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Journalof Voice

Vol. 7, No. 3, pp. 242-249


1993 Raven Press, Ltd., New York

Effects of the Manual Laryngeal Musculoskeletal Tension


Reduction Technique as a Treatment for Functional Voice
Disorders: Perceptual and Acoustic Measures
N e l s o n R o y a n d * H e r b e r t A. L e e p e r
Department of Speech~Language Pathology, General Hospital, Sault Ste. Marie, and *Department of Communicative
Disorders, University of Western Ontario, London, Ontario, Canada

Summary: During a 2-year period, 17 patients with "functional dysphonia"


were assessed and managed in a hospital setting. A single treatment approach,
known as manual laryngeal musculoskeletal tension reduction, was employed.
The effects of the therapy regimen were analyzed using perceptual and acoustical measures of vocal function. The results indicated a significant change in
the direction of"normal" vocal function in the majority of patients within one
treatment session. Perceptual measures of severity were consistently more
likely to be rated as normal following treatment. Acoustic measures of voice
confirmed significant improvements in jitter, shimmer, and signal-to-noise ratio (SNR). Results are discussed in terms of the clinical utility and effectiveness of this treatment approach for functional dysphonia. Key Words: Manual
laryngeal musculoskeletal tension reduction--Functional dysphonia.

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

various management techniques. The majority of


investigations of functional dysphonia have not
documented specific treatment techniques nor addressed changes in vocal function resulting from
this management. In fact, the preponderance of the
literature is anecdotal in nature and relies on clinical
impression rather than on more objective or reliable
forms of data collection and analysis.
Recently, Koufman and Blalock (3) reported the
results of management efforts on a group of patients
presenting with laryngeal tension-fatigue syndrome
(TFS). TFS is associated with hoarseness or vocal
fatigue characterized by fluctuating vocal quality.
The authors attribute the existence of the voice
problem to the presence of excess laryngeal musculoskeletal tension. Although they report impressive results after one treatment session (i.e., the
reduction in dysphonic symptoms using progressive
relaxation, breath support, and pitch elevation), the
authors rely solely on perceptual measures to document improvement and fail to control adequately
for reliability of listener judgments.
Bridger and Epstein (7) reviewed 109 patients
presenting with functional voice disorders and

Accepted April 29, 1991.


Address correspondence and reprint requests to N. Roy at
Department of Speech/Language Pathology, General~Hospital,
941 Queen Street East, Sault Ste. Marie, Ontario, Canada P6A
2B8.

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

found that 56% were " c u r e d " by speech therapy


(i.e., their voices returned to their premorbid state)
and a further 26% had vocal quality "improved" by
therapy. Of the patients that were "cured," approximately one-half were discharged after 3 months of
treatment and 72% were discharged after 6 months
of treatment. Unfortunately, the authors failed to
describe adequately the treatment approaches employed that resulted in the reported success rates.
As well, these investigators relied on patient chart
review, single clinician judgments, and patient report as their criteria for establishing improvement.
Bridger and Epstein (7) indicated that the results of
treatment are rather disappointing overall and that
there is a need for further research to understand
the mechanisms underlying functional voice disordersl Several researchers have focused on describing the psychiatric and social characteristics of patients with functional dysphonia (8), while other investigators have evaluated the effects of combining
voice therapy with psychological counseling (9). Although these studies have been valuable in understanding selected aspects of functional voice loss,
they generally offer little objective data demonstrating the effects of these treatment techniques on
voice production.
Despite the lack of adequate empirical evidence
to support one treatment approach over another,
Aronson (1) suggested that all patients with voice
disorders, regardless of etiology, should be assessed for excess laryngeal musculoskeletal tension, either as a primary or a secondary cause of the
persisting dysphonia. Furthermore, he described
and advocated one treatment technique, that of
kneading the laryngeal musculature and lowering
the position of the larynx in the neck as the primary
approach for patients with musculoskeletal tension
voice disorders. Aronson (1) believes that the degree of voice improvement following treatment for
musculoskeletal tension should be proportional to
the reduction in muscle tension. In addition, he is
convinced that less aggressive methods, such as
progressive relaxation, the chewing approach, and
biofeedback, have the same objective as his manual
laryngeal muscle tension reduction technique, but
often fail because of the powerfully resistive force
of musculoskeletal tension. Therefore, Aronson (1)
offered this technique, not as an alternate therapy
approach, but as an essential one.
In addition to musculoskeletal tension, Aronson
(1) is mindful that factors that produce a dysphonic
voice are often a complex mixture of physiologic,

