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Vocal and Laryngeal Effects of Voiced Tongue VibrationTechnique According to Performance Time

*Marcia H. Menezes,Andre de Campos Duprat, andHenrique Olival Costa

Sao Paulo, Brazil

Summary: Our objective is to study the vocal and laryngeal effect as well

as the negative signs and sensations related to the voiced tongue vibration

technique (VTVT), regarding the time of performance (from 0 to 7 minutes).

Thirty adults (15 men and 15 women) with no vocal complaints nor laryngeal

disorders were involved. All subjects underwent laryngostroboscopic andauditory perceptual analysis and answered about the existence of

uncomfortable sensations that occurred during the exercise (1, 3, 5, and 7minutes) and postexercise. For the auditory perceptual analysis, the female

group presented better outcomes in the third minute of exercise, whereas

in general the male group showed no modification because of performance

time. Some men presented a significant change in the parameters involved

from the fifth minute on. Men and women showed a gradual increase of

undesirable sensations. It is extremely important that the performance time

of the VTVT is properly prescribed to provide the expected results, without

causing undue injuries to the vocal system. Therefore, we suggest this

technique should be recommended for 3 and 5 minutes for women andmen, respectively.

Key Words: TongueVibrationExerciseVoice rehabilitation.

INTRODUCTION

The use of techniques for improvement of theemission of the voice is prescribed by health profes-sionals worldwide. These techniques are phonatoryexercises that alter the characteristics of the emissionand have as an objective the reach of a balanced andnatural phonation.1 The voiced tongue vibration

Accepted for publication November 7, 2003.

From *Guarulhos University and ENT Department, Santa

Casa de Sao Paulo, Medical school. Sao Paulo, Brazil.

Address correspondence and reprint requests to Marcia H.

Menezes, Rua Prof. Artur Ramos 183, CJ 34, Sao Paulo SP

01454-000, Brazil. E-mail: [email protected]

Journal of Voice, Vol. 19, No. 1, pp. 6170

2005 The Voice Foundation

0892-1997/ $30.00

doi:10.1016/j.jvoice.2003.11.002

61

technique (VTVT) is part of the arsenal of exercises

used with the intent of voice rehabilitation. It in-

volves the elevation of the tip of the tongue toward

the dental alveoli of the superior incisive teeth and

its vibration in the superior and posterior directions

inside the oral cavity, making a trill, like when we

say /r/ as in rat.

Morrison and Rammage2 denominated the voiced

tongue vibration technique as bubbling or tongue

trilling.This technique is accomplished through the eleva-

tion of the tip of the tongue toward the alveoli of

the superior incisors, followied by fast and repeti-

tive movements of sway of the whole body of the

tongue, and caused by the passage in high speed

of the expiratory airflow, in that area, concomitant

to the phonatory emission.
mailto:[email protected]:[email protected]


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MARCIA H. MENEZES ET AL62

TABLE 1. Numerical Distribution of Women According to the Effect of the VTVT

with Respect to Vocal Quality, by Period of Exercise

Exercise execution, by period, in minutes

Vocal quality 01 13 35 57 03 05 07

Increased 2 6 0 0 2 1 0

No change 7 7 9 13 11 8 9

Decreased 6 2 5 2 2 6 6

Total 15 15 15 15 15 15 15

p 0.145 0.145 0.031 0.05 0.05 0.062 0.016

p statistical significance comparing each period with its previous one.

Many studies have demonstrated the efficiencyof this exercise in the rehabilitation of the voice. Thistechnique is considered one of the most effective

methods to increase the amplitude of vibration ofthe vocal fold mucosa and to balance myoelasticand aerodinamic forces.36

The VTVT is advocated by speech and hearingtherapy organizations in Brazil, known by profes-sional voice users such as teachers, actors, sing-ers, and broadcasters, who suggest its practice toone another in an informal way.

