Paradoxical vocal fold movement (PVFM), also known as “vocal cord dysfunction”, is when the vocal folds close when they should be open. This can impact breathing and be very stressful for your patients.
This article covers how to do speech therapy for PVFM, including:
- What PVFM is (and what it’s not)
- How to assess PVFM
- Evidence-based treatments
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What is Paradoxical Vocal Fold Movement (Vocal Cord Dysfunction)?
Paradoxical vocal fold movement (PVFM) is a disorder where the vocal folds sometimes close (adduct) when they should be open. It can happen on the inhale and/or exhale and cause airway restriction and respiratory distress (Patel et al., 2015).
As a result, it is sometimes misdiagnosed as asthma or other respiratory conditions. That said, many people with PVFM also have asthma.
PVFM is also known as vocal cord dysfunction (VCD) or paradoxical vocal fold motion (Guglani et al., 2014). It’s more common in adults than children and in females than males (Patel et al., 2015).
Your patient with PVFM may report the following intermittent or chronic symptoms:
- Shortness of breath (dyspnea), especially with activity
- Difficulty breathing, especially when inhaling
- Inhalatory stridor
- Throat tightness
- Choking (Mathers-Schmidt, 2001)
What Triggers PVFM/Vocal Cord Dysfunction?
PVFM events have specific triggers. It’s hypothesized that in people with PVFM, the larynx becomes hypersensitive to these triggers over time. This means that it takes less exposure to the trigger to cause an event.
PVFM may be triggered by:
- Gastroesophageal reflux disease (GERD) or laryngopharyngeal (LPR)
- Environmental irritants (smoke, strong odors, allergens, dust)
- Psychological stress and anxiety
- Post-nasal drip
- Exercise-induced stress
- Neurological factors such as dysrhythmia of the respiratory muscles, tremor, etc. (Mathers-Schmidt, 2001). These are rare and may be best treated by medical intervention.
(Sandage, n.d.a)
How To Diagnose PVFM/Vocal Cord Dysfunction
Your comprehensive speech therapy evaluation will inform a PVFM diagnosis. Complete a thorough case history and voice assessment, including what triggers the patient’s PVFM events. Rule out dysphasia, as appropriate. See the Evaluation Pack for more help.
Refer your patient to a laryngoloist/otolaryngologist to diagnose PVFM before starting treatment. Your case history and assessment report will support that diagnosis (Mathers-Schmidt, 2001).
The patient will have a laryngoscopy so that the laryngologist can view and assess the larynx and a respiration test, likely with a pulmonologist.
If PVFM happens sporadically, it can be challenging to diagnose. Sometimes the patient may need to trigger the PVFM, such as exercising before their laryngoscopy (Patel et al., 2015).
We recommend voice expert and speech-language pathologist Mary Sandage’s papers and online courses for more guidance on how to assess and treat this disorder.
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How To Treat PVFM/Vocal Cord Dysfunction
Speech therapy for PVFM/vocal cord dysfunction is very effective and relatively quick! The symptoms can often be resolved in 1-6 sessions (Sandage, n.d.b.)
During treatment, you will teach patients how to identify and manage their PVFM triggers.
You’ll teach patients to feel into their bodies and identify the clues that they’re about to have a PVFM event. Once they can identify this, they can do their breathing and relaxation exercises to diminish or even avoid PVFM events altogether.
Below are 5 recommended speech therapy treatment options for patients with PVFM.
1. Patient Education
Help your patient understand PVFM and their personal triggers.
Educate patients about what PVFM is and how it is different from other respiratory conditions. Include education about the role of the vocal folds in breathing.
Identify and manage their PVFM triggers. Work with your patient to identify and then avoid their triggers as much as possible. Common triggers are GERD/LPR, allergies, anxiety, and stress (Patel et al., 2015)
For example, if their trigger is GERD, focus on avoiding reflux. This may include eating smaller meals more often, sitting upright during and 30 minutes after each meal, wearing loose-fitting clothing around the waist, etc.
Or if their trigger is environmental allergens, focus on avoiding pet dander, wearing a mask, etc.
