Lax Vox as a Voice Training Program for Teachers:

A Pilot Study
*Eva Mailänder, †Lea Mühre, and ‡,§Ben Barsties, *†§Hamburg, Germany, and ‡Belgium

Summary: Objectives. The objective of this study was to explore the effectiveness of a 3-week training program
with the voice therapy “Lax Vox” for teachers.
Methods. Four healthy female teachers participated as volunteers for the study. Several voice measurements of per-
ception, acoustics, aerodynamics, and self-evaluation were investigated. Furthermore, a survey to rate the applicability
of Lax Vox was also part of the study. To assess the treatment effects of the Lax Vox training, an effect size analysis
(dunb) was conducted.
Results. After 3 weeks of training, medium and large improvements were found in some parameters of perceptual and
acoustic voice quality assessments (dunb >0.50 and dunb >0.80, respectively). Furthermore, medium improvements were
revealed in some parameters of self-evaluation (ie, physical and total scale of the Voice Handicap Index) and aerody-
namic (ie, maximum phonation time) assessments (all dunb >0.50). Additionally, acoustic measures of vocal function showed
an expansion in the upper contour of voice range profiles after training. Particularly, the main improvements in the voice
range profile was found in the modal and the beginning of the falsetto voice registers. There was an increase of the in-
tensity levels of about 4.6 dB. No changes were revealed in some acoustic measures of the voice range profile, self-
evaluation measurements, and the perception of breathy voice quality (all dunb <0.20). Finally, the applicability of Lax
Vox perceptually showed clear support in training success, learning process, and transfer to the daily routine.
Conclusions. Lax Vox training for teachers appears to improve select measures of voice quality, maximum phona-
tion time, vocal function, self-evaluation, and perceived applicability.
Key Words: lax vox–voice therapy–preventive voice training–teacher–dysphonia.

