Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

Exploring autonomic dysfunction in functional dysphonia: A protocol for a case-control study and a randomized controlled trial

BACKGROUND

Although psychological factors have been implicated in patients with functional dysphonia (FD), conventional voice therapy (CVT) typically targets the aberrant voice symptoms exclusively. Yet, CVT is not always successful, and in view of the significant adverse quality of life impact combined with the financial burden on the healthcare system and society, research is needed to elucidate the underlying psychophysiology of FD and improve treatment outcomes.

OBJECTIVES

The first objective of this research project is to compare the occurrence and frequency of symptoms and/or disorders related to autonomic nervous system (ANS) dysfunction in patients with FD with gender- and age-matched vocally healthy controls, using a case-control study. The second objective is to compare the effects of a novel therapy for FD based on ANS regulation (i.e., ANS therapy: heart rate variability (HRV) biofeedback) on both autonomic function and voice function versus CVT alone or in combination with ANS therapy (i.e., ANS therapy + CVT), using a randomized controlled trial (RCT).

METHODS

Case-control study: Autonomic (dys)function of patients with FD will be compared with gender- and age-matched vocally healthy controls, using both physiological measures (e.g., HRV, skin conductance level) and psychological patient-reported outcome measures (PROMs, e.g., Neuroception of Psychological Safety Scale, Depression Anxiety and Stress Scale). RCT: The FD group will be randomly assigned to the innovative ANS therapy group, the CVT group or the ANS therapy + CVT group. All patients received 1 month of treatment with 20 min of daily practice. Both the autonomic assessment and the voice assessment will be performed pretherapy and immediately after therapy by assessors blinded to group allocation and study phase.

EXPECTED RESULTS

Higher occurrences of symptoms and/or disorders related to autonomic dysfunction are expected in patients with FD compared with vocally healthy controls. Physiological outcomes: lower HRV, lower cardiac pre-ejection period, higher respiration rate and higher skin conductance level are hypothesized in patients with FD compared with vocally healthy controls. Psychological PROMs: higher self-report of feelings/symptoms related to autonomic dysfunction (e.g., perceived stress, anxiety) is expected in patients with FD compared with vocally healthy controls. The autonomic function is hypothesized to improve more after the ANS therapy and the ANS therapy + CVT compared with the CVT only. Voice function is expected to improve more after the ANS therapy + CVT compared with the ANS therapy and the CVT alone.

WHAT THIS PAPER ADDS

What is already known on the subject Autonomic dysfunction is well recognized in the field of psychology but remains understudied in the area of voice. Given that the vagus nerve, innervating the larynx, also helps to regulate the ANS, and psychological symptoms commonly observed in patients with FD may reflect ANS dysregulation, research in this area is needed. There is some preliminary evidence that autonomic dysfunction might indeed be associated with FD. However, physiological ANS measures are needed, as well as validated psychological PROMs. What this paper adds to the existing knowledge The first objective of this study is to investigate the occurrence and frequency of symptoms and/or disorders related to autonomic dysfunction in patients with FD as compared with a gender- and age-matched vocally healthy control group. Autonomic (dys)function will be determined by employing both physiological measures (e.g., HRV, skin conductance level) and psychological PROMs (e.g., Neuroception of Psychological Safety Scale, Depression Anxiety and Stress Scale). The second objective is to compare the effects of a novel therapy for FD based on ANS regulation (HRV biofeedback) versus CVT alone or in combination with ANS therapy. What are the potential or actual clinical implications of this work? Success rates of symptomatic CVT for FD are highly variable. This study is expected to lead to innovative results related to the pathogenesis and psychophysiology of FD, a prevalent voice disorder associated with a significant adverse quality of life impact and a substantial financial burden on the healthcare system and society. The results of this study will lead to crucial new insights into both the diagnosis and treatment of FD, contributing to evidence-based practice in the field of voice.

