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Logopedics Phoniatrics Vocology

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The resonance tube method in voice therapy:
Description and practical implementations
Susanna Simberg a; Anneli Laine b
a
Department of Logopedics, Åbo Akademi University, Turku, Finland
b
Department of Otorhinolaryngology, Turku University Central Hospital, Turku,
Finland

First Published on: 18 April 2007

To cite this Article: Simberg, Susanna and Laine, Anneli (2007) 'The resonance tube
method in voice therapy: Description and practical implementations', Logopedics
Phoniatrics Vocology, 32:4, 165 - 170
To link to this article: DOI: 10.1080/14015430701207790
URL: http://dx.doi.org/10.1080/14015430701207790

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Logopedics Phoniatrics Vocology. 2007; 32: 165
170

ORIGINAL ARTICLE

The resonance tube method in voice therapy: Description and practical

implementations

SUSANNA SIMBERG1 & ANNELI LAINE2

1
Åbo Akademi University, Department of Logopedics, Turku, Finland, 2Turku University Central Hospital, Department of
Otorhinolaryngology, Turku, Finland

Abstract
Phonation into glass tubes, keeping the free end of the tube in water, has been a frequently used voice therapy method in
Finland for more than four decades. These so-called resonance tubes, introduced by Professor Sovijärvi in the 1960s, are
used in different ways depending on the patient’s diagnosis and the goal of the voice therapy. In this paper, some of the most
common ways of using the tube are presented.

Key words: Acoustic impedance, resonance tube, voice exercise

Introduction *
The resonance tube a brief history
Several methods used in voice therapy involve partial Phonation into resonance tubes made of glass has
occlusion of the vocal tract in order to create been used in voice therapy in Finland since the
acoustic impedance. Recent reviews by Bele (1) 1960s. The method has also been used by normal-
and Titze (2) show that there has been an increasing voiced persons such as singers for vocal care. It
interest in exploring the effects of such methods. was introduced by Professor Antti Sovijärvi at
Some of them include phonation into different kinds the Department of Phonetics at the University of
of tubes or straws. The Finnish so-called ‘resonance Helsinki, the department where also speech thera-
tube method’ is mentioned in several articles (e.g. pists were trained at that time.
(1
4)). There are no recent detailed published Sovijärvi used the resonance tube as a part of his
reports of how the method is used in the treatment voice therapy and treated about 700 voice patients
of persons with voice disorders in languages other with good results (7). He was at first interested in
than Finnish (5), except for a brief description in the testing different kinds of glass tubes in the voice
proceedings from the 5th Nordic Congress of therapy of children who had rhinolalia aperta (hy-
Logopedics and Phoniatrics in Helsinki 2000 (6). pernasality), but he soon started to use the tubes also
Finnish speech therapists find the method effective with adult singers who had voice problems (8). He
for the treatment of different kinds of voice dis- tried out different kinds of glass tubes with various
orders. lengths and diameters. Based on his studies of X-ray
Unfortunately, no evidence-based research of the pictures of the tracheal bifurcation he came to the
effectiveness of this method has been performed. conclusion that the thickness of the glass should be
The intent of this paper is merely to describe the 1 mm and that the inner diameter should be 8 mm
resonance tube method and to present some exam- for children and 9 mm for adults. The length of
ples of how it can be used in various ways depending the tube was 24
25 cm for children and 26
28 cm
on the voice disorder and the aims of the therapy. for adults, which was the length from the tracheal

Correspondence: Professor Susanna Simberg, Åbo Akademi University, Fabriksgatan 2, 20500 Åbo, Finland. Fax: /358-2-2154833. E-mail: susanna.
[email protected]

(Received 20 July 2006; accepted 2 January 2007)

