Vocal Function Exercises With and Without Maximally Sustained Phonation: A Randomized Controlled Trial of Individuals With Normal Voice

Published:November 12, 2022DOI:



      To determine the effect of maximally sustained phonation on efficacy of Vocal Function Exercises as measured by percent of maximum phonation time goal attained. The hypothesis was that maximally sustained phonation would result in greater improvements in percent of maximum phonation time goal attained.

      Study Design

      Randomized controlled trial.


      A convenience sample of individuals with normal voice were recruited in a university academic clinic setting. Of 34 participants who volunteered for the study, 31 completed baseline assessment and 23 completed all study procedures. Participants were randomized to complete Vocal Function Exercises (traditional group TG), modified Vocal Function Exercises with reduced requirement for maximally sustained phonation (midpoint group MG), or modified Vocal Function Exercises with removed requirement for maximally sustained phonation (baseline group BG). The primary outcome measure was percent of maximum phonation time goal obtained during Vocal Function Exercises.


      The MG (p = 0.008) and TG (p = 0.001) groups significantly improved percent of maximum phonation time goal attained after six weeks of exercise, while the BG group (p = 0.0202) did not (ɑ = 0.0125). Difference among groups was not statistically significant (p = 0.67, ɑ = 0.0125). Hedges’ g effect sizes of 0.29 (-0.66, 1.25) and 0.51 (-0.57, 1.58) were obtained comparing MG and TG groups, and BG and TG groups, respectively.


      Greater requirements for maximally sustained phonation improved efficacy of Vocal Function Exercises in enhancing normal voice as measured by percent of maximum phonation time goal attained. Maximally sustained phonation may be modified to some extent while preserving efficacy of Vocal Function Exercises, however complete elimination of maximally sustained phonation may attenuate improvement. Additional research in a clinical population is warranted.