Heart Rate Variability in a Vocal Stress Test with Special Consideration of the Objective Voice Function

OBJECTIVE

Many employees, especially in voice-intensive professions, are under psychological stress at work, which is very difficult to objectify. The aim of the study was to analyze correlations between heart rate variability (HRV) parameters and objective voice function using weighted voice parameters (Dysphonia Severity Index [DSI]) in order to determine whether subjects with impaired vocal function show a predominance of sympathetic control during a vocal stress test.

STUDY DESIGN

Prospective.

METHODS

Fifty-three people of working age were examined. After asking for sociodemographic, occupational, and voice-related data, the objective voice function was determined using the DiVAS voice diagnostics system, and a 20-minute vocal stress test was performed. The electrocardiogram was recorded using medilog AR12plus during the vocal stress test and in a 5-minute rest phase before and a 5-minute recovery phase after the test. HRV was analyzed using the Kubios HRV Premium software.

RESULTS

HRV was reduced during the vocal stress test compared to the resting and recovery phase. A Spearman correlation analysis showed significant correlations, particularly between the frequency-related HRV parameters and the DSI. The DSI correlated positively with the high frequency (HF) band (the relative power and the normalized unit). The DSI correlated negatively with the quotient between low frequency and HF and the low frequency normalized unit.

CONCLUSION

During a vocal stress test, adults in working age show a correlation between parameters of objective vocal function and parameters of HRV. The more impaired the objective vocal function, the higher the predominance of sympathetic activation under vocal stress. The voice can therefore be seen as a "warning signal" for the processes in the autonomic nervous system. The use of preventive strategies for stress management and for voice health appears to be particularly beneficial in vocally stressful occupations in order to achieve a positive effect on parasympathetic activity.

Relations Between Dysphonia and Personality: An Approximation From Gray' Theories

Our study sought to show the relation between dysphonia and personality traits as explained by Gray's theories. Personality traits were analyzed in a patient group of 141 patients who showed functional and congenital voice disorders. The results were compared to the control group made up of 99 vocally healthy individuals. Their objective voice quality was measured by using the Dysphonia Severity Index, Voice Handicap level was measured using the VHI-10, and a perceptive analysis was conducted with a listening jury. The results showed significant differences in Introversion and Neuroticism and a greater tendency for activating the behavioral inhibition system in the patient group. Such an influence was also evident in voice quality measures. The results were similar to specialized literature.

Integrative Review and Framework of Suggested Mechanisms in Primary Muscle Tension Dysphonia

PURPOSE

Despite the high prevalence of primary muscle tension dysphonia (MTD-1), its underlying mechanisms and their interrelationships have yet to be fully identified. The objectives of this integrative review were (a) to describe and classify the suggested underlying mechanisms for MTD-1, (b) to appraise the empirical evidence supporting each of the proposed mechanisms, and (c) to summarize the information in an integrative model.

METHOD

PubMed, Scopus, and CINAHL were searched for all publications pertaining to muscle tension dysphonia. Papers were retained if they included theoretical or empirical data pertaining to underlying mechanisms of MTD-1. A total of 921 papers initially qualified for screening, of which 100 remained for consideration in this review. Underlying mechanisms of MTD-1 were extracted using a consensus approach.

RESULTS

Seven broad categories of putative mechanisms involved in MTD-1 were identified: psychosocial, autonomic, sensorimotor, respiratory, postural, inflammatory, and neuromuscular. These categories were further divided into 19 subcategories detailed in the body of this review article. Based on the reviewed evidence, our proposed integrative model presents MTD-1 as an idiosyncratic motor adaptation to physiological perturbation or perceived threat. Under this model, physiologically or psychologically aversive stimuli can instigate a series of motor adaptations at multiple levels of the nervous system, ultimately disturbing muscle activation patterns and their biomechanical outcomes. Importantly, these adaptations appear to have the potential to become chronic even after threatening stimuli are withdrawn.

CONCLUSIONS

The proposed model highlights the importance of personalized rehabilitation in MTD-1 treatment. Limitations of the literature are discussed to provide guidance for future research aimed at improving our understanding of MTD-1.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19586065.

