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MUSCULOSKELETAL STRESS SYNDROME, EXTRINSIC LARYNGEAL MUSCLES AND BODY POSTURE: THEORETICAL CONSIDERATIONS

Síndrome de tensão musculoesquelética, musculatura laríngea extrínseca e postura corporal: considerações teóricas

Carla Aparecida Cielo(1), Mara Keli Christmann(2), Vanessa Veis Ribeiro(3), Carla Franco Hoffmann(4), Juliana Falcão Padilha(5), Eduardo Matias dos Santos Steidl(6), Gabriele Rodrigues Bastilha(7), Débora Bonesso Andriollo(8), Letícia Fernandez Frigo(9)

ABSTRACT

The theme of this study is the musculoskeletal stress syndrome, extrinsic laryngeal muscles and body posture. The purpose is to describe, from the literature review, the characteristics of the extrinsic muscles of the ; posture; vocal implications of musculoskeletal stress syndrome; evaluation and physical therapy and voice therapy. We performed a literature review of the last 13 years which included articles aimed and/or body textwere in line with the objectives of this study. The research was conducted in the databases of Literatura Latino-Americana e do Caribe em Ciências da Saúde, Biblioteca Regional de Medicina, Public Medline, Medical Literature Analysis and Retrieval System on Line, Scientific Electronic Library Online and Google Schoolar. Were established important relationships within the physical therapy and voice therapy, among which stand out the relationships muscular, postural and functional synergy in the vocal apparatus. In physical therapy to reduce muscle tension, the literature indicates use of transcutaneous electrical stimulation, low level laser, laser acupuncture, cryotherapy, manual therapy and traction, massage, cervical manipulations and mobilizations, associated or not to exercise, stretching, isometric relaxation , assisted soft tissue mobilization, therapeutic exercises aimed at correcting balance and muscle, diaphragm and respiratory rehabilitation therapy craniocervical flexion. In speech therapy, studies found only through digital manipulation of the larynx and semi-ocluded vocal tract exercises.

KEYWORDS: Larynx; Dysphonia; Posture; Laryngeal Muscles; Musculoskeletal System; Therapeutics

(1) Universidade Federal de Santa Maria - UFSM, Santa Maria, „„ INTRODUCTION RS, Brazil. (2) Universidade Federal de Santa Maria - UFSM, Santa Maria, RS, Brazil. The laryngeal muscles can be divided, according (3) Universidade Federal de Santa Maria - UFSM, Santa Maria, to its localization in the extrinsic and intrinsic. The RS, Brazil. extrinsic musculature has one of the inserts in the (4) Universidade Federal de Santa Maria - UFSM, Santa Maria, laryngeal cartilages and the other in adjacent struc- RS, Brazil. tures, while the intrinsic has two inserts structures of (5) Universidade Federal de Santa Maria - UFSM, Santa Maria, the larynx itself1. RS, Brazil. (6) Universidade Federal de Santa Maria - UFSM, Santa Maria, RS, Brazil. (9) (7) Universidade Federal de Santa Maria - UFSM, Santa Maria, Universidade Federal de Santa Maria - UFSM, Santa Maria, RS, Brazil. RS, Brazil. (8) Universidade Federal de Santa Maria - UFSM, Santa Maria, Source: CAPES; CNPq; FAPERGS RS, Brazil. Conflict of interest: non-existent

Rev. CEFAC. 2014 Set-Out; 16(5):1639-1649 1640 Cielo CA, Christmann MK, Ribeiro VV, Hoffmann CF, Padilha JF, Steidl EMS, Bastilha GR, Andriollo DB, Frigo LF

