Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Digital Manipulation for Voice Therapy

No description
by

James Curtis

on 19 March 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Digital Manipulation for Voice Therapy

A Voice Therapy Guide to Laryngeal Palpation & Massage Acknowledgments Introduction Laryngeal Palpation Overview of Palpatory Assessment Laryngeal Massage Overview of manual laryngeal therapy Conclusion Acknowledgments & References Palpation: Palpation is the process to medically examine, by touch, body structures.
Massage: is the kneading of muscles and joints, with hands, to relieve tension or pain.
Functional Voice Disorders: A disorder of the voice in the absence of any physical or organic lesion
Muscle Tension Dysphonia: Condition where the muscles surrounding the larynx are in a state of imbalance and increased tension, causing decreased voice quality and an inefficient and strained voice production
Similar names/concepts: manual circumlaryngeal therapy (MCT), laryngeal manual therapy (LMT), circumlaryngeal massage, manual laryngeal musculoskeletal tension reduction, myofascial release, manual laryngeal reposturing maneuvers General Terminology The goal of massage is to target relaxation of excessively stiff muscles inhibiting normal physiologic function. Tense muscles are chronically tense and contracted, and massage relaxes and lengthens these muscles.
Inefficient laryngeal function of the synergistic-antagonistic physiology can lead to musculoskeletal tension. This muscular tension may give rise to voice problems and vocal pathologies.
Treatment for functional voice disorders (e.g., MTD) should utilize techniques to recalibrate to the anatomy’s natural resting posture and primary physiologic function (e.g., laryngeal massage), and to habilitate therapeutic techniques for improved vocal efficiency (e.g., resonant voice therapy). Philosophy Laryngeal palpation is part of a comprehensive voice evaluation and is used to manually assess maladaptive compensatory habits of the laryngeal musculoskeletal system. It is a helpful diagnostic tool for MTD.
The aim for laryngeal massage is to focus on reducing the excessive tension of the intrinsic and extrinsic laryngeal muscles and improve range of movement of the laryngeal joints.
Common complaints for patients with MTD include: increased vocal effort, fatigue. sensitivity, pain, and tightness in the neck. Laryngeal massage helps to rehabilitation the voice and alleviate these symptoms. Purpose of Digital Manipulation Extensive research has been published concluding the short and long-term efficacy of laryngeal massage in the treatment of voice disorders secondary to musculoskeletal disorders (e.g., muscle tension dysphonia).
According to Van Lierde, et al. “analysis of variance (ANOVA) revealed significant different between the objective overall voice quality before and after MCT... MTC is an effective treatment technique for patients with elevated laryngeal position, increased laryngeal muscle tension, and MTD.”
According to Bridget Russell, “a manual tension reduction therapy was used successfully to treat a pediatric client’s FD (functional dysphonia) and return her voice to expected acoustic and perceptual values)”
According to an evaluation of short- and long-term treatment outcomes for manual circumlaryngeal therapy for functional dysphonia, Roy et al. confirmed (via perceptual, acoustic, and interview assessments) therapeutic gains in vocal function with clinical utility of manual techniques for patients with FD
Efficacy of laryngeal manual therapy in treating muscle tension dysphonia can be measured acoustically, as well as through perceptual self-rating scales (e.g., Vocal Tract Discomfort (VTD))
Patients with laryngeal cancer following radiation treatment often experience stiffened that can become fibrotic if not treated. These patients exhibit benefit from laryngeal massage treatment evidenced by reduced muscular tension. (Stamer et al., 2008)
Evidence also shows laryngeal massage is effective as a supplement to traditional treatment methods for disorders on the umbrella of Irritable Larynx Syndrome (i.e., Paradoxical Vocal Fold Movement (PVFM) and Chronic Cough) (Andrianopoulus et al., 2000)
Some research suggests symptomatic treatment of hyperphonic voice disorders secondary to neurologic disease (e.g., Multiple Sclerosis, UMN Amyotrophic Lateral Sclerosis) with laryngeal massage is also therapeutic. (Cohen et al., 2009). Efficacy of Digital Manipulation Archeological evidence indicates the use of massage by ancient civilizations as early as B.C. 2330
Manual therapy has existed for centuries under the purview of osteopaths and physiotherapists.
In the past, voice disorders were treated by ENTs only. Voice disorders are now being treated by speech-language pathologists and otolaryngologist specialists.
The traditional approach for voice therapy was to treat the superficial symptoms (e.g., strained voice quality), and not the underlying condition (e.g., hypertonic cricothyroid muscle)
