Physiologic Approaches to Voice Therapy

Goals for the Session † Understand the rationale behind

JJoseph p C. Stemple, p , Ph.D.

Case 1 † 42 year old female † 3rd grade teacher † Mother of 3 † c/o / progressive i h hoarseness, reduction d ti iin pitch, it h

vocal fatigue, difficulty projecting the voice † Cyclic pattern † Interfering with ability to perform job requirements

Case 1 – Strobe

and use of physiologic voice therapy † Identify cases where physiologic voice therapy is appropriate † Identify and begin to develop expertise in voice therapy methods supported by the evidence

Case 1 † Perceptual Evaluation – mod dysphonia

Hoarseness B thi Breathiness „ Reduced pitch † Acoustic Evaluation „ Reduced fo and fo range „ Reduced SPL „ Increased noise to harmonics ratio † Voice Handicap Index (VHI) = 50 (mod impairment) „ „

Case 1 † Findings † Management Ideas Ideas….

Case 2

Case 2

† 78 year old male

† Auditory Perceptual – Mild to moderate

† Retired auctioneer † Married, grandfather of 5 † c/o weak voice,, breathiness,, reduced

loudness, runs out of air when talking † Reports p reducing g social interactions due

to his voice limitations

Case 2 - Strobe

dysphonia „ Reduced loudness „ Breathiness † Acoustic „ Increased Fo „ Reduced SPL „ Increased Noise to Harmonics Ratio † VHI = 59 59, M Moderate d t iimpairment i t ((social i l and d functional impact)

Case 2 † Findings † Management Ideas Ideas….

Case 3

Case 3 † Auditory Perceptual – Moderate-severe

dysphonia y p † 55 year old female

„

† Sudden onset of voice change

„

† c/o weak voice

„

„ „ „ „ „ „

Monopitch Breathiness Inability to control the voice Inconsistent “strangling” on water Diffi lt b Difficulty breathing thi d during i exertion ti Inhalatory stridor

„

Reduced loudness Increased pitch Frequent breaths; few syllables per breath Inconsistent diplophonia

† Acoustic „ Decreased SPL „ Increased Fo „ Increased NHR NHR, increased jitter and shimmer

‰ VHI = 64, Moderate impairment (social

p ) and functional impact)

C Case 3 – Strobe St b

Case 3 † Findings † Management Ideas

Commonalities? † Complaints † Auditory Perceptual Findings † Functional Impact † Stroboscopy St b † Treatment Goals? † Treatment Methods?

Wh t is What i Physiologic Ph i l i V Voice i Th Therapy? ?

Wh t is What i Physiologic Ph i l i V Voice i Th Therapy? ? † Based on expanded p knowledge g of vocal function

as evaluated through objective voice assessment / measurement † Improve the relationship / balance among: „ (1) respiratory support „ (2) laryngeal muscle strength, control and stamina, t i „ (3) supraglottic modification of the laryngeal tone/resonance † Treat the voice holistically; single training focus

Subsystems of Voice Production Resonance

† Presented by Colton and Casper

(1990) and Stemple Stemple, Glaze Glaze, and Gerdeman (1993) † Modification of underlying

physiology of the voice producing mechanisms: respiration, phonation, resonance

Requires balance among the 3

Phonation

R Respiration i ti

Disruption in 1 may perturb the other 2

Foundations of Ph i l i V Physiologic Voice i Th Therapy

Foundations of Ph i l i V Physiologic Voice i Th Therapy Voice Disorder

Voice Disorder Resonance

„ „

Phonation

Respiration

Same pathology /problem may lead to different responses p Example – Nodules ‡ Response 1 - Overwork the system (increase glottic and subglottic effort to improve sound, function) ‡ Response 2 - Underuse the system t (decrease (d respiratory i t and/or glottic effort to “protect” the voice)

Foundations of Ph i l i V Physiologic Voice i Th Therapy

Resonance

„

„

Phonation

Respiration

Same pathology /problem may lead to different responses Example – Unilat. VF Paralysis ‡ Response 1 - Overwork the system (increase supraglottic effort to improve sound, function) ‡ Response 2 - Underuse the system (decrease effort and enter/permit falsetto to achieve b better approximation) i i )

Foundations of Ph i l i V Physiologic Voice i Th Therapy

Treatment Resonance

† Many voice disorders (pathologically-

Phonation

based or functional) share the same underlying physiology „ LOSS OF NORMAL PHYSIOLOGICAL BALANCE † Many voice disorders will respond to a shared approach „ RESTORATION OF PHYSIOLOGIC BALANCE