The increased tension of the extrinsic muscles implications; assessment and treatment of Physical leads to elevation of the larynx in the , with Therapy and Speech Therapy. the constant participation of the extrinsic muscles on phonation1-3. In some cases, this tension is so „ intense that the set of manifestations is renamed „ METHODS Musculoskeletal Tension Syndrome (MSTS) or muscle tension dysphonia1-3 and includes several Have been performed theoretical and explor- vocal impairments. The MSTS may be classified as atory research with the technique of non-systematic primary, when there are no lesions in the laryngeal review of the literature. The search was performed structure, and secondary, when it presents tissue in data banks of databases Literatura Latino- reactions1-3. Americana e do Caribe em Ciências da Saúde Evolution may be accompanied by some (Lilacs), Biblioteca Regional de Medicina (Bireme), laryngeal and vocal signs and symptoms, as Medical Literature Analysis and Retrieval System median compression of the vocal folds, causing online (MedLine), PublicMedline (PubMed), decrease in opening-angle.; constriction global, Scientific Electronic Library Online (Scielo) e Google median (approximation of the vocal folds) or antero- posterior of vestibule; presence of triangular slits; Schoolar (Academic Google), selecting the studies laryngeal elevation and predominance of abrupt published in the period from 2000 to 2012. The vocal attack1-3. Health Sciences Descriptors (DeCS, 2013) used for Furthermore, signals may be observed as the the location of the articles were: voice; dysphonia; elevation of thoracic cage and shoulders; increase larynx; laryngealmuscles; posture; musculoskeletal of muscular mass of the neck and nape; mandibular system; therapeutic. The search was performed locking; venous distension; tension of supra- by isolated descriptors and subsequently by the hyoid muscle; hyperextended head; short and association between them. compressed breathing; restricted and tense facial Have been included books, original research expression; resulting in excessive global effort and articles and bibliographic review about MSTS, not efficient1-3. extrinsic muscles of the larynx, body posture and In general, the prejudice in vocal production is treatment of Speech Therapy and Physical Therapy, related to inadequate respiratory function, incorrect correlated or not, of classical sources and current use of resonators, hypertension of lingual, glottal to the national and international scientific literature. and cervical muscles1-3. The exclusion criteria adopted were: non-indexed The participation of the extrinsic laryngeal muscle periodicals in the databases mentioned above; on the voice has been the focus of scientific studies studies which dealt with other types of musculo- and research in recent years, once the dysphonia, especially hyperfunctional, may be related to muscle skeletal syndromes; studies with publishing time imbalances craniocervical2-7. upper than 13 years. Through of careful assessment, it is possible It was applied the criteria of inclusion and to determine if the vocal dysfunction alters the exclusion in the researchers found, leaving 40 behavior of the cervical muscles and to verify studies for review. These materials have been the possible influence on body posture and organized according to the authors, title, year of contrariwise. It is importance to study the relation publication and type of study. It was necessary to between body posture, laryngeal musculature and reduce the number of references, adopting as a vocal production, because the action (multiprofes- criterion to maintain 80% of the studies of the last sional and interdisciplinary) of speech therapy and five years, giving priority to the original research physical therapy may optimize the treatment and articles, within a total of 40 maximum references, provide greater benefits for patients3. excluding studies that did not brought individual 8-11 Studies suggest that rehabilitation of vocal contributions to this review. production, focusing on the extrinsic muscles of the larynx and other cervical muscle groups associated From this categorization, the references were with respiratory reeducation and correction of grouped according to the themes that gave rise postural deviations, may decrease the time of to the subtitles of the body of this work: extrinsic therapy. muscles of the larynx and body posture; musculo- Considering the above, this paper intends to skeletal tension; MSTS and its vocal implications; describe, from the literature review, the extrinsic assessment and treatment of Physical Therapy, and muscles of the larynx; posture; MSTS and its vocals Speech Therapy to MSTS.

