Musculoskeletal patterns in patients with voice disorders

Clinical Characteristics of Individuals Presenting to Physiotherapy for Voice and Throat Care: A Retrospective Case Notes Review

BACKGROUND

Currently, little is known about the characteristics of individuals presenting for physiotherapy care with voice and throat problems.

PURPOSE

The aim of this study is to describe the demographic and clinical characteristics of individuals presenting to physiotherapy for voice and throat-related problems, and to use this information to clarify the role of physiotherapy in the management of people with voice and throat problems.

METHODS

A retrospective clinical case notes review was conducted of all clients who accessed physiotherapy for voice and throat problems at a private practice based in Christchurch within a 12-month period from 1st October 2020 to 1st October 2021.

RESULTS

Data were analyzed from 53 patient charts. The typical profile of an individual accessing physiotherapy for voice and throat problems were female (n = 37), NZ European (n = 26), singer (n = 43), with chronic problems (n = 20), of a nontraumatic origin (n = 45). Voice problems were present in 39 cases and muscle-related problems were present in 42 cases. Treatment primarily included manual therapy and various modes of exercise therapy.

CONCLUSIONS

The clinical characteristics described offer insight into the demographic and clinical characteristics of individuals accessing physiotherapy services for voice and throat problems. A high prevalence of muscle-related problems and wider issues were identified, consistent with the physiotherapy skill set. Physiotherapy appears to complement existing ENT or SLT services by identifying and managing muscle-related voice problems and addressing wider factors contributing to voice and throat problems.

A multidimensional strategy to managing dysfunctional breathing and exercise-induced laryngeal obstruction in adolescent athletes

BACKGROUND

Exercise induced laryngeal obstruction (EILO) causes inspiratory distress in the upper airway in many adolescent athletes. The nature of EILO is not fully understood, and effective management strategies are lacking. This study aimed to assess the effectiveness of a multidimensional individually tailored intervention, including Norwegian Psychomotor Physiotherapy (NPMP), elements of cognitive behavioural therapy and a rehabilitation plan, in reducing inspiratory distress and dysfunctional breathing in adolescent athletes with EILO.

METHODS

A mixed methods design, which combined qualitative and quantitative research, was used. Data, including subjective experiences of respiratory distress, findings from body examinations and objective measurements of lung function and aerobic capacity were gathered before and after a five month intervention involving 18 participants.

RESULTS

Following the intervention, the participants showed a reduction in respiratory distress and anxiousness associated with their breathing difficulties. Furthermore, the participants reported to be more in control of their breathing. The body assessments revealed a more functional breathing motion and improved posture, which imply that the breathing was less thoracic and more diaphragmatic in rest and exercise in all participants after the intervention.

CONCLUSIONS

Our results suggest that a multidimensional individually tailored intervention, including NPMP based physiotherapy, cognitive behavioural therapy elements, and a rehabilitation plan may reduce inspiratory distress and dysfunctional breathing in athletes with EILO.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration and Results system NCT06033755, date of registration: September12, 2023. Retrospectively registered.

Effects of Transcutaneous Electrical Nervous Stimulation (TENS) on Dysphonic Patients: A Systematic Review Study

Background and Objectives: Transcutaneous electrical nerve stimulation (TENS), a pain-alleviating and muscle-relaxing treatment used in physio-therapeutic clinical practice, has recently appeared to be just as effective in dysphonia. This review aimed at clarifying whether TENS can be an effective practice in dysphonia therapy and/or management on its own or combined with other types of interventions and, hence, whether its practice can be a useful, more widespread establishment to speech and language therapy intervention methods. Materials and Methods: A search was conducted on the PubMed database using specific terms based on the PICO search strategy. Eventually, four randomized controlled studies and four clinical trials were included. The methodological quality of the included studies was evaluated using the physiotherapy evidence-based database (PEDro) assessment tool, and this indicated high-quality research with an average score of 8.43. Results: The studies utilized various TENS devices, predominantly the Dualpex 961 device (frequency of 10 Hz, phase of 200 ms). The assessment methods varied, including auditory perception, vocal therapy, electrostimulation, audio and video perceptual assessments, and laryngeal evaluations. The clinical outcomes of TENS showed a reduction in musculoskeletal pain in various areas, while the acoustic analysis results were significant in only one study. TENS was compared to manual laryngeal therapy (LMT), placebo TENS, and vocal therapy in different studies with mixed results. Conclusions: This review supports the idea that a multidimensional approach, incorporating various therapeutic modalities (TENS, LMT, speech therapy, and vocal training) can yield positive outcomes for patients with voice disorders. Further research is needed to explore the specific mechanisms of action and optimal treatment protocols for TENS in voice therapy.

Muscle Tension Dysphonia: A Sequeale of Chemoradiotherapy in Patients of Head and Neck Cancer

It's very important to demarcate that voice is the production of sound by the larynx while speech is articulation of the produced sound by tongue movements, soft palate and the lips. Mucositis, dysphagia, change in speech and voice are the common sequelae of Radiotherapy (RT) alone or in combination with chemotherapy (CRT) which is commonly used in the treatment of head and neck cancer (HNC). The aim of this study was to investigate the patient-reported voice impairment among non laryngeal head and neck cancer survivors who were treated with curative RT/CRT with or without surgery. This tertiary institutional assessor blinded study consists of a study cohort of 128 patients who after of completion of treatment for HNC reported to the laryngology clinic for voice complaints and throat discomfort. The assessment included laryngeal endoscopic and stroboscopic imaging, acoustics assessment and VHI (Vocal handicap index). This study cohort consisted of 89.8% males and 11.2% females. There was hyperadduction and strain of ventricular bands in almost all the cases. There was hyperactivity and compression of both true and false cords in 80.5% of the cases. DSI impairment level showed significant association with gender, VHI, GRBAS score and RT/CRT and it did not show significant association with smoking and surgery, while VHI showed significant association with DSI and RT/CRT and it did not show significant association with gender, smoking and surgery. Muscle tension is a very common effect of RT/RCT and dysphonia can be easily associated with it. Future research needs to focus on specific voice treatment regimens in HNC treated with RT/CRT to improve the quality of life of these patients.

