Final revisions to

Integration of Singing into Voice Therapy

Martin L. Spencer, M.A. CCC-SLP August 26, 2009 (Revision)

Dick,

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. . . interdisciplinary management of speakers and singers.”1

SINGER PATHOLOGY (possible new sub-heading)

The author has observed that typical contributing factors to pathologic occurrence in
singers include:
• Excessive predominance of high-pitched chest register phonation.
• Consistent mismatch of tessitura, fach, or voice part with innate physiologic
capacity.
• Sustained excessive loudness or voce piena, and lack of awareness to "mark" or
rest when vocally fatigued.
• Lack of vocal warm-up before rehearsals or performances.
• Insufficient amplification or feedback monitoring in enhanced acoustic
environments.
• Poor vocal hygiene via factors such as smoking, excessive alcohol intake,
excessive social voice usage, physical deconditioning, poor hydration, and
unattended reflux or allergy control.
• Ignoring early warning signals of vocal injury: (moved section)
1) loss of phonatory ease thereby incurring compensatory strain;
2) delayed or disrupted tonal onset;
3) diminished breath control;
4) loss of intensity, or inability to vary intensity;
5) curtailment of pitch range, loss of register, or atypical change in voice
category;
6) loss of smooth passaggio transition;
7) persistently undesirable quality such as voice breaks, burring or
diplophonia;

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 8) Atypical delay of vocal recovery after performance, or excessive warm-up
times.

Increased awareness and correction of these pathologic triggers is a basic component

of voice rehabilitation. Voice therapy also typically utilizes regulatory programs such as
Vocal Function Exercises (Stemple), Resonant Voice Therapy variants (Verdolini-
Madsen) or Hybrid Voice therapy (Spencer). 2 This article posits that singing-based
exercise will be is of additional rehabilitative value. Its range of repair includes
behavioral voice dysfunction (muscle tension dysphonia), neuropathy, atrophy, lesioning
resolution, and phonosurgical recovery.3 4 5

In the sense that singing heightens speech, singing also heightens voice
therapy. Rationale for the inclusion of singing into voice therapy may touch upon
numerous bases:
• Optimized alignment of respiration, phonation and resonance via tonal sustain.
• Accurate targeting of pitch zones of therapeutic interest including register
exploration and passaggio development.
• Conditioning of extrinsic and intrinsic laryngeal musculature.
• Systematic sustain of vocal fold oscillation may decrease stiffness associated with
scarring and fibrosis, and may encourage optimal phenotypic expression of new
vocal fold tissue.6 7 (This new hypothesis provides significant support for therapy
after phonosurgery, and therapeutic dissolution of fibrous lesions such as singer’s
nodules.)
• Musical notation provides objective documentation of changing vocal capacity
across treatment; a desirable feature within a contemporary professional climate
of “evidence-based practice.”
• Exercise variations are limitless in number, fun, and can be tailored to changing
phases of recovery.

ORIGINS OF VOICE THERAPY

Speech pathology is a recent profession. The earliest related 20th century writings
primarily concern identification and treatment of stuttering and lisping . . . and Freud
figured prominently.8 In 1939, Charles Van Riper produced a seminal text in which
voice disorders were realized as a distinct diagnostic classification.9 The modern era of
voice rehabilitation started in the 1930s and 1940s through humanists such as Emil
Froschels, Nathan Weiss, Friedrich Brodnitz, and G. Paul Moore. There were several
voice therapy texts in the 1960s and 1970s but the one to really take hold was by Daniel
Boone (the 8th edition will be released in 2009)10 "Clinical voice pathology" coalesced as
a more distinct branch of speech pathology in the early 1980's, spurred by the practical
application of stroboscopy as a diagnostic tool and the concomitant identification of the
uniqueness of lamina propria anatomy and physiology by figures such as Minoru Hirano
and Diane Bless.
As clinical voice pathology has gained a significant threshold only in the last thirty
years, its corpus has developed via globalized scientific method, thereby constraining
subjective influence and seeking to consolidate theory.

