natural talking. These phonatory tasks were sequentially
is individually scored on a five-point Likert scale anchored
included in the treatment period during the six sessions as
by "never" (score of 0) and "always" (score of 4).28 VTDS is
presented in Table 1. Participants were required to perform
also a self-administrated questionnaire designed to measure
phonatory tasks until they reached an appropriate execution
subjective perception of sensory discomfort in throat (vocal
(ie, vibratory sensations and to feel ease of phonation).
tract). Assessment is based on the frequency of occurrence
Appropriate execution was controlled by experimenters and
and severity manifestation of eight qualitatively different sen-
self-controlled by participants. Before and during practice,
sations: burning, tightness, dryness, aching, tickling, sore-
the clinicians provided individual demonstrations and
ness, irritability, and lump in the throat. Frequency and
verbal descriptions of each phonatory task.
severity are rated separately on a seven-point Likert scale
For a home exercise program, the subjects were required
ranging from 0 to 6 for frequency (0 = never, 2 = sometimes,
to complete, 6-8 times daily and during 5-10 minutes each
4 = often, 6 = always) and for severity (0 = none, 2 = mild,
time, the same exercises that were practiced during each ses-
4 = moderate, 6 = extreme).30
sion. At the end of each session, the subjects were given on a
All participants were also required to self-assess their
paper sheet, detailed instructions for the home exercise
voice quality. Perceptual assessment was performed on a
100 mm visual analogue scale (VAS). Only one perceptual
variable was assessed (resonant voice quality), defined as a
voice that feels easy and with sensation of vibration on the
front part of face and mouth (0 = not resonant at all,
100 = very resonant).18,19

Voice therapy procedures

The treatment period included six voice therapy sessions
within 3 weeks, with a frequency of two sessions per week.
Each session lasted for 30 minutes. Therapy sessions were
administrated by four trained clinicians. To standardize the
therapeutic performance, all clinicians underwent a 3-hour
training period (conducted by the first and second authors
of the present study) before performing the therapy. This
training period included aspects related to: (1) sensory-
motor learning principles applied to voice rehabilitation FIGURE 1. Semioccluded ventilation mask.
Marco Guzman, et al A Voice Rehabilitation Protocol With the Semioccluded Ventilation Mask in Subjec 63

