The Effect of Stretch-and-Flow Voice Therapy

on Measures of Vocal Function and Handicap

*Christopher R. Watts, *Shelby S. Diviney, Amy Hamilton, Laura Toles, Lesley Childs, and Ted Mau, *Fort Worth
and yDallas, Texas

Summary: Objectives. To investigate the efficacy of stretch-and-flow voice therapy as a primary physiological
treatment for patients with hyperfunctional voice disorders.
Study Design. Prospective case series.
Methods. Participants with a diagnosis of primary muscle tension dysphonia or phonotraumatic lesions due to hyperfunctional vocal behaviors were included. Participants received stretch-and-flow voice therapy structured once weekly
for 6 weeks. Outcome variables consisted of two physiologic measures (s/z ratio and maximum phonation time), an
acoustic measure (cepstral peak prominence [CPP]), and a measure of vocal handicap (voice handicap index [VHI]).
All measures were obtained at baseline before treatment and within 2 weeks posttreatment.
Results. The s/z ratio, maximum phonation time, sentence CPP, and VHI showed statistically significant (P < 0.05)
improvement through therapy. Effect sizes reflecting the magnitude of change were large for s/z ratio and VHI (d 1.25
and 1.96 respectively), and moderate for maximum phonation time and sentence CPP (d 0.79 and 0.74, respectively).
Conclusions. This study provides supporting evidence for preliminary efficacy of stretch-and-flow voice therapy in a
small sample of patients. The treatment effect was large or moderate for multiple outcome measures. The data provide
justification for larger, controlled clinical trials on the application of stretch-and-flow voice therapy in the treatment of
hyperfunctional voice disorders.
Key Words: DysphoniaVoice therapyFlow phonationStretch-and-flowSpeech therapyVocal handicap.
INTRODUCTION
Among the etiologies underlying voice disorders, hyperfunctional classifications such as muscle tension dysphonia (primary or secondary) and vocal behaviors that result in benign
midmembranous lesions are the most commonly diagnosed categories in patients seeking treatment.13 These voice disorders
are a public health problem, as a substantial proportion of the
public will be impacted by voice disorders during their
lifespan, with lifetime prevalence approaching 30%.4 The economic impact of these conditions is substantial. A recent study
mined data from a large national health-claims database and
found that approximately 1% of claims, corresponding to
536,943 treatment-seeking individuals, were linked to diagnosis codes associated with dysphonia.2 This evidence supports
the argument that efficacious and effective therapies aimed at
rehabilitating vocal function in patients with voice disorders
can have significant benefits to the individual, the community,
and the society at large. As such, the establishment of treatment
efficacy for voice therapy approaches is critical to inform best
practices for clinicians treating these problems.
Scholarly evidence has supported the efficacy of behavioral
voice therapy approaches for a wide range of etiologies underlying voice disorders. Therapy approaches for hyperfunctional
etiologies have been studied in a number of clinical trials, with

Accepted for publication May 21, 2014.

From the *Department of Communication Sciences and Disorders, Texas Christian University, Fort Worth, Texas; and the yClinical Center for Voice Care, Department of OtolaryngologyHead and Neck Surgery, University of Texas Southwestern Medical Center,
Dallas, Texas.
Address correspondence and reprint requests to Christopher R. Watts, Department of
Communication Sciences and Disorders, Texas Christian University, TCU Box 297450,
Fort Worth, TX 76129. E-mail: c.watts@tcu.edu
Journal of Voice, Vol. 29, No. 2, pp. 191-199
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.05.008

