Combined Functional Voice Therapy in Singers With Muscle Tension Dysphonia in Singing

The role and impact of voice physiotherapy: A qualitative study of service user perspectives

BACKGROUND

Physiotherapy has the potential to benefit people with voice and throat problems in conjunction with existing services.

PURPOSE

This study aims to explore the impact and role of physiotherapy in voice and throat care, from the perspective of people who have accessed such care. Gaining a better understanding of how physiotherapy contributes to care has the potential to improve services.

METHODS

An interpretive description design was used to explore participants perspectives of the impact and role of physiotherapy through individual semi-structured interviews with people who had accessed physiotherapy for voice or throat care through a single private practice. Transcripts were analyzed with a general inductive approach suitable for qualitative evaluation data. Data were analyzed from six interviews and four main themes emerged, with each theme further characterized by categories.

RESULTS

Two themes related to the impact of physiotherapy in voice and throat care: Offers a deeper understanding of issues affecting their voice/throat; facilitates individualized specific management. Two themes related to the role of physiotherapy in voice and throat care: Complements existing services; Valuable service. Each theme is further illustrated by categories.

CONCLUSION

This study indicates that physiotherapy for voice and throat problems can complement existing services while adding value, providing people with a deeper understanding of their problem and facilitating specific management. There is great potential for physiotherapy to benefit voice users. Future research should further evaluate the potential to include physiotherapy in the voice care team and consider how best to capture the broad impacts illustrated.

Sensation and Repercussion of the Use of Humid Heat in the Treatment of Dysphonia due to Laryngitis in Singers

PURPOSE

To verify the efficiency of thermotherapy perceptively and acoustically with hot vapor in the treatment of acute laryngitis.

METHODS

This is a pre and post test quasi-experimental study without a control group, approved by the ethics committee. Its sample counted with 65 singers - 37 females (56.9%) and 28 males (43.1%), mean age 33.7 years (±7.9) years, nonsmokers, with dysphonia due to acute laryngitis. They were submitted to videolaryngostroboscopy and perceptive-acoustic assessment of the voice before and 30 minutes after applying the inhalation of hot vapor. The appropriate statistical tests were used, adopting the significance level lower than 0.05.

RESULTS

In the acoustic assessment, there was a statistically significant improvement in jitter and shimmer for vowels A and E, P < 0.001. The F0 assessed separately per sex, as it presented a significant difference, P < 0.001. The women's F0 results before and after the heat were higher than the men's. In the analysis of the acoustic results based on harmonics-to-noise ratio and normalized noise energy, there was significant improvement after the heat. All the mean values increased after the heat. There was a statistically significant decrease in the parameters related to the perceptive-auditory assessment for G (grade of hoarseness), R (roughness), B (breathiness), and S (strain). Of the 47 singers that scored 2 for G, 28 (59.6%) reduced it to 1 after the heat, P < 0.001. All the 45 that scored 2 for R reduced it to 1, P = 0.011. Of the 8 who scored 2 for B, 6 (75%) reduced it to 1, P = 0.020. All the 28 singers that scored 1 for S reduced it to 0, P < 0.001. Only for A (asthenia), there was no significant improvement, P = 0.513. The results of the videolaryngostroboscopy revealed a statistically significant difference in all parameters analyzed, such as hyperemia, edema, muco-undulatory movement, and glottal coaptation.

CONCLUSION

The thermotherapy with using humid heat, provide symptomatic benefits in the treatment of dysphonia caused by laryngitis, demonstrating that the hyperthermoterapy is a potential auxiliary therapeutic resource for the treatment of acute dysphonia due to laryngitis since the intervention with the technique proposed increased the voice quality. It is suggested that this method be used in speech-language clinical practice and that new studies be conducted with stronger designs for its efficacy to be confirmed.

