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.

References:

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

How your tongue could be connected to your TMJ (jaw) dysfunction in my opinion …..

You probably may not associate the tongue as being a part of an average physiotherapy treatment, however from a very young age your tongue function starts to have a direct relationship to your TMJ joint by affecting the development of the bones that make up your jaw, affecting muscle function and breathing ability. So within a head, neck and jaw physiotherapy treatment the tongue is definitely one component of a whole picture that we look at.

We tend to forget that the tongue is a muscle, in fact it is more than just one muscle, it is a series of muscles that are grouped into extrinsic and intrinsic muscles. Some of these attach to the mandible (the moving bone that makes up the jaw joint), the soft palate and hyoid bone (the horse shoe shaped bone that sits on the anterior neck). In general, physiotherapists deal with muscles but more commonly it may be a speech therapist that deals with the muscle we call the tongue. However as a physio treating the TMJ and orofacial area, it is impossible not to at least assess and look at what the tongue is doing.

So lets talk a little a bit about anatomy. There are two bones that make up what we call the “jaw” – the maxilla and the mandible. The tongue sits inside the mandible and has a strong role in supporting our airways, studies have shown that some of the muscles that make up the tongue dilate the upper airways and help stabilise it.

Often in an assessment I will ask this question; “If you think about where your tongue is resting in your mouth, could you tell me what it is touching and if it is sitting high or low”. In almost every occasion I am given a very odd look in return. “Um I am not sure, I’ve never thought about that” is the likely answer! To tell you the truth most of us don’t need to think about it as the correct resting tongue position should really be something that automatically happens and isn’t something we have to put too much thought into.

So what is the correct tongue position?

The tongue when at rest should be sitting on the roof of the mouth behind the top front teeth. It naturally goes to this position when you say the letter “N”, try it! When it sits here it causes the airways to be tense and because of this the airways are strengthened resulting in normal breathing patterns.

It knows how to do this naturally because this neural pattern starts as an infant through the act of breastfeeding. When the tongue spends a lot of time in the top palate it begins to mould the very pliable palate and allows for a normal U shaped arch to form. If this doesn’t occur the person is often left with a narrow palate and a V shaped arch as an adult. When the palate is narrow the tongue sits at the bottom of the mouth and the muscles of the tongue can’t hold the airways open as they are designed to. You’ve heard the saying “use it or lose it”, when your tongue isn’t used the way it should it leads to decrease muscle tone, I mean you have to remember it is just like all the other muscles if you don’t use it they way it is designed it will start to lose it’s strength and endurance.

U shaped palate Vs V shaped palate

When the palate is narrow and pushes upward it starts looking like a cathedral arch and when this happens it starts to push up into it’s neighbours house, the nasal cavity and begins to infringe on its space. When the palate is pushed up so is the nasal cavity, decreasing the entire nasal space which can make breathing through the nose difficult.

What can then happen is open mouth breathing… Your body will do whatever it needs to to get oxygen! Open mouth breathing tends to change muscle function. This cascade of changes inevitably causes imbalances in the orofacial area which could lead to TMJ (temporomandibular joint) dysfunction and neck problems.

So if you have problems with your jaw, have a think about where your tongue sits at rest, you may be surprised by what you find.

If you would like to know more contact me at hello@mettapphysiotherapy.com

References:

Palmer, B. (1998). The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary. Journal of Human Lactation, 14(2), 93–98. doi:10.1177/089033449801400203

Ono, T. (2012). Tongue and upper airway function in subjects with and without obstructive sleep apnea. Japanese Dental Science Review, 48(2), 71–80. doi:10.1016/j.jdsr.2011.12.003