significant treatment effects reported across studies.58 A

number of systematic reviews reporting compilations of data
from treatment studies have concluded that the clinical effects
of voice therapy applied to hyperfunctional voice disorders are
positive.9,10 The methodologic approaches to treatment across
these studies, and the outcome variables used to assess
treatment effects, have been variable.9,11 Although reports have
demonstrated that voice therapy directly targeting imbalanced
or abusive vocal use is superior to no therapy or indirect
approaches, multiple authors have called for the need of future
treatment studies to restrict the participant population and
report a well-defined and scientifically controlled program of
treatment.9,11 As evidence for the effectiveness of specific
voice interventions continues to grow in the literature, greater
specificity and control of the processes studied in those
interventions will allow clinicians and clinical scientists to
better understand which characteristics of specific interventions
maximally impact vocal rehabilitation.
A number of voice therapy approaches are constructed in a
systematic way, which has allowed their application to investigations using a rigorously controlled scientific methodology
while retaining the theoretical constructs supporting the
approaches. Examples include the Lee Silverman Voice Treatment for Parkinsonian hypophonia and vocal function exercises
for hyperfunctional imbalance between the subsystems of voice
production.8,10,12 Stretch-and-flow (SnF) voice therapy is
another treatment approach used by clinicians to rehabilitate
vocal function secondary to hyperfunctional etiologies. Also
known as flow phonation, this approach was first described by
Stone and Casteel in the early 1980s as SnF.13,14 A number of
speech-language pathologists (SLPs) who were trained in this
technique have gone on to use it as an approach in their clinical
practices and have subsequently described, trained, or presented the structure of the approach to other professionals.1416

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Journal of Voice, Vol. 29, No. 2, 2015

The fundamental target in SnF is to initiate volitional control

over vocal subsystems, using voiced and unvoiced airflow
stimuli, while maintaining a perception of minimal muscular
effort during phonation.17 To achieve this goal, SnF instructs
the patient to better control respiratory patterns for support of
voice production, coordinate respiratory and laryngeal behavior
in speech while focusing on oropharyngeal resonance, and
reduce the overall physiological effort when phonating.
SnF is a structured physiological voice intervention characterized by a hierarchy of progressively challenging vocal tasks
designed to rebalance the respiratory, phonatory, and resonatory subsystems of voice production. A unique characteristic
of SnF is the use of voiceless sounds and words within the hierarchy of stimuli. By its nature SnF lends itself to scientific
study through its goal-oriented requirements of progression
through the systematic vocal hierarchy. Clinical experience in
voice therapy illustrates the need for flexibility in the application of treatments based on the characteristics and needs of the
client. However, the adherence to a scientific methodology
when studying outcomes in voice therapy requires control of
clinical procedures throughout the phases of treatment. As
illustrated in Table 1, SnF is characterized by a hierarchy of
vocal behaviors (horizontal axis) which must be demonstrated
at a specific level of performance across an ascending gradient
of challenging contexts (vertical axis). By establishing rigorous
requirements for clinician instruction and client progression

through the contexts and vocal behaviors, this approach can

be scientifically controlled to study its effects on treatmentseeking populations.
Although SnF has been used clinically for some time, the
evidence supporting the efficacy of SnF is sparse. Only one
outcome study has empirically tested the treatment efficacy
of SnF, although additional facilitative approaches were applied
concurrently. McCullough et al18 used SnF in a case series of six
patients with primary muscle tension dysphonia without
organic lesion. The authors used an eclectic approach by using
SnF in combination with semioccluded vocal tract (SOVT)
exercises. In addition, participants were asked to gargle water
during the intervention. This combination of tasks was similar
to those presented by Gartner-Schmidt in a case study.14 Results
indicated that this eclectic intervention incorporating SnF had a
significantly positive effect on auditory-perceptual measures of
dysphonia severity and self-perceived vocal handicap.
Although intervention effects could not be generalized to SnF
separate from the inclusion of SOVT or gargling, the findings
of the McCullough et al study supported the need for additional
studies investigating the clinical efficacy of SnF as a primary
intervention approach.
The purpose of this study was to investigate the clinical effect
of SnF on measures of vocal function and handicap in a
treatment-seeking population diagnosed with hyperfunctional
voice disorders. Specifically, we tested the following

