Can specialized physical therapy play a role in human voice problems?
Did you ever have experienced voice related problems during your daily life, your work as a singer or teacher? Symptoms like hoarseness, difficulties producing a strong or normal voice, difficulties reaching that high pitch or discomfort or pain in the laryngeal region? Seeking help, where do you go?
The General Practitioner (GP), Ear, nose and throat (ENT) specialist or laryngologist, speech therapist are mainly professions of first choice. But what role can a specialized physical therapist like a CRAFTA® therapist play for you?
Voice problems (Dysphonia) are prevalent in all ages.
Prevalence of voice disorders is variable. Amongst the most reported disorders are Laryngitis (8%), vocal fold nodules (VFN) and functional voice disorder (FVD) both about 20% and vocal fold paralyses (VFP) about 14%. Nodules are mostly seen in young people, both VFP and FVD in the elderly. In adults FVD was the most prevalent disorder (De Bodt et. al. 2015)
Different types of dysphonia are described but an international unified classification system for dysphonia is still lacking.
There are some general accepted classification systems for Functional Dysphonia (Morrison, Rammage, 1993, Van Lawrence, 1987). These describe typical features seen during inspection of the focal folds. Researchers criticise these classifications because clinical features seen in functional dysphonia are also seen in people without functional dysphonia (Sama et. al. 2001). Typical for these functional voice disorders are: high tonus of the muscles that surround the larynx, altered activity pattern of infra- and suprahyoidal muscles (that are the muscles that connect the laryngeal region to the mandible, head, neck and thorax) and postural changes. All these connections, specifically the tiny little muscles that lie within the larynx, play an important role in the functionality of the vocal folds. Alteration of normal functional patterns can have detrimental effects on voice production.
Voice disorders are categorised in structural and non-structural voice disorders.
Some examples of structural voice disorders are; Laryngitis, VFN, polyps, VFP, trauma or tumors. Functional Voice Disorder (FVD), psychogenic or puberphonia are examples of non-structural voice disorders. Vocal nodules may be a result of a functional voice disorder but it’s still not elucidated whether organic lesions lead to FVD or whether FVD leads to organic pathology. (Van Houtte et. al. 2011)
What are the main symptoms of functional Dysphonia
Dysphonic patients often described hoarseness as the cardinal symptom.
Changing of voice like fatigue, weak voice, low voice, unregularly voice, pitch level, volume, range and nasality but also pain in the laryngeal region or radiating to the ear, coughing, problems with respiration, swallowing problems, globus sensation (lumpy throat) are clinical features.
Research shows a negative impact on quality of life in persons with dysphonia (Bassi et al 2011). Voice related professions like teachers and professional singers are at risk.
Considering the functional chain
In daily practice, neuro-musculo-skeletal therapists see patients with: postural related problems, neck problems, headache, cranial and temporomandibular related problems. Often these people complain of voice problems, too, maybe as a side symptom or a delayed clinical feature. These complaints stay unnoticed because patients do not mention these symptoms during the subjective examination. They do not relate these symptoms to other complaints or regions. Therapists often do not ask specifically because of a lack of knowledge in this field.
Further, speech pathologists and voice therapists see patients with voice problems that also have widespread postural, functional muscular alterations. There are no profound data in what way these factors correlate to each other. Nevertheless altered muscle activity, bad postural aspects and loss of mobility and flexibility are clinical features that can be observed in these patient groups and are often treated.
In case of FVD, voice therapy used by voice therapists mainly consists of indirect voice therapy i.e. education and vocal hygiene and direct voice therapy with the main focus on posture, breathing, phonation, articulation and muscle tension and combined they have better effect compared to no treatment. (Van Houtte et al, 2011, Ruotsalainen et al, 2007,2008)
Voice research traditionally focuses on the vocal tract, articulators and the larynx thereby missing a broader scope of the direct and indirect biomechanical and functional relationship of the skull, cervical spine and sternum. (Miller et. al. 2012)
Several authors describe the extensive correlation of the relationship between the airway, the craniofacial structures, the cervical spine and the vocal structures. They emphasize the need to consider the function of the vocal structures and the airway in a wider context (Miller et al. 2012). Craniocervical postural changes and mandibular position influence the function of swallowing and phonation (Sakuma 2010, Furuya et. al. 2011, Nakayama et. al. 2013). Some aspects of postural alignment differ between normal and dysphonic speakers (Franco et. al. 2014)
Specialized (Craniofacial) CRAFTA® therapy of the laryngeal region
Prior to treatment there should be a thorough examination for serious pathologies.GP’s, ENT specialists and speech pathologists should rule out organic causes and diseases.When these are ruled out probably dysfunctions of the structures, which are responsible for normal voice, may play a major role. In this case treatment by a skilled CRAFTA® therapist, in collaboration with speech or voice pathologist or therapists may be useful.