Development and Psychometric Evaluation of the Laryngeal Palpation Pain Scale (LPPS)

INTRODUCTION

One of the most important assessment and therapy methods for patients with muscle tension dysphonia (MTD) and other voice disorders is laryngeal palpation. However, there is no comprehensive scale for measuring pain during laryngeal palpation. The goal of the present study was to develop and validate a new scale to evaluate pain during palpation for patients with MTD.

METHODS

The present study consisted of two phases: (1) Development of the Laryngeal Palpation Pain Scale (LPPS) based on an in-depth literature review, the palpatory evaluation of MTD patients, interviews with experts in the field of voice disorders, and consultation with a registered pain expert, and (2) evaluation of the validity and reliability of the LPPS. The validity of the LPPS was investigated using qualitative and quantitative content validity, qualitative face validity, discriminant validity, and convergent validity. Content validity of the LPPS was assessed by experts' opinions (10 speech-language pathologists and five laryngologists), and face validity was investigated using the opinions of speech-language pathologists. The reliability of the LPPS was determined using test-retest and inter-rater reliability.

RESULTS

The item generation phase of the study led to the development of a scale to assess pain during palpation that included eleven locations in the neck region for palpatory assessment. These 11 items were divided into 13 different items (neck locations) based on the opinions of the experts. The content validity ratio values of all scale items were higher than 0.78. The content validity index (CVI) value for each of the items of the scale was higher than 0.79 and for the entire scale CVI (S-CVI) was 0.915. The results of the reliability of the LPPS items were satisfactory with weighted kappa values ranging from 0.655 to 1 for the test-retest and 0.77-1 for the inter-rater reliability. Convergent validity of the LPPS was shown with a significant positive correlation (r = 0.68) between the LPPS and the pain severity of vocal tract discomfort (P < 0.001). Moreover, MTD patients had more pain severity than the control group in all items of the LPPS (P < 0.05) except for the submental item (P = 0.89). These results indicate that the LPPS can differentiate MTD patients from healthy subjects. The final version of the LPPS includes 13 potential pain locations. The severity of pain at each of these locations is determined on a numeric pain rating scale of zero (no pain) to ten (the most severe pain).

CONCLUSION

The study showed that the LPPS is a valid and reliable scale to assess pain in MTD patients during palpation evaluations. More studies are recommended for further psychometric evaluation of the LPPS including responsiveness to change (the use in before-and-after intervention studies) and concurrent validity of the LPPS. The LPPS can be used for clinical and research purposes.

Working Together to Find a Voice: Recommendations for Voice Healthcare Based on Expert-By-Experience and Practitioner Consensus

OBJECTIVES

Voice care services aim to provide effective and meaningful voice care. Current practice guidance recommends a multidisciplinary voice care approach, supported by the evidence-base and practitioner experience. However, unlike other areas of physical and mental health, current voice care guidance does not explicitly include the voices of experts-by-experience, meaning those who have lived experience of voice difficulties. The perspectives of those working within nonclinical voice professions, such as vocal coaches, are also often omitted. There is therefore a need for updated practice guidance which prioritizes expert-by-experience and nonclinical perspectives.

METHODS

Vocal Health Education hosted a consensus meeting in London, UK. The meeting was coproduced with experts-by-experience, and attendees included those with lived experience of voice difficulties and practitioners across a range of disciplines within voice care. The content of the meeting was synthesized into themes and associated recommendations were drafted and agreed to by all attendees.

RESULTS

The consensus statement offers practical advice to those working in voice care. Recommendations are offered for multidisciplinary and biopsychosocial voice care, with a focus on person-centered practice and the valuing of lived experience. Through discussion, consensus was reached regarding recommendations for voice care assessment and treatment, practitioner approach, psychosocial considerations, and service design. The need for greater expert-by-experience involvement, coproduction, and co-construction was emphasized throughout.

CONCLUSIONS

This report emphasizes the voices of those with lived experience. It highlights ways of updating or improving current care, with the aim of informing clinical practice as well as research and service development. The consensus statement is the first in voice care to include experts-by-experience at the center of its recommendations, underlining the need for more coproduced and co-constructed research and practice within voice healthcare.

