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Voice disorders that are not due to structural lesions (i.e., the absence of any visible vocal fold
pathology) fall under the general descriptive term
"functional dysphonia" or "functional aphonia."
Several subtypes of this disorder have received attention in the research literature, namely hyperfunctional or muscle tension voice disorders (1-3).
It is assumed that laryngeal musculoskeletal tension
plays a major role in the development and maintenance of this form of dysphonia, and treatment generally involves the use of techniques that are designed to reduce muscle tension in the laryngeal
region, such as chewing, yawn-sigh, and progressive relaxation (4-6). Although these conditions are
quite common in clinical practice, there remains a
paucity of substantive information in the clinical
research literature regarding the effectiveness of
242
M A N U A L L A R Y N G E A L M U S C U L O S K E L E T A L TE NSIO N R E D U C T I O N
243
psychologic, and social factors. As a parallel component of voice disorder diagnosis and therapy, he
advocates a complete discussion of the interpersonal stresses surrounding the onset of the voice
problem to assist in determining its etiology. This
psychosocial interview therefore is an integral and
indispensable part of the assessment procedure.
Given the numerous treatment approaches available to the practicing voice clinician, it is important
to substantiate or reject Aronson's claims with empirical data. Hence, the present investigation was
designed to evaluate the perceptual and acoustic
effects of the manual laryngeal musculoskeletal tension reduction technique on patients with functional
dysphonia.
METHODS
Subjects
244
N. R O Y A N D H, A. L E E P E R
TABLE
1.
Summary data on patients who were submitted to the technique o f manual laryngeal
musculoskeletal tension reduction
Age
(years)
Sex
1
2
3
4
5
35
62
40
33
70
F
F
F
F
F
5
8
3
3
3
63
2 years
7
8
9
10
70
58
20
38
F
F
F
F
2
5
4
2
years
days
days
months
+
+
+
11
12
65
53
F
F
8 weeks
8 months
+
-
13
14
15
16
33
37
39
43
F
F
F
F
3
3
1
7
+
+
+
+
17
39
2 years
Pt. #
D.P.V.D.
weeks
months
months
months
years
months
months
year
months
Ex.
use
Smoker
Allergy
URI
Norm-1
MQ1
+
-+
+
+
-
+
+
.
+
+
+
+
+
+
+
+
+
P.H.V.D.
H.P.C.
Pain
L.E.
+
+
+
+
+
+ (employment)
+ (sister)
+ (employment)
+-- ( f a t i g u e )
+ (spouse,
depression)
+ (death brother
a n d sister)
+ (sister)
+ (marital)
+ (work)
+ (marital and
work)
+ (depression)
+ (death and
friend conflict)
+ (marital)
+
-+ ( d e n i a l )
+ (sister and
death)
+ (consort)
+
+
+
_+
+
+
.
+
+
___
+
+
+
.
.
+
-
+
+
.
+
+
--+
.
-
.
.
.
.
.
.
+
-
+
+
+
+
+
+
+
+
.
.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
.
.
D.P.V.D., duration of present voice disorder; P.H.V.D., previous history of voice disorder; H.P.C., history of psychological conflict;
Pain, laryngeal pain present on palpation; L.E., larynx elevation; Ex. use, history of excessive voice use; Smoker, cigarette smoker;
A l l e r g y , e n v i r o n m e n t a l a l l e r g i e s ; U R I , u p p e r r e s p i r a t o r y i n f e c t i o n p r e c e d i n g o n s e t ; N o r m - l , n o r m a l v o i c e a c h i e v e d in o n e s e s s i o n ; M Q 1 ,
m a i n t e n a n c e o f i m p r o v e d v o c a l q u a l i t y (1 w e e k p o s t t r e a t m e n t c h e c k ) .
+ = p r e s e n t , - = a b s e n t , -+ = e q u i v o c a l .
245
Pretreatment,
x
(or)
Posttreatment,
x
(or)
Significance
level
4.75
(1.74)
1.72
(0.93)
p < 0.0001
5.56
(1.64)
1.46
(0.55)
p < 0.0001
246
N . R O Y A N D H. A. L E E P E R
both connected speech and sustained vowels. However, no significant changes were observed in
modal vocal fundamental frequency after treatment.
During the connected speech analysis, cycle-percycle variations in the frequency of vocal fold vibration (i.e., jitter) showed statistically significant
decreases when comparing pre- and posttreatment
means [t(16) = 3.12, p < 0.01]. A mean jitter measure of 0.57 ms was reduced to a mean of 0.092 ms
following one treatment session (Table 3).
Shimmer, a measure of the variability in the amplitude of vocal fold vibration, also showed significant decreases pre-/postmanagement [t(16) = 4.11,
p < 0.001]. A pretreatment mean of 25% shimmer
was substantially reduced to a posttreatment mean
of 5.6% shimmer. Significant increases [t(16) =
4.42, p < 0.001] in the SNR measures were demonstrated following treatment. The SNR provides a
ratio in decibels (dB) of total signal energy to noise
in the speech waveform. From a pretreatment mean
of 10.9 dB, SNR measures increased to a posttreatment mean of 16.0 dB.