Teach vocal hygiene. Identify if there are other habits they could add or reduce to improve their voice. Download our vocal hygiene checklist for more ideas.
2. Breathing Strategies
Teach your patient breathing strategies to help manage their PVFM.
Again, encourage your patient to feel into their bodies to learn how to identify the clues that they’re about to have a PVFM event.
If they feel an event coming, they should use the breathing strategies to minimize and eventually avoid the event.
Breathing strategies:
- Diaphragmatic Breathing: Encourage deep, slow, abdominal breathing. Focus on relaxing the chest and sholders.
- Pursed lip breathing improves oxygenation and ventilation when breathing. This helps your patient relax and decreases shortness of breath (Nguyen & Duong, 2025)
- Encourage an open throat and a complete exhale. Encourage patients to keep a relaxed and open throat as they breathe and also to complete a full exhale to avoid hyperventilating (Sandage, n.d.b.)
Some studies show that respiratory muscle training, like EMST, may improve symptoms of PVFM.
Learn more about respiratory strategies by reading 3 Effective Breathing Exercises For Speech Therapy
3. Laryngeal Relaxation Exercises
Excessive laryngeal tension can also exacerbate PVFM symptoms. Relaxation strategies include:
- Yawn-Sigh Technique. The yawn sigh relaxes the throat and vocal folds
- Progressive Muscle Relaxation. Tensing and then relaxing the muscles of the neck, shoulders, and chest can assist with laryngeal relaxation
- Laryngeal Massage. Massage can help reduce muscle tension around the larynx and neck that contributes to PVFM
4. Manage Stress And Anxiety
Stress and anxiety can exacerbate PVFM.
- Mindfulness and Meditation. Mindfulness has been shown to reduce stress-induced PVFM episodes.
- Refer Out: Collaborate and refer your patient to a mental health professional to address stress and anxiety that may contribute to PVFM symptoms and episodes.
5. Coordinate With The Multidisciplinary Team
Treating and managing PVFM often involves a multidisciplinary approach. You may need to refer your patient out to manage comorbidities such as allergies, asthma, GERD, or anxiety disorders (Sandage, n.d.b.)
Common referrals for PVFM include:
- Pulmonologist
- Otolaryngologist (ENT)
- Gastroenterologist (GI)
- Immunologists/allergist
- Psychologist/mental health professional
Read When And Where To Refer Out Speech Therapy Patients for more help.
Check out the Voice & Resonance Pack for our handouts and additional treatment ideas!
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References
- Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
- Guglani, L., Atkinson, S., Hosanagar, A., & Guglani, L. (2014). A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction. Frontiers in pediatrics, 2, 82. https://doi.org/10.3389/fped.2014.00082
- Mathers-Schmidt, B. A. (2001). Paradoxical vocal fold motion: A tutorial on a complex disorder and the speech-language pathologist’s role. American Journal of Speech-Language Pathology, 10(2), 111–125. https://doi.org/10.1044/1058-0360(2001/012)
- Nguyen JD, Duong H. Pursed-lip Breathing. (Updated 2025 Jan 25). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK545289/
- Patel, R. R., Venediktov, R., Schooling, T., & Wang, B. (2015). Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion. American journal of speech-language pathology, 24(3), 566–584. https://doi.org/10.1044/2015_AJSLP-14-0120
- Sandage, M.J. (n.d.). Paradoxical Vocal Fold Motion/Vocal Cord Dysfunction Assessment. [Online Course]. Medbridge. Retrieved February, 2025 from: https://www.medbridge.com/educate/courses/paradoxical-vocal-fold-motion-vocal-cord-dysfunction-assessment-mary-sandage-speech-language-pathology
- Sandage, M.J. (n.d.). Paradoxical Vocal Fold Motion/Vocal Cord Dysfunction Treatment. [Online Course]. Medbridge. Retrieved February, 2025 from: https://www.medbridge.com/educate/courses/paradoxical-vocal-fold-motion-vocal-cord-dysfunction-treatment-mary-sandage-speech-language-pathology
