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Digital Manipulation and Laryngeal Massage

Overview of Digital Manipulation and Laryngeal Massage in the treatment of voice disorders.
by

Jacqueline Craig

on 28 January 2016

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Transcript of Digital Manipulation and Laryngeal Massage

Digital Manipulation/Laryngeal Massage
Technique History
Individuals with functional dysphonia (FD) (i.e., voice problems without a specific structural or neurological cause)
deviant vocal qualities (e.g., aphonia, strain, hoarseness, breathiness, higher pitch, etc.)
muscle tension dysphonia (MTD), conversion dysphonia, laryngeal hyperfunction (Russell, 2010)
combination of social, psychological, physiological factors (Roy et al., 1997)
stress, phonotrauma (Russell, 2010)

Types of Laryngeal Manipulation and Massage
By: Jackie and Tarah
Appropriate For...
Methods
Digital Pressure for Lowering Pitch
Unilateral Digital Pressure for Patients with Unilateral Vocal Fold Paralysis
Monitoring the Vertical Movements of the Larynx
EBP
Ease of Use
Effectiveness
MCT Technique:

1. Assess vertical laryngeal positioning and muscular tension. Only continue if one or both are found.





2. Attempt Yawn-Sigh first, if successful (lower larynx and increased muscle relaxation) discontinue laryngeal manipulation and massage.

3. "We follow Aronson’s (1990) procedures for reducing ‘musculoskeletal tension associated with vocal hyperfunction’ (MCT):

Encircle the hyoid bone with the thumb and middle finger. Work back posteriorly until the major horns are felt.
Apply light pressure with fingers in a circular motion over the tips of the hyoid bone.
Repeat this procedure with the fingers from the thyroid notch, working posteriorly
Find the posterior borders of the thyroid cartilage (medial to the sternocleidomastoid muscles) and repeat the procedure.
With the fingers over the superior borders of the thyroid cartilage, begin to work the larynx gently downward and laterally at times.
Ask the patient to prolong vowels during these procedures and note changes in quality or pitch. Clearer voice quality and lower pitch indicate relief of tension. Because of possible fatigue, rest periods should be provided.
Improvement in voice is immediately reinforced. Practice should be given in producing voice in vowels, words, phases, and sentences.
Discuss with the patient how voice tension has been reduced. Repeat the procedures. Can the patient maneuver his or her own larynx to a lower position?"

4. Determine if the same success can be found with yawn-sigh. If so, discuss possibility of using both to reduce excess tension. (Boone et al., 2014)
*DEMONSTRATION*
References
Although there are no available Clinical Practice Guidelines for laryngeal massage/manipulation or EBP guidelines on ASHA, there are systematic reviews regarding the treatment of functional dysphonia, in which laryngeal massage is consistently highlighted as being an effective therapy technique for treating voice disorders. In addition, there have been several individual studies conducted to examine the effectiveness of these techniques, which also yielded positive results.

However, it should be noted that much of the available literature on laryngeal massage discusses the results of studies conducted on few participants (e.g., <25 participants) and lacks in adequate follow-up about long-term maintenance of improved functioning; hence, we should remain cautious as most evidence supports positive short-term effects.
Best Practice
As Boone (2014) states, “A number of studies in the literature report reductions of hyperfunctional voice symptoms and normal vocal quality after a single therapy session using this laryngeal manipulation-massage therapy. Although the present authors can report good results with this technique, we have also achieved lower laryngeal posturing with greater muscle relaxation using the yawn-sigh technique (Boone and McFarlane, 1993). Therefore, in our clinical practice, we employ the yawn-sigh first for the patient with a high larynx and laryngeal tension. If the patient is not successful employing the yawn-sigh followed by focus, our next approach is the use of manual circumlaryngeal massage (VFA 15)” (p.219-220).

Note on Focus: Employing this technique (bringing sound to the mask of the face; voice coming from the middle of the mouth) allows individuals with dysphonia to successfully balance oral-pharyngeal resonace for conversational speech (Boone, 2014).