TABLE 1.
Phonatory Tasks Included Throughout the Six Voice
Therapy Sessions With SOVM
Session
Number Phonatory Tasks
1 Sustained vowel [a:] at comfortable pitch
and loudness.
Ascending and descending glissandos with
vowel [a:] within a comfortable range.
Mesa di voce with vowel [a:].
2 Vowel sequence [ieaou] at comfortable pitch
and loudness.
Syllable sequences with different vowels
and nasal [m:] at comfortable pitch and
loudness.
Syllable sequences with different vowels
and nasal [n:] at comfortable pitch and
loudness.
3 Counting numbers at comfortable pitch
range and loudness.
FIGURE 2. Scheme of a subject performing connected speech Repeating days of the week at comfortable
with the semioccluded ventilation mask. pitch range and loudness.
Repeating months of the year at comfort-
able pitch range and loudness.
program. The instructions included all phonatory tasks 4 Counting numbers at three different
learned during the session. To monitor patient compliance, loudness levels (soft, medium, loud) and
a WhatsApp (WhatsApp Inc. Menlo Park, CA) message three different pitches (low, medium, high)
was sent daily to each participant. However, data on com- within a comfortable range.
pliance across participants were not gathered in the present Repeating days of the week at comfortable
study. pitch range and loudness at three different
The first therapy session also included instructions about loudness levels (soft, medium, loud) and
vocal hygiene habits (hydration, avoidance of high loudness three different pitches (low, medium, high)
within a comfortable range.
speech, and avoidance of laryngeal irritants) for both groups.
Repeating months of the year at comfort-
Although the content of the hygiene program was targeted to able pitch range and loudness at three
each individual in both control and experimental groups, gen- different loudness levels (soft, medium,
eral recommendations included (1) Hydration habits: sufficient loud) and three different pitches (low,
intake of water (2 L of water approximately), increase water medium, high) within a comfortable range.
intake with perspiration, decrease dehydrating beverages, 5 Natural talking tasks such as responding
decrease use of nonessential diuretics; (2) Control of exogenous what did the patient do last weekend? What
inflammation: behavioral LPR precautions, reduction or stop did the patient do last vacation? At
smoking, and avoidance of chemical exposures; (3) Control comfortable pitch range and loudness.
of high vocal folds impact stress: control of background 6 Natural talking tasks such as responding
noise, avoidance of loud speech during therapy sessions, what did the patient do last weekend? What
did the patient do last vacation? At three
avoidance of uncontrolled yelling and screaming.
different loudness levels (soft, medium,
loud) and three different pitches (low,
Post-therapy assessment medium, high) within a comfortable range.
Once the six-session voice therapy period was completed, all
participants in both groups underwent the same assessment
procedure they underwent for the pretherapy assessment.
The procedure included aerodynamics and self-assessment
Kolgomorov-Smirnov test was used to analyze normality of
of voice. Post-testing was performed 1 week after completion
samples. Levene test was performed to verify homogeneity of
of voice therapy.
variance. For intragroup comparison, t tests for paired sam-
ples were used to compare between before and after therapy
Statistical analysis conditions. Finally, a one-way factor analysis of variance
Numerical variables were described by mean and stan- with repeated measurements was performed to compare dif-
dard deviation. All statistical tests were performed using ferences between treatments (control-experimental groups).
the SPSS version 25.0 program (SPSS, Inc., Chicago, IL). A P< 0.05 was considered statistically significant.
64 Journal of Voice, Vol. 37, No. 1, 2023

RESULTS
Subjective variables
Figure 3 shows results from the VHI. No significant dif-
ferences were found when comparing pre-post conditions
for control group (t: 0,273: DF = 11; P = 0,790). Signifi-
cant differences (decrease) were found when comparing
pre-post conditions for experimental group (t: 9,300:
DF = 16; P < 0,001). Statistically significant differences
were found when comparing experimental and control
groups (F = 4,775; DF = 1; 27 and P = 0.038).
Figure 4 shows results from the VTDS. No significant dif-
ferences were found when comparing pre-post conditions
for control group (t: 0,116; DF = 11; P= 0.910). Signifi-
cant differences (decrease) were found when comparing FIGURE 4. VTDS data evaluated before and after the applica-
pre-post conditions for experimental group (t: 8,753; tion of SOVTE therapy in subjects from the experimental and con-
DF = 16; P < 0.001). Statistically significant differences trol groups.
were found when comparing experimental and control
groups (F = 15,638; DF = 1; 27 and P < 0.001).
Figure 5 displays results from the self-perceived resonant conditions for experimental group (t: 2,560; DF = 16; P =
voice quality. No significant differences were found when 0.021). Statistically significant differences were found when
comparing pre-post conditions for control group (t: 1,058; comparing experimental and control groups (F = 5,560;
DF = 11; P = 0.313). Significant differences (increase) were DF = 1; 27 and P = 0.027).
found when comparing pre-post conditions for experimental
group (t: 4,070; DF = 16; P = 0.001). No statistically signif-
icant differences were found when comparing experimental DISCUSSION
and control groups (F = 1,440; DF = 1; 27 and P = 0.241). This randomized controlled trial assessed the efficacy of a
physiologic voice therapy program with the SOVM in a group
of subjects with voice complaints (vocal effort and fatigue).
Aerodynamic variables Results seem to support the role of the present therapy
Figure 6 shows results from the PTP. No significant differ- protocol as a potentially effective treatment for subjects with
ences were found when comparing pre-post conditions for functional voice disorders. As hypothesized, data showed sig-
control group (t: 1,523: DF = 9; P = 0.162). Significant dif- nificant improvements for the self-assessed outcomes. Patients
ferences (decrease) were found when comparing pre-post con- from the experimental group reported a significant decrease in
ditions for experimental group (t: 2,128: DF = 16; P = 0.049). voice complaints (VHI) after six sessions. Also, a significant
No statistically significant differences were found when com- improvement (decrease) on VTDS was observed. In addition,
paring experimental and control groups (F = 2,479; DF = 1; a significant increment was observed for self-assessed resonant
27 and P = 0.128). voice. Results from objective measures showed a significant
Figure 7 shows results from the Psub. No significant differ- decreased after voice therapy in both Psub and PTP in subjects
ences were found when comparing pre-post conditions for from experimental group. However, significant differences
control group (t: 2,008; DF = 9; P = 0,076). Significant dif- between groups were reported only for Psub.
ferences (decrease) were found when comparing pre-post