Respiration

Physiologic Therapy Approaches Therefore… † May consider all 3 of our cases have

the same basic concern: „ Lack of glottic closure „ Leading to inefficient use of the glottal / phonation system „ Possible compensatory patterns † All 3 share the same need: „ Obtaining the most efficient use of the system „ Elimination of compensatory patterns

Resonance

Phonation

† Treatment is focused on returning

th system the t to t normall (more ( normal) patterns of production † Applicable across a variety of diagnoses because all share the same goal…restored balance

Respiration

Physiologic Approaches to Tx † May simplify approaches to Tx planning † Address underlying y gp physiology y gy of voice

production rather than specific symptoms † May use 1 or a combo of physiologic approaches † Used with the understanding that other areas may need to be addressed (eg, emotions hygiene, emotions, hygiene etc)

E Examples l off Ph Physiologic i l i M Methods th d † Vocal Function Exercises † Resonant Voice Therapy py

Questions? Q ti ? Comments?

† Manual Therapy / Laryngeal Massage † Accent Method † Lee Silverman Voice Treatment (for

select p populations p only) y)

Physiologic Therapy: Evidence † Evidence „ „

Physiologic y g / theoretical evidence Clinical evidence ‡

‡

Majority, well-controlled Majority well controlled group studies 5 methods have lines of evidence emerging

Physiologic: Clinical Evidence † Accent Method „

„ „

„

Physiologic: Clinical Evidence † Vocal Function Exercises „ „

„

Series of 4 systematic exercises for the intrinsic laryngeal y g muscles To “strengthen” and increase the flexibility of the laryngeal muscles, improve balance among subsystems Evidence: Stemple et al. (1994); Sabol et al. (1995); Roy et al. (2001); Gillivan-Murphy et al. (2006), Bell et al. (2007); Pasa, et al. (2007); Gorman et al. ((2008); ); Nguyen g y et al. (2009) ( )

Based upon use of pulsed abdominal breaths to facilitate g glottal closure Uses principle of Bernoulli effect Builds new respiratory / voice pattern from basic syllable intonations through conversation Evidence: Smith & Thyme (1976); Kotby et al. (1991); Fex et al. (1994); Bassiouny (2001)

Physiologic: Clinical Evidence † Resonant Voice Therapy „ „ „ „ „

Based on work of Lessac Voice produced in “mask” of face is most efficient form of voice Systematically builds resonant / front front-focused focused voice from basic phonatory gestures through conversation Lessac-Madsen Resonant Voice Therapy Evidence: Verdolini-Marston et al. (1995); Chen et al. (2003); Roy et al. (2003); Bell et al. (2007)

Physiologic: Clinical Evidence † Manual Laryngeal Musculoskeletal Reduction

Technique „ „

„

First proposed Aronson; Current name – Roy Systematic digital manipulation of laryngeal complex t return to t larynx l to t relaxed, l d normalized li d posture t Evidence: Roy and Leeper (1993); Roy et al al. (1997); Van Lierde et al. (2004)

Other Orientations to Therapy † Hygiene „ Examples: Hydration, Elimination of abuses † Symptomatic „ Examples: Chewing, Raising pitch, Chant talk, Yawn-Sigh † Psychogenic „ Examples: E l C Counseling, li Id Identifying tif i th the underlying cause

S Symptomatic t ti Evidence E id † One line of promising work - Biofeedback † Future Directions „

„

Potential examination of theoretical bases of the methods More rigorous research designs

Physiologic: Clinical Evidence † Lee Silverman Voice Treatment „ „ „ „

„

Ramig Originally designed for PD Now known effective with other disorders P Premise i – Increase I effort ff t (“Loud”) (“L d”) speech h to t enhance fx of respiratory, phonatory, resonance, and articulatory systems Evidence: Ramig et al. (1995) Ramig et al. (1996); Ramig, Sapir, Countryman et al. (2001); Ramig Sapir Ramig, Sapir, Fox et al al. (2001)

V Vocal lH Hygiene i E Evidence id † Few large scale studies support the therapeutic benefit

of general hygiene education as a stand alone Tx „ Hygiene should be used only as an adjunct to direct forms of treatment. † Hygiene yg may y insulate from further voice decline † Growing support for use of hydration † Future work „ Monitor M i / quantify if compliance li „ Increase number of studies on disordered p p populations

