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Vocal Function Exercises Laryngeal Adduction Exercises. Angie Predmore Robyn Renwick. Purpose. To improve vocal quality Increase muscle activity. Laryngeal Adduction Exercises. Pushing/pulling Holding breath Glottal attack Pseudo supraglottic swallow. Who?.

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Vocal function exercises laryngeal adduction exercises l.jpg

Vocal Function ExercisesLaryngeal Adduction Exercises

Angie Predmore

Robyn Renwick

Purpose l.jpg

To improve vocal quality

Increase muscle activity

Laryngeal adduction exercises l.jpg

Laryngeal Adduction Exercises

Pushing/pulling Holding breath

Glottal attack Pseudo supraglottic swallow

Slide4 l.jpg

used with patients with poor vocal fold adduction (hypo-adduction)

laryngeal trauma (may result in recurrent laryngeal nerve paralysis)

neurological diseases

PD, MS, closed head injury, stroke, congenital conditions such as sulcusvocalis (vocal fold furrow)

should not be used in patients with voice problems due to vocal fold inflammation or mass lesions on the folds (i.e. nodules, polyps)

Pushing and pulling exercises should not be used with patients that have uncontrolled high blood pressure

(Ramig & Verdolini, 1998)

Purpose5 l.jpg

Voice quality

Facilitate improved vocal fold closure during voice production

Helps to treat breathiness, low intensity, hoarseness, or overall vocal quality

Conditions such as vocal fold bowing and vocal fold weakness or paralysis

(Logemann, 1998)

Purpose6 l.jpg

Swallowing safety / airway protection

Increase muscle activity in the larynx

Basic to good laryngeal closure during swallowing

A sequence of these exercises should be completed before actual swallowing therapy

if laryngeal incompetence can’t be managed quickly by postural assists or teaching the patient to voluntarily close their airway

(Logemann, 1998)

Method l.jpg

Two sets of exercises

The series of exercises should be completed five to ten time per day for five minutes

Each exercise should be repeated 5 times before moving on to the next exercise in the set

The whole series of exercises should be repeated three times

(Logemann, 1998)

Set 1 l.jpg
Set 1

Exercise 1:

Be seated.

Hold your breath as tightly as possible while pushing down or pulling up on your chair with both hands for 5 sec.

(Logemann, 1998)

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Set 1

Exercise 2:

Be seated.

Bear down against a chair with only one hand. Produce clear voice simultaneously.

(Logemann, 1998)

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Set 1

Exercise 3:

Repeat ‘ah’ 5 times with a hard glottal attack on each vowel.

(Logemann, 1998)

Ah.. Ah..ah..ah..ah..

Set 111 l.jpg
Set 1

Patients should practice this series every day for one week.

A follow-up swallow evaluation should be completed to assess improvements in airway protection from the larynx.

The SLP and patient can also monitor improvements in laryngeal function by listening to clarity and vocal quality.

If no improvements are noted, the exercises should be changed to those in Set 2.

This prevents monotony and introduces exercises in a hierarchy

(Logemann, 1998)

Set 2 l.jpg
Set 2

The series of exercises should be completed five to ten time per day for five minutes

Each exercise should be repeated 5 times before moving on to the next exercise in the set

The whole series of exercises should be repeated three times

(Logemann, 1998)

Set 213 l.jpg
Set 2

Exercise 1:

Pull up on chair with both hands while prolonging phonation.

(Logemann, 1998)

Set 214 l.jpg
Set 2

Exercise 2:

Begin phonation of ‘ah’ with a hard glottal attack and sustain phonation with a clear, smooth vocal quality for 5-10 seconds

(Logemann, 1998)

Set 215 l.jpg
Set 2

Exercise 3:

Pseudo-supraglottic swallow

Take a breath, hold it, and cough as strongly as possible

(Logemann, 1998)

Recovery l.jpg

Improvement should be seen within 2 weeks

Occasionally it will take 6-8 months with some patients to attain adequate airway protection or vocal quality

these are often those who have had more serious conditions (i.e. extended supraglottic laryngectomy)

(Logemann, 1998)

Cautions l.jpg

Stemple, Glaze & Klaben (2000) suggested that the effectiveness of these exercises depends on the degree of vocal fold gap

prognosis for improvement is most favorable if a light touch closure is evident during the videostroboscopic evaluation

Patient should be monitored closely for signs of hyperfunction (Miller, 2004)

(Stemple, Glaze & Klaben, 2000; Miller, 2004)

Efficacy l.jpg

There is very little research about the use and efficacy of laryngeal adduction exercises.

Since there are extremely few efficacy studies concerning vocal fold adduction exercises, few SLPs currently use the pushing and pulling type of exercises.

Yamaguchi et al. (1990)

Silverman Voice Treatment (LSVT)

Yamaguchi et al 1990 l.jpg
Yamaguchi et al. (1990)

Cases of glottal incompetence

Treated by the pushing exercises technique.

Three patients that had paralysis of the vocal folds or sulcus vocalis

All three individuals improved following voice treatment.

Two improved 20 dB (statistically significant increase in intensity), and one improved 7 dB (clinically significant increase in intensity).

Slide20 l.jpg

The Lee Silverman Voice Treatment (LSVT) program utilizes intensive high phonatory effort exercises in order to increase vocal fold adduction.

It has been documented to have short and long term effectiveness for those with idiopathic Parkinson’s Disease.