INTRODUCTION disorders.4,15 Sixth, teachers reported experiencing signifi-

The prevalence of developing voice disorders or voice prob-
lems in teachers is very high.1–4 It was shown that teachers have
twice the risk of developing voice problems compared with other
professional groups.1,2 Reasons for the high prevalence in teach-
ers might be related to several risk factors. First, a high number
of pupils in the classroom have a significantly higher impact on
teachers developing voice problems.4,5 More effort in voice pro-
duction is needed for the teacher because each pupil must hear
the teacher, who is normally standing at the front of the class-
room. Second, a high noise level inside the classroom has a
significant impact on developing voice problems.4–6 A high noise
level in the classroom ensures that a higher sound pressure level
is used by the teacher, which results in greater vocal loading.7–9
Third, teachers frequently showed an insufficient voice consti-
tution and inadequate voice technique in accomplishing their voice
tasks.10,11 Fourth, female teachers showed a significantly higher
risk of developing voice disorders than male teachers.9,12,13 Because
women enter the teaching profession clearly more often than
men,14 the chances of developing voice disorders increase greatly
for this profession in comparison with other professions. Fifth,
psycho-emotional factors such as an intense workload and stress
increase the risk of teachers developing voice complaints or voice
Accepted for publication April 25, 2016.
Disclosure: This study has no actual or potential conflict of interest and was not finan-
cially supported.
From the *Logopädie Harburg, Hamburg, Germany; †Praxis für Logopädie Stefan Witt,
Hamburg, Germany; ‡Faculty of Medicine and Health Sciences, University of Antwerp,
Belgium; and the §Medical School, Hochschule Fresenius University of Applied Sci-
ences, Hamburg, Germany.
Address correspondence and reprint requests to Ben Barsties, BHth Universiteitsplein
1 2610 Wilrijk, Antwerp, Belgium. E-mail: ben.barsties@t-online.de
Journal of Voice, Vol. 31, No. 2, pp. 262.e13–262.e22
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.04.011
cantly more allergies, colds, and laryngitis annually as compared
with nonteachers.2
Many of these risk factors are treated with interventions (eg,
vocal hygiene and/or voice exercises that are included in several
preventive voice training programs). The aim of these interven-
tions is to reduce the probability of developing voice problems
or voice disorders for teachers.16–18 There are several publica-
tions that investigate the effectiveness of voice training. Two
literature reviews on this topic have been conducted to analyze
the effectiveness of voice training from 1967 to 200919 and from
1950 to 2010.20 Both reviews found no clear evidence for pos-
itive effects of voice training. The effectiveness of voice training
programs in improving the voice constitution is controversial.
The authors of the reviews concluded that more robust re-
search should be performed to draw a firm conclusion.
Furthermore, the weakness of the investigations in the past was
based on methodological quality, which was poor in most of the
studies because of rather small sample sizes, nonrandomized
designs, large diversity of training programs (content, length in
time, and amount of sessions), and short time between training
and follow-up measurements. Nevertheless, a recent voice train-
ing program for future teachers by Richter et al18 tried to comply
with these recommendations of the literature reviews. Richter
et al randomized 204 student teachers in a control and an in-
tervention group. The main focus was the improvement of vocal
function and vocal capacity after vocal loading. All student teach-
ers were measured twice at the beginning and at the end of the
student teachers’ training period (duration 1.5 years). The results
showed a positive impact on improving the voice constitution
and better vocal capacity after vocal loading in the interventional
group as compared with the control group, who had no train-
ing. Based on Richter et al’s results, the authors of this study
Eva Mailänder et al Lax Vox as Voice Training for Teachers
concluded that a voice training program should be integrated in
the education and occupational routine of teachers.18
The use of physiological programs, which modify the under-
lying physiology of voice production, 21 may ensure an
improvement of vocal loading capacity and voice constitution.
This is because it is suggested that the use of physiological ap-
proaches to the voice production influences three key
components.22 First, the balance among the primary voice pro-
duction systems of respiration, phonation, and resonance improve.
Second, the strength, balance, tone, and stamina of the laryn-
geal muscles improve. Third, a healthy mucosal covering of the
true vocal folds can be developed. Exercises of semi-occluded
vocal tract (SOVT) belong to physiological approaches that are
used in voice therapy, for example, Lax Vox, straw phonation,
lip trill, tongue trill, humming, and hand-over-mouth exercise.23,24
The commonality among these exercises is the fact that they are
all executed using some kind of occlusion on the vocal tract.24
The benefit of using SOVT exercises has been recommended
for vocal pathologies like vocal fatigue, recurrent laryngeal nerve
paresis, and vocal nodules.23 Additionally, normophonic sub-
jects produced a clearer, brighter, and more sonorous voice after
using SOVT exercises.25
The success after using SOVT exercises is related to the in-
creased impedance in the vocal tract. It is suggested that ways
of voice source function affect the positive clinical results.25 First,
the level of acoustic-aerodynamics interaction affects the acous-
tic pressures in the vocal tract by influencing the shape (ie,
amplitude and harmonic content) of the glottal flow pulse. It
results in a faster ending of the glottal flow. Second, the level
of mechanical-acoustic interaction affects the acoustic pres-
sures in the vocal tract by influencing the vibrational
characteristics of the vocal folds. Based on these two voice source
functions, three parameters decrease in their outcome, which
implies a more efficient phonation26: transglottal pressure (ie,
subglottal pressure minus supraglottal pressure), laryngeal muscle
activity, and phonation threshold pressure (ie, required subglottal
pressure to barely initiate and sustain phonation). Further-
more, supraglottal pressure increases, and this feature further
supports the decrease of the three parameters mentioned above.26
Additionally, it is said that SOVT exercises produce a massag-
ing effect in the vocal tract and at the vocal folds. This massaging
effect is caused by two different fluctuations or extra vibra-
tions. Changes of intraoral pressure fluctuations caused by
obstruction might reveal a strong massage effect, particularly when
a larger variability in the contact quotient range of the vocal folds
closure is presented.23 In addition, a secondary source of vibra-
tion (eg, by tongue and lip trills or Lax Vox) might promote a
massaging effect because of changes of the behavior from the
vocal fold vibration and vibration of the entire vocal tract.23,27
A secondary source of vibration showed significant differences
in contact quotient of vocal folds vibration and pitch in com-
parison with SOVT exercises with a steady single source.23
In summary, SOVT exercises improve the sound production
by increasing vocal efficiency and vocal economy, and by pro-
moting an easy phonation with more harmonicity.23
Several SOVT exercises show clear differences with regard
to implementation and physiology. One group of SOVT techniques
262.e14
uses a constant frontal obstruction of the vocal tract (eg, humming,
hand-over-mouth). A second group of SOVT methods is char-
acterized by artificial lengthening of the vocal tract through tubes
in the mouth (eg, straw phonation, Lax Vox) and creates higher
impedance and back pressure (sic higher intraoral pressure fluc-
tuation and vibration of entire vocal tract) by phonating with the
tube into water (eg, Lax Vox). A third group of SOVT exercises
imparts a secondary source of vibration into the vocal tract (eg,
tongue and lip trills, Lax Vox). In the present study, the Lax Vox
method28 is likely to yield results as an intervention method. This
method is based on the Finnish resonant voice tube method and
has existed since the 1960s to treat voice patients.29
The aim of the pilot study was to explore the effectiveness
and applicability of the Lax Vox method for daily use as a pre-
ventive voice program for healthy teachers. For this initial pilot
investigation, women were selected because they report a higher
prevalence of voice disorders and more often seek medical at-
tention for those disorders.9,12,13,30 Our two research questions
address the following:
(1) Do several voice assessments (ie, perception, acous-
tics, aerodynamics, and self-evaluation) improve after a
3-week Lax Vox training in healthy teachers?
(2) How do teachers rate the applicability of Lax Vox as a
preventive voice training program for daily use?
MATERIALS AND METHODS
Subjects
A total of three female teachers and one female teacher trainee
served as volunteers for the study. They were all adults ranging
in age from 26 years to 34 years. We aimed to identify
“normophonic” German female teachers using the following strict
exclusion criteria: a perceived moderate or severe hoarseness se-
verity degree (prejudged by two independent examiners, who
were speech-language therapist trainees in their final phase, and
had used the roughness, breathiness, and hoarseness [RBH]
scale31) or a perceived slight hoarseness severity degree (pre-
judged by two independent examiners using the RBH scale31)
plus reported vocal complaints (ie, a total Voice Handicap Index
[VHI] score of >1432,33); trained voices; alcohol consumption more
than 15 g per day; smoking of more than one cigarette per day;
allergic diseases of the upper respiratory tract; asthma; laryn-
gopharyngeal reflux (ie, as measured through the reflux symptom
index34); hyper- or hypothyroidism; other chronic diseases with
an impact on voice; use of citalopram, amitriptyline, or Prozac
(antidepressive); use of angiotensin-converting enzyme inhibi-
tor or a beta-blocker; and use of sex hormone medication such
as anabolic steroids or androgens.
On the day of assessment, all subjects had to be free of in-
fluenza or cold symptoms. Additionally, they were not to exceed
caffeine consumption of 250 mg, no alcohol consumption within
the past 5 hours, and were not pregnant. The purpose of the strict
exclusion criteria above was to avoid potential confounds by elimi-
nating factors that could potentially influence voice production
and misinterpretation of the effectiveness of the voice training
program.
262.e15 Journal of Voice, Vol. 31, No. 2, 2017