During the sustained vowel analysis, jitter measures showed nonsignificant decreases when comparing pre- and posttreatment means [t(9) = 2.04, p
Acoustic evaluation
Marked improvements in jitter, shimmer, and
SNR measures were seen following therapy for
A
5
S
e 4
V
e
r
f 3
t
Y
S
o
V
8
r
I
t
Y
2
1[
1 2 3 4 5 8 7 8 9 10 11 12 13 14 15 18 17
Subject8
I ~Preqqx
--Post-Rx
10
SubJect8
~Pre-Rx
--Post-Rx
FIG. 1. Mean pre- and posttreatment listener severity ratings for individual subjects in (A) connected speech and (B) sustained vowel
production.
Journal of Voice, Vol. 7, No. 3, 1993
M A N U A L L A R Y N G E A L M U S C U L O S K E L E T A L TE NSIO N R E D U C T I O N
T A B L E 3. Mean, standard deviation, and significance
Pretreatment,
y
(~)
Posttreatment,
~
(~)
Jitter (ms)
Shimmer
(%)
SNR (dB)
0.569
0.092
25.0
10.9
(0.633)
(19.34)
(4.55)
5.61
16.0
Significance
level
(0.018)
p < 0.01
(1.95)
(3.31)
p < 0.001
p < 0.001
< 0.07] (Table 4). A mean pretreatment jitter measure of 0.31 ms, however, was reduced to a posttreatment mean of 0.018 ms.
Shimmer measures did reveal significant decreases following the management session [t(9) =
2.47, p < 0.05]. Table 4 reveals that a pretreatment
mean of 22.4% shimmer was reduced to 3.8%.
Significant increases [t(9) = 4.75, p < 0.001] in
the SNR measures following treatment were observed. SNR measures increased from a pretreatment mean of 12.2 dB to a posttreatment mean of
20.0 dB.
In addition, changes in modal vocal fundamental
frequency were not found to be statistically significant when comparing pre- and posttreatment values in either connected speech or sustained vowel
contexts [t(16) = 0.73, p < 0.5 and t(9) = 0.59, p <
0.57, respectively]. Also, no significant differences
were detected between the acoustic measures from
connected speech samples and the sustained vowel
samples.
DISCUSSION
The purpose of this investigation was to examine
the effects of one treatment approach (the manual
laryngeal musculoskeletal tension reduction technique) on perceptual and acoustic parameters of vocal function in patients with functional dysphonia.
Significant changes in the direction o f " normal" vocal function in the majority of patients occurred
within one treatment session. Perceptual measures
TABLE 4. Mean, standard deviation, and significance
Pretreatment,
x
(Gr)
Posttreatment,
X
(~)
Jitter (ms)
Shimmer
(%)
SNR (dB)
0.312
0.018
22.35
12.19
(0.462)
(23.46)
(5.14)
a Nonsignificant difference.
3.83
20.03
Significance
level
(0.010)
p < 0.07 a
(2.91)
(5.90)
p < 0.05
p < 0.001
247
248
N . R O Y A N D H. A. L E E P E R
(iii) Discussion of the therapy plans once the patient appeared to understand the mechanism of the
voice disorder. The therapy approach was explained and the outlook for recovery was established.
(iv) The manual laryngeal musculoskeletal tension reduction technique was undertaken following
the description of Aronson (1). First, (a) the hyoid
bone was encircled with the thumb and middle finger, working them posteriorly until the tips of the
major horns were felt. (b) Light pressure was exerted with the fingers in a circular motion over the
tips of the hyoid bone. (c) The procedure was repeated beginning from the thyroid notch and working posteriorly. (d) The posterior borders of the thyroid cartilage just medial to the sternocleidomastoid
muscles were located and the procedure was repeated. (e) With the fingers over the superior borders of the thyroid cartilage, the larynx was worked
gently downward, also moving it laterally at times.
(f) The patient was asked to hum or prolong vowels
during the above procedures, noting changes in vocal quality or pitch. Clearer voice quality and reduction in pain and laryngeal height suggested a relief of tension. Finally, the improved voice was progressively shaped from vowels and words (usually
automatic/overlearned speech, i.e., counting, days
of the week) to sentences and finally conversation.
(v) After completion of the procedure, the results
of the therapy approach were discussed with the
patient in terms of the unpleasant life situations
contributing to the voice disorder and whether further psychological assessment or counseling was
necessary.
(vi) All of the patients were encouraged to tele-
249
phone a friend, relative, or spouse while in the office to stabilize the voice.
(vii) Each patient was instructed to contact the
clinician by telephone in 1 week to ensure maintenance of the improved vocal quality.
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