FIGURE 3. VHI data evaluated before and after the application FIGURE 5. Self-perceived resonant voice data evaluated before
of SOVTE therapy in subjects from the experimental and control and after the application of SOVTE therapy in subjects from the
groups. experimental and control groups.
Marco Guzman, et al A Voice Rehabilitation Protocol With the Semioccluded Ventilation Mask in Subjec 65

secondary Muscle Tension Dysphonia. However, a reduc-

tion of the frequency and intensity of symptoms of vocal
tract discomfort has been also reported in studies performed
with subjects with others voice disorders.31,32 The degree of
reduction on frequency and intensity of symptoms vary
depending on the etiology of voice disorders.33 A previous
randomized-controlled trial aimed at assessing the effective-
ness of a physiologic voice therapy program based on differ-
ent SOVTEs in subjects with behavioral dysphonia reported
a significant reduction on VTDS score.19 The same as to the
present study, recruited subjects did not present vocal folds
lesions but all of them reported vocal discomfort at least
FIGURE 6. PTP data evaluated before and after the application during a period of 1 year. The treatment period included
of SOVTE therapy in subjects from the experimental and control eight voice therapy sessions within 8 weeks. Voice therapy
groups. protocol included several SOVTEs (drinking straw phona-
tion, lip-buzz, Y-buzz, tongue trills, and lip trills).19
Similar to our outcomes, previous studies have reported
Subjective outcomes positive changes on VHI after voice therapy with
Laryngoscopic examination from all recruited participants SOVTEs.18,19,21 Kapsner-Smith et al21 conducted a ran-
showed normal larynx, and absence of organic lesions or domized-controlled trial in a group of subjects diagnosed
other tissues changes. However, all of them reported symp- with dysphonia and/or vocal fatigue. VHI scores showed
toms of vocal fatigue, phonatory effort and discomfort in significant improvement for both treatment groups (Vocal
the throat area. In general, both phonatory effort and vocal function exercises and stirring straw phonation therapy) rel-
fatigue are defined by self-reported subjective sensations. As ative to the no-treatment group. Authors concluded that
mentioned before, vocal fatigue can occur regardless of a both vocal function exercises (VFE) and stirring straw pho-
normal voice and normal laryngeal structure. Therefore, the nation therapy may improve voice quality of life in some
diagnosis of vocal fatigue ought to rely upon symptoms of individuals with dysphonia. Similarly, in a study which pur-
continuous vocal usage, increased vocal effort and allevia- pose was to assess the effectiveness of water resistance ther-
tion of symptoms following voice rest.3 Findings from the apy (WRT), it was observed a significant reduction of VHI
present study demonstrated a reduction in both VHI and score after an eight-therapy sessions period in both subjects
VTDS total score. Voice symptoms constitute one of the from the experimental group (WRT) and subjects from the
most important groups of clinical variables to detect a possi- control group (straw phonation therapy).18 Also, a decrease
ble voice disorder. These symptoms can vary on a contin- in VHI score was recently reported after eight sessions of
uum, both in terms of the frequency and the intensity with voice therapy using a treatment protocol based on a combi-
which these symptoms occur. The VTDS is the only vocal nation of different SOVTEs.19 Previous studies exploring
assessment instrument to specifically assess vocal tract dis- the effectiveness of other physiologic voice therapy pro-
comfort symptoms and has the advantage of presenting a grams have also found significant improvements on VHI
shorter administration time compared to other vocal self- after treatment. Roy et al34 designed a study to assess the
assessment instruments. The VTDS was designed to be used effect of VFE (a therapy program including some semioc-
as part of the evaluation of patients with primary or cluded vocal tract postures) in a group of teachers. After a
6-week treatment period, participants reported a significant
reduction in mean VHI score. A study with behavioral dys-
phonia also showed reduction in VHI score after treatment
with VFE.35 Two studies conducted with elderly subjects
obtained positive outcomes in VHI after voice therapy with
VFE.20,36 Moreover, studies have reported improvement in
VHI scores after treatment with resonant voice therapy
(RVT).37
Hunter et al1 in a recent published paper aimed to re-
define several terms, proposed that: “vocal effort is the per-
ceived exertion of a vocalist’s response (vocal demand
response) to a perceived communication scenario (vocal
demand).” Previous definitions of effort have stated that it
is a perceptual phenomenon (not a physiological phenome-
FIGURE 7. PTP data evaluated before and after the application non) experienced by the speaker and not the listener.40,41
of SOVTE therapy in subjects from the experimental and control The vocal effort is by definition measured via self-report
groups. and it is usually described by subjects as a physical
66 Journal of Voice, Vol. 37, No. 1, 2023