Vocal Self-Perception of Home Office Workers During the COVID-19 Pandemic

OBJECTIVE

To investigate the self-perception of vocal fatigue symptoms and musculoskeletal pain in home office workers before and during the coronavirus disease (COVID-19) pandemic.

MATERIALS AND METHODS

A total of 424 individuals participated in this cross-sectional, observational, and descriptive study; they were stratified into the experimental group (EG), consisting of 235 individuals working from home office during the COVID-19 pandemic; and the control group (CG), with 189 individuals who continued to work in person during this period. All participants answered the vocal fatigue index and the musculoskeletal pain investigation questionnaires. The data were analyzed in a descriptive and inferential manner.

RESULTS

Participants in the EG reported more vocal fatigue symptoms and musculoskeletal pain than those in the CG before the pandemic. However, during the pandemic, the EG presented a higher frequency of pain in the posterior of the neck, shoulder, upper back, and temporal and masseter muscles, while the CG presented a higher frequency of pain in the larynx. With regard to vocal fatigue, during the pandemic, EG had an increase in scores to factors such as tiredness and voice impairment, avoidance of voice use, and total scores. No such differences were noted in the CG.

CONCLUSION

Workers who migrated to home offices during the COVID-19 pandemic are at risk of developing vocal disorders.

The influence of the low-frequency transcutaneous electrical nerve stimulation application moment in vocal quality of dysphonic women

Objective: to compare the immediate effects of low-frequency TENS employment on vocal quality in women with behavioral dysphonia before and after vocal exercises.Methodology: 30 women (mean = 31.3 years old), diagnosed with behavioral dysphonia received low-frequency TENS before (TENS + VE Group) and after vocal exercises (VE + TENS Group) with a 1-week washout. They had their sustained vowel/a/and running speech recorded before and after each procedure for auditory-perceptual analysis and acoustic measures. The low-frequency TENS parameters applied were symmetrical biphasic quadratic pulse, 200 µs phase, 10 Hz frequency, intensity on the motor threshold, and the electrodes were positioned on the submandibular and superior fibers of the trapezius muscle region. The vocal exercises: tongue trill, humming, finger kazoo, and water resistance therapy were performed totalizing 20 min.Results: intragroup analysis of sustained vowel/a/showed reduction in both groups of strain parameter and increased the breathiness; only VE + TENS Group increased the instability parameter, decreased fundamental frequency, and increased in SPI values; the running speech analysis showed an increase in the overall degree, roughness, and breathiness parameters. However, in VE + TENS Group, there was a statistically significant decrease in the intensity of the strain and an increase in breathiness. The acoustic measures showed that VE + TENS Group had a higher variation than TENS + VE Group regarding NHR.Conclusion: vocal exercises followed by low-frequency TENS have more immediate positive effects on voice quality than the low-frequency TENS followed by vocal exercises. This is a preliminary immediate effects study, and these effects could be verified through long-term assessments.

Can Vocal Therapy With Transcutaneous Electrical Nerve Stimulation (TENS) Followed by Vocal Exercises Reduce Benign Laryngeal Lesions in Dysphonic Women?: Randomized, Blind Clinical Trial

PURPOSE

To investigate the effectiveness of vocal therapy with the use of low-frequency transcutaneous electrical nerve stimulation (TENS) followed by voice exercises on vocal fold lesion size, vocal quality and quality of life in dysphonic women.

METHODS

27 women with vocal nodules participated, randomized into to: experimental group (EG)-13 women who received vocal therapy with 12 sessions of 20 min of TENS application (pulse:200μs, frequency:10Hz, motor threshold intensity, electrodes positioned in the trapezius muscle [descending fibers and submandibular region, bilaterally]). Each TENS session was followed by 30 min of vocal exercises; and the Control Group (CG)- 14 women who received 12 sessions with 20 min of application of placebo TENS (same conditions EG, but without receiving the stimulus electric), followed by 30 min of vocal exercise. Before, immediately after and one month after vocal therapy, participants underwent vocal recording for acoustic analysis, vocal self-assessment, laryngological examination and answered voice-related quality of life (V-RQOL) protocol.

RESULTS

There was reduction in the size of vocal fold lesions only in the EG, immediately after treatment and one month after treatment. Acoustic analysis showed decreases in SPI values immediately after and one month after treatment in both groups. There was improvement in voice self-perception in both groups after treatment and one month after, but no significant difference in V-RQOL values.

CONCLUSION

TENS followed by vocal exercises produced results similar to vocal therapy without TENS regarding voice quality, self-perception and quality of life in voice. However, vocal therapy with low-frequency TENS followed by vocal exercise was effective in reducing vocal fold lesion size in dysphonic women.

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.

Stressed and Distressed: Potential Underpinnings of Exercise-Related Inspiratory Distress in Adolescent Sport Performers

Many adolescent sport performers present with exercise-related respiratory symptoms consistent with exercise-induced laryngeal obstruction (EILO). The pathogenic underpinnings of EILO are not fully resolved, and existing behavioral management includes therapies targeting laryngeal physiology whereas surgical interventions target laryngeal anatomical anomalies. Recent findings from research and clinical practice indicate that psychological stress and thoracic breathing co-occur with laryngeal tightness in adolescent sport performers with EILO. This Perspective article theorizes on this potential coexistence. It discusses possible underpinnings of respiratory symptoms (including EILO) and thoracic breathing in adolescent sport performers by considering the effects of various stressors to which adolescent sport performers are exposed, and the impact these may have on the breathing, including in terms of laryngeal narrowing. The effect of stress on the breathing is examined in light of the reciprocal communication between the brain and the body and the relationship between psychological stress and stress responses in the respiratory system mediated by the autonomic nervous system. To inform decision-making and clinical awareness in this area, it may be worth expanding the focus from targeting mainly laryngeal structures to also include constrictions of the airways and the effects of thoracic breathing on the larynx during exercise. The importance of considering respiratory distress from a multidimensional perspective, and of incorporating the complexity of sport performers' psychological and physical experiences in the management of their health and well-being, is emphasized.

IMPACT

This Perspective adds to the understanding of respiratory distress in populations other than adults, which is important and necessary.

LAY SUMMARY

Adolescent sport performers are exposed to a number of stressors that may affect breathing and laryngeal narrowing, which in turn may have implications for the management of their overall health and well-being.