This study consisted of a prospective and interventional anal-
ysis of recordings and measurements. We followed the
requirements of the declaration of Helsinki: Ethical Principles
for Medical Research Involving Human Subjects.
Lax Vox voice training
The framework of the Lax Vox voice training is conducted by
the time and context conditions based on the study of Sihvo
et al.35 The hierarchy of the training is based on Table 1. Al-
though the steps in performing Lax Vox are clearly described,
some essential scopes of voice production are imprecise. To
support efficient voice production, extra exercises of posture,
breathing, tone, and articulation were completed if it was nec-
essary to improve one of these scopes for the participant.
Each participant had three individual 60-minute sessions, one
session a week for 3 weeks. All subjects attended each session.
The training program began with the first individual session in
which exercises were performed from steps one to four from the
hierarchy of Table 1. In the second and third sessions, the ex-
ercises from the hierarchy of Table 1 were expanded to steps
five and six, respectively. Furthermore, daily practice of the Lax
Vox method was obligatory for each participant. The content of
the exercises for the daily practice was dependent on the number
of conducted sessions with their related hierarchy level from
Table 1. All subjects did the exercises for daily practice three
times per day for a total of 12 minutes. These exercises were
integrated in the working situation of the teachers. The three daily
routines were divided into warming up (ie, before the first pro-
fessional voice use), refreshing (ie, in a break between teaching),
and cooling down (ie, at the end of the working day). On free
days (eg, weekend), the three exercise routines per day were re-
tained, but the time of the performance could vary in comparison
with a working day.
Measures and equipment
To assess the multidimensional phenomenon of the voice, we
followed the recommendation of the European Laryngological
Society (ELS)36,37 without visualization of the vocal folds using
videolaryngostroboscopy because of practicable and financial
reasons.
The outcome of Lax Vox was assessed by auditory-perceptual
judgment of voice quality (ie, perception), acoustic measurements,
aerodynamic measurement, and self-evaluation measurement. All
used measures of the present study were explained in detail in
the next sections of the Materials and Methods section. All these
measures were performed on all subjects twice, before and 1 day
after the voice program.
In the beginning of assessment, all participants were in-
structed to read aloud a German phonetically balanced text “Der
Nordwind und die Sonne” (The Northwind and the Sun) at com-
fortable pitch and loudness. After that, the subjects were asked to
sustain the vowel [a:] for five seconds at habitual pitch and loud-
ness level based on the reading text. Subsequently, they were asked
to maximally sustain vowel [a:] on habitual pitch and loudness after
taking a deep breath. This recording was repeated twice. Finally,
a manual voice range profile was administered by following the
distance of the sound level meter of 30 cm and registration pro-
posed by Schutte and Seidner.38 The VHI and the survey were
completed only for the posttesting period. The VHI was an inclu-
sion criterion as mentioned above and thus it was not completed
in the pretesting period. There was no rating appropriate in the pre-
testing period to evaluate the applicability of Lax Vox.
All measurements were made in a quiet room at an ambient
noise of 40 dBA or less as recommended by Schutte and Seidner.38
To verify post hoc the level of environmental noise of the voice
recordings, the signal-to-noise ratio by Deliyski et al39,40 was used.
All voice samples were consistent with the recommended signal-
to-noise ratio norm for acceptable circumstances of acoustic
recordings and analysis.
All recordings of the text and sustained vowels were con-
ducted with an AKG C555 L head-mounted condenser microphone
with a constant mouth-to-microphone distance of approximate-
ly 5 cm and an AKG B29 L battery power supply (AKG Acoustics
GmbH, Vienna, Austria). The microphone signal was digitized
at 44,100 samples per second using an external soundcard from
Creative Sound Blaster X-Fi 5.1. USB (Creative Technology LTD,
Singapore) and saved as wav format. A Voltcraft SL-100 sound
level meter and a digital piano from Yamaha Classic Cantabile
SP-15 were used for the voice range profile.
Auditory-perceptual judgment of voice quality
To acquire auditory-perceptual evaluations of voice quality, three
experienced speech-language therapists with a minimum of
5 years’ experience in clinical voice assessment rated