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„„ LITERATURE REVIEW increase of the fundamental frequency of the voice to produce treble sounds5,14,15. Extrinsic muscles of the larynx and body The style-hyoid muscle originates at the styloid posture process and its insertion occurs in the body of the hyoid bone13, raising and making posterior this bone The larynx is constituted of a composite structure and larynx, also contributing to the production of by articular cartilage, connected by ligaments and treble sounds15. membranes, activated by intrinsic laryngeal muscles. The extrinsic muscles have connection with external In summary, the anterior digastric muscles, structures of the larynx and is responsible for genius-hyoid and milo-hyoid raise and make maintaining the position of the larynx in relation to anterior the hyoid bone, favoring the treble sound; other structures of the neck (laryngeal support) and also act in mandibular depression and production of front vowels or consonants which require high their depression, elevation and traction anteropos- 5,13-15 terior to speech and swallowing movements, with position of the tongue . The posterior digastric possible an influence on phonation1,3. muscle and hyoid-style raise and make posterior the hyoid bone and larynx. The combined action of all The extrinsic muscles are subdivided into supra- these supra-hyoid muscles lifts and fixed the larynx hyoid and infra-hyoid muscles, its innervations are without anteroposterior traction, favoring vocal fold performed from the and the blood adduction15. irrigation derives from the superior laryngeal , The group infra-hyoid musculature is composed anteroposterior and branch of the superior thyroid of muscles attached to the hyoid bone inferiorly: artery12. sterno-hyoid, omo-hyoid, thyrohyoid sternothy- The supra-hyoid muscle encompasses four reoid8,13,15. These muscles participate in depression, muscles: digastric, mylohyoid, genius-hyoid and fronting, posteriorly or fixation of the larynx in hyoid-style, located in the region of anterior neck, the neck15, with the exception of thyrohyoid that 1,3,8,13,14 above the hyoid bone and inserted . In depresses the hyoid and raises the larynx. He general, these muscles are involved in elevation, exerts traction a thyroid cartilage upward, stretching anteriorization, and posteriorization and or fixation the vocal folds and favoring the treble, because of the larynx in the neck, stretching the vocal folds, its activity is similar to the intrinsic cricothyroid increased subglottic pressure and alteration of muscle, which may also help in medialization of the resonant cavities during the production of treble vestibular folds8,15. sounds and strong loudness15. The sterno-hyoid muscle inserts on the posterior The is thick and deep, divides surface of the manubrium of sternum, in the medial into anterior and posterior beam, with inserts on the extremity of the , in the ligamentous tissue inner edge of the mandible and the mastoid of the adjacent, whose fibers make a vertical route, and temporal bone, respectively13. The anterior belly of at the lower edge of the body of the hyoid bone13. the digastric is activated during the production of When contracted during phonation, exerts traction front vowels and consonants which require high down the larynx and vocal folds are stretched, influ- position of the tongue. Helps to lift and anteriorization encing the glottal adduction and control of air flow, of hyoid bone and larynx, mandibular depression, may increase the duration of the emission, subglottic cough and swallow. The posterior belly posterioriza pressure and loudness15. 15 and lift the hyoid bone and larynx . The omo-hyoid has inferior and posterior bellies. The is located on the floor of The lower is inserted on the upper surface of the the mouth, originates in the hyoid, mylohyoid line of scapula and intermediate tendon, the higher fits into the mandible, from the mentalis symphysis, to the the intermediate tendon, in the greater cornu and region of the third molar, has insertion in the body of along the lower face of the greater cornu of the hyoid the hyoid bone13. Its function in phonation is related bone13. Its function is to depress and make posterior to speech articulation; production of treble sounds, the larynx and maintain the cervical tense, because participates of the elevation, stabilization impeding the collapse of the neck region during and traction anterior of the hyoid bone and larynx, deep inspiration and the veins and of the and swallowing15. neck and the apex of the lungs to be compressed The genie-hyoid has an insert in the inferior during inspiration15. portion of the mentalis muscle and another in The sternothyreoid originates on the posterior the hyoid bone13 over which exerts force directly surface of the manubrium of sternum and the first and indirectly on the thyroid cartilage, because it costal cartilage13. When acting in conjunction with elevates both structures and exerts anterior traction, the intrinsic , participates in the stretching the vocal folds and influencing the production of treble sounds, because it helps tilting