Are There Differences in Abdominal Muscle Function in Female Singers With and Without Voice Disorders? - An Observational Study

OBJECTIVES

The purpose of this study was to determine the motor function of the abdominal muscles in singers with and without functional voice disorders and to examine them for possible differences. Additionally, the breathing behaviour and posture control was investigated.

STUDY DESIGN

Observational study.

METHODS

Female subjects (n = 20) with differing levels of professional competence were used to provide the data for analysis. By using the Singing Voice Handicap Index (SVHI) the grade of dysphonia could be measured, and the subjects were organized in groups. The change of muscle thickness of the M. transversus abdominis (TVA) and the M. obliquus internus abdominis (OIA) during different singing tasks was measured by using ultrasound. The subjects were then asked to perform the Abdominal Hollowing Test (AHT) with the STABILIZER. Finally, the subjects were all filmed while singing. The videos recordings of the singing sessions were analysed by an independent clinical expert regarding breathing and secondary motor activities (SMA). For the statistical analysis, the Mann-Whitney-U Test and the Chi-Square-Test was mainly used.

RESULTS

The results showed a significantly thinner TVA in the group with dysphonia in comparison to the group without dysphonia. Ultrasound measurements showed significantly higher changes of muscle thickness of the TVA during singing tasks in the group with dysphonia. Regarding the AHT there was a significant difference between the two groups. The group with dysphonia was not able to increase the pressure by 15mmHg. Furthermore, the healthy subjects demonstrated abdominal breathing, while the group with dysphonia present with thoracic breathing. Additionally, it was noted that the subjects with dysphonia showed a higher level of associated movements especially at and/or on the lumbar spine, cervical spine and the left arm and shoulder.

CONCLUSION

Differences in TVA-recruitment, breathing behaviour and secondary motor activities while singing were found. This study sparks new ideas for neuromusculoskeletal assessments and therapy.

Strain Elastosonography Measurement in Patients with Primary Muscle Tension Dysphonia Compared with Healthy Speakers: A Pilot Study

OBJECTIVES

The purpose of this study was to investigate real-time elastosonography (RTE) to measure strain of the (para)laryngeal muscles in patients with primary muscle tension dysphonia (MTD) and healthy speakers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Ten patients with primary MTD (37.8 ± 10.53 years) and 10 healthy speakers (36.9 ± 9.8 years) participated. Participants were diagnosed as MTD patient or healthy via voice history, voice self-assessment, perceptual voice evaluation, laryngeal palpation, and videostroboscopy. Then, RTE was performed to extract strain index (SI) and strain ratio (SR) for all participants. The RTE was utilized for the suprahyoid, thyrohyoid, and the cricothyroid muscles, both in right and left sides during rest, /a/, and /i/ prolongations. To study the effect of group, task, and interactive effect on the SI and SR, two-way repeated-measures analysis of variance was performed.

RESULTS

The effect of group on the SI was significant for the right cricothyroid (P ˂ 0.001). Significant effect of group on the SR obtained for the right suprahyoid, left thyrohyoid, and right cricothyroid (P < 0.05). Moreover, the only muscle whose SR was significantly affected by task was the left suprahyoid (P < 0.05). Compared to healthy speakers, the interactive effect was significantly lower in SI for the left cricothyroid, and higher in SR for both the right suprahyoid and left cricothyroid in patients (P < 0.05).

CONCLUSIONS

The RTE can discriminate patients with primary MTD from healthy subjects in some laryngeal muscles, especially suprahyoid and cricothyroid. It may be regarded as a clinical instrument in the assessment of MTD in future. Further studies with bigger sample size are recommended.

Development and Preliminary Validation of a Pain Scale Specific to Patients With Voice Disorders: The Voice-Related Pain Scale (VRPS)

INTRODUCTION

Although pain is one of the complaints reported by voice patients, still there is no valid and reliable scale to evaluate pain in Patients with Voice Disorders (PWVDs). Therefore, the aim of the present study was to develop and validate the Voice-Related Pain Scale (VRPS).

METHODS

The present study was conducted in two stages: (1) development of the VRPS based on semistructured interviews with PWVDs and experts in the field of voice disorders and an in-depth literature review, and (2) Evaluation of the psychometric properties of the VRPS. Determining the validity and reliability of the VRPS was performed using qualitative and quantitative content validity, the qualitative face validity, and the test-retest reliability. Content validity of the VRPS was assessed by Speech and Language Pathologists who are experts in the assessment and treatment of voice patients and laryngologist. The reliability of the scale was determined using test-retest reliability.

RESULTS

Based on the interviews with PWVDs and experts, and a thorough review of the related literature, a self-reported scale with 11 items and three sections was developed. The three items included ear, temporomandibular joint, and shoulder all of which were divided into right and left pairs based on the experts' suggestion. One item was eliminated because it had a content validity ratio less than 0.62. The content validity index (CVIs) for all the remaining items were higher than 0.79 and the scale content validity index was equal to 0.93. The test-retest reliability was satisfactory with weighted kappa ranging from 0.64 to 1 for VRPS items. The final version of the VRPS comprised of 13 items related to the pain location in the human body. Each of these items has three sections: frequency of pain, severity of pain, and time of pain occurrence.

CONCLUSION

The present study indicated that VRPS is a valid and reliable tool to evaluate pain in PWVDs. The VRPS is a useful tool for clinical and research purposes. However, more studies are needed in this regard for further evaluation of the VRPS.

Determining pain in patients with voice disorders: a qualitative study

AIM

The present study aimed to determine pain in patients with voice disorders (PWVDs).

PATIENTS AND METHODS

A total number of 28 patients with a range of voice disorders and without any other diseases participated in the study. To gain maximum variation, purposive sampling method was used. Moreover, semi-structured interviews were employed for data collection. The interviews were then continued until data saturation was reached, and the data were subsequently recorded and transcribed verbatim. Qualitative content analysis was utilized for data analysis.

