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Unlocking the voice


Does physiotherapy have a role in voice therapy? Previous studies have shown the value of osteopathy in this field but most clients do not have access on the NHS. While Lyn Steven, Janie Thompson and Denise Brown would have preferred more conclusive results from their research, they believe a joint speech and language / physiotherapy approach could be the key for a specific group of clients.

he idea for this project began after treating KM, a 70 year old woman with disordered voice. She presented with, among other vocal problems, an intractable high pitch which did not respond to conventional means of voice therapy. The presence of a psychogenic disorder was eliminated as a factor. Literature suggested that the problem may be due to locked cricothyroid visor (Harris & Leiberman, 1993; Harris et al, 1998) or other postural imbalances, and that this could be remediated by manual circumlaryngeal therapy. In the absence of such osteopathic expertise within the hospital, KM was referred for physiotherapy to mobilise her neck which had restricted range of movement. Tape recordings were made of connected speech immediately pre- and post-physiotherapy and showed a marked drop in habitual pitch and an extension of her pitch range at the bottom end following one session of manual physiotherapy. How might this effect be explained? Theoretically, poor neck posture can contribute to hypermobility of the upper cervical spine as a direct result of hypomobility or stiffness of the lower cervical spine and thoracic spine (Jull, 1986). The forward head posture which results leads to lengthening of the deep neck flexor group of muscles making them less effective as stabilisers of the cervical spine. This muscle imbalance could hypothetically lead to musculoskeletal problems which would have an effect on voice quality via the tensioning system of the cricothyroid mechanism. Habitual forward head posture can lead to the development of a cervico-dorsal shelf (figure 1). Success with KM and others raised the question: could this effect, similar in outcome to that reported by Harris et al (1998) using osteopathic and postural realignment techniques, be achieved by physiotherapy in other patients in conjunction with traditional voice therapy? As Schneider et al (1997) commented, Postural alignment is not an inherent trait....[but] is acquired through training postural muscle groups. We undertook a pilot study to find out.

Randomised control study


Based on the previous years referral numbers, we predicted we would receive between 60 and 70 new dysphonia referrals from ENT consultants annually. (Figures for 1998 were 14 male and 53 female patients). The original project design proposed that each new dysphonia referral over one year would be admitted to a randomised control study. It would exclude those over 75 years of age (who have normal, age-related changes in the larynx and voice), those with concomitant neurological conditions and those with contraindications to manual therapy (osteoporosis, previous cerebrovascular accident or malignancy, anticoagulant therapy, previous steroid therapy or longterm anti-epileptic therapy).

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A control group would receive conventional voice therapy and a study group would receive additional manual therapy from the physiotherapist. Approval was sought and given from the Ayrshire & Arran Health Board Ethics Committee. Patients were informed and consented into the study with GPs notified of their patients involvement. ENT consultants gave blanket approval for each patient to be referred for physiotherapy at the speech and language therapists discretion. Patients were given a conventional initial interview by the speech and language therapist with a case history taken of relevant medical history and voice usage. A vocal assessment was carried out and the patient audiotaped reading the phonetically balanced Grandfather Passage and giving a sample of connected speech (Fex, 1992). The limitations of subjective analysis are acknowledged. However, there is sufficient support from the literature to indicate that while there still remained no gold standard for instrumental testing (Andrews, 1995), the human ear is the ultimate instrument in the evaluation of the human voice (Sonninen & Hurme, 1992). Each patient was rated on the revised Buffalo Voice Profile (III) (Wilson, 1987) by the speech and language therapist, and on a departmental vocal abuse record. The patient was asked to self-rate their perception of any neck problem and their voice problem using a baseline visual analogue scale and thereafter a weekly record. Each was also asked to keep a voice diary for one week to monitor voice usage and potential abuse. Each patient was seen for assessment by the physiotherapist to determine range of neck movement and suitability for manual therapy . Patients self-allocated randomly into either the study or control group by choosing a number from an envelope and were accordingly offered either a block of five speech and language therapy sessions plus five physiotherapy sessions or five speech and language therapy sessions only, chosen to reflect our average number of sessions. Patients were asked to rate their voice problem on a weekly basis using a visual analogue scale (figure 2). All assessments were repeated following the completion of treatment and the patient made a final rating of their voice and neck problem on a visual analogue scale (figure 3).

manual circumlaryngeal therapy (Roy et al, 1997). Despite discussion with ENT consultants in an attempt to stimulate a greater number of referrals, no significant increase was forthcoming. Thirteen of the 33 patients with dysphonia seen over the year by the speech and language therapist also had neck problems (39 per cent). Unfortunately only five patients could be included in the randomised control trial. Statistically we were advised by the Ayrshire & Arran Health Board Research Co-ordinator that this was an insufficient cohort of patients. We therefore decided to revise the project design to one of a single case study using a three condition ABC design:A = two weeks of repeat assessment with no treatment being given so the patient acts as their own control B = four weeks of conventional voice therapy C = four further weeks of conventional voice therapy plus additional physiotherapy. All other components of the previous design were maintained. An amended patient information leaflet was produced.

