Immediate Effects of the Finnish Resonance Tube

Method on Behavioral Dysphonia

*Sabrina Mazzer Paes, *,Fabiana Zambon, *Rosiane Yamasaki, Susanna Simberg, and *Mara Behlau, *yS~ao
Paulo, Brazil, and zTurku, Finland
Summary: Objective. To investigate the immediate effects of the Finnish resonance tube method for teachers with
behavioral dysphonia.
Methods. Twenty-ve female teachers (m 39.9 years of age) with at least a 5-year history of dysphonia were in-
cluded. Additional inclusion criteria were the diagnosis of chronic behavioral dysphonia with an indication for speech
therapy and the absence of any prior speech therapy. Subjects produced three sets of 10 tokens of sustained phonation
with a 1-minute rest interval between tokens into a 27-cm glass tube immersed in at least 2 cm of water. Voice samples
were recorded before and after these sets. The effects of these exercises were evaluated by self-assessment, auditory
perceptual analysis, and acoustic evaluation involving extraction of fundamental frequency and visual spectrographic
analysis.
Results. Sixty-eight percent of the teachers reported increased phonatory comfort and 52% reported improved voice
quality after performing the exercises. Perceptual analysis indicated improved voice quality in the samples of counting
numbers, conrmed by decreased instability, subharmonics, noise in high frequencies, and the tendency for reduced low
frequency noise on spectrographic evaluation. Additionally, mean fundamental frequency decreased.
Conclusion. The Finnish resonance tube method increased phonatory comfort and vocal changes suggestive dimin-
ished hyperfunction.
Key Words: VoiceVoice disordersDysphoniaVoice trainingTeachers.
INTRODUCTION
The Finnish resonance tube method involves vocalization in
a glass tube, typically with the free end of the tube immersed
in water and is thought to be a variant of semi-occluded vocal
tract (SOVT) exercises.
1,2
Various SOVT exercises have
received increased interest in recent years. These exercises
are thought to expand the area of the vocal tract, while glottal
closure and airow are maintained, thereby reducing the
vibration dose and collision stress in the vocal folds. The
primary indication for these exercises is individuals with
extensive daily voice use to facilitate more efcient and
economical voice production.
3,4
Titze
4
comprehensively de-
scribed the rationale for SOVT exercises previously.
Resonance tubes have been used in voice therapy in Finland
for more than 40 years.
2,57
Several variables may dictate the
characteristics of these tubes; for example, shorter and
narrower tubes are typically used for children and the depth
of immersion of the tube is varied based on the diagnosis or
pathology.
5
Simberg and Laine
2
described the various charac-
teristics of tubes. In patients with behavioral dysphonia, the
tube must be kept near the surface of water
8
to facilitate a
sensation of vibration typically reported to be relaxing.
2
Exercises that promote increased phonatory comfort, re-
duced tension, and vocal resistance are essential for patients
with hyperfunctional dysphonia, particularly in teachers who
experience more chronic dysphonia.
9
These professionals typ-
ically teach under suboptimal conditions for many hours daily,
contributing to the high prevalence of voice disorders
10
and fre-
quently report vocal symptoms such as hoarseness, discomfort,
and increased effort to speak.
1115
Multiple variables must be considered in the diagnosis and
treatment of patients with voice disorders. Specically, the
evaluation of patients with dysphonia typically includes patient
complaints, history of the vocal problem, laryngeal exam-
ination, auditory perceptual assessment of voice quality, acous-
tic and aerodynamic analyses, and patient self-assessment of
the impact of the voice problem.
16,17
Cumulatively, these
parameters must be considered to properly assess a patient
and also to evaluate the effect of a selected treatment.
18,19
However, particularly when considering the immediate
effect(s) of a therapy task, it is often unclear which parameters
are most sensitive to highlighting potentially subtle shifts in
phonatory physiology or patient symptoms. Visual imaging of
the larynx can reveal changes in muscular adjustments
2022
;
however, the degree of changes may be quite small when
considering the effect of a therapy single session and not the
result of a complete rehabilitation program.
23,24
Moreover,
although some studies have included repeated laryngeal
evaluations,
22,25
practical considerations related to the
inherently invasive nature of the examination and potential for
topical anesthetic to interfere with laryngeal physiology.
Auditory, acoustic, and self-assessment approaches avoid these
confounds and are regularly performed clinically. The correla-
tion between these assessments varies among different studies
and must be considered as complementary and not exclusive
evaluative approaches.