Rev. CEFAC. 2014 Set-Out; 16(5):1639-1649 1642 Cielo CA, Christmann MK, Ribeiro VV, Hoffmann CF, Padilha JF, Steidl EMS, Bastilha GR, Andriollo DB, Frigo LF and fixing larynx. In isolation, its activation exerts for hypertension of sternocleidomastoid and traction the larynx, tongue and hyoid caudally, genius-hyoid muscles. The combination of hyper- helping to produce bass sounds. Furthermore, tension genius-hyoid muscle, elevated position of influences to open of the glottis and larynx during the hyoid bone and forward head were the most inspiration and yawn15. important predictors of low scores on the DSI. The Besides the extrinsic laryngeal muscles supra results showed worsening of dysphonia index as and infra-hyoid, other not laryngeal muscles are decreased the quality of life in relation to the voice related to the cervical spine, the region where there and increased the incidence of hypertension, under- are larynx and vocal folds3,7,12. The sternocleido- scoring the importance of the evaluation of muscle mastoid muscle, whose insertion occurs along the tension and body posture in the voice disorders mastoid, superior nuchal line, manubrium of the diagnosis5. sternum and anterior border of the medial third of Search with 27 healthy subjects aimed to 3 the clavicle , when contracted unilaterally, tilts and determine if the vocal tension is a side effect of effort rotates the head at the same-side and bilateral and improper posture during communication, evalu- 14 contraction, participates in the cervical flexion . ating them on three different levels of vocal effort. It Originating the last five and was observed that with increase of magnitude and inserting on the first and second , there are the duration of body movement, the vocal effort was , which contracted unilaterally, also greater, with a significant correlation6. These have for primary action is the ipsilateral tilt of the data confirm the close relationship and coordination neck and when contracted bilaterally, participate in between body posture and voice on communi- the elevation of the in inspiration. Meanwhile, cative behavior. Another study sought to correlate the muscle is originan a superior nuchal body posture and tension during phonation using line, nuchal ligament and spinous process of stabilometry, verified a positive correlation between the seventh cervical and 12th thoracic the center displacement of gravity of the body and vertebra, inserting in the posterior border of the increase the electrical signal of postural muscles clavicle, acromion and spine of the scapula, with during vocal effort16. function tilt and rotate the head to the same-side, The identification of the influence of different body when contracted unilaterally, and participate in cervical extension when contracted bilaterally3. postures in vocal production was investigated by analyzing 25 samples of sustained vowel /a/ in three During cervical extension, the anterior muscles different postures: orthostatic (A), with forward head of the neck stretches and posture associated with cervical spine extension (B) (trapezius and the elevators of the scapula) are and increased thoracic kyphosis associated with shortened. When the position cervical extensionis forward head (C). The comparison was performed position is established, muscle weakness emerges by means of photogrammetry and perceptual voice the anterior neck with adaptive shortening of the analysis and acoustics. The results showed signif- suboccipital group. Course may change in shape of icant variation of jitter between the positions A and the larynx, especially to tighten, which increases the B and significant modifications auditory perceptual adduction of the vocal folds and vocal resonance between the positions A-B and A-C as resonance, alters. Thus, there is the influence of paralaringea pitch and vocal quality, saying that the erect posture musculature that participates to the cervical posture 7 over the larynx and vocal production7. is more appropriate for vocal production . In cervical flexion, occurs the suboccipital A pilot study investigated the relationship between musculature stretching and the shortening of cephalometric, magnetic resonance images and anterior neck musculature (muscles supra and infra- muscle function of the stomatognathic system during hyoid). The depresses larynx with cervical flexion, voice production. Verified the presence of correla- favoring the abduction glottal and vocal resonance tions between structures phonation, the craniofacial changes. Current studies5-7 emphasize the corre- bones and cervical spine, with increased the size lation between body posture and extrinsic muscles of the airways associated with larger distances of the larynx. between the base of the skull, hyoid bone, larynx, 17 The relationship between hypertrophy of the epiglottis, uvula and C3 from the chin . extrinsic laryngeal muscle, postural deviations The literature shows the importance of correct and voice handicap, through the application of the posture for efficient vocal production. The mainte- Voice Handicap Index (VHI) and the Dysphonia nance of torso erect, turn down head slightly, Severity Index (DSI) was investigated in 25 female shoulders relaxed, seeking the free movement of the professors. It was observed a positive correlation larynx, without locks for production and projection of between tension index, DSI and VHI, especially sound in the vocal tract seems to be the ideal6,7,17,18.