Lyn Steven

Janie Thomson

Denise Brown

Single Case Study


NS, a 69 year-old married man, was the only patient willing and deemed suitable for this phase of the study. NSs voice was hoarse, habitually high pitched with a reduced pitch range and intermittent periods of aphonia. He reported a daily fluctuation of voice quality although the overall severity of his problem had remained static over the three months since onset following an upper respiratory tract infection. On palpation, the cricothyroid visor was locked. Range of neck movement was reduced. Breathing at rest and for speech was clavicular. Conventional methods of assessing expiration control and phonation time were used; that is, sustained /s/ and /z/ with expiration control times of 23 and 11 seconds on repeated attempts at sustaining /s/. Phonation time was markedly reduced at 5 and 3 seconds on repeated attempts at sustaining /z/. A hard glottal attack was employed and considerable laryngeal constriction was utilised throughout phonation. No other patterns of vocal misuse were detected. He presented with mild asthma for which he used a Becotide inhaler, and slight hearing loss but without aid usage, and his hobby was presenting talks on local history to interested groups. He was a non-smoker although he spent most of his day in the same room as his wife who smoked heavily; he felt this to be a particular vocal irritant. Baseline self-rating on the visual analogue scale for severity of voice problem was 7 on scale of 010, where 10 was most severe. The therapists rating was 8 on the same scale. Traditional voice therapy procedures were carried out. General advice was given on good vocal hygiene, for example appropriate hydration levels, decreasing caffeine intake and reduction of"
Figure 1 Client with cervico-dorsal shelf

The parameters worked on in voice therapy most intensively were those showing the highest degree of positive change

Figure 2 Weekly Patient Visual Analogue Scale:WEEK 1: How is your voice at present?

0 1 2 no problem at all

9 10 extreme problem

How easily can you turn your head at present?

0 1 2 easily from side to side

9 10 not at all from side to side

Figure 3 Final Patient Visual Analogue Scale:WEEK 1: How much has your voice problem changed?

Psychogenic overlay
The predicted number of new patients was not achieved due to normal fluctuations and the loss of an ENT consultant, and by midway through the study period only 19 instead of the anticipated 30 referrals had been received. Numbers who met exclusion criteria, were higher than anticipated. Only seven met inclusion requirements and were willing to take part. Two of these withdrew due to family/personal problems. These personal difficulties had contributed a psychogenic overlay to the original dysphonia, although literature suggests that this patient group also benefit from

0 1 2 Got worse

9 10 Much improved

How much has your neck problem changed? 0 1 2 Got worse 3 4 5 6 7 8 9 10 Much improved

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Figure 4 Physiotherapy screening


Have you had: Neck Pain Upper limb pain Pins and needles Numbness Headaches Dizziness Have you ever had a neck x-ray? If yes reason: Y/N Y/N Y/N Y/N Y/N Y/N Y/N

shouting. Laryngeal constriction was addressed by means of standard relaxation exercises, retraction of false cords and use of Have you had any previous ingressive airstream. physiotherapy for a neck problem? Y/N Lower pitch, diaphragHave you ever had a whiplash injury? Y/N matic breathing and Observation of posture: increased breath conPast Medical History: Rheumatoid Arthritis Y/N trol were all encourMeasurements of flexion / Epilepsy Y/N aged and worked on. extension of the cervical Diabetes Y/N NS was encouraged to Other spine were taken using an monitor his own voice Drug History: inclinometer mounted on a Anticoagulants Y/N and voice usage by headband which was Steroids Y/N means of a weekly visual aligned to the tragus of the Other analogue scale and ear (Klaber-Moffett et al, Suitable for Study Y/N voice diary. These were 1989). Rotation in the ceralso completed on the vical spine was measured two occasions when the using a tape-measured disspeech and language therapist was on holiday. tance from nose to tip to anterior angle of The physiotherapist assessed NS using the stanacromion (Viitanen et al, 1998). dard neck assessment protocol (figure 4). This It was expected, with improved cervical spine was to identify any restriction in range of movealignment and posture, that the range of movement in the cervical and thoracic spine, and any ment would improve and/or become less painful. pain contributing to altered posture or movement Subsequently the patient would consider they had patterns. Movement pattern was noted in raising less of a problem with their neck which would be the head from a pillow, which identifies if a indicated by a lower visual analogue scale score. In patient recruits the superficial neck muscles in our single case study with NS, this was not the case. substitution to the deep layer.

Changes to voice use, quality and production techniques, and to neck status, were seen over the treatment periods.