RESULTS

Data analysis of the interviews emerged three themes about pain experienced by PWVDs. The emerged themes included location of pain, type of pain, and time of pain occurrence. In this respect, PWVDs reported pain in different locations on their body including head, ears, anterior neck, posterior neck, larynx, temporomandibular joint, submandibular area, shoulders, and upper back. Furthermore, chronic, acute, severe, and mild were the most common types of pain reported by PWVDs. The PWVDs also stated that they had experienced pain at different times, i.e. during speaking, after long-time speaking, after voice use, during swallowing, during palpation, and all the time (even at rest).

CONCLUSIONS

One of the physical discomforts experienced by PWVDs is pain. According to the results of the present study, pain should properly be considered in the assessment and treatment of PWVDs in clinical practices. Also, our study suggested that a specific scale is needed to measure pain in voice disorders.

Effects of transcutaneous electrical nervous stimulation (TENS) associated with vocal therapy on musculoskeletal pain of women with behavioral dysphonia: A randomized, placebo-controlled double-blind clinical trial

Recently, electrical stimulation in vocal rehabilitation has been the subject of studies. This treatment has shown promising results regarding the decrease of vocal/laryngeal symptoms, pain and the improvement of vocal tension. In addition to decreasing pain symptoms, TENS treatments may lead to muscle relaxation. There is no data on the effects of this resource as a vocal therapy in women with behavioral dysphonia. Research in this area may provide evidence to assist the clinical decision related to the treatment of women with complaints of behavioral dysphonia and musculoskeletal pain.

OBJECTIVE

To verify the effects of low-frequency TENS in association with vocal therapy on musculoskeletal pain in women with behavioral dysphonia.

METHODS

Participants included 27 women with vocal nodules randomized into two groups. The experimental group (EG) - 13 women received 12 sessions of TENS (pulse of 200 μs, frequency at 10 Hz, in motor threshold) with electrodes placed bilaterally on the trapezius muscle and submandibular area for 20 min followed by 30 min of vocal therapy, and the control group (CG) - 14 women received 12 sessions of 20 min of a placebo TENS followed by 30 min of vocal therapy. We investigated the frequency and intensity of the musculoskeletal pain in several body regions, as well as the intensity of pain at rest and in the application of pressure with an algometer applied to the descending fibers of the trapezius muscle. The pressure-pain threshold (PPT) was also investigated. All evaluations occurred before, immediately after, and at one and three months after treatment in both groups.

RESULTS

We observed a reduction in the frequency of pain in the larynx after treatment of both groups, but only the EG showed a decrease in pain intensity in this region. It was verified with an algometer to the trapezius muscle that the electrical stimulation associated with the vocal therapy decreased the intensity of pain during the application of pressure and increased the PPT. There were no significant differences with regard to variables investigated in the comparison between the interventions. On the other hand, there was decreased pain in the trapezius muscle for the EG in comparison to the pre- and post-intervention.

CONCLUSION

The vocal therapyprogram reduced the frequency and intensity of the musculoskeletal pain in the regions proximal to the larynx of women with behavioral dysphonia. In addition, TENS followed by vocal therapy increased the threshold of sensitivity to muscular pain in the trapezius, demonstrating that it is a good resource to use in conjunction with traditional vocal therapy in cases of behavioral dysphonia associated with pain and muscle tension.

Efeito do programa integral de reabilitação vocal em professoras com disfonia comportamental

RESUMO Objetivo analisar os efeitos do Programa Integral de Reabilitação Vocal (PIRV) e os estágios motivacionais durante a terapia de voz em professoras com disfonia comportamental. Método estudo observacional longitudinal retrospectivo com dados de prontuários de 33 professoras referente à análise perceptivo-auditiva, acústica, autopercepção vocal e Protocolo de Índice de Desvantagem Vocal (IDV-10) nas situações pré e pós-fonoterapia e estágios motivacionais de adesão ao tratamento. Resultados Na avaliação perceptivo-auditiva da voz, 64,7% das participantes melhoraram a qualidade vocal pós-fonoterapia. Quando comparados os momentos pré e pós-fonoterapia, observou-se que 82,4% das professoras melhoraram a voz segundo a autopercepção. O IDV-10 não mostrou diferença entre os momentos pré e pós-fonoterapia (p=0,879). Na análise acústica da voz, observou-se melhora da média de todos os parâmetros avaliados. Houve associação estatisticamente significante na análise entre os momentos pré e pós-fonoterapia apenas nas variáveis tempo máximo de fonação e shimmer. A maioria das professoras encontrou-se no estágio de contemplação na escala URICA-VOZ. Não houve significância estatística na análise de associação entre o IDV-10, análise perceptivo-auditiva, tempo máximo de fonação e parâmetros da análise acústica com a autopercepção vocal das professoras e com a avaliação perceptivo-auditiva da voz. Conclusão o uso do PIRV para tratamento de disfonias comportamentais promoveu resultados positivos quando comparada a avaliação vocal antes e após tratamento. Quanto à motivação, as professoras acreditavam com firmeza na possibilidade de enfrentar o problema, mas ainda sem muito esforço para mudar essa situação.

Intrinsic Laryngeal Muscle Response to a Public Speech Preparation Stressor

PURPOSE

Research suggests that abnormal levels of intrinsic laryngeal muscle (ILM) contraction is a potential causal factor in stress-induced voice disorders. This study seeks to characterize the ILM stress response in a cohort of vocally healthy women.

METHOD

The authors used an unblinded, nonrandomized, repeated-measures design. Forty vocally healthy female adults were subjected to a stressful speech preparation task. Measurements of heart rate, blood pressure, trapezius muscle (positive control) activation, and tibialis muscle (negative control) activation were obtained from 37 participants before and during stressor exposure, in a nonvoice and nonspeaking task paradigm, to confirm physiological stress response compared to baseline. Fine wire electromyography of the ILMs (posterior cricoarytenoid, thyroarytenoid/lateral cricoarytenoid muscle complex, and cricothyroid) was performed simultaneously so that the activity of these muscles could be measured prior to and during stressor exposure.

RESULTS

The protocol successfully elicited the typical and expected physiological stress responses. Findings supported the hypothesis that, in some individuals, the ILMs significantly increase in activity during stress reactions compared to baseline, as do the control muscles.

CONCLUSIONS

This study characterizes ILM responses to psychological stress in vocally healthy participants. Some of the female adults in this study appeared to be "laryngeal stress responders," as evidenced by increased activity of the ILMs during a silent (i.e., nonvocal, nonspeech) speech preparation task that they considered to be stressful.

