Psychological and physical patient state as well as the influence of other social factor is of great influence voice rehabilitation.
A team of experts in the field of voice and its function are involved in voice therapy. Our research was focused
on the succefulness of voice recovery depending on the patient vocal disorder approach. We made a comparison of two
methods: RVT and Accent method. We attempted to evaluate clinically relevant voice disorders in relation to certain vocal
methods, we propose that a lot can be learned about voice trough therapeutic procedures, which can also be used to enhance
the practical application of vocal methods and raise the level of success in dealing with people that suffer from
voice pathology

Josipa Pankas

Marinela Rosso

Radan Starčević

Tatjana Šepić

Vlatka Pitlović

English

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Coll. Antropol. 35 (2011) Suppl. 2: 259–262Professional paperImportance of Correct Therapeutic ProcedureSelection in Voice RecoveryJosipa Pankas1, Tatjana [epi}1, Vlatka Pitlovi}2, Marinela Rosso3 and Radan Star~evi}11 Clinic for Otorinolaringology and Head and Neck Surgery, Rijeka University Hospital Centre, Rijeka, Croatia2 Department of Surgery, General Hospital in Slavonski Brod, Slavonski brod, Croatia3 Department of Otorhinolaryngology and Head and Neck Surgery, Osijek University Hospital Centre, Osijek, CroatiaA B S T R A C TPsychological and physical patient state as well as the influence of other social factor is of great influence voice reha-bilitation. A team of experts in the field of voice and its function are involved in voice therapy. Our research was focusedon the succefulness of voice recovery depending on the patient vocal disorder approach. We made a comparison of twomethods: RVT and Accent method. We attempted to evaluate clinically relevant voice disorders in relation to certain vo-cal methods, we propose that a lot can be learned about voice trough therapeutic procedures, which can also be used to en-hance the practical application of vocal methods and raise the level of success in dealing with people that suffer fromvoice pathology.Key words: vocal methods, accent method, RVT method, and brainIntroductionIn order to explain why one vocal method would bemore successful than the other in terms of rehabilitationwe must start with the way voice is created1. There areseveral theories on how voice is formed: mechanical, mio-elastical, aerodynamical, neurohronaxic and biophysical2.All the above-mentioned theories are intertwined andreplenish each other. We will consider the biophysicaltheory that proposes that the central nervous system(CNS) is in control of phonation trough nervous impulsescoming to the larynx. CNS regulates the starting impulseand further vibrations are controlled trough feedbackloop – hearing. It is a reflex loop, which is based onproprioceptive analyzers, which has special significancefor emissions of certain tones3.The voice is created in the mouth by the position ofthe tongue, palate, teeth and lips and so speech is formedunder the influence of the center in the cortex of the ce-rebrum. There are several parts of the brain, and centersrelated to voice and speech: temporal, prefrontal and pa-rietal lobe4.The following functions of each lobe were importantin our investigation:1. Frontal-motor area – enables the preconceived muscleuse, detailed performance of fine voluntary move-ment2. Parietal – processing and language comprehension3. Temporal – the center for cortical representation ofauditory sensesBasal ganglia, which are of great importance for mo-tor function, release movement5.According to [kari} (1991) there are three maingroups of speech organs: Control group (central and pe-riphery nervous systems), executor group (breathing or-gans, phonation, articulation) and sensory group (audi-tory and extra auditory control). There are numerousbrain functions important to our investigation6.There are several functions of importance to voiceand speech depending on the hemisphere7: Left hemi-sphere is responsible for speech rhythm, making sense of259Received for publication June 17, 2011facts and lecture accents while the right hemisphere holdsthe importance on integration, emotion and prosody.We must also emphasize the importance of workingmemory, which is a short-term memory that involves vol-untary attention unlike watchfulness. Working memorycapacity is responsible for all the individual differencesin the cognitive processes and task completion. The cen-tral executor coordinates and controls the transfer of in-formation between different parts of this system, there-fore forwarding data to phonological and articulationloops and at the same time recalls information fromlong-term memory8.Materials and MethodsTesting was conducted on 30 phoniatry patients. Theywere divided into two groups, a group with organ damageand one with functional impairments. To test our set-tings, groups were treated with various therapeutic pro-cedures. Selection of therapeutic procedures was carriedout according to ability, not age. Patients were of differ-ent ages and sexes. The goals of therapy are determinedby the communication and personal