Stress and autonomic dysfunction symptoms related to voice in Brazilian university professors during the covid-19 pandemic

OBJECTIVE

To analyze the association of autonomic dysfunction symptoms with stress in Brazilian university professors of the Speech Language-Pathology course during the Covid-19 pandemic.

METHODS

Fifty-five Brazilian university professors participated in the study, with a mean age of 42 years and 10 months old (±8.75), 49 female and six male subjects. The evaluated outcomes were the symptoms of stress and self-assessment of autonomic dysfunction symptoms. The results were inferentially analyzed using binary logistic regression and chi-squared tests (p < .05).

RESULTS

In 54.54% of the university professors presented stress, with a predominance of psychological symptoms and a higher frequency resistance phase. Stress was a risk factor for the high occurrence of autonomic dysfunction symptoms related (OR 5.841) and unrelated (OR 29.750) to voice. There was an association between the predominance of psychological symptoms and the higher occurrence of autonomic dysfunction symptoms related to voice (p < .001).

CONCLUSIONS

There was an association between autonomic dysfunction symptoms and stress in Brazilian university professors during the Covid-19 pandemic.

[Physiotherapy treatment of vegetative disorders in patients with voice disorders]

OBJECTIVE

To increase the effectiveness of treatment of hypotonic functional dysphonia using physiotherapy in patients with neurovegetative disorders.

MATERIAL AND METHODS

The study included 42 patients, aged from 25 to 64 years, with disturbed vocal function, which included anamnestic analysis, an objective study of ENT organs by conventional methods, a video stroboscopy of the larynx, a cytological study of smears from the laryngeal mucosa, and the determination of the functional state of the autonomic nervous system (ANS).

RESULTS

The clinical-physiological study of VNS shows neurovegetative dysfunction (inadequate autonomic support of activity) in 10 patients. In these patients, the traditional conservative treatment was ineffective. Acupuncture used for treatment of neurovegetative disorders in these patients significantly improves the results of traditional treatment.

CONCLUSION

The results indicate an increase in the effectiveness of physiotherapy treatment (reflexotherapy using magnetic-infrared laser radiation and acupuncture) of ANS condition. These measures can be carried out in conjunction with traditional methods of treatment or in the case of their low efficiency.

Associations Between Teachers' Autonomic Dysfunction and Voice Complaints

OBJECTIVE

This investigation aimed to verify if there were any differences in autonomic nervous system function and voice parameters of teachers with and without voice complaints.

STUDY DESIGN

Cross-sectional study.

METHODS

The Questionnaire of Autonomic Dysfunction was answered by 24 teachers, 6 males, and 18 females, whose heart rate variability was also assessed. Aerodynamic assessment of voice, acoustic and auditory-perceptual analysis of voice were done. Participants were divided into two groups: without voice complaints (WVCG; n = 11) and with voice complaints (VCG; n = 13) based on the completion of the Sociodemographic and Clinical Questionnaire.

RESULTS

For auditory-perceptual analysis, VCG showed significantly higher values on GRBASH subscales Grade (P < 0.001) and Roughness (P = 0.011). Regarding the heart rate variability, it was found that in the VCG, the square root of the mean squared difference of successive RR intervals (RMSSD) and the percentage of adjacent NN intervals differing by more than 50 milliseconds (pNN50) were significantly lower than in the WVCG (P = 0.023 and P = 0.032, respectively). The VCG presented a higher occurrence of neurovegetative symptoms directly related to voice, namely in fluctuating nose obstruction (P = 0.011), neck pain (while or after speaking) (P = 0.017) and in fatigability when speaking (P = 0.004). Concerning the aerodynamic assessment of voice, acoustic analysis of voice and neurovegetative symptoms not directly related to voice, no statistically significant differences between groups were found.

CONCLUSIONS

Findings indicated significantly lower values in RMSSD and pNN50 of teachers VCG when compared with teachers WVCG and that the teachers VCG presented a higher occurrence of neurovegetative symptoms directly related to voice than the ones WVCG.