26,27
The contemporary literature suggests favorable immediate
effects of SOVT exercises in nondysphonic participants, as
Accepted for publication April 17, 2013.
Portions of this study were presented at the 19th Congresso Brasileiro de Fonoaudiologia/
8th Congresso Internacional de Fonoaudiologia; October 30 to November 2, 2011; S~ao
Paulo, Brazil, and at The Occupational Voice Symposium; March 28-29, 2011; London, UK.
From the *Centro de Estudos da Voz - CEV, S~ao Paulo, Brazil; ySindicato dos Profes-
sores de S~ao Paulo - SINPROSP, SLP Service, CEV- Specialization Program in Voice, S~ao
Paulo, Brazil; and the zDepartment of Psychology and Logopedics,

Abo Akademi Univer-

sity, Turku, Finland.
Address correspondence and reprint requests to Sabrina Mazzer Paes, Rua Machado
Bittencourt, 361 S~ao Paulo SP 04044-001, Brazil. E-mail: sabrinapaes@outlook.com
Journal of Voice, Vol. 27, No. 6, pp. 717-722
0892-1997/$36.00
2013 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2013.04.007
determined by improved vocal quality or phonatory comfort.
These studies used tongue trills, bilabial fricatives, nasal
sounds,
28
nger kazoo, and straws,
29
as well as Finnish reso-
nance tubes with the free end unimpeded.
7
However, there is
a paucity of scientic data on the immediate effects of the Finn-
ish resonance tube on voice production in dysphonic subjects.
Therefore, the purpose of the present study was to investigate
the immediate effects of the Finnish resonance tube method
in teachers with behavioral dysphonia.
METHODS
The present study was approved by the Ethics Committee of
CEV(2317/09) and all participants provided Informed Consent.
All subjects were recruited via the Teachers Union Voice Pro-
gramand were invited to participate in the study during their rst
session of therapy, during the second, and third quarters of 2010.
Twenty-ve female teachers were included (m 39.9 years,
standard deviation [SD] 8.8 years; range 2553 years); all
worked full time in either public or private schools (the only op-
portunity for them to receive treatment was at the end of the
day), had voice complaints, and a history of dysphonia for
over 5 years. All subjects were diagnosed with chronic behav-
ioral dysphonia by an otolaryngologist and a speech-language
pathologist (SLP) and presented with altered vocal quality via
auditory perceptual analysis. Subjects with normal voices
were excluded but were offered vocal training. Voice therapy
was indicated as the primary treatment for all subjects included
in the present study. Exclusion criteria were prior voice therapy
and upper respiratory infection on the day of data collection.
As a component of the study, each teacher received instruc-
tion regarding the tasks; specically, they were oriented to the
tube (27 cm, ie, the average size for adults)
1,2,7
immersed in
up to 2 cm of water.
8
A mark was made on the tube to attempt
to consistently maintain the appropriate depth of immersion.
Subjects performed three sets of 10 repetitions for as long as
phonation remained comfortable, with a 1-minute rest interval
between repetitions. Instructions were given verbally and the
participants were advised to perform the task without tension,
in their habitual and comfortable pitch. Loudness and subject
posture were monitored by the SLP. Data collection was initi-
ated after each subject demonstrated prociency in the task.
Samples of sustained emission, vowel , and counting
110 were recorded directly using FonoView-2.0 (CTS Infor-
matica, Brazil) with a unidirectional microphone headset (Kar-
sect HT-2; Karsect, Brazil), at response 6012.1 kHz,
positioned at 45

and 5 cm away from the mouth and connected

to an external sound card (Andrea PureAudio USB; Andrea
Electronics, USA), 44.1 kHz rate recording. Each recording
was individually calibrated to the software requirements. No
external feedback regarding vocal intensity was provided to
the subjects. Recordings were made in a quiet environment,
in the same room, before and after exercise. Subjects were in-
structed to produce the voice samples as naturally as possible,
according to each speakers typical voice frequency and
intensity.
To quantify vocal alterations before the exercises, an SLP
specialized in voice performed auditory perceptual analysis
via a visual analog scale (VAS) of 100 mm, in which 0 (zero)
represents no vocal deviation and 100 represents maximum
vocal deviation focusing on the overall degree of vocal de-
viation. No samples were excluded at this stage and the mean
overall degree of deviation was 61.6 mm (SD 12; range
3780 mm), consistent with moderate dysphonia.
