ARTICLE IN PRESS

Objective Evaluation of Presbyphonia: Spectroacoustic

Study on 142 Patients with Praat
*Chiara Mezzedimi, †Marta Di Francesco, *Walter Livi, *Maria Carla Spinosi, and ‡Claudio De Felice, *†‡Siena, Italy

Summary: Objectives. Presbyphonia is the sequence of physiological events related to the process of senility of
the vocal folds. The aim of our analysis was to provide deeper knowledge of presbyphonia, raising awareness of this
condition as well as giving basic suggestions on how to treat related vocal alterations.
Study Design. This is a randomized study.
Methods. In 2015, we conducted a study on 182 subjects. Each participant underwent an ENT examination (video-
laryngo-stroboscopy and subjective acoustic analysis using the General degree of dysphonia; degree of voice Instability;
degree of voice Roughness; degree of voice Breathiness; degree of voice Asthenia; degree of voice Strain (GIRBAS)
scale) and a logopedic examination (anamnesis, medical history, and acoustic voice analysis using the free software
Praat).
Results. The comparison between the voice of young people and the seniors showed significant differences for the fol-
lowing Praat-analyzed acoustic parameters: modal fundamental frequency (F0) in women (P < 0,0001), fraction of locally
unvoiced frames (P < 0,0001), number of voice breaks (P < 0,0001), jitter local (P < 0,0001), jitter local abs (P < 0,0001),
jitter rap (P < 0,0001), jitter ppq5 (P < 0,0001), shimmer local (P < 0,0001), shimmer local dB (P < 0,0001), shimmer apq3
(P < 0,0001), shimmer apq5 (P < 0,0001), mean N/H (P < 0,0001), and mean H/N (P < 0,001), for both sexes.
Conclusions. The Praat was confirmed to be a useful tool to detect the existence of the variation of the speech pa-
rameters in relation to aging and to quantify statistically significant differences that show a general deterioration in the
voice quality, defined numerically. This might lead to a phoniatric treatment or speech therapy, which could improve
patients’ quality of life, leading to better vocal performance and social and communicative interaction.
Key Words: presbyphonia–aging voice–Praat–voice analysis–dysphonia.

