THE USE OF LARYNGEAL MASSAGE IN TREATING PRIMARY MUSCLE TENSION DYSPHONIA (“MTD”)

Felicity Graham

Voice Disorders – BBSQ 5113

March 7, 20111

INTRODUCTION: WHAT IS MTD?

FUNCTIONAL VOICE DISORDER:

Hyper-adduction, constriction or bowing of the vocal folds

FUNCTIONAL DYSPHONIA:Umbrella diagnosis for vocal impairment

without structural change or neurogenic disease of the larynx

TWO FORMS OF MTD:

Primary: no predominantly ORGANIC cause or abnormality of the structures/laryngeal function other than MTD

Secondary: abnormality is a result of another, underlying disorder,

such as paralysis, vocal fold atrophy or a benign lesion2

Qualit

ies

Poor control of the breath stream

Abnormally low-pitched speaking

voice

Increased frequency of hard

glottal attacks

Higher prevalence in female patients

WHAT IS MTD? CONT’DS

ym

pto

ms

Very high shoulder position

Laryngeal elevation

Reduced cricothyroid space

Painful palpation of laryngeal

musculature

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RATIONALE: TENSION & MTD

Tension degrades resonance

Subject’s voice is

becomes fuzzy, loses

intensity

Subject attempts a

clearer sound using more air pressure

With higher subglottic pressure, larynx is

destabilized

Compensatory behavior,

causing tension

All patients with voice disorders, regardless of etiology, should be tested for excess musculoskeletal tension, either as a primary or as a secondary cause of

the dysphonia.(Aronson, 1990)

Circular Nature of Tension on Phonation

Effective Therapy?

…indirect (i.e., non-manual) tension reduction

techniques often fail because of the stubborn

nature of excess laryngeal musculoskeletal tension

(Roy, 2008).

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TREATMENT: PRINCIPLES

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Reducing musculoskeletal tension releases the inherent capability of the larynx to produce normal voice

When gently rubbed or kneaded, muscles relax and

become less painful

Lowering laryngeal position in the neck permits more

normal phonation (Aronson, 1990)

The primary aim of manual therapies in the perilargyneal and laryngeal area is to relax the excessively tense

musculature which inhibits normal phonatory function… (Mathieson, et al., 2009).

LARYNGEAL MANUAL THERAPY

(“LMT”)

• Palpatory exam before• Uses both hands• Vocalization after

MANUAL CIRCUMLARYNGEAL THERAPY (“MCT”)

• Palpatory exam during • Uses one hand• Vocalization during

Why is vocalization so important?

TREATMENT: MANUAL THERAPY

“In some cases of muscle misuse, the larynx abnormally contracts during voicing, but returns to normal during rest.

The clinician is encouraged to manually assess not only resting muscle tone, but also contracted muscle tone and laryngeal position observed during voicing attempts (Roy, 2008).”

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TREATMENT: STEPS

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Massage Techniques

The medial suprahyoid musculature is palpated at rest and during phonation. Stiffness, tension, and sites of focal tenderness signal excessive muscle activity. Begin peripherally to the sites of intense tenderness.The hyoid bone is encircled with the thumb and index finger, which are worked posteriorly until the tips of the major horns are felt. Use circular movement with the fingers over the tips of the hyoid bone and within the thyrohyoid space, light pressure.

Circular movement is repeated beginning from the thyroid notch and working posteriorly. Then, with the fingers over the superior borders of the thyroid cartilage, the total larynx is worked downward, and moved laterally at the same time.

Phonation

During the steps outlined above, patients may be asked to sustain vowels, produce syllables, or to speak or sing words or phrases. Roy (2008) suggests having the patient begin with humming , then sustaining /α/ or /u/, eventually moving to serial speech, sentences/recitation, and finally to conversation.

According to Roy (2008), the patient should be considered an active participant, and encouraged to become aware of and monitor the changes in vocal quality during treatment, in order to transfer their progress into daily conversation.(Sources: Roy, 2008; Van Lierde, et al., 2010; Mathieson, et al., 2009; Aronson, 1990)

TREATMENT: CAUTIONS

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Skills must be acquired under the supervision of a skilled practitioner!

The process can be very painful for patients with higher levels of dysfunction: tenderness may persist for up to 48 hours after an intense session!

Although the procedure is extremely safe when practiced correctly, care should be taken to avoid sustained or vigorous carotid compression.

Additionally, MCT should be used with caution on patients with laryngeal, thyroid or vascular disease, or who previously have had anterior neck surgery or pathology.

Finally, if changes do not occur within two treatment sessions, it is unlikely that extra-laryngeal muscle tension is the primary or sole explanation for the observed dysphonia

…perhaps the most important step in preventing muscle tension is becoming conscious of the sensory […] experience (Deeter,

2005).

Allows therapist to observe patient’s

phonation habits more closely

Allows therapist aural and tactile

feedback simultaneously

Often offers immediate

improvement in phonation (and/or

relief of discomfort)

Allows patient an active role in their own recovery

Awareness is the key to prevention!

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SUMMARY

(See handout for notes and bibliography)

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