H. Dialogue

c. Clinician
b. Paragraphs

G. Read

a. Sentences

F. Five words
E. Three words
D. Two words
C. One word
B. Breathy phonation (vowel)

5. Reduced Flow

4. Reduced
Stretch

3. Stretch & Flow

with Voice

2. Stretch & Flow

(Slow Whisper)

A. Voiceless

1. Flow (sigh)

HIERARCHY

TABLE 1.
Hierarchy of Stretch-and-Flow Voice Therapy, Across Levels and Stimuli

(least)-----Degree of Muscle Activity-----(most)

HIERARCHY

Christopher R. Watts, et al

Stretch-and-Flow Voice Therapy

hypotheses: SnF will lead to changes in (1) maximum phonation

time, (2) s/z ratio, (3) cepstral peak prominence (CPP) in
sustained vowels and connected speech, and (4) voice handicap
index (VHI).19
METHODS
Participants
Eight participants were recruited from the treatment-seeking
population of the authors clinical practices. Potential study
participants were identified at the initial voice evaluations.
Participant characteristics are listed in Table 2. The severity
of dysphonia based on auditory-perceptual evaluation was not
controlled in this investigation because this was a preliminary
study for efficacy. Inclusion criteria for the study were as
follows:
 Adult18 years old or above.
 Diagnosis of primary muscle tension dysphonia without
vocal fold lesion, or phonotraumatic lesions where hyperfunctional vocal behavior was the primary etiologic factor
for which voice therapy was recommended as the first-line
treatment.
 Diagnosis confirmed by speech-language pathologist via
clinical voice evaluation and fellowship-trained laryngologist via assessment of laryngeal videostroboscopy.
 No prior history of voice therapy where SnF was used as a
primary treatment approach for the duration of therapy.
Three certified SLPs with experience treating voice disorders, including the application of SnF, administered the experimental treatment. Before enrolling the first participant, the
SLPs met as a group to formalize a consensus treatment protocol incorporating the SnF hierarchy as illustrated in Table 1 and
described in the following.
Procedures
Pretreatment (baseline) recordings and measurements were
obtained before the first treatment session. Before initiating
SnF, the participant was educated regarding anatomy and
physiology of the laryngeal mechanism and voice production
in laymans terms. They were then introduced to aspects of

TABLE 2.
Participant Demographics
Participant
1
2
3
4
5
6
7
8

Gender

Age

Medical Diagnosis

F
F
F
F
F
F
F
F

25
39
22
48
55
74
47
59

VF polyp
VF nodules
MTD
MTD
MTD
MTD
MTD
MTD

Abbreviations: F, Female; VF, vocal fold; MTD, muscle tension dysphonia.