profile. The therapywas carried out systematically, with the removal of audi-tory and visual distracters. The performance of two vocalmethods was examined: RVT methods and methods ofaccent. The first group came once a week for 45 minuteson an exercise with the speech therapist (15 patients),the second group carried out the exercises independentlyat home. Rehabilitation lasted 6 weeks. We divide meth-ods of vocal therapy into specific and non-specific. Wewill review the nonspecific because that is the groupmethods used in our investigation are in9. We divide thenonspecific vocal methods into integral (Accent method)and directed (RVT method). Integral methods of voiceand speech disorders view the voice as a result of uniquewhole of all parts of voice and speech as well as all oftheir qualities. Directed methods come from each charac-teristic of voice individually. The importance is given tovolume, intensity, resonance, rhythm, tempo and intona-tion. These voice qualities should be treated individually10.RVT method is characterized by a strong and clear voicethat uses less tension in order to avoid vocal cord dam-age. Also it uses the air pressure in combination withcheek and nasal bone vibrations that are practiced troughdifferent exercises. It lasts for 8 weeks and utilizes chan-ges in voice tone trough a three step vocalization, empha-sizes the importance of sensory input and uses feeling,listening and seeing in learning new skills4. The accentmethod is characterized by diaphragm breathing withcontractions and releases, clearing of the throat and vo-cal cords, rhythmical whole body movements, creatingnew »motor programs« in the brain, adjusting phona-tion, respiration and articulation and making accentchanges to words and syllables in different rhytms11.Several aims, in which we attempted to cover the successrate issues of therapeutic procedures in voice recovery,have been set. Confirmation of which therapy, RVT or ac-cent, was more successful in rehabilitation of voice disor-ders. To ascertain why one was better than the other andwhat it means to voice disorders. To determine whetherthe success rate of therapy is important to build »motormaps« in the brain. To establish if there is a difference inregard to gender and to the way exercises were con-ducted (individually or with a speech therapist). Regularspeakers and voice professionals, aware of their vocalabilities and restrictions were involved in our study. Atfirst, the patients are warned about voice hygiene andpreservation. It is necessary to use our voice in an appro-priate manner in noise conditions, trough telephone con-versations and group talks. Special attention should begiven to hydration of the air inhaled as well as the entirebody. Lack of moisture between vocal cords can lead toswelling due to friction. The accent should be on easy andsoft vocalization with soft start to phonation12.It is also necessary to watch the diet, overwhelmingconsummation of fatty and spicy foods, sweet and spar-kling can lead to redness, swelling and other vocal prob-lems. Special care should be taken not to consume alco-hol and caffeine, to avoid antihistamines (dry larynx) aswell as aspirin as it increases capillary sensitivity andhas a anticoagulation properties and can lead to vocalcords hemoraghe12. Voice hygiene and preservation werefollowed by exercise, respirations and performance of vo-cal methods.Results and DiscussionPatients using the accent method have had a moresuccessful rehabilitation than the patients using the RVTvocal method (Table 1). The reason for that is the level ofconsciousness or the activation of specific speech func-tions in the brain. Tactile and kinesthetic reverse feed-back loop are responsible for voice realization, tempo,volume, quality, articulation13. In performing the exer-cises of the RVT vocal method, the patient is focused onexperiencing voice trough the mentioned feedback loops,which happens on a less conscious, level with the delay ofcrating »motor maps« in the brain14. Accent methodstresses the importance of breathing and its connectionto movement and phonation. Movements release tensionand use the human body as a great resonator and an in-J. Pankas et al.: Voice Recovery, Coll. Antropol. 35 (2011) Suppl. 2: 259–262260TABLE 1THERAPY SUCCESS RATE DEPENDING ON THE METHOD USEDSuccess rate ofvocal methodsRVTmethodAccentmethodTotalNo change 1 3 4Satisfactory voice 7 11 18Very satisfactory voice 3 0 3Excellent voice 2 1 3*»New« voice 2 0 2Total 15 15 30*voice of sufficient quality with a new way of phonation estab-lishedstrument for voice creation. During the conductance ofthese »useless« exercises there is an instantaneous cre-ation of »motor maps« in the brain. This utilizes a higherlevel of speech functions of the brain15. There was no sig-nificant difference in the success rate based on genderbias in proportion to the number of female and male pa-tients (Table 2). If we ignore the disproportion in gendersize, male patients were less successful in the therapeuticprocedures (Table 2 and 3). By comparing the successrate, depending on the method used, we come to the con-clusion that females performed better (Table 4). Thereare several