Find Your Voice, Improve Your Health

Have you ever considered the voice as a biomarker of your health? In this post I’ll address how to find your voice to improve your health.

For example, when you think of pelvic health, what comes to mind? Maybe obvious things like annual ob/gyn visits or for them, sexual function or a urology issue. For healthcare providers like pelvic floor PT’s, we think the pelvic girdle, abdominals and related synergists, mental health, and gut and respiratory health as top of the top of the list items to address for pelvic health.

It’s Time to Shift Toward a Three Diaphragm Model

Historically, speech-language pathologists’ study of vocal health has stopped at the respiratory diaphragm. Likewise, physical and occupational therapists’ study of pelvic health has stopped, well, in the same place.

Neither has traveled beyond that until recently. 

However, there is a third diaphragm beyond the respiratory and pelvic, the laryngeal diaphragm. It’s also known as the cervical, cervicothoracic, vocal, and/or thoracic diaphragm.

What are the Three Diaphragms?

The Three Diaphragms
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©2016. Garner, G. Medical Therapeutic Yoga. Used with kind permission of the author and Handspring Publishing, Ltd. Scotland, UK.
  • The Laryngeal Diaphragm – is responsible for neurological optimization of stress response and physiological control of swallowing and communication; but, it also influences vagal tone for cardiorespiratory functioning and respiratory and pelvic diaphragm functioning. It contains the muscles that are responsible for phonation, which includes intrinsic variables such as the arytenoids, but also extrinsic components which have a direct impact on the vocal fold health, such as the suprahyoid muscles.
  • The Respiratory Diaphragm – is the connecting point between cephalad and caudad (top and bottom) diaphragms and is the main muscle influencing pulmonary function. However, the respiratory diaphragm exacts a major influence on mind-body health, which goes far beyond pressure regulation of the vocal and pelvic diaphragms.
  • The Pelvic Diaphragm – is the terminal end of the tri-diaphragmatic (3D) system, and can bear the brunt of trauma and impairment if dysfunction is present in the two upstream diaphragms. The pelvic diaphragm contains the levator ani, coccygeus, and related synergists, pelvic fascia, and neurovascular structures, which in turn can work with or against breathing and voicing tasks. 

The diaphragms are in constant movement and none work in isolation. Together, their intersectional action provides us with the key to both internal and external biopsychosocial stability and structure of the mind-body. 

The Vocal Diaphragm

The laryngeal diaphragm has a supradiaphragmatic (above the diaphragm) vagal impact, while the pelvic diaphragm exacts subdiaphragmatic (below the diaphragm) vagal health, chiefly through afferent and efferent input, respectively. The 10th cranial nerve lives up to its namesake, “the wandering,” as it touches each of the three diaphragms on its journey, harnessing the capacity to lessen pelvic and visceral pain, while also improving vocal quality and lung function, and changing pain, mood, and digestive function. 

The mind-body interface of the 3D system has been further defined in recent years, broken down into a voluntary motor system (the one we spend all our time studying and treating), and the “emotional motor system,”  and the implications are profound. Anatomists and researchers tell us that in order to generate speech, we need both motor systems to function. But specifically, our emotional motor system must first perceive safety before speech can be produced or produced well.  

To get a feel for your own emotional motor system health, try this brief exercise: 

  1. Think about a recent incident that made you feel nervous, or anxious. 
  2. How well could you breathe? 
  3. Talk? 
  4. Sing or hum? 
  5. Engage in intimacy with someone? 

Not very well, right? This feeling is the fallout from your emotional motor system perceiving danger or threat. It’s what Dr. Stephen Porges means by the phrase, “neuroception.” Neuroception is the ability to detect risk – but it’s not just the ability to detect it – neuroception is the ability to accurately detect risk. 

Here lies the problem: 

If we cannot detect external risk or internal threat accurately, aka if our neuroception wiring is faulty, then we may move to 1 of 4 default modes for behavior: fight, flight, freeze, or fawn. If we are left in this state of reactivity, courtesy of the sympathetic nervous system, then polyvagal theory predicts we will enter into a dissociative state, termed a dorsal vagal response (DVR).