193

vocal hygiene, using the attached form as guideline

(Appendix A). Vocal hygiene was not targeted during the treatment phase of the study. After this, the treatment approach of
SnF was introduced. The criterion for advancement through the
levels of SnF was standardized and set at 90% accuracy on 10
consecutive trials for the target vocal behavior at each level of
the SnF hierarchy (A through H in Table 1), as judged by the
clinician and perceptually verified by the participant. Homework consisting of exercises at the current skill level along
with a tracking log was required of the participant to increase
compliance (Appendix B). These were returned to the treating
SLP at the next treatment session. The structure of SnF adhered
closely to that reported by Gartner-Schmidt14 and Stone and
Casteel,13 as illustrated in Table 1 and as follows:
Skill level 1: flow. The overall goal for this skill level was
for the speaker to gain control over airflow. The speakers
task was to elicit a steady flow of unvoiced air without effort
through rounded lips (ie, prolonged, easy exhale), resulting
in forward movement of a piece of tissue paper held in front
of the mouth for visual feedback. This feedback technique is
similar to that described by previous authors.14,15,18
Progression to the next level required 90% accuracy on 10
consecutive trials.
Skill level 2: stretch-and-flow. The goal for this skill level
was production of voiceless airflow through the glottis along
with slow (stretched out) movements of the articulators, while
using minimal effort. The gesture elicited was effortless, whispered, connected speech at a reduced speech rate. Similar to
skill level 1, a soft tissue was used as a form of visual feedback
Progression to the next level required 90% accuracy on 10
consecutive trials.
Skill level 3: stretch and voiced flow. The goal for this
skill level was production of voiced airflow through the glottis
along with slow (stretched out) movements of the articulators,
while using minimal effort. The gesture elicited was breathy,
effortless voice quality in connected speech at a reduced speech
rate. Similar to skill levels 1 and 2, a soft tissue was used as a
form of visual feedback. Progression to the next level required
90% accuracy on 10 consecutive trials.
Skill level 4: reduced stretch with increased flow. The
goal for this skill level was production of voiced airflow
through the glottis with a faster rate of speech, while maintaining minimal effort. The gesture elicited was effortlessly voiced
but breathy speech associated with a normal rate. Progression
to the next level required 90% accuracy on 10 consecutive
trials.
Skill level 5: reduced air flow. The goal for this skill level
was production of normal voice quality with an appropriate rate
of speech, while maintaining minimal effort. The gesture
elicited was perceptually appropriate conversational loudness
with normal (nonbreathy) air flow, normal rate, and modal
(natural for that person) fundamental frequency. Success at
this skill level was defined as 90% accuracy on 10 consecutive
trials.

194
Measurement
Pretreatment data were obtained before the first treatment session, whereas posttreatment data were obtained within 2 weeks
after the last (sixth) treatment session. Data were collected as
follows:
1. Completion of the VHI
2. Producing maximum /a/, /s/ and /z/ prolongations
a. Participants were instructed to: Take a deep breath,
and sustain the (vowel, consonant) as long as possible,
until you run out of air. Two repetitions of each sound
were acquired using a digital timer and the longer
maximum prolongation measure was used for data
analysis. For /s/ and /z/, the longer prolongation
measures were applied to the formula (s/z) to derive
the s/z ratio. These measures represented respiratoryphonatory coordination along with the ability to
control airflow.20,21
3. Producing sustained /a/ vowels for 3 to 5 seconds.
a. Acoustic recordings (described in the following) were
acquired while participants sustained the vowel /a/,
prompted with the following instructions: Take an
easy breath, and sustain the vowel /a/ at a comfortable
pitch and loudness, as steady as possible, until I say
stop. I will say stop after about 5 seconds. From the
recorded vowel, measures of CPP were obtained.
CPP is related to the periodicity and harmonic structure
of the cepstrum, can be used as an indirect measure of
vocal fold vibratory periodicity, and has been found to
correlate well with perceptions of dysphonia.2227
Larger values of CPP reflected greater periodicity in
the cepstrum. For a detailed description of CPP, see
Awan and Roy.25
4. Reading the sentence We were away a year ago.28
a. Acoustic recordings were acquired while the participants read the sentence, taken from the stimulus used
in the Consensus Auditory-Perceptual Evaluation of
Voice (CAPE-V). This sentence was chosen because
it has been found in a number of studies to correlate
well with auditory-perceptual ratings of dysphonia.24
Participants were prompted with the following instructions after quietly reading the passage to themselves:
Read this sentence at a comfortable pitch and loudness, just as if you were speaking to me in a conversation. From the recorded sentence, measures of CPP
were calculated.