INTRODUCTION (Parkinson’s disease, stroke, essential tremors, and Alzheim-

Presbyphonia is defined as the sequence of physiological events
related to the process of senility of the vocal folds. It includes
a range of morphological, endoscopic, and vocal acoustic changes
associated with the aging of the larynx. Such a process causes
alterations of mucous membranes, intrinsic and extrinsic muscle
mass and cartilage, as well as a neurological and functional
deficit.1
The common symptoms of voice aging are reduced projec-
tion of the voice and of vocal endurance, raucousness, and
difficulty in being heard in noisy situations. Auditory-perceptive
vocal analysis shows a decrease in the harmonic and vocal range,
tremor, reduced rate of speech, lack of pneumophonic
coordination1 together with reduced vocal intensity and maximum
time of phonation.
The frequency of voice disorders in seniors is estimated to
be between 12% and 35%. Among those seniors, presbyphonia
is generally defined by a diagnosis of exclusion to be con-
ducted using accurate medical evaluations.2
Indeed, in a vast proportion of patients, dysphonia tends to
be linked to pathological and age-related processes rather than
just physiological aging. Such processes include central neuro-
logical disorders affecting the primary functions of the larynx
Accepted for publication May 31, 2016.
From the *ENT Department, University Hospital of Siena, Siena, Italy; †University Hos-
pital of Siena, Siena, Italy; and the ‡Department of Neonatology, University Hospital of
Siena, Siena, Italy.
Address correspondence and reprint requests to Maria Carla Spinosi, ENT Department,
University Hospital Santa Maria Alle Scotte, Viale Bracci n.16, 53100 Siena, Italy. E-mail:
mariacarla.spinosi@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.05.022
er’s disease), benign lesions of vocal cords (Reinke’s edema and
epithelial dysplasia), inflammatory disorders (mucous mem-
brane dryness caused by pharmacological effects), laryngeal
neoplasia, and paralysis. In addition, a variety of medicines neg-
atively affect vocal emission (antihistamines and inhaled
corticosteroids), whereas tooth loss interferes with word intel-
ligibility as well as hormonal alterations that have an impact on
the excitability of the glottic sphincter.3
According to some studies, presbyphonia affects just 4% of
older people with dysphonia, whereas other studies identify it
as the cause of symptoms in 30% of people with dysphonia above
60 years of age.2
The quality of voice in seniors is also indirectly affected by
alterations of other structures: nervous system alterations, pos-
tural alterations, respiratory system alterations, resonance system
alterations, muscular alterations as well as psychiatric and psy-
chological pathologies.
The evaluation protocol of the patient with dysphonia4 in-
cludes anamnesis and patient’s voice auto-evaluation,
noninstrumental (with perceptual assessment of voice), and in-
strumental (fiberoscopy, stroboscopy, and electroglottography)
objective tests and spectroacoustic voice analysis.
The laryngeal examination of the patient with presbyphonia
via fiberoscopy reveals a slight concavity, a “bowing” of the vocal
folds’ margins with a persistent glottic gap during phonation.
Moreover, the vocal processes of the arytenoid cartilages tend
to be more prominent. When videolaryngoscopy is used, the
larynx images may reveal vibration asymmetry and opening phase
predominance.5
The spectroacoustic voice test is a partly objective and partly
semisubjective clinical-instrumental analysis.6 The objective
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016
analyses include the multiparametric voice assessment, the
maximum phonation time test, and the phonetogram, whereas
the semiobjective ones comprise the spectrogram analysis.
Nowadays, the multiparametric voice assessment is easily con-
ducted through a series of computer programs, among which the
“Praat” is an easily accessible and user-friendly software avail-
able for free and developed by P. Boersma and D. Weenink from
the Phonetics Department of the University of Amsterdam
(www.Praat.org).
Praat’s voice analysis output consists of a waveform of the
analyzed signal, a spectrogram, and a voice report.
The Voice Report is useful for the evaluation of a series of
vocal parameters related to:
– F0 (median pitch, mean pitch, minimum pitch, maximum
pitch);
– temporary vocal interruption: Voicing (fraction of locally
unvoiced frames; number of voice breaks; degree of voice
breaks)
– micro perturbation of frequency: Jitter (jitter local; jitter
local absolute; jitter rap; jitter ppq5; jitter ddp);
– microperturbation of amplitude: Shimmer (shimmer local;
simmer local dB; shimmer apq3; shimmer apq5; shimmer
apq11; shimmer ddp);
– spectral energy balance between harmonic and dishar-
monic components: signal noise (mean autocorrelation,
mean H/N, mean N/H).7
Despite the wide range of studies conducted on older pe-
ople’s voices, there is still a lack of objective and univocal criteria
to clearly define presbyphonia.
Running the “Praat” software has been successful in provid-
ing an objective benchmark, which confirms the symptoms
previously described from a purely subjective point of view.
The final aim of this analysis was to provide deeper knowl-
edge of presbyphonia, raising awareness of this condition as well
as giving basic suggestions on how to treat related vocal alterations.
MATERIALS AND METHODS
Between May and September 2015, we conducted a study on
182 subjects recruited from the “Università dell’età Libera” (lit-
erally translated as “Free Age University”) in Colle di Valdelsa.
After signing an informed consent module, each participant un-
derwent a phoniatrics and logopedics examination at “St. Maria
Le Scotte” Hospital, in Siena, Italy. The examination was con-
ducted in two different phases:
ENT examination:
• Video-laryngo-stroboscopy, to evaluate laryngeal mor-