Eficacia de los ejercicios de tracto vocal semiocluído en el Temblor Esencial

El temblor esencial (TE) es una enfermedad neurológica que se manifiesta con trastornos del movimiento, experimentando la persona que lo sufre temblores que no puede controlar. Además de producirse temblores en manos, también manifiestan temblores en las mandíbulas y laringe, quedando principalmente la voz de estos pacientes afectada.  Por otro lado, se ha demostrado que los ejercicios de tracto vocal semiocluído (ETVSO) provocan cambios beneficiosos en el patrón vibratorio de los pliegues vocal. Es por ello que se presenta el caso clínico de una mujer de 61 años diagnosticada de TE con la finalidad de comprobar la efectividad de los  ETVSO en pacientes con dicha enfermedad. Los resultados post intervención logopédica mostraron un descenso en los Hz de los formantes de la voz, una mejora de fonación continua y mejora de la prosodia. Por lo que se concluye que el uso de los ETVSO podría ser beneficioso en pacientes con temblor esencial.

Effects of Laryngeal Manual Therapy on Primary Muscle Tension Dysphonia (MTD-1): Implications for MTD-1 Type

OBJECTIVE

The study investigated effects of laryngeal manual therapy on different types of primary muscle tension dysphonia (MTD-1).

STUDY DESIGN

Interventional pre-test post-test design.

METHODS

Thirty-two traditional Iranian singers (mean age of 36.75 ± 9.34 years.) diagnosed with MTD-1, 8 female and 24 male, and recruited by convenience sampling completed the study. MTD-1 was classified as Morrison and Rammage's types 1-5, based on standardized criteria (1993). Pre-post-treatment measures were based on visual ratings of the larynx, acoustic analyses, auditory-perceptual assessments of voice (Auditory-Perceptual Rating Instrument for Operatic Singing Voice: EAI Scale Form), and the Persian Singing Voice Handicap Index (P-SVHI), reported before and after 10 sessions of laryngeal manual therapy (LMT).

RESULTS

The most notable finding was that the number of cases with MTD-1 types 1 and 2 actually increased after treatment, while the number of cases with MTD-1 types 3, 4 and 5 decreased. The data suggested that MTD-1 types 3, 4, and 5 tended to convert to types 1 and 2 with LMT. Acoustic analyses showed a significant decrease in F0 (males only; P = 0.011), a sharp decrease in HNR from 23.26 dB to 14.74 dB (P = 0.000), and an increase in shimmer from 4.18% to 6.90 % while no appreciable change was found in jitter (P = 0.57). Mean P-SVHI score decreased significantly from 52.03 to 41.16 (P = 0.002) and EAI score increased from 4.41 to 6.31 (P = 0.000) after treatment.

CONCLUSIONS

The primary finding was that the distribution of MTD-1 type changed after treatment in many cases, converting from one to another type. Acoustic as well as glottal closure measures for several participants revealed closure insufficiency after treatment, unveiled as hyperfunction was unloaded with LMT. For those participants, complementary treatments aimed at reinforcement of laryngeal closure functions would be appropriate.

Voice Therapy Expectations for Injured Singers

OBJECTIVES/HYPOTHESIS

Voice therapy is a mainstay treatment modality in the management of phonotrauma in singers. However, the typical duration of therapy an injured singer undergoes is unknown. The primary aims of the study were to determine (1) the number of therapy sessions preceding a decision for surgery and (2) the number of sessions and length of time to achieve improvement in singers who did not undergo surgery. Whether specific singer factors were associated with the length of therapy was also investigated.

STUDY DESIGN

Retrospective.

METHODS

Records of singers with phonotraumatic vocal fold lesions seen over a 9-year period at a tertiary care voice center were reviewed.

