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ARTICLE IN PRESS

Effects of Voice Therapy on Muscle Tension Dysphonia:


A Systematic Literature Review
*Gabriela da Cunha Pereira, †Isadora de Oliveira Lemos, †Camila Dalbosco Gadenz, and ‡Mauriceia Cassol, *†‡Porto
Alegre, Brazil

Summary: The present study aimed to carry out a systematic review of the effects of voice therapy on individuals
diagnosed with muscle tension dysphonia (MTD) or hyperfunctional dysphonia. This is a systematic literature review
on the databases Medline (via PubMed), Cochrane Library, Scopus, and Lilacs using a search strategy related to the
theme of the study. The selection included clinical trials that assessed the effects of speech therapy intervention on
patients diagnosed with MTD or hyperfunctional dysphonia published over the last 10 years in Portuguese, English, or
Spanish. The Physiotherapy Evidence-Based Database (PEDro) Scale was used to assess the methodology of the studies.
Of the 634 publications, 12 studies were included in this review, of which three were excluded due to a low score on
the PEDro Scale, resulting in a final number of nine publications. Regarding the techniques approached, semioccluded
vocal tract exercises (22.22%), nasal sound and frequency modulation (22.22%), maximum phonation time (MPT) tech-
nique and vocal hygiene (11.11%), vocal function exercises (11.11%), respiratory exercises along with phonoarticulatory
sounds (11.11%), manual laryngeal therapy (11.11%), and manual laryngeal therapy associated with respiratory exer-
cises (11.11%) were identified. These techniques promoted the following effects: improvement in intraoral and subglottal
pressure, positive alterations in the glottal contact quotient, significant changes in fundamental frequency measures,
increased MPT, and reduced voice roughness. Methodology was identified to be a shortcoming in the studies. The clin-
ical trials reviewed showed positive results in using the therapeutic techniques selected in the speech therapy approach.
Key Words: Voice–Dysphonia–Voice therapy–Muscle tension–Systematic review.

INTRODUCTION the term MTD is preferred because this marker assumes the phys-
Voice production depends on the complex and interdependent iopathology of the disorder.1 For etiological purposes, MTD is
action of all muscles involved and on the integrity of the speech categorized according to the following classification: primary,
apparatus. However, when muscle action is imbalanced due to related to the absence of structural alteration in the larynx; and
excessive tension in the (para)laryngeal muscles, muscle tension secondary, with the presence of tissue reactions.1–3
dysphonia (MTD) occurs,1,2 which manifests as characteristic signs The global objective of voice therapy is the reduction or cor-
in the extrinsic laryngeal support and postural musculature, such rection of improper voice use and a therapy program comprising
as deviation in head and neck posture with hyperextension, short indirect and direct therapy, yielding benefits in most cases.1 The
and compressed respiration, larynx in a high position, tension literature reports the beneficial use of indirect therapy, com-
on the face, and locked joints.1,3 posed of raising awareness to healthy vocal habits and their
As for the glottal source, the most common signs are importance, along with direct therapy, composed of voice therapy
hyperadduction of vocal and vestibular folds, the presence of tri- techniques.6,7 The direct approach aims to correct posture; relax
angular chinks of different lengths, and reduced vocal fold opening (para)laryngeal and cervical musculatures; promote respirato-
angle,1,3 which lead to complaints of a feeling of tightening and ry control, efficient glottal closure, and resonant equilibrium;
pain in the throat, irritation, and fatigue when speaking as a con- reduce voice symptoms; improve articulation; and reduce tension
sequence of the alteration in the perilaryngeal musculature in the laryngeal musculature.1,5
pattern.3,4 Signs related to voice quality include tense, com- Given the complexity of building a broad therapeutic plan that
pressed, breathy, and hoarse voice; jitter and shimmer alterations; aims to reduce the variety of body and voice manifestations in
instability during emission; and laryngopharyngeal resonance.2,5 this voice disorder, the present study aims to systematically review
The literature contributes with a variety of nomenclatures for the effects of voice therapy on subjects diagnosed with MTD
this disorder, such as hyperfunctional dysphonia, hyperkinetic dys- or hyperfunctional dysphonia, as well as assess the uniformity
phonia, musculoskeletal tension dysphonia, musculoskeletal tension of evidence on this voice disorder.
syndrome, and isometric larynx dysphonia, among others.6 Overall,
MATERIAL AND METHODS
Accepted for publication June 22, 2017.
Study design
From the *Speech-Language Pathology, Federal University of Health Sciences of Porto This is a systematic literature review, developed according to
Alegre, Porto Alegre, Grande do Sul, Brazil; †Rehabilitation Sciences, Federal University
of Health Sciences of Porto Alegre, Porto Alegre, Grande do Sul, Brazil; and the ‡Federal
the guidelines of the Prisma protocol for systematic reviews and
University of Health Sciences of Porto Alegre, Rehabilitation Sciences Program and Speech meta-analyses,8 which aims to answer the following question:
Therapy Department, Porto Alegre, Grande do Sul, Brazil.
Address correspondence and reprint requests to Gabriela da Cunha Pereira, Speech-
What interventions are selected for voice therapy on MTD, and
Language Pathology, Federal University of Health Sciences of Porto Alegre, 245, Sarmento what effect do they promote?
Leite Ave., Porto Alegre, Rio Grande do Sul 90050-170, Brazil. E-mail: gabycunhap@
gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ Search strategies
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
The search was carried out on May 20th, 2016 on the data-
http://dx.doi.org/10.1016/j.jvoice.2017.06.015 bases Medline (via PubMed), Cochrane Library (Central Register
ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2017