phology, motility, and vocal folds vibration during speech.
• Subjective acoustic analysis using the GIRBAS scale.
Logopedic examination:
• Chief complaint and history of the present illness, child-
hood diseases, past medical and surgical history (focusing
on allergies, gastroesophageal reflux disease (GERD), upper
aerodigestive tract disorders, and surgical procedures) family
diseases; social history (including occupation, living
arrangements, tobacco and alcohol consumption, environ-
mental pathogens exposure, and voice misuse and abuse);
regular and acute medications.
• Acoustic voice analysis using the free software Praat.
SAMPLING AND INCLUSION/EXCLUSION CRITERIA
We analyzed 182 subjects: 109 females (59.89%) and 73 males
(40.10%).
Inclusion criteria were: no physiological or organic anoma-
lies shown during the video-laryngo-stroboscopy, and no evidence
of common presbylarynx features such as vocal fold bowing and
prominence of vocal processes.
Exclusion criteria were neurological disorders affecting la-
ryngeal functions, chronic degenerative diseases, vocal cord
lesions (nodules, polyps, granulomas, cysts, and paralysis), dys-
functional dysphonia due to an incomplete glottic closure
(posterior triangle or oval-like glottis), patients with allergies or
other pharyngeal-laryngeal acute inflammations or alterations due
to pharmacological effects, and previous vocal-tract surgery.
According to these criteria, 40 subjects could not be in-
cluded in the analysis: 27 females (67.5%) and 13 males (32.5%).
Consequently, we designed a clinical study to assess the voice
of 142 patients.
Based on the references in recent scientific articles,8 we chose
the limit of 60 years of age to divide the sample in two different
groups. We also considered the voice differences according to
the gender, comparing younger and elderly people in relation to
their sex. Thus, we subdivided our sample in four subcatego-
ries: (group 1) 21 young men aged between 21 and 54 years (age
mean = 35.79); (group 2) 39 elderly men aged between 63 and
93 years (age mean = 74.43); (group 3) 35 young women aged
between 20 and 55 years (age mean = 38.49); and (group 4) 47
elderly women aged between 61 and 84 years (age mean = 72.76).
Materials
For the recording, we used:
– a personal computer;
– the Praat software;
– An omnidirectional microphone with a G&BL condens-
er (Frequency Response 20 Hz ~ 16kHz, Impedance 2.0
KΩ), suitable for all sound cards, positioned at a dis-
tance of 20 cm from the lips and with an axial tilt of
45 °, thus eliminating disruption related to the airflow.
Praat software: Setting
Before the examination, it is necessary to configure how the spec-
trogram is computed and displayed according to “view range,”
“window length,” and “dynamic range.” The standard range rec-
ommended by P. Boersma and D. Weenink8 is from 75 Hz to
500 Hz. As advised, for our analysis, we set two different pitch
ranges:
– one specifically for female voices (100–500 Hz);
– the other specifically for male voices (75–300 Hz).
 ARTICLE IN PRESS
Chiara Mezzedimi et al. Presbyphonia: a Study on 142 Patients with Praat
The recording was conducted by the same speech therapist
in the very same conditions, in the same room, with a sam-
pling rate of 22 050 Hz9 with a background noise of less than
50 dB.
Recording methods and analysis procedures
As suggested by the Praat10 e-guidebook, after listening to an
example given by the examiner, participants were asked to pro-
nounce the vowel “a” with an intensity of voice similar to a
normal conversation, with no changes in intensity and frequen-
cy, for at least 5 seconds. The test was repeated three times.
We then further proceeded recording with Praat and analyz-
ing the three middle seconds of each spectrogram. We did not
take into consideration the beginning and the end of the pho-
nation, when the most relevant disturbances occur. Moreover,
with a segment of 3 seconds, it is certain that at least 110 cycles
of vibration of the vocal folds are recorded.7
For each subject, we evaluated the mean of the values ob-
tained in the three recordings.
According to Società Italiana Foniatria e Logopedia (SIFEL)
protocol,4 we also carried out the maximum phonation time (MPT)
evaluation, asking our subject to repeat “a” three times and taking
into account only the maximum value obtained from the three
tests.
We therefore achieved an objective measurement with respect
to F0, fraction of locally unvoiced frames, number of voice breaks,
jitter local, jitter local absolute, jitter rap, jitter ppq5, shimmer
local, shimmer local dB, shimmer apq3, shimmer apq5, noise
to harmonic ratio, and harmonic to noise ratio. Once the re-
cordings had been completed, we reported our data in Excel
format, divided according to the before-mentioned four categories.
As regard the absolute intensity, we referred to the SIFER4
protocol for spectroacoustic analysis, although it does not refer
specifically to Praat. However, in our analysis, we also took into
account anamnesis and videolaryngostroboscopy to compare our
subjects.
RESULTS
The nonparametric Kruskal-Wallis test has been applied to all
the Voice Report parameters except for “Mean N/H,” which
follows a normal distribution (analysis of variance).
The aim of the analysis was to determine whether there were
significant differences in the medians between the two groups
(young voices and aged voices) so as to infer and establish sys-
tematic difference in the two vocal classes with fixed probability.
The arithmetic means of all the categories analyzed have been
taken into account except for those following a non-Gaussian
distribution for which median values and 95% confidence in-
tervals for the median have been considered (Table 1).
The comparison between the voice of young people and those
of the seniors showed significant differences for the following
Praat-analyzed acoustic parameters: modal fundamental fre-
quency (F0) in women (P < 0,0001), fraction of locally unvoiced