ISSN 1401-5439 print/ISSN 1651-2022 online # 2007 Taylor & Francis
DOI: 10.1080/14015430701207790
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166 S. Simberg & A. Laine

bifurcation to the teeth (8). Sovijärvi chose the main principle in the tube exercise is that the patient
length of the tube in relation to how he, by palpation, phonates a vowel-like sound into the tube keeping
felt the larynx sinking during the phonation of a the free end of the tube in water. This will change the
lengthened /b/ into the tube (7). The length of the magnitude of the input impedance of the vocal tract,
most suitable tube for a patient corresponded and the amount of impedance change is controlled
with the voice category, so that a 26 cm long tube by the depth of the submersion of the tube (4).
corresponded to the soprano and tenor voices, 27 cm The resonance tube method is suitable for the
to mezzo-soprano and baritone voices and 28 cm to therapy of most voice disorders. The focus is on
alto and bass voices (7,8). phonation, breathing and posture. When performing
The resonance tube was kept about 1 mm in the exercise correctly, the muscles involved in voice
between the teeth, the lips rounded so that no air production are in balance and enhance economical
would leak from the mouth, and the free end was voice production. The tube can be used in different
kept either below the surface of water in a bowl or in ways in different phases of the therapy depending on
the air as an extension of the vocal tract. Sovijärvi the specific problems and short-time goals. The aim
pointed out that the water bowl should be kept in a
is often to achieve a normal, well functioning voice.
position that enabled a good body posture for
Working with patients with neurological disorders,
phonation. It should also be big enough for the
such as Parkinson’s disease, the goal might be to
patient not to feel afraid that the water would run
delay the deterioration of the quality or strength of
over the edge of the bowl (7). The patient phonated
the voice.
the logatomes (nonsense words) /jibbii/, /jobboo/,
Sometimes the resonance tube method might be
/jybbyy/ with the /bb/ phase lengthened so that the
the only method used but usually the patients also do
laryngeal depressor had more time to react (9). The
purpose of /j/ was to eliminate a hard glottal attack other voice exercises. The voice therapy almost
(7). Additionally, the articulatory configuration of /j/ always includes information on voice ergonomics,
(the contact of the dorsum of the tongue with the which comprises all actions that facilitate verbal
anterior part of the palate) widened the lower part of communication and issues usually referred to as
the pharynx and brought the epiglottis to a more vocal hygiene (12,13).
upright position (10). The exercise should be carried In clinical practice today, it is seldom possible to
out several times a day for about 2 minutes each offer very long voice therapy periods. When the
time, and the treatment periods varied from 2 to patient is treated, for example, for vocal hyper- or
6 months (9). hypofunction, ventricular voice, chronic laryngitis or
According to Sovijärvi (10), the positive outcomes vocal nodules, the voice therapy period usually lasts
of the resonance tube method were due to the for about 2 months, with about two appointments
efficient lowering of the larynx and the firming of during the 3 first weeks. In total, the speech therapist
the vibration of the vocal folds. When the free end of has scheduled 8
12 appointments and at least one
the tube was kept in water, the water bubbled during appointment for a control after the therapy period
the phonation and he thought that the vibration from has ended. Depending on the aetiology and the
the bubbling was reflected in the glottis, having a severity of the disorder, the voice therapy period can
densing effect. Sovijärvi not only used the resonance be longer.
tubes in the treatment of professional singers and
patients who experienced phonasthenia (vocal fati-
gue), but he also treated patients with vocal nodules The length of the tube
and vocal fold paralysis (10,11).
Sovijärvi thought that the length of the tube should
be chosen according to the voice category of the
The resonance tube method in voice therapy for patient and the lowering of the larynx during the
some groups of patients tube phonation (7,8). The glass tubes that Sovijärvi
The authors of this paper have been using the designed are still in frequent use. It is common,
resonance tube method in voice therapy for different however, that patients do not know their voice
groups of patients for more than three decades. As category. Additionally, the patient’s voice quality is
with other voice training methods, speech therapists often so deviant at the beginning of the therapy
often make modifications to suit the goals of period that it is impossible to determine the normal
the therapy and the problems of the patient. The voice category. A main principle for Finnish speech
descriptions below are based on the guidelines therapists is to choose the tube that best enhances
of Professor Sovijärvi, with some modifications the lowering of the larynx during the phonation of a
based on clinical experience and practice. The lengthened /b/ into the tube.
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The resonance tube method in voice therapy 167