What does a CRAFTA therapist do in case of functional dysphonia
In their 3 to 4-year education, specialized craniofacial therapist learn to examine andmanage voice problems which is partwise manual therapy ,exercises and coaching of the voice inclusive collaboration with other disciplines
Subjective examination consists of a thorough and detailed history taking which often gives clues to the understanding of the patient’s problem. Not only questions revealing the source of the symptoms but also insight in the underlying pathobiological processes and the contributing factors. Screening for contraindications is part of the questioning. Seeking information about the prognosis is an important part to get a good expectation of what therapy can do or not do.
In the absence of a clear etiological picture one has to judge the dysfunctions found on examination on their relevance to the patients complaints.
Sound clinical reasoning, which is the clinical decision process done by the therapist, provides the well-educated and trained CRAFTA® therapist with the ability to make clinical judgements to reach an optimal examination and treatment plan.
Different from speech pathologists and voice therapists, CRAFTA® therapist are trained/capable of screening the above mentioned wider context, the craniocervical-, craniofacial- , temporomandibular-, shouldergirdle-, thoracic regions and the neural attachments the cranial nervous system.
Specific techniques and differentiation tests are used to examine the relationship between the voice problem and dysfunctions found in these connected regions. One aspect of specialized examination and treatment lies in the specific mobilisation of the laryngeal structures like the laryngeal muscles and joints. Unique are the specific mobilisation- and palpation techniques for the cranial nerves that innervate this region.
Picture 1 and 2, Examination and treatment example of the laryngeal region. Picture 3 Specific palpation of the Thyroid-Hyoid space
The clear goal of therapy
… should be to minimize the related dysfunctions and contributing factors that play a role in voice problems. Therapy should therefore not only contain passive hands-on techniques but also hands-off parts, e.g. fitted exercise, (if indicated) stress-reduction and above all, good explanation to the patient to reach an optimal treatment outcome. No fixed prescribed recipe but a tailor-made individual examination and treatment plan, which include multi-structural approach and in collaboration with other health care disciplines.
Is there evidence for manual therapy around the voice box (laryngeal region)?
Research on effect and treatment outcome is growing. Very recent studies show positive effects of manual treatment of the laryngeal region, manual therapy and exercise in case of dysphonia. (Van Lierde et al 2004, Speyer 2008, Ruotsalainen et al 2009, Mathieson et al 2009, Wichmann 2010, Schemmann 2011, Kennard et. al. 2014, Tomlinson 2015).
Some nice clinical examples of possible causes that can paly a role in the development of dysphonia and that easily could be missed are; minor nerve pathologies like minimal neuropathies after whiplash trauma or excessive traumatic neck extension or prolonged antero-position of the head. They could comprise the function of the cranial nerves and other structures that are responsible for normal voice and may contribute to the development of functional voice problems.
My experience is that these symptoms tend to start not immediately but weeks to months later. Others like craniomandibular- and tongue dysfunctions could influence normal voice. Specialized therapists like CRAFTA® therapists are capable of recognising and examining these often overlooked pathophysiological processes and functional relationship.
Once a colleague said to me;
When your instrument, your guitar doesn’t sound that well you can exercise to play it better or go to a specialist, a mechanic that fix or tune your instrument.
But what if your voice isn’t working properly? Sometimes a lot of training and exercise or operation doesn’t benefit. Here maybe a screening of your voice instrument, i.e. your laryngeal region and its functional connections could be indicate.
Roald Luning, PT, OMT, Int. CRAFTA® teacher.