Acoustic recording
Participants were recorded in a room with background noise
levels below 45 dBSPL. The participants wore a headmounted cardioid microphone (AKG Acoustics model C420,
Vienna, Austria) positioned approximately 3 cm off-center of
the left mouth corner. This provided a constant mouth-tomicrophone distance during the recording session. The microphone was connected to the Computerized Speech Lab
(CSLKayPENTAX, Montvale, NJ). The core software of

Journal of Voice, Vol. 29, No. 2, 2015

the CSL was used to digitize each recorded sample at

44.1 kHz. CPP was calculated using the program Analysis of
Dysphonia in Voice and Speech (ADSVKayPENTAX, Montvale, NJ).29
Statistical analysis
The treating clinicians obtained acoustic recordings but did not
carry out the CPP calculation, which was performed separately
by the first author. The files were presented in sequential order
without identifiers. Five outcome variables were obtained during this study, which included (1) VHI score, (2) maximum
vowel prolongation (MPTin seconds), (3) s/z ratio, and (4
and 5) CPP from sustained vowel and connected speech. Paired
t tests were applied to each variable, with the level of significance set at 0.05. Statistically significant outcomes were
followed-up with effect size calculations using Cohen
d (d pretreatment mean  posttreatment mean/pooled standard deviation).
Reliability
Intermeasurer and intrameasurer reliability was calculated for
CPP (in sustained /a/, and connected speech We were away
a year ago) by randomly selecting 10% of the recorded files
and remeasuring the stimuli. A Pearson product-moment correlation was applied to each paired data set. Measurement reliability was high for both inter and intrameasurer analyses,
with all correlation coefficients (Pearson r) resulting in values
greater than 0.96 (CPP-sustained vowel r 0.98; CPPconnected speech 0.96).
This study was approved by the Institutional Review Boards
of Texas Christian University (IRB # 31246) and UT Southwestern Medical Center (IRB# STU06212103).
RESULTS
Table 3 shows the pretreatment and posttreatment measures of
the eight participants. Each outcome variable is also illustrated
separately in Figures 15. Compared with pretreatment average
measures, average VHI score reduced by 30 points, average s/z
ratio reduced by 0.66 seconds, average maximum phonation
time increased by 1.41 seconds, average vowel CPP increased
by 1.72 points, and average sentence CPP increased by 1.28
points.
Results of the paired-samples t tests revealed a statistically
significant treatment effect (pretreatment vs posttreatment)
for four of the five outcome measurements. VHI scores reduced
significantly (t(7) 3.78, P 0.007), s/z ratio reduced significantly (t(7) 2.73, P 0.029), MPT increased significantly
(t(7) 3.28, P 0.014), and measures of sentence CPP
increased significantly (t(7) 2.47, P 0.043). Effect sizes
were calculated for the significant outcomes, and were found to
be large for VHI and s/z ratio (d 1.96 and 1.25, respectively),
and moderate for MPT and sentence CPP (d 0.79 and 0.74,
respectively). Vowel CPP also changed in the direction of
improvement, but the difference did not reach statistical
significance.

Christopher R. Watts, et al

195

Stretch-and-Flow Voice Therapy

TABLE 3.
Descriptive Statistics (Means With Standard Deviations in Parentheses) for Each Outcome Variable at Pretreatment and
Posttreatment Measurement Intervals, With Calculated Probability Value (P) From Paired t Tests and Effect Sizes (d)
Parameter
VHI
s/z
MPT
Vowel CPP
Sentence CPP

Pre

Post

68.25 (13.7)
1.47 (0.44)
12.36 s (3.61)
7.68 dB (2.9)
6.00 dB (2.2)

38.50 (16.6)
1.05 (0.18)
15.49 s (4.33)
9.39 dB (1.5)
7.27 dB (0.9)

0.007
0.029
0.014
0.141
0.043

1.96
1.25
0.79
n/a
0.74

Abbreviations: VHI, voice handicap index; s/z, s/z ratio, MPT, maximum phonation time (in seconds [s]); CPP, cepstral peak prominence (in decibels [dB]); n/a,
not available.