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Musculoskeletal tension observed in results in the two situations evaluated. Physiologically, during muscle contraction, Professors with higher workload and service time occurs chemical processes that provide energy showed greater alterations14. to the execution of movements. After contraction Research with dysphonic women and control (during muscle relaxation), energy reserves are group with voice adapted analyzed the posture again reconstructed. According to the level of and function of the craniocervical region by demand, there is a reduction of energy reserves means of photogrammetry and evaluation of the (sugar and phosphorus bonds) and increase of Craniocervical Dysfunction Index (CDI). The results waste (including, lactic acid and carbonic acid), of the photogrammetric evaluation showed no occurring acidification of muscle tissue, which can difference between the mean values ​​of the angle of cause decreased its function19. head protrusion between the groups, this suggests When a muscle loses the flexibility, with that the position of the head in the sagittal plane decreased length-tension relationship, incapaci- not differ between the groups studied. However, tating to produce adequate peak tension, which the majority of women in the dysphonic group had causes weakness and retraction20. Increased muscle moderate and sereve craniocervical dysfunction in tension represents a way for the body to demon- CDI. Dysphonic subjects did not present postural strate the alteration of a given body segment. This alteration of craniocervical region, but the dysphonic leads to compensation and overloads that generate women were classified as having a greater degree damage in the body functionality. This reasoning of craniocervical dysfunction than clinically normal. may be made to the stomatognathic system, larynx The study suggests that the dysphonia is more and cervical posture because they have muscles related to functional alterations of the cervical region 22 and connections in common20. than the posture of the same region . The bilateral contraction of the neck muscles, Observed in research that women are more causing flexion of the cervical spine on the thoracic susceptible to cervical tensions, since the main and forward head, makes possible the increased responsible for muscle pains was the increase of inspiratory effort, contributing an apical ventilatory thoracic kyphosis caused by environmental factors, pattern and, in turn, increased recruitment of bad posture habits, muscle retractions, physical and 1 accessory muscles of inspiration21. Hypertension emotional stress . neck muscles also damages body balance, because it affects positioning of the vestibular apparatus Musculoskeletal Tension Syndrome and its and musculature responsible for the regulation of vocal implications ocular movements, also causing decreased cervical In MSTS primary, there is tension generalized range of movement and forward head, increasing increased in the whole intrinsic and extrinsic muscle tension and tractioning a hyoid mandible laryngeal muscles simultaneously, associating with posteriorly21. altered laryngeal posture2,3,14,22,23. In presence of In a study about muscles involved in posture tissue reaction laryngeal lesions, MSTS is classified external and internal of the larynx at rest and during as secondary1-3,24. phonation, it was found that the increased tension The MSTS is also classified as type “I” and type of the supra-hyoid muscles resulted in excessive “II”, the latter being subdivided into “a” and “b”1,3. elevation of the larynx. The contraction of the thyro- In type “I”, to the otorhinolaryngological exam, hyoid muscles exerts traction the hyoid bone and the larynx presents structurally normal, but with thyroid cartilage together and, in severe cases, posterior chink during phonation and stiffness of closes the space thyrohyoid, producing anteropos- supra-hyoid muscle upon palpation. The MSTS type terior supraglottic constriction8. “II” resembles the first category, but with organo- In research with professors, were evaluated functional lesion established. In MSTS type “II b”, postural aspects during the professional voice the larynx is located higher in the neck, with the use and in situations outside employment. It was presence of posterior chink, besides alterations in observed the majority had significant hypertension location outside the larynx, such as the jaw, among of sternocleidomastoid muscle and genius-hyoid; others. There may be diffuse changes in entire body weight was altered in position in relation to the length of the vocal folds and episodes of chronic frontal plane, being concentrated in the posterior laryngitis1-3. region; were also observed hyoid bone in the high The installation of MSTS occurs slowly and position, muscular hypertension and anteriorization progressively, the degree of alteration is generally of the thyroid cartilage. Through questionnaires, compatible with the clinical history and data from participants referred pain at the end of the day, a speech evaluation performed. Although MSTS fit as result of musculoskeletal tension, no difference was a subclassification of psychogenic dysphonia, there

