Voice problems (dysphonia) affect one in 13 adults annually, causes a major impact on
quality of life and livelihood and is a substantial healthcare burden. It is more common
in women and in those with vocally demanding professions and the elderly. Forty percent
of patients referred for assessment of a voice problem have Muscle Tension Dysphonia
(MTD) as a cause brought on by an imbalance of breathing mechanism and/or uncontrolled
tightness of the muscles of the voice box or throat. The main symptoms are hoarseness,
abnormal pitch or loudness, variability in quality or control of the voice, throat
discomfort or difficulty in using the voice such as being able to use a louder voice when
needed, or a voice that fatigues with use with a consequent impact on quality of life.
Traditionally there are six described recognisable patterns of MTD based on the
presenting symptoms, voice quality and on appearance of the larynx (voice box) on
examination with a video camera. Three types (MTD patterns I-III) are more related to
ineffective voice use, also known as 'voice abuse' or 'voice misuse', while the other
three types (MTD patterns IV-VI) have a predominantly psychological basis.
In the United Kingdom (UK), patients with persistent or unexplained hoarseness who are
over the age of 45 are referred under the two-week wait (2WW) cancer referral process. In
other cases, referral to an Ear, Nose and Throat (ENT) benign voice service is usually
considered if the dysphonia persists for more than six weeks, if it has not improved with
simple measures such as voice rest, reducing irritation to the vocal cords and drinking
plenty of fluids (known as vocal hygiene advice) or it is impacting significantly on the
patient's work or social life. In practice patients with MTD may come through both the
2WW and benign voice pathways.
A diagnosis of MTD is made by an ENT surgeon and/or Speech & Language Therapist who has
specialised in voice disorders (SLT-V) based on the history of the vocal complaint and by
excluding an organic cause by examination of the patient's voice box (larynx) with a
small flexible video camera passed through the nose. Treatment is with voice therapy
given by a SLT-V. Voice therapy consists of two main types: Indirect Voice Therapy and
Direct Voice Therapy and is guided by advice from professional organisations such as
Royal College of Speech and Language Therapists Clinical Guidelines and the American
Speech-Language-Hearing Association (ASHA) Clinical Practice Guideline: hoarseness
(dysphonia). Indirect therapy consists of education, information, vocal hygiene, and
stress management to encourage behavioural change. Direct therapy consists of
establishing healthy voice production by rebalancing the three subsystems of voice
production namely breathing (respiration), voice production (phonation) and more
efficient use of resonance.
The aim of voice therapy is generally to (a) return the patient's voice to normal or as
best as possible within the patient's anatomic and physiologic capabilities and (b) to
satisfy the patient's occupational, social and emotional vocal needs and (c) promote
habit changes that will ensure voice improvement will be maintained. Therapeutic goals
should be specific and determined by the patient prior to therapy to empower the patient
in shared decision making with the aim of improving motivation and compliance. In
addition, the aim should be maximum improvement in the minimum time.
MTD is a mixed group of conditions with different patterns of presentation and numerous
patient specific factors. In addition, Direct Voice Therapy is not just one treatment
method and many SLT-Vs use a hierarchical approach, which focuses in the early stages on
postural and relaxation techniques, followed by breathing exercises, voicing and
resonance work with final consolidation and review. The techniques applied by a SLT-V are
also dependent on abnormal findings on clinical examination the training and experience
of the therapist and the response and engagement of the patient. Although having a large
variety of techniques that can be used which can be tailored to the individual, Voice
therapy has been portrayed as a "black box" and many recognised treatment regimens
overlap in the treatment aims and therapeutic goals. This makes it difficult to determine
why patients improve, which therapy tasks are most beneficial and for how long the tasks
should be continued.
Another limitation of traditional Direct Voice Therapy can be that patients often have
difficulty transferring the voice improvement on sustained vowels and during therapy
sessions into conversational voice and day-to-day voice use. It is also recognised that
patients do not always complete the therapy sessions in up to 18-65% of cases. Numerous
reasons have been put forward for this, including clinician and clinic-related factors,
gender, ethnicity, age, employment and perceived vocal severity, complex laryngeal
diagnoses, additional medical problems, time commitment for treatment sessions or lack of
rapid progress, adequate, if not complete, improvement in symptoms or failure to achieve
goals. There is greater treatment satisfaction and likelihood of success if Direct Voice
Therapy techniques are functionally orientated and have a more meaningful effect on
quality of life with an emphasis on carryover activities into conversation so that it is
more relevant to the patient's daily vocal demands. There is also increasing recognition
that a patient may require more than one 'voice' to addresses the changing vocal needs
(e.g., quiet talking, talking over noise, and yelling) in different environments.
