Kathleen Mary Bell, DMA Candidate in Voice Pedagogy

Shenandoah University
Winchester, Virginia USA

The Utility of Vocal Function Exercise (VFEs) as an Adjunct Therapy for Voice Disorders
in Singers with Suspected Laryngopharyngeal Reflux (LPR)

Abstract

Introduction: The study’s purpose was to examine changes within the participants’ voices over

six weeks of lessons. Laryngopharyngeal Reflux (LPR) incidence is increasing at epidemic

proportions (a 400% increase since the 1970s) with serious health consequences, including voice

disorders. LPR affects the upper airway, irritating the supra-glottal and glottal tissues' mucosal

lining, and may be an underlying insult that leads to phonotraumatic vocal fold lesions or other

comorbidities.

Singers with LPR are acutely affected by any irritation and edema in the vocal folds. They often

utilize maladaptive singing behaviors to address the voice symptoms caused by LPR. These

compensatory gestures hinder voice production and lead to voice disorders, such as muscle

tension dysphonia, vocal nodules, and vocal hemorrhage. Even after LPR has been successfully

treated medically or surgically, singing voice symptoms often persist. Singers with LPR often

experience dysphonia, poor voice quality in the morning, prolonged warm-up time, pitch breaks,

and loss of range, and inability to sing softly.

Voice teachers are uniquely faced with the task of working with students with any manner of

voice symptoms. Voice teachers have used the Vocal Function Exercises (VFEs) for vocal

training and speech-language pathologists as an adjunct therapy for various voice disorders. The

VFEs is a systematic exercise program to regain balance between airflow, laryngeal muscle

activity, and supraglottic tone placement. To date, no published studies have addressed their use
with singers who experience the specific debilitating effects of Laryngopharyngeal Reflux. The

purpose of this quasi-experimental outcome study was to examine the effects (if any) of using the

VFEs to address the voice symptoms associated with suspected LPR.

Method/Design:

This quasi-experimental outcome study with pre- and post-measures was approved by the

Shenandoah University Institutional Review Board (IRB#503) in 2018. It included both direct

and proxy measures. Objective (acoustic and aerodynamic) and self-perceived measures of

specific voice tasks made up the dependent variables. The application of the VFEs Protocol in

the treatment group's practice regimen was the independent variable.

A convenience sample of singers diagnosed with LPR, Hiatal hernia, or GERD with voice

symptoms was recruited from the Northern Virginia area (N=17). The participants were divided

into two cohorts: treatment (N=10) and Control (N=7) based on their ability to reproduce the

“knoll buzz” sound. The study was not double-blinded as only the principal investigator knew

the group designation of the participants. Both cohorts received six weeks of weekly thirty-

minute private voice lessons and reflux education materials with only the treatment group

assigned to daily practice the VFEs at home. The participants' age range was 19-80, with an

average age of 38. Ten female and seven male participants made up the final sample. The

Singers were categorized by “style” as predominantly classical (N=8) or Contemporary

Commercial Music (CCM; N=9) singers.

Pre- and Post-measures of CPP, CSID, CTP, VRP, RSI, VHI-10, SVHI-10, The Adapted Borg

CR10, and SSQ were collected to document voice symptoms and treatment efficacy. Six LPR-

related symptoms were explored, including hoarseness, change in voice quality, longer warm-up
time, voice breaks (change in registration), voice range, and ability to sing softly (especially in

the upper frequencies).

Results/Conclusion:

This quasi-experimental study yielded significant voice quality improvements in at least one

measure for every participant in the treatment group. Conversely, the control group only showed

minimal change in vocal function of their register shift. At the end of the six weeks, treatment

participants expressed an increase in quality of life and vocal efficiency. Based on these results,

the VFEs have shown efficacy in improving the vocal range, easing the transition between

registers, and singing more quietly with increased vocal ease in the study population regardless

of age or singing style. Since all treatment participants across the board found some usefulness

(particularly warming up the voice), this indicates that VFEs show efficacy for inclusion in the

practice regimen of singers with suspected LPR-related voice symptoms.

 This Photo by Unknown Author is licensed under CC BY

I. What is Reflux? LPR - GERD that affects the larynx and pharynx
II. Symptoms
a. Hoarseness, chronic throat clearing, globus pharyngeus, chronic cough,
postnasal drip, Otis media (ear pain)
b. Voice professionals -Hoarseness, longer voice warm-up time, low voice in the
morning, inability to sing high notes softly, loss of falsetto or shift in falsetto
lift with men, difficulty negotiating the passaggio/voice breaks
c. Reflux laryngitis, Barretts Esophagus, and Laryngeal cancer
III. Physical findings
a. Vocal fold – edema & erythema (swelling & redness)
b. Interarytenoid pachydermia (cobblestoning)
c. Mucosal damage
d. Hyperactive gag reflex
 credit Thomas Carroll, MD permission granted
LPR vs. GERD

LPR GERD

Organs affected larynx, pharynx, sinus esophagus

cavities, ears

Most common symptoms cough, hoarseness, post-nasal heartburn, chest pain

drip

Motility normal motor dysfunction abnormal motor dysfunction

Location of dysfunction upper esophageal sphincter lower esophageal sphincter

(UES) (LES)

Occasion of dysfunction symptoms occur when sitting symptoms occur when lying
or standing down

Occurrence during the day at night

BMI factors obesity not correlated obesity correlated

Causes acid activated pepsin; gastric acid, bile salts,

neurogenic

Consequences any exposure to acid up to 50 times a day is

damaging “normal”

