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Summary: Objectives. Water resistance therapy by phonating through a tube into the water is used to treat dys-
phonia. Deep submersion (10 cm in water, deep bubbling) is used for hypofunctional voice disorders. Using it with
caution is recommended to avoid vocal overloading. This experimental study aimed to investigate how strenuous deep
bubbling is.
Study Design. Fourteen subjects, half of them with voice training, repeated the syllable [pa:] in comfortable speak-
ing pitch and loudness, loudly, and in strained voice. Thereafter, they phonated a vowel-like sound both in comfortable
loudness and loudly into a glass resonance tube immersed 10 cm into the water.
Methods. Oral pressure, contact quotient (CQ, calculated from electroglottographic signal), and sound pressure level
were studied. The peak oral pressure P(oral) during [p] and shuttering of the outer end of the tube was measured to
estimate the subglottic pressure P(sub) and the mean P(oral) during vowel portions to enable calculation of transglottic
pressure P(trans). Sensations during phonation were reported with an open-ended interview.
Results. P(sub) and P(oral) were higher in deep bubbling and P(trans) lower than in loud syllable phonation, but
the CQ did not differ significantly. Similar results were obtained for the comparison between loud deep bubbling
and strained phonation, although P(sub) did not differ significantly. Most of the subjects reported deep bubbling to
be stressful only for respiratory and lip muscles. No big differences were found between trained and untrained subjects.
Conclusions. The CQ values suggest that deep bubbling may increase vocal fold loading. Further studies should
address impact stress during water resistance exercises.
Key Words: resonance tubeswater resistance therapycontact quotientimpact stressvocal loading.
and higher impact stress. Based on these facts, CQ and P(trans) estimating the subglottic pressure from oral pressure during pho-
were used as estimates of strenuousity of voice production in nation into the tube.
the present study. P(sub) was estimated from oral pressure during Figure 1 shows the experimental setup. Oral pressure P(oral),
vocal tract occlusion (eg,26). The CQ and P(trans) from a vowel- EGG signal, and acoustic signal were recorded simultaneously
like phonation into resonance tube submerged 10 cm in water in all tasks. P(oral) was registered with MS-110 transducer elec-
were compared with the same parameters from repetitions of syl- tronics unit (Glottal Enterprises, Syracuse, NY) using transducer
lable pa produced in comfortable loudness, loudly, and in very PT-75, which is capable of registering also high pressures (up
strained (loud, high-pitched, and pressed) voice. Syllable pro- to 75 cm H2O). The pressure signal was calibrated into cm H2O
ductions were used as reference as the vocal tract occlusion during values using PC-1H calibration unit. Vocal function was studied
voiceless plosive p allows for estimating P(sub) from P(oral).26 with electroglottography (dual-channel EGG, Glottal Enter-
When phonating into the resonance tube in the water, the vocal prises), which shows the glottal contact area variation during
tract occlusion was established by rapid manual shuttering of phonation.26 To obtain the EGG signal, two pairs of electrodes
the outer end of the tube.5 were tightly placed on both sides of the thyroid cartilage using
a Velcro band. The EGG signal was high pass (HP) filtered at
40 Hz, as in Ref.15 The signal quality was monitored on an os-
METHODS
cillogram during recording. Acoustic signal was recorded with
Fourteen subjects with no known pathology of the larynx or voice
a head-mounted microphone (AKG C5441, Vienna, Austria) at
(14 subjects; 6 male, 8 female; mean age: 43 years) volun-
6 cm from the lips. The acoustic signal was calibrated for sound
teered as participants. The subjects were divided into two groups
pressure level measurements by recording a sine signal, 1 kHz,
according to their prior training in voice. Half of the subjects
73.6 dB as reference. Recordings were made with Computer-
(4 female, 2 male) had taken at least their bachelors degree in
ized Speech Lab (CSL 4500, KayPENTAX, Lincoln Park, NJ)
vocology (ie, 34 courses in speech training during 3 years of
using 44.1 kHz sampling rate and 16 bits amplitude quantiza-
study), whereas the other half (4 female, 4 male) had not re-
tion. Additionally, the subjects were asked on an open-ended
ceived any formal voice training. The subjects with speech training
interview about their sensations during the exercise. The inter-
were familiar with water resistance therapy. The study fol-
view question was: Describe your sensations during and after
lowed the ethical principles of experimental studies in human
phonation into the tube in the water.
subjects.