Psychogenic Evidence † Limited systematic study of this form

of therapy † Form of therapy often used in combo with other methods; hard to investigate

Evidence: Overall Conclusions † Physiologic methods possess strongest

support † Efficacy of hygiene training inconclusive † Limited evidence for symptomatic therapy † Lack of evidence for psychogenic approaches

Planning the Physiologic Voice Therapy Program

Physiologic Therapy: Sample Sequence Patient Education

Vocal Function Exercise Program

Resonant Voice Therapy

Vocal Hygiene

*VFE Training *Initiation of Home Practice

*RVT Training *Continue Continue home practice of VFEs and build practice of RVT

Vocal Function Exercises „

Vocal Function Exercises: Building the Physiologic Foundation

A series of systematic voice manipulations, similar in theory to physical therapy for the vocal folds folds, designed to strengthen and coordinate the laryngeal y g musculature, and to improve p the efficiency of the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation

Vocal Function Exercises † Long sustained tones † Maximal p pitch g glides † Efficient posturing of the voice

producing mechanism to permit maximum output with minimal effort

Vocal Function Exercises

Vocal Function Exercises

† A series of s systematic stematic voice oice manip manipulations lations † Similar in theory to physical therapy † Designed D i d tto strengthen t th and d coordinate di t th the

laryngeal musculature † Designed D i d tto iimprove th the efficiency ffi i off th the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation

Vocal Function Exercises

† Consider the knee † Made of multiple cartilages, muscles,

and connective tissue † A jointed system † May y become injured, j , weakened,, or imbalanced in its function

V Vocal l Function F ti Exercises E i

† Rehabilitation for injuries of the knee „ „

„ „ „

rest to reduce edema appropriate supports, casts, bracings, and wraps as needed ambulatory devices systematic exercise Return to previous activities

† Consider the larynx y

Vocal Function Exercises

What is missing?

† How are disorders / injuries of the larynx

typically treated?

„

Sometimes voice rest / modified use Sometimes hygiene counseling Supports (mics, etc) Treatment of symptoms

„

Return to previous activity

„ „ „

‡

M d B Meds, Behavioral h i l Th Therapy

† Made of multiple cartilages, muscles,

and connective tissue † A jointed system † May y become injured, j , weakened,, or

imbalanced in its function

† Systematic vocal exercise to rehabilitate the

laryngeal complex itself – the muscles muscles, cartilages, joints, etc. † Vocal functions exercises were designed to offer this systematic exercise

Direct Systematic Exercises † Restrengthening and coordinating the

Four Steps of VFEs † Warm up

laryngeal y g musculature † Stretching Exercise † Enhancing g the relationship p of the three

subsystems of voice production

† Contracting Exercise † Adductory Strengthening Exercise

Vocal Function Exercises Manner of Production

Resonance

† Posture † Breathing † Placement

Phonation

† Onset † Muscle Engagement

Respiration

Vocal Function Exercises Vocal Function Exercises 1.

(Warm-up) Sustain the vowel /i/ for as long as possible on the musical note (F)

† Exercise 1 Goal „

„

“F” F above middle (C) for females

Goal based upon the patient’s personal anatomy & physiology Know that efficient voice production has a flow rate of 80-200 80 200 liters / second ‡

“F” F below middle (C) for males)

‡

Below 80 – limiting the air flow through the system Above 200 – allowing excessive air through the system

Vocal Function Exercise

Vocal Function Exercises

† Exercise 1

† Exercise 1

„ „

Calculate goal in 1 of 2 ways Method 1 ‡ ‡ ‡

„

„

‡ ‡

Determine patient’s expiratory volume Divide by 80 (most efficient system) Obtain # seconds patient should sustain tone

‡

„

‡

Sustain lightest /s/ possible for as long as possible

Tone focus T f Breathing, Onset of tone (top of breath) Posture

Expectations ‡

Method 2 ‡

Monitor for:

‡

Poor control early on Voice breaks Loss of focus

Vocal Function Exercises

Exercise 1 - Rationale † Contracting laryngeal adductors and

2.

cricothryoid † Warming W i up th the muscles l † As patient works to increase duration, they are improving their ability to valve the exhaled air „

(Stretching) Glide from your lowest note to your highest note on the word “knoll” knoll , “whoop” whoop , tongue trill trill, lip trill Goal = no voice breaks

When reach target g –p producing g tone with most efficient balance of 3 subsystems

Olol Pharynx y

Vocal Function Exercises † Exercise 2 „

Rationale ‡ ‡

„

Stretches the VF Slow, controlled contraction of the CT

E Expectations t ti ‡ ‡

Difficulty maintaining tone focus Voice breaks

Lip Buzz Lips

Vocal Function Exercises 3 3.