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Advice
Movement dysfunction was treated with manual therapy to mobilise stiff segments using Maitland mobilisations (Grade 3) to cervical levels C6 and C7 (Maitland, 2001). Advice on improving posture was given verbally, for example, sitting with the back supported to avoid slumped posture and an ideal head position when walking. To improve neck posture by shortening the lengthened deep neck flexors, NS was taught a strengthening exercise for this muscle group. Lying supine with the head supported on one pillow he was asked to put his tongue on the roof of his mouth and perform a retraction movement of the neck without using superficial muscles of the neck. Where the deep neck flexors are long and weak they become difficult to recruit and a patient will more readily substitute the superficial muscles, in this case the sternocleidomastoid. To ensure a specific contraction of the deep neck flexors, BioSense EMG electrodes were placed on the sternocleidomastoid and NS was asked to perform the exercise without the EMG increasing that is, with the sternocleidomastoid remaining relatively inactive during the exercise. NS was asked to hold the contraction for 10 seconds. It was noted if he was unable to do so and the time noted that he could hold the contraction without the superficial group being recruited. The exercise was repeated 10 times. NS was instructed to perform this exercise twice daily (10 seconds hold x 10). This has been shown to be an effective holding time to shorten postural muscle (Hides et al, 1996).

Positive change
The parameters worked on in voice therapy most intensively were those showing the highest degree of positive change, namely the use of diaphragmatic breathing for speech and a decrease in laryngeal tension (figures 5, 6 and 7). By the final assessment, diaphragmatic breathing was being used only for speech, not at rest. This could indicate the effect of awareness of a test situation whereby NS knows how to produce an appropriate breathing pattern but is not yet using this habitually. Further work would be required to promote carry-over to habitual usage. Reduction of laryngeal tension (initially rated 4) could be as a direct result of speech and language therapy intervention, physiotherapy, or a combination of both, given that there was no change in a tension rating of 2 following speech and language therapy only and following joint speech and language therapy / physiotherapy. Expiration time reduction at final assessment can be accounted for by an increase in NSs asthma levels on that day. Fluctuation of voice problems had decreased over time showing an increase in awareness and control of voice production techniques and improved vocal hygiene.

stamina was seen in the use of deep neck flexors. We felt the lack of range improvement was likely to be due to the patients osteoarthritic neck state. In the patients final visual analogue scale, after completion of therapy, he reported no change in his neck problem (lack of range of movement), but a marked improvement in overall voice status. The role of deep neck flexors was not recorded by NS but this does not mean the effect was absent. In all voice parameters targeted in voice therapy there were gains made to a greater or lesser extent as measured by the repeated departmental voice assessment. The Buffalo Rating Scale (III) was carried out by the research therapist and in a blind rating by a further speech and language therapist with considerable experience in the field of voice, to eliminate bias (Gelfer, 1988). Although there were some minor inter-rater discrepancies in the numerical values given, there was general agreement to the trend and areas of improvement. The patients own rating of voice showed minor fluctuations of voice quality from initial assessments, through the no-treatment phase and began to show substantial gains after weeks four and five of voice therapy (figure 8). Anecdotally, the researcher would expect improvement at this point in her treatment of most dysphonia patients. NS continued to rate his voice very good during the next period of the joint therapy approach. The shown results of this pilot study are discouraging, particularly when we had seen the effectiveness of manual physiotherapy for the cervical spine for several patients prior to the study being initiated, specifically in lowering habitually high pitch and extending pitch range. However, lack of sufficient numbers of referrals resulted in the abandonment of the proposed randomised control study. The single case study may have been seen to be more therapeutically valid on a patient who did not have osteoarthritis of the neck.

Opportunity
As many adult dysphonic patients are under sixty years of age they may experience poor posture but not necessarily have a reduced range of neck movement. This group may respond to physiotherapy based on postural exercises alone rather than solely manipulation. This would increase the patient cohort and therefore create an opportunity for further study into the role of physiotherapy in dysphonia treatment. A multicentred approach with larger numbers would be more statistically significant for a randomised controlled trial. The pilot could be extended, or repeated as a single case study with a different patient, should further opportunity arise. It is our considered opinion that patients with current emotional difficulties or history of psychiatric involvement, while probably benefiting from this treatment approach (Roy et al, 1997), would not make the ideal study subjects. Until this approach is demonstrated more scientifically, our impression remains that this is a valuable

Improvement
Changes to voice use, quality and production techniques, and to neck status, were seen over the treatment periods. It was agreed by both NS and the physiotherapist that no change had been effected in range of movement, although greater

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Figure 5 Scores using Adaptation of the Buffalo Voice Profile (III) (Speech and language therapy researcher rating)
Severity Rating 1 - 5 where 1 - normal and 5 = very severe

adjunct to conventional dysphonia therapy, especially where patients are using inappropriately high pitch and have difficulty in modifying this. Lyn Steven is a speech and language therapist at Crosshouse Hospital, Kilmarnock (tel. 01563 521133), Janie Thompson is a physiotherapist at Ayr Hospital (tel. 01292 610555) and Denise Brown is with the Clinical Effectiveness Department at Crosshouse Hospital (tel. 01563 577554). All work for NHS Ayrshire & Arran Acute Hospitals Trust.

