Tissues vs Humming For Muscle Tension Dysphonia: Let’s Get Ready to Rumble!


But my graduate class ONLY taught me about RVT…

For voice therapy geared toward patients who suffer from muscle tension dysphonia (MTD), maybe you feel like the list of exercises from your old supervisor will suffice. Maybe you feel like if resonant voice doesn’t work well for your patient, voice therapy won’t work. Maybe you have been hitting a wall with your MTD patients and you both are frustrated. Maybe you are in for a treat…

The Old Guard

In the voice therapy game, the most popular boxer in the ring is resonant voice therapy (RVT). Ingo Titze discusses it in his 2001 Journal of Voice article that resonant voice is more likely to be vocal fold vibration and supraglottic acoustic pressure helping each other (happy friends in the laryngeal area) than a facial resonance that boosts certain frequencies (Titze, 2001). We use this science in our treatment rooms to help patients suffering from MTD, and we get great outcomes. Kittie Verdolini Abbott, Mary Katherine Burke, Arthur Lessac, Leslie Glaze and Elizabeth Caldwell got together in 1995 to compare confidential voice (actually derived from what we are about to discuss) finding that both this and RVT had good outcomes for patients receiving voice therapy. (This wasn’t their only conclusion from this study, and it’s worth a read if you have never read it)

Enter: Stretch and Flow

Ed Stone and Robert Casteel wrote a chapter (chapter 6 in the book called Phonatory Voice Disorders in Children) discussing the phenomenon of a non-organic dysphonia (MTD) and the problem we face trying to create something to elicit “respiratory and phonatory neuromuslcar coordination” and how to “shape that behavior into optimal voice performance.” (Stone & Casteel 1982) The proposed Stretch and Flow (SnF) with a hierarchy of unvoiced stimuli and voiced stimuli, that was different than anything else we were using for voice rehabilitation. They were on to something, but it did not become as popular as RVT.

Ding-ding, we’re in the ring

Chris Watts, Amy Hamilton, Laura Toles, Lesley Childs, and Ted Mau wondered if there is truly evidence that one approach is better for patients with MTD. We know that we need better information about evidence based approaches to treat MTD, which is why this study was created. There are only a handful of studies comparing alternative voice treatments for MTD using a noninferiority design. We don’t want to leave a treatment method out in the cold without a good randomized control trial first. ☺ It seems that RVT has been undefeated and SnF is the new contender in the ring. A randomized control trial was created with 21 folks with MTD, giving 12 of them SnF and 9 of them RVT. Participants’ improvement was measured with multiple assessment tools, including perceptual and objective (full description on Data Collection can be found on page 275.) Attrition (drop outs, non-high school ☺ ) is expected, so of the 34 initially, only 21 were included in the final results. (A nice chart on page 277 shows how this occurred.)

How can I benefit from this match-up?

So how does this help you when treating patients with MTD? This study demonstrates that RVT and SnF both improve outcomes in patients with MTD. It has a nice long discussion (page 281) about types of patients appropriate for single or combined treatment modalities of this nature, as well as how one might troubleshoot a session as the clinician. Obvious limitations in this study include a small sample size, inclusion limitations, and long term outcome or dosage recommendations.

So what?

Hopefully after reading this blog, you have some places to start researching Stretch and Flow as a lesser-known treatment method for MTD, and you can use it independently of Resonant Voice Therapy, or alongside it, to help your patients get the best outcomes.


Stone, R.E., & Casteel, R. (1982). Restoration of voice in nonorganically based dysphonia. In M. Filter (Ed.) Phonatory voice disorder in children. Springfield, IL: Charles C Thomas.

Titze, I.R. Acoustic interpretation of resonant voice. J Voice. 2001; 15: 519–528

Verdolini-Marston, K., Burke, M.K., Lessac, A., Glaze, L., and Caldwell, E. Preliminary study of two methods of treatment for laryngeal nodules. J Voice. 1995; 9: 74–85

Watts, C.R., Hamilton, A., Toles, L., Childs, Lesley, & Mau, T. (2019). Intervention Outcomes of Two Treatments for Muscle Tension Dysphonia: A Randomized Controlled Trial. Journal of Speech, Language and Hearing Research. Doi: /doi/pdf/10.1044/2018_JSLHR-S-18-0118

Want more on Stretch and Flow?

Watts and Awan have a nice write up in Laryngeal Function and Voice Disorders: Basic Science to Clinical Practice from Theme Publishing.

Sin City Laryngology conference next year is having a hands-on teaching lectures on stretch and flow and many other techniques given by Sarah Schneider, with help from Amanda Gillespie, Leah Helou and Edie Hapner.

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Also, I have video demonstration in The Confident Clinician Video Series; Voice Rehabilitation and in Voice in a Jiff. Also, there is a kid-friendly version with a ladder clip art and more, in the Confident Clinician Series: No-Prep Voice Therapy manual.









You can click on the links above for my main store, or you can choose to obtain though Teachers Pay Teachers.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on voice science nationally. She is part of the Professional Development Committee for ASHA Special Interest Group 3, Voice and Upper Airway Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.


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