3033
The immediate effects of the resonance tube method were
evaluated via three perspectives: self-assessment, auditory per-
ceptual assessment, and acoustic analyses.
For self-assessment, teachers were asked about their percep-
tion of phonatory comfort and voice quality immediately after
the recording of postexercise speech samples: Please, focus on
vocal tract comfort and indicate if you feel equal, better or
worse than before the exercise and subsequently, Please,
now consider your voice and evaluate if you believe the quality
is equal, better or worse than before performing the exercise.
Subjects were not allowed to consult their previous recordings.
For auditory perceptual analysis, three SLPs specialized in
voice, all with similar basic educational background and
more than 10 years of clinical experience, listened to the voice
samples of sustained vowels and counting, pre- and postexer-
cise, edited in pairs in random order; SLPs were blinded to
whether samples were from pre- or postexercises, via VoxMe-
tria-4.5 (CTS Informatica). The samples were analyzed in the
same room, via loudspeakers, individually. Raters compared
the overall degree of vocal deviation between the pre- and post-
exercise samples judging if they were similar or if one sample
was better than the other. In this preliminary study, only the
overall degree of dysphonia was addressed and specic param-
eters such as roughness, breathiness, or strain were not consid-
ered individually. All samples were played only once, except
for 10 (40%) repeats selected at random to examine reliability.
Only the data fromthe most reliable rater were considered (80%
of intrarater reliability for sustained phonation and 90% for
counting).
For acoustic analysis, the mean fundamental frequency and
spectrographic images of sustained vowels were extracted by
VoxMetria (4.5; CTS Informatica). The rst second of the sus-
tained vowels was eliminated to remove the voice onset and the
three subsequent seconds were analyzed. This was done to
avoid offering any additional information regarding the condi-
tion (pre- or postexercise) that could interfere with the raters
evaluation; an aberrant voice onset could induce the listeners
to evaluate the sample as a pre-exercise condition. Spectro-
graphic images were transformed to black and white, paired
pre- and postexercise, in random order, and inserted into a slide
show program (PowerPoint 2007; Microsoft Ofce) for visual
assessment. This analysis was performed by three SLPs special-
ized in voice, blind to the sample condition; these SLPs judging
the samples did not participate in the auditory perceptual anal-
ysis and used a 100-mm VAS. The following parameters were
assessed visually: instability of tracing, subharmonics, noise
at high frequencies (above 4 kHz), noise at lowfrequencies (be-
low 2 kHz), and series of harmonics. Raters were also in-
structed to note the presence or absence of frequency and
phonatory breaks.
34
All slides were shown once, except 10
(40%) to allow for examination of intrarater reliability. Only
Journal of Voice, Vol. 27, No. 6, 2013 718
data from the most reliable rater were considered (80% of intra-
rater reliability).
In addition, analysis of the number of parameters that im-
proved following exercise was performed to gain insight into
the cumulative effects of these exercises. Eleven total parame-
ters were included in the present study.
Data was tabulated and analyzed statistically by equality of
two proportions test and paired Student t test, with a signicance
level of 5%.
RESULTS
Self-assessment
Self-assessment after performing the resonance tube exer-
cises showed that most of the subjects (68%) reported im-
proved phonatory comfort, whereas six (24%, P 0.002)
reported no change in comfort and two (8%, P 0.001) re-
ported less phonatory comfort than before performing the ex-
ercises (Figure 1). Regarding voice quality (Figure 2), 88%
of the participants reported that their voice improved or
did not notice any difference after exercise performance
(52% and 36%, respectively; P 0.254); only 12% reported
worse voice (better vs worse: P 0.002 and equal vs worse:
P 0.047).
Auditory perceptual analysis
Regarding auditory perceptual analysis of counting (Figure 3),
60% of subjects were rated to have improved vocal quality after
exercise (better vs equal: P 0.023 and better vs worse:
P < 0.001); 40% were considered equal or worse (28% and
12%, respectively, P 0.157). No change was observed for sus-
tained vowels (Figure 4).
Better
17 (68%)
Worse
2 (8%)
Equal
6 (24%)
p<0.001*
p=0.002*
p=0.123
FIGURE 1. Values of the self-assessment to phonatory comfort.
*Signicance.
Better
13 (52%)
Worse
3 (12%)
Equal
9 (36%)
p=0.047*
p=0.254
p=0.002*
FIGURE 2. Values of the self-assessment to voice quality.