Functional voice disorders: Clinical presentations and differential diagnosis

In this chapter, an overview of the heterogeneous group of functional voice disorders is given, including the psychogenic voice disorder (PVD) and hyperfunctional or muscle tension voice disorder (MTVD) subgroups. Reference is made to prevalence and demographic data, with empiric evidence for psychosocial factors commonly associated with the onset and maintenance of these disorders. Clinical features that distinguish between the different presentations of PVD and MTVD are described. While there are some shared characteristics, key differences between these two subgroups indicate that PVD more closely resembles the psychogenic movement disorders and a range of other functional neurologic disorders. Assessment procedures and auditory-perceptual features of the voice that distinguish these disorders from the neurologically based voice disorders are discussed, with case examples highlighting ambiguous features that may influence differential diagnosis. The clinical profiles of PVD and MTVD affirm approaches to clinical management by speech-language pathologists that integrate symptomatic behavioral voice therapy with "top-down" models of counseling or psychotherapy. They also support the proposition that PVD may be construed as a subtype of functional neurologic disorders.

The behavioural treatment of muscle tension voice disorders: A systematic review

PURPOSE

A systematic review of behavioural intervention for the treatment of adults with muscle tension voice disorders (MTVD).

METHOD

A search of 12 electronic databases and reference lists for studies published between the years 1990-2014 was conducted using the PRISMA guidelines. Inclusion and exclusion criteria included type of publication, participant characteristics, intervention, outcome measures and report of outcomes. Methodological quality rating scales and confidence in diagnostic scale supported the literature evaluation.

RESULT

Seven papers met the inclusion criteria. Significant improvement on at least one outcome measure was reported for all studies. Effect sizes were small-to-large. Methodological qualities of research were varied. No study explicitly reported treatment fidelity and cumulative intervention intensity could only be calculated for two out of seven studies. Outcome measures were used inconsistently and less than half of the measures had reported reliability values. Confidence in the accuracy of subject diagnosis on average was rated as low. Specific "active ingredients" for therapeutic change were not identified.

CONCLUSION

Voice therapy for the treatment of MTVD is associated with positive treatment outcomes; however, there is an obvious need for systematic and high quality research designs to expand the evidence base for the behavioural treatment of MTVD.

Body pain in classical choral singers

PURPOSE

To identify and characterize the presence of body pain related to voice usage in choral singers.

METHODS

A questionnaire investigating the occurrence of voice problems, vocal self-evaluation, and a report of body aches was given to 50 classical choral singers and 150 participants who were non-singers. Thirteen types of aches were investigated that were distributed into two groups: larynx proximal ache (temporomandibular joint, tongue, sore throat, neck, back of the neck, shoulder, and pain while speaking) and distal ache (headache, backache, chest, arms, hands, and ear ache).

RESULTS

Classical choral singers had less presence of pain than the general population. The most related pain types reported in singers were sore throat, chest, and shoulder, respectively.

CONCLUSION

Reduced vocal signs of pain in singers may suggest that singers can benefit from vocal training once they have better voice usage due to voice practice, offering a protective -effect to the development of voice disorders since voice training builds up a better musculoskeletal endurance.

Psychosocial distress in patients presenting with voice concerns

OBJECTIVES

To assess the prevalence of psychosocial distress (depression, anxiety, somatization, and perceived stress) in a consecutive sample of patients presenting with voice concerns and to qualitatively analyze patient comments on challenges associated with voice problems.

STUDY DESIGN

Cross-sectional study.

METHODS

New patients presenting to a multidisciplinary voice clinic with voice concerns were invited to participate. Respondents (n = 197) completed the Brief Symptom Inventory 18-item scale, the 4-item Perceived Stress Scale, and the Voice Handicap Index 10-item scale. Qualitative analysis was performed of responses to an open-ended question about challenges associated with a voice problem.