RESULTS

Sixty singers who underwent surgery and 183 singers who did not undergo surgery were included in the final analysis. In nearly ¾ of the surgical patients, five or fewer voice therapy sessions were completed prior to the decision for surgery. Singers who did not undergo surgery required on average 3-4 sessions before noting improvement. Over 60% of the non-surgical singers improved within 3 months and 84% were judged to be improved by 6 months. Lesion type, professional/amateur status, formal voice training, and having a current voice teacher/coach were not associated with the length of voice therapy.

CONCLUSIONS

The length of voice therapy prior to decision for surgery was limited, and so was the length of therapy leading to initial improvement in singers who did not require surgery. These findings provide a framework for voice therapy expectations and could be reassuring for this unique population.

Extreme Vocals-A Retrospective Longitudinal study of Vocal Health in 20 Professional Singers Performing and Teaching Rough Vocal Effects

BACKGROUND

Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism.

OBJECTIVE

To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching.

METHODS

Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale.

RESULTS

Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry.

CONCLUSION

The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.

Transcutaneous Electrical Nerve Stimulation in Dysphonic Patients: A Systematic Review

OBJECTIVE

This paper aims to systematically review the application methods and clinical outcomes of transcutaneous electrical nerve stimulation (TENS) in the rehabilitation of dysphonic patients.

METHODS

The study consists of a systematic review performed in the Medline (via PubMed), Cochrane Library, Scopus and Lilacs databases, using a search strategy related to the research theme. Inclusion criteria involve experimental studies that investigated the effects of TENS on dysphonic patients, published in the last 15 years in Portuguese, English or Spanish. The Physiotherapy Evidence-Based Database was used to evaluate the methodological quality of the articles.

RESULTS

In the first search, 100 publications were found, 57 of which were duplicated and 23 did not address TENS as an intervention. According to the exclusion criteria of the remaining 20 studies, eight were selected for this review. The studies showed a pattern regarding the application of TENS. Of the studies analyzed, 87.5% had effective results after the intervention. Regarding pain, studies have found a reduction of this symptom in the neck, shoulders, back, masseter, and larynx. In the perceptual analysis, an improvement was verified in the parameters of tension, breathiness, roughness, instability, and asthenia. In addition, different types of vocal symptoms such as pain, burning, lump in the throat and effort to speak were reduced after TENS.

CONCLUSION

Although the studies included in this review indicate that there were changes related to the reduction of vocal symptoms, reduction of pain and improvement of vocal quality after the application of TENS in dysphonic patients, studies with a higher level of evidence and rigorous assessments of methodological quality are necessary so that findings are more robust and replicable in clinical practice.

Monitoring the Outcome of Phonosurgery and Vocal Exercises with Established and New Diagnostic Tools

Instrument-assisted measuring procedures expand the options within phoniatric diagnostics by quantifying the condition of the voice. The aim of this study was to examine objective treatment-associated changes of the recently developed vocal extent measure (VEM) and the established dysphonia severity index (DSI) in relation to subjective tools, i.e., self-evaluation via voice handicap index (VHI-12) and external evaluation via auditory-perceptual assessment of hoarseness (H). The findings for H (3 raters' group assessment), VHI-12, DSI, and VEM in 152 patients of both sexes (age range 16–75 years), taken before and 3 months after phonosurgery or vocal exercises, were compared and correlated. Posttherapeutically, all of the recorded parameters improved (p < 0.001). The degree of H reduced on average by 0.5, the VHI-12 score sank by 5 points, while DSI and VEM rose by 1.5 and 19, respectively. The correlations of these changes were significant but showed gradual differences between H and VHI-12 (r = 0.3), H and DSI (r = −0.3), and H and VEM (r = −0.4). We conclude that all investigated parameters are adequate to verify therapeutic outcomes but represent different dimensions of the voice. However, changes in the degree of H as gold standard were best recognized with the new VEM.

