9 Muscle Tension Dysphonia Exercises & Treatments

Muscle tension dysphonia is a voice disorder caused by muscle tension. It can be painful, irritating, and limiting for patients who have it.

In this article, you’ll learn all about voice therapy for this common voice disorder, including 9 muscle tension dysphonia exercises and treatments.

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What Is Muscle Tension Dysphonia?

Muscle tension dysphonia (MTD) is a voice change caused by muscle tension. Around 40-70% of people with a voice disorder have MTD.

MTD is known by many other names, including hyperfunctional dysphonia (da Cunha Pereira et al., 2018), spastic dysphonia, and psychogenic dysphonia.

Types Of Muscle Tension Dysphonia

There are 2 main types of muscle tension dysphonia: primary and secondary.

Primary muscle tension dysphonia is when there is a voice disorder or dysphonia without the presence of a neurologic or structural abnormality (Gillespie, n.d.).

Secondary muscle tension dysphonia is when MTD co-occurs with another laryngeal disorder or abnormality (Gillespie, n.d.). For example, a patient may have vocal nodules and then develop MTD as a result.

Vocal Characteristics Of Muscle Tension Dysphonia

Patients with MTD may exhibit a variety of vocal characteristics, including:

• Weak voice
• Decreased vocal range when speaking
• Lower pitch when speaking
• Harsh or constricted voice
• Tension of the voice
• Glottal fry or hard glottal attacks
• Breathiness
• Monopitch
• Pitch breaks
• A double voice (“diplophonia”)
• Periods of no voice (“aphonia”; Gillespie, n.d.)

Causes Of Muscle Tension Dysphonia

Although no one fully understands what cause primary muscle tension dysphonia, we do know it is associated with underlying patient factors, including:

• Excessive force of the voice, such as yelling, whispering frequently, straining, and too much vocal cord tension
• Lifestyle habits such as smoking. Or speaking excessively, too loudly, or in too low or too high of a pitch.
• Stress, including anxiety and depression, can cause tension in breathing, the neck, shoulders, and/or the larynx 
• Health issues such as acid reflux, allergies, or respiratory infections

(Center For Vocal Health, n.d.)

Signs And Symptoms Of Muscle Tension Dysphonia

Patients with MTD often complain of the following symptoms:

• Odynophagia (painful swallowing)
• Vocal fatigue
• Globus sensation
• Shortness of breath when speaking
• Vocal hoarseness

In addition, research shows that patients with MTD often have:

• Imbalance of tension in the throat
• Forward head posture (causing hyperextension of the head and neck)
• Laryngeal positioning that’s too high
• Facial tension
• Locked joints (da Cunha Pereira et al., 2018)
• Tight, pulled-in abdomen during inhalation (vs relaxed and released; Gillespie, n.d.)

Laryngeal imaging in patients with MTD has shown:

• Overuse of the vocal folds with over-compression or hyperadduction
• Gaps during vocal fold closure (“glottal chinks”)
• Reduced vocal fold opening (da Cunha Pereira et al., 2018)

How To Assess Muscle Tension Dysphonia 

If you suspect that your patient has muscle tension dysphonia, complete a thorough voice assessment. Also recommend a laryngoscopy (particularly a videostroboscopy).

A videostroboscopy allows a provider to see the vocal folds moving. Seeing the larynx and vocal folds can better guide your MTD treatment goals and plans.

Muscle Tension Dysphonia Exercises And Treatment

Voice therapy works for many patients with muscle tension dysphonia! Here are 9 evidence-based exercises and treatment strategies.

1. Manual Therapy

Manual therapy can help patients with laryngeal tension reposition and relax the larynx and surrounding structures (Stemple et al., 2018). There are 3 primary maneuvers:

• Push-back maneuver. Gently apply the pointer finger on the thyroid cartilage. Gently push back on the thyroid cartilage to change the shape of the glottis. 
• Pull-down maneuver. Find the space between the thyroid notch (Adam’s apple) and the hyoid bone. Gently place your thumb and pointer finger and pull the larynx down.
• Medial compression and downward traction. Place your thumb and pointer finger gently on the space between the thyroid notch (Adam’s apple) and hyoid bone. Gently pull the larynx down while also squeezing to apply medial compression.