The DVR drives self-preservation in severe trauma states, which can preserve life; but it is also to blame for bradycardia and left unchecked, death. Especially now post-COVID, it’s imperative that all therapists understand how to recognize, screen for, and help nurture healthy self-regulatory strategies via trauma-informed care.  

We must also learn how to create a therapeutic landscape (aka safe space) conducive to healthy neuroception, one that appeals to the “safety switch” of the emotional motor system.

Establishing safe space is critical in pelvic health (and overall health) because the same motor system that controls the creation of sound, dictates everything associated with pelvic health, including:

  • bowel and bladder function,
  • birth,
  • sexual functioning,
  • digestion, and
  • stress response.

Optimizing Vocal to Pelvic Floor Function

To optimize function, we need to understand the basis of “3D” neurophysiology, because it makes targeting the voice a perfect alternate but necessary pathway for successful comprehensive pelvic health care. The same is true for optimizing vocal function.

Ultimately, the ability to create sound literally determines how we interact with the world around us, and whether or not we can do so with empathy and safety.

Additionally, the success of our vocal to pelvic floor health is also determined by the degree to which your healthcare providers are using the following:

  • an evidence-based biopsychosocial model, which has long been supported as the most effective and cost-effective way to manage pain and tackle chronic disease and impairment. 
  • integrative medicine (using mindfulness and nutrition to treat issues)
  • lifestyle medicine (improving lifestyle habits to treat impairment or optimize function)
  • functional medicine (using biochemistry to identify root cause)

What does including the voice look like in pelvic health and vice versa?

For starters, your healthcare provider should do a physical exam based on a “three diaphragm” approach. This approach should be used if you are having vocal, breathing, digestion, stress, jaw or neck pain, and/or hip, back, or pelvic pain.

These assessments work to identify red flags that place undue stress through the downstream diaphragms and stress response system. More complex assessment can include lumbopelvic ultrasound imaging as well, which provides a more comprehensive way to individualize therapy prescription. 

ultrasound in physical therapy
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Dr. Garner uses rehabilitative lumbopelvic ultrasound imaging in her practice to treat voice to pelvic floor issues

Assessment is essentially a 7-pronged process:

  1. Orofacial assessment, including the neck, jaw, and shoulder
  2. Respiratory assessment
  3. Abdominal wall/core assessment
  4. Pelvic floor and girdle assessment, including the hip and low back
  5. Gastrointestinal health
  6. Lifestyle contributors like sleep, social or interpersonal stress, environmental influences, physical activity, and nutrition
  7. Identifying integrative and biomedical therapies that will help

Overall, the voice is an incredible tool for improving pelvic health outcomes. Likewise, the pelvic floor is essential for optimizing vocal health.

Join Dr. Ginger Garner for The Voice and the Pelvic Floor, her course at Herman & Wallace Pelvic Rehabilitation Institute, to learn more. New dates announced on a rolling basis.

Here are a few more resources you may enjoy:


  1. HOLSTEGE, G., 2016. How the Emotional Motor System Controls the Pelvic Organs. Sexual Medicine Reviews, 4(4), pp. 303-328.
  2. HOLSTEGE, G. and SUBRAMANIAN, H.H., 2016. Two different motor systems are needed to generate human speech. The Journal of comparative neurology, 524(8), pp. 1558-1577.
  3. Speer LM, Mushkbar S, Erbele T. Chronic Pelvic Pain in Women. afp. 2016;93(5):380-387. 
  4. Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic “common factors” model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012;26(2):394-403. doi:10.1111/j.1471-6712.2011.00923.x
  5. Padoa A, McLean L, Morin M, Vandyken C. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med Rev. 2021;9(1):76-92. doi:10.1016/j.sxmr.2020.04.002
  6. Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368-384. doi:10.1080/09593985.2016.1194651
  7. Porges SW. The polyvagal perspective. BiolPsychol. 2007;74(2):116-143.

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