A Preliminary Comparison of Laryngeal Manipulation

and Postural Treatment on Voice Quality in a

Prospective Randomized Crossover Study
Elliot J. Kennard, Jacob Lieberman, Arjmand Saaid, and Kerstin J. Rolfe, London, United Kingdom
Summary: Background. This crossover study compared the effects of two osteopathic treatments specific laryngeal
manipulation (SLM) and postural manual therapy (PMT) on voice quality and pitch.
Methods. Twelve asymptomatic singers were measured acoustically immediately before and immediately after each
intervention using a laryngograph. Fundamental frequency and the glottal closing quotient were used to determine any
differences between groups before and after.
Results. Fundamental frequency showed a statistically significant change following both interventions (combined
[P 0.007] and PMT and SLM individually (P 0.0143, P 0.018, respectively). Although the benefit demonstrated
using SLM was greater than that with PMT (2.4, 2.02, respectively), following Bonferroni correction there was no
statistical significance demonstrated between the two groups. There was no statistically significant change with glottal
closing time for any intervention or at any time (P 0.52).
Conclusion. This pilot study provides evidence of the benefit for both SLM and PMT in singers. A significant difference was found in the voice quality of the participants involved in both PMT and SLM. These results set the way for
further larger scale studies to evaluate group interactions and potential benefits in symptomatic patients.
Key Words: Functional dysphoniaSpecific laryngeal manipulationPostural manual therapyOsteopathy.
INTRODUCTION
Functional dysphonia (FD) is a voice disorder that occurs with no
structural or neurologic laryngeal pathologies and is characterized by an abnormal quality of the voice. Over 40 000 patients
in the United Kingdom are referred annually for voice disorders1
with a number of studies indicating that occupational voice users
are most at risk from vocal health issues.2,3 Occupational voice
users are individuals whose voice has a significant association
with their occupational requirements requiring the voice to
be used at a significant level such as teachers, singers, and
instructors. To date, there is no universal classification for
voice problems,4 although traditionally there are two major classes: organic and functional, although this classification may be
over simplified. Voice disorders can affect pitch, loudness, and/
or quality of the voice.5 It has been proposed that vocal misuse
and abuse that affect individuals may be responsible for creating
a dysregulation or imbalance to structures that make up the vocal
mechanism.6 Previous theories involving the dysregulation of
laryngeal muscle tension has been challenged and it has now
been thought that poorly regulated activity of the intrinsic and
extrinsic laryngeal muscles may be the cause of FD.7
A Cochrane review in 2009 suggested that a combination of
direct and indirect therapies are effective in improving voice
quality compared with no intervention.8 A limited number of
direct manual approaches, such as manual circumlaryngeal therapy and laryngeal manual therapy, have reported some effect in
the treatment of FD.914 Most treatments to date have focused on
rehabilitation, treatment, and/or prevention of FD.15
Accepted for publication September 24, 2014.
From the British College of Osteopathic Medicine (BCOM), 120-122 Lief House,
Finchley Road, London, United Kingdom.
Address correspondence and reprint requests to Kerstin J. Rolfe, BCOM, Lief House,
120-122 Finchley Road, London NW3 5HR, United Kingdom. E-mail: work@
kerstinrolfe.com
Journal of Voice, Vol. 29, No. 6, pp. 751-754
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.09.026

