Exercises for Unilateral Vocal Fold Paralysis

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All Licensed Speech Language Pathologists are instructed about various vocal fold disorders in their training as graduate students. I can't confirm that every class in voice disorders delves heavily into one disorder over another, but in most cases vocal fold paralysis is covered at least minimally in most curriculums. In saying that, when the student graduates they may decide upon different employment settings and there are certain professionals and settings that have more opportunities and experiences in with working with voice disordered patients. Usually Speech Language Pathologists (SLPs) that work in clinics, hospitals or other out patient rehabilitation units have more experience working with patients with paralyzed vocal fold conditions. My suggestion is to seek out those facilities in your immediate area and locate a professional who specializes in voice and voice related disorders.

In terms of exercises, my experiences have differed greatly depending on the patient and their specific presenting symptoms. Not all paralysis cases look identical, some more severe, some accompanied by muscle tension in the laryngeal musculature, some paralysis may affect both vocal folds (bilateral VFP) and some may only affect one fold (unilateral VFP). Therefore, it is important to seek an evaluation by a qualified SLP and ENT (ear nose and throat physician) before attempting any of the listed activities.

In saying that, there are typical facilitating approaches that usually are attempted with VFP cases. Some of these techniques were outlined in the website you listed, "Unilateral Vocal Cord Paralysis and Dysphagia" (www.speechpathology.com/askexpert).

Often if a specific therapy technique is not working effectively the focus of therapy and the activities change to suit the patient's needs and goals for therapy. Typically as a therapist the goal would be to improve the overall vocal quality, loudness and maintain appropriate pitch for the patient's age and gender. Usually decreased loudness is the primary concern for most VFP patients. In order to increase loudness it is imperative to improve vocal fold closure and thereby increase the pressure beneath the vocal folds (subglottal pressure). As you are aware this is the main problem, the vocal folds are not coming together at midline in order to build this pressure underneath. Typically, the initial routines are to improve this closure through push/pull and other similar activities that attempt to have the healthy cord move more toward midline and compensate for the immobile cord or to get the immobile cord moving again.

There are also surgical procedures that will physically move the affected cord to midline (medialization techniques) to allow the "healthy" cord to not have to move as far over to get to midline in order to contact the immobile cord. However, this is usually discussed after therapy has not improved the condition. There are also surgical interventions that involve "increasing the size" of the affected cord by injecting a substance such as collagen, Teflon or Radinesse. This effectively makes the affected cord bigger and again eases the movement of the "healthy" cord to make midline closure.

Now back to the exercises of push/pull. This exercise involves pushing or pulling up on a chair or a wall with your hands and trying to forcefully close the vocal folds while pushing/pulling up or out (depending on the activity). The theory is that when people lift objects or push objects there folds naturally close to build pressure to gain force to complete the action. The pulling or pushing usually is for about 1-2 seconds with repetitions of 8x per activity. The therapist and the patient should always be careful that excess muscle strain present in other laryngeal muscles is not occurring as this can impede the movement of the folds and create more problems and ultimate worsen voice quality. It is a delicate balance between strengthening one muscle group in the larynx and making sure tension does not elevate in the surrounding muscles impeding easy voicing.

Other exercises that seem to create this balance are starting with a gentle massage of the laryngeal musculature through manual circumlaryngeal massage (Aronson Technique). This allows decreased muscle tension prior to starting voicing therapies. Also the Lee Silverman Voice Treatment Program (Developed by Lori Ramig) has been used to improve loudness in VFP cases. This approach has a series of exercises with the basic premise of talking "loud" even if your goal is normal loudness. Essentially by attempting to speak louder you are moving the vocal folds closer together thus there is the increased possibility of improved closure and thus increased loudness levels. Other exercises in this approach include flexibility drills (attempting to move from lowest to highest pitch on a glide at various frequencies on a vowel /a/).

Another technique is digital manipulation of the larynx. Essentially the affected cord is physically pushed over to the other mobile cord again to reduce the distance between the immobile and mobile fold. The larynx is moved over with the hand and the hand is eventually removed over time when the patient is used to the positioning of the larynx. Other elements of successful therapies include improving overall patient awareness of respiratory support of voice, appropriate hygiene and vocal care (water intake, etc), vocal fold and upper airway anatomy. Progress in therapy should also be monitored constantly and manipulated to suit the patient's goals in therapy. Facilitating approaches to improving vocal quality should constantly be evaluated by the therapist and the patient.

Bridget A. Russell is an Associate Professor at the State University of New York Fredonia and directs the Speech Production Laboratory in the Youngerman Centers for Communicative Disorders at the University. She has published in the Journal of Speech, Hearing and Language (JSHLR), Speech and Voice Review. She has presented over 70 peer reviewed presentations at national and international conferences on voice and respiratory disorders. Dr. Russell also has served as an editorial consultant for JSHLR, National Science Foundation (NSF) and DelMar Publishing Group. Dr. Russell's research interests include voice disorders in children and adults, professional voice, and respiratory disorders of speech production.