DISCUSSION
The results of this small clinical efficacy study found statistically significant changes from pretreatment to posttreatment
in four of five outcome measures. Each of the four significant
outcome measures changed in the direction of improvement
with a moderate to large effect size, suggesting a practical clinical effect. Posttreatment changes in VHI, s/z ratio, MPT, and
sentence CPP reflected less perceived vocal handicap, greater
control of airflow with voicing, and improved phonatory
stability.
The VHI evaluates a patients self-perception of handicap
resulting from a voice disorder and is widely used as a functional outcome measure from behavioral voice treatment in
hyperfunctional and hypofunctional populations.18,30,31 The
large 30-point difference in the mean pre- and posttreatment
VHI scores in this study is similar in magnitude to that of
McCullough et al,18 whose cohort experienced a posttreatment
reduction of 39 points. These differences are substantially
larger than the 18-point threshold for judgments of clinical
effect using this measure.19 A primary target of SnF is control
over airflow while maintaining a perception of minimal
muscular effort during phonation. In the sample of participants

studied in this investigation, we believe this physiological target

promoted greater efficiency (improved functional output with
reduced physiological effort) of voicing along with improvement in voice quality and thus reduced vocal handicap after
6 weeks of treatment. The degree to which VHI improves
further with a greater frequency of treatment and/or longer
duration of treatment will need to be investigated in further
studies.
The s/z ratio was originally developed as an indicator of
laryngeal pathology and purported to be influenced by glottal
insufficiency due to midmembranous lesions.20 Some authors
have since questioned the validity of the s/z ratios sensitivity
to membranous pathology, suggesting that individuals with
glottal lesions are able to compensate and control airflow for
/s/ and /z/ such that maximum sustained duration is equivalent.32 It has been suggested that the clinical application of s/
z ratio should be made with caution given uncertainties
regarding the underlying causes of differences between /s/
and /z/ measurements.32,33 In our study, this measurement
was not used as a diagnostic marker of midmembranous

FIGURE 2. Box-and-whisker plot showing pretreatment and postFIGURE 1. Box-and-whisker plot showing pretreatment and posttreatment measurement of VHI. Upper and lower borders of the shaded
box represent the 75th and 25th percentiles, respectively, whereas the
horizontal line within the shaded box represents the median.

treatment measurement of s/z ratio. Upper and lower borders of the

shaded box represent the 75th and 25th percentiles, respectively,
whereas the horizontal line within the shaded box represents the
median.

196

FIGURE 3. Box-and-whisker plot showing pretreatment and posttreatment measurement of maximum phonation time (in seconds).
Upper and lower borders of the shaded box represent the 75th and
25th percentiles, respectively, whereas the horizontal line within the
shaded box represents the median.

pathology (eg, presence vs absence of glottal lesion) but rather a

treatment outcome variable related to control of airflow and
voicing efficiency during phonation. Measures of s/z ratio
decreased in the two participants with benign
midmembranous vocal fold lesions and the six participants
with muscle tension dysphonia without benign lesion. We
believe s/z ratio was positively impacted because SnF targets
the participants abilities to (a) control respiratory support by
efficiently managing breathing cycles, (b) coordinate
respiratory-laryngeal interactions during phonation for more
efficient voicing, and (c) reduce the physiological level of effort
in laryngeal musculature.

FIGURE 4. Box-and-whisker plot showing pretreatment and posttreatment measurement of cepstral peak prominence (CPPin dB)
in sustained vowels. Upper and lower borders of the shaded box represent the 75th and 25th percentiles, respectively, whereas the horizontal
line within the shaded box represents the median.