(contracting) Glide from a comfortable high note to your lowest note on the word “knoll”, “boom” boom , tongue trill trill, lip trill Goal = no voice breaks

Vocal Function Exercises

Vocal Function Exercises

† Exercise 3

4.

„

Rationale

„

Expectations

‡

‡ ‡

Slow, controlled contraction of the TA

(Power) Sustain the musical notes (CD-E-F-G) for as long as possible on the word “old” old without the /d/ /d/. Middle dd e (C) females e a es Octave below middle (C) males

Difficulty Diffi lt maintaining i t i i ttone ffocus Voice breaks †

Goal same as for exercise 1

Pitch Modifications Vocal Function Exercises † Exercise 4 „

† GABCDEFGABC

Rationale ‡ ‡

Adductory Strengthening Exercise Sustained contraction of adductors (IA, LCA)

† GABCDEFGABC † GABCDEFGABC

Vocal Function Exercises Vocal Function Exercises ƒ

notes t are matched t h d to t a pitch it h pipe, i audio di CD CD, kkey b board, d piano

¾ ¾

ƒ

daily record is charted by the patient ¾

ƒ

estimated time of completion 8-10 weeks ¾

ƒ

some patients experience minor laryngeal aching the fi t few first f days d off exercise i

¾ ¾

all exercises are done 2 x each, 2 x per day all exercises are done as softly as possible, but engaged quality of tone is monitored for breaks, wavering, and breathiness extreme care is taken to teach the production in a forward tone focus without tension attention is paid to the glottal onset of the tone to assure an easy onset without breathiness appropriate breathing technique is assured

Ad Advantages t for f the th Patient P ti t

Explanation to the Patient Admit that it seems silly Compare it to workout program, physical therapy, weight lifting, etc. – Show the anatomy Stress the necessity of systematic exercise without b k breaks Explain that the times do not increase due to increased lung capacity

ƒ ƒ

ƒ

ƒ

ƒ

E il understood, Easily d d reasonable bl model d l

ƒ

Systematic permits plotting of progress Systematic,

ƒ

Patient must attend to the voice at least 2 times per day

ƒ

Involves doing something positive as opposed to the “don’t do’s”

Vocal Function Exercises † Maintenance Sched Schedule le ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Full program 2 x each 2 x per day Full program 2 x each 1 x per day Full program 1 x each 1 x per day Exercise 4 2 x each 1 x per day Exercise 4 1 x each 1 x per day Exercise 4 1 x each 3 x per week Exercise 4 1 x each 1 x per week

Resonant Voice Therapy: py Generalizing the Balanced Voice

Each taper involves approximately 1 week

Resonant Voice Therapy † Lessac (1965) „

The well-placed voice yields optimal functioning of respiratory, phonatory and resonance systems phonatory,

† Titze (2003) „

„

RV maximum transfer of power through the vocal tract from glottis to lips and ultimately to the listener Proper energy conversion at the vocal folds results in excellent p propagation p g of sound -- vibrations of the g glottal tone can extend into the facial regions

Resonant Voice Therapy † RV produced with vocal folds barely

separated † Berry (2001) „

„

Glottic configuration observed in RV produces maximum transfer of sound through vocal tract Implications: Glottal configuration for RV is most efficient use of the system

Resonant Voice Therapy

Resonant Voice Therapy

† Voice production involving oral vibratory

† Fundamental perceptual target is focused, oral

sensations, usually on the anterior alveolar ridge or higher in the face † In the context of easy phonation † Where resonant voice is a continuum of oral sensations and easy phonation b ild ffrom b builds basic i speech h gestures t through conversational speech

Basic RVT Training Maneuvers † Stretches and Breathing Warm-Ups „ „ „ „ „ „ „

Shoulders N k Neck Jaw Floor of Mouth Lips Tongue Pharynx

RT Hierarchy: Stage 1 “All All Voiced Voiced” 1.