RESULTS

Approximately one-third (32%) of the patients met the strict case criteria for depression, anxiety, and/or somatic concerns based on the Brief Symptom Inventory 18-item scale. Most patients had no prior diagnosis of depression or anxiety, and the degree of distress was not predicted by the type of voice-related diagnosis. Perceived stress was higher among female patients (P = 0.02). As expected, scores on the Voice Handicap Index 10-item scale were indicative of concurrent voice-related handicap (mean, 19.5; standard deviation, 9.4). In qualitative analysis of responses regarding challenges associated with a voice problem, 19 themes were identified (eg, threat to occupational functioning).

CONCLUSIONS

These findings identify a high prevalence of multiple types of distress among patients with voice disorders, presenting an opportunity to provide more comprehensive care to this patient population.

Sinais e sintomas da disfunção autônoma em professores

Objetivo comparar sinais de disfunção autônoma gerais e relacionados à voz em professores com e sem queixas vocais. Métodos aplicação do Protocolo de Disfunção Autônoma (PDA) em 83 professores, sendo 60 mulheres e 23 homens, com a média de idade de 37,6 anos. A amostra foi dividida em dois grupos, com e sem queixas vocais, definidas de acordo com o número de sintomas apresentados no Protocolo de Sinais e Sintomas Vocais. Resultados o grupo com queixa vocal apresentou a média de 13,7 sintomas no PDA e o grupo sem queixa 7,7 (p=0,001). Considerando apenas os sintomas neurovegetativos relacionados com a voz, o grupo com queixa obteve a média de 4,7 sintomas e o grupo sem queixa 1,8 (p<0,001). Os sintomas relacionados com a voz que mais predominaram no grupo com queixa vocal, quando comparado com o grupo sem queixa, foram: cansaço quando fala (p<0,001), necessidade de engolir constantemente (p=0,014), dor de garganta (p=0,001), dor no pescoço enquanto fala (p=0,003), dor ou desconforto na ATM (p=0,017), necessidade constante de bocejar (p=0,023), pigarros constantes (p=0,010) e tensão na cabeça quando fala (p=0,019). Os sintomas observados no grupo sem queixa foram: nariz entupido (33,3%), respiração nasal difícil (29,2%) e espirros (25%). Conclusões o grupo com queixa vocal apresentou maior número de sinais neurovegetativos, principalmente nas questões relacionadas à voz do que o grupo sem queixa.

Interactions between voice fundamental frequency and cardiovascular parameters. Preliminary results and physiological mechanisms

OBJECTIVES

To determine heart rate influence on voice fundamental frequency under stress conditions.

METHODS

In 14 healthy volunteers, heart rate and blood pressure variables were analyzed during three classical autonomic tasks. Sustained voice samples were obtained to analyze F0.

RESULTS

Cold pressure test increased mean blood pressure, without effect on heart rate; isometric and mental tasks increased heart rate and blood pressure. Voice F0 was only affected by mental and cold ice tasks; it significantly correlated with the heart rate that occurred before and during every vocal emission.

DISCUSSION

Cardiovascular changes showed that subjects were significantly stressed during autonomic tasks. Heartbeat variations had a regular and significant influence on phonatory frequency, and this effect occurred during baseline and stress conditions.

Sinais e sintomas da disfunção autônoma em indivíduos disfônicos

OBJETIVO: Verificar a ocorrência de sinais e sintomas da disfunção do sistema nervoso autônomo em indivíduos com disfonia comportamental e compará-la com resultados obtidos por indivíduos sem queixa vocal. MÉTODOS: Participaram 128 indivíduos adultos, com idades entre 14 e 74 anos, que foram divididos em dois grupos: disfonia comportamental (61 sujeitos) e sem queixa vocal (67 sujeitos). Foi aplicado o Protocolo de Disfunção Autônoma contendo 46 questões, sendo 22 relacionadas ao sistema nervoso autônomo e sem relação direta com a voz, 16 relacionadas tanto ao sistema nervoso autônomo quanto à voz, seis questões não-relevantes e duas questões de confiabilidade. RESULTADOS: Nas questões relacionadas à voz, como pigarros constantes, necessidade de engolir frequentemente, cansaço ao falar e dor de garganta, houve maior ocorrência de alterações neurovegetativas no grupo com disfonia comportamental. Nas questões sem relação direta com a voz, os indivíduos disfônicos apresentaram maior ocorrência de três dos 22 sintomas: gases, zumbido e engole ar enquanto fala. Os dois grupos apresentaram resultados semelhantes nas questões consideradas não relevantes ao sistema nervoso autônomo. As questões de confiabilidade necessitaram de reformulação. CONCLUSÃO: Indivíduos com disfonia comportamental apresentam maior ocorrência de sintomas neurovegetativos, principalmente daqueles que possuem relação direta com a voz. Tais resultados indicam maior labilidade do sistema nervoso autônomo nesses indivíduos.