*Signicance.
Better
15 (60%)
Worse
3 (12%)
Equal
7 (28%)
p<0.001*
p=0.023*
p=0.157
FIGURE 3. Values of the auditory perceptual analysis of counting.
*Signicance.
Better
10 (40%)
Worse
7 (28%)
Equal
8 (32%)
p=0.758
p=0.556
p=0.370
FIGURE 4. Values of the auditory perceptual analysis of vowel.
Sabrina Mazzer Paes, et al Finnish Resonance Tube Method on Behavioral Dysphonia 719
Acoustic analysis
Spectrographic analysis (Table 1) detected reduced instability
(36.122.1, P 0.005), subharmonics (16.42.4, P 0.003),
and noise at high frequencies (19.013.3, P 0.041), as well
as signicant tendency to reduce noise at low frequencies
(15.79.0, P 0.057).
Frequency breaks were observed in a minority of samples an-
alyzed (32% pre-exercise and 24% postexercise; P 0.529)
and there were no phonatory breaks in any samples, pre- and
postexercise. The mean fundamental frequency (Table 1) re-
duced from 184.8 to 180.9 Hz (P 0.043).
Analysis of the amount of vocal parameters
Across all subjects, an average of 4.4 parameters improved im-
mediately postexercise (SD 1.9), with a range from one to
eight parameters (Table 2). Furthermore, 12 of the 25 subjects
(48%) improved in three perspectives of analysis (self-assess-
ment, auditory perceptual assessment, and acoustic analyses),
10 subjects (40%) improved in at least two perspectives, and
three subjects (12%) presented with improvement in only one
perspective.
DISCUSSION
The three methods of analysis used in the present study suggest
immediate positive effects on associated with Finnish reso-
nance tube exercises.
Self-assessment showed that most of the teachers reported
more comfortable voice, which is extremely important because
these professionals typically present with increased occurrence
of vocal problems, such as discomfort and increased effort.
1115
Because this study did not have a control group, we cannot
ensure that present ndings are related to the exercise or due
to a placebo effect. There is also a risk that subjects sought to
please the research team by reporting good results. On the
other hand, these ndings were recent corroborated via the
immediate effects of other SOVT exercises, such as bilabial
fricative exercises, vibratory tasks, nasal sounds,
28
nger
kazoo, and straw phonation.
4
Patients with hyperfunctional
dysphonia generally present with increased tension of the laryn-
geal muscles and reduced anterior-posterior laryngeal dimen-
sions.
35
Increased phonatory comfort reported following
SOVT tasks was hypothesized to be related to changes in the
vocal tract promoted by these exercises, such as enlargement
of the oral and oropharyngeal cavities.
36
Consistent with previ-
ous work, we hypothesized that few subjects may report nega-
tive effects after resonance tube exercise
2
; this hypothesis was
conrmed in the present study (two subjects reported less pho-
natory comfort after exercise).
Regarding self-assessment of voice quality, most of the
teachers reported improved voice quality or did not notice
any difference after exercise. The fact that some teachers did
not notice any vocal changes postexercise may be related to dif-
culty in identifying subtle changes in this population.
37,38
One
potential explanation for this phenomenon is related to the
chronicity of their dysphonia; they adapt to the situation via
unfavorable vocal manipulations, increasing vocal intensity
and effort.
38,39
Teachers frequently seek professional help
when dysphonia is well-established, moderate in severity, and
increasingly impacting their capacity to work.
40
This seems
to be the case in this study; subjects presented with an overall
degree of vocal deviation corresponding to a moderate dyspho-
nia (61.6).
31,32
Auditory perceptual analysis showed positive effects of the
exercises in the samples of counting numbers (ie, most voices
were considered better postexercise), which did not occur for
sustained vowels. This discordance may be related to counting
being a more natural speech sample offering inherently more
vocal characteristics for analysis. Alterations in vocal charac-
teristics such as pitch and loudness variations are critical for
the assessment of voice function and these variations are not
common during sustained phonation.
41
It would be interesting
to obtain information regarding specic vocal parameters, par-
ticularly roughness, breathiness, and tense vocal quality
42
;
however, our primary interest was to verify the overall impact
and not to quantify specic parameters.
TABLE 1.
