The Use of Oscillatory Positive Expiratory Pressure Devices for Voice Therapy

Over the last three years, a variety of oscillatory positive expiratory pressure (OPEP) devices have been commonly used by voice therapist and trainers (e.g. Acapella Choice, Shaker Deluxe, Shaker Medic Plus, New Shaker), even if they were not originally created for voice-treatment purposes. OPEP are intended to be used by physiotherapists to mobilize secretions from the lower airway when treating excessive sputum or secretion retention. The mechanism of oscillatory OPEP is based on a continuous and rapid shuttering of airflow, which in turn produces modulation of the oral and tracheal air pressure as patients blows into them. People diagnosed with cystic fibrosis and neurogenic diseases are usually recommended using OPEP devices [1, 2]. OPEP devices are different from expiratory/inspiratory muscle strength training devices, which have no oscillatory mechanisms inside.

Different phonatory tasks such as sustained pitches, glissandos, accents, song melody, etc. can be performed when OPEP devices are used for voice purposes.  Previous voice studies with OPEP devices have suggested that they can be useful (when they are used with phonation) to reduce sensation of muscle tension, vocal effort, and vocal fatigue [3-5] in a similar way to what water bubbling does. Comparisons of the massage-like sensation effect between OPEP devices and water bubbling have been carried out. The same or greater positive effects in reducing throat discomfort has been reported for OPEP devices [6].

Oral pressure (Poral) oscillation has also been explored during phonation with OPEP devices. Acapella Choice produces a greater mean peak-to-peak amplitude of Poral and higher regularity of Poral modulation than water bubbling [2]. The higher regularity of Poral modulation displayed by Acapella Choice can be explained by the more mechanistic shuttering of airflow offered by the magnetic system inside this device compared to water bubbles. A more intense massage-like sensation than water bubbling has also been reported for Acapella Choice [2]. When comparing phonation through Shaker deluxe device (another OPEP) with water bubbling, amplitude of Poral modulation was higher for the latter. This may imply that bubbles offer stronger massage-like sensation than Shaker Deluxe device. Moreover, it has been shown that Shaker Deluxe upright had slightly higher flow resistance than resonance tube 10 cm in water, while Shaker horizontally had a half of that (5 cm) [7].

Accelerometers have been used to explore neck, face and chest tissue mobilization during phonation with OPEP devices. Data show that Acapella Choice produces the highest amplitude, the lowest frequency and the greatest regularity of tissue oscillation, when compared to double source of vibration semi occluded vocal tract exercises (e.g. water bubbles, lip trills, tongue, trills) [6]. Control of these variables could be relevant to obtain the best massage-like sensation, which in turns, may positively impact in the reduction of perception of muscle tension, vocal effort, and vocal fatigue felt by patients.

Only a couple of studies have assessed the efficacy of a long-term voice therapy using OPEP devices in subjects with voice complaints despite      evidence of      the presence of a massage-like sensation, Poral oscillation, and tissue oscillation during phonation with different OPEP devices [4]. Authors have compared the efficacy of Acapella Choice and Shaker Medic Plus against water bubbling in participants diagnosed with vocal fatigue. Improvements in self-reported variables when comparing Pre and Post treatment measures have been reported for OPEP devices, but no significant differences have been found when comparing these devices with water bubbles [4]. It seems that both water bubbles and OPEP devices are equally effective in reducing voice discomfort in people with vocal fatigue after several sessions of voice therapy.

Even though OPEP devices are expected to be a higher cost option compared to water bubbles, it might prove to be beneficial to increase adherence to vocal exercise practice for those who do not feel comfortable      using a bottle filled with water in certain circumstances.  OPEP devices could constitute a more practical option compared to water bubbles.

References

  1. Patterson JE, Hewitt O, Kent L, Bradbury I, Elborn JS, Bradley JM. Acapella versus ‘usual airway clearance’ during acute exacerbation in bronchiectasis: a randomized crossover trial. Chron Respir Dis. 2007;4(2):67-74. doi: 10.1177/1479972306075483. PMID: 17621572.

  2. Saccente-Kennedy B, Amarante Andrade P, Epstein R. A Pilot Study Assessing the Therapeutic Potential of a Vibratory Positive Expiratory Pressure Device (Acapella Choice) in the Treatment of Voice Disorders. J Voice. 2020 May;34(3):487.e21-487.e30. doi: 10.1016/j.jvoice.2018.09.019. Epub 2018 Oct 26. PMID: 32389238.

  3. Saters TL, Ribeiro VV, Siqueira LTD, Marotti BD, Brasolotto AG, Silverio KCA. The Voiced Oral High-frequency Oscillation Technique’s Immediate Effect on Individuals With Dysphonic and Normal Voices. J Voice. 2018 Jul;32(4):449-458. doi: 10.1016/j.jvoice.2017.06.018. Epub 2017 Aug 24. PMID: 28844805.

  4. Guzman M, Ortega A, Rocha C, Salgado L, Quezada C. Efficacy of Voice Therapy With Acapella Choice ® Device in Subjects With Vocal Fatigue Delivered Via Telepractice. J Voice. 2022 Sep 21:S0892-1997(22)00229-6. doi: 10.1016/j.jvoice.2022.07.027. Epub ahead of print. PMID: 36153205.

  5. Antonetti AEDS, Ribeiro VV, Brasolotto AG, Silverio KCA. Effects of Performance Time of the Voiced High-Frequency Oscillation and Lax Vox Technique in Vocally Healthy Subjects. J Voice. 2022 Jan;36(1):140.e29-140.e37. doi: 10.1016/j.jvoice.2020.04.008. Epub 2020 Jun 3. PMID: 32507328.

  6. Guzman M, Acevedo K, Castro C, Moran C, Espinoza V, Quezada C. Tissue Mobilization During Double Source of Vibration Semioccluded Vocal Tract Exercises: A Neck and Face Surface Acceleration Study. J Speech Lang Hear Res. 2021 Nov 8;64(11):4124-4137. doi: 10.1044/2021_JSLHR-21-00033. Epub 2021 Oct 18. PMID: 34662217.

  7. Laukkanen A-M, Horáček J, & Radolf V. Buzzer versus water resistance phonation used in voice therapy. Results obtained with physical modeling. Biomedical Signal Processing and Control. 2021; 66(12): 102417. http://dx.doi.org/10.1016/j.bspc.2021.102417
Dr. Guzman received his Ph.D. in Vocology from Tampere University, Finland. He is currently an associate professor at the Universidad de los Andes, Department of Communication Sciences and Disorders. He also works as a clinician in the Department of Otolaryngology, Las Condes Clinic. Dr. Guzman joined the faculty at the Summer Vocology Institute in 2022 (University of Utah). He is an active researcher and author of numerous scientific articles related to the underling physiology of SOVT exercises and physiologic voice therapy.
Marco Guzman
Editor, NCVS Insights

How to Cite

Guzman, M. (2023), The Use of Oscillatory Positive Expiratory Pressure Devices for Voice Therapy. NCVS Insights, Vol 1(4), pp. 3-4. DOI: https://doi.org/10.62736/ncvs192743