TABLE 1.
Instructions of Lax Vox28
1. Perception of posture Achieving a correct body posture
2. Preparing for bubbling with phonation Placement of the tube in the mouth
Placement of the tube in the bottle
Inhaling through the nose, exhaling through the mouth
3. Vocalizing Bubbling water with phonation: /hhhooo/
Varying the pitch
Singing familiar melodies
4. Advanced level of vocalizing Pitch gliding
Altering the resistance by changing the position of the tube (max. 4 cm)
5. Preparing the transfer to daily life Continuing phonation without dipping the tube into the water
6. Transfer to daily life Continuing phonation without the tube
Eva Mailänder et al Lax Vox as Voice Training for Teachers
hoarseness, roughness, and breathiness (ie, RBH scale31) using
a four-point equal-appearing interval scale (ie, 0 = normal,
1 = slightly disordered, 2 = moderately disordered, and 3 = se-
verely disordered). They were blinded to the testing period and
listened to all eight continuous speech samples of the German
text. To assess intra-rater reliability, all voice samples of each
testing period were repeated randomly a second time in the rating
session without informing the listeners that stimuli were repeated.
A voice was considered normal when modal agreement
between the three judges scored a voice sample with a mean result
of RBH parameters <0.5. A disordered voice was considered as
soon as the mean rating was rounded off to about ≥0.50 of RBH
parameters. Thus, the disordered ratings of RBH parameters
ranged from ≥0.50 to ≤3.
Acoustic measurements
First, a multivariate index of overall dysphonia severity was ad-
ministered. The Acoustic Voice Quality Index (AVQI)41,42 is a
six-factor acoustic model to measure overall voice quality in con-
catenated connected speech and sustained vowel segments
analyzed with the computer program Praat.43 The AVQI anal-
ysis was applied to the segmentation and concatenation of the
voiced segments of the first 22 syllables of the German text (ie,
continuous speech part) using the extraction Praat script by Maryn
et al.41 Three-second mid-vowel [a:] segment was appended to
this chain of voiced text segments. Although AVQI was origi-
nally developed for Dutch speakers, the AVQI has also been
validated and found reliable for German speakers.44 The inter-
pretation of the AVQI scores was based on the guidelines by
Barsties and Maryn,44 who concluded that an AVQI score ≤2.70
is normal. Second, a voice range profile was manually re-
corded. The size of the standardized form for phonetography was
15 mm for 10 dB on the ordinate with a range of 40 dB to 120
dB, and 36 mm for one-octave distance on the abscissa using a
tone range from C1 to c5 in the Helmholtz notation. To com-
plete the voice range profile, the lower and the upper contours
were measured interpreting the intensity and the frequency range
(ie, in dBA and semitones, respectively) as well as extreme markers
of the softest and the loudest intensity (ie, Imin in dBA and Imax
in dBA), and lowest and highest frequency (ie, Flow in Hz and
Fhigh in Hz). Firstly, the lower contour was analyzed using the
softest voice on the vowel [a:] for approximately 2 seconds. Each
participant started at c1 (262 Hz) and lowered in two semitones
in frequency until the lowest voice was reached. After that, at
the beginning of c1, two semitones in frequency were raised until
the highest voice was attained. Secondly, the procedure was
similar to the upper contour, but here we used the loudest voice
for the several frequencies. The interpretation scores of the
extreme markers, and intensity and frequency range were based
on the guidelines by the ELS,37 which concluded that Imin < 55
dBA, Imax > 90 dBA, Flow > 165 Hz, Fhigh > 659 Hz, frequency
range >24 semitones, and intensity range > 40 dBA are normal
for women.
Aerodynamic measurement
The measurement for aerodynamics was the maximum phona-
tion time (MPT; in seconds). MPT is an objective measure of
262.e16
the efficiency of the respiratory mechanism during phonation by
maximally sustaining a vowel after having taken a maximal
inspiration.45 It was measured as the longest of three sustained
phonations on a habitually produced vowel [a:]. Simultane-
ously displayed oscillogram and narrow-band spectrogram in the
program Praat43 were used to record/measure the beginning and
end of phonation as precisely as possible. The interpretation of
the MPT scores was based on the guidelines by the ELS,37 which
concluded that an MPT score >10 seconds is normal.
Self-evaluation measurement
The VHI was used as a standardized questionnaire to quantify
functional (VHI-F), physical (VHI-P), and emotional (VHI-E)
impacts of voice problems. It captures the participants’ subjec-
tive rating of a series of questions. The original version of the
VHI was introduced by Jacobson et al,32 and it consists of 30
questions. The participants answer on a 5-point Likert scale (from
0 = never to 4 = always). The VHI sum score (ie, VHI total score
or VHI-T) ranges from 0 to 120 points. The highest value rep-
resents the maximum level of self-experienced voice handicap.
The VHI has also been validated and found reliable in German
speakers.46 The interpretation of the three subscales and total
scores was addressed to the guidelines by Vanneste and
Verbrugghe,47 who concluded that a VHI-T < 24, a VHI-F < 6,
a VHI-P < 17, and a VHI-E < 6 are normal.
Survey of the applicability of Lax Vox
After the voice training, the subjects completed a survey to
rate the applicability of Lax Vox as a preventive voice training
program for daily use. The content scheme of this survey was
based on the evaluation model by Kirkpatrick48 to rate the
training success, the learning process, and the transfer to the
daily routine. The results of the training success were divided
into satisfaction and personal profit of the voice training. The
results of the learning process of the training were knowledge,
capabilities, and perceptual experience.49 The estimation of
the transfer to the daily routine was based on the learned
knowledge and capabilities through the preventive voice train-
ing program. In total, the subjects were asked 10 questions
based on a 5-point scale (from strongly agree to strongly
disagree).
Statistical analysis
All statistical analyses were completed using SPSS Statistics 22.0
(IBM Corp., Armonk, NY, USA), except when stated other-
wise. First, intra-rater and inter-rater reliability were established
using percentage of agreement. The sample size of the present
study was small and, because only normophonic subjects were
included, less variation of the severity degrees was expected. Typ-
ically, kappa coefficients50,51 are used to assess rater reliability
of ordinal rating scales, and bootstrapping52 might be used to
estimate significant differences between kappa values. However,
the design of the present study caused too many errors to use
kappa coefficients and bootstrapping (eg, a judge constantly rated
the same results for a voice quality parameter, and bootstrap-
ping variance is too small for minimal replication of 100052 to
262.e17 Journal of Voice, Vol. 31, No. 2, 2017