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

Seventeen subjects (16 female and 1 male, ages 20


to 70 years, mean age of 46.9 years) participated in
this study. All of the subjects presented with "functional dysphonia" that ranged in duration from 4
days to 3 years, with a mean duration of 8.3 months.
The diagnostic label of functional dysphonia was
made after a transoral fiberscopic laryngeal examination by one of two otolaryngologists revealed
both (a) the absence of visible mucosal disease and
(b) normal vocal fold mobility on phonation. Other
possible causes of the voice problem (e.g., chronic
sinusitis or myxedema) were excluded by the appropriate diagnostic procedures (i.e., radiographs
and blood tests). All subjects were referred by an
otolaryngologist and were seen within 1 day from
the time of referral. All were assessed and treated
by a single clinician using the same management
protocol.
A complete description of individual and group
subject profiles including age, sex, duration of
symptoms, history of previous dysphonia, presence
or absence of psychological conflict/stress, laryngeal pain and elevation, voice use, allergies, history
of upper respiratory infection (URI) symptoms preceding onset, and follow-up data are presented in
Table 1.
Procedures
Assessment and treatment protocol

An assessment and treatment protocol based on


an interview technique and on Aronson's manual
laryngeal muscle tension reduction procedure (1)
was employed for each of the 17 subjects. The asJournal of Voice, Vol. 7, No. 3, 1993

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 .

sessment protocol was developed according to


Aronson's guidelines to evaluate the voice in a traditional manner and also to assist in determining the
presence of emotional factors and the extent to
which they were instrumental in causing or perpetuating the voice problem. The assessment and interview protocol is outlined in detail in Appendix A.
After completing the case history, voice evaluation, and musculoskeletal tension assessment, the
treatment protocol described in Appendix B was
completed with each patient. For all 17 patients, the
assessment and treatment protocol was completed
in one session that ranged in total duration from 60
min to 3 h.
Because the majority of patients participating in
this study traveled considerable distances at significant personal expense, they were instructed to
contact the clinician by telephone 1 week posttreatment to assess the status of their voice and whether
partial or total recurrence of vocal symptoms had
occurred.
Perceptual evaluation

The majority of the patient's voices were recorded


on a high-quality Sony cassette tape recorder
Journal of Voice, Vol. 7, No. 3, 1993

(model CFS-3000) in combination with an Aiwa


Cardioid condenser microphone (model CM-60).
Each subject was recorded in a quiet setting while
reading a standard passage prior to and immediately
following the assessment and therapy regimen. In
addition, the final 10 of the 17 subjects had their
sustained vowel /a/ productions recorded before
and after treatment.
Connected speech. The central portion of a standard reading passage (The Rainbow Passage) was
dubbed from the original pre- and posttherapy audio
recordings onto a master tape for the perceptual
phase of this study. The signal level was manually
adjusted to prevent overload distortion using the
VU meter. The connected speech samples were
randomized and a 10 s interstimulus interval (rating
period) was maintained to allow for listener judgments.
Sustained vowel. A similar procedure was used
for the perceptual evaluation of pre- and posttherapy recordings of the sustained vowel/a/. The mid
5 s portions of the original vowel recordings were
copied in random order onto a second master tape
in the same manner as above. To permit an estimate
of the intrajudge reliability of the perceptual ratings,

M A N U A L L A R Y N G E A L MUSCULOSKELETAL TENSION REDUCTION


the first five samples on each experimental tape
were repeated at the end of the rating session.
Severity measures. To obtain severity ratings,
judges were instructed to rate each voice sample on
a 7 point equal-appearing interval scale, where 1
indicated a normal voice quality and 7 indicated a
severe quality disorder. Ten practice samples were
presented to familiarize the listeners with a range of
severity of vocal dysfunction. These voice samples
were selected as representative of the experimental
samples, but were not the same as those included in
the experimental tape-recorded portion. The selection of the practice samples was predicated on the
agreement of the investigators. Following each
practice sample, the judges compared and discussed their ratings until agreement on all practice
items was achieved. For the experimental portion
of the severity rating voice tape, listeners were required to rate connected speech and sustained
vowel samples separately. The listeners were also
instructed that they might employ midpoint measures for this particular rating scale.
Listeners. Four clinically certified, speechlanguage pathologists with extensive experience in
the assessment and treatment of voice disorders
served as listeners. The audiotapes were presented
at a comfortable loudness level from a research
quality recording/reproduction system. Listeners
were seated equidistant from the speakers in a quiet
setting and were provided with a standard scoring
package and written and verbal instructions.
Listener reliability
Interobserver and intraobserver reliability estimates were calculated for the perceptual ratings of
severity. Interobserver ratings were considered to
be in agreement if judges' severity ratings were
within 1.5 scale point value of one another on the
severity rating scale. For both connected speech
and sustained vowel stimuli, an interobserver concordance level of 91% was achieved. Intraobserver
reliability measures were also calculated. The same
criteria employed in the interobserver measures
were used to determine intraobserver concordance.
An intraobserver agreement level of 90% was attained for severity ratings of sustained vowel stimuli and a 100% intraobserver concordance level was
achieved for connected speech samples.
Acoustic evaluation
A signal processing technique (CSPEECH)
(P. H. Milenkovic, University of Wisconsin, Madison, WI, U.S.A.) was used to analyze digitally and