Treatment duration need aggressive and long- 3 months of treatment

term treatment
LPR Treatment
Phase 1
1. Dietary modification - cut out citrus, chocolate, mint, alcohol, high acid foods,
high-fat foods, fried foods, lactose, or gluten
2. Lifestyle modification – small frequent meals, last meal 3 hours before bedtime,
raise the bed or sleep upright, quit smoking, chew gum, sleep on the left side,
avoid tight clothing
3. Medications - antacids Tums® (GlaxoSmithKline, St. Louis, Missouri), Maalox®
(Sanofi, Paris, France), and Mylanta® (McNeil Consumer Healthcare, Johnson and
Johnson, New Brunswick, NJ)– quickly neutralize acid
4. Alginates (Gaviscon) - “mechanical barrier” to stomach contents entering the
upper esophageal tract
Phase 2
1. H2 blockers – Zantac® (generic name Rantitidine sold by Sanofi, Paris, France)
and Pepcid® (generic name Famotidine marketed by Johnson and Johnson-Merck,
New Brunswick, NJ) -block histamine-induced gastric acid secretion from the
parietal cells of the gastric mucosa
2. Proton pump inhibitors – Prilosec® (generic name Omeprazole, Procter and
Gamble, Cincinnati, OH), lansoprazole (Prevacid®, Takeda Pharmaceuticals U.S.A.,
Inc, Deerfield, MI), esomeprazole (Nexium®, AstraZeneca, Cambridge, UK) –
block the enzyme in the wall of the stomach that produces acid
3. Prokinetic agents –metoclopramide (Reglan® ANI Pharmaceuticals Inc., Baudette,
MN) stimulate contractions of the stomach muscles (Tighten LES)
Phase 3
1. Double dose PPI
2. Surgery
a. Nissen fundoplication – tighten LES (upper curve of stomach wrapped around)
b. Hiatal Hernia surgery
c. Stretta procedure -tiny cuts in the esophagus to form scar tissue and strengthen
muscles
d. Bard EndoCinch System – stitches made to create pleats in LES to support it
e. Linx surgery – ring of tiny magnetic titanium beads strengthens LES
Low Acid Diet and High pH Water (water above 7.5)
Pepsin is deactivated at a pH of 7.8 or above
Jamie Koufman promotes drinking high pH water of 8.8
Water pH Values
Name pH
Propel ~3.4
Perrier ~5.2
Dasani ~5.6-7.2
Deer Park ~6.31
Distilled ~6.5
Fiji ~6.65-7.3
Smart Water ~6.05-7.6
Zepher Hills ~7.5
Evian ~7.5
Danon ~7.8
Penta ~7.8
Aqua Panna ~6.2
Islandic ~8.4-8.8
Spring
Evermore ~8.4-8.8
Essentia ~8.8-9.5
Qure ~9.5-10

Vocal Function Exercise Protocol

1. (warm-up) Sustain an extremely bright, forward /i/ for as long as possible on the musical note
(C) for bass/baritone, (F) below middle (C) for tenors, middle C for altos, and (F) above
middle C for Sopranos. Goal = __ sec.

Bass Tenors Altos Sopranos

2. (stretching) Glide from your lowest note to your highest note on the word “knoll” without the
“kn.” There should be vibration at the lips. Goal = no voice breaks.

3. (contracting) Glide from a comfortably high note to your lowest note on the word “knoll”
without the “kn.” There should be vibration at the lips. Goal = no voice breaks.

4. (power) Sustain the musical notes C-D-E-F-G (starting at middle C for sopranos and mezzo-
sopranos starting one octave below middle C for baritones and basses) E-F-G-A-B for tenors
for as long as possible on the word “knoll” without the “kn.” There should be vibration at the
lips. Goal = __ sec.
 Figure 29 Pharyngeal SpaceError! Bookmark not defined.
Notation: Complete Practice log indicating times for exercises #1 and #4
Frequency:
1. Complete exercises 1-4 twice, two times a day
2. There should be at least one hour between practice times
Tone Quality Goals:
1. Softly as possible
2. Clear quality of tone
3. No breaks, wavering, or breathiness
4. Forward focus without tension
5. Balanced onsets without breathiness or glottal attack
Technique:
1. Low abdominal breathing
2. Excellent singing posture
3. The pharynx should be very large, and the lips should be very small when completing
Exercises 2- 4.
 Treatment Group Results

+ means CCM singer; * means below normal threshold; highlighted means improved.

Participant # P3 P5+ P6+ P7+ P9+

Age 80 29 61 24 19
BMI 21.9 24.9 27.4 26.1 20.5
Gender F F M M F

Pre-CPP 5.559* 8.679* 14.46 13.148 9.433*

Post-CPP 8.221* 10.703* 14.346 12.082 10.239*
Pre-CSID 42.034* 51.188* -16.195 6.74 18.913
Post-CSID 15.692 9.947 -4.222 24.661* 13.075
Pre-CTP 5.885 2.55 4.69 2.16 4.38
Post-CTP 1.12 2.265 4.4 2.12 2.1
Pre-VRP 1155 933 1376 1307 995
Post-VRP 1256 1282 1257 1469 1270
Pre-Upper 1000 1500 600 600 1000
Post-Upper 1000 1500 500 1000 1000
Pre-Register 75 85 100 95 87
Post-Register 90 105 95 100 100
Pre-SPL 50 70* 55 60 60
Post-SPL 50 50 60 55 50
Pre-RSI 27* 12 13* 23* 16*
Post-RSI 2 25 13 14 10
Pre-VHI-10 28* 22* 2 31* 10
Post-VHI-10 7 7 3 19* 2
Pre-SVHI-10 36* 21* 15* 23* 16*
Post-SVHI-10 12 7 17* 10 12
Pre-Borg 4 2 3 2 2
Post-Borg 3 .5 7* 2 3
Pre-SSQ 30* 23* 17* 11 14*
Post-SSQ 14 15 22* 4 8

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