Exercise-induced laryngeal obstruction in athletes: Contributory factors and treatment implications

Otherwise healthy adolescent athletes presenting with respiratory symptoms consistent with exercise-induced laryngeal obstruction (EILO) are frequently encountered in clinical practice. The symptoms are often incorrectly considered to result from exercise-induced asthma, and may be wrongly treated as such. Given the potential implications for health and performance if EILO is left untreated, a more comprehensive understanding of contributory mechanisms is essential in order to create appropriate treatment procedures. Informed by knowledge from physical therapy, as well as the fields of voice rehabilitation and vocal pedagogy, this theoretical article presents a novel way of understanding and managing EILO by exploring bodily mechanisms and structures that may disturb laryngeal function during strenuous exercise. Firstly, the status quo of the EILO diagnosis, its aetiology and treatment options are reviewed. Secondly, considerations associated with laryngeal structures and mechanisms, and their potential influence on laryngeal movement and sensitivity are examined. Thirdly, the manner in which postural de-alignment and breathing pattern may interfere with laryngeal functioning will be discussed. Finally, interventions for voice disorders and singing and the relevance of these for EILO are evaluated. It is argued that clients with EILO should undergo a thorough physical examination to identify constrictions in the body as a whole - such as postural de-alignments and a dysfunctional breathing pattern - as these are hypothesized as playing a critical role in laryngeal tightness during exercise. Physical therapists possess particular skills and competence with regard to examining breathing patterns and postural de-alignments, and should be included in the treatment process of EILO.

Validity and Reliability of Surface Electromyography in the Assessment of Primary Muscle Tension Dysphonia

OBJECTIVE

The study aims to evaluate the reliability and the discriminative validity of surface electromyography (sEMG) in the assessment of patients with primary muscle tension dysphonia (MTD).

STUDY DESIGN

The study design is cross-sectional.

METHODS

Fifteen patients with primary MTD (mean age: 34.07 ± 10.99 years) and 15 healthy volunteers (mean age: 34.53 ± 10.63 years) were included. All participants underwent evaluation of sEMG to record the electrical activity of the thyrohyoid and cricothyroid muscles. The outcome measures were the root mean square (RMS), activity peak, duration, and time to the peak activity, which were obtained during /a/ and /i/ prolongation for test-retest reliability.

RESULTS

The test-retest reliability was good to excellent for the RMS and peak activity measures (intraclass correlation coefficient [agreement] [ICC_agreement] = 0.49-0.98). The reliability for the activity duration was poor to excellent (ICC_agreement = 0.19-0.9). Poor test-retest reliability was found for the time to peak measure (ICC_agreement = 0.15-0.37). The standard error of measurement for all sEMG measures was between 0.41 and 2.05. The smallest detectable change (SDC) was calculated between 1.13 and 5.66. The highest SDC values were obtained for the peak and the lowest SDCs were documented for the duration (5.66 and 1.13, respectively). All sEMG measures were not able to discriminate between the MTD patients and healthy subjects (P > 0.05).

CONCLUSIONS

The sEMG is a reliable tool to measure the RMS, the peak activity, and the activity duration in primary MTD. However, it is not able to discriminate the patients with primary MTD from healthy subjects.

Voice disorder in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic disease characterized by progressive tissue damage. In recent decades, novel treatments have greatly extended the life span of SLE patients. This creates a high demand for identifying the overarching symptoms associated with SLE and developing therapies that improve their life quality under chronic care. We hypothesized that SLE patients would present dysphonic symptoms. Given that voice disorders can reduce life quality, identifying a potential SLE-related dysphonia could be relevant for the appraisal and management of this disease. We measured objective vocal parameters and perceived vocal quality with the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale in SLE patients and compared them to matched healthy controls. SLE patients also filled a questionnaire reporting perceived vocal deficits. SLE patients had significantly lower vocal intensity and harmonics to noise ratio, as well as increased jitter and shimmer. All subjective parameters of the GRBAS scale were significantly abnormal in SLE patients. Additionally, the vast majority of SLE patients (29/36) reported at least one perceived vocal deficit, with the most prevalent deficits being vocal fatigue (19/36) and hoarseness (17/36). Self-reported voice deficits were highly correlated with altered GRBAS scores. Additionally, tissue damage scores in different organ systems correlated with dysphonic symptoms, suggesting that some features of SLE-related dysphonia are due to tissue damage. Our results show that a large fraction of SLE patients suffers from perceivable dysphonia and may benefit from voice therapy in order to improve quality of life.

Efeito imediato da terapia manual laríngea em indivíduos disfônicos

RESUMO Objetivos: Verificar o efeito imediato da terapia manual laríngea (TML) na dor musculoesquelética, na voz e nas sensações autorreferidas em indivíduos com disfonia funcional/organofuncional de origem comportamental e em indivíduos sem disfonia. Métodos: Participaram 30 indivíduos do gênero feminino e masculino, com idade entre 18 e 45 anos. Foram divididos em grupo disfônico (GD), 15 indivíduos com disfonia funcional/organofuncional; e grupo controle (GC), 15 indivíduos com vozes saudáveis, sem queixas vocais. Todos preencheram questionário de investigação de dor e foram submetidos a registro vocal para posterior avaliação perceptivo-auditiva e acústica da voz. Aplicou-se a TML por 20 minutos em ambos os grupos e repetiu-se a avaliação inicial. Após a TML, os indivíduos realizaram autoavaliação referente às sensações vocais, laríngeas, articulatórias e respiratórias. Resultados: No GD observou-se diminuição da dor após aplicação da TML nas regiões: temporal, laringe, parte posterior do pescoço, punhos/mãos/dedos, parte superior e inferior das costas, quadril/coxas, não observado no GC. A análise perceptivo-auditiva da vogal /a/ revelou que não houve diferença significante em nenhum parâmetro de ambos os grupos após TML. Na fala espontânea, houve piora no parâmetro rugosidade após a TML apenas no GD. Os indivíduos do GD relataram melhor sensação na laringe e articulação após a TML, o mesmo não foi observado no GC. Conclusão: A TML diminuiu a intensidade da dor corporal em disfônicos, o que não ocorreu com os indivíduos sem alterações vocais. Apesar da análise perceptivo-auditiva revelar aumento da rugosidade vocal, foram relatadas sensações positivas na laringe e na articulação pelos disfônicos após a TML.