Rev. CEFAC. 2014 Set-Out; 16(5):1639-1649 1644 Cielo CA, Christmann MK, Ribeiro VV, Hoffmann CF, Padilha JF, Steidl EMS, Bastilha GR, Andriollo DB, Frigo LF is no suppression of symptoms with symptomatic possible that functional alterations resulting of the manipulation1,2. The MSTS is influenced by external syndrome favoring the formation of organofunc- factors such as work stress, family problems, profes- tional lesions due to the inadequate vocals adjust- sional concerns, as well as intrinsic factors related to ments, which confirms the difficulties to preparing the subject’s personality that can lead to increased the correct diagnosis1. It was proposed a tool of tension, such as perfectionism and anxiety1,2. for clinical evaluation of extrinsic laryngeal muscle The patients present muscular hypertension tension (ELMT) by palpation and the investigation during speech, without direct association with of the relationship between the tension and the laryngeal affections. The incoordination or excessive different types vocal alterations, mainly MSTS, and contraction of muscles associated with the voice the presence or absence of gastroesophageal reflux production may manifest itself hoarse vocal quality, disease (GERD). Establish a palpation technique compressed or strained-strangled hyperadduct of and a classification system of tension for four vocal folds and the ventricular bands, sphincter separate muscle groups (supra-hyoid, thyrohyoid, constriction of the larynx, with a predominance of cricothyroid and pharyngolaryngeal). Participated vocal sudden, laryngopharyngeal resonance and 465 patients, 65% female and 35% male, and the increasing the number of voice breaks. Are also results of ELMT were analyzed in relation to the observed deviations of pitch and loudness for both diagnosis of GERD. Found a strong relationship extremes, addition to symptoms such as pain in the between tension and MSTS and neck region and/or fatigue or, even, aphonia1,3,24. RGE. Thyrohyoid muscle tension was the only group In cases of fatigue the laryngeal muscle, there that showed a significant relationship with MSTS. is consistent increase in effort in voice production There was no significant difference of ELMT for the and mechanical stress resulting from the collision presence or absence of GERD, and also found a between the vocal folds during phonation possible causal relationship between GERD and excessive, causing the death of epithelial cells and ELMT8. the separation of the fibers of collagen and elastin, Other studies have also considered relevant of the basement membrane. Subsequently, due to the tension from other muscle groups such as the the increase of vibration may be increased intra- sternocleidomastoid, cervical paraspinal, upper vascular pressure and consequent extravasation fibers of the trapezius and scalene9,10. Surface of erythrocytes and the variation fluid dynamics of electromyography makes it possible to evaluate in the structure of the vocal fold. These processes objectively the muscles in various situations as to alter the biomechanical properties of the tissue as determine the possible influence of cervical limit and viscosity and, therefore, have the capacity of bring postural alteration in muscle activation pattern9. modifications in the vibration characteristics. This The increase in electromyographic activity of displace phonation threshold pressure and would the superficial cervical muscles is associated with cause phonation instability with breaks voice. This cervical spine disorders such as pain, whiplash process results in symptoms of discomfort, pain or (concussion lesion or whip after trauma to the scratching voice1,3,24-26. cervical spine), cervicogenic headaches, among Another sign commonly found in the MSTS is the others9,10,28. Thus, it is assumed that hypertension tongue in the lowered position and hypertensive, and of superficial cervical flexor muscles may being a firmly supported against the dental arches, with the compensatory strategy for the deep flexor muscle tongue edge marked and grooved by the teeth. The dysfunction9. tongue is connected to the larynx by means of the hyoid bone and moves constantly during speech. Still, with a possible relationship with MSTS, Thus its position hyperfunctional posteriorized among the various types of pain, those of muscular causes posterior horizontal resonance. Symptoms origin usually occurs by cranial or cervical muscle 9,10,28 of vocal MSTS tend to soften during periods of tension . higher rest and lower stress1,27. The diagnosis of MSTS is difficult, since there Treatment of Physical Therapy and Speech is the possibility of the vocal folds present normal Therapy for MSTS aspects on otorhinolaryngological exam, but The literature suggests that evaluation to identify symptom profile of unexplained and persistent the MSTS is comprised of interview, followed dysphonia. Sometimes, even, an error occurs in the by the evaluation of vocal function, palpation of diagnosis according to the similarity of symptoms the tension of the extrinsic muscles of the larynx, with other types of dysphonia, as the adductor standard otorhinolaryngology exam and videolar- spasmodic dysphonia1,2,27. yngostroboscopy8, being interesting the referral to Although there is no direct relationship between physiotherapy assessment, given the nature of this MSTS and presence of laryngeal affections, it is generalized muscular hypertension syndrome.