frames (P < 0,0001), number of voice breaks (P < 0,0001), jitter
local (P < 0,0001), jitter local abs (P < 0,0001), jitter rap
(P < 0,0001), jitter ppq5 (P < 0,0001), shimmer local (P < 0,0001),
shimmer local dB (P < 0,0001), shimmer apq3 (P < 0,0001),
3
shimmer apq5 (P < 0,0001), mean N/H (P < 0,0001), mean H/N
(P < 0,001), for both sexes.
Differences in intensity absolute mean (P = 0,2225) for both
men and women and F0 in young and old males (P = 0,3272)
were not statistically significant (Figure 1; in every figure the
abscissa shows the patients divided in four groups according to
age: (group 1) young males, (group 2) elder males, (group 3)
young females, and (group 4) elder females.
DISCUSSION
The aim of our research is to define any voice changes in
presbyphonia, objectifying them through an analysis con-
ducted with Praat. Our review of the scientific literature showed
that the “aging voice” is generally identified as a “gradual weak-
ening” of the voice. Clinical signs of presbyphonia are voice
fatigue, hoarseness, difficulty in singing, decreased intensity, varia-
tions and reduction of tonal range, low phonation duration, and
general deterioration of voice quality. Referring to GIRBAS scale,
we can say that the deterioration is expressed by six param-
eters: general degree of dysphonia, degree of voice instability,
degree of voice roughness, degree of voice breathiness, degree
of voice asthenia, and degree of voice strain. Because there is
a correlation between GIRBAS scale parameters and acoustic
spectral ones,11 we established a correspondence between the lit-
erature data and the objective evidence obtained through the use
of Praat (Table 1).
The F0 modal analysis shows a lower frequency both in older
males and females, with a significant difference reported only
in women (Figure 2). This could be due to the postural change
of the elderly, with forward flexion of the upper spine, which
drags down the vocal cords. Even if the difference was not sig-
nificant, it should be noted that, as regards men, our results differ
from the ones obtained by other authors.12,13 They reported that
F0 increases in older men, whereas it remains constant or de-
creasing in older women.14,15
Jitter (Figure 3) expresses the regularity of the vibratory cycle,
the perturbation of the F0 mean and is related to the degree of
hoarseness (Roughness). It is significantly higher in the elderly
of both sexes. Our results justify hoarseness as a clinical sign
of presbyphonia.
Equally significant results (Figures 4–6) were obtained ana-
lyzing other parameters that test the same characteristics (jitter
local abs, rap, ppq5) to reduce the error due to inadequate fun-
damental period extraction.
Shimmer (Figure 7) expresses the perturbation of the glottic
vibration amplitude, which is the amplitude of the sound wave,
and it is related to the degree of voice breathiness and to inten-
sity variations. Higher values of shimmer justify what has been
observed in video-laryngo-stroboscopy: the “bowing” of the vocal
folds because of the atrophy of the vocal muscles.
Thus, seniors’ voice is hypophonic and “blown.” Similar results
(Figures 8–10) emerged studying other parameters (shimmer local
dB, apq3, and apq5) that analyze similar vocal characteristics.
The intensity (Figure 1) is associated with the degree of vocal
asthenia; according to our results, the intensity absolute mean
is lower in seniors than in younger subjects, although not with
a significant difference.
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4 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 1.
Means, CI for the Means, and Standard Deviations for Each Acoustic Parameter Analyzed with Praat
Men Women
Young Elderly Young Elderly
Intensity (dB) Arithmetic mean 67,78 67,73 67,68 64,98
95% CI for the mean 64,81–70,76 64,66–70,80 65,29–70,07 62,45–67,52
SD 6,52 9,47 6,95 8,63
Frequency (Hz) Arithmetic mean 141,64 139,56 217,54 177,98
95% CI for the mean 131,0–152,29 126,91–152,22 207,59–227,49 165,12–190,84
SD 23,38 39,02 28,97 43,8
Fraction unvoiced Median 0 0 0 0
95% CI for the median 0,00–0,00 0,00–0,68 0,00–0,00 0,00–0,30
SD 0 8,58 0 2,97
N° Voice breaks Median 0 0 0 0
95% CI for the median 0,00–0,00 0,00–0,00 0,00–0,00 0,00–0,00
SD 0 0,97 0 0,9
Jitter local(%) Median 0,284 0,65 0,275 0,493
95% CI for the median 0,234–0,377 0,345–0,770 0,244–0,304 0,406–0,690
SD 0,095 1,102 0,077 0,525
Jitter local abs (μs) Median 20,876 45,447 13,765 33,999
95% CI for the median 16,039–26,937 24,906–63,11 11,9–14,606 24,612–46,812
SD 8,837 120,708 2,731 37,391
Jitter rap (%) Median 0,189 0,325 0,178 0,262
95% CI for the median 0,164–0,223 0,169–0,429 0,146–0,203 0,227–0,409
SD 0,047 0,662 0,046 0,289
Jitter ppq5 (%) Median 0,183 0,362 0,173 0,261
95% CI for the median 0,149–0,256 0,189–0,416 0,156–0,207 0,231–0,354
SD 0,078 0,55 0,042 0,298
Shimmer local (%) Median 3,254 6,71 3,119 6,306
95% CI for the median 2,591–3,865 5,285–7,883 2,424–3,311 5,155–7,852
SD 1,083 3,516 0,846 4,013
Shimmer local (Db) Median 0,317 0,616 0,246 0,574
95% CI for the median 0,230–0,373 0,41–0,704 0,21–0,299 0,488–0,71
SD 0,1 0,313 0,086 0,359
Shimmer apq3 (%) Median 1,764 3,567 1,761 2,99
95% CI for the median 1,631–1,996 2,441–4,261 1,559–1,969 2,664–3,743
SD 0,271 1,786 0,537 1,957
Shimmer apq5 (%) Median 1,936 4,069 2,046 3,962
95% CI for the median 1,509–2,62 2,986–5,021 1,495–2,304 3,138–4,921
SD 0,84 2,145 0,805 2,614
Mean N/H Median 0,009 0,053 0,011 0,041
95% CI for the median 0,005–0,026 0,024–0,079 0,008–0,018 0,028–0,058
SD 0,015 0,116 0,012 0,084
Mean H/N (dB) Arithmetic mean 23,483 15,669 22,793 16,011
95% CI for the mean 22,334–24,633 14,241–17,098 21,766–23,819 14,646–17,376
SD 2,525 4,407 2,988 4,649
MPT (s) Median 18,14 10,3 16,4 9,73
95% CI for the median 15,606–19,54 9,489–14,191 14,413–18,491 8,54–11,385
SD 3,311 5,775 3,515 4,492
Abbreviation: CI, confidence interval; SD, standard deviation; MPT, maximum phonation time.