Review on Laryngeal Palpation Methods in Muscle Tension Dysphonia: Validity and Reliability Issues

BACKGROUND

Laryngeal palpation is a common clinical method for the assessment of neck and laryngeal muscles in muscle tension dysphonia (MTD).

OBJECTIVE

To review the available laryngeal palpation methods used in patients with MTD for the assessment, diagnosis, or document of treatment outcomes.

STUDY DESIGN (METHOD)

A systematic review of the literature concerning palpatory methods in MTD was conducted using the databases MEDLINE (PubMed), ScienceDirect, Scopus, Web of science, Web of knowledge and Cochrane Library between July and October 2013. Relevant studies were identified by one reviewer based on screened titles/abstracts and full texts. Manual searching was also used to track the source literature.

RESULTS

There were five main as well as miscellaneous palpation methods that were different according to target anatomical structures, judgment or grading system, and using tasks. There were only a few scales available, and the majority of the palpatory methods were qualitative. Most of the palpatory methods evaluate the tension at both static and dynamic tasks. There was little information about the validity and reliability of the available methods.

CONCLUSION

The literature on the scientific evidence of muscle tension indicators perceived by laryngeal palpation in MTD is scarce. Future studies should be conducted to investigate the validity and reliability of palpation methods.

Muscle Tension Dysphonia: A Rationale for Symptomatic Subtypes, Expedited Treatment, and Increased Therapy Compliance

This article will briefly identify the variable nature of muscle tension dysphonia (MTD). Causes such as psychogenicity and maladaptive “vocal posture” will be described and questioned. Special Interest Group (SIG) 3 members may benefit from identification of the strengths and weaknesses of an ongoing movement towards a symptomatically generic “MTD.” More specific subtyping of MTD into 9 categories will be proposed, as well as description of associated therapy methods. Increased patient awareness that some subtypes may be self-correctable could simplify intervention, increase compliance, and improve clinician and researcher effectiveness.

Manual therapy and exercise to improve outcomes in patients with muscle tension dysphonia: a case series

BACKGROUND AND PURPOSE

Muscle tension dysphonia (MTD), a common voice disorder that is not commonly referred for physical therapy intervention, is characterized by excessive muscle recruitment, resulting in incorrect vibratory patterns of vocal folds and an alteration in voice production. This case series was conducted to determine whether physical therapy including manual therapy, exercise, and stress management education would be beneficial to this population by reducing excess muscle tension.

CASE DESCRIPTION

Nine patients with MTD completed a minimum of 9 sessions of the intervention. Patient-reported outcomes of pain, function, and quality of life were assessed at baseline and the conclusion of treatment. The outcome measures were the numeric rating scale (NRS), Patient-Specific Functional Scale (PSFS), and Voice Handicap Index (VHI). Cervical and jaw range of motion also were assessed at baseline and postintervention using standard goniometric measurements.

OUTCOMES

Eight of the patients had no pain after treatment. All 9 of the patients demonstrated an improvement in PSFS score, with 7 patients exceeding a clinically meaningful improvement at the conclusion of the intervention. Three of the patients also had a clinically meaningful change in VHI scores. All 9 of the patients demonstrated improvement in cervical flexion and lateral flexion and jaw opening, whereas 8 patients improved in cervical extension and rotation postintervention.

DISCUSSION

The findings suggest that physical therapists can feasibly implement an intervention to improve outcomes in patients with MTD. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the intervention. A clinical implication is the expansion of physical therapy to include referrals from voice centers for the treatment of MTD.

Observational study of differences in head position for high notes in famous classical and non-classical male singers

INTRODUCTION

Differences in classical and non-classical singing are due primarily to aesthetic style requirements. The head position can affect the sound quality. This study aimed at comparing the head position for famous classical and non-classical male singers performing high notes.

METHOD

Images of 39 Western classical and 34 non-classical male singers during live performances were obtained from YouTube. Ten raters evaluated the frontal rotational head position (depression versus elevation) and transverse head position (retraction versus protraction) visually using a visual analogue scale.

RESULTS

The results showed a significant difference for frontal rotational head position.

DISCUSSION AND CONCLUSION

Most non-classical singers in the sample elevated their heads for high notes while the classical singers were observed to keep it around the neutral position. This difference may be attributed to different singing techniques and phonatory system adjustments utilized by each group.

Muscleskeletal pain in dysphonic women

Objective:To investigate the location, frequency and intensity of muscle pain in dysphonic functional/organofunctional women in comparison to women with healthy voices.Methods:Sixty women, ranging in age from 18 to 45 years, divided into two groups: Dysphonic Group (DG) – 30 women with functional or organofunctional dysphonia; Non-Dysphonic Group (NDG) – 30 women without vocal complaints, and with adapted voices. All answered a protocol, marking the localization, frequency and intensity symptoms of pain on the temporal area, masseters, submandibular areas, larynx/pharynx, front and back of the neck, shoulders, upper back, lower back, elbows, fists/hands/fingers, hip/this, knees and ankles/feet. The volunteer should report the frequency in which pain was present in the last 12 months: no, rarely, frequently or always. The intensity of pain was measured by visual-analogue scales. The DG and NDG groups were compared using the Mann-Whitney test (p<0.05).Results:The women of the DG reported significantly greater frequency of submandibular area (p=0.008), laryngeal pain (p<0.001), front of the neck (p=0.015), back of the neck (p=0.001), shoulder pain (p=0.027), upper back (p=0.027) and also reported significant greater intensity of pain in the larynx/pharynx (p=0.022) and back of the neck (p=0.003).Conclusion:The frequency and intensity of musculoskeletal pain was more frequent and more intense in dysphonic women than in women without vocal complaints, showing that pain may be related to functional and organofunctional dysphonia in women.

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.

Is the sagittal postural alignment different in normal and dysphonic adult speakers?