Specific laryngeal manipulation (SLM) is a manual treatment

of tight structures of the larynx that may restrict movement. As
a consequence, there is an alteration in the vocal mechanism
causing suboptimal laryngeal function.16 SLM was first developed as an approach in the management of hyperfunctional
voice disorders that take place due to excessive muscle tension
requiring more effort in voice use.6,17 Muscles and joints,
including temporomandibular and jaw function, the floor of
the mouth, the middle constrictor thyrohyoid, cricothyroid
muscles, and the rest of infrahyoid muscles are assessed and
targeted manually using the Lieberman Laryngeal
Assessment protocol (Table 1). Tight hypertonic muscles are
stretched using various techniques, and joints with limited
range of movement are articulated to improve suboptimal
laryngeal function.
Postural manual therapy
Postural manual therapy (PMT) is an umbrella term coined by
the authors for this study. It relates to the therapeutic manipulation of the structures found to have an influence voice production.18 These include stretching and massage of the scaleneus,
sternocleidomastoids, and the trapezius muscles and articulation of the cervical and thoracic spine. The articulation of the
cervical and thoracic spine helped to enhance posture, therefore
influencing airway flow and easing the tension on the vocal
structure.19 There was also a secondary effect on stabilizing
muscles including the semispinalis capitus, iliocostalis cervicis,
and the longissimus cervicis. PMT therefore indirectly targets
both mobility and stabilizing structures to promote optimal
postural alignment leading to changes in the shape and structure
of the soft tissue surrounding the vocal mechanism.20 PMT is a
more indirect approach than SLM. PMT improves vocal function through posture rather directly on the vocal structures.
This study aimed to compare SLM with PMT in a population
of asymptomatic singers. Fundamental frequency (F0) was the

Descargado de ClinicalKey.es desde Universidad Austral De Chile marzo 26, 2016.

Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

752

Journal of Voice, Vol. 29, No. 6, 2015

TABLE 1.
Summary of Study Participants
Patient
Identifier

Gender

Age
(y)

Trained
in Singing

Years of
Singing

1
2
3
4
5
6
7
8
9
10
11
12
Range

M
F
M
F
M
M
F
F
M
M
F
M
7 M, 5 F

23.8
20.6
31.9
21.5
31.6
24.7
22.3
24.6
24.6
18.2
24.4
21.7
18.231.9

Y
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
9 Y, 3 N

15
7
22
3
19
10
0.5
6
6
3
10
6
0.522

cartilage, and measurements were detected by the signal. The

acoustic speech signals were processed and recorded using the
Laryngeal Speech Studio software (version 3.5). Measurements
were taken for the duration of the passage, which lasted
approximately two and a half minutes, as the participants read
aloud the short passage from start to finish.
Statistical analysis
SPSS v 20 (IBM, Armonk, NY) was used to analyze the acoustic
data obtained from the laryngograph. Data were assessed for
normality using the Shapiro-Wilk test, data failed normality.
A Friedman two-way Analysis on ranks with post hoc analysis
with Wilcoxon Signed rank tests conducted with Bonferroni
correction was applied. This was performed for both GCQ and
F0. The significance level was set at P 0.05; following Bonferroni adjustment P 0.013.

Abbreviations: M, male; Y, yes; F, female; N, no.

METHODS
Following local ethical approval, 12 asymptomatic participants
(mean age, 24 4 years; Table 1) who sang a minimum of once
a week for at least the last 6 months were recruited following
written informed consent. Participants were randomized into
two groups, which were then crossed over after their initial
treatment, following a washout period of 6 weeks. A washout
period of 6 weeks was selected as the optimal length of time
for any treatment effect to dissipate, while still retaining the
participants. The first group was initially treated with SLM,
whereas the second group commenced with PMT.
Each intervention required the participant to attend for 30
minutes, which was sufficient for the procedures and is a standard time for a clinical session. This included the reading of
the passages before and after each intervention and as well as
the assessment and treatment with each respective approach.
The standardized passage used was Arthur the Rat. It is
commonly used to assess the voice, as it requires the reader to
use all the various sounds in the English language.21 This was
performed in a seated position so the participant would be
comfortable while reading.

280
260
240

Voice quality (Hz)

primary end point. It measures the frequency of vocal fold

vibration and correlates with the vocal fold tension and subglottal air pressure and is a measure of high or low frequency of the
persons voice or pitch. A further analysis evaluated whether
SLM or PMT would improve the glottal closing quotient
(GCQ). This is a measurement of the fraction of the time the
glottis is considered closed and has been considered to be an
indicator of voice quality.

