Hard onset therapy for functional hypoadduction and presbylaryngis: Our experience in 22 patients

A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System

BACKGROUND

The prevalence of voice disorders for people aged >65 years is four times higher than for the population at large. The most common cause of dysphonia in this group is presbyphonia, the preferred first-line treatment for which is voice therapy with a speech-language pathologist. This systematic review seeks to identify how voice therapy affects multidimensional voice outcomes in people with presbyphonia.

METHODS

A systematic search of CINAHL, Embase, Emcare, MEDLINE, and Google Scholar was conducted in March 2023. Comparative and noncomparative studies of voice therapy in participants aged >50 years with presbyphonia were considered for inclusion. No limitations were placed on date or language of publication. Study quality and risk of bias were assessed with the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies. Subgroup analysis was used to compare studies based on participant sex, intervention duration, study design, and intervention content. Interventions were specified using the Rehabilitation Treatment Specification System (RTSS) employing a consensus methodology among reviewers. The results were synthesized utilizing meta-analysis when outcomes were adequately specified and narrative analysis when they were not.

RESULTS

Twenty-three studies were included with 1050 subjects (mean age: 72.5 ± 8.6 years; 51% female). The most reported intervention was vocal function exercises. Per the RTSS, 14 interventions employed a predominantly Organ Functions approach, and the 14 remaining interventions employed a Skills & Habits approach. Meta-analysis confirmed posttherapy improvement in patient-related outcome measures of 0.93 standard mean difference (P < 0.00001, 95% confidence interval [CI]: 0.70-1.17); studies with predominantly males and with longer treatment periods were associated with larger improvements, while randomized controlled trials reported more modest improvements. Meta-analysis also identified a mean posttherapy increase in maximum phonation time (MPT) of 5.37 seconds (P < 0.00001, 95% CI: 3.52-7.22). Treatments with an Organ Functions focus resulted in greater gains in MPT than those with a Skills & Habits focus (7.52 seconds versus 2.90 seconds). Finally, meta-analysis identified reductions in acoustic perturbation measures (jitter: 0.62%, P < 0.001, 95% CI: 0.26%-0.97%; shimmer 1.05%, P < 0.00001, 95% CI: 0.67%-1.44%). Narrative synthesis further identified improvement in auditory-perceptual voice quality in all active treatment groups as well as improved glottal function in most studies that reported this.

CONCLUSIONS

Despite the uncertainty around internal validity introduced by the inclusion of a wide range of study designs, there is convincing evidence that voice therapy for presbyphonia results in significant improvement in patient-reported, aerodynamic, acoustic, and expert-rated voice outcomes. Treatments with an Organ Functions focus may better address the underlying physiological deficits of presbyphonia, although future comparative studies with multidimensional voice assessment are warranted.

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.