(Gillespie, n.d.)

While doing manual therapy, note the impact of the maneuver on your patient’s pitch, loudness, and/or vocal quality. Pay attention to how your finger placement and the direction and amount of pressure you use impact their voice.

If you don’t have training or experience with manual therapy, then reach out to a local voice specialist or seasoned colleague who can offer support. Be mindful of your finger placement and the amount of pressure you apply.

2. Circumlaryngeal Massage

Circumlaryngeal massage is a form of manual therapy that can stretch and relax muscle tissue and fascia, increase circulation, and reduce pain and discomfort. It’s been shown to improve symptoms of muscle tension dysphonia long-term (Dehqan & Scherer, 2019)

• Have your patient hum
  • Ask your patient to hum while you perform the massage.
  • You’ll listen for changes in pitch, loudness, and vocal quality as feedback.
• Massage the hyoid bone:
  • Place your thumb and pointer finger on either side of the hyoid bone.
  • Apply gentle, circular pressure and gently move the hyoid bone side to side.  
  • Your patient will continue to hum as you massage.
• Find the thyroid notch:
  • Next, find and apply gentle circular pressure on either side of the thyroid notch. Your patient will continue humming.
  • Repeat, starting on each posterior (back) border of the thyroid cartilage as the patient hums.
  • Repeat and apply pressure down toward the inferior border as your patient hums. Move the thyroid cartilage laterally as your patient hums. Note the placement and amount of pressure that improves your patient’s voice (vocal quality, effort, and range).

Be mindful of your finger placement and the amount of pressure you apply.

3. Vocal Function Exercises

Vocal function exercises are a set of four exercises designed by Joseph Stemple to help people regain healthy vocal function. 

Before teaching the exercises, remind your patient to take big breaths and use good posture with a forward focus.

A forward focus means using a voice that resonates forward, toward the front of the face. Teach patients to feel vibrations at the front of their face (lips, nose). Model good posture, breathing, and airflow when speaking.

Instruct your patient to complete the following.

1. Warm up. “Say the sound /i/ as long as possible (on a comfortable note).” Repeat 2 times.
2. Stretch. “Glide from your lowest to highest comfortable sound on the sound /o/ as in the word ‘knoll’.” Repeat 2 times.
3. Contract. “Go from a comfortably highest sound to your lowest sound on the sound /o/ as in the word ‘knoll’.” Repeat 2 times.
4. Power. “You will sustain 5 different musical notes (middle C, D, E, F, G) for as long as you can on the sound /o/ as in the word ‘knoll’.” Repeat two times.

(Stemple, n.d.)

Read our full guide to Vocal Function Exercises.

4. Stretch And Flow Phonation

Stretch and Flow is a hierarchical therapy first developed by Stone and Casteel that targets increased airflow, easier phonation, and forward oral resonance. It is intended for patients with laryngeal tension who hold back airflow.

Instruct your patient to complete the following steps in order. Hold a tissue in front of a patient’s mouth for helpful biofeedback about airflow!

1. Airflow. Have your patient first work on releasing a slow breath with the vowel sound /u/ with only airflow (no voicing). Watch the tissue to assess airflow.
2. Voiceless sounds/speech with airflow. In this step, your patient will articulate speech with no voicing. Have your patient breathe, “Who is Sue?” The focus is on the flow of the breath while articulating.
3. Add voiced sounds/speech. Have your patient add in voicing while easily sighing, “Who is Sue?” while still focusing on the forward movement of airflow.
4. Stretch with pitch change. Have your patient say, “Who is Sue?” while stretching the sounds with more pitch variations, still focusing on airflow.
5. Reduce stretch. Have your patient say, “Who is Sue?” using more natural pitch variation, yet still focusing on airflow.
6. Reduce flow. Finally, have your patient produce, “Who is Sue?” in a more functional voice. The sound of their voice should still have a forward focus with good airflow.