1. Yawn-Sigh 2. Focus 3. MCM
Patient Dependent
(must consider aspects such as anatomy, age, health, duration of impairment, responsiveness to therapy, motivation, etc.)
However, the effects of manual therapy can be quite immediate, either it works and improvement of target function can be seen/heard during/after manipulation or not (Boone, 2014).
Indications of effectiveness:
can feel/see a difference (positioning/movement, relief of tension and/or pain, etc.)
perceptual information (hear a change in vocal quality and/or resonance)

“The effectiveness of any one of the three digital manipulation approaches can be determined immediately. Either the anterior digital pressure to the thyroid cartilage lowers voice pitch or it does not" (Boone, 2014, p.203).
Arnold Aronson in 1990
First explained manual circumlaryngeal therapy (MCT) as a strategy to reduce musculoskeletal tension underlying vocal hyperfunction
involves manual massage and manipulation of the laryngeal and perilaryngeal structures and musculature (Boone et al., 2014)
Several disciplines (e.g., speech-language pathology, osteopathy, and physiology) have since adopted and slightly modified the original technique variations
Laryngeal Manual Therapy (LMT)
Digital Manipulation
Others
(Mathieson et al., 2007)

1. "Ask the patient to prolong a vowel. During phonation, apply light pressure to the thyroid cartilage (immediate results)."

2. “Ask patient to maintain the lower pitch after the fingers are removed. If he can do this, he should continue practicing the lower pitch. If the high pitch quickly reverts back, repeat the digital pressure."

3. “If the method is used to let the patient hear and feel a lower pitch, the patient should practice producing the lower pitch with and without digital pressure on the thyroid cartilage."
(Boone et al., 2014, p.201-202)



*DEMONSTRATION*
1. “For a patient with excessive pitch variability and tension related to much vertical movement of the larynx, demonstrate how to place the fingers on the thyroid cartilage and monitor laryngeal vertical movement while phonating.”

2. “Ask the patient to produce a pitch level several full musical notes off the bottom of his or her lowest note. Keeping the fingers on the thyroid cartilage, ask the patient to lower pitch one note at a time to the lowest note in his or her pitch range. Usually, the larynx will lower its position in the neck at the low end of the pitch range. Then ask the patient to sing one note at a time up to the top of the singing range, exclusive of falsetto. Toward the top of the scale, the patient should feel (through the fingertips) a slight elevation of the larynx. Review both the lowering and rising of the larynx at the extremes of the pitch range.”

3. “Once the patient has experienced vertical movement in the preceding steps, point out that, in production of a speaking voice that is relatively free of strain, no vertical movement of the larynx should be felt during digital monitoring. Oral reading and speaking should be developed with little or no vertical laryngeal movements. Practice in oral reading with encouraged pitch variability can then be monitored by slight digital pressure of the thyroid cartilage."
(Boone et al., 2014, p.202)



*DEMONSTRATION*
1. “There appears to be a slight phonation improvement by pressing on the thyroid lamina on the side of the paralysis, bu this is not always found. We begin, however, by having the patient posture the head straight forward (looking slightly down rather than upward). The patient phonates and extends a vowel. While the patient phonates, the clinician exerts medium finger pressure to the lateral thyroid wall on the side of the vocal fold paralysis. If a louder, firmer voice is produced with this pressure, continue various phonation tasks, coupled with finger pressure on the thyroid cartilage on the side of the involvement.”

2. “If a louder voice was not achieved in step 1, the patient continues to look forward while the clinician applies pressure to the opposite side of the thyroid cartilage (pressing the side opposite the vocal fold paralysis). Attempt various phonation tasks while exerting this lateral finger pressure.”

3. "If later pressure to either thyroid lamina while the patient looks ahead has not produced an improvement in voice, provide lamina pressure with the head turned to one side. If the head is turned to the left, first apply pressure to the left lamina; if unsuccessful , keep the head turned left with pressure then given to the right lamina. If this produces better voice, continue phonation tasks with the head turned to the left and finger pressure on the side that seems to produce the best voice.”

4. “The last posture is for the head turned to the right with each side pressed in an attempt to find the better, more functional voice.”

(Boone et al., 2014, p.202-203)

*DEMONSTRATION*
Teaching:
Fairly simple to teach since the clinician will perform laryngeal manipulation/massage directly on the patient, but in addition can demonstrate on themselves (providing a visual cue/model; perhaps even in unison with the patient).

Learning:
Quite easy to learn as there is rich biofeedback involved with the direct touch cues (although there may be an initial learning curve with regards to feeling/finding anatomical structures). Also relatively few steps for each technique that are straightforward once practiced; patient can access step-by-step instructions.
Laryngeal Manual Therapy (LMT):
Manual Circumlaryngeal Therapy (MCT):
Digital Manipulation:
Palpatory evaluation occurs before LMT
Works from sources of least to most tension (depending on patient's tolerance/comfort levels)
More time spent treating areas with greater tension
Targeted structures:
sternocleidomastoid muscles supralaryngeal area
hyoid bone larynx
Phonation occurs AFTER completion of final stage
Similar methods to MCT, but begins with SCMs