-

molm-molm-molm….. (sustained pitch) ____ note vary the rate only discover the vibrations; experiment with broad and narrow vibrations; eventually focus on the narrow vibration; “like a narrow beam of light” increase the ease of p production by y reducing the effort by 1/2 and 1/2 again increase “lift” (as if pitch were increasing)

vibratory sensations in the context of easy phonation. † The singular training focus (resonance) is expected to affect multiple levels of physiology (breathing and laryngeal). † Large numbers of repetitions are used, in varying speech contexts. † Training is strongly goal (results) driven, i involving l i ad dogged d iinsistence i t upon th the greatest possible precision in the achievement of the perceptual tasks.

Basic Training Gesture for RT (Step 1 for all stages of RT) † Holm-molm-molm-molm-molm…..As a

sigh † Extreme forward focus is required with appropriate breath support † Make the connection from the abdominal muscles to the lips † Patient should feel very relaxed at the end of this gesture

RT Hierarchy: Stage 1 “All All Voiced Voiced” 2. molm-molm-molm….. ‡ ‡

slow-fast-slow soft-loud-soft on ____ note

3. molm-molm-molm….. as speech ‡ ‡ ‡

use non-linguistic phrase vary the rate, pitch, and loudness make the connection from the abdominal muscles to the lips

RT Hierarchy: STAGE 2 “Voice-Voiceless Contrasts”

RT Hierarchy: Stage 1 “All All Voiced Voiced” 4. Chant the following g voiced p phrases on the musical note ___ ‡ ‡ ‡ ‡ ‡ ‡

Basic Training Gesture 1. mamapapa….. vary the rate on ___ note 2. mamapapa…..

Mary made me mad. My mother made marmalade. My merry mom made marmalade. My mom may marry Marv Marv. My merry mom may marry Marv. Marv made my mother merry.

• ‡

slow-fast-slow soft loud soft on ___ note soft-loud-soft

3. mamapapa….. As speech ‡

5. Over-inflect these phrases as speech

‡ ‡

RT Hierarchy: STAGE 2 “Voice-Voiceless Contrasts”

use non-linguistic g p phrases vary the rate, pitch, and loudness make the connection from the abdominal muscles to the lips

RT Hierarch Hierarchy: STAGE 3 “ANY PHRASE”

Basic Training Gesture 4. Chant the following voiced/voiceless phrases on the musical note ___ „ „ „ „ „

Mom may put Paul on the moon. Mom told Tom to copy my manner. My manner made Pete and Paul mad. mad Mom may move Polly’s movie to ten. My movie made Tim and Tom sad.

5. Over-inflect these phrases as speech

RT Hierarchy: STAGE 3 “ANY PHRASE” -

All the girls were laughing. Get there before they close. Did you hear what she said? Come in and close the door. Are yyou g going g tonight? g Put everything away. Come whenever you can. W heard We h d th thatt yesterday. t d The player broke his leg. The children went swimming swimming.

† Produce the following phrases in sequence as follows:

First, chant the phrase on the note___, (no breath) Then over-inflect it with extreme forward focus, and „ Then finally repeat it as natural speech with a forward focus. † Note: N t E Each h iindividual di id l phrase h should h ld b be produced d d ffollowing ll i this 3-step sequence before moving onto the next phrase. „ „

RT Hierarchy Stage 4 “Paragraph Reading”

† read a paragraph with phrase markers † separate t each h phrase h only l b by th the natural t l

inhalation of air † exaggerate gg focus and then repeat p with a more normal speech/voice production † repeat the above without phrase markers

RT Hierarchy Stage 5 “C “Controlled C Conversation” „

„

RT Hierarchy Stage 7 “E ti “Emotional lM Manipulations” i l ti ” „

p practice forward speech p p placement in conversation do not permit glottal attacks, glottal fry, etc.

RT Home Exercises ƒ The critical portion of each exercise for each week is tape

RT Hierarchy Stage 6 “E i “Environmental lM Manipulations” i l i ”

recorded d d as a h home exercise i example. l ƒ 15-20 minute home sessions, two times per day with “minis” as needed 1. Stretches 2. Basic RV gesture 3 Selected level of hierarchy 3.