assess significant differences in rater reliability between and
among judges).
Second, treatment effects in the voice assessments of the ex-
perimental group were analyzed with an effect size to interpret
how strong the relationship between the testing periods was. We
expected to assess tendencies for the magnitude of the treat-
ment effects by comparing differences between the outcome
means of the measures. Thus, we investigated only the practi-
cable significance of the treatment. The Cohen d effect size (d)
was used by comparing the pretest scores with the partici-
pants’ own posttest scores.53,54 The analysis was computed to
use the original standard deviations for the two means of
assessment scores: d = Mean1 − Mean2/σpooled; where σpooled
=√[(σ12 + σ22)/2].
This effect size was determined with the Effect Size Calcu-
lator software.55 However, Fritz et al56 recommended using an
unbiased calculation of d (dunb) for small sample sizes because
d tends to overestimate the population effect size. The formula56
to adjust d is dunb = d(1 − 3/4df − 1).
Interpretation guidelines for the effect size were provided by
Cohen.53 Effect sizes are defined as small at d = 0.2, medium
at d = 0.5, and large at d = 0.8.
RESULTS
Reliability of the auditory-perceptual judgment
The three judges had an average intra-rater reliability of 88%
agreement for hoarseness (range: 75% to 100% agreement), 96%
agreement for breathiness (range: 88% to 100% agreement), and
92% agreement for roughness (range: 88% to 100% agreement).
The inter-rater reliability between the three experts showed
an agreement of 75%, 75%, and 50% in hoarseness, breathiness,
and roughness respectively.
Outcomes of auditory-perceptual and acoustic
measure of voice quality
Most of the voice quality measures revealed an improvement after
3 weeks of Lax Vox training, as presented in Table 2. A large

TABLE 2.
Individual, Mean With Standard Deviation (SD), and Effect Size (dunb) Results of the Voice Assessment Before and After
Lax Vox Training Related to Perception, Acoustics, Aerodynamics, and Self-evaluation
Measures Testing Period Subject 1 Subject 2 Subject 3 Subject 4 Mean SD dunb
Perception
Hoarseness Pre 1 0 0.3 0 0.33 0.47 0.52
Post 0.3 0 0 0 0.08 0.15
Roughness Pre 1 0 0.7 0.7 0.60 0.42 1.02
Post 0.3 0 0.3 0 0.15 0.17
Breathiness Pre 0 0 0.3 0 0.08 0.15 0.00
Post 0 0 0.3 0 0.08 0.15
Acoustics
AVQI Pre 3.84 3.01 3.05 2.75 3.16 0.47 1.10
Post 2.99 2.48 2.50 2.09 2.52 0.37
Flow (Hz) Pre 131 131 147 147 139 9.24 —
Post 131 131 131 131 131 —
Fhigh (Hz) Pre 880 1319 1175 1047 1105.25 186.80 −0.19
Post 1319 1047 1175 1047 1147.00 129.57
Imin (dBA) Pre 43 42 47 48 45.00 2.94 −0.07
Post 44 49 43 45 45.25 2.63
Imax (dBA) Pre 99 101 100 99 99.75 0.96 0.12
Post 100 98 102 98 99.50 1.91
Frequency range (semitones) Pre 33 40 36 34 35.75 3.10 −0.49
Post 40 36 38 36 37.50 1.91
Intensity range (dBA) Pre 56 59 53 51 54.75 3.50 0.09
Post 56 49 59 53 54.25 4.27
Aerodynamics
MPT (s) Pre 16 23 15 16 17.5 3.73 −0.53
Post 14 27 18 25 21.1 5.90
Self-evaluation
VHI-T Pre 14 4 14 5 9.25 5.50 0.54
Post 6 8 4 7 6.25 1.71
VHI-P Pre 10 2 9 4 6.25 3.86 0.66
Post 4 4 4 3 3.75 0.50
VHI-F Pre 3 1 2 1 1.75 0.96 0.12
Post 2 0 0 4 1.50 1.91
VHI-E Pre 1 1 3 0 1.25 1.26 0.11
Post 0 4 0 0 1.00 2.00
Eva Mailänder et al Lax Vox as Voice Training for Teachers 262.e18