of Controlled Trials), Scopus, and Lilacs. Those databases were RESULTS


chosen for being widely used by the health-care sciences com- After 634 publications were acquired and verified through the
munity and for being internationally renowned reference sources. search strategy adopted, 24 were selected for full-text reading
The MeSH terms “muscle tension dysphonia” and “hyperfunc- and 12 were included in the review according to the eligibility
tional dysphonia” were used in association with the Boolean term criteria. All stages of the paper selection and analysis process
OR for the search on PubMed and equivalent terms on the other are shown in Figure 1, based on recommendations by Prisma.8
databases. Next, three studies were excluded for scoring below 3 on the
PEDro Scale. In face of that, this review worked with a final
Eligibility criteria and data extraction number of nine papers.
Paper selection began with title analysis, which excluded du-
plicates and studies that were not related to the key words defined Study characterization
by the search strategy, as well as papers whose full text was not Table 1 shows the characterization of the studies. The subjects
available. After the abstracts were read, clinical trials that as- were between 18 and 84 years old, most (n = 172) were
sessed the effects of voice therapy intervention on patients women,12–16 and 80 subjects were men. Eight studies (88.88%)
diagnosed with MTD or hyperfunctional dysphonia published had subjects with primary MTD or hyperfunctional dysphonia.
over the last 10 years in Portuguese, English, or Spanish were Among the nine articles, two (22.2%) are randomized and con-
selected. However, those whose samples comprised subjects below trolled clinical trials,13,14 while four (44.44%) are controlled clinical
18 years old, with syndromic or neurological diagnostic, or head trials.12,16–18
and neck cancer were excluded. Due to the limited number of
clinical trials in the area, both randomized controlled trials and Effects of interventions
nonrandomized or uncontrolled studies were selected for a full- Table 2 shows the effects of the interventions proposed by the
text review. studies selected. The table lists the methods assessed, the tech-
The studies that lacked sufficient information in the abstract niques used, and the results of speech therapy on the subjects
were also included in the full-text analysis. Finally, the papers with MTD or hyperfunctional dysphonia. The survey of tech-
were read in full and analyzed in order to include only those niques employed identified semi-occluded vocal tract exercises12,17
that matched the eligibility criteria. The following information (22.22%), maximum phonation times (MPTs) and vocal hygiene13
was extracted from the full-text reading: sample characteris- (11.11%), nasal sounds and frequency modulation18,19 (22.22%),
tics, study design, voice assessment methods, and intervention vocal function exercises14 (11.11%), manual laryngeal therapy15
protocol and its effects on the subjects’ voice. The analysis of (11.11%), manual laryngeal therapy associated with respirato-
the title and the abstract, and the full-text reading of the papers ry exercises20 (11.11%), and respiratory exercises along with
found were carried out by three independent judges, and the dif- phonoarticulatory sounds16 (11.11%).
ferences among them were settled through consensus. Moreover,
only the information regarding the effects obtained by the in-
Approach with semi-occluded vocal tract exercises
terventions on patients diagnosed with MTD were considered,
The studies12,17 applied the technique with resonance tubes of
and the other groups in the studies that had other voice disor-
different diameters and length whose end was in open air or sub-
ders were excluded.
merged in water at a depth of 3 and 10 cm. In addition, one study17
also used lip and tongue trill exercises, hand over the mouth,
Methodology evaluation
and bilabial plosive sound. The exercises took between 517 and
The Physiotherapy Evidence-Based Database (PEDro) Scale was
approximately 3012 minutes and were applied one17 and three12
used to assess the methodological quality of the studies.9,10 It
times in the session.
comprises 11 criteria, and for each criterion met, one point is
scored. Criteria 2–9 assess internal validity, and criteria 10 and
11 verify whether the studies have sufficient statistical infor- Approach with MPTs along with vocal hygiene
mation for the results to be interpretable. Criterion 1, which relates This intervention, employed by one study,13 comprises infor-
to the external validity, has been retained so that the Delphi list mation on voice health and the MPT technique for 6 weeks,
is complete, but it is not calculated. Therefore, the final score although the duration and weekly frequency of the application
can range from 0 to 10 points. of this therapy approach were not described.
Methodological quality was assessed by three independent re-
searchers. The assessors of the PEDro Scale analyzed only what Approach with nasal sounds and frequency
was reported in the manuscript, and when there was doubt due modulation
to unclear information, the studies were scored as not meeting The studies18,19 that adopted the nasal sound technique, along
the criterion, such as those that reported blinding but did not with frequency modulation, chose at least 3 seconds of emis-
explain the blinding procedure. For studies featuring a single sion with five repetitions of the same task.
group of participants in the sample, the answer “does not apply”
was added to the criteria involving the analysis of groups (cri- Approach with manual laryngeal therapy
teria 3, 4, 8, and 10). In addition, the studies that scored below Of the two studies15,20 that selected manual laryngeal therapy,
3 in the analysis were excluded.11 one20 chose to combine it with respiratory approaches for
ARTICLE IN PRESS
Gabriela da Cunha Pereira, et al Effects of Voice Therapy on Muscle Tension Dysphonia 3