Rationale:
many patients with FD have very tense SCMs; massage results in decreased levels of overall discomfort decreased stress and anxiety early facilitates treatment of the proceeding areas
massage of supralaryngeal area lowers the larynx and the range of laryngeal excursion returns to normal
(Mathieson et al., 2007)


Various contact points of finger pressure on the thyroid cartilage can target different voice problems:
Assessing vertical positioning of the larynx place fingers lightly on the thyroid cartilage (placement could vary depending on vocal task, e.g., swallowing, singing, etc.)
monitoring larygneal height appropriate for those who have excesive laryngeal vertical movement and variability or concerning laryngeal posture.
Rationale: Allows patient to monitor and hence correct
Lowering pitch patients who are using a consistently high pitch (e.g., puberphonia) light pressure anteriorly on the thyroid cartilage to feel raising and depression of the larynx/thyroid cartilage
Rationale: pressure moves the cartilage back to shorten the length of the vocal folds, resulting in lowering pitch
Unilateral digital pressure appropriate for people with unilateral vocal fold paralysis finger pressure on lateral thyroid cartilage wall
Rationale: Results in improved vocal fold approximation, leading to stronger phonation.
(Boone et al., 2014)

Palpation occurs DURING the process of intervention
Least to most tension, based on patient's comfort level
More time spent on areas of tenderness or tightness
Targeted structures:
hyoid bone thyrohyoid space larynx
medial/lateral suprahyoid musculature (as necessary)
phonation occurs DURING massage (improved vocal quality shaped from vowels to conversation)
*ability to monitor changes during treatment and modify as needed

Rationale: tense musculature postures become habitual over time; releasing tension allows the larynx to lower into its natural position to produce normal vocal quality

(Mathieson et al., 2007)


Assessment of Musculoskeletal Tension
"Aronson suggested that all patients with voice disorders, regardless of etiology should be assessed for excess laryngeal musculoskeletal tension, either as a primary or a secondary cause of the persisting dysphonia" (Roy et al., 1997, pg. 322).

Manually palpate the circumlargyneal area to evaluate degree, nature, and location of tenderness, tension, and/or pain.

Direct Pressure On:
1) major horns of the hyoid bone
2) superior cornu of the thyroid cartilage
3) along the anterior border of the sternocleidomastoid muscle to the suprahyoid musculature (including posterior belly of digastric)

Areas of increased tension will result in discomfort or pain where pressure is applied patient will likely respond to trigger points by displaying discomfort (e.g., wincing) at trigger points indicating target areas.

Laryngeal flexibility is evaluted by moving the larynx from side-to-side. Any resistance reveals extralargyneal hypertonicity. Additional excessive tension sites may include the uprahyoid region, which is especially noticeable during upward pitch gliding.
(Roy et al., 1996)

Reference: https://classconnection.s3.amazonaws.com/93/flashcards/1905093/jpg/picture21348761145359.jpg
Reference: Roy et al, 1996
Anatomy
Boone, D., McFarlane, S., Shelley, V., & Richard, Z. (2014).
The voice and voice therapy
(Ninth ed.). Upper Saddle River, NJ: Pearson Education.

Kennard, E., Lieberman, J., Saaid, A., & Rolfe, K. (2014).
A preliminary comparison of laryngeal manipulation and postural treatment on voice quality in a prospective randomized crossover study
. Journal of Voice, 1-4.

Lowell, S., Kelley, R., Colton, R., Smith, P., & Portnoy, J. (2012).
Position of the hyoid and larynx in people with muscle tension dysphonia
. The Laryngoscope, 122(2), 370-377.

Mathieson, L., Hirani, S., Epstein, R., Baken, R., Wood, G., & Rubin, J. (2007).
Laryngeal Manual Therapy: A preliminary study to examine its treatment effects in the management of muscle tension dysphonia
. Journal of Voice, 23, 353-366.

Roy, N., Ford, C., & Bless, D. (1996).
Muscle tension dysphonia and spasmodic dysphonia: The role of manual laryngeal tension reduction in diagnosis and management
. Ann Otol Rhinol Laryngol, 105(11), 851-856.

Roy, N., Bless, D., Heisey, D., & Ford, C. (1997). M
anual 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 Sciences and Disorders, 37, 131-140.
Reference: http://image.slidesharecdn.com/ravindraanatomyoflarynx2-131124072407-phpapp01/95/anatomy-of-larynx-by-ravindra-daggupati-67-638.jpg?cb=1385277961
Reference: http://images.slideplayer.com/15/4544705/slides/slide_13.jpg
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