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EXERCISE OVERVIEW

It is best to model each exercise prior to patient iteration; the better the model, the
greater the expectation for positive change. Breathe deeply and freely before each task, a
patient will instinctively mimic this preparation. The author regards each breath as an
opportunity for calmed inspiration and structured preparation for vocalization. (Note to
singing teachers: do not permit the metronomic demands of rapid 4/4 exercises to
habituate tensions associated with “catch breaths” or “breath stacking.”)
Each exercise should be sequentially transposed upwards or downwards by semi-
tones so that a completed series taxes a patient’s usable compass. The gist of such therapy
is to preserve vocal quality as pitch borders are gently extended upwards and downwards.
Start each series with a lower mid-range pitch that elicits optimal voicing characteristics.
Make notes of pitch versus quality correlations when either parameter is challenged by
the pathology. (Treatment notes are used throughout medicine to document patient
condition upon each encounter.)
Unison humming may be used to introduce tasks and dispel patient self-
consciousness. Once confidence in exercise shaping is established, gradually “open” the
sound to become more acoustically assertive (e.g., /mū/ => /mō/ => /mā/.) Gradually
withdraw support until the patient is soloing. Make sure that you are satisfied with quality
before advancing in task difficulty; there is little point of voice exploration without a
stable base.
Loudness levels depend on the particular treatment agenda:
• soft for the rehabilitation of hyperfunctional disorders such as muscle tension
dysphonia or “nodules”
• moderately loud for hypophonias such as presbylaryngis (aging voice) or
Parkinsonism.
Increased loudness should primarily be regulated primarily with trans-glottal airflow
rather than hyperadductive pinching of the TVFs.
Each voice possesses an upper pitch limit. Exploring this limit, or adjacent range,
may be counterproductive to rehabilitation. Although brief forays are useful for
diagnostic or prognostic value, more sustained habilitation is best left to a singing
specialist.
An exercise should not promote significant strain if patient capacity has been
accurately assessed. Singing exercises should be discontinued if any sensation beyond
mild discomfort is experienced . . . with the caveat of non-productive coughing; this
adverse reaction has not been remarked upon in the literature but appears to be an
inhibitory myogenic feedback mechanism which ceases once a basal threshold of
conditioning has been reached.
Once rehabilitation objectives in singers are consolidated, the author turns to
traditional scale/arpeggio patterns in tempo rubato which enable slow motion detailing of
onset, passaggio transition, and high end muscular release. Ballads or aria snippets are
then utilized as wordless vocalizes before the final challenge of conveying sentiment
through lyrics. At this point it is the singer’s best interest for clinician and singing teacher
to engage in transitional dialogue.

Registration

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 Many untutored singers are not familiar with concepts of registration. It is routine for
these patients to imagine that they have reached a (conservative) pitch ceiling, when a
whole upper range (or less commonly lower range) is obtainable. Vocal fold contact area
and wave propagation change with register transitions; ideal objectives when trying to
dissipate TVF stiffness or edema.11 12
Impairment of smooth register transfer, or register absence, are cardinal symptoms of
pathologic presence. Conversely, return of a functional passaggio or reactivated registers
are significant indicators of vocal recovery. It is not necessary to work with equalized
register transfer in a non-singing population, however many patients profit from an
awareness of register zones. It is common for untutored patients to damp register transfer
as they perceive loss of vocal control as undesirable.
Elicitation of different registrations for the same speaking range pitch may be
valuable. For example, C4 in many females may be produced in chest or mid registers.
The author has observed variations of muscle tension dysphonia which involve rapid
switching between registers, or loss of ability to lock into chest register during speech.
Register coordination may be subtle for patients to distinguish, and obvious to the
clinician with a singer's ear. Increasing patient awareness of registration may significantly
impact quality, intelligibility, strain, and vocal fatigue.

Speaking pitch

Excessively lowered speaking pitch, yielding a raspy or creaky quality, typically falls
below the frequency threshold required for periodic TVF oscillation.11 A surprisingly
quick fix to a large number of speaking voice complaints is to simply raise spoken
tessitura by several tones and increase transglottal airflow. These adjustments will often
stabilize undesirable perturbation (think of raising the idle speed in an engine to smooth
erratic combustion). This method is of significant value in treating a common form of
muscle tension dysphonia demonstrated in adult females who habitually speak in an
excessively low alto range. Increasing patient awareness of pitch and intensity
modifications that facilitate more effective communication accelerates therapy objectives.

THE EXERCISES

The following text outlines a rehabilitative method which places singing exercises
within the context of voice therapy.

A. Sustained tone

This exercise uses sustained speaking range pitches to habituate consistent airflow,
tone, and intensity (Figure 1a). Pathologic Voices affected by lesion presence frequently
demonstrate decreasing quality proportionate to rising pitch; increased frequency
accentuates vibratory irregularity. Functional range may be limited to less than an octave
in moderate cases and a perfect fifth in more severe cases. There is significantly less
margin of error for optimal quality within these restrictions so pitch targets for therapy
must be carefully considered.

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 Establish a range of acceptable quality through probes and choose a base pitch as the
subject for variation. Each pitch is sustained as a hum which is sensed through buzzing
resonance localized above the upper lip. Progressively release the nasalance through
opening vowels such as /mū/, /mō/, and /mā/. The logic of this sequence is that acoustic
impedance and aerodynamic inertance induced by lip closure may stabilize phonation.13
Consequently, an open-most /mā/ could be regarded as the series endpoint which is most
prone to perturbation, a consistently observed pattern in clinical practice.
The syllabification process continues through an expanding program such as:
• Continuant-laden monotone chants in which the nasals are slowly and deliberately
accented; “mmanny-menn-inn-the-mmoonn." (hopefully the gist is clear!)
• Continuously voiced sentences (for fluid voiced onsets) first with natural prosody,
then with word breaks, and finally with natural phrase breaks. “My-mom-may-
marry-Marv," leads to "My . . . mom . . . may . . . marry . . . Marv," which leads to
"My-mom, may-marry-Marv."
• Rote sets with jumbled articulatory features: “1, 2, 3 . . . 50” or “January,
February, March . . . December.”
• Conversational sentence lists of progressively greater length.14
Chanting is valuable for stabilization of undesirable pitch-related voice change, and
provides a transitional mode from prosaic therapy tasks to utilitarian speech. It is
common in therapy to return to chanting when tasks are inconsistently transferred into
speech.
The ultimate goal of rehabilitation is maintenance of newly learned skills in real-life
conversation.