Values of Acoustic Parameters Obtained Pre and Postexercise
Statistic
Instability Subharmonic
Noise at High
Frequencies
Noise at Low
Frequencies
Harmonic
Series
Fundamental
Frequency
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Mean 36.1 22.1 16.4 2.4 19.0 13.3 36.1 22.1 15.7 9.0 184.8 180.9
SD 17.6 20.9 22.4 7.4 24.1 20.4 17.6 20.9 19.5 13.8 24.6 24.2
P value 0.005* 0.003* 0.041* 0.057
y
0.283 0.043*
* Signicance.
y
Tendency.
TABLE 2.
Descriptive Analysis of Number of Parameters That
Improved Postexercise (Range of 11)
Parameters
Mean 4.4
SD 1.9
Minimum 1
Maximum 8
Journal of Voice, Vol. 27, No. 6, 2013 720
Spectrographic analysis of sustained vowels revealed favor-
able changes in almost all parameters. Reduced instability,
subharmonic and noise at high frequencies, and signicant ten-
dency for noise reduction in low frequencies were observed,
likely resulting froma greater control of airowrequired to per-
form this exercise.
6
Because we used 3-second productions for
spectrographic analyses, we could not evaluate the impact of
the exercise on vocal onset and offset. In fact, the onset and off-
set were excluded from analyses to avoid providing any percep-
tual context for this analysis. Reduced mean fundamental
frequency was also observed, consistent with previous investi-
gation regarding SOVT exercises, such as straw and nger ka-
zoo.
29
These data must be considered with caution; a shift of
4 Hz likely has no clinical impact and it can be only a physiolog-
ical change due to repetition.
43,44
It is important to highlight that in all the previous studies of
SOVT exercises, the participants did not have dysphonia.
Therefore, it is tenuous to generalize and compare results to
the dysphonic population.
A nal comment must be made regarding the effect of the
exercise considering the three perspectives of analysis (self-
assessment, auditory perceptual, and acoustic analysis). Re-
garding the number of voice parameters that improved in this
study (Table 2), the average of 4.4 of 11 parameters analyzed
represents an improvement of 40% on the selected parameters,
which is a considerable high value for an immediate effect.
In addition, all participants presented with some difference
after performing the vocal exercise. This observation reinforces
the fact that multidimensional analysis is imperative
19
be-
cause it is not clear which characteristics of the patients
(laryngeal conguration, vocal habits, duration of symptoms,
and type of personality) will play a role in producing self-
assessment, perceptual, or acoustic changes. The subject popu-
lation in the present study was relatively homogeneous: female
teachers, behavioral dysphonia, chronic voice problems (for
more than 5 years), full day teachers, and no history of treat-
ment. However, we did not consider the level of teaching and
discipline, size of class and room acoustics among other poten-
tial confounds.
Regardless, the immediate effects found in this study are fa-
vorable and should be discussed with patients, promoting in-
creased credibility of treatment and subsequent increased
motivation and adherence to therapy. Patient opinion regarding
the effects of the prescribed exercise is of fundamental impor-
tance and must be considered.
45,46
Study limitations
The teachers participated in this study after a full workday.
Time-of-day confound onvocal performance in vocally healthy,
untrained women has been investigated
47
and there did not
seem to be any difference between morning and evening. How-
ever, teachers often report discomfort and increased effort to
speak after a workday.
9,12,13,15
Therefore, further studies must
account for the potential time-of-day effect on voice, in partic-
ular dysphonic groups. Specically, the immediate effects of
the Finnish resonance tube exercises should be investigated dur-
ing the morning, before a work day.
In addition, although this exercise may be useful technique
for the dysphonic patient as increased phonatory comfort, fu-
ture research should address the effects of a complete program
using this exercise long-term, with either a nontreatment con-
trol group or a placebo treatment group or when having the
same subjects recorded twice or using different sound levels.
It would also be of interest to evaluate if the same effects (pos-
itive subjective, auditory perceptual, and visual evaluations)
could be obtained by alternative means, comparing therapeutic
approaches.
CONCLUSIONS
The Finnish resonance tube method produced vocal changes
froma hyperfunctional phonation to a more balanced phonatory
state. The participants voice quality improved and increased in
stability with less subharmonics and less noise at high frequen-
cies. Decreased fundamental frequency was also observed.
Subjects in the present study identied positive effects such
as improvement in voice quality and phonatory comfort. At
least one parameter of voice improved after the proposed exer-
cise. Multidimensional analysis helped to highlight the effects
of this program.
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