Journal of Voice, Vol. 29, No. 2, 2015

FIGURE 5. Box-and-whisker plot showing pretreatment and posttreatment measurement of cepstral peak prominence (CPPin dB)
in connected speech. Upper and lower borders of the shaded box represent the 75th and 25th percentiles, respectively, whereas the horizontal
line within the shaded box represents the median.
This study also found a significant clinical effect of SnF on
MPT with sustained /a/. MPT increased on average across the
eight participants by 3.13 seconds and corresponded to a
medium effect size (d 0.79). This increase paralleled the
longest production of /z/, which is also voiced and showed an
average pre- to posttreatment increase of 3.74 seconds. Other
than a semiocclusion produced by lingual articulation for the
/z/ sound, aerodynamic and phonatory control are similar for
these phonemes when produced as a maximum prolongation
task. We believe the effect of SnF on MPT was due to improvement in similar physiological control strategies resulting in a
lower s/z ratio posttreatment, specifically controlling and coordinating respiratory-laryngeal motor activation along with
reduced physiological effort.
The CPP is derived from the cepstrum, which itself is derived
from the sound spectrum, and is the amplitude of the highest peak
in the cepstrum relative to the expected amplitude as derived via
linear regression.24,29 This statistic reflects the degree of
regularity or periodicity in the voiced signal, with higher
values reflecting greater phonatory periodicity. Unlike
traditional time-based acoustic measures of jitter and shimmer,
calculations of CPP can be validly measured from connected
speech samples such as words and sentences and in clinical populations with a wide range of dysphonic severity.27 This measure
has also been found to correlate well with auditory-perceptual
impressions of dysphonia from vowels and connected
speech.23,24,27 The increase in CPP in the present study
suggests that SnF resulted in greater periodicity and less
spectral noise (ie, improved phonatory physiology) during
production of connected speech. We believe SnF resulted in
these physiological changes by improving the ability of the
participants to regulate the activity of laryngeal muscles during
phonation. Throughout the hierarchy of SnF, participants are
required to generate muscle force in a graduated manner from
low force contractions (slightly abducted vocal folds requiring

Christopher R. Watts, et al

Stretch-and-Flow Voice Therapy

activity of fewer motor neurons) to normal force contractions

(adducted vocal folds with perception of minimal effort
requiring activity in a greater number of motor neurons). By
improving control of laryngeal motor activation, participants
were better able to negotiate the rapid muscular adjustments
required in connected speech, which we suggest is related to
the improvement of connected speech CPP measures in this
study.
Although the pattern of change from pre- to posttreatment
was similar in measures of CPP from connected speech and sustained vowels (Figures 4 and 5), we did not find a significant
effect of SnF on vowel CPP. There are several possible
explanations. The most important one may be the types of
training stimuli used in the SnF hierarchy. As illustrated in
Table 1, vowels are only targeted in a single stage, skill level
1. All other training targets are connected speech items. The
greater specificity of SnF to connected speech may have influenced phonatory control mechanisms more positively in this
context compared with sustained vowel production. An additional possibility lies within the increased variability in CPP
exhibited between participants when producing sustained
vowels. Although vowel CPP increased posttreatment, which
is consistent with previously reported outcomes, the larger variability inherent in the data would necessitate a larger sample
size to detect a statistically significant difference.34 Future
studies are needed to investigate this supposition. Finally, it
may be possible that CPP in connected speech is more sensitive
to changes in phonatory periodicity in the current sample of
eight participants. This sensitivity may be related to clinically
important markers in the acoustic signal of connected speech,
which differs from that of sustained vowels. These acoustic
markers arise from a number of factors requiring alterations
in phonatory physiology during connected speech, such as
points of voicing onset and offset, the requirements of frequency amplitude adjustments due to intonation, and/or
different requirements for aerodynamic control in connected
speech.24,26 These physiological differences potentially
support the role of acquiring clinical measurements in both
sustained vowel and connected speech contexts, as speakers
are likely using different strategies for controlling the vocal
mechanism when producing a single sustained sound
compared with dynamic vocal changes during connected
speech.
There are several important limitations to this study. It was
meant as a preliminary investigation to determine if larger
controlled trials are warranted. Although a positive clinical
effect was demonstrated in a small sample, larger studies will
be needed to demonstrate the efficacy and effectiveness of
SnF for patients with hyperfunctional voice disorders. Although
we did not select for gender, all the participants happened to be
female in this cohort, so we could not generalize the findings to
males. We chose not to control for dysphonic severity or presence of benign lesions. As a result, the variability these factors
may have introduced into the study could have influenced
outcome measures. Future studies should attempt to control
for these factors to further understand the impact of SnF in
different populations and dysphonic speaker subgroups.