At least three groups of muscles are activated bythe VTVT: the oral, the laryngeal, and the thoracicmuscles, to which the central nerve system sendsnerve impulses that result in a complex system of

contractions and relaxations. This complexity con-sumes energy that is provided by the cellular metab-olism. If not well administered, the energy couldvanish with the exaggeration, leading to muscle fa-tigue. Therefore, training programs based on VTVTshould consider their frequency, duration, and inten-sity, because the inappropriate recommendation

TABLE 2. Numerical Distribution of Men According to the Effect of the VTVT

with Respect to Vocal Quality, by Period of Exercise

Exercise execution, by period, in minutesVocal quality 01 13 35 57 03 05 07

Increased 5 4 3 7 3 2 4

No change 6 6 7 6 9 10 9

Decreased 4 5 5 2 3 3 2

Total 15 15 15 15 15 15 15

p 0.500 0.500 0.363 0.090 0.656 0.500 0.344


Journal of Voice, Vol. 19, No. 1, 2005

could result in harmful outcomes, such as overheat-ing and inflammatory reaction.

Studies used to guide speech and hearing thera-

pists commonly assess the efficacy of a vocal tech-nique, its effects on laryngeal mucosa and muscles,and changes in acoustic and perceptual voice fea-tures considered in the pre-exercise and postexer-cise periods.

Because few studies detail the impact of theperformance time of the VTVT over the vocal fold,we decided to study this variable.

The aim of this study was to assess the acousticand laryngostroboscopic changes on the voice andlarynx as well as the unpleasant sensations noticed bythe subjects submitted to the VTVT in a total

7-minute performance time.

MATERIAL AND METHOD

This study comprised 30 subjects, all speech ther-apy students, 15 men and 15 women, ranging from


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VOICED TONGUE VIBRATION TECHNIQUE 63


with Respect to Voice Projection, by Period of Exercise


Voice projection 01 13 35 57 03 05 07

Increased 1 11 1 1 8 6 4

No change 11 3 10 8 6 8 7

Decreased 3 1 4 6 1 1 4

Total 15 15 15 15 15 15 15

p 0.05 0.003 0.05 0.062 0.020 0.062 0.637


20 to 42 years old. None had a history of dysphonia,

and all were capable of performing the VTVT with-

out effort.Subjects were instructed by the speech therapist

to do the exercise in their habitual and comfortablepitch and loudness. As they all have some experi-

ence in the matter, the explanation was facilitated.

All subjects received a previous preparation for theexercise, rehearsing it in such a way that they reach

a uniform and homogeneous result. A model of the

technique was shown by the speech therapist, and

the study started only after adequacy was

achieved. The subjects were asked not to move the

head or the jaw forward, or contract the shoulder and

suprahyoid muscles. The subjects were also asked tokeep pitch, loudness, and rhythm steady during the

exercises. These parameters were monitored by

the speech therapist in a way that was not distracting.

The study was divided into four steps to be easily

understood, as follows:


with Respect to Voice Projection, by Period of Exercise

Exercise execution, by period, in minutesVoice projection 01 13 35 57 03 05 07

Increased 6 3 3 4 4 5 6

No change 6 8 7 8 8 5 6

Decreased 3 4 5 3 3 5 3

Total 15 15 15 15 15 15 15

p 0.254 0.500 0.363 0.500 0.500 0.623 0.254



First step1. Pre-exercise voice recording2. Pre-exercise stroboscopic evaluation3. Voiced tongue vibration1-minute perfor-

mance time

Steps 241. Voice recording2. Consult about negative sensations3. Stroboscopic evaluation4. Voiced tongue vibration2-minute perfor-

mance time

All steps were perfomed in the same way, excep-ting the time of exercise: 1 minute in step 1, 2

minutes in step 2 (total performance time: 3 mi-nutes), 2 minutes in step 3 (total performance time:5 minutes), and 2 minutes in step 4 (total perfor-mance time: 7 minutes). After everyperiod of exercise,each subject had his or her larynx stroboscopicallyevaluated.


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with Respect to Voice Sustaining, by Period of Exercise


Voice sustaining 01 13 35 57 03 05 07

Increased 2 3 4 1 0 2 0

No change 8 9 8 11 12 9 7

Decreased 5 3 3 3 3 4 8

Total 15 15 15 15 15 15 15

p 0.227 0.656 0.500 0.05 0.05 0.344 0.004


There were no pauses between the steps, and thesubjects remained seated the entire time.