The subjects phonated (1) three repetitions of [pa:] in their
comfortable conversational speaking pitch and loudness, (2) three Analyses
repetitions of the syllable loudly (as when speaking in a large Peak P(oral) pressure during [p] in the syllables pa and during
auditorium without a microphone), and (3) three repetitions of shuttering of the outer end of the tube was measured for an es-
the syllable in loud, strained voice. Then they produced (4) three timate of subglottic pressure P(sub). The mean P(oral) during
repetitions of vowel-like phonation into a glass resonance tube [a:] in the syllables and during phonation into the water through
immersed 10 cm into water. Comfortable loudness was used. Each the tube while the outer end of it was free (unshuttered) gave
vowel-like tube phonation sample lasted approximately 5 seconds. the mean P(oral) during phonation. Transglottic pressure P(trans)
Thereafter, (5) the subjects repeated the same tube phonation was then calculated as P(sub) P(oral). Analyses were per-
task, but this time using loud voice. Loudness was auditorily formed with Soundswell Signal Workstation (Nyvalla DSP,
monitored by the experimenter during recordings, and sound pres- Stockholm, Sweden). The measurement error obtained through
sure level was measured from the acoustic recordings. While repeated measurements of the same signal was +/ 0.3 cm H2O.
phonating into the water (tasks 4 and 5), the outer end of the Figure 2 illustrates the pressure measurements.
tube was rapidly fully closed with a finger at random intervals VoceVista was used to calculate the contact quotient
(34 times per sample). This shuttering procedure5 allows for (CQ = contact time/period time) from EGG (35% threshold level)
FIGURE 1. (A) The experimental setup for simultaneous registration of acoustic, electroglottographic, and oral pressure signals. (B) The pro-
cedure in shuttering: The outer end of the tube was rapidly fully closed with a finger (top) and then released (bottom picture). This was done at
random intervals during phonation into the tube. The position of the tube in the water was not changed during shuttering.
262.e3 Journal of Voice, Vol. 31, No. 2, 2017
FIGURE 2. Measurement of the oral pressure signal for (A) syllables and (B) phonation into a tube in the water.
TABLE 1.
Mean Values for CQ, Sub-, Oral-, and Transglottal Air Pressure and Sound Pressure Level (N = 14 Subjects)
CQ (%) P(sub) (cm H2O) P(oral) (cm H2O) P(trans) (cm H2O) SPL (dB)
[pa:] habitual
Mean 44.6 5.2 0.2 5 73.1
SD 8 1 0.1 1 6.1
[pa:] loud
Mean 50.9 9.5 0.3 9.2 83.6
SD 4.9 2.9 0.1 2.9 6
[pa:] strained
Mean 60.1 21.5 0.3 21.3 95.3
SD 7.8 7.8 0.1 7.8 4.7
[u:] tube 10 cm
Mean 54.2 15.7 11.3 6.8 71.6
SD 7.6 4 2.7 3.7 4.9
[u:] tube 10 cm loud
Mean 56 23.4 10.4 13.1 75.9
SD 8.1 6.5 4.2 6 7.8
Differences
[pa:] loud/tube habitual P = 0.103 P = 0.001 (W) P = 0.000 (W) P = 0.011 (W) P = 0.000
[pa:] strained/tube loud P = 0.102 P = 0.484 P = 0.000 P = 0.006 (W) P = 0.000
Notes: Significance of differences between sample types was studied with t test. Because the pressure values for bubbling in comfortable loudness and
P(trans) for loud bubbling did not show a normal distribution, the Wilcoxon signed-rank test was used (W); in other cases Students t test was applied.
Statistically significant P values in bold.
Abbreviations: CQ, contact quotient; SD, standard deviation.
P(sub) was significantly larger in deep bubbling. Relatively high amplitude of the vocal folds and therefore possibly a lower impact
CQ values and high P(sub) suggest increased vocal effort. Large stress.
CQ may indicate higher impact stress, and thus higher vocal fold There was a slight tendency that untrained subjects had some-
loading.19,25,28 On the basis of the results of the present study, it what higher CQ values for comfortable and loud phonation and
seems that deep bubbling may increase vocal fold loading. On for deep bubbling in comfortable loudness, and higher P(trans)
the other hand, because P(oral) was significantly higher in deep values for loud phonation and for deep bubbling in comfort-
bubbling than in syllable production, P(trans) was also signifi- able loudness, compared with the trained subjects (Figure 4).
cantly lower in bubbling, which seems to suggest a lower vibratory The trained subjects may, thus, be able to produce loud phonation
FIGURE 4. Distributions for contact quotient (CQ) and P(trans) (N = 14 subjects, 6 with training).
262.e5 Journal of Voice, Vol. 31, No. 2, 2017
and deep bubbling with less effort. Most of them also re- 5. Titze IR, Finnegan EM, Laukkanen A-M, et al. Raising lung pressure and
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