Exam 2 Lecture 2 Manual Circumlaryngeal Techniques

how many patients who participated achieved some degree of improvement to circumlaryngeal massage?

96% 80% achieved a 2 scale treatment change (pre and post treatment)

"primary" muscle tension dysphonia (MTD-1)

-a voice disorder in the absence of visible structural or neurological laryngeal pathology -dysregulated actvitiy of the intrinsic and extrinsic laryngeal muscles is the primary (proximal) cause of the voice disturbance

what are symptoms of excess laryngael muscle tension?

-laryngeal tenderness, soreness, pain, tightness which intensifies with extended voice use -unilateral symptoms are more common -pain radiates to one or both ears -vocal fatigue, increased effort, "swellings" (lumps you feel before exam--knot when anticipating a stressful event) -dynamic range (frequency range and loudness range) restricted

typical sites of focal palpation or laryngeal area?

-major horns of the hyoid -superior border of thyroid cartilage -anterior border of SCM -suprahyoid musculature -within hyoid space -det. the size of the thyrohyoid space -at rest and during phonation (dynamic)

how many patients experienced further improvement following discharge (after circumlaryngeal massage)?

17%

how many patients from circumlaryngeal massage experienced relapse?

25% -1 scale value more severe than post 1rating

voice mutation in males occurs over a ____ to ____ month period and is typically completed by ___ years of age

6-12 15

after circumlaryngeal massage, how many got normaly or mildly dysphonic following tx?

64%

"push back" maneuver (#1)

apply pressure on those muscles and free the larynx just to see if there's any sign of improvement when push on this region

purpose/effects of laryngeal reposturing/repositioning

brief displacement/sustained pressure in certain sites (engender some degree of voice improvement) -may not be normal voice but is an approximation while patient vocalizes, want them to attend to these brief moments of improvements

what is circumlaryngeal massage (CLM)?

circular motion over the tips of the hyoid bone thyrohyoid space posterior border of the thyroid c. medial and lateral suprahyoid m. (stretching of muscle, lengthening, and reduced tension) -if push or pull larynx in a certain way, respond much faster -a little bit of change in tension can produce a big diff. in voice

why is determining the contribution of dysregulated laryngeal muscle activity important?

critical to proper diagnosis and selection of appropriate treatments -avoid unnecessary medical or surgical management

whats the primary (proximal) cause of voice disturbance in "primary" muscle tension dysphonia "MTD-1)?

dysregulated activity of the intrinsic and extrinsic laryngeal muscles

when should manual laryngeal reposturing techniques be considered with mutational falsetto?

early in the treatment

examples of manual circumlaryngeal techniques

focal palpation manual laryngeal reposturing maneuvers circumlaryngeal massage

MF=____ voice disorder =

functional voice disorder = absence of structural or neurological pathology

mutational falsetto dominant feature?

high pitch

what was found after treatment?

improvement of vowel-space area -seemed to be spreading effects to articulation -something similar to tension that exists, constraints are being applied to all aspects of the vocal tract -

what can circumlaryngeal techniques help with?

knowing the extent to which disordered voice is due to muscle tension

how long did most the relapses last?

less than 3-4 days -majority of relapse resolved by itself

mutational falsetto primarily occurs in (male or female)

males

what are manual circumlaryngeal techniques?

manual: use your hands circumlaryngeal: around the larynx

laryngeal reposturing #3 medial compression and downward traction is used for patients who?

medial compression and downward traction with most pressure directed over posterior aspect of thyroid cartilage (& within thyrohyoid space) -non-adducted hyperfunction aka hypofunction of the voice (recruiting muscles that will keep the vocal folds apart) f

_____ practice is an important component to assist in mastery, transfer, and maintenance of improved voice

negative

certain subgroups of patients to be cautious about

older arthritic cardiovascular disease anterior neck surgery diagnoses need to exercise caution for

negative practice tells us larynx resopnds to signals from

our brain -neurosensory feedback loop in the brain to get them closer to better production -patients may be vulnerable for relapse (path in brain) -is the discomfort an outcome of talking in a certain way? -is the tension contributing to voice disturbance or an outcome of their voice disturbance (it could be an outcome because these folkies can switch voices) -critically important: informs you about nature and helps them with mastery! :)

what would dr. roy recommend for everybdoy?

palpation reposturing (patients who can't sustain improvements could go to massage. if patients arent responding the way we want but convinced they have the capacity)

Observe Voice Effect of Laryngeal Resposturing (#2) -pull down maneuever

patient is vocalizing and want to apply downward traction in thyrohyoid space by applying traction on superior border of thyroid cartilage --impede laryngeal elevation

negative practice (self-efficacy)

patient quickly alternates between disordered voice and normal voice instills a sense of mastery clinician provides anchoring techniques to reestablish normal voice (a lot of patients will have 2 programs in their brain--1 for disordered voice and 1 for good vocie) want to help patient feel sense of control over their voice--want clinician to go back to disordered voice and know how to fix themselves

What's negative practice?

patient simulates disordered voice--important for patient to get a sense of mastery

muscle tension dysphagia

people who might have swallowing problems due to muscle tension

what does to palpate the larynx mean?

physically use your hands -see if there's any evidence of excess of muscle activity -can come about by tenderness (dull aching or intense pain where patient will wince or withdraw In response to palpation) -tense muscle will not be easy to move (mobility of the larynx) -muscle nodularity (nodes inside of neck. sensitive to touch. can be in context of