Laryngeal Tone Hoarse

Pitch too high

Loudness

Nasal Res

Breath inadequate

Laryngeal Tension Hypertense

Rate

Voice Abuse

Speech Intelligibility

Overall rating

References
Andrews, M.L. (1995) Manual of Voice Treatment: Paediatrics through Geriatrics, Singular, California. Fex, S. (1992) Perceptual Evaluation. Journal of Voice 6 (2). Gelfer, M.P. (1988) Perceptual Attributes of Voice: Development and Use of Rating Scales. Journal of Voice 2 (4). Harris, T. & Lieberman, J. (1993) The cricothyroid mechanism, its relation to vocal fatigue and vocal dysfunction. Voice 2, 89-96. Whurr Publishers, London. Harris, T., Harris, S., Rubin, J.S. and Howard, D.M. (1998) The Voice Clinic Handbook. Whurr Publishers, London. Hides, J.A., Richardson, C.A. & Jull, G.A. (1996) Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 21: 2763-2769. Jull, G.A. (1986) Clinical observations of upper cervical mobility. In: Grieve, G.P. (ed) Modern Manual Therapy of the Vertebral Column. Churchill Livingstone, Edinburgh, pp 315 - 321. Klaber-Moffett, J.A.K., Hughes, I. & Griffiths, P. (1989) Measurement of Cervical Spine Movements Using A Simple Inclinometer. Physiotherapy June, 75 (6). Maitland, G.D. (2001) Maitlands Vertebral Manipulation, 6th Edition. Butterworth Heinemann, Oxford. Roy, N., Bless, D.M., Heisey, D. & Ford, C.N. (1997) Manual Circumlaryngeal Therapy for Functional Dysphonia: An Evaluation of Short- and Longterm Outcomes. Journal of Voice 11 (3). Schneider, C.M., Dennehy, C.A. & Saxon, K.G. (1997) Exercise Physiology Principles Applied to Vocal Performance: The Improvement of Postural Alignment. Journal of Voice 11 (3). Sonninen, A. & Hurme, P. (1992) Terminology of Voice Research. Journal of Voice 6 (2). Viitanen, J.V., Kokko, M.L., Heikkila, S. & Kautiainen, H. (1998) Neck Mobility Assessment in an ankylosing spondylitis: A clinical Study of Nine Measurements including new tape methods for cervical rotation and lateral flexion. British Journal of Rheumatology 37: 377-381. Wilson, D.K. (1987) Voice Problems of Children. Williams & Wilkins, Baltimore.

1st visit initial assessments carried out 2nd visit in order for patient to act as his own control 3rd visit following completion of speech and language therapy treatment only 4th visit following completion of speech and language therapy treatment and physiotherapy

Figure 6 Scores using Adaptation of the Buffalo Voice Profile (III) (Blind rating)
Severity Rating 1 - 5 where 1 - normal and 5 = very severe

Laryngeal Tone Hoarse

Pitch too high

Loudness

Nasal Res

Breath inadequate

Laryngeal Tension Hypertense

Rate

Voice Abuse

Speech Intelligibility

Overall rating

Figure 7 Changes in assessment over time


Date of Assessment Breathing - Clavicular At rest For Speech Breathing - Diaphragmatic At rest For Speech Expiration Time (secs) Best of two attempts Phonation Time Best of two attempts Hard Attack Laryngeal Constriction 1-5 (1=least & 5=most) Fluctuation of Voice Problems Pitch range Habitual Pitch Caffeine Intake 1/9/00 Yes Yes No No 23 5 Yes 4 Yes 21/9/00 3/11/00 7/12/00 Yes Yes No No Yes Yes No No 19 13 Yes 2 Yes Yes No No Yes 8* 11 Yes 2 No

Reflections
Do I encourage clients to record and monitor their own progress? Do I make full use of second opinions (such as a blind rating) from colleagues? Do I consider the influence of a clients posture on their communication?

Reduced Reduced Reduced Reduced High High High High 6 cups Decaff Decaff Decaff coffee * increase in severity of asthma when assessment was carried out

Figure 8 NSs visual analogue scale scoring of voice


0 - 10 with 0 = no problem at all & 10 = extreme problem

Resources
BioSense Dual Channel EMG Feedback Machine: DMI Medical Ltd.
N.B. The Patients Neck Score stayed at 5 throughout the 12 weeks

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