Exercise physiology principles applied to vocal performance: The improvement of postural alignment

Postural alignment is not an inherent trait. Proper alignment is acquiredthrough training postural muscle groups. This training is based on scientific principles associated with improving the physiological parameters of muscle mechanics. The purpose of this report is to describe and demonstrate the application of exercise physiology training principles to the improvement of postural alignment, which may enhance vocal performance. Specific exercise principles are explained and key concepts highlighted. Selected exercises for training postural muscles are presented to assist in establishing techniques that result in the expected adaptations. The application of training principles to postural muscles has been shown to improve postural alignment by strengthening synergistic muscles and establishing a balance between the agonistic and antagonistic activity of these muscles. Since posture has been well established as an important component of vocal performance, the application of these principles to vocal training seems to warrant the attention of vocal trainers and performers.     

Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review

Background: Tension-type headache (TTH) is a disease with a great incidence on quality of life and with a significant socioeconomic impact. Objectives: The aim of this review is to determine the effectiveness of physical therapy by using manual therapy (MT) for the relief of TTH. Data sources: A review was done identifying randomized controlled trials through searches in MEDLINE, PEDro, Cochrane and CINAHL (January 2002 – April 2012). Study selection: English-language studies, with adult patients and number of subjects not under 11, diagnosed with episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) were included. Data extraction: Initial search was undertaken with the words Effectiveness, Tension-type headache, and Manual therapy (39 studies). In addition, a search which included terms related to treatments such as physiotherapy, physical therapy, spinal manipulation was performed (25 studies). Results: From the two searches 9 studies met the inclusion criteria and were analysed finding statistically significant results: 1) myofascial release, cervical traction, neck muscles trigger points in cervical thoracic muscles and stretching; 2) Superficial heat and massage, connective tissue manipulation and vertebral Cyriax mobilization; 3) cervical or thoracic spinal manipulation and cervical chin-occipital manual traction; 4) massage, progressive relaxation and gentle stretching, program of active exercises of shoulder, neck and pericranial muscles; 5) massage, passive rhythmic mobilization techniques, cervical, thoracic and lumbopelvic postural correction and cranio-cervical exercises; 6) progressive muscular relaxation combined with joint mobilization, functional, muscle energy, and strain/counterstrain techniques, and cranial osteopathic treatment; 7) massage focused on relieving myofascial trigger point activity; 8) pressure release and muscle energy in suboccipital muscles; 9) combination of mobilizations of the cervical and thoracic spine, exercises and postural correction. All studies used a combination of different techniques and none analyzed treatments separately, also all the studies have assessed aspects related to TTH beyond frequency and intensity of pain. Conclusions: The findings from these studies showed evidence that physiotherapy with articulatory MT, combined with cervical muscle stretching and massage are effective for this disease in different aspects related with TTH. No evidence was found of the effectiveness of the techniques applied separately.     

Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review

The modern theory of hoarseness is that there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. METHODS: This project is a retrospective chart review of all patients seen in the Voice Speech and Language Service and Swallowing Center at our institution with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period. A literature search and review is also performed regarding current and emerging concepts of muscle tension dysphonia. RESULTS: One hundred fifty subjects were identified (60% female, 40% male, with a mean age of 42.3 years). Significant factors in patient history believed to contribute to abnormal voice production were gastroesophageal reflux in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. Otolaryngologic evaluation was performed in 82% of patients, in whom lesions, significant vocal fold edema, or paralysis/paresis was identified in 52.3%. Speech pathology assessment revealed poor breath support, inappropriately low pitch, and visible cervical neck tension in the majority of patients. Inappropriate intensity was observed in 23.3% of patients. This set of multiple contributing factors is discussed in the context of current and emerging understanding of muscle tension dysphonia. CONCLUSIONS: Results confirm multifactorial etiologies contributing to hoarseness in the patients identified with muscle tension dysphonia. An interdisciplinary approach to treating all contributing factors portends the best prognosis.     