197

Additionally, this study did not include a control group, which

will be needed to determine the effect of SnF separate from
other factors, such as time or exposure to a voice evaluation.
To our knowledge this is the first study to use SnF as the primary treatment for participants with hyperfunctional voice disorders without using additional facilitative techniques (ie,
SOVT or gargling). It is only the second prospective study reporting the effects of SnF using a scientific methodology in
peer-reviewed literature. A larger clinical trial with a control
group is in progress at our centers.
Acknowledgments
The authors would like to thank Kimberly Chachere-Coker for
her assistance in helping to develop the clinical methodology
used in this study and for her role as a clinical mentor for the
SLPs in their application of SnF in this study. We would also
like to thank Janis Deane for her support and participation
throughout this study.
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Christopher R. Watts, et al

APPENDIX A
Vocal hygiene guidelines

Hydration
-

199

Stretch-and-Flow Voice Therapy

Your goal is 8 glasses (64 ounces) of water per day.

Anything non-caffeinated counts as water (ex., Gatorade,
Sprite, juice, non-caffeinated herbal teas).
Caffeine and alcohol are drying to the vocal folds. For
every ounce of caffeine or alcohol you consume, add an
extra amount of water (ounce for ounce) in addition to
your 64 ounces.
Decaffeinated tea and coffee has a small amount of
caffeine, so neither one is a hydrating beverage.
Add an extra glass of water for drying medications.
Steam inhalation, OTC glycerin-based throat lozenges
and sprays, and room humidifiers are methods of external
hydration. Avoid menthol.

Eat small frequent meals instead of heavier meals.

APPENDIX B
Homework tracking form - Practice represents
repetitions of the exercise
Home Practice Log
Step 1: Blow air out through pursed lips. Feel air at the lips
and nothing in the throat.

Day Day Day Day Day Day Day Day Day Day
1
2
3
4
5
6
7
8
9 10
Practice #1
Practice #2
Practice #3

Step 2: Blow air out through pursed lips and add a trace of
voice to the airflow to make the sound extremely breathy
90% air and 10% voice.

No smoking
-

Avoid vocal abuses

-

Do a hard, effortful swallow instead of throat clearing or

coughing.
Use a noisemaker or closer proximity instead of yelling or
shouting.
Limit voice use when you have an upper respiratory
infection.
Avoid talking over ambient noise.
Do not sing out of your comfortable range.
Limit character voices/impersonations/sound effects if
this causes throat discomfort or hoarseness.
Do not talk louder on the phone.

Vocal fatigue
-

Day Day Day Day Day Day Day Day Day Day
1
2
3
4
5
6
7
8
9 10

Also limit exposure to second-hand smoke

Take frequent 5-minute voice rest breaks throughout long

periods of talking.
Always warm-up and cool down your voice prior to
and following heavy voice use (speaking or singing).
Send emails instead of returning phone calls.

Practice #1
Practice #2
Practice #3

Step 3: Count one to 10, one word per breath, with no voice/
open airflow OR with an extremely breathy voice (your
therapist will indicate which one to practice). Stretch out the
vowels of each word and slow the rate.

Day Day Day Day Day Day Day Day Day Day
1
2
3
4
5
6
7
8
9 10
Practice #1
Practice #2
Practice #3

Step 4: Count 1 to 10, two words per breath, with no voice/

open airflow OR with an extremely breathy voice (your therapist will indicate which one to practice). Stretch out the vowels
of each word and slow the rate.

Day Day Day Day Day Day Day Day Day Day
1
2
3
4
5
6
7
8
9 10

Behavioral anti-reflux regimen

-

Common triggers for reflux include alcohol, caffeine, and

spicy, acidic, or fatty foods
Do not eat or drink 2 hours before bedtime.

Practice #1
Practice #2
Practice #3