FIGURE 1. Study flowchart.

TABLE 1.
Characterization of the Studies Selected
Sample Age Sample
First Author Group Composition (n) Range (y) Sex Type of Study
Guzmán et al 2015 12
Untrained normal voice (n = 12) 20–33 6F6M Controlled clinical trial
Untrained normal voice (n = 12) 21–37 7F2M
MTD (n = 14) 23–35 9F5M
Unilateral VF paralysis (n = 10) 31–56 8F2M
Watts et al 201513 Primary MTD (n = 10) 22–74 9F1M Controlled randomized
Primary MTD (n = 10) 32–64 7F3M clinical trial
Nguyen and Kenny 200914 Primary MTD (n = 22) 22–54 22 F Controlled randomized
Primary MTD (n = 18) 24–54 18 F clinical trial
Mathieson et al 200915 Primary MTD (n = 10) 19–55 8F2M Clinical trial
Liang et al 201316 Primary MTD (n = 21) 18–48 20 F Controlled clinical trial
Normal voice (n = 20) 20–45 21 F
Guzmán et al 201517 Hyperfuncional dysphonia (n = 40) 20–49 NA Controlled clinical trial
Vocally healthy (n = 40) 22–47
Ogawa et al 201418 Primary MTD (n = 21) 35–84 5 F 16 M Controlled clinical trial
Nondysphonics (n = 20) 24–72 5 F 15 M
Ogawa et al 201319 Primary MTD (n = 23) 49–81 10 F 13 M Clinical trial
No voice alterations and with 56–82 6F9M
sleep apnea (n = 15)
Van Lierde et al 201020 Primary MTD (n = 10) 18–65 4F6M Clinical trial
Abbreviations: F, female; M, male; MTD, muscle tension dysphonia; NA, not available; VF, vocal fold.
4
TABLE 2.
Effects of Vocal Techniques on Individuals with MTD
First Author Assessment Methods Intervention Frequency Effects Described
Guzman et al Aerodynamic SOVT 1 session All postures led to an increase in Poral, Psub, and CQ; however,
201512 assessment (Psub, (approximately phonation into a silicone tube below water surface (10 cm) and on a
Poral, and Ptrans); 30 min) with 3 times stick produced the highest values.
EGG [CQ]; acoustic each task
analysis (f0)
Watts et al VHI; MTP; z/s ratio; Maximum phonation 6 weeks (frequency Reduced VHI values; MPT and CPP in speech and significantly longer
201513 CPP with sustained time technique and and duration of vowels, leading to a reduction in vocal handicap, improvement of
vowel; CPP in vocal hygiene application not respiratory control, and greater phonation periodicity.
sentence reading informed)
Nguyen and Acoustic analysis Vocal function 2 weekly sessions Significant alterations in disturbances, harmonics-to-noise ratio, and
Kenny (jitter, harmonics-to- exercises (approximately perceptual data were observed in the complete protocol but not in
200914 noise ratio, f0, and 20 min each) for the partial one. The group with the complete protocol had an