After undergoing the VTVT, the participants wereasked about any negative sensations during or just

after the performance. A closed questionnaire wasnot offered, and the subjects were free to informus of any complaint considered by them related tothe exercise. We also looked for subjects with throatclearing or performance failure, which were consid-ered harmful signs.

If the subject complained of unbearable discom-fort because of the laryngeal examination, she or hewould be immediately removed from the evaluationsample. No subject mentioned any discomfort.

The voice recording was made with a digitaldevice Sony 33 connected to a Sony microphoneECM 909 (Sony Corporation of America, New York,NY). A 3-inch distance between the speaker and thedevice was observed, and the microphone was keptat a lateral angle (45) to the mouth opening. Thedisk used was a minidisk Sony, 70 minutes.

The voice material consisted of the emission ofa sustained /a/, which should be done as naturally as


with Respect to Voice Sustaining, by Period of Exercise

Exercise execution, by period, in minutesVoice sustaining 01 13 35 57 03 05 07

Increased 1 4 3 7 0 2 2

No change 7 8 8 5 8 2 8

Decreased 7 3 4 3 7 11 5

Total 15 15 15 15 15 15 15

p 0.035 0.500 0.500 0.172 0.008 0.011 0.227



possible according to each speakers usual voice

frequency and intensity.

With respect to the auditory perceptual analysis,

the following parameters were assessed, as stated

by Behlau and Pontes4:voice quality, voice projec-tion, and voice sustaining.

According to Behlau and Pontes4:

1. Vocal quality is the group of characteristics

that identify a human voice, mainly noticing

the presence or absence of vocal noise, as

breathness, roughness, and harshness. It also

establishes if a voice seems astenic or tense.

The voice quality was considered normal if no

roughtness, harshness, strain, breathness, or asthenia

was heard.A four-level (0 to 3) scale was used to classify the

parameters evaluated in terms of level of alteration:

none (0), mild (1), moderate (2), and severe (3).

2. Vocal projection determines if there is a larger

or smaller amplification of the sound in the

resonance areas and in the environment. It has


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with Respect to Glottal Closure, by Period of Exercise


Glottal closure 01 13 35 57 03 05 07

Increased 3 2 1 1 5 3 4

No change 12 13 11 14 10 12 11

Decreased 0 0 3 0 0 0 0

Total 15 15 15 15 15 15 15

p 0.05 0.05 0.05 0.05 0.031 0.05 0.05


a direct relationship with breathing, subglotticpressure, and mouth opening.

3. Vocal sustentation is the capacity of the subjectto produce a stable emission, maintaining the

frequency, intensity, and continuity.

A videolaryngostroboscopy was performedwith a rigid 70 telescope. No topical anesthetic wasused. The subjects underwent a conventional evalua-tion, which involved deep mouth breathing and ef-fortless emission of sustained /e/ and /i/ vowels.The frequency and intensity should be as naturaland effortless as possible.

The following laryngeal imaging parameters,which belong tothe laryngeal imaging analysis ac-

cording to Woo,7

were considered:

vocal fold contact0total contact1presence of triangular chink2presence of middle posterior triangularchink


with Respect to Glottal Closure, by Period of Exercise

Exercise execution, by period, in minutesGlottal closure 01 13 35 57 03 05 07

Increased 1 0 0 1 1 0 2

No change 14 15 15 14 14 15 13

Decreased 0 0 0 0 0 0 0

Total 15 15 15 15 15 15 15

p 0.05 0.05 0.05 0.05 0.05 0.05 0.05



constriction of laryngeal vestibule (medial oranteroposterior)

0no constriction1constriction

amplitude of vocal fold vibration0normal1limited2increased3extremely increased

symmetry of vocal fold vibration0symmetric1asymmetric

vocal fold opening/closing duration0duration of vocal fold opening equal toduration of vocal fold closing1duration of vocal fold opening shorter thanduration of vocal fold closing2duration of vocal fold opening longer thanduration of vocal fold closing


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with Respect to the Amplitude of Mucosal Vibration, by Period of Exercise