A Study of Vocal Facilitating Techniques Compared to Manual Circumlaryngeal Therapy in Teachers With Muscle Tension Dysphonia

OBJECTIVE

There are several voice therapy techniques been suggested in patients with muscle tension dysphonia (MTD), however a few studies are compared between them. The purpose of present study was to compare the effect of vocal facilitating techniques (VFTs) and manual circumlaryngeal therapy (MCT) in teachers with MTD.

STUDY DESIGN

This is a randomized clinical trial study.

METHODS

Sixteen teachers with MTD (female; mean age: 38.6 ± 4.6 years) participated in this study. The participants allocated to two treatment groups: the first group received VFTs (n: 8) and MCT was presented to the second one (n: 8). In each group, the voice therapy techniques were given for 10 individual sessions twice a week. The effect of both techniques was assessed using voice handicap index (VHI) and dysphonia severity index (DSI).

RESULTS

Within group comparison, the VHI, DSI, and theirs components showed significantly better results after both treatment groups (P ≤ 0.05). Although, effect size was strong for all target features (η2 > 0.36); the greatest magnitude was obtained on the physical subscale of VHI following MCT and for the DSI after VFTs (η2 = 0.92 and 0.90, respectively). Moreover, the interactive effect of time and treatment groups indicated that there was significant main effect on the physical and functional subscales of VHI (P = 0.00 and 0.02, respectively) as well as I-low and DSI (P = 0.01 and 0.02, respectively).

CONCLUSION

VFTs and MCT are two effective techniques in voice therapy of teachers with MTD. However, the greatest improvement obtained on the DSI following VFTs and for the physical aspect of VHI after MCT demonstrated voice therapist can use appropriate technique based on the voice complaints and results of voice assessments in MTD.

Efficacy of Phonosurgery, Logopedic Voice Treatment and Vocal Pedagogy in Common Voice Problems of Singers

INTRODUCTION

Functional and organic impairments of the singing voice are common career-threatening problems of singers presenting in phoniatric and laryngological departments. The objective was to evaluate the efficacy of phonosurgery, logopedic voice treatment and vocal pedagogy in common organic and functional voice problems of singers, including investigation of the recently introduced parameter vocal extent measure (VEM).

METHODS

In a prospective clinical study, the analysis of treatment outcome in 76 singers [57 female, 19 male; 38 ± 11 years (mean ± SD)] was based on pre- and post-therapeutic voice function diagnostics and videolaryngostroboscopy. Examination instruments included auditory-perceptual voice assessment, voice range profile (VRP), the VEM calculated from area and shape of the VRP, acoustic-aerodynamic analysis, and patients' self-assessment (e.g., Singing Voice Handicap Index).

RESULTS

While 28% of all singers (21/76) presented with functional dysphonia, 72% (55/76) were diagnosed with organic vocal fold changes, of which marginal edema (n = 25), nodules (n = 9), and polyps (n = 8) were the most common pathologic changes. Of the 76 singers, 57% (43) received phonosurgery, 43% (33) had conservative pedagogic (14) and logopedic (19) treatment. Three months post-therapeutically, most parameters had significantly improved. The dysphonia severity index (DSI) increased on average from 6.1 ± 2.0 to 7.4 ± 1.8 (p < 0.001), and the VEM from 113 ± 20 to 124 ± 14 (p < 0.001). Both parameters correlated significantly with each other (rs = 0.41). Phonosurgery had the largest impact on the improvement of vocal function. Conservative therapies provided smaller quantitative enhancements but also qualitative vocal restoration with recovered artistic capabilities.

CONCLUSIONS

Depending on individual medical indication, phonosurgery, logopedic treatment and voice teaching are all effective, objectively and subjectively satisfactory therapies to improve the impaired singing voice. The use of VEM in singers with functional and organic dysphonia objectifies and quantifies their vocal capacity as documented in the VRP. Complementing the established DSI, VEM introduction into practical objective voice diagnostics is appropriate and desirable especially for the treatment of singers.