The fraction of locally unvoiced frames (Figure 11) and the
number of voice breaks (Figure 12) are associated with the degree
of voice stability over time. Statistical analysis has led to a highly
significant difference: the voice of an elderly person does not
remain stable over time, as in young individuals, and the F0
suffers interruptions in both men and women.
Mean N/H (Figure 13) indicates the amount of noise in re-
lation to the harmonics of the signal: the higher its value, the
more the overall degree of voice quality is lowered. Our results
showed that the parameter value is significantly higher in those
with more than 60 years of age in both sexes. This confirms the
reliability of the previous data because the noise is due to changes
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Chiara Mezzedimi et al. Presbyphonia: a Study on 142 Patients with Praat 5

FIGURE 1. Intensity (ordinate) in the four groups (abscissa). Cat 1: FIGURE 4. Jitter local abs (ordinate) in the four groups (abscissa).
young males 21–54 years old (mean age = 35,79); Cat 2: elderly males
63–93 years old (mean age = 74,43); Cat 3: young females 20–55 years
old (mean age = 38,49); Cat4: elderly females 61–84 years old (mean
age = 72,76).

FIGURE 5. Jitter local rap (ordinate) in the four groups (abscissa).

FIGURE 2. Fundamental frequency F0 (ordinate) in relation to the
four groups (abscissa).