FIGURE 1. Large improvements of treatment effects: left slopegraph of AVQI (light gray = normal area, and dark gray = pathologic area sepa-
rated with a black line) and right slopegraph of the perceived roughness (light gray = normal area, and dark gray = pathologic area separated with
a black line).

improvement was found in AVQI and perceived roughness se-
verity degree (both dunb > 0.80) (Figure 1). The hoarseness severity
degree showed only medium improvement (dunb > 0.50; Figure 2),
but the breathiness degree revealed no improvement because no
perceived breathiness was reported before and after training
(dunb = 0.00).
In AVQI, slightly pathologic results in roughness and hoarse-
ness were found in the pretest period for some subjects. In the
posttest session, all subjects reached normal hoarseness and rough-
ness severity level, but in AVQI only one subject did not reach
a normal score.
Outcomes of acoustic measures from the voice
range profile
No treatment effects were measured in the extreme markers of
the voice range profile, intensity range, and frequency range (all
dunb < 0.20), as shown in Table 2. Furthermore, the treatment effect
of Flow could not be evaluated because there was no standard de-
viation in the posttesting period (ie, the same results between
all three subjects were measured). All measures of the voice range
profile were normal for every subject and each testing period.
However, the upper contour of the voice range profiles ex-
panded after Lax Vox training (Figure 3). Particularly, the largest

FIGURE 2. Medium improvements of treatment effects: upper left slopegraph of VHI-P (light gray = normal area), upper right slopegraph of
VHI-T (light gray = normal area), at the bottom left slopegraph of MPT (light gray = normal area, and dark gray = pathologic area separated with
a black line), and at the bottom right slopegraph of the perceived hoarseness (light gray = normal area, and dark gray = pathologic area separated
with a black line).
262.e19 Journal of Voice, Vol. 31, No. 2, 2017

Outcome of self-evaluation measure

The quantitative improvements of the three other categories (ie,
perception, acoustics, and aerodynamics) were realized in VHI
as well (Table 2 and Figure 2). VHI-T and VHI-P parameters
revealed a medium improvement after Lax Vox training (both
dunb > 0.50). No changes were found in the two subscales, VHI-F
and VHI-E, respectively (both dunb < 0.20). All measures of
the VHI were normal for every subject and each testing
period.

Rating applicability of Lax Vox

FIGURE 3. The plotted voice range profiles (executed by the voice
range profile contour software57) of the four subjects illustrated the mean
results of pre-Lax Vox training (ie, plus symbols curve), and post-Lax
Vox training (ie, circle symbols curve), respectively.
improvements were shown in the modal and beginning falsetto
voice registers. The mean intensity increased about 4.6 dB of
the frequency range of 180 Hz to 368 Hz. The results of the lower
contour showed similar results in this area between pre- and
posttest periods. In the posttest, the lower contour showed a clear
increase of intensity of about 8.9 dB in the range of 517 Hz to
861 Hz.
Outcome of aerodynamic measure
Figure 2 and the data of Table 2 show that a medium improve-
ment was found in MPT after 3 weeks of Lax Vox training
(dunb > 0.50).
All MPT scores were normal for every subject and each testing
period.
In total, the subjects had positive responses to the statements for
the applicability of Lax Vox (Table 3). The results of the train-
ing success showed that most volunteers were satisfied after using
Lax Vox (100% strongly agree or agree). For the personal profit
of voice training, most participants evaluated Lax Vox as easy
to integrate and worthwhile to use in their occupational routine
(76% strongly agree or agree). The subjects showed a high pos-
itive response in the learning process about knowledge,
capabilities, and perceptual experience by using Lax Vox (88%
strongly agree or agree). Finally, to use the learned knowledge
and capabilities of Lax Vox, the participants revealed a very high
response for behavioral changes in transfer to the daily routine
(92% strongly agree or agree).
DISCUSSION
In this pilot study, we explored the effectiveness of Lax Vox for
healthy teachers. We investigated various aspects of voice con-
stitution and applicability of Lax Vox as a preventive voice training
program for daily use. Special attention was paid to a number
of exclusion/inclusion criteria before enrolling the female teach-
ers in this study and thus, to minimize potential confounding
factors on the results (ie, factors known to influence voice pro-
duction related to diseases, habits, occupation, and medication