ARTICLE IN PRESS
pitch); informal 4 weeks increase in size and rate of pitch alteration. The subjects of either
auditory-perceptual group had positive alterations in some tonal parameters after
assessment; EAI treatment. More positive alterations in the participants of the
complete intervention.
Mathieson Acoustic analysis Manual laryngeal 1 session (45 min) The average disturbance during chained speech was significantly
et al 200915 (frequency of therapy reduced after MLT, indicating a reduction in abnormal vocal
formants); function. The severity and frequency of the VTD Scale was reduced.
spectrographic
evaluation; VTD
Liang et al Aerodynamic analysis Respiratory and 4 sessions (2 h each) SGP and AP decreased, and MEA and MPT increased.
201316 (SGP, AP, MEA, and phonoarticulatory
MPT) exercises
Guzman et al EGG (CQ) SOVT 1 session (5 min each Lip and tongue vibration promoted lower CQ. Lower tube depth tends
201517 task) to lead to lower CQ, while deeper submersion tends to produce
higher CQ.
Ogawa et al EGG (CQ); acoustic Nasal sounds and 1 session (minimum Increase in F0 with glissando nasal sound. Reduction in roughness
201418 analysis (f0); frequency of 3 min each and in standard deviation of CQ, suggesting an immediate decrease

Journal of Voice, Vol. ■■, No. ■■, 2017


GRBAS (G/R/B/) modulation emission) with up to in contact irregularity of the vocal folds during phonation. The
5 times each task humming technique tends to slightly increase glottal contact degree
in patients with MTD.
Ogawa et al Transnasal Nasal sounds and 1 session (minimum Reduction in roughness, except for 5 women in the MTD group. The
201319 laryngoscopy; frequency of 3 min each humming technique corrects both lateral compression between the
GRBAS (G/R/B/) modulation emission) with up to VFs and the anterior-posterior compression of the larynx, favoring
5 times each task the latter.
Van Lierde DSI (f0, MPT, jitter, Manual laryngeal 1 session (45 min for Significant effect on overall voice quality with MLT. The DSI value of
et al 201020 and shimmer) therapy and the respiratory the subjects improved in face of the variables MPT, lower intensity,
respiration exercises and and jitter. Decrease in intrinsic and extrinsic laryngeal muscle
exercises 45 min for MLT) tension. MLT was more effective than respiration exercises.
Abbreviations: AP, aerodynamic power; CPP, cepstral peak prominence; CQ, contact coefficient; DSI, dysphonia severity index; EAI, equal-appearing interval; EGG, electroglottography; f0, fundamental
frequency; GRBAS, overall grade, roughness, breathiness, asthenia, and strain; MEA, mean expiratory airflow; MLT, manual laryngeal therapy; MPT, maximum phonation time; MTD, muscle tension
dysphonia; Poral, intraoral pressure; Psub, subglottal pressure; Ptrans, transglottal pressure; SGP, subglottal pressure; SOVT, semi-occluded vocal tract; VHI, Vocal Handicap Index; VTD, Vocal Tract Dis-
comfort Scale.
ARTICLE IN PRESS
Gabriela da Cunha Pereira, et al Effects of Voice Therapy on Muscle Tension Dysphonia 5

45 minutes. The other study applied only manual laryngeal therapy

Van Lierde
in a single session for 45 minutes.15

(2010)20
et al

4/10
Yes

Yes

Yes

Yes
NA
NA

NA

NA
No

No
No
Approach with vocal function exercises
The study14 that elected vocal function exercises for MTD de-
termined the duration of application at approximately 20 minutes

(2013)19
twice a week for 4 weeks.

