Part II Voice Physiotherapy & altered head posture in my opinion ….

In part I of voice physiotherapy I explained what MTD is and what physiotherapy for the voice involves. In this post we are going to talk about what you need for efficient voicing and things you can start thinking about for yourself .

There are a few things you need for effortless use of your voice, such as;

  • Healthy vocal cords
  • dynamic vocal cords that are able to be used in an efficient way in walking, sitting and talking
  • efficient breathing pattern and control
  • good laryngeal posture and also overall posture

In this blog my main emphasis will be overall posture. Why? Well In my experience physiotherapists loooove to harp on about “good posture” …… and well … I guess I better stick to the stereotype. But in all seriousness, it is often the one basic thing, that is contributing to peoples symptoms and often all that is needed is a little conscious awareness of habitual positions to change symptoms.

Why is it so important in voice physiotherapy?

It is because head and neck position has a direct influence on how the larynx is positioned.

An “altered head position” often results in a forward head and has been found to decrease the natural curve of the neck. As a result of this angle change, there is a change in the resting length in the neck muscles, in particular, the suprahyoid group. These muscles are located above the hyoid bone (horse shoe shaped bone) and are made up of mylohyoid, digastric, stylohyoid and geniohyoid.

What tends to be the issue is that there is a relative shortening of these muscles. The flow on effect is that this results in a lift of the hyoid bone which then results in an elevated larynx due to the fact that there are muscles that attached from your hyoid bone to your thyroid cartilage.

When this happens there is a disruption to the way the cricothyroid muscles work (see below for image). The cricothyroid muscles are not attached to the vocal folds however they influence their length and thickness by causing movement at the cricothyroid joint, which indirectly causes the vocal folds to elongate and narrow, raising the pitch of the voice. When there is an elevated larynx the cricothyroid muscles are placed in a biomechanical disadvantage where they have to work harder to elongate the vocal folds.

So to put it simply, having an altered head position results in vocal range difficulties due to structures and muscles having a biomechanical disadvantage. This makes muscles work harder and inevitably making them weaker. It takes time to improve your posture, you may need some flexibility in your thoracic spine, strength and endurance in the posterior muscles of your body and you may even need to increase your body awareness. However if you are having issues with your voice whether that may be poor quality, increased effort, fatigue or pain why not see if using your voice with a nice neutral position of the head and neck and see if that changes your symptoms.


  1. Honda, K., Hirai, H., Masaki, S., & Shimada, Y. (1999). Role of Vertical Larynx Movement and Cervical Lordosis in F0 Control. Language and Speech, 42(4), 401–411. doi:10.1177/00238309990420040301
  2. Jull, G. A. (2000). Deep Cervical Flexor Muscle Dysfunction in Whiplash. Journal of Musculoskeletal Pain, 8(1-2), 143–154. doi:10.1300/j094v08n01_12
  3. Rubin, J. S., Blake, E., & Mathieson, L. (2007). Musculoskeletal Patterns in Patients With Voice Disorders. Journal of Voice, 21(4), 477–484. doi:10.1016/j.jvoice.2005.02.001

Voice physiotherapy (Part I) in my opinion …..

When you think of physiotherapy, your first reaction may not necessarily be to think of the voice, rather you might think about shoulder or back pain… and to be honest voice physiotherapy is a relatively new concept in the physio arena. However over the past decade there has been an increase in evidence to show that there is efficacy for the use of manual therapy of the laryngeal and perilaryngeal (around the larynx) area for Muscle Tension Dysphonia (MTD).

So lets talk about Muscle Tension Dysphonia. What is it?? MTD is a common disorder of the voice where there is excessive muscle recruitment which results in incorrect vibratory patterns of the vocal folds and altered voice production. This can really negatively impact your life especially when you think about the fact that your voice is how you communicate with the world and if you use your voice as part of your profession and daily work then it may impact you quite heavily. I think it is important to remember that it is not only singers who use their voice in their profession… school teachers, trainers, lawyers, hairdressers, call centre employees all use their voice an extensive amount.

How does MTD start? Before we answer that lets think about normal anatomy of the voice, when there is normal voice production the expiratory airflow causes the small intrinsic muscles of the larynx to vibrate. The muscles contract and relax allowing the vocal folds to move and produce sound. The larger extrinsic muscles such as the supra hyoids and infra hyoids give the larynx stability while the voice production is being made.

Tomlinson and Archer (2015) explain that MTD starts when there is an increase in tension of the extrinsic muscles, this increase in tension can cause mal-positioning of the larynx which then has a flow on effect of increasing the tension of the intrinsic muscles and vocal folds.

What symptoms do people report with MTD?

  • Altered vocal quality
  • increased vocal effort
  • vocal fatigue
  • pain
  • elevated hyoid bone and thyroid cartilage

What does voice physiotherapy involve?

The main aim with voice physiotherapy is to restore the tissue quality, length tension relationship between muscles and improve bio-mechanical efficiency, with an overriding goal to improve the efficiency of the vocal fold vibration and voice production.

Voice physiotherapy sessions may involve:

  • soft tissue and myofascial releases
  • trigger point therapy
  • laryngeal mobilsations
  • cervical spine mobilisations
  • TMJ management
  • soft palate release
  • diaphragm release
  • shoulder girdle management

A common theory that is spoken about in voice physiotherapy is the idea that a “maladaptive voice cycle” occurs with MTD. When you are in the cycle compensatory neuromuscular recruitment keeps you in the loop. It is also important to note that there are many other factors feeding into this loop such environmental, psychological and vocal load.

Because MTD is multifactorial in nature it is really important to have a team to support you on your healing journey because once you start to get a better length tension relationship with your voice muscles it is important to use this window to then reeducate the muscles in this area to produce a more efficient voice production. So as well as physiotherapy it is crucial to have one or more people on board; voice coach, speech pathologist, ear nose and throat specialist, GP.

If any of this resonates with you, please feel free to contact me to book an appointment.


Tomlinson, C. A., & Archer, K. R. (2014). Manual Therapy and Exercise to Improve Outcomes in Patients With Muscle Tension Dysphonia: A Case Series. Physical Therapy, 95(1), 117–128. doi:10.2522/ptj.20130547

Rubin, J. S., Blake, E., & Mathieson, L. (2007). Musculoskeletal Patterns in Patients With Voice Disorders. Journal of Voice, 21(4), 477–484. doi:10.1016/j.jvoice.2005.02.001

Van Lierde, K. M., Bodt, M. D., Dhaeseleer, E., Wuyts, F., & Claeys, S. (2010). The Treatment of Muscle Tension Dysphonia: A Comparison of Two Treatment Techniques by Means of an Objective Multiparameter Approach. Journal of Voice, 24(3), 294–301. doi:10.1016/j.jvoice.2008.09.003