TABLE 3.
Responses of the Survey to Rate the Applicability of Lax Vox
Strongly Strongly
Category Statements Agree Agree Neutral Disagree Disagree
Training success Using Lax Vox as voice training has met my 25% 75% 0% 0% 0%
expectation.
Learning process I can explain Lax Vox to a colleague. 50% 25% 25% 0% 0%
I am confident using Lax Vox. 50% 50% 0% 0% 0%
I know how to monitor myself using Lax Vox. 50% 25% 25% 0% 0%
Since I started using Lax Vox, my perceptual 75% 25% 0% 0% 0%
experience of my voice has improved.
Training success I can easy integrate Lax Vox into my 0% 50% 25% 25% 0%
occupational routine.
It is worthwhile to use Lax Vox in my 75% 25% 0% 0% 0%
occupational routine.
Transfer to daily use I would regularly use Lax Vox to prevent voice 25% 50% 25% 0% 0%
problems.
I would use Lax Vox in an acute phase of voice 100% 0% 0% 0% 0%
problems.
I would use Lax Vox before high vocal loading. 100% 0% 0% 0% 0%
Eva Mailänder et al Lax Vox as Voice Training for Teachers
use in adults). Therefore, we included a homogenous group of
only female teachers who were highly comparable in terms of
age and normophonia.
Of the 16 experimental variables related to voice quality (ie,
perceptually and acoustically), vocal function, aerodynamics, and
self-evaluation, seven showed medium to large improvements
of treatment effects after 3 weeks of Lax Vox training. The ma-
jority of the variables did not show meaningful changes after
using Lax Vox. However, in this pilot study, we used only
normophonic volunteers, and some parameters could not be im-
proved, for example, the perceived breathiness. Additionally,
normophonic subjects show in general smaller or no variations
in voice quality, vocal function, or aerodynamics in compari-
son with dysphonic subjects after a voice intervention.58,59
Furthermore, we used only a physiological program to strength-
en the voice constitution. Therefore, several parameters are
minimally influenced, for example, VHI-F and VHI-E. Never-
theless, the following parameters, which may reach improvements
after Lax Vox training, were observed: AVQI, perceived rough-
ness and hoarseness, MPT, the contour of the voice range profile,
and VHI-T and VHI-P. In the sections that follow, we discuss
each of the findings and their potential treatment effect as these
variables appear to influence voice constitution after Lax Vox
training.
Voice quality is a multidimensional phenomenon in the
voice sound that can be measured with a subjective approach
(eg, auditory-perceptual judgment of hoarseness, roughness,
and breathiness) or an objective approach (eg, acoustic analy-
sis as in AVQI).60 In this study, we used both assessments to
estimate the presence, degree, and progression of voice quality.
Furthermore, variations in voice quality are the most frequent
voice complaints in clinical practice.61 In cases of teachers,
several investigations showed that teachers with abnormal
voice quality significantly influence a pupil’s or a student’s
learning performance.62–67 All in all, voice quality is a promi-
nent factor of the voice constitution. We expected an improvement
in voice quality with the Lax Vox training because in several
studies physiological approaches with SOVT exercises showed
a significant improvement of perceived and/or acoustic mea-
surements of voice quality.68–70 The present results confirmed
that Lax Vox also improved overall voice quality/hoarseness
and roughness. Because of the fact that objective and
subjective voice quality assessments meaningfully improved
after Lax Vox training, we can preliminarily conclude that
using Lax Vox has a high positive effect on voice quality
improvements.
Turning our attention to the aerodynamics, the MPT demon-
strates the efficiency of vocal fold vibration. The present results
showed that MPT meaningfully increased after Lax Vox train-
ing. Only one subject showed a slight decrease of 2 seconds in
the posttest of MPT. The other three subjects increased in du-
ration of MPT. Also the MPT never fell below the normative
threshold of 10 seconds37 in every testing period of every subject.
However, the common increase of MPT scores in this study con-
firms the theory of physiological voice programs. Their goal is
to improve the strength, balance, and stamina of the laryngeal
muscles. Furthermore, these methods include improving the
262.e20
balance among laryngeal muscle effort, and respiratory effort
and control.
Although no differences in the extreme markers of the voice
range profile were observed, it is interesting to note that after
the Lax Vox training, a shift in the contour average of the voice
range profiles was found. Particularly, an increase of about 4.6
dB in the upper contour was revealed in the frequency range of
180 Hz to 368 Hz. Thus, a treatment effect was measured by using
Lax Vox to improve the maximum intensity level (ie, a loud voice)
in lower frequencies, especially of the modal register where the
speaking fundamental frequency is used. The present results
showed a doubling of intensity (ie, increasing of the intensity
level of more than 3 dB) for the lower frequencies. Teachers are
obliged to use louder voices in different classroom situations.
This is caused by a high number of pupils in the classroom and
a high noise level inside the classroom (eg, pupils’ and teach-
ers’ activities and results from normal daily school routines such
as talking, walking, moving furniture, handling papers and other
materials, and babbling). To improve their maximum level of
loudness, teachers should avoid an overloading of voice capaci-
ties. Overloading may easily result and develop into voice
problems.
Contrary to the positive results of the upper contour after Lax
Vox training, the lower contour showed on average an increase
of about 8.6 dB in intensity between 517 Hz and 861 Hz. The