OBJECTIVE

Clinical research in the field of voice disorders, in particular functional dysphonia, has suggested abnormal laryngeal posture due to muscle adaptive changes, although specific evidence regarding body posture has been lacking. The aim of our study was to verify if there were significant differences in sagittal spine alignment between normal (41 subjects) and dysphonic speakers (33 subjects).

STUDY DESIGN

Cross-sectional study.

METHODS

Seventy-four adults, 35 males and 39 females, were submitted to sagittal plane photographs so that spine alignment could be analyzed through the Digimizer-MedCalc Software Ltd program. Perceptual and acoustic evaluation and nasoendoscopy were used for dysphonic judgments: normal and dysphonic speakers.

RESULTS

For thoracic length curvature (TL) and for the kyphosis index (KI), a significant effect of dysphonia was observed with mean TL and KI significantly higher for the dysphonic speakers than for the normal speakers. Concerning the TL variable, a significant effect of sex was found, in which the mean of the TL was higher for males than females. The interaction between dysphonia and sex did not have a significant effect on TL and KI variables. For the lumbar length curvature variable, a significant main effect of sex was demonstrated; there was no significant main effect of dysphonia or significant sex×dysphonia interaction.

CONCLUSIONS

Findings indicated significant differences in some sagittal spine posture measures between normal and dysphonic speakers. Postural measures can add useful information to voice assessment protocols and should be taken into account when considering particular treatment strategies.

The assessment methods of laryngeal muscle activity in muscle tension dysphonia: a review

The purpose of this paper is to review the methods used for the assessment of muscular tension dysphonia (MTD). The MTD is a functional voice disorder associated with abnormal laryngeal muscle activity. Various assessment methods are available in the literature to evaluate the laryngeal hyperfunction. The case history, laryngoscopy, and palpation are clinical methods for the assessment of patients with MTD. Radiography and surface electromyography (EMG) are objective methods to provide physiological information about MTD. Recent studies show that surface EMG can be an effective tool for assessing muscular tension in MTD.

Laryngeal and pharyngeal activity during semioccluded vocal tract postures in subjects diagnosed with hyperfunctional dysphonia

High vertical laryngeal position (VLP), pharyngeal constriction, and laryngeal compression are common features associated with hyperfunctional voice disorders. The present study aimed to observe the effect on these variables of different semioccluded vocal tract postures in 20 subjects diagnosed with hyperfunctional dysphonia. During observation with flexible endoscope, each participant was asked to produce eight different semioccluded exercises: lip trills, hand-over-mouth technique, phonation into four different tubes, and tube phonation into water using two different depth levels. Participants were required to produce each exercise at three loudness levels: habitual, soft, and loud. To determine the VLP, anterior-to-posterior (A-P) compression, and pharyngeal width, a human evaluation test with three blinded laryngologists was conducted. Judges rated the three endoscopic variables using a five-point Likert scale. An intraclass correlation coefficient to assess intrarater and interrater agreement was performed. A multivariate linear regression model considering VLP, pharyngeal width, and A-P laryngeal compression as outcomes and phonatory tasks and intensity levels as predictive variables were carried out. Correlation analysis between variables was also conducted. Results indicate that all variables differ significantly. Therefore, VLP, A-P constriction, and pharyngeal width changed differently throughout the eight semioccluded postures. All semioccluded techniques produced a lower VLP, narrower aryepiglottic opening, and a wider pharynx than resting position. More prominent changes were obtained with a tube into the water and narrow tube into the air. VLP significantly correlated with pharyngeal width and A-P laryngeal compression. Moreover, pharyngeal width significantly correlated with A-P laryngeal compression.

Associations between voice ergonomic risk factors and acoustic features of the voice

The associations between voice ergonomic risk factors in 40 classrooms and the acoustic parameters of 40 schoolteachers' voices were investigated. The risk factors assessed were connected to participants' working practices, working postures, and the indoor air quality in their workplaces. The teachers recorded spontaneous speech and sustained /a/ before and after a working day. Fundamental frequency, sound pressure level, the slope of the spectrum, perturbation, and harmonic-to-noise ratio were analysed. The results showed that the more the voice ergonomic risk factors were involved, the louder the teachers' voices became. Working practices correlated most often with the acoustic parameters; associations were found especially before a working day. The results suggest that a risky voice ergonomic environment affects voice production.

An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers

OBJECTIVES

The purpose of this study was to investigate the baseline muscle thickness and recruitment patterns of the transversus abdominis muscle (TAM) and the internal oblique muscle (IOM) during semisupine phonation in a group of healthy performers.

STUDY DESIGN

This was a 2 × 3×2 within-group, repeated-measure study in which 25 professional vocalists--12 male and 13 female performed a series of sustained pitches in differing vocal qualities. Measurements were taken with ultrasound (Sonosite Micromaxx Ultrasound System) of the baseline thickness and % recruitment during voicing, of two deep abdominal muscles--TAM and the IOM. Correlations between TAM and IOM absolute change scores, TAM and IOM percentage change scores, and changes in muscle thickness (absolute and percentage) and age were examined using Spearman's correlations. Gender differences in the four types of change scores within each combination of pitch and quality were conducted with one-way analysis of variances. Differences in muscle thickness change 1) absolute scores and 2) percentage change in TAM and IOM, by pitch and quality (and their interactions) were analyzed using linear mixed models, using restricted maximum likelihood estimations, employing a Toeplitz variance-covariance matrix structure in SPSS (IBM, 2011). Post hoc analyses for independent variable group differences used Sidak's correction for multiple comparisons. Alpha level was set to 0.05.

RESULTS

In terms of absolute contractions (changes in the actual millimeter thickness of the muscle), the IOM was greater than the TAM. However in terms of percentage changes in muscles during phonation, the TAM was always greater than the IOM. The TAM as a percentage change was recruited preferentially and significantly in most vocal qualities tested. Although there were differences in muscle mass and recruitment patterns between genders, and males had thicker muscle mass at rest, differences due to muscle mass were not conclusive.

CONCLUSIONS

Overall this study supports the argument that the peri-abdominal muscles do indeed play a role in supporting the "performing" or athletic voice in healthy subjects, and will hopefully act as a database for further research in individuals with healthy and injured voices.