Mucosal vibration 01 13 35 57 03 05 07

Increased 2 2 0 0 3 2 1

No change 10 12 12 13 9 8 9

Decreased 3 1 3 2 3 5 5

Total 11 11 11 11 11 11 11

p 0.05 0.05 0.05 0.05 0.656 0.227 0.109


presence of mucusamount of secretion onvocal folds during phonation

0not present1mild

2moderateA form was filled for each subject with the results

of the previously related analysis.The results concerning the acoustic and laryngeal

aspects were compared in an attempt to identifychanges related to performance time and whetherthese changes were beneficial. A binomial distribu-tion for random variables was implemented in away of establishing whether each performance timeachieved similar results compared with each other.The test was used to ascertain the significance ofthe change if there was any (levels of significance:

p 0.05 and p 0.10).

RESULTS

Auditory perceptual analysis

Vocal quality

Women: There was a significant decrease betweenthe following periods: 35, 05, and 07 (Table 1).


with Respect to the Amplitude of Mucosal Vibration, by Period of Exercise

Exercise execution, by period, in minutesMucosal vibration 01 13 35 57 03 05 07

Increased 3 4 2 0 7 10 11

No change 10 11 11 15 6 3 2

Decreased 2 0 2 0 2 2 2

Total 15 15 15 15 15 15 15

p 0.500 0.05 0.05 0.05 0.090 0.019* 0.019



Males: There was a significant increase between5 and 7. Few changes were related to the wholeperiod (Table 2).

Voice projection

Women: There was a significant increase from 1to 3and a significant decrease from 5 to 7. Com-pared with the baseline, there was an increase up tothe 3 and a decrease from this moment on. Afterthe fifth minute, both increasing and decreasing wereequivalent (Table 3).

Men: There were no significant changes (Table 4).

Voice sustaining

Women: There were no significant changes be-tween each evaluated period. Regarding the wholeperiod (up to 7 minutes), there was a significantdecrease (Table 5).

Men: There was a significant decrease from 0to1, 0 to 3, and 0 to 5 periods. There were nosignificant changes during the whole period (07)(Table 6).


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with Respect to the Presence of Mucus, by Period of Exercise


Presence of Mucus 01 13 35 57 03 05 07

Increased 1 0 3 3 1 1 2

No change 9 13 11 9 7 8 7

Decreased 5 2 1 3 7 6 6

Total 15 15 15 15 15 15 15

p 0.109 0.05 0.05 0.656 0.035 0.062 0.145


Laryngeal imaging evaluation

Glottal closure

Women: There were no statistically significantchanges from one period to another; there was a

significantincreaseduringthe03period;therewereno significant changes concerning the whole period(Table 7).

Men: There were no significant changes relatedto the whole period (Table 8).

Amplitude of mucosal vibration

Women: There werenosignificant changes relatedto the whole period (Table 9).

Men: There were no significant changes betweenthe 01, 13, 35, and 57 periods. Concerningthe pre-exercise moment, there was a significantincrease from the third minute on (between the 03, 05, and 07 periods) (Table 10).

Presence of mucus

Women: There were no significant changes be-tween the related periods. There was a subtle but


with Respect to the Presence of Mucus, by Period of Exercise

Exercise execution, by period, in minutesPresence of Mucus 01 13 35 57 03 05 07

Increased 4 1 1 2 3 3 3

No change 8 13 13 11 10 10 10

Decreased 3 1 1 2 2 2 2

Total 15 15 15 15 15 15 15

p 0.500 0.05 0.05 0.05 0.500 0.500 0.500



significant decrease up to 3, leading to a slight risein the decrease in the whole period(Table 11).

Men: There were no significant changes duringthe whole period (Table 12).

There were no significant changes during thewhole period in females and males with regard tothe symmetry of vocal folds vibration, the relationbetween the duration of vocal fold opening and vocalfold closing, and the supraglottic medial constrictionand the supraglottic anteroposterior constriction.

Unpleasant sensations and signs

Statistical analysis was not performed on theseparameters, but unpleasant sensations reported bythe subjects and laryngoscopic signs of tissueinjury like hyperemia and mucus were likely to in-

crease according to the performance time in menand women (Figure 1andTables 13 and 14).