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        • Thomas LB
        • Stemple JC.
        Voice therapy: does science support the art?.
        Comm Disord Rev. 2007; 1: 49-77
        • Roy N.
        Optimal dose-response relationships in voice therapy.
        Int J Speech Lang Pathol. 2012; 14: 419-423
        • Whyte J.
        Contributions of treatment theory and enablement theory to rehabilitation research and practice.
        Arc. Phys Med Rehabil. 2014; 95: S17-S23
        • Stemple JC
        • Lee L
        • D'Amico B
        • et al.
        Efficacy of vocal function exercises as a method of improving voice production.
        J Voice. 1994; 8: 271-278
        • Angadi V
        • Dressler E
        • Kudrimoti M
        • et al.
        Efficacy of voice therapy in improving vocal function in adults irradiated for laryngeal cancers: a pilot study.
        J Voice. 2020; 34: 962.e9-962.e18
        • Berg EE
        • Hapner E
        • Klein A
        • et al.
        Third Voice therapy improves quality of life in age-related dysphonia: a case-control study.
        J Voice. 2008; 22: 70-74
        • Gelfer MP
        • Van Dong BR.
        A preliminary study on the use of vocal function exercises to improve voice in male-to-female transgender clients.
        J Voice. 2013; 27: 321-334
        • Gillivan-Murphy P
        • Drinnan MJ
        • O'Dwyer TP
        • et al.
        The effectiveness of a voice treatment approach for teachers with self-reported voice problems.
        JVoice. 2006; 20: 423-431
        • Gorman S
        • Weinrich B
        • Lee L
        • et al.
        Aerodynamic changes as a result of vocal function exercises in elderly men.
        Laryngoscope. 2008; 118: 1900-1903
        • Jafari N
        • Salehi A
        • Izadi F
        • et al.
        Vocal function exercises for muscle tension dysphonia: auditory-perceptual evaluation and self-assessment rating.
        J Voice. 2017; 31: 506.e25-506.e31
        • Kaneko M
        • Hirano S
        • Tateya I
        • et al.
        Multidimensional analysis on the effect of vocal function exercises on aged vocal fold atrophy.
        J Voice. 2015; 29: 638-644
        • Kao YC
        • Chen SH
        • Wang YT
        • et al.
        Efficacy of voice therapy for patients with early unilateral adductor vocal fold paralysis.
        J Voice. 2017; 31: 567-575
        • Kapsner-Smith MR
        • Hunter EJ
        • Kirkham K
        • et al.
        A randomized controlled trial of two semi-occluded vocal tract voice therapy protocols.
        J. Speech Lang. Hear. 2015; 58: 535-549
        • Kumar R
        • Sharma P
        • Vir D
        • et al.
        Voice therapy outcomes in type-I sulcus vocalis: Case studies.
        Int J Clin Exp Otolaryngol. 2016; 2: 42-44
        • Lim H-J
        • Kim J-K
        • Kwon D-H
        • et al.
        The effect of vocal function exercise on voice improvement in patients with vocal nodules.
        J Korean Soc Speech Sci. 2009; 1: 37-42
        • Nguyen DD
        • Kenny DT.
        Randomized controlled trial of vocal function exercises on muscle tension dysphonia in Vietnamese female teachers.
        J Otolaryngol Head Neck Surg. 2009; 38: 261-278
        • Pasa G
        • Oates J
        • Dacakis G.
        The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers.
        Logoped Phoniatr Vocol. 2007; 32: 128-140
        • Patel RR
        • Bless DM
        • Thibeault SL.
        Boot camp: a novel intensive approach to voice therapy.
        J Voice. 2011; 25: 562-569
        • Pedrosa V
        • Pontes A
        • Pontes P
        • et al.
        The effectiveness of the comprehensive voice rehabilitation program compared with the vocal function exercises method in behavioral dysphonia: a randomized clinical trial.
        J Voice. 2016; 30 (377.e11–377.e3.77E19)
        • Radhakrishnan N
        • Mathisen D.
        Idiopathic subglottic stenosis: surgical and therapeutic results in an adult woman.
        Int J Clin Exp Otolaryngol. 2016; 2: 23-25
        • Radhakrishnan N
        • Scheidt T.
        Modified vocal function exercises: a case report.
        Logoped Phoniatr Vocol. 2012; 37: 123-126
        • Roy N
        • Weinrich B
        • Gray SD
        • et al.
        Three treatments for teachers with voice disorders: a randomized clinical trial.
        J Speech Lang Hear. 2003; 46: 670-688
        • Roy N
        • Gray SD
        • Simon M
        • et al.
        An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial.
        J Speech Lang Hear. 2001; 44: 286-296
        • Sauder C
        • Roy N
        • Tanner K
        • et al.
        Vocal function exercises for presbylaryngis: a multidimensional assessment of treatment outcomes.
        Ann Otol Rhinol Laryngol. 2010; 119: 460-467
        • Sharma N
        • De M
        • Martin T
        • et al.
        Laryngeal reconstruction following shrapnel injury in a British soldier: case report.
        J Laryngol Otol. 2009; 123: 253-256
        • Tanner K
        • Sauder C
        • Thibeault SL
        • et al.
        Vocal fold bowing in elderly male monozygotic twins: a case study.
        J Voice. 2010; 24: 470-476
        • Tay EY
        • Phyland DJ
        • Oates J.
        The effect of vocal function exercises on the voices of aging community choral singers.
        J Voice. 2012; 26 (672.e19–672.e6.72E27)
        • Teixeira LC
        • Behlau M.
        Comparison between vocal function exercises and voice amplification.
        J Voice. 2015; 29: 718-726
        • Ziegler A
        • Verdolini Abbott K
        • Johns M
        • et al.
        Preliminary data on two voice therapy interventions in the treatment of presbyphonia.
        Laryngoscope. 2014; 124: 1869-1876
        • Bane M
        • Angadi V
        • Dressler E
        • et al.
        Vocal function exercises for normal voice: the effects of varying dosage.
        Int J Speech Lang Pathol. 2019; 21: 37-45
        • Bane M
        • Brown M
        • Angadi V
        • et al.
        Vocal function exercises for normal voice: with and without semi-occlusion.
        Int J Speech LangPathol. 2019; 21: 175-181
        • Ellis LW
        • Beltyukova SA.
        Effects of compliance monitoring of vocal function exercises on voice outcome measures for normal voice.
        Percept Mot Skills. 2011; 112: 729-736
        • Guzman M
        • Angulo M
        • Muñoz D
        • et al.
        Effect on long-term average spectrum of pop singers' vocal warm-up with vocal function exercises.
        Int J Speech LangPathol. 2013; 15: 127-135
        • Sabol JW
        • Lee L
        • Stemple JC.
        The value of vocal function exercises in the practice regimen of singers.
        J Voice. 1995; 9: 27-36
        • Stemple JC
        • Hapner ER.
        Voice Therapy: Clinical Case Studies.
        5th ed. Plural Publishing Incorporated, 2019
        • Croake DJ
        • Andreatta RD
        • Stemple JC.
        Immediate effects of the vocal function exercises semi-occluded mouth posture on glottal airflow parameters: a preliminary study.
        JVoice. 2017; 31: 245.e9-245.e14
        • Verdolini K
        • Druker DG
        • Palmer PM
        • et al.
        Laryngeal adduction in resonant voice.
        J Voice. 1998; 12: 315-327
        • Stemple JC
        • Roy N
        • Klaben BK.
        Clinical Voice Pathology: Theory and Management.
        5th ed. Plural Publishing Incorporated, 2014
        • American Speech-Language-Hearing Association
        Evidence-Based Practice in Communication Disorders., 2005 (Accessed January 3, 2021)
      1. Hart T, Whyte J, Dijkers M, et al.Manual of rehabilitation treatment specification. 2018.

        • Turkstra LS
        • Norman R
        • Whyte J
        • et al.
        Knowing what we're doing: why specification of treatment methods is critical for evidence-based practice in speech-language pathology.
        Am J Speech-Lang Pathol. 2016; 25: 164-171
        • Van Stan JH
        • Dijkers MP
        • Whyte J
        • et al.
        The rehabilitation treatment specification system: implications for improvements in research design, reporting, replication, and synthesis.
        Arch Phys Med Rehabil. 2019; 100: 146-155
        • Borkovec TD
        • Miranda J.
        Between-group psychotherapy outcome research and basic science.
        J Clin Psycho. 1999; 55: 147-158≤147::AID-JCLP2≥3.0.CO;2-V
        • Sandage MJ
        • Hoch M.
        Exercise physiology: perspective for vocal training.
        in: Sataloff RT Voice Science. 2nd ed.ed. Plural Publishing, Incorporated, 2017: 271-276
        • Stemple JC.
        A holistic approach to voice therapy.
        Semin Speech Lang. 2005; 26: 131-137
        • Angadi V
        • Croake D
        • Stemple J.
        Effects of vocal function exercises: a systematic review.
        J Voice. 2019; 33: 124.e13-124.e34
        • Hogikyan ND
        • Sethuraman G.
        Validation of an instrument to measure voice-related quality of life (V-RQOL).
        J Voice. 1999; 13: 557-569
        • Kempster GB
        • Gerratt BR
        • Verdolini Abbott K
        • et al.
        Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol.
        Am J Speech-Lang Pathol. 2009; 18: 124-132
        • Hirano M.
        Pyscho-Acoustic Evaluation of Voice: GRBAS Scale.
        Springer Verlag, 1981