perception of work associated with voice production. In the degree of physical vocal discomfort. An association between
present study self-perceived phonatory effort was not these variables is therefore to be expected.18
directly measured, but the self-perceived resonant voice Subglottic pressure also showed a significant reduction
quality. However, this subjective variable involves not only after voice therapy for the experimental group in the present
vibratory sensations on the face and front part of the mouth, study. Four previous studies on physiologic voice therapy
but also a self-perceived ease of phonation (effortless voice have reported a decrease in Psub. After a 20-week period of
production). When comparing pre and post-therapy condi- voice treatment with Accent Method in a group of subjects
tions in the present study, the self-perceived resonant voice diagnosed with a wide variety of voice disorders, Kotby and
quality showed a significant increase. Similar results were Fex showed a decrease in Psub. Similar findings were
reported by Guzman et al18 in a group of subjects diag- reported by Bassiouny. Furthermore, two previous voice
nosed with behavioral dysphonia after eight voice therapy therapy studies have reported a reduction on Psub after a
sessions with physiologic voice therapy. Earlier investiga- period of voice treatment with SOVTEs.18,19 Possibly,
tions have explored the self-perceived phonatory effort this reduction could also be an objective sign of the lower
after voice treatment. Sauder et al20 carried out a study to phonatory effort perceived by subjects after voice treatment.
examine the effect of VFE in subjects with aging voice.
After six weeks of voice therapy, a significant decrease in
self-perceived phonatory effort was found. Comparable CONCLUSION
results were reported by Verdolini-Marston et al.42 Physiologic voice therapy based on the SOVM with con-
Authors found a decrease in self-perceived phonatory nected speech exercises seems to be an effective tool to
effort after 2 weeks of voice treatment in a group of improve voice in subjects diagnosed with voice complaints.
patients with vocal folds nodules. It is possible that the Apparently, improvements are reflected in both subjective
patients from the present investigation and those from the and objective outcomes. A reduction in phonatory effort
above-mentioned earlier studies learned to produce a and perceptual aspects of vocal fatigue are the main subjec-
more resonant voice after the treatment period. Neverthe- tive improvements. Reduction of air pressure-related varia-
less, it is also possible that they just learned to pay atten- bles seems to be the most important objective change after
tion to some sensations associated with voice production. voice therapy.
That as such may also be seen as a positive outcome.

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