(Gillespie, n.d.)

5. Semi-Occluded Vocal Tract (SOVT) Exercises

Semi-occluded vocal tract exercises aim to improve vocal quality by decreasing vocal fold stress. They do this by partially occluding (rounding) at the lips to improve supraglottal pressure (Gillepsie, n.d.). 

Imagine a reverse megaphone with an open throat and a small, rounded mouth. Have patients focus on feeling the vibrations at the lips and keeping an open throat.

SOVT exercises may be best used as a vocal warm-up rather than for carryover into everyday speech.

Some SOVT exercises include:

• Straw phonation. Put a straw in your mouth. Close your lips gently around the straw and puff air into the cheeks, making an /u/ or ‘ooo’ sound, feeling the vibration in the face.
• Straw singing. Sing through a straw with your lips end at the edge of the straw. 
• Straw bubbles. Use the straw to blow bubbles in a cup of water. Continue by blowing bubbles while making an “oo” or voicing sound (Gillepsie, n.d.). 
• Lip and tongue trill.
• Small card or Post-it® note. Hold up the card perpendicular to the lips (but not touching the lips) and ask the patient to glide up and down in a comfortable range. The card will ‘buzz’ as auditory biofeedback that they are doing the exercise correctly. This can be helpful for patient who can’t sustain a lip or tongue trill (Rosenberg, 2014).

6. Resonant Voice Therapy Exercises

A resonant voice feels like vibrations at the front of the face (lips, nose, cheeks) with a focus on easy phonation. Easy phonation is voicing and articulation that feels minimally effortful and free of tension.

Some common resonant voice therapy exercises include:

• Chanting
• Humming
• Lip trills
• Forward/oral focus
• Nasal consonant exercises /m/, /n/, /ng/

There are different resonant voice therapy protocols. The most well-known are Lessac-Madsen Resonant Voice Therapy by Kathrine Verdonlini Abbott and Resonant Voice Therapy by Joseph Stemple.

Read How To Do Resonant Voice Therapy Exercises for a step-by-step guide.

7. Conversation Training Therapy

Conversation Training Therapy (CTT) is a voice therapy approach that uses conversation to treat voice disorders, including muscle tension dysphonia.

It aims to generalize the gains of voice therapy into patients’ everyday lives. CTT does this by keeping treatment short and functional and by following the principles of motor learning.

CTT was developed by Jackie Gartner-Schmidt and Amanda Gillespie.

During CTT, the clinician focuses on:

• Clear speech
• Increasing the patient’s sensory awareness of their voice
• Negative practice (switching between their “old” and “new” voice to compare)
• Basic training gestures
• Prosody

How to know if your patient is a good fit for CTT:

• The patient can speak at the conversation level (i.e. mild to no aphasia, enough breath support to produce sentences, etc.)
• Stimulable for clear speech
• Cognition is intact
• They can hear the difference in their voice with and without clear speech

Here’s a step-by-step guide on How To Do Conversation Training Therapy.

8. Vocal Hygiene Education

Teach your patients how to add good vocal hygiene habits while decreasing the harmful ones for a healthier voice.

Click here for a free checklist!

9. Reduce Postural Tension

If you observe tense or imbalanced posture, such as a forward head position or shallow upper-chest breathing, consider working on reducing postural tension.

You may teach your patient diaphragmatic breathing, bringing the shoulders back, and/or experimenting with the voice as they move their head forward and back.

Do negative practice so that the patient can hear and feel the difference between their usual posture and what you’ve taught them.

Refer to physical therapy and other specialists if your patient is interested in more help reducing postural tension.

(Gilman, 2018).

