Da Cunha Pereira 2017
Da Cunha Pereira 2017
Da Cunha Pereira 2017
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
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
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
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
4/10
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
9. Intention-to-treat analysis
6. Blinding of therapists
7. Blinding of assessors
5. Blinding of subjects
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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