Age-Related Change in Muscle Characteristics and Resistance Training for Older Adults

In older adults, muscle weakness contributes greatly to functional restrictions on daily living activities, increased risk of falls, and adverse physiological changes. It has been suggested that not only muscle mass but also muscular infiltration of noncontractile elements may influence muscular performance such as strength and rapid force production. It is proved that resistance training may provoke substantial increases in muscle size even if it is performed at low intensities in older individuals. Also, recent studies have demonstrated the effectiveness of resistance training on muscle quality such as muscular infiltration of noncontractile elements for older people. This review shows the age-related changes in muscle mass and muscle quality, which were measured by muscle echo intensity on ultrasound images, and low-intensity resistance training effects on muscle volume and muscle quality.     

Common Practices of Voice Therapists in the Evaluation of Patients

This study surveys voice therapists regarding common diagnostic practices in patients referred for therapy with the diagnosis of muscle tension dysphonia (broadly defined as the "hyperfunctional" component of the dysphonia). Through postings on the e-mail list of the ASHA special interest division on voice, speech pathologists with at least 3 years' experience in stroboscopy and acoustic instrumentation were invited to complete the survey. Results from 53 completed surveys demonstrated that voice quality and patient self-perception are the sole assessments performed by all therapists. Voice quality, observation of body posture and movement, and probing the patient's ability to alter voice production are each significantly more likely to be performed than the more objective stroboscopic, acoustic, aerodynamic, and EGG assessments. Further, the tasks of defining specific therapy session goals and helping the patient to achieve a particular target skill are considered best served by measures of vocal quality, observation of body position and movement, and judging the patient's ability to alter voice production. For definition of the overall therapy goal, stroboscopy and patient perception scales are added to all of the subjective assessment measures as being important. Acoustic data are considered most important for patient reinforcement and outcomes assessment. Implications of these findings are discussed, and topics for further exploration are identified.     

Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders

The objective of this study was to establish a standard clinical evaluation tool for assessment by palpation of extrinsic laryngeal muscular tension (ELMT) and investigate the relationship between ELMT and different voice disorder diagnosis categories, particularly muscle misuse dysphonia (MMD), and the presence or absence of gastroesophageal reflux (GER). A palpation technique and tension grading system for four separate muscle groups (suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal) were established. 465 patients, 65% female and 35% male, were assessed sequentially and ELMT results were analyzed in relation to diagnosis and reflux status. A strong relationship was found between thyrohyoid muscle tension and both GER and MMD (p < or = 0.01). Thyrohyoid muscle tension is the only group that demonstrated a significant relationship with MMD. No significant difference in the ELMT scores was found between GER and non-GER patients, although a possible causal relationship was found between MMD type 3 and reflux. It is postulated that palpation of extrinsic laryngeal muscles can yield important information about internal laryngeal postures and diagnosis of muscle misuse voice disorders, particularly MMD type 3 (anteroposterior supraglottic compression). Integration of this technique into routine laryngeal examination can be a significant aid to diagnostic accuracy.     

The Change of Grip Strength in a Patient with Congenital Myotonic Dystrophy Over a 4-year Period

Myotonic dystrophy (MyD) is a neuromuscular disease that is autosomal dominant and the most common form of muscular dystrophy affecting adults. The clinical features of MyD include a multisystemic disorder characterized by myotonia, progressive muscle weakness and wasting, cataracts, premature balding and mental retardation. The most severe type of MyD is classified as congenital MyD (CMyD). The muscle weakness in CMyD is very severe, but muscle development can be observed in the period of growth. However, no clinical case of this type has been reported yet. Therefore, we report on a girl with CMyD who had an increase in muscle strength over a four-year period. The girl with CMyD participated in this study from the age of 9 to the age of 12. The measurement of muscle strength was recorded as the maximum score of grip strength with the use of dynamometers. Grip strength was assessed once a year by the same two physical therapists. Grip strength of CMyD for each year was markedly weak when compared with the normal controls, but muscle strength changed within some specific growth areas. The muscle weakness in CMyD was remarkable, but the result showed that specific muscle strength of CMyD in childhood was actually increased.     