Comparison between palpatory findings of the hyoid position and their acoustic, videostroboscopic, and perceptual attributes in patients with muscle tension dysphonia (with and without organic lesions)

SUMMARY

The direction in which the hyoid is pulled may change as a result of muscle tension dysphonia (MTD). The disposition usually occurs owing to paralaryngeal muscular imbalance (decompensation), which can create laryngeal dysfunction and consequently deteriorating the voice quality. This study aimed at reporting on a comparison between palpatory findings of hyoid position and their acoustic and perceptual and stroboscopic attributes among patients with MTD.

DESIGN

Cross-sectional random triple-blinded study.

METHOD

Palpatory, acoustic, audioperceptual, and stroboscopic findings of 39 patients with MTD were analyzed descriptively and using independent sample t test.

RESULTS

Dominant perceptual vocal characteristic of patients with pulled-up hyoid position was rough and the degrees of jitter and shimmer were higher in patients with pulled-up hyoid position than in patients with pulled-down hyoid position (jitter, P=0.019; shimmer, P=0.004), whereas signal-to-noise (S/N) ratio was lower in patients with pulled-up hyoid position than in pulled-down hyoid patients, but not significantly (S/N ratio, P=0.56). The dominant perceptual characteristic of patients with pulled-up hyoid position was rough voice, whereas that for pulled-down hyoid patients was strained voice. On the other hand, the dominant observable pattern in patients with pulled-up hyoid was MTD type II (lateral constriction), whereas that in patients with pulled-down hyoid was MTD type III (moderate anteroposterior constriction).

CONCLUSION

There is a general congruence between the hyoid pulled direction and its perceptual, acoustic, and videostroboscopic findings in patients with MTD.

Compliance and Quality of Life in Patients on Prescribed Voice Rest

Objectives. To determine patient compliance with voice rest and the impact of voice rest on quality of life (QOL).

Study Design. Prospective.

Setting. University hospital.

Subjects and Methods. Demographics, self-reported compliance, QOL impact on a 100-mm visual analog scale (VAS), and communication methods were collected from 84 participants from 2 academic voice centers.

Results. Of 84 participants, 36.9% were men, 63.1% were women, and 64.3% were singers. The mean age of participants was 47.2 years. The mean duration of voice rest was 8.8 days (range, 3-28), and the median was 7 days. Overall compliance was 34.5%. Postoperative voice rest patients were more compliant than non-postoperative patients (42.4% vs 16.0%, P = .04, χ2). Voice rest had an impact on QOL (mean ± SD, 68.5 ± 27.7). Voice rest also had a greater impact on singers than nonsingers (mean VAS 77.2 vs 63.6, P = .03, t test) and on those age <60 years than those age ≥60 years (mean VAS 74.4 vs 46.7, P < .001, t test). More talkative patients and those with longer periods of voice rest had worse QOL scores (Spearman correlation = 0.35, P = .001 and Spearman correlation = 0.24, P = .03, respectively). Restrictions in personal and social life were noted in 36.9% of patients, 46.4% were unable to work, 44.0% felt frustrated, and 38.1% reported feeling handicapped while on voice rest.

Conclusions. Given poor patient compliance and the significant impact of voice rest on QOL, further studies are warranted to examine the efficacy of voice rest and factors that may contribute to patient noncompliance with treatment.

The putative involvement of the transabdominal muscles in dysphonia: a preliminary study and thoughts

OBJECTIVES/HYPOTHESIS

Real-time ultrasound was used as an adjunct to assess patterns of periabdominal musculature in 14 individual with dysphonia and muscle tension dysphonia.

MATERIALS

Fourteen individuals with muscle tension dysphonia were evaluated with real-time ultrasound as a part of their initial evaluation and management.

RESULTS

In 13 of 14 individuals, there was an imbalance found during phonation between the transversus abdominis muscles (TAs) and internal oblique muscles (IOs), whereby the IOs were found to be overactive and the TAs underactive. After physiotherapy, this pattern was reversed.

CONCLUSION

The abdominal muscle pattern of overactivity of the internal oblique and underactivity of the TA during phonation was found to be present in the large majority of patients in this pilot sample who had presented with muscle tension dysphonia. The significance of this is unclear but deserves further review.

Transcutaneous electrical nerve stimulation in dysphonic women

BACKGROUND

studies indicate correlation between dysphonia and muscle tension.

AIM

to evaluate bilaterally the electrical activity of the suprahyoid muscles (SH), sternocleidomastoid (SCM), and trapezius (T), the presence of pain and the voice, after applying transcutaneous electrical nerve stimulation (TENS).

METHOD

ten (10) women with nodules or bilateral mucus thickening, and phonation fissure. Volunteers were submitted to 10 TENS sessions (200 micros and 10 Hz) for 30 minutes. Pain was evaluated using an analogical visual scale; the voice was evaluated through laryngoscopy and through a perceptive-auditory and acoustic analysis; and the myoelectric signal was converted using the Root Media Square (RMS). Voice and EMG data gathering was performed during the production of the E/vowel and during spontaneous speech (SS).

STATISTICAL ANALYSIS

Shapiro-Wilk Test followed by the Wilcoxon Test, or t Student, or Friedman Test (p < 0.05).

RESULTS

It was observed that the TENS decreased the RMS readings, pre and pos treatment, for the Right T (RT) (2.80 +/- 1.36 to 1.77 +/- 0.93), the Left T (LT) (3.62 +/- 2.10 to 2.10 +/- 1.06), the Left SCM (LSCM) (2.64 +/- 0.69 to 1.94 +/- 0.95), and the SH (11.59 +/- 7.72 to 7.82 +/- 5.95) during the production of the E/vowel; and for the RT (3.56 +/- 2.77 to 1.93 +/- 1.13), the LT (4.68 +/- 2.56 to 3.09 +/- 2.31), the Right SCM (RSCM) (3.94 +/- 2.04 to 2.51 +/- 1.87), and the LSCM (3.54 +/- 1.04 to 3.12 +/- 3.00) during SS. A relieve in pain was also observed. Regarding the voice analysis, there was a decrease in level of laryngeal injuries; no difference was observed during the production of the E/vowel in the perceptive-auditory analysis; there was a decrease in the level of dysphonia and hoarseness during SS.

CONCLUSION

TENS is effective in improving the clinical and functional signs of dysphonic women.