(Ramig, 1998)

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  • Beneficial to treat

    • Hyperfunction

      • Too much laryngeal activity

    • Hypofunction

      • Too little laryngeal activity

  • Prevention

    • Hyperfunction

    • Vocal symptoms

  • Research has demonstrated improvements for

    • Vocal nodules

    • Singers

    • Aging voice

Philosophy l.jpg

The laryngeal mechanism, like other muscle systems, may become imbalanced and/or strained.

VFE treat in a holistic manner.

“Physical therapy” for the voice

(Stemple, Glaze, & Gerdeman-Klaben, 2000)

Purpose24 l.jpg

Increase the bulk, strength, and coordinated interaction of muscles

Improved glottal efficiency

Improved vocal quality

Easy onset

Frontal focus

Respiratory support

Balance respiration, phonation, & resonance

(Stemple, 2000; “Vocal function exercises”, n.d.)

Method25 l.jpg

Set of 4 exercises

Completed 2x each, 2x daily

1x in the morning, 1x in the afternoon

Complete as softly as possible to

Purpose: increase muscular and respiratory effort to maintain phonation

(Andrews, 2006)

Step 1 warm up l.jpg
Step 1: Warm-Up

Sustain the vowel /i/ for as long as possible

on a musical note F

above middle C for women and children

below middle C for men.

May be modified based on patient’s vocal range.


Dependent on patient’s airflow volume.

Targeted volume is 80-100 mL/s of airflow.

Flow volume, mL H2O/100 mL H2O = _______ seconds

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 2 stretching l.jpg
Step 2: Stretching

Say “Knoll” and glide from lowest note to highest note in vocal range.


Complete without voice breaks.

Use of the word “knoll” encourages a forward vocal focus and an open pharynx.

Lips should be rounded and the patient should feel vibration on the lips.

During this exercise, vocal folds are stretched and muscle control and flexibility is improved.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 3 contraction l.jpg
Step 3: Contraction

Say “Knoll” and glide from highest note to lowest note in vocal range.


Complete without voice breaks.

Encourages a forward focus and an open pharynx.

Complements the previous stretching exercise by contracting the laryngeal muscles.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Step 4 adductory power exercise l.jpg
Step 4: Adductory Power Exercise

Voice “Oll” (“knoll” without “kn”) as long as possible on musical notes C, D, E, F, and G

above middle C for women and children

below middle C for men

modify based on patient’s vocal range).


dependent on patient’s airflow volume.

The goal is the same as the first exercise with a targeted volume is 80-100 mL/s of airflow.

(Stemple, Glaze, and Klaben, 2000; Andrews, 2006)

Recovery30 l.jpg

Patients track progress on a graph

Sustained times

Daily variation is expected

Improvement typically seen within 6-8 weeks

(Stemple, Glaze, and Klaben, 2000)

Maintenance l.jpg

Once goals have been met and vocal quality has improved, the following weekly program is recommended:

Full program 2 times each, 2 times per day

Full program 2 times each, 1 time per day (morning)

Full program 1 time each, 1 time per day (morning)

Exercise #4, 2 times each, 1 time per day (morning)

Exercise #4, 1 time each, 1 time per day (morning)

Exercise #4, 1 time each, 3 times per week (morning)

Exercise #4, 1 time each, 1 time per week (morning)

(Stemple, Glaze & Klaben, 2000)

Slide32 l.jpg
EfficacyVoice Therapy: Clinical Studies (Stemple, 2000)Provides a variety of cases in which he has used VFE


9 year old

21 year old

Improved vocal quality

Easy onset, respiratory support, frontal focus

Balance among respiration, phonation, resonance

Prevention of hyperfunction

53 year old

Avoid hyperfunction as a new, higher pitch is learned


71 year old

36 year old

Improved efficiency of breath support for phonation

Treatment of vocal nodules

26 year old

Improved vocal quality

Overall improvement in vocal folds

Frontal focus

Increased MPT

Prevention of vocal symptoms l.jpg
Prevention of Vocal Symptoms

Pasa, Oates, & Dacakis (2007)

37 primary school teachers

Ages: 21 to 55


Decrease in vocal symptoms

Improved vocal quality

Increased maximum phonation times

Singers l.jpg

Wrycza-Sabol, Lee, and Stemple (1995)

20 healthy graduate-level voice majors

Ages 21 to 55


Improved glottal efficiency

Increased airflow rates

Imporved phonation volumes

Increased MPTs

Aging voice l.jpg
Aging Voice

Gorman, Weinrich, Lee, and Stemple (2008)

19 male participants

Ages 60 to 78


Continuous improvements in MPT

Improved glottal closure

References l.jpg

Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through geriatrics. Thomson: Canada.

Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic changes as a result of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903.

Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX.

Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North American, 37, 105-119.

Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics Phoniatrics Vocology 32, 128-140.

Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech, Language, and Hearing Research, 41, 101-116.

Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada.

Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice pathology: Theory and management. Singular: Canada.

Vocal function exercises. In Vocology. Retrieved July 13, 2009, from http://ncvs.org/museum-archive/vocologyguide.pdf

Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function exercises in the practice of regimen of singers. Journal of Voice, 9(1), 27-36.

Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990). Pushing exercise program to correct glottal incompetence. Annual Bulletin of the Research Institute of Logopedics, 24, 223-234.