Ogawa
et al

5/10
Yes

Yes

Yes
Yes
Yes
No
No
No
No
No
No
Approach with respiratory exercises along with the
phonoarticulatory method
Exercises of convex and concave abdominal respiration exer-

(2014)18
Ogawa
et al

6/10
Yes

Yes
Yes

Yes
Yes
Yes
No
No
No
No
No
cise, exercises of diaphragm control with convex abdomen and
rapid respiration, exercises of relaxation of muscles at the base
of the tongue and throat, and respiratory exercises with poem
reading were used by one study16 for 1 hour once a week for 4

Guzman

(2015)17
et al

4/10
weeks.

Yes

Yes

Yes
Yes
No
No
No
No
No
No

No
Methodological quality
Table 3 shows the methodological quality analysis of the studies

Liang et al
through the application of the PEDro Scale. In this evaluation,

(2013)16

5/10
Yes

Yes

Yes
Yes
Yes
88.88% of the studies12–14,16–20 properly presented the inclusion

No
No
No
No
No
No
criteria for subjects in the sample, 22.22% randomly allocated13,14
the subjects, 11.11% used13 secret allocation of subjects in-
cluded in the studies, 22.22% had13,14 similar groups regarding

Mathieson
the prognostic, 11.11% used14 subject blinding, 11.11% reported15

(2009)15
et al

4/10
therapist blinding, 33.33% blinded15,18,20 the evaluators, 77.77%

Yes
Yes

Yes

Yes
NA
NA

NA

NA
No
No

No
reported12–14,16–19 results measured in 85% of the sample, 66.66%
reported14–16,18–20 intention to treat, 77.77% reported12–14,16–19 results
of group comparison, and 100% employed central tendency and

Abbreviations: NA, not applicable; No, the criterion was not met; Yes, the criterion was clearly met.
dispersion measures.
and Kenny
Nguyen

(2009)14

In 22.22% of the studies,15,20 the term “does not apply” was

8/10
Yes
Yes

Yes
Yes

Yes

Yes
Yes
Yes
No

No
No
used due to the presence of only one group for intervention. Fewer
than half of the studies had trouble meeting the criteria regard-
ing the secret allocation of subjects in the samples and blinding
of subjects, therapists, and evaluators.
List of Papers and Their Scores According to the PEDro Scale

Watts et al
(2015)13

7/10
Yes
Yes
Yes
Yes

Yes

Yes
Yes
No
No
No

DISCUSSION No
This review presented satisfactory outcomes in the use of the
therapeutic techniques selected for intervention on MTD or hy-
perfunctional dysphonia based on the studies analyzed.
Guzman

(2015)12

Laryngeal hyperfunction is characterized by excessive activ-


et al

4/10
Yes

Yes

Yes
Yes
No
No
No
No
No
No

No

ity of the laryngeal and paralaryngeal muscles, with an increase


in force or tension in that region,21 which leads to excessive glottal
and supraglottal compression.22 Recently, the term MTD has been
8. Measures of key outcomes from

preferred by researchers to describe functional voice issues related


11. Point and variability measures
10. Comparison between groups

to the imbalance in laryngeal and paralaryngeal muscle activity.23,24


In face of that, the key words “hyperfunction dysphonia” and
more than 85% of subjects
4. Similar groups at baseline

9. Intention-to-treat analysis

“muscle tension dysphonia” were used as the search strategy on


2. Randomized allocation
Studies Criteria Critérios

6. Blinding of therapists
7. Blinding of assessors

the databases to ensure that the results contained only studies


3. Concealed allocation

5. Blinding of subjects

on individuals with clinical manifestations that fit the defini-


1.Eligibility criteria

tion of MTD while eliminating the other voice disorders belonging


to the category of functional dysphonia. This way, the studies
that did not clearly present the diagnostic of MTD or hyper-
Total score:

functional dysphonia were excluded.


TABLE 3.

The sample in the experimental group of most studies14–20 in-


cluded in this review comprised individuals diagnosed with
primary MTD. Primary MTD is characterized by the absence
ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2017