General muscle tension of the head and neck has been historically addressed in voice therapy through use of voice and stretching exercise, however manipulative techniques for specific laryngeal musculature has only recently gained greater popularity History of Digital Manipulation In-depth and fluent understanding of the anatomy and physiology of the structures of the larynx
Skills should be acquired under the supervision of an experienced and skilled practitioner. Supplemental training and CEUs include:
Workshops (e.g., Myofascial Release for the SLP – Multivoice Dimensions)
Literature/books
Palpation/massages should be applied with a moderate pressure (≈2.5 on a scale of 1-5 of increasing pressure)
Check in with the patient by asking them how it feels (have them rate on a scale of 1-5), and looking at their facial expressions throughout
Requires skill and caution (e.g., major arteries, medical conditions, etc.)
The follow protocol was compiled after observations and hands-on experience under the supervision of clinical voice specialist Shirley Gherson, MA, CCC-SLP Clinical Training in Digital Manipulation Terminology, Philosophy, History, Purpose, and Efficacy Laryngeal Palpation is used for diagnostic purposes and performed during the initial voice evaluation
Assessment parameters include:
General body posture and head position
Laryngeal resting position (high, low)
Quality of tissue (symmetry, tonicity, fibrotic, irregular anatomical characteristics)
Range of Motion (laryngeal elevation, hyoid & laryngeal lateral excursion, cricothyroid space, thyrohyoid space)
Sensitivity/tenderness/pain (reported by patient) Laryngeal Palpation:
Assessment Parameters Explain what you are doing, why you are doing, and if it is permissible to do.
Example: “One way for us to better get to know the compensatory (squeeze) habits you’ve developed, is to actually feel the muscles in your throat. Your larynx, or voice box, is suspended in your throat by a variety of muscles. By physically placing my hands on your neck, I can better assess how you use the muscles in your throat and carry your voice as you speak.”
Sterilize hands in front of patient so they know you are clean. Apply lotion to fingers. Stand behind the seated patient.
Place hands firmly on shoulders/trapezius/posterior neck and begin conversation. This allows for the patient to acclimate to the beginning of a laryngeal palpation. Applying moderate downwards pressure (careful not to squeeze with fingers) helps to feel comfortable and confident in your abilities. Palpation Assessment: Preparatory Protocol Muscles Assessed: deltoids, trapezius, stylohyoid, omohyoid, sternocleidomastoid
Clinician Posture: stand behind seated patient with both hands on shoulders/posterior neck region
Protocol:
Place hands firmly on shoulders and observe resting tonicity.
Begin conversation. Assess tonicity as they speak.
Begin massage. Observe tenderness and pain.
Transition to next clinician posture Palpation Assessment:
Gross Musculature Protocol Muscles Assessed: Stylohyoid, hyoglossus, geniohyoid, genioglossus, mylohyoid, digastric (anterior/posterior belly)
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand’s middle finger and apply upward pressure to underside of chin.
Protocol:
Observe resting tonicity.
Begin conversation. Assess tonicity as they speak.
Palpate with various pressures.
Apply moderate pressure (2.5 on a scale of 1-5).
Ask patient to identify, on a scale of 1 to 5 of increasing pressure, how much pressure they feel you apply.
Transition to next position Palpation Assessment:
Base of Tongue Muscles Assessed: Stylohyoid, hyoglossus, geniohyoid, mylohyoid, digastric (anterior/posterior belly)
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to suprahyoid muscles.
Tip: To locate hyoid bone, feel for tonsils then move inferior and anterior OR feel for Adam’s Apple and move superior and posterior
Protocol:
Apply pressure during resting tonicity.
Begin conversation. Assess tonicity as they speak.
Palpate with various pressures rocking your fingers anterior and posterior.
Apply moderate pressure (2.5 on a scale of 1-5).
Ask patient to identify, on a scale of 1 to 5 of increasing pressure, how much pressure they feel you apply.
Transition to next position Palpation Assessment:
Suprahyoid Musculature Muscles Assessed:
Suprahyoid: stylohyoid, hyoglossus, geniohyoid, mylohyoid
Infrahyoid: omohyoid, thyrohyoid, sternohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to lateral sides of the hyoid bone.
Tip: To locate hyoid bone, feel for tonsils then move inferior and anterior OR feel for Adam’s Apple and move superior and posterior
Protocol:
Assess range of motion for the muscles surrounding the hyoid bone by lateralizing the hyoid bone, stretching it to the right and then to the left. Consider ease of the stretch. Is there much resistance?
Apply moderate pressure (2.5 on a scale of 1-5).
Ask patient to identify, on a scale of 1 to 5 of increasing tenderness/sensitivity, how much pressure they feel you apply.
Transition to next position Palpation Assessment: Hyoid Bone Structures Assessed: Thyrohyoid Muscle




Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to thyrohyoid muscles.
Protocol:
Apply pressure during resting tonicity and assess size of gap between hyoid bone and thyroid cartilage.
Apply moderate pressure. Caution! This may be uncomfortable for them!
Ask patient to identify, on a scale of 1 to 5 of increasing pressure, how much pressure they feel you apply.
Move fingers onto the lateral portion of the hyoid bone, and assess lateral ROM.
Transition to next position Palpation Assessment:
Thyrohyoid Space Muscles Assessed: Cricothyroid Muscle






Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand’s middle finger to cricothyroid muscles.
Tip: This is felt as the gap inferior to the Adam’s Apple and superior to the Cricoid Cartilage
Protocol:
Apply pressure during resting tonicity and assess size of gap between thyroid and cricoid cartilage.
Ask patient to say “ah” and glide up and down in pitch. Notice if the gap changes in size. Palpation Assessment:
Cricothyroid Muscle Muscles Assessed: sternothyroid, sternohyoid, omohyoid, thyrohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone. Use dominant hand to cup four fingers (no thumb) anteriorly and laterally around the gross laryngeal structures (i.e., hyoid bone, thyroid cartilage, cricoid cartilage).
Caution: Palpate close to the larynx. Palpating too lateral could be applying pressure to the carotid artery!
Protocol:
Assess ROM and ease of lateralization by pulling structures lateral to one side (and slightly up).
If dominant hand is right, stand on right side of patient, cup fingers over to the left side of larynx, and pull to the right.
Repeat with other hand (switching standing position, and use of dominant/non-dominant hand) Palpation Assessment: Larynx Lateralization Explain what you are doing, why you are doing, and if it is permissible to do.
Clinician Posture: Stand behind seated patient with hands on shoulders.
Massage shoulders/trapezoids/posterior neck and begin conversation. This allows for the patient to acclimate to the start of a laryngeal massage while also decreasing general upper body tension Laryngeal Massage:
General Protocol Muscles Massaged: Masseter
Clinician Posture: Stand behind seated patient with the back of their head facing your torso Masseter Circles: Using the index fingers and middle fingers of both hands, apply moderate pressure and rotate over the masseter muscle clockwise 8-10x Face Wipe-Downs: Using the heels of the palms of both hands, place (with moderate pressure) on the temporalis muscles, and wipe down over the masseter, down the mandible towards the chin. Verbalize to the patient, “Allow your jaw to relax into an unhinged and sagged posture.” Laryngeal Massage: Masseter Muscles Massaged: Digastric, Geniohyoid, Mylohyoid, Stylohyoid
Clinician Posture: Stand behind seated patient with the back of their head facing your torso Anterior-Posterior Swipes: Place heels of the palms under the patient’s mandibular angle. Extend middle fingers to meet in the medial/inferior portion of the chin. Pull middle fingers back, tracing the jaw line, back to the mandibular angle. Medial-Lateral Pull-Outs: Place heels of the palms under the patients mandibular angle. Extend middle fingers to meet in the medial/inferior portion of the chin Pull fingers lateral until you reach the mandible. Release. Repeat anteriorly and posteriorly. OR use only one middle finger and knead back and forth laterally. Laryngeal Massage: Tongue Base Muscles Massaged: Digastric, Geniohyoid, Mylohyoid, Stylohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone.
Suprahyoid Pinch: Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to suprahyoid muscles. Rock your fingers back and forth, pinching your fingers together as the move anterior, and allowing them to separate as the trace the superior ridge of the hyoid bone when the move posterior. (Think rocking chair) Laryngeal Massage: Suprahyoid Muscles Massaged: Thyrohyoid, Digastric, Geniohyoid, Mylohyoid, Stylohyoid, Sternohyoid, Omohyoid

Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone.

Peri-Hyoid Protocol: Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to suprahyoid muscles. In an elliptical shape, massage around the hyoid bone, moving from superior, to posterior, to inferior, to anterior. Repeat 5-10x. Feel free to pause in a pinch in the thyrohyoid space. Laryngeal Massage: Perihyoid Muscles Massaged:
Suprahyoid: stylohyoid, hyoglossus, geniohyoid, mylohyoid
Infrahyoid: omohyoid, thyrohyoid, sternohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone.
Protocol:
Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to lateral sides of the hyoid bone.
Lateralize hyoid bone, alternating back and forth.
Lateralize moderately slow, never stopping. Extend the lateralized movement further and further when the muscles appropriately allow.
Transition to next position Laryngeal Massage: Perihyoid Stretch Muscle Massaged: Thyrohyoid Muscle