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Studies suggest a physical therapist therapy manipulation and prolonged /b/, leads to a better including electrotherapy and transcutaneous quality of voice production12. electrical nerve stimulation (TENS), light amplifi- The relationship of postural alterations with cation by stimulated emission of radiation (laser) dysphonia was investigated in 40 women before of low intensity, laser acupuncture, cryotherapy, and after speech therapy, associated with postural 10,29 among others . A proven effective modality for modifications. The results showed, through laryn- normotensive cervical muscles is manual therapy gostroboscopy improves of the dysfunction in with traction, massage, cervical manipulation and all participants. This suggests relationship with mobilization, associated or not to exercise, as well as increased accuracy of postural performance, passive stretching and/or resistive, isometric relax- probably due to the fact that the rehabilitation ation, assisted soft tissue mobilization (important provided greater proprioceptive awareness of in the treatment of muscle fascia), therapeutic body structures. The authors believe that improved exercises aiming to correct and balance muscle, control over the voice and breathing promotes diaphragm respiratory reeducation and therapy with postural reeducation, and the opposite is also true. 9,10,29 craniocervical flexion . It is suggested, therefore, that the rehabilitation Research30 that investigated the effect of the should not be focused exclusively on the larynx, but Global Posture Reeducation (GPR) body alignment also involve postural rehabilitation11. and the clinical condition of patients with temporo- A study of 11 theater students (aged 18 to 23 mandibular joint dysfunction and postural deviation, years), diagnosed with MSTS type I (four men and with hypertension of the sternocleidomastoid seven women) used spectrographic narrowband, muscles, trapezius (upper fibers), masseter and questionnaires on quality of life and nasofibrolar- temporalis, noted that after the RPG there was yngoscopy to evaluate the effect of a therapeutic improvement of the horizontal alignment of the program exercises with semi-occluded vocal tract head. This shows that postural deviations generate (SOVTE). The therapy consisted of six sessions tension in muscle chains, and result in the masti- (once a week), each lasting 30 minutes, which was 28,30 cator and neck muscles , being able to influence conducted in a sequence of three exercises, sorted the function of the larynx. according to the degree of impedance applied to Speech therapy treatment for MSTS includes the the vocal tract, from the most artificial to the most use of physical techniques, laryngeal and shoulder natural: phonation plastic tube (inner diameter girdle massage, postural modifications of the head, 0.19in and 11.8in length); phonation plastic tube as well as smoothing techniques of vocal emission1,2. (inner diameter of 0.19 in and 3.93 in length), and In extreme cases, may be employed the botulinum sound fricative /ß:/. Each exercise was applied with toxin injection for relief of symptoms and as a help in three variations: sustained emission in pitch and the development of rehabilitation for vocal behavior loudness usual; glissan the ascending intervals of therapy1. fifth and eighth; glissan of descendants with the Techniques of digital manipulation of the larynx same intervals fifth and eighth 3. may also be employed in the treatment of MSTS, Participants were instructed to perform the resulting in changes in vocal quality, issuing more exercises twice a day. After therapy, the results relaxed and gravest fundamental frequency. showed significant improvement in spectroscopy However, their performance may cause extreme and in nasofibrolaryngoscopy, six subjects showed discomfort to patients1,2. decreased muscular tension patterns laryngeal The main goal of manual therapy of the larynx three remained the same tension and two triggered is to relax the hypertensive muscles that inhibits contraction of the ventricular bands to phonation, normal phonation function2 and has been used in it is possible to suggest that the speech therapy several studies of subjects with MSTS31,32. One of should extend for a longer time. There was a them verified, by improving the acoustic analysis positive correlation between improvement in nasofi- results, that manual therapy of the larynx is effective brolaryngoscopy and improvement in spectrograph in the treatment of vocal disorders arising from indicating that subjects who improve the standards MSTS33. Other34, with 93 patients with functional also improve laryngeal spectrographic. Thus, it is dysphonia, evaluated the effects of circumlaryngeal possible that the use of resonance tubes having one massage performed in a single session and favored easier and relaxed phonation3. observed acoustics improve, but unrelated to the Study carried with 23 women without vocal improvement of perceptual voice. complaints and ages between 23 and 40 years, The literature suggests that the reduction who performed twice the exercises FingerKazoo of musculoskeletal tension, obtained by voice and phonation with straw, showed reduction of techniques such as yawning and sigh, laryngeal the fundamental frequency after both exercises,