More Voice Therapy Materials

For bestselling assessment templates, patient handouts, and worksheets, see The Evaluation Pack and Voice & Resonance Pack.

Take The Adult Speech Therapy Roadmap Course for a step-by-step guide to assessing and treating voice disorders (eligible for 1.55 ASHA CEUs).

References

1. American Speech-Language-Hearing Association. (n.d). Voice Disorders. (PracticePortal). Retrieved February, 2025 from www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/
2. Barsties V Latoszek, B., Watts, C. R., & Hetjens, S. (2024). The Efficacy of the Manual Circumlaryngeal Therapy for Muscle Tension Dysphonia: A Systematic Review and Meta-analysis. The Laryngoscope, 134(1), 18–26. https://doi.org/10.1002/lary.30850
3. Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
4. Center For Vocal Health (n.d.) Exploring Muscle Tension Dysphonia: Causes, Symptoms, and Treatment Options. Retrieved February, 2025 from https://www.centerforvocalhealth.com/vocal-health-and-care/exploring-muscle-tension-dysphonia-causes-symptoms-and-treatment-options.
5. da Cunha Pereira, G., de Oliveira Lemos, I., Dalbosco Gadenz, C., & Cassol, M. (2018). Effects of Voice Therapy on Muscle Tension Dysphonia: A Systematic Literature Review. Journal of voice : official journal of the Voice Foundation, 32(5), 546–552. https://doi.org/10.1016/j.jvoice.2017.06.015
6. Dehqan, A., & Scherer, R. C. (2019). Positive Effects of Manual Circumlaryngeal Therapy in the Treatment of Muscle Tension Dysphonia (MTD): Long Term Treatment Outcomes. Journal of voice : official journal of the Voice Foundation, 33(6), 866–871. https://doi.org/10.1016/j.jvoice.2018.07.010
7. Gartner-Schmidt, J. (n.d.). Optimize the Flow of Your Voice Therapy Patients: Flow Phonation. Medbridge. Retrieved February, 2025, from https://www.medbridge.com/blog/optimize-the-flow-of-your-voice-therapy-patients-flow-phonation
8. Gillespie, A.I. (n.d.). Muscle Tension Dysphonia. [Online Course]. Medbridge. Retrieved February, 2025 from https://www.medbridge.com/educate/courses/muscle-tension-dysphonia-amanda-i-gillespie
9. Gillespie, A. I., Yabes, J., Rosen, C. A., & Gartner-Schmidt, J. L. (2019). Efficacy of Conversation Training Therapy for Patients With Benign Vocal Fold Lesions and Muscle Tension Dysphonia Compared to Historical Matched Control Patients. Journal of speech, language, and hearing research : JSLHR, 62(11), 4062–4079. https://doi.org/10.1044/2019_JSLHR-S-19-0136
10. Gilman, M. (2018). The Influence of Postural Changes on Extralaryngeal Muscle Tension and Vocal Production. Perspectives of the ASHA Special Interest Groups, 3(3), 82-87. https://pubs.asha.org/doi/full/10.1044/persp3.SIG3.82
11. Rosenberg, M. (2014). Using Semi-Occluded Vocal Tract Exercises in Voice Therapy: The Clinician’s Primer. Perspectives on Voice and Voice Disorders. 24(2). 71-79. https://doi.org/10.1044/vvd24.2.71
12. Stemple, J. (n.d.) Vocal Function Exercises [Online course] Medbridge. https://www.medbridgeeducation.com/courses/details/vocal-function-exercises-joseph-stemple-speech-langauge-pathology-vocal-therapy
13. Stemple, J.A., Roy, N., & Klaben, B.K. (2018). Clinical voice pathology: Theory and management (6th ed.). Plural Publings, Incorporated.
14. Voice And Speech Co. (2018). Treating Vocal Tension with Massage. Retrieved February, 2025 from https://www.voiceandspeech.ca/voice-speech-therapy-blog/laryngeal-massage