Clinician Posture: Stand behind patient. Use non-dominant to support head.
Protocol:
Use dominant hand’s thumb and index/middle finger to apply upward pressure to the inferior side of the hyoid bone to provide passive stretching of the thyrohyoid muscle
Hold stretch. Release. Repeat.
Transition to next position Laryngeal Massage: Thyrohoid Stretch Muscles Massaged: Thyrohyoid Muscle
Clinician Posture: Stand behind the patient.
Note: Pressure applied here should be lite (1/5). Think of it as a suggestion for a stretch.
Protocol:
Place middle fingers of both hands in the cricothyroid space.
Using the finger of one hand, apply upward pressure on the inferior side of the thyroid notch –
…at the same time…
– use the finger of the other hand and apply downward pressure on the superior side of the cricoid cartilage
Hold stretch. Release.
Transition to next position Laryngeal Massage: Cricothyroid Stretch Muscles Massaged: Thyrohyoid, Sternothyroid, Sternohyoid, Omohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone.
Anterior Neck: Use dominant hand’s thumb and index or middle finger and apply medial pressure (as if pinching) to anterior portion of the hyoid. Slowly swipe the pinched fingers until just above the cricoid cartilage. Release. Repeat 5-10x. Laryngeal Massage: Strap Muscles Muscles Assessed: sternothyroid, sternohyoid, omohyoid, thyrohyoid
Clinician Posture: Stand behind seated patient. Use non-dominant to support head cupping the angle of the skull’s occipital bone.
Caution: Palpate close to the larynx. Palpating too lateral could be applying pressure to the carotid artery!
Lateral Larynx:
Use dominant hand to cup four fingers (no thumb) anteriorly and laterally around the gross laryngeal structures (i.e., hyoid bone, thyroid cartilage, cricoid cartilage).
Slowly pull structures lateral to one side (and slightly up). Sustain the pull.
If dominant hand is right, stand on right side of patient, cup fingers over to the left side of larynx, and pull to the right.
Repeat with other hand/side of larynx Laryngeal Massage: Lateral Larynx Questions? Adrianopoulos, M., Gallivan, G., Gallivan, H. (2000). PVFM, PVCD< EPL, and Irritable Larynx Syndrome: What are we talking about and how do we treat it? Journal of Voice. 14 (4), 607-618.
Cohen, S., Elackattue, A., Noordzij, J. P., Walsh, M., Langmore, S. (2009). Palliative treatment of dysphonia and dysarthria. Otolaryngology Clinics of North America. 42, 107-121.
Colton, R. H., Caspter, J. K., Leonard, R. Understanding Voice Problems: A Physiologic Perspective for Diagnosis and Treatment, 4th ed.. Baltimore, MD: Lippincott Williams 2009
Harris, T., Harris, S., Rubin, J.S., Howard, D.M., eds. The Voice Clinic Handbook. London, England: Whurr Publishers; 1998
Mathieson, L., Hirani, S. P., Epstein, R., Baken, R. J., Wood, G., and Rubin, J. S. (2007) Laryngeal manual therapy: A preliminary study to examine its treatment effects in the management of muscle tension dysphonia. Journal of Voice. 23 (3) 353-366
Rosing-Schow, A., Gunvor Pedersen, S. (2010). VoiceRelease. Logopedics Phoniatrics Vocology. 35, 166-168
Roy, N., Bless, D., Heisey, D., Ford, C. (1997). Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes. Journal of Voice. 11 (3), 321-331
Russell, B. (2010). Using manual tension reduction treatment in treating pediatric functional dysphonia. Contemporary Issues in Communication Science and Disorders. 37, 131-140
Speyer, R. (2008). Effects of voice therapy: A systematic review. Journal of Voice. 22 (5), 565-580
Starmer, H., Tippett, D., Webster, K. (2008). Effects of laryngeal cancer on voice and swallowing. Otolaryngology Clinics of North America. 41, 793-818
Titze, I., Verdolini Abbott, K. (2012). Vocology: The science and practice of voice habilitation. The National Center for Voice and Speech: Salt Lake City, UT
Van Houtte, E., Van Lierde, K., Claeys, S. (2009). Pathophysiology and treatment of muscle tension dsyphonia: A review of the current knowledge. Journal of Voice. 25 (2), 202-207
Van Lierde, K., De Bodt, Marc., Dhaeseleer, E., Wuyts, F., Claeys, S. (2008). The treatment of muscle tension dysphonia: A comparison of two treatment techniques by means of and objective multi-parameter approach. Journal of Voice. 24 (3), 294-301 References Digital Manipulation James Curtis, M.S. Candidate
New York University, 2013 Special thanks to Shirley Gherson (NYU Langone Medical Center/NYU Voice Center) for providing me with extended training and direct supervision in laryngeal palpation and massage.

Additional thanks to Marina Gilman (Emory Voice Center) and Katherine McConville (UW-Madison Voice Center) for contributing conversations and observations involving laryngeal palpation and massage, as well as Sim Matharu (NYU, M.S. Candidate) for being my patient "model"
Full transcript