Rev. CEFAC. 2014 Set-Out; 16(5):1639-1649 1646 Cielo CA, Christmann MK, Ribeiro VV, Hoffmann CF, Padilha JF, Steidl EMS, Bastilha GR, Andriollo DB, Frigo LF according to the authors, may be related to tension After the execution of SOVTE, expected some reduction to phonation35. effects as: reduction of phonatory pressure and It is highlighted that the literature is scarce when glottal airflow, increased harmonic energy, modifi- it comes to MSTS, possibly due to the difficulty cation in shape of the glottal pulse air and oscillatory of diagnosis of the patients. For this reason, are characteristics of the vocal folds, increasing the suggest studies with that population to promote sound pressure, and increased perception of vibra- greater support to speech therapy treatment. tions in various regions of the vocal tract. So that, Inclusive, it was not found in literature studies on as the psalmody voice, the SOVTE also divide the simultaneous treatment between Speech Therapy effort between the three levels of vocal production, and Physical Therapy, which seems to be more reducing hypertension3,35. Thus, it is also possible to effective, in view of the researched literature10,29. consider that patients with MSTS would benefit from However, although few researches on vocal the use of SOVTE. speech therapy in MSTS, many authors 2,3,35-37 indicate different vocal techniques for the reduction „„ CONCLUSION of phonatory hyperfunction, stress and fatigue, among which are the SOVTE (vibration of the lips and The literature shows that MSTS may be tongue, fricatives sounds, /b/ prolonged, humming, considered as a series compensations that postural firmness glottic, FingerKazoo, lip constriction, Lessac Y-Buzz and phonation into tubes), yawn-sigh, deviations can generate body adaptations and, rotation speaking in the vestibule, overarticulation therefore, cause modifications in the morphophysio- techniques and psalmody voice. The exercise logical larynx and throughout the body musculature, of basal tone or vocal fry can also be indicated in highlighting the extrinsic laryngeal and cervical. some cases of muscle tension dysphonia (laryngeal It was possible to better understand the interface isometrics, vocal fatigue, uncomfortable speech, of Physical Therapy and Speech Therapy treat- mid-posterior triangular chink)1,38,39. ments, among which we highlight the relationship The psalmody voice is a vocal technique that between the body muscles, especially the respi- promotes muscle adjustment more efficiently and ratory and cervical, the posture and functional at lower muscle tension intrinsic and extrinsic of aspects on the vocal apparatus synergy that should the larynx, as well as greater respiratory support, be reflected in the evaluation and therapy of MSTS. making the individual use greater airway pressure Thus, the effectiveness of therapy will occur more over the strong adduction between the vocal folds. quickly and with less chance of relapse. Since this technique also works the resonant level, In Physical Therapy to reduce muscle tension, the individual begins to divide the forces in the three the literature suggests the use of TENS, low intensity levels of vocal production40. In a study conducted laser, laser acupuncture, cryotherapy, as well as with four professors with a history of vocal fatigue manual therapy with traction, massage, cervical that compared therapy with psalmody voice with manipulation and mobilization, associated or not to placebo therapy (each of the two modes of therapy exercise, stretching, isometric relaxation, assisted consisted of six sessions of one hour each), it was soft tissue mobilization, therapeutic exercises observed that the technique decreased fatigue aiming to correct and balance muscle, diaphragm muscle justly by improving motor adjustments during respiratory reeducation and craniocervical flexion speech and reduce hypertension40. Although the therapy. authors do not bring the indication for patients with In Speech Therapy, studies found only through MSTS, based on the benefits shown by psalmody digital manipulation of the larynx and SOVTE voice technique, it is possible to think that it may be directed to MSTS, however, many authors suggest used in speech therapy for patients with MSTS. different vocal techniques for the reduction of vocal The same way, it is possible to make an analogy hyperfunction, effort and fatigue: nasals, yawn-sigh, with other techniques, such as SOVTE. The /b/ prolonged technique, vocal fry, rotation speaking literature suggests that such exercises increase in the vestibule, overarticulation techniques and the impedance of the vocal tract, generating a psalmody voice. phonation with less effort because the retroflex resonance, causes increase the air pressure in the „ sub region and supraglottic and, consequently, at „ ACKNOWLEDGEMENT the glottic level. This tends to increase the amplitude of mucosa vibration, but with reduced impact on the To the Conselho Nacional de Desenvolvimento medial contact between the vocal folds. In other Científico e Tecnológico (CNPq) for the support words, we can say that these exercises produce a with the development of this research, CAPES and more economical and effortless phonation3,35-37. FAPERGS.

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RESUMO

O tema deste estudo é a Síndrome de tensão musculoesquelética, musculatura laríngea extrínseca e postura corporal.Tem como objetivo descrever, a partir de revisão de literatura,as características da musculatura extrínseca da laringe; postura corporal; Síndrome de tensão musculoesquelética e suas implicações vocais; avaliação e tratamento fisioterapêutico e fonoaudiológico.Foi realizado levanta- mento bibliográfico dos últimos 13 anos em que foram incluídos artigos cujo objetivo e/ou corpo do texto estivessem em consonância com os objetivos do estudo. A pesquisa foi realizada nos bancos de dados das bases Literatura Latino-Americana e do Caribe em Ciências da Saúde, Biblioteca Regional de Medicina, PublicMedline, Medical Literature Analysis and Retrieval System on Line, Scientific Electronic Library Online e Google Schoolar. Estabeleceram-se relações importantes do âmbito fisio- terapêutico e fonoaudiológico, dentre as quais se destacam as relações musculares, posturais e funcionais na sinergia do aparato vocal. Na fisioterapia para redução da tensão muscular, a literatura aponta uso de eletroterapia transcutânea, laser de baixa intensidade, laser acupuntura, crioterapia, bem como terapia manual com tração, massagens, manipulações e mobilizações cervicais, associa- das ou não a exercícios, alongamentos, relaxamento isométrico, mobilização assistida dos tecidos moles, exercícios terapêuticos visando à correção e equilíbrio muscular, reeducação respiratória dia- fragmática e terapia com flexão craniocervical. Na fonoaudiologia, foram encontrados apenas estudos com a manipulação digital da laringe e exercícios de trato vocal semiocluído.

DESCRITORES: Laringe; Disfonia; Postura; Músculos Laríngeos; Sistema Musculoesquelético; Terapêutica

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Received on: June 13, 2013 Accepted on: October 04, 2013

Mailing address: Carla Aparecida Cielo Rua Guilherme João Fabrin, 545 - Nossa Senhora de Lourdes Santa Maria – RS – Brasil CEP: 97050-280 E-mail: [email protected]

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