differences in the function of the male and fe-male brain that can also be the reason for the differencesin success rate in therapy. Research shows that the Brockand Wernicke areas are larger in female brains. The fe-male brain processes spoken language in frontal lobes ofboth hemispheres simultaneously while men do the sameusing primarily the left hemisphere. Due to this differ-ence females are generally better at verbal skills15. Dueto advanced neuroscientific methods and instruments anarea in the inferior parietal lobe, significantly larger inmales, has been discovered. The inferior parietal lobe en-ables the brain to process information that it receivedfrom sensory input, which aids in selective attention andperception. Studies connect this lobe to the manipulationof spatial relations and the ability to sense differences be-tween body parts (accent method16). Patients practicingwith speech therapists have not achieved better resultsthan informed patients doing the exercises individuallyat home. As necessary they could contact a speech thera-pist personally or over the phone in regard to exercise de-tails (Table 5). The success rate of the exercise was re-corder according to the scale form 1 to 5 respectivelymeaning no change, satisfactory voice, very satisfactoryvoice, excellent voice and »new« voice.ConclusionWe all have »optimal« voices at birth and they changetrough various physical ad psychological limitations17.Methods of voice disorder therapy are very complex anddemand multidisciplinary approach to its application14.The appropriate use of phonation demands a higher levelof event consciousness and the activation of higher speechfunctions of the brain18. This study indicates to the factthat treating voice as a whole is of great importance tovoice therapy, which activates higher level of brain fun-ctions19.R E F E R E N C E S1. ESTILL J, Voice Craft: A Users Guide to Voice Quality (Santa Ro-sa, 1995). — 2. CVEJI] D, KOSANOVI] M, Fonijatrija (Univerzitet uBeogradu, Beograd, 1982) 36. — 3. BOONE DR, McFARLANE SC, Thevoice and voice therapy (Englewood Cliffs, N.J. Prentice Hall, 1994). — 4.BERRY DA, VERDOLINI K, CHAN RW, TITZE IR, J Speech Hear Di-sord, 12 (1998) 33. — 5. MOCK JR, FOUNDAS AL, GOLOB EJ, EJN, 33(2011) 1001. — 6. BUCCINO G, RIGGIO L, Kineziologija, 38 (2006) 1. —7. MILDNER V, Govor izme|u lijeve i desne hemisfere, (Zagreb,1998) 28.— 8. HUNTER MD, LEE KH, TAWDON P, PARKS RW, WILKINSON ID,WOODRUFF PWR, Cereb Cortex, 18 (2007) 1295. — 9. STEMPLE JC,Semin Speech Lang, 26(2005) 131. — 10. [KARI] I, VARO[ANEC-[KA-RI] G, Vje`be za glas i izgovor (Nova Gorica, 1999) 197. — 11. DALHOFFK, KITZING P, Rev Laryngol Otol Rhinol, 110 (1989) 407. — 12.BEHLAU M, OLIVEIRA G, Curr Opin Otolaryngol Head Neck Surg, 17J. Pankas et al.: Voice Recovery, Coll. Antropol. 35 (2011) Suppl. 2: 259–262261TABLE 2DIFFERENCES IN RVT METHOD SUCCESS RATE DEPENDINGON GENDERGender Total RVT methodSuccess No changeM–422F–1091TABLE 3DIFFERENCES IN ACCENT METHOD SUCCESS RATEDEPENDING ON GENDERGender Total Accent methodSuccess No changeM–541F–11110TABLE 4COMPARISON OF DIFFERENT METHODS SUCCESS RATE INRELATION TO GENDERGenderRVTsuccessRVTno changeAccentmethodsuccessAccentmethodno changeTotalM 2 2 4 1 9F 9 1 11 0 21Total 11 3 15 1 30TABLE 5EXERCISES AT HOMESuccess rateIndividual exer-cises at homeTotalNo change 3 4Satisfactory voice 8 18Very satisfactory voice 2 3Excellent voice 1 3»New« voice 1 2Total 15 30(2009) 149. — 13. JANOVI] T, PE]NJAK D, Na~elo vezanost, Searle inesvjesna intencionalnost (Prolegomena, 2007). — 14. VERDOLINI K,DRUKER DG, PALMER PM, SAMAWI H, Journal of Voice, 12 (1998) 315.— 15. THURMAN L, WELCH G, Body mind & Voice, (Iowa City, IA: Na-tional Center For Voice and Speech, 2000). — 16. PERROT-SINAL T,NEJM, 358 (2008) 2189. — 17. LYNN R, IVANEC D, ZAREVSKI P, CollAntropol, 33 (2009) 515. — 18. TITZE IR, Principles of Voice Production(Englewood Cliffs, NJ:Prentice Hall, 1998) 1148. — 19. KOTBY M, EL--SADY S, BASIOUNY S, ABOU-RASS Y, HEGAZI M, Journal of Voice, 5(1991) 316. — 20. MATHIESON L, Curr Opin Otolaryngol Head NeckSurg, 35 (2009) 67.J. PankasClinic for Otorinolaringology and Head and Neck Surgery, Rijeka University Hospital Centre, Rijeka, Croatiae-mail: jpankas80@gmail.comVA@NOST U ODABIRU TERAPIJSKIH POSTUPAKA OPORAVKA GLASAS A @ E T A KZa glasovnu rehabilitaciju od velikog su zna~aja psihofizi~ko stanje pacijenta te utjecaj drugih socijalnih ~imbenika.U terapiji glasa sudjeluje cijeli tim stru~njaka ~ija je domena glas i njegova funkcija. Napravili smo ispitivanje uspje-{nosti oporavka glasa s obzirom na na~in pristupa vokalnim problemima pacijenta. Napravljena je komparacija dvijuvokalnih metoda: RVT metode i Akcentne metode. Poku{ali smo ispitati klini~ki relevantna o{te}enja glasa u relaciji sodre|enim vokalnim metodama. Smatramo da se o glasu mo`e puno nau~iti kroz terapijske postupke koji ujedno moguunaprijediti prakti~nu primjenu vokalnih metoda te podi}i razinu rada s osobama s glasovnom patologijom.J. Pankas et al.: Voice Recovery, Coll. Antropol. 35 (2011) Suppl. 2: 259–262262

Importance of Correct Therapeutic Procedure Selection in Voice Recovery

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