Traditionally voice therapy has been given in a clinic environment face-to-face. However,
with the onset of the Coronavirus (COVID-19) pandemic, Voice Therapy has almost entirely
been given using telepractice via a video link. Prior to the COVID-19 pandemic,
telepractice had been used by Speech and Language therapists mostly for geographical
reasons and difficulties in patients' attending outpatient clinics. There are relatively
few studies in its use for voice disorders and most studies on effectiveness have
involved small cohorts of patients with a range of voice pathologies such as Parkinson's
disease. There are few randomised controlled studies comparing face-to-face versus
Telepractice and only one study of MTD patients using the same voice therapy technique
(Flow phonation). This showed no significant difference in outcome between the two
methods of delivery. Disadvantages of telepractice for voice therapy include generic
problems with technology, patient environmental and cultural considerations, some
instructional and practical issues with an inability to deliver more 'hands-on'
techniques such as laryngeal manipulation. The Complete Vocal Technique (CVT) is
pedagogic technique primarily used by singing teachers and vocal coaches to aid singers
and actors produce the vocal sound and function that the performer requires. It has been
used for over 35 years particularly in Europe and CVT practitioners (CVT-P) undergo an
accredited 3-year training programme to achieve competency. It uses a hierarchical,
systematic approach with terminology that is clearly defined and supported with
scientific characterisation. It is based on four key building blocks enabling for example
a singer to produce any vocal sound required in a healthy manner and regardless of genre
of music. The first building block in CVT training is to ensure a healthy voice is
produced by adopting the three overall principles: adequate support for the voice, use of
a degree of twang ('necessary twang') and avoidance of jaw protrusion and tightening of
the lips. Secondly one of four main vocal modes (Neutral, Curbing, Overdrive and Edge) is
chosen which provides a set up for the larynx depending on the vocal requirement. These
terms were introduced to avoid confusion with other more frequently used singing terms
which lack precise definition. The choice of mode is determined by vocal demand
(loudness, pitch range, vowel and genre 'norm' (vocal style) that is required: Neutral
relates to normal conversational voice while the Curbing is a medium loud voice.
Overdrive can be used for voice projection up to a shout loudness, while Edge can be used
for a yelling and screaming quality. It would be expected that training in Neutral and
Overdrive would allow good vocal function for most social situations for patients with
MTD. The third element is to adjust the degree of sound colour (from dark to light)
mostly achieved by lowering or raising the larynx and increasing or decreasing the
pharyngeal space. The fourth element is to add specific vocal effects such as vibrato,
ornamentation, distortion etc., which can be added once the first three have been
achieved. In this way the precise sound required by the singer can be fashioned in any
style or genre of music. The principles have been applied to training the speaking voice
and provide a recipe for producing any desired voice quality for any environmental
situation. A similar approach, that has not been widely adopted, has also been described
whereby the aim is not to support the production of 'one voice', as is frequently the
case with traditional SLT-VT, but to provide the patient with a range of 'new' voices to
meet the patient's vocal needs.
Training programmes have been developed, using this methodology, to enable singers and
singing teachers to improve, achieve vocal goals and overcome technical issues many of
which are due to unintentional hyper-constrictive muscle activity within the larynx and
vocal tract. CVT has also been applied to problems with the professional speaking voice
and can help with reducing constriction and improved voice production and projection.
Specific elements of CVT have also been packaged together in what is termed CVT Voice
Therapy (CVT-VT). CVT-VT is used for singers and other performers presenting with acute
vocal problems leading to hoarseness or loss of voice when time is of the essence in
getting a vocalist back to professional voice use. Although widely used by CVT-Ps and
published in several books it has not been formally evaluated.
The application of telepractice during the COVID-19 pandemic has also become a necessity
in teaching singing and has been adopted by the Complete Vocal Institute (CVI) in Denmark
where almost all tuition is now delivered on-line. Informal feedback from singers has
been positive with many advantages (comfort of own home, reduction in cost, and no travel
time) outweighing the disadvantages (some technical issues with audio/connection). It is
likely a complete return to previous methods of delivery of SLT and CVT practice will not
happen after the COVID-19 pandemic with the adoption of the new methods of service
delivery for both.
In conclusion, the rationale for this Proof-of Concept study is to see whether an
established pedagogic technique, CVT, which is used to train singers and performers with
healthy voices and restore the voice when not functioning, can be used to treat patients
with MTD and whether it offers advantages to traditional SLT-VT techniques. Many of the
voice problems in performers and patients are due to faulty technique of voice production
and are therefore similar to patients with MTD. In addition, the focus of CVT is not only
to improve the voice and vocal function by reducing unhealthy throat constrictions but
also allowing patients to develop the voice needed for the vocal requirement. Further,
the terms and pedagogic process used in CVT are well defined and the theoretical
framework on which it is built has been extensively investigated. The main questions are
does it offer benefit, and how does it differ, from traditional SLT-VT methods and could
it be a useful additional tool for SLT-VTs in the management of MTD?