Dynamic evaluation of cervical spinal cord by magnetic resonance imaging: Improvement of indication for surgical treatment of chronic cervical myelopathy

A. Breig measured the change in length of the cervical spine and spinal cord during movement of the cervical spine in postmortem studies. Magnetic resonance imaging gives the same information about the impact of cervical movement on the cervical spinal cord. The method of measurement is described. First results point in the direction that the axial tension of the spinal cord increases during flexion. As, for example, a clinical application serves the chronic cervical myelopathy.     

Length-tension relationship of the feline thyroarytenoid muscle

Vocal fold tension during phonation is generated by coordinated contraction of the intrinsic laryngeal muscles. The thyroarytenoid muscle has been found to have increased stiffness at various levels of strain when compared with other intrinsic laryngeal muscles. The objective here is to test the hypothesis that the thyroarytenoid muscle exhibits high passive tension during maximal isometric tetanic force generation, and to test the hypothesis that the thyroarytenoid maintains the ability to generate contractile force at high levels of strain more effectively than other skeletal muscle. The thyroarytenoid muscles (n=9) and digastric muscle strips (n=7) were removed from adult random-bred cats. Maximal isometric tension and passive tension at optimum length were measured from each muscle in vitro. Active and passive length-tension curves were constructed for each muscle. The contractile properties of the thyroarytenoid group were compared with those of the digastric muscle group. The thyroarytenoid muscle group required on average 140 mN of passive tension to generate maximal isometric tetanic tension. This represented 39% of the average maximal isometric tetanic tension generated by the muscles. These results were significantly higher than the digastric muscle group, which required on average 28 mN of passive tension (9% of maximal isometric tetanic tension, p<0.05). At 110% of optimum length, the thyroarytenoid muscle maintained 89.8% of maximal isometric tetanic force, whereas the digastric muscle group maintained 67.7% of maximal isometric tetanic force (p<0.05). The thyroarytenoid muscle exhibits higher passive tension when generating maximal isometric tension than the digastric muscle control group. The thyroarytenoid muscle maintains higher levels of active tension at high strain than the digastric muscle control group. We conclude that these findings are related to the ability of the thyroarytenoid muscle to function as a fine tensor of the vocal fold in a high strain environment.     

The Effects of Comprehensive Exercise Program on the Adjustments of Standing Balance in Community-Dwelling Elderly Persons

The objective of this study was to assess the effect of comprehensive exercise program widely accepted as a community-based physical intervention for the prevention of falling in the elderly persons on their controlling standing balance. Twenty-six community-dwelling elderly persons (13 males and females; 69.8 ± 2.8 years old) participated in this study. Daily exercise was comprised of walking for more than 30 min, stretching, muscle strengthening and balance exercise without exercise equipments. The intervention was continued for three months. Indicators of standing balance related to static balance, dynamic balance and postural response were measured before and after the intervention. As an effect of the intervention on static balance, the sway of center of pressure (COP) in the static stance significantly increased. In the dynamic balance, significant improvements were observed in one leg standing time, the 10-m gait time, functional reach. Additionally, the maximal movable length of COP which subjects can move voluntarily to right and left significantly increased. In the postural response, the integrated electromyography (IEMG) induced by postural response for sudden postural perturbation significantly decreased in the lower leg muscles. Since less muscular activities were sufficient to maintain posture, it was suggested that postural response was elicited more efficiently following the intervention. This study suggested that the comprehensive exercise program, which has been widely introduced as community-based interventions for the prevention of falling, have extensive effects on the control of standing balance covering static balance, dynamic balance and postural response in the elderly persons.     

Physiological mechanisms of vocal frequency control: The role of tension

Control of fundamental frequency by the human voice may be accomplished using a variety of physiological mechanisms. Most of these mechanisms are myoelastic and include the length, mass, and longitudinal tension of the vocal folds. In this paper, a review of some of the data concerning the mechanisms for the creation of tension in the vocal folds is presented. The physiological mechanisms for the development of passive tension are reviewed and the potential contribution of passive tension in the control of fundamental frequency is discussed. Some of the mechanisms for the development of active muscle tension are described and the biomechanical characteristics of muscle are considered in the effort to explain the physiological control of fundamental frequency in the human voice     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.     