FIGURE 3. Jitter local (ordinate) in the four groups (abscissa). FIGURE 6. Jitter ppq5 (ordinate) in the four groups (abscissa).
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6 Journal of Voice, Vol. ■■, No. ■■, 2016

FIGURE 7. Shimmer local (ordinate) in the four groups (abscissa). FIGURE 10. Shimmer apq5 is the amplitude perturbation quotient—
(ordinate) in the four groups (abscissa).

FIGURE 8. Shimmer local (ordinate) in the four groups (abscissa).

FIGURE 11. Fraction of locally unvoiced frames (ordinate) in the
four groups (abscissa).

FIGURE 9. Shimmer apq3 is the amplitude perturbation quotient— FIGURE 12. Number of voice breaks (ordinate) in the four groups
(ordinate) in the four groups (abscissa). (abscissa).
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Chiara Mezzedimi et al. Presbyphonia: a Study on 142 Patients with Praat
FIGURE 13. Mean N/H (ordinate) in the four groups (abscissa).
in frequency and amplitude (jitter and shimmer), to subharmonic
components, and to momentary voice breaks. This allows us to
state that presbyphonia leads to a general deterioration in the
voice quality, which can be measured objectively.
Mean H/N dB (Figure 14) defines the relationship between
the intensity of the harmonic and disharmonic components
across the entire spectrum of the signal examined; the higher
its value, the better the vocal performance. In our study, elderly
subjects achieved significantly lower scores than younger people,
thus their vocal performance, both in men and women aged over
60, is worse. The harmonic component reduction could be ex-
plained by the alteration of the resonance structures of the vocal
tract.
The maximum phonation time (MPT) (Figure 15) is signifi-
cantly reduced in older women and in older men. The vital
capacity and expiratory flow reduction lead to expiratory stress,
with repercussions on speech intensity and rhythm. Combined,
lung capacity and muscle control impairment cause inaccura-
cies in the vocal attack, poor pneumophonic coordination, vocal
fatigue, and hypophonia.
FIGURE 14. Mean H/N (ordinate) in the four groups (abscissa).
7
FIGURE 15. Maximum phonation time (ordinate) in the four groups
(abscissa).
CONCLUSIONS
Nowadays, we are living through a crucial sociocultural change:
the proportion of the elderly population is increasing signifi-
cantly. In recent times, the number of elderly people visited by
our phoniatrics experts has been growing: their frequent com-
plaints are hoarseness, phonasthenia, and breathing difficulties
related to speaking. Even though in the not so distant past, aging
voice was not considered a pressing problem, it is now evident
that presbyphonia prevalence and its psychological conse-
quences cannot be ignored anymore. The current biopsychosocial
model for health, which encourages doctors to improve the
“welfare” of each individual and not to simply cure their ill-
nesses, demands that clinicians meet the needs of those people,
improving their voice and life quality.
Thanks to advanced technologies, digital tools useful to analyze
the voice are currently available. Our intent was to provide a con-
tribution to the scientific literature, characterized by a lack of
acoustic instrumental, objective, and parametric evaluations of
the voices of elderly people to quantify the vocal changes in re-
lation to aging.
Moreover, the use of objective data could be helpful in ending
the disagreement arising from the lack of an objective defini-
tion of presbyphonia in the scientific doctrinal corpus.
Thereafter, the Praat was confirmed to be a useful tool to detect
the existence of the variation of the speech parameters in rela-
tion to aging and to quantify the significance of aging on the
voice. We highlighted statistically significant differences that show
a general deterioration in the voice quality, defined numerically.
We have demonstrated the presence and the type of voice phys-
iological alterations in the elderly; this might lead to a phoniatric
treatment and speech therapy. Speech therapy and ENT treat-
ment could improve the quality of life, leading to better vocal
performance and social and communicative interaction. Even if
individual differences require treatment “ad personam,” it can
be stated that vocal hygiene is beneficial to prevent presbyphonia
and for voice maintenance, and targeted exercises are helpful
to improve muscle tone, pneumophonic coordination, and vocal
characteristics (frequency and intensity).15 Additional data could
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8 Journal of Voice, Vol. ■■, No. ■■, 2016
be obtained by conducting further studies to verify the effec-
tiveness of a rehabilitation program, via a comparison between
the values found.
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