Body posture training. Gradually, the patient starts to use more

varied intonation such as glides and simple intervals
It is important that the patient feels comfortable and
in a glissando mode. The patient is asked to keep the
relaxed when performing the resonance tube ex-
phonation stable and to follow a normal and
ercise. The bowl of water should be kept on a table
comfortable breathing pattern in all exercises.
and not in the hand, and the chair should be
The resonance tube exercise is practised in the
adjusted according to the height of the patient in
voice clinic until both the speech therapist and the
order to enable a relaxed posture. The patient keeps
patient feel confident that the patient is doing it
the tube in the hand between the thumb and the
correctly, without effort. After that, usually on the
fingers, and the bowl should be kept in a position
first or second therapy appointment, the patient is
that does not force the patient to bend the neck and
given the tube for home exercises. Every patient
lower the chin but to support a good body posture
receives detailed written instructions on how to use
for phonation. Thus, the use of a drinking glass or a
the tube at home, such as how long every training
bottle is not appropriate.
session should last and how many training sessions
there should be a day. When the patient takes the
Starting the resonance tube exercise tube home, an appointment is usually scheduled for
within 2 days. Even if the exercise has been practised
As described above, Sovijärvi used the logatomes with the speech therapist, some patients may forget
/jibbii/, /jobboo/, /jybbyy/ for the tube exercise. the instructions, especially at the beginning of the
Today it is common that the speech therapists merely voice therapy period. The most common mistake is
advise patients to phonate a vowel-like sound into that the patient forgets to phonate and merely blows
the tube (the prolonged /bb/ phase), using their air into the tube. The bubbles are seen in the water
habitual speaking pitch and volume. Patients are but no tone of voice is heard. When this occurs, the
often more motivated to do the exercise this way patient is asked to phonate into the tube when
because of the strong vibration they feel in their keeping the free end in the air, following the speech
throat during the phonation. Additionally, many therapist’s example. When the patient understands
patients find it easier to do the exercise when they the idea of phonating into the tube, ‘making the
do not have to ‘say’ anything. Most patients find it sound’, the free end of the tube is submerged.
easy to phonate into the tube and they usually do the Sometimes it is advantageous to record the exercise
exercise correctly merely by imitating the speech on a tape or on a CD to help the patient remember
therapist. The patient keeps the free end of the tube how the exercise should be performed. Other ordin-
1
2 cm under the surface of water (Figure 1). This
ary mistakes are that the patient has an improper
exercise is used for patients who have for example
body posture when training at home or that the
hyper- or hypofunctional voice, ventricular voice,
patient forgets to breathe and becomes exhausted.
chronic laryngitis, and vocal nodules. At the begin-
Some patients might use a pitch which is too high or
ning of the voice therapy period, the patient uses an
too low, or they keep the tube too deep under the
almost monotonous voice at least for the first week of
surface of the water, which can be harmful because
the impedance becomes too great and makes the
phonation forceful. Phonating into the tube requires
concentration, at least when patients first start to do
the exercise. Some patients have difficulties concen-
trating and some have auditory perception problems,
which hinder them from learning to do the exercises
correctly. Some patients with asthma might feel that
the resonance tube exercise provokes coughing. In
such cases, the method is not suitable. However,
patients usually find the exercises easy to perform,
and problems rarely arise.
Sometimes patients who have breathy voices, for
example due to a functional voice disorders, ask
‘What do you mean by breathy?’ They simply seem
to have difficulties in hearing that feature in their
own voice production. In these cases, the resonance
tube can be used so that the patient keeps the end of
Figure 1. The end of the tube is about 1
2 cm under the surface the tube only about 1 mm under the surface of the
of the water. water (Figure 2) or does not keep it in the water at
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168 S. Simberg & A. Laine

the patient finds it relaxing to phonate into the tube

keeping it 1
2 cm below the surface of the water (as
described above) after the ‘tube-pushing’ exercise.