RESULTS
All participants completed the study; however, one following
SLM failed to connect with the laryngograph, so no signal
was received for an unknown reason.
Fundamental frequency (F0) showed a statistically significant
reduction of pitch following intervention (X2 12.2; df 3;
P 0.007, Figure 1). Post hoc analysis with Wilcoxon Signed
rank tests showed statistical significance between pre- and
post-PMT (z 2.019; P 0.043) and pre- and post-SLM
(z 2.366; P 0.018). However, on performing the Bonferroni correction and setting the significance level at P 0.013,
there were no statistically significant differences between the
two intervention groups. There was no statistically significant
change with GCQ at any time or with any intervention
(X2 2.3; df 3; P 0.52; Figure 2).
There were no untoward effects on voice or other systems
reported by participants after the washout period between treatment arms. No long term data are available after the second
treatment. Both GCQ and F0 data failed normality; therefore,
a Friedman test was performed.

220
200
180
160
140
120

Equipment
Participants recordings were made in a quiet room using an electroglottograph (Laryngograph microprocessor EGG D400), a
validated method to measure F0 and GCQ.2224 The gold
electrodes were placed on the skin overlying the thyroid

100
Pre PMT

Post PMT

Pre LM

Post LM

Treatment

FIGURE 1. Box plot graph demonstrating the median, upper quartile, and lower quartile of voice quality measure in Hz (n 7).

Descargado de ClinicalKey.es desde Universidad Austral De Chile marzo 26, 2016.

Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

Elliot J. Kennard, et al
90

CONCLUSION
There is a growing interest in the use of osteopathy and other
manual therapies in the field of the voice. This study demonstrated that SLM may be beneficial in the treatment of FD.
Although singers were the focus of this research, other frequent
voice users could benefit from SLM. This study sets the foundation for larger studies to further validate the technique. This
larger study would include both symptomatic and asymptomatic as well as other voice users.

80

70

GCQ %

753

Comparison of SLM and PMT

60

50

40

REFERENCES
30

Pre PMT

Post PMT

Pre SLM

Post SLM

Treatment

FIGURE 2. Box plot graph demonstrating the median, upper quartile, and lower quartile of percentage change in glottal closing (n 7).

DISCUSSION
The present study compared SLM with PMT in asymptomatic
singers with the hypothesis that SLM, as a more direct approach
to the laryngeal structures, would improve outcome compared
with PMT, in a group of asymptomatic singers. A Cochrane
review identified six randomized controlled trials that used
therapies such as direct voice therapy, indirect voice therapy,
combination of therapies, and other treatments.10 However, no
study was found to evaluate direct therapy alone. A number of
other studies have assessed voice quality after a single treatment
but used other forms of direct therapy.11,13,14 The present study
predominately assessed the effect immediately after treatment;
however, others have shown that direct and indirect techniques
may provide a positive effect that may be long lasting25; therefore the long term beneficial effects need to be investigated.
This is the first reported study that systematically compared
SLM and PMT as potential treatments for FD. Consequently, it
can be the basis of further research in this area as it helps
confirm the rapid, low cost (if an electroglotograph is available)
application of the techniques in various groups. The treatment
in the present study was highly standardized with all participants receiving PMT from the first and SLM from the second
author. To maximize homogeneity in this study, PMT was performed solely by the first author and SLM by the second author.
There are limitations to the present study. As a small pilot
study, numbers were not sufficient for sub-analyses. There
was also no collection of long-term data. Only asymptomatic
singers were recruited. Greater changes may have been found
if symptomatic participants were involved in the study.
Although all participants had a keen interest in singing, with
75% (n 9/12) having received some form of training, there
was a relatively low level of professional singers with only
33% (n 4/12) being semi-professional and the majority
singing as serious amateurs. A further limitation of this study
is that to increase homogeneity the participants were asymptomatic, and all recordings were within normal values before
treatment; it is possible that a greater change may have been
identified in symptomatic participants.