A virtual trajectory model predicts differences in vocal fold kinematics in individuals with vocal hyperfunction

A simple, one degree of freedom virtual trajectory model of vocal fold kinematics was developed to investigate whether kinematic features of vocal fold movement confirm increased muscle stiffness. Model simulations verified that increases in stiffness were associated with changes in kinematic parameters, suggesting that increases in gesture rate would affect kinematic features to a lesser degree in vocal hyperfunction patients given the increased levels of muscle tension they typically employ to phonate. This hypothesis was tested experimentally in individuals with muscle tension dysphonia (MTD; N = 10) and vocal nodules (N = 10) relative to controls with healthy normal voice (N = 10) who were examined with trans-nasal endoscopy during a simple vocal fold abductory-adductory task. Kinematic measures in MTD patients were less affected by increased gesture rate, consistent with the hypothesis that these individuals have elevated typical laryngeal muscle tension. Group comparisons of the difference between medium and fast gesture rates (Mann-Whitney, one-tailed) showed statistically significant differences between the control and MTD individuals on the two kinematic features examined (p<0.05). Results in nodules participants were mixed and are discussed independently. The findings support the potential use of vocal fold kinematics as an objective clinical assay of vocal hyperfunction.

Interventions for preventing voice disorders in adults

BACKGROUND

Poor voice quality due to a voice disorder can lead to a reduced quality of life. In occupations where voice use is substantial it can lead to periods of absence from work.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent voice disorders in adults.

SEARCH STRATEGY

We searched MEDLINE (PubMed, 1950 to 2006), EMBASE (1974 to 2006), CENTRAL (The Cochrane Library, Issue 2 2006), CINAHL (1983 to 2006), PsychINFO (1967 to 2006), Science Citation Index (1986 to 2006) and the Occupational Health databases OSH-ROM (to 2006). The date of the last search was 05/04/06.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) of interventions evaluating the effectiveness of treatments to prevent voice disorders in adults. For work-directed interventions interrupted time series and prospective cohort studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified two randomised controlled trials including a total of 53 participants in intervention groups and 43 controls. One study was conducted with teachers and the other with student teachers. Both trials were poor quality. Interventions were grouped into 1) direct voice training, 2) indirect voice training and 3) direct and indirect voice training combined.1) Direct voice training: One study did not find a significant decrease of the Voice Handicap Index for direct voice training compared to no intervention.2) Indirect voice training: One study did not find a significant decrease of the Voice Handicap Index for indirect voice training when compared to no intervention.3) Direct and indirect voice training combined: One study did not find a decrease of the Voice Handicap Index for direct and indirect voice training combined when compared to no intervention. The same study did however find an improvement in maximum phonation time (Mean Difference -3.18 sec; 95 % CI -4.43 to -1.93) for direct and indirect voice training combined when compared to no intervention. No work-directed studies were found. None of the studies found evaluated the effectiveness of prevention in terms of sick leave or number of diagnosed voice disorders.

AUTHORS' CONCLUSIONS

We found no evidence that either direct or indirect voice training or the two combined are effective in improving self-reported vocal functioning when compared to no intervention. The current practice of giving training to at-risk populations for preventing the development of voice disorders is therefore not supported by definitive evidence of effectiveness. Larger and methodologically better trials are needed with outcome measures that better reflect the aims of interventions.