DISCUSSION

Patients with dysphonia must comply with vocalexercises, which are commonly recommended by


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FIGURE 1. Distribution of men and unpleasant symptoms by performance time.

otolaryngologists and speech therapists. To do it

properly, these professionals should choose carefully

the best exercise according to the case and recom-

mend the exercise that would lead to beneficial

results to the subject. Besides that, they should

guide the patient in the better way of doing the

exercise and determine the time and frequency

the patient should do it.This study aimed to show the results of laryn-

geal and auditory perceptual analysis related to the

time of performance of voiced tongue vibration

technique.

Concerning the results of this study, the voiced

tongue vibration exercise can be considered a way to

provide a beneficial effect in the auditory perceptual

analysis parameters when the technique is prescribed

for up to 3 minutes for women. These results are

similar to the literature outcomes. However, if per-

formance time is longer, this study indicates negativeeffects mayoccur. Withregard to men, thesame vocal

technique causes slight changes from the 3-minute

performance time on. Therefore, when there are bad

effects in men, they appear later than they do in

women.

With respect to laryngeal imaging evaluation,

only the glottal closure, the amplitude of mucosal


vibration, and the presence of mucus showed statisti-

cally significant outcomes when compared with the

pre-exercise examination.

Glottal closure in women was associated with a

significant increase during the 03 minute period

and a nonsignificant decrease during the 35 minute

one. There were no significant changes in glottal

closure in men, because most of the subjects showedcomplete glottal closure in the pre-exercise and

whole exercise periods.

The outcomes of the amplitude of mucosal vibra-

tion were statistically significant in men during the

whole period (most of the subjects showed better

outcomes during the 07 period). There were no

significant changes in women according to perfor-

mance time.

There was a statistically significant increase in

the presence of mucus in women from the 03 to the

05 minute period. The same number of subjectshad this bad effect during the 07 period (06), al-

though with no statistic difference. Regarding men,

there were no significant changes during the

whole period.

The presence of mucus may be related to muscle

activation during phonation. After this activation

ends, elastic energy is replaced with thermic energy,8


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TABLE 13. Distribution of Women Who Felt

Any Kind of Negative Sensation During the Performance

Considered by Them as Related to the VTVT

Time/min

Negative Sensations 0 1 3 5 7 Total

Dry throat 3 3 5 3 6 20

Dry mouth 5 6 8 8 8 35

Throats foreign body 4 6 4 4 5 23

sensation

Tongues paresthesia 2 5 4 3 14

Odinofagia/pain in the 1 3 4

throat

Glossodynia 1 5 2 8

Difficulty to do the 6 9 7 6 28

exercise

Throat clearing 3 1 1 1 6

Total 15 23 33 26 27

which overheats the neck area. The production ofthe mucus may be related to dissipation of heat.9

Althoughthebiomechanicalresponsetothevoicedtongue vibration exercise may not be the same ineach subject, because the vocal folds and the airflowoscillate in a nonlinear way,10 significant data, espe-cially related to women, is concordant to the findingsof the auditory perceptual analysis. Data and thefindings of the auditory perceptual analysis are likelyto increase up to the third minute and to decrease

from this period on.

FIGURE 2. Distribution of women and unpleasant symptoms by performance time.


TABLE 14. Distribution of Men Who

Felt Any Kind of Negative Sensation During the

Performance Considered by Them as Related to the VTVT

Time/min

Negative Sensations 0 1 3 5 7 Total

Dry throat 2 4 6 5 4 21

Dry mouth 3 4 5 8 8 28

Throats foreign body 3 4 4 4 7 22

sensation

Tongues paresthesia 1 3 4 2 10

Odinofagia/pain in the

throat

Glossodynia

Difficulty to do the 6 6 7 5 24

exercise

Throat clearing 1 2 4 5 2 14

Total 9 21 28 35 28

Some of the effects caused by the performancetime, such as worsening of voice quality, sustaining,and projection, as well as sore throat and throatclearing are considered symptoms of vocal fatigue.11

Women and men presented an increase in un-pleasant sensations and failure in the exercise perfor-mance as time passed. Although statistical tests didnot exist to assess these results, they were clearlypresent and were more frequent in women than inmen (Figure 2). Mens glottal and muscular features

probably make vocal fatigue less likely to occur.
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