1. Wilson JA, Deary IJ, Scott S, MacKenzie K. Functional dysphonia. BMJ.

1995;311:10391040.
2. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467479.
3. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of
teachers voice problems. J Voice. 1997;11:8187.
4. Oates J. The evidence base for the management of individuals with voice
disorders. In: Reilly S, Douglas J, Oates J, eds. Evidence-Based Practice
in Speech Pathology. London - Philadelphia: Whurr Publishers; 2004:
110139.
5. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang
Hear Res. 1998;41:S101S116.
6. Lieberman J. The human larynx: a therapeutic challenge. De Osteopaat.
2012;13:913.
7. Roy N. Functional dysphonia. Curr Opin Otolaryngol Head Neck Surg.
2003;11:144148.
8. Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. Cochrane Database Syst
Rev. 2007;CD006373.
9. Van Lierde KM, De Ley S, Clement G, De Bodt M, Van Cauwenberge P.
Outcome of laryngeal manual therapy in four Dutch adults with persistent
moderate-to-severe vocal hyperfunction: a pilot study. J Voice. 2004;18:
467474.
10. Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy for
functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice. 1997;11:321331.
11. Mathieson L, Hirani SP, Epstein R, Baken RJ, Wood G, Rubin JS. Laryngeal manual therapy: a preliminary study to examine its treatment effects
in the management of muscle tension dysphonia. J Voice. 2009;23:
353366.
12. Roy N, Ferguson N. Formant frequency changes following manual circumlaryngeal therapy for functional dysphonia: evidence of laryngeal
lowering? J Med Speech Lang Pathol. 2001;9:169175.
13. Van Lierde KM, Bodt MD, Dhaeseleer E, Wuyts F, Claeys S. The treatment of muscle tension dysphonia: a comparison of two treatment techniques by means of an objective multiparameter approach. J Voice.
2010;24:294301.
14. Lieberman J. Principles and techniques of manual therapy: application in
the management of dysphonia. In: Harris T, Harris S, Rubin JS, et al,
eds. The Voice Clinic Handbook. London, United Kingdom: Whurr Publishers; 1998:91138.
15. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline:
hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141:
S1S31.
16. Van Houtte E, Van Lierde K, Claeys S. Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge. J Voice. 2011;25:
202207.
17. Solomon NP. Vocal fatigue and its relation to vocal hyperfunction. Int J
Speech Lang Pathol. 2008;10:254266.
18. Pettersen V, Westgaard RH. The activity patterns of neck muscles in professional classical singing. J Voice. 2005;19:238251.
19. Pettersen V, Bjrky K, Torp H, Westgaard RH. Neck and shoulder muscle
activity and thorax movement in singing and speaking tasks with variation
in vocal loudness and pitch. J Voice. 2005;19:623634.

Descargado de ClinicalKey.es desde Universidad Austral De Chile marzo 26, 2016.

Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

754

Journal of Voice, Vol. 29, No. 6, 2015

20. Johnson G, Skinner M. The demands of professional opera singing on

cranio-cervical posture. Eur Spine J. 2009;18:562569.
21. Haase C, Orlova N. ELT Converging Approaches and Challenges. UK:
Cambridge Scholars Pub; 2011.
22. Peterson KL, Verdolini-Marston K, Barkmeier JM, Hoffman HT. Comparison of aerodynamic and electroglottographic parameters in evaluating
clinically relevant voicing patterns. Ann Otol Rhinol Laryngol. 1994;103:
335346.

23. Kazi R, Kanagalingam J, Venkitaraman R, et al. Electroglottographic and

perceptual evaluation of tracheoesophageal speech. J Voice. 2009;23:247254.
24. Fourcin A, Abberton E, Miller D, Howells D. Laryngograph: speech pattern
element tools for therapy, training and assessment. Eur J Disord Commun.
1995;30:101115.
25. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic review of
the treatment of functional dysphonia and prevention of voice disorders.
Otolaryngol Head Neck Surg. 2008;138:557565.

Descargado de ClinicalKey.es desde Universidad Austral De Chile marzo 26, 2016.

Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.