of organic lesion in the vocal fold associated with excessive, atyp- increase in this measure. MPT is the longest period during which
ical, or abnormal movements during phonation with no the patient is able to sustain the phonation of a sound, which is
neurological or psychogenic cause and is found in about 10%– commonly assessed using the vowel /ɑː/.29 This technique allows
40% of clinical cases diagnosed in specialized outpatient measuring the efficiency of the respiratory mechanism during
clinics.1,3,23,24 In face of that, eight studies employed a therapy phonation30 and is closely related to pneumophonic coordina-
approach with no organic alteration because the approach has tion. Excessive tension of laryngeal muscles, as well as the
a different goal when organic pathology is present. presence of muscle fatigue in this dysphonia, may cause
The samples of participants diagnosed with MTD or hyper- pneumophonoarticulatory incoordination and reduce MPT.31
functional dysphonia in the studies13–16,18 comprise mostly women, Voice roughness, assessed by perceptual analysis in the studies
which matches the finding in the literature because primary MTD by Ogawa et al,19 was reduced after the intervention. This measure
more commonly affects women23,25 who exert activities with great corresponds to the irregularity in vocal fold vibration, noises,
social pressure and intense vocal use.1,3,25 One study14 ap- and fluctuations in voice emission.32 In MTD, this indicator is
proached speech therapy intervention exclusively on women of part of the signs belonging to the setting of clinical manifesta-
an elementary school and dealt with a characteristic risk group tions related to alterations in voice quality due to this disorder.
given the voice demand, social pressure, and sex. Several evaluation methods have been used to measure la-
A variety of instruments were employed in the assessments of ryngeal muscle tension in patients with MTD, such as clinical,
the effect of the speech therapy intervention, which, consequent- radiological, and electromyographic analysis.24 However, Van
ly, led to a diversified presentation of the therapeutic effect Lierde et al20 and Liang et al16 concluded that the voice tech-
promoted. Such diversity is caused by the different techniques used niques employed in their researches led to lower excessive tension
in the studies and the various objectives set by each researcher. in laryngeal muscles based on the analysis of aerodynamic and
The intervention protocol by Watts et al13 employed voice health acoustic parameters. It is believed that, in those cases, the re-
information along with voice exercises so as to achieve a more duction in tension in the laryngeal region was an observable sign
complete planning by taking into account psychological and be- interpreted and presumed based on the results of those studies.
havioral factors involved in this voice disorder.1,24 There is The great variability in methodology used in those studies hin-
scientific consensus that voice therapy for MTD must compre- dered the detailed comparison of the therapeutic methods and
hend the joint approaches of indirect therapy, which raises goals as well as their effects on MTD. Nonetheless, the thera-
awareness for healthy vocal habits and their importance, and direct peutic approaches identified showed positive signs on the vocal
therapy, which comprises voice therapy techniques.1,7 behavior of the patients regarding the goals of the voice therapy
The studies by Guzman et al12,17 employed semi-occluded vocal and provide better quality of life to individuals with MTD.
tract exercises,15,16 which increased the glottal contact quotient The PEDro Scale, recommended to assess controlled and ran-
(CQ). However, the study by Ogawa et al18 achieved a reduc- domized clinical trials, was used in this review to also assess
tion in CQ by applying the nasal sound and frequency modulation noncontrolled studies. In those cases, the questions that did not
techniques. CQ is a quantitative measure assessed by fit the design were not scored, which justifies the lower final scores
electroglottography, corresponding to the relation between the in those studies. Hence, the methodology of new studies must
complete glottal period and the time of contact phase of the vocal be properly planned so that the effectiveness of the therapeutic
folds.25,26 Furthermore, it estimates the stress caused by the impact techniques can be assessed and the positive effects of the voice
of the vocal fold and increases with glottal adduction as it shows therapy intervention on MTD indicated by this review can be
the mode of phonation produced.26,27 Regarding the use of res- confirmed.
onance tubes submerged in water, the literature reports that the
tube must be positioned between 1 and 2 cm below the surface CONCLUSION
for patients with hyperfunctional voice disorders.28 All clinical trials analyzed and included in this review showed
Such data show that the greater the approximation of the vocal positive results in using the therapeutic techniques selected in
folds, the higher the contact quotient; ie, the value of this vari- the voice therapy approach. Although the studies employed various
able must be lower for lower excessive adduction. In addition, assessment methods, therapeutic protocols, duration and fre-
patients with those voice issues should be prescribed exercises quency of intervention, and shortcomings in methodology, the
with less high-flow resistance. findings in this systematic review indicate the benefit of the vocal
The studies by Ogawa et al18 and Nguyen and Kenny14 re- techniques identified both in the glottal source and in the ex-
ported a significant increase in fundamental frequency. Based trinsic laryngeal support musculature. In addition, it is worth
on the principle that one of the signs of MTD is the larynx at pointing out the need for further randomized clinical trials and
an elevated position in the neck, this alteration will lead to more studies with better methodological quality on dysphonia.
anterior resonance and to higher fundamental frequency.1–3,24
However, an elevated larynx is not found in all MTD patients
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