245

measure jitter, shimmer, and signal-to-noise ratio


(SNR) of the tape-recorded pre-/posttreatment
voice samples. These measures were derived by
computing the short-term autocorrelation function
of the speech waveform. A pitch predictor filter was
employed to improve the accuracy of SNR measures. The speech waveform was sampled at a rate
of 20 kHz and filtered at 10 kHz. A zero-phase highpass filter (cutoff of 20 Hz) was used to remove DC
bias before integration.
Acoustic analyses of the audio-recorded pre- and
posttreatment voice samples were undertaken for
both contextual speech and vowel prolongation.
The central 100 ms portion of the pre- and posttreatment vowel/a/production was selected for analysis. In addition, the neutralized stressed vowel/A/
in the word "above" from the middle sentence of
The Rainbow Passage (i.e., "These take the shape
of a long round arch with its path high above, and its
two ends apparently beyond the horizon") was selected for acoustic analysis because of its voiced
CVC environment. The central I00 ms of the vowel
segment was selected to avoid the potential aperiodicity associated with the onset and offset of the
vowel.
RESULTS
The results of perceptual and acoustic analyses
are reported separately for connected speech and
sustained vowels.
Perceptual evaluation
Severity
Substantial reductions in listener ratings of the
severity of the voice disorder were achieved after
one treatment session. The mean pretreatment severity rating of 4.75 was statistically significantly
greater than the posttreatment mean of 1.72 [t(16)
= 6.70, p < 0.0001] (see Table 2). Sixteen patients
(94%) were rated as improved on the connected
speech voice samples. Fourteen patients (82%)

T A B L E 2. Mean, standard deviation, and significance

levels for pre- and posttreatment listener ratings o f


the severity dimension
Speech
context
Connected
speech
Sustained
vowel

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

Journal of Voice, Vol. 7, No. 3, 1993

246

N . R O Y A N D H. A. L E E P E R

were considered by the listeners as either normal or


exhibiting the mildest dysphonic symptoms (i.e., received a mean severity rating of ~<2). This is compared to only two patients (12%) who received such
a rating prior to treatment (see Fig. 1A).
Listener judgments of the sustained vowels compare favorably with the connected speech findings.
On the severity dimension, the mean pretreatment
rating of 5.56 was significantly higher (i.e., poorer)
[t(9) = 7.35, p < 0.0001] than the posttreatment
severity mean rating of 1.46. All 10 of the patients
demonstrated improvements, while 9 patients (90%)
were considered either normal or only mildly impaired (i.e., <~2) after treatment (Fig. 1B).
Following a telephone interview procedure 1
week posttreatment, it was subjectively determined
that of the 14 patients who were rated as demonstrating either normal voice or only the mildest dysphonic symptoms immediately following treatment,
13 patients (93%) were judged by the principal investigator to have maintained the improved vocal
quality.

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

levels f o r pre- and posttreatment acoustic measures


(connected speech)
Acoustic
parameters

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

levels f o r pre- and posttreatment acoustic


measures (sustained vowel)
Acoustic
parameters

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

of severity of voice during contextual speech and


vowel prolongation were consistently improved following treatment. Measures of jitter, shimmer, and
SNR improved in both contextual speech and sustained vowel voice contexts following the management session. Short-term follow-up telephone interviews 1 week posttreatment confirmed the maintenance of improved vocal quality in 93% of the
patients who demonstrated either normal or only
the mildest dysphonic symptoms immediately following treatment.
Although CSPEECH has only recently been used
in the analysis of disordered voices (10,11), and audio-recorded voice samples were selected for the
acoustic analyses (12), the highly significant and
consistent trend towards improved vocal function
achieved in one session cannot be easily discounted. Normative data do exist for the various
acoustic measures of jitter, shimmer, and SNR, but
direct comparison of our results to established
norms is restricted because of the distinctly different recording and analysis procedures employed to
derive these measures.
Aronson (1) attributed improvements in vocal
quality following implementation of his procedure
to a reduction in laryngeal musculoskeletal tension
and lowering of the position of the larynx in the
neck. Because there exists a complex interaction
between psychological and physiological components in functional voice disorders, and because we
did not perform objective studies of muscle tension,
e.g., electromyography, we are cautious when reporting that normal voice return was solely or even
partially due to a reduction in muscle tension. The
assessment of both laryngeal pain and extent of laryngeal elevation is completely subjective and the
present authors are unaware of any study employing normal (control) subjects to determine the presence, absence, or significant reduction in such muscle tension. Because laryngeal muscle tension was
in no way objectively evaluated here, and the reactive psychological effects of clinical interaction with
the patients could not be controlled, we cannot
wholly substantiate the muscle tension reduction
explanation offered by Aronson for the improvements observed.
Given that both psychological and physiological
factors have been implicated in the pathogenesis of
functional dysphonia, a blanket explanation and interpretation of the results is not possible. However,
it is reasonable to speculate that several subgroups
exist within the diagnostic category of functional
Journal of Voice, Vol. 7, No. 3, 1993