Simulated effects of cricothyroid and thyroarytenoid muscle activation on adult-male vocal fold vibration

Adjustments to cricothyroid and thyroarytenoid muscle activation are critical to the control of fundamental frequency and aerodynamic aspects of vocal fold vibration in humans. The aerodynamic and physical effects of these muscles are not well understood and are difficult to study in vivo. Knowledge of the contributions of these two muscles is essential to understanding both normal and disordered voice physiology. In this study, a three-mass model for voice simulation in adult males was used to produce systematic changes to cricothyroid and thyroarytenoid muscle activation levels. Predicted effects on fundamental frequency, aerodynamic quantities, and physical quantities of vocal fold vibration were assessed. Certain combinations of these muscle activations resulted in aerodynamic and physical characteristics of vibration that might increase the mechanical stress placed on the vocal fold tissue.     

The impact of preventive voice care programs for training teachers: A longitudinal study

The teaching profession puts vocal health at a higher risk than other professions, causing what is referred to as "occupational dysphonia." There is a need for primary prevention of "occupational dysphonia" among the teaching profession, where good vocal health is promoted before a problem occurs. To investigate the primary prevention of occupational dysphonia among teachers, this study uses a sample population of 55 training teachers, in the postgraduate certificate of education (PGCE) course at the University of Ulster, Northern Ireland, who were randomly assigned to three training groups: control, indirect, and direct. The vocal performance of the three groups was measured at two points over the year of the PGCE course: first before any teaching or training began, and again after the first teaching practice. The training for the indirect and direct groups was provided before the teaching practices. Acoustic and self-perceptual measurements were used to assess the multidimensional outcomes. The results demonstrate interesting trends, that although not found to be significant, are approaching significance. Their voices will be reevaluated at a third point of measurement. The acoustic measurement reflects deterioration from time 1 to time 2 for the control group, improvement for the direct group, and no change for the indirect group, indicating that the training has proved beneficial. The self-rating scores vary in agreement with the acoustic results, presenting interesting findings. The findings of this study will be of benefit to teachers, their educators, voice therapists, health promoters, and human resource personnel.     

Voice handicap index change following treatment of voice disorders

Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patient's perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patient's perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.     

One-dimensional chain of quantum molecule motors as a mathematical physics model for muscle fibers

A quantum chain model of multiple molecule motors is proposed as a mathematical physics theory for the microscopic modeling of classical force-velocity relation and tension transients in muscle fibers. The proposed model was a quantum many-particle Hamiltonian to predict the force-velocity relation for the slow release of muscle fibers, which has not yet been empirically defined and was much more complicated than the hyperbolic relationships. Using the same Hamiltonian model, a mathematical force-velocity relationship was proposed to explain the tension observed when the muscle was stimulated with an alternative electric current. The discrepancy between input electric frequency and the muscle oscillation frequency could be explained physically by the Doppler effect in this quantum chain model. Further more, quantum physics phenomena were applied to explore the tension time course of cardiac muscle and insect flight muscle. Most of the experimental tension transient curves were found to correspond to the theoretical output of quantum two- and three-level models. Mathematical modeling electric stimulus as photons exciting a quantum three-level particle reproduced most of the tension transient curves of water bug Lethocerus maximus.     