The sensations of the patient

During the performance of the resonance tube
exercises, the patients usually feel distinct vibrations
and backpressure in the larynx, even if the phonation
is unforced. They also feel a sensation of vibration
and resonance in the face and sometimes in the
chest. This is very motivating; the patients feel ‘that
something is actually happening’. Most patients
find the vibrations relaxing, like a ‘massage’. If the
sensation of backpressure is too strong or uncomfor-
table for the patient, the tube is pulled closer to the
surface of the water.
Figure 2. The end of the tube is about 1 mm under the surface of
the water. Some patients might have negative sensations
when they first start to use the resonance tube. It is
therefore important to inform them of this before-
all. Phonating into the tube strengthens the auditory
hand so that they do not get worried and stop doing
feedback, and most patients realize the difference
the exercises. Such sensations include a feeling of
between breathy and normal voice during this kind
dryness or too much mucus in the throat, a sensation
of tube phonation.
of tickling in the throat or a need to clear the throat.
If the patient suffers from incomplete vocal fold
The speech therapist can advise the patient to
closure, for example due to recurrent laryngeal nerve
drink water after (or during) the training session.
paresis, the resonance tube can be used so that the
The negative sensations generally disappear within
tube is kept 5
15 cm below the surface of the water
2 days, when the patients become accustomed to
(Figure 3). In this exercise, it is of particular
performing the exercises. If the sensations persist,
importance that the phonation is extremely short,
which is very unusual, the speech therapist chooses
as in the pushing exercises. The patient carries out
other voice therapy methods.
the exercise about 10 times a day, with 5
15 short
The patient should under no circumstances feel
phonations on every training session. The patient is
pain during the exercise. If the patient suffers from
given exact instructions according to the diagnosis,
laryngitis and feels pain when phonating into the
the laryngeal status, and the degree of breathiness.
tube, the exercises should be postponed until the
This exercise is forceful and the patient might feel
laryngitis is less severe (e.g. after having medicated
that the larynx becomes tense or tires. Frequently
for reflux). When the patient suffers from an upper
respiratory tract infection and phonating into the
tube feels painful or provokes a cough, the tube
should not be used. It is important that the speech
therapist keeps informed of possible negative sensa-
tions during the whole therapy period. Usually the
subjective sensations of the patients are reliable and
the speech therapist makes changes in the therapy
programme accordingly.
Sometimes voice patients seem to overstress the
control of their voice production or feel very anxious
performing voice exercises. These patients often feel
confident when they use the resonance tube. The
bubbling of the water can be felt as an effective
‘masking’ of the voice, which might be advanta-
geous, at least in the beginning of the voice therapy
Figure 3. The end of the tube is about 15 cm under the surface of period. Additionally, patients often feel comfortable
the water. having a device for training.
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The resonance tube method in voice therapy 169