248

N . R O Y A N D H. A. L E E P E R

dysphonia. For each subgroup, the mechanism that


underlies the onset of the voice problem may be
different than the mechanism that is maintaining it.
We speculate that muscle tension will play an extremely variable role depending upon where the patient is placed on the psychological vs. physiological continuum.
This investigation raises additional questions
concerning the manual laryngeal muscle tension reduction procedure. For example, the effect of the
psychosocial interview was not formally assessed.
Although none of the 17 patient's voices spontaneously improved following the interview alone, the
question remains: Would the voice change have occurred with no interview at all? Furthermore, the
assessment and treatment was administered by a
single clinician. If clinician attitudes and attributes
can enhance or reduce the effectiveness of therapies (13), then would these results have been
achieved across clinicians varying in levels of experience, confidence, and expectation? Until these
questions are answered and objective long-term
maintenance data become available, it is premature
to give unqualified endorsement of Aronson's view
that this technique should be employed as the primary therapy for functional dysphonia. However,
by virtue of the observed short-term voice improvement, clinical efficiency of this approach, and the
fact that almost no empirical evidence exists in the
research literature to support any alternative therapy approaches, Aronson's technique deserves serious consideration by practicing voice clinicians.
Future research should be directed at isolating
the causative factors that precipitate significant
voice improvement. The interrelationship among
vocal, physiological, psychological, and clinician
characteristics must be better defined in order to
separate the critical variables contributing to successful management of patients with "functional
dysphonia" (14).
In light of the present findings, further research
must be undertaken to evaluate seriously the effectiveness of alternative conventional facilitating approaches as described by other authors for the
treatment of functional dysphonia.
Acknowledgment: This study was conducted by the first
author as partial fulfillment of the requirements for the
Master of Clinical Science Degree in Communicative Disorders at the University of Western Ontario. Parts of this
manuscript were presented at the 1989A.S.H.A. Convention, St. Louis. The authors gratefully acknowledge the
advice and assistance of Drs. Kevin Munhall and Philip
Journal of Voice, Vol. 7, No. 3, 1993

Doyle. Also, we would like to express our appreciation to


Donna Lee and Brenda Veltri for their assistance in the
preparation of this manuscript.
APPENDIX A: VOICE ASSESSMENT AND
INTERVIEW PROTOCOL
(i) Baseline audio recordings of (a) contextual
speech (The Rainbow Passage) and (b) sustained
vowel/a/production.
(ii) Familiarization period: Rapport was established from the time of initial contact.
(iii) Onset of the voice disorder: Conditions surrounding the onset of the dysphonia were explored
with the patient, i.e., when and how did the voice
trouble begin? Did the voice disorder begin suddenly or gradually?
(iv) History of previous periods of partial or total
voice loss.
(v) Course of the voice disorder: Had the voice
disorder been present from the time of onset? Had
there been periods of normal voice return?
(vi) Events associated with onset: The major emphasis in this section was to determine if the voice
disorder began in association with emotional problems (i.e., stress, anxiety, conflict, and communication breakdown.)
(vii) Traditional evaluation of vocal function:
This included MPT, pitch and loudness characteristics, etc.
(viii) Musculoskeletal tension evaluation: This
was employed to determine subjectively (a) the extent of laryngeal elevation and (b) pain in response
to pressure in the region of the larynx. By encircling
the larynx with the thumb and middle finger in the
region of the thyrohyoid space, it was established
whether the space had been narrowed by laryngeal
elevation. The presence or absence of pain was detected by manually palpating in the area of hyoid
bone and thyrohyoid space bilaterally.
(ix) Posttreatment audio recordings of (a) The
Rainbow Passage and (b) sustained v o w e l / a / p r o duction.
APPENDIX B: TREATMENT PROTOCOL
(i) Review of the laryngologist's findings and reassurance that there was no evidence of lesions or
disease.
(ii) Discussion and explanation of the patient's
voice in relation to the effects of emotion on muscle
tension and phonatory control.

M A N U A L LARYNGEAL MUSCULOSKELETAL TENSION REDUCTION

(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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Journal of Voice, VoL 7, No. 3, 1993

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