B. Major tetrachord

A major tetrachord is one symmetric half of a major scale, either "doh re mi fa" or
"soh la ti doh." This pattern may be hummed or sung on the vowel sequences outlined in
exercise A (Figure 1b). Seldom is the tetrachord useful beyond a mezzo piano or mezzo
forte dynamic. (Why does music not have a median dynamic between mp and mf? This
hypothetical “mezzo mezzo” could provide an ideal dynamic neutrality for therapy.)
There is great value in the clinician tightly controlling an innate tendency for patients to
progressively push intensity as rising transpositions enter higher pitch range; phonation
should proceed from a balance of energized, but not hyperfunctional production.
The author favors tetrachord structure for several reasons:
• Rising transposition of the semitone interval between the top two pitches permits
creeping exploration of recovery margins.
• The narrow scalar interval provides an accurate gauge of register boundaries,
which in turn facilitates focus on voice production without the complication of
register change. The semitone advancement also ensures accurate documentation
of changing patient capacity across time, and is likely more reliable and accurate
than a pitch glide. (Descending P5 or octave scales are useful for determining
lower boundaries.)
• The narrow intervallic range of a P4 permits numerous transpositions within
registers of relative strength; typically chest in males, and chest or mid in females.

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 • The several seconds required for each iteration may comfortably fit within the
brief time span dictated by pathology.
• Controlled, gentle stretching of the vocal folds may serve to dissipate “nodules”,
or teach range extension whilst minimizing habitual strain.

C. Portamento

In cases of mild vocal impairment, for diagnosis, or as intended therapeutic benefit is

taking place, the clinician may proceed to more extended musical patterns.
A portamento is a smooth glide between two boundary pitches. The movement is
primarily activated by continuous differential engagement of the cricothyroid and
thyroarytenoid muscles in conjunction with finely tuned respiratory control.9 This
physiologic underpinning makes the portamento an ideal vehicle for increased vocal
control.
Inhibitory hyperfunction is typically encountered when traditional scales breach
outside a central zone of pitch comfort. The subtle onset of associated rigidity may be
faint to detection as senses are dulled by habitual acceptance. These tensions may be
brought into relief with portamenti particularly in the zona di passaggio or when
extending into higher pitch range. Correction requires vigilant monitoring. Vocal freedom
may be most fully realized with early recognition and release from these insidious
patterns. Mirror usage, finger placement on the sides of the neck, and clinician mimicry
greatly increase patient awareness of neck, jaw, tongue or facial tensions which are
invariably linked to laryngeal strain.
Two intervals are used in portamento therapy: the perfect fifth and octave (Figures
1c and 1d). Perfect fifth portamenti are useful in the treatment of moderate to severe
dysphonias, and in an initial phase of phonosurgical recovery. Treatment of milder
dysphonias may utilize octave portamenti which tax greater phonatory and respiratory
control, particularly in areas of register transfer.
The author structures each exercise iteration as follows:
• Eased, deep, trans-nasal inhalation with diaphragmatic primacy and pharyngeal
expansion. The patient should direct awareness to the quality of tonal onset,
conceptualized as a “marker.” When the tone is even in timbre and easily
produced, move on to rising pitch then proceed to pitch change. If the marker is
sub-optimally engaged then the patient should stop and repeat the onset until
satisfactory performance is achieved. Accuracy of initial intent is more important
than ill founded exercise completion.
• The marker glides upwards to a fermata on the upper boundary pitch. The ensuing
quality should reference similar characteristics to the starting tone (even if
registers are crossed). Once the highest pitch is accepted for quality gently return
to the starting tone.

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Changes to bio

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 Martin Spencer is a voice pathologist working with two surgical groups, Ohio ENT
Surgeons and Central Ohio ENT, in Columbus, Ohio. His scope of activities includes
laryngeal evaluation and rehabilitation, with a specialty in professional voice. He is
President of the Ohio Voice Association and has organized four state-wide conventions;
most recently co-chair of the Midwestern Vocal Perspectives conference entitled
“Multidisciplinary Rehabilitation of the Performance Voice.”

He received his vocology track MA from the University of Iowa under the mentorship of
Ingo Titze. Recent textbook contributions include “Breath Sensitivity Training” in
Workbook of Voice Therapy and “Intervention for Bilateral TVF Nodules in a Praise &
Worship Leader” in Voice Therapy: Clinical Studies (3rd ed.) Articles include . . . .