The home training programme Discussion

The home training programme is intensive. At least When using the resonance tube exercises with the
during the first 1 or 2 weeks, the patient performs free end of the tube in water, the impedance can
the tube exercises 10
12 times a day for about easily be manipulated according to the purposes of
1 minute each time. After this, the patient can carry the exercise. Complications can occur, however.
out the tube exercise for about 4
5 minutes, five to Bele (1) reports that phonating into tubes can be
six times a day. Gradually, the patient is instructed to problematic because it can ‘kill’ phonation if the
vary the tube exercises so that the free end of the resistance of the vocal tract is excessive, which might
tube is kept in the water and in the air in turns, and happen if a tube is very narrow, extremely long, or is
to use more intonation, ‘humming’ simple tunes or kept very deep in the water. This is also the
intervals. When the free end of the tube is kept in the experience of the authors of this paper. Additionally,
air it is easy for the patient to monitor the vocal if the diameter of the tube is very large and the tube
production. The patient can also add vowels to the is very long, the phonation might be effortful for the
/bb/, for example /jibbii/, /abba/, /ebbe/, et cetera. patient. During the last decade, tubes made of
Usually, the patient also has other voice exercises to silicon or similar materials have been used for voice
do at home. If the patient is working, it can often be training. These tubes can be bought (per meter) in
arranged for the patient to have short breaks for hardware stores. A new phenomenon is that some
performing the exercises. If the patient has a severe patients who come to voice therapy have bought a
voice disorder and is working in a vocally demanding piece of silicone tube because they have ‘read in a
occupation, it is often necessary for the patient to be magazine or on a web site’ or ‘heard from someone’
on sick-leave for at least 2 weeks when the voice that phonating into tubes with the free end in the
therapy starts. water is good for the voice. Sometimes these tubes
The home training programme is updated at every have been very long and/or have had a very large or a
voice therapy session. When the voice therapy period very small diameter, which makes phonating into
ends, the patient is usually given a personal home them forceful, especially when holding the free
training programme. This includes the voice exer- end very deep in the water. This kind of voice
cises and voice ergonomic advice which the speech production might be harmful for someone who has
therapist considers the most beneficial for the vocal nodules, for example. It is essential that
patient. The patient might be given the instruction persons with possible voice disorders undergo a
‘Do this exercise/these exercises those days that you medical examination by a phoniatrician or a laryn-
feel that your voice is strained or tired’ or ‘Always do gologist before starting the voice therapy. The
these exercises after a vocally demanding activity’. speech therapist can ensure that the patients use
Patients often ask whether they should continue with tubes that are appropriate for the purpose of the
the resonance tube exercises ‘for ever’ but generally voice therapy and give exact instructions for the
that is not necessary. However, it feels good for the exercises.
patients to have a familiar and easy method for voice One disadvantage with tubes made of soft-walled
training and many patients, especially professional materials is that they seem to absorb the sound,
voice users, have reported that they continue to use which makes the auditory feedback blurred. Some
the resonance tube from time to time. patients also think that they do not feel the reso-
nance as intensely when phonating into a silicone
tube as when using a glass tube. One benefit with
Summary tubes made of soft materials is that they do not break
Finnish speech therapists have found the resonance as easily as glass tubes. Even if the resonance tubes
tube to be a functional tool in the treatment of used today are made usually of laboratory glass, they
various voice disorders, some of them mentioned in are more fragile than soft-walled tubes. Tubes made
this paper. A schematic presentation of how the of soft materials might be suitable when there are
resonance tube can be used is presented in Table I. reasons to believe that a tube of glass might easily
This is not intended to be seen as a ‘manual’, but break, as in the case of patients who suffer from
merely to give some suggestions of how the tube can neurological diseases affecting the cerebellum caus-
be used in voice therapy. As pointed out above, each ing ataxia and patients with Parkinson’s disease
patient receives personal instructions and a person- tremor. When the speech therapist decides to use a
ally adjusted training programme. The instructions soft-walled tube with a patient, the length and the
change depending on the progress of the patient and diameter should be selected to suit the goals of the
the goals of the therapy. voice therapy.
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170 S. Simberg & A. Laine

Table I. Some examples of how the resonance tube method can be used.

Position of the tube under the

Diagnosis surface of the water Goals

Hyperfunctional voice, vocal 1
2 cm. Keeping the tube at this depth Relaxation of the muscles of the larynx,
nodules allows an effective but still relaxed phonation. improved vocal economy.
Hypofunctional voice, incomplete 1
2 cm. For some patients 5
15 cm (short Depending on the diagnosis and laryngeal
vocal fold closure phonation). Keeping the tube deep in the status: relaxation of the muscles of the
water forces the vocal folds to adduct very larynx, efficient voice production, activating
effectively. of the laryngeal muscles. Compensation, like
a pushing exercise.

Speech therapists have a responsibility to ensure References

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