ƒ simulate actual speaking environments ƒ use tapes of background noise ƒ go to noisy cafeteria

Physiologic Therapy: Sample Sequence

† †

Patient Education

Vocal Function Exercise Program

Resonant Voice Therapy †

Vocal Hygiene

† †

*VFE Training *Initiation of Home Practice

†

†

† †

†

† †

References

*RVT Training

†

*Continue Continue home practice of VFEs and build practice of RVT

†

D'Antonio, L., Lotz, W., Chait, D. & Netsell, R. (1987). Perceptual-physiologic approach to evaluation and treatment of dysphonia. dysphonia Annals of Otology Otology, Rhinology Rhinology, and Laryngology, 96, 187-190. Fex, B., Fex, S., Shiromoto, O., & Hirano, M. (1994). Acoustic analysis of functional dysphonia before and after voice therapy (Accent Method). Journal of Voice, 8, 163167. Fi h KV Fisher, KV., Li Ligon, JJ., S Sobecks, b k JJ.L. L &R Roxe, D D.M. M Ph Phonatory t effects ff t off b body d flfluid id removal. Journal of Speech, Language, and Hearing Research, 44, 354-367. Gillivan-Murphy, P., Drinnan, M., O’Dwyer, T., Ridha, H., & Carding, P. (2006). The effectiveness of a voice treatment approach for teachers with self-reported voice problems. Journal of Voice,, 20,, 423-431. p Holmberg, E., Hillman, R., Hammarberg, B., Sodersten, M., & Doyle, P. (2001). Efficacy of a behaviorally based voice therapy protocol for vocal nodules. Journal of Voice, 15, 395-412. Kotby, M., El-Sady, S., Abou-Rass, Y., Hegazi, M. (1991). Efficacy of the Accent Method of voice therapy therapy. Journal of Voice, Voice 5, 5 316 316-320. 320 Kotby, M. N., Shirmoto., O., & Hirano, M. (1993). The Accent Method of voice therapy: Effect of accentuations on Fo, SPL, and airflow. Journal of Voice, 7, 319325.

use materials and topics that increasingly engage and challenge the patient

References

Bassiouny, S. (1998). Efficacy of the accent method of voice therapy. Folia Phoniatrica et Logopedica 50, Logopedica, 50 146-164 146 164. Bell, S., Kidd, B., Leemkuil, C., Smith, A., & McCrae, C. (2007, November). Vocal function exercises (VFE) verses resonant voice therapy (RVT) in the treatment of hyperfunctional voice disorders. Poster presented at the American Speech-Language-Hearing Association Annual Convention, Boston, MA. B dd L Broaddus-Lawrence, P P., T Treole, l K K., M McCaabe, C b R R., All Allen, R R., & T Toppin, i L L. (2000) (2000). The Th effects ff t of preventative vocal hygiene education on the vocal hygiene habits and perceptual voice characteristics of training singers. Journal of Voice, 14, 58-71. Carding, P., Horsley, I., & Docherty, G. (1999). A study of the effectiveness of voice therapy patients with nonorganic g dysphonia. y p Journal of Voice,, 13,, 72-104. in the treatment of 45 p Casper, J. (2000). Confidential voice. In J. C. Stemple (Ed.), Voice therapy: Clinical studies (2nd ed., pp. 128-139). San Diego, CA: Singular Publishing. Chan, R. W. K. (1994). Does the voice improve with vocal hygiene education? A study of some instrumental voice measures in a group of kindergarten teachers, Journal of Voice, 8, 279 291 279-291. Chen, S. H., Huang, J., & Chang, W. (2003). The efficacy of resonance method to hyperfunctional dysphonia from physiological, acoustic and aerodynamic aspects: The preliminary study. Asia Pacific Journal of Speech, Language and Hearing, 8, 200-203.

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Ramig LO LO, Sapir S, S Countryman S S, et al. al Intensive voice treatment (LSVT) for patients with Parkinson's disease: a 2 year follow up. J Neurol Neurosurg Psychiatry. Oct 2001;71(4):493-498. Ramig LO, Sapir S, Fox C, Countryman S. Changes in vocal loudness following intensive voice treatment (LSVT) in individuals with Parkinson's di disease: a comparison i with ith untreated t t d patients ti t and d normall age-matched t h d controls. Mov Disord. Jan 2001;16(1):79-83. Rattenbury, H. J., Carding, P. N., & Finn, P. (2004). Evaluating and effectiveness and efficacy of voice therapy using a transnasal flexible y g py a randomized control trial. Journal of Voice, 18, 522-533. laryngoscopy: Roy, N. (1993). Ventricular dysphonia following long-term endotracheal intubation: A case study. Journal of Otolaryngology, 23, 189-193. Roy, N., Bless, D. M., Heisey, D., & Ford, C. N. (1997). Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes outcomes. Journal of Voice Voice, 11, 11 321-331 321-331.

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References †

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References †

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