Control of Fundamental Frequency in Dysphonic Patients During Phonation and Speech

PurposeThe pitch-shift reflex (PSR) is the adaptation of the fundamental frequency during phonation and speech and describes the auditory feedback control. Speakers without voice and speech disorders mostly show a compensation of the pitch change in the auditory feedback and adapt their fundamental frequency to the opposite direction. Dysphonic patients often display problems with the auditory perception and control of their voice during therapy. Our study focuses on the auditory and kinesthetic control mechanisms of patients with muscle tension dysphonia (MTD) and speakers without voice and speech problems. Main purpose of the study is the analysis of the functionality of the control mechanisms within phonation and speech between patients with MTD and normal speakers.MethodSixty-one healthy subjects (17 male, 44 female) and 22 patients with MTD (7 male, 15 female) participated following two paradigms including a sustained phonation (vowel /a/) and speech ([‘mama]). Within both paradigms the fundamental frequency of the auditory feedback was increased synthetically. For the analysis of the PSR the electroencephalogram, electroglottography, the voice signal, and the high-speed endoscopy data were recorded simultaneously. The PSR in the electroencephalogram was detected via the N100 and the mismatch negativity. Statistical tests were applied for the detection of the PSR in the physiological response within the electroglottography, voice, and high-speed endoscopy signals. The results were compared between both groups.ResultsNo differences were found between the controls and patients with MTD regarding latency and magnitude of the perception of the pitch shift in both paradigms, but for the magnitude of the behavioral response. Differences also could be found for both groups between the “no pitch” and “pitch” condition of the two paradigms regarding vocal fold dynamics and voice quality. Patients with MTD showed more vibrational irregularities during the PSR than the controls, especially regarding the symmetry of vocal fold dynamics.ConclusionPatients with MTD seem to have a disturbed interaction between the auditory and kinesthetic feedback inducing the execution of an overriding behavioral response.     

Supraglottic contribution to voice quality

Although there has been continuing interest in voice quality, much of this research has focused on the vocal folds rather than the supraglottal structures. This paper reports the use of videoendoscopy for studying supraglottal participation in various singing tasks. In a preliminary study presented last year by the present authors, CT scanning was used to corroborate videoendoscopic observation. Vocal tract activities observed included variation of laryngeal height with pitch, variation of pharyngeal wall dimension with pitch and vowel, and marked supraglottic constriction with certain vocal imitations. In order to gain a better understanding of vocal training, and its effect upon vocal tract physiology, a study was designed using videoendoscopy to observe singers with significant experience and training while performing various vocal tasks. The tasks focused on the following: (1) vocal tract activity associated with pitch changes; (2) the physiology involved in the production of “cover”; (3) the structures involved in the production of vibrato; and (4) the physiology of the singer's “ring.” It would appear that videoendoscopy will become increasingly more valuable to the voice community as our understanding of vocal tract physiology improves.     

Boot Camp: A Novel Intensive Approach to Voice Therapy

It is well known in the disciplines of neurobiology, exercise physiology, motor learning, and psychotherapy that desirable learning and behavior changes occur primarily from practice that involves high-intensity overload, variability, and specificity of training. We propose a novel treatment approach called intensive short-term voice therapy that uses these practice parameters for recalcitrant dysphonia. Intensive short-term voice therapy involves multiple sessions with a variety of clinicians, incorporating multiple simultaneous therapeutic approaches. The intensive short-term voice therapy approach is characterized by voice therapy for 1–4 successive days each with an average of 5 hours of therapy and five clinicians. This form of intensive voice therapy provides rigorous practice, involving not only overload but also opportunities for specificity and individuality thereby facilitating better transfer of learned skills. This article discusses the conceptual, theoretical, and practical foundations of this novel therapy approach.     

Use of topical lidocaine in the treatment of muscle tension dysphonia

This investigation explored the potential usefulness of topical lidocaine in the treatment of muscle tension dysphonia. Three patients with this disorder, who were previously unresponsive to standard voice therapy, were treated with lidocaine. In each case, the outcome was prompt, clinically significant, and sustained. Persistently high-pitched and shrill vocal quality was converted to near normal voice patterns within 15 minutes after transcricothyroid membrane lidocaine injection. We suggest that this temporary and simple laryngeal and tracheal anesthetic technique may have helped to break the perverse cycle of hyperactive glottal and supraglottal muscle contractions evident in each of these patients during phonation efforts. We discuss the possible sensorimotor mechanism of action of this therapeutic technique.