increase in higher frequencies for minimum intensity levels is
unknown to reach these great differences after Lax Vox train-
ing. The voice training with Lax Vox was based on the modal
register and beginning falsetto register and was based less on
the extreme areas of intensity in the lowest and highest frequen-
cies. Actually, comparable results in these areas were expected
between the two testing periods.
The assessment of self-evaluation results supported the find-
ings of the other three elements of the voice assessment. The
subjects recognized considerable improvement in their physi-
cal capabilities using Lax Vox. This was measured with the
subscale of the VHI-P, which decreased in three of four sub-
jects. The other two subscales of the VHI showed no meaningful
improvement after Lax Vox training. Only the total score of the
VHI showed a medium improvement as well. The decrease in
VHI-T is mainly due to the decrease in VHI-P. To summarize,
these findings are related to the theory of SOVT principals, which
are physical-based methods. Thus, the physical subscale of the
VHI should be the highest sensitive measure of self-evaluation
when voice constitution improves after Lax Vox training.
Finally, a survey was implemented to estimate the applica-
bility of Lax Vox for teachers in addition to the treatment effects
of various voice assessments. To summarize, the volunteers es-
timated Lax Vox positively as a preventive tool for their
occupational routine. They rated as highly positive the satisfac-
tion, learning process, and behavioral changes using the acquired
knowledge and capabilities of the Lax Vox training. The worth-
while use and personal profit to easily integrate Lax Vox into
the occupational routine was evaluated less positively. This might
be explained through the strict daily use of Lax Vox three times
a day for several minutes. Some working days are stressful and
little time is available for extras such as exercising, but the
262.e21
exercise units had to be organized and done. We have assessed
that the first 3 weeks require, for the short term, a great deal of
effort to organize the daily units of Lax Vox into the everyday
working life. In the long term, the habitual process of daily Lax
Vox use might be generally accepted by the participants. To in-
vestigate this hypothesis, a follow-up study is necessary in future
studies to use Lax Vox as a preventive training program. However,
based on the current survey, we can hypothesize that teachers
appreciate the benefit of using Lax Vox for their occupational
routine with a willingness to use this method in future.
Limitations and future direction
Although the results from this pilot study are intriguing and allow
us to describe the first associations of the effectiveness of using
Lax Vox as a preventive voice training program, we cannot gen-
eralize the treatment effects. In addition to this specific limitation,
a number of additional limitations should be acknowledged.
The first limitation pertains to the small number of partici-
pants. This leads to reduced power and difficulty using parametric
or nonparametric statistics (eg, paired t test, Wilcoxon) to eval-
uate significant differences of the voice constitution performance
between before and after Lax Vox use. We decided to use only
effect size measures because of the small number of subjects.
In future studies, a higher number of volunteers should be
included.
A second limitation is the absence of a control group to
compare the treatment effects. Future studies should include a
control group to estimate treatment effects.
A third limitation is the absence of a follow-up measure-
ment of the voice assessments and applicability survey. In future
studies, a follow-up measurement should be implemented to assess
the effectiveness on the voice constitution and the willingness
of the teachers to use Lax Vox in future.
A fourth limitation is the absence of laryngeal imaging (ie,
laryngoscopic, laryngostroboscopic, videokymography, and high-
speed digital imaging) as recommended by the ELS. In the
absence of such imaging, it is impossible to know the true status/
health of the vocal folds and surrounding structures. Thus, the
findings would have been strengthened by additional informa-
tion regarding laryngeal/vocal structure and physiology. Future
studies should include endoscopic methods to place these results
in context.
A fifth limitation is related to the use of a manual voice range
profile setting in place of an automatic voice range profile (eg,
Voice Profiler from Alphatron, The Netherlands). Automatic
phonetography is more precise in the detection of intensity, and
more details in frequency can be measured. Future studies should
use an automatic voice range profile.
A sixth limitation is the rater reliability of judging voice
quality. In the present study, the rater reliability was investi-
gated with percentage of agreement because of the small
sample size. In future studies with higher sample sizes, kappa
coefficients or intraclass correlation coefficient should be used.
Furthermore, the present results of rater agreement were com-
monly good, but only inter-rater reliability of roughness was
moderate.
Journal of Voice, Vol. 31, No. 2, 2017
CONCLUSION
The results of this pilot study of healthy teachers using Lax Vox
as voice training might suggest a positive impact to improve select
measures of voice quality, MPT, vocal function, and self-
evaluation. Furthermore, Lax Vox was assessed by the volunteers
as highly applicable for integration into the occupational teacher
routine to prevent voice problems and improve their voice
constitution.
Acknowledgments
This investigation was a bachelor’s thesis from the Medical School
of the Hochschule Fresenius University of Applied Sciences,
Hamburg, Germany, on July 2015.
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