The Effects of Adding Expiratory Muscle Strength Training in Voice Therapy

• Fundamental frequency[ Time Frame: 16 weeks ]
  Fundamental frequency, measured in herz, will be obtained using the Multidimensional Voice Profile on Kay Pentax Computerized Speech Lab.
• Dynamic pitch range[ Time Frame: 16 weeks ]
  Dynamic pitch range will be measured using Voice Range Profile on Kay Pentax Computerized Speech Lab.
• Jitter[ Time Frame: 16 weeks ]
  Jitter, measured in relative average perturbation, will be obtained using the Multidimensional Voice Profile on Kay Pentax Computerized Speech Lab.
• Shimmer[ Time Frame: 16 weeks ]
  Shimmer, measured in decibels, will be obtained using the Multidimensional Voice Profile on Kay Pentax Computerized Speech Lab.
• Noise to harmonic ratio[ Time Frame: 16 weeks ]
  Noise to harmonic ratio, which is measured in a ratio, will be obtained using the Multidimensional Voice Profile on Kay Pentax Computerized Speech Lab.
• Voice Handicap Index[ Time Frame: 16 weeks ]
  This is quality of life assessment tool quantifying perception of the impact of their vocal disorder on various aspects of lifestyle. It is 30-questions in length and is divided into 3 subscales including emotional, physical, and functional, divided into 10 questions each. Each question scored from 0-4. Total score range from 0-120. Higher score indicates increased handicap.
• Maximum phonation time[ Time Frame: 16 weeks ]
  The patient will be asked to inhale deeply and sustain the vowel /a/ at a comfortable loudness level for a many seconds as possible.
• Peak expiratory flow rate[ Time Frame: 16 weeks ]
  Peak expiratory flow rate, measured in units of liters per minute, will be measured for purposes of measuring cough function.

Evaluate if adding expiratory muscle strength training to traditional voice therapy for individuals with dysphonia due to glottal insufficiency improves maximal expiratory pressure, acoustic and aerodynamic measures (i.e. amplitude, maximum phonation time, peak expiratory flow), and voice related quality of life.

• Other: Standard of care voice therapy
  Exercises will include improved breath coordination, sustained humming and vowels, vocal glides, resonant voice therapy, and relaxation techniques to the neck and shoulder
• Device: Expiratory muscle strength training (EMST)
  EMST150 used at 75% of their maximum expiratory pressure. Participants will be directed to perform 5 sets of 5 breaths, 5 days per week, for 5 weeks, at the pressure threshold established in therapy. Maximum expiratory pressure will then be determined at the beginning of each therapy session and recalibration of the device will be performed if indicated.

• Experimental: Unilateral vocal fold paralysis standard of care voice therapy
  The participants will receive the standard of voice therapy including improved breath coordination, sustained humming and vowels, vocal glides, resonant voice therapy, and relations techniques.
• Experimental: Unilateral paralysis standard of care voice therapy plus EMST
  The participants will receive the standard of voice therapy including improved breath coordination, sustained humming and vowels, vocal glides, resonant voice therapy, and relations techniques. EMST consists of blowing into respiratory device at a measure threshold pressure. As strength improves threshold resistance will be increased.
• Experimental: Parkinson's disease standard of care voice therapy plus EMST
  The participants will receive the standard of voice therapy including improved breath coordination, sustained humming and vowels, vocal glides, resonant voice therapy, and relations techniques. EMST consists of blowing into respiratory device at a measure threshold pressure. As strength improves threshold resistance will be increased.