Care of the Professional Voice ASSOCIATE EDITOR: Robert T. Sataloff, MD, DMA
Posture and Voice
John S. Rubin Lesley Mathieson Ed Blake
The necessity for proper posture The larynx is suspended from the pendicularly oriented shoulder gir- has been recognized by singing teach- base of the skull, not by direct bony dle; vertically over the hip joints and ers for centuries. However it has taken attachment, but by a series of mus- the pelvis; and vertically over the for- the medical community (and the gen- cles and ligaments. It could, in one ward facing feet. A plumb line through eral public) longer to recognize its sense, be considered to be in the cen- the coronal plane formed by the ears value. ter of a constant battleground between would pass directly over the plane of Recently, the importance of pos- the deep extensor and flexor groups of the shoulders and hip joints. The eye ture to well being has become popu- muscles of the neck and upper back. plane is horizontal, the rib cage is neu- larized through the works of authors Additionally, it even could be tral. The spine "rests in the pelvis such as Alexander, 1 Pilates,2 Felden- viewed as a victim in this struggle due much as a person sits in a rocking krais,3 and others. Physiotherapy and to its location in the front of the neck, chair. "s It has four curves. The sacral osteopathy have become integral to its dense muscular attachments to the and thoracic curves are concave ven- the field of sports medicine, and to tissues in front of the cervical spine, trally, the lumbar and cervical curves rehabilitation of musculoskeletal and its connections to the trachea. are convex. injuries. Only very recently, however, Furthermore every time that we swal- In our society, however, this ideal has consideration of such sciences low, the larynx is forced to move up state of affairs rarely happens. Many been applied to voice research and and down in the neck. The strong of us spend most of our time, both at rehabilitation. The authors believe muscles that connect the larynx to work and leisure, in a seated position that it is helpful for singers to be famil- the bottom of the tongue bring it in front of various consoles or screens. iar with the latest concepts and per- upwards when we swallow. The rib- We tend to sit slouched, with our legs spectives on posture from the medical bon-like (strap) muscles connecting it crossed, pelvis tilted, stomachs com- and alternative medical literature. to the sternum (chest-plate) are the pressed and lower back stretched. It major muscles bringing it downwards. is not surprising that chronic lower Rolf has described the ideal state back pain is a problem of enormous journal of singing, January/February 2004 of posture as "equipoise" in which magnitude in our society. Volume 60, No. 3, pp. 271-275 .4 Copyright 2004 the individual stands upright The We shall now look at the muscles National Association of'Feachers of Singing head is held vertically over the per- in the neck around the spine, and try
JANUARY/FEBRUARY 2004 271 John S. Rubin, Lesley Mathieson, and Ed Blake
to understand how they might affect a b the larynx. The posterior extensors of the back, the "erector spinae," support and span the spine. The major action of the erector spinae is to maintain the C upright position of the body. When standing at rest, the center of gravity lies just in front of the second sacral vertebra. Body movement, however, frequently carries the center of grav- ity forward. This mass of muscle is ED then required to restore the upright position (Figure 1). The muscles attached to the skull produce extension, lateral flexion, and —h C
Figure 2. Suboccipital muscles a. Semispinalis Capitis: b. Rectus Capitis Posterior Minor; c. Occiput; d. Obliquus Capitus Superior; e. Obliquus Capitis Inferior; f. Rectus Capitus Posterior Major; g. Atlas; h. Axis R. Ger, P. Abrahams, and T R. Olson. Essential C!inicalAna.tomy, 2nd ed. (New York: Parthenon h Publishing Group; 1996).
rotation of the head .6 One group, the We shall look at all these muscles suboccipital muscles (the muscles now from a different perspective. attached to the occiput), permits accu- Muscular involvement of the cervi- rate positioning of the head and thus cal spine can be categorized into sta- lets us see in 3-D. These muscles bility and mobility activities. Stability extend and rotate the skull (Figure 2). muscles control the head and neck in They are countered by the deep a neutral position, thereby minimiz- muscles of the anterior neck that twist ing the various pressures (loads) the head on the neck and flex the neck placed on the cervical spine when we (bend it forward), including the move around. The longus colli is the ru scalenes and prevertebral muscles. primary anterior muscular stabilizer These muscles attach from the cer- of the cervical spine. This is impor- Figure 1. Deep neck muscles: Erector vical spine down to the upper two tant, as becomes clear below. spinae and Transversus Spinalis ribs (the scalenes), to the upper tho- Mobility muscles are the prime a. Occiput; b. Semispinalis Capitis; c. Atlas; racic spines (longus colli), or up to movers of the head, neck, and shoul- d. Semispinalis Cervicis; e. C 7; f. Semi- the skull base (longus capitis).79 der girdle. They serve also to provide spinalis Thoracis; g. Longissimus Capitis; In addition four more superficial a stability mechanism in the event of h. Iliocostalis Cervicis; i. Iliocostalis muscles, the sternocleidomastoid, 1ev- reduced muscular support from the Thoracis;j. Iliocostalis Lumborum; k. Longissimus Cervicis; 1. T 12; m. ator scapulae, trapezius, and the sple- longus coll. Examples of mobility mus- Longissimus Thoracis; n. Pelvis nius, bind the neck to the shoulder cles include the stemocleidomastoid, girdle. When the neck has a muscular trapezius, and levator scapulae. Adapted from R. Ger, P. Abrahams, and T. R. Olson. Essential Clinical Anatomy, 2nd ed. (New problem, they can also become impor- It must be pointed out that this is York: Parthenon Publishing Group; 1996). tant in neck movement (Figure 3))0 simplistic. Among other factors, the
272 JOURNAL OF SINGING Care of the Professional Voice
on a raked (canted) stage, will more bone. in particular, we postulate that likely than not cause the performer one of these muscles, the stylohyoid to lean his or her head up, or, in more muscle that connects the hyoid to the anatomic terms, put the upper and base of the skull, shortens (Figure 3). mid cervical spine in a substantial In so doing, in its resting position, it degree of extension. Alternatively, in causes the larynx to rise up in the nonsingers, shorter individuals have neck, thereby changing the shape of a tendency to tilt their heads upwards the vocal tract, altering resonance and when in the presence of taller indi- pitch.' viduals. Taller individuals have a ten- We also believe that a higher posi- d dency to stoop, with one postural tion of the larynx in the neck reduces element including leaning forward the efficiency of the voice as we reach and extending the head on the neck. for higher notes and can ultimately The problem here is as follows: this cause a reduction in the upper part forward position of the head results in of the pitch range (how high we can increasing pressures on the joints sing). What we believe happens (this Figure 3. Superficial neck muscles, lat- between the vertebrae, especially if it is anecdotal, and not yet proven) is eral view becomes a habit, which it often does. that a muscular imbalance occurs a. Stylohyoid; h. Posterior Belly of It can also cause pressure (compres- between the muscles that raise and Digastric; c. Sternocleidomastoid; d. sion) on these (facet) joints. This also lower the larynx, particularly the sty- Trapezius; e. Hyoid; f. Oniohyoid; g. causes long standing changes in some lohyoid and sternohyoid. The short- Clavicle; h. Anterior Belly of Digastric of these supporting muscles. In par- ening of the stylohyoid thereby resists ticular, the erector spinae muscles in upper and forward movement of the stiffness of the upper thoracic spine in the back go into chronic contraction hyoid bone and thyroid cartilage dur- itself can have an influence on cervi- and become overly powerful. In the ing singing. This, in turn, alters vocal cal spine motion. If it is stiff going front there are changes in the resting fold length and tension, leading to into extension, this then can require length of the longus colli. This puts potential loss of the singer's top range, increased movement from the cervi- the longus colli at a significant in addition to the presence of breathy cal spine to achieve a functional range mechanical disadvantage. Because it phonation. of extension. Over time, this increased is the main anterior stabilizer of the Others believe that shortening load has potential to cause hypermo- cervical spine, this is probably along- (chronic contraction) of the cricothy- bility of certain segments of the cer- term problem.12 roid muscle also may occur) 4 This vical spine versus their proximal and The tug of war changes in favor of could be postulated to occur in re- distal segments. other muscles. The sternocleido- sponse to the laryngeal elevation Furthermore, as the cervical spine mastoid, levator scapulae, and upper described above, or even to the for- often has inappropriate muscular sta- trapezius are relative "winners" and ward position of the larynx due to the bility, as discussed above, there is a pull the upper cervical spine into even cervical spine being held extended. case for increased tension from mobil- further extension. This is a vicious The cricothyroid muscle is important ity muscles like the sternocleido- circle, experienced by many of us. in that it is the key muscle responsible mastoid, to provide some muscular One consequence can be too much for stretching and "bow-stringing" support for these segments, thereby pressure (load) on the more delicate the larynx and thereby raising pitch further compromising muscular structures of the cervical spine, caus- in conversational speech. Anything recruitment patterns.'1 ing injury to the interspinous struc- affecting the movement of this muscle Why is all of this important to us tures and leading to slipped discs, a could potentially affect voice. from the standpoint of voice, the familiar condition. Another conse- In people with these types of mus- reader might well ask? We shall take quence, of great concern to voice users, cle problems, we have found a clini- a closer look. is adaptive shortening (and strength- cal correlation with tender, contracted Stage direction that involves singing ening) of some of the muscles attached muscles that attach to the hyoid bone. to the dress circle (upper level), often to the top of the larynx, the hyoid This is frequently associated with a
JANUARY/FEBRUARY 2004 273 John S. Rubin, Lesley Mathieson, and Ed Blake
high resting position of the larnx.1 helps certain performers to maintain 6. J. S. P. Lumlev, J. L. Craven, andJ. T. It is also often associated with pain more efficient vocal use.2' Aitken, Essential Anatomy (Edin- or discomfort after using the voice That said, evidence is required to burgh: Churchill Livingstone, 1973). for only a short time, perhaps only take into account the placebo effect. 7. R. Ger, P. Abrahams, and T R. Olson, ten or fifteen minutes.'6 Blake uses a biofeedback device for Essential Clinical Anatomy, 2nd ed. assessment of cervical spine position (New York: Parthenon Publishing TREATMENT and muscle recruitment patterns, Group, 1996). Various physical techniques have which we shall shortly study. We are 8. Stedman 's Medical Dictionary, 22d been developed to help alleviate the currently looking into the possibility ed. (Baltimore: Williams and Wilkins, 1972). problems described above. These of studying surface EMG recording include those that deal with: of muscle activity. Patient satisfac- 9. J. C. Grant Boileu, andJ. V. Basmajian, 1) release of tension/contraction of tion indices may prove another Grants Method ofAnatomy, 7`1 ed. the neck muscles that attach to method for charting improvement. (Baltimore: Williams and Wilkins, 1965). the hyoid bone, techniques cham- Singing teachers have extensive pioned by workers such as Lesley experience working with posture. 10. E. Blake, personal observation, 2001. Their involvement in future research Mathieson'7 and Nelson Roy;'8 11. E. Blake, personal communication, 2) release/stretch of the cricothyroid would be invaluable. The recom- September, 2002. muscle or of tight strap muscles, mendations regarding posture and its 12. E. Blake, personal observation, 2001. techniques championed by Jacob modification, particularly in per- Lieberman;` formers, should best be reviewed in 13, E. Blake, personal observation, 2001. 3) repositioning of the forward the world literature of voice peda- 14.J. Lieberman, "Problems and (hyperlordotic) cervical spine, gogy. One hopes that evolving science Techniques of Manual Therapy," in through gentle muscle stretching may not only provide new informa- T. Harris, S. Harris, I. S. Rubin, and techniques, together with an tion of the value to voice training, but D. Howard (eds), The Voice Clinic exercise program designed to also techniques and technologies to Handbook (London: Whurr Pub- lishers, strengthen the deep flexor mus- test approaches advocated for studio 1998), 91-138. cles. Such techniques are not teaching. 15.J. R. Rubin, J. Lieberman, and T. M. uncommonly used in physio- Harris, "Laryngeal Manipulation," therapy, osteopathy, and to a lesser in C. A. Rosen, and T. Murry (eds), NOTES degree in massage. For voice The Otolaryngolic Clinics of North America: Voice Disorders and Phono- patients, they have been champi- 1. K. Fisher, "Early Experience of a surgei-y 11200033, no. 5: 1017-1034. oned by Ed Blake."' Multidisciplinary Pain Management Programme," Holistic Medicine 16. L. Mathieson, GreeneandMathieson's THE WAY FORWARD (1988): 47-56. The Voice and Its Disorders, 6" ed. (London: Whurr Publishers, 2001). Many of the concepts put forward 2. L. Robinson, H. Fisher, J. Knox, and 17. Ibid. above are still in their early phases. G. Thomson, The Official Body We know from clinical experience, Control Pilates Manual (London: 18. N. Roy, and H. A. Leeper, "Effects of for example, that gentle manipula- Macmillan Publishers Ltd., 2000). the Manual Laryngeal Musculo- tion by a qualified practitioner of the skeletal Tension Reduction Tech- 3. M. Feldenkrais, Awareness Throuqh nique as a Treatment for Functional upper thoracic spine, when stiff and Movement (New York: Harper and Voice Disorders: Perceptual and impeding cervical spine motion, in Row, 1972). Acoustic Measures, "Journal of Voice the short term will improve the cer- 7 (1993): 242-249. vical spine resting position. Blake 4. I. P. Rolf, Rolfing: Reestablishing the 19. Lieberman, "Problems." has developed a series of exercises Natural Alignment and Structural that will strengthen the longus colli Integration of the Human Body for 20. E. Blake, personal communication, Vitality and Well-bein'j (Rochester, over time and allow for longer term 2001. VT: Healing Arts Press, 1989). muscular balance, and it appears on 21. E. Blake, personal communication, anecdotal evidence that such therapy 5. Ibid, 175. 2002.
274 JOURNAL OF SINGING Care of the Professional Voice
I .1 iii HLN cnn/nil! \/i: Rnbiii lin 'ncl in lallhi/ilc/ailrii pat/inlijit* anil itic John Rubin. MD. FACS, FRCS, is a Con- on ma n,y international editorial and sci- ted to the study and care of the pi'rJornu'r s sultant Ear, Nose, and Throat Surgeon at entific boards and committees. He is the voice. Subsequently, she was made an affil- The Royal National Throat Nose and Ear current President of the British Voice Asso- iate of the Center for Voice Disorders at the Hospital Division of The Royal Free NHS ciatioufhr the 2003-2004 term. New York Eye and Ear Infirmary. As a Trust, where he is the Lead Clinician of the Past-President of the British Voice Associ- Voice Disorders Unit, He is also an Hon- Lesley Mathieson, DipCST FRCSLT is a ation (2002-2003), Ms. Math ieson con- orary Consultant ENT Surgeon at St. Bar- speech-language pathologist specializing tinues to bra member of the BVA Council. tholonews Hospital and Honorary Senior in the treatment of patients with clinical Lecturer at University College London. whom are per- voice disorders, many of Ed Blake is an Australian trained manip- formers. She is the author Greene and Mr. Rubin trained primarily in America. of ulative physiotherapist who has achieved Mathieson's The Voice and Its Disorders He obtained his BA at Dartmouth College, Masters degree qualification specializing (6th edition), and her publications include and his MD at New York Medical College. in spinal dysfunction. He works primarily various chapters and journal papers. A He did his ear, nose, and throat training with individuals associated with the per- the editorial board of the re at Manhattan Eye Ear and Throat Hos- member of fer forming arts, specifically opera, musical, Logopedics Phoniatrics Vocol--eed journal pital, He consulted at Montefiore Medical and pop musicians. He has pioneered con- its "Forum" section. Center in New York prior to coming to Enij- ogy, she is editor of cepts and treatment techniques that asso- is an external lecturer in voice pathol- land, and is still a Visiting Associate Pro- She ciate musculoskeletal vocal dysfunction to ogy to the Department of Human Com- fessor at The Albert Einstein College of cervical spine muscle imbalance disorders. munication Science, University College Medicine in New York. He lectures regularly and is associated with London, following many years as Visiting a number of voice associations in the United Mr. Rubin 's particular interests lie in voice Lecturer in Voice Pathology, University of Kingdom. disorders and laryngeal surgery. He has Reading. in 7995, she was elected as an written extensively, including several books, Associate Member of Collegium Medico- numerous articles and chapters, and he rum Theatri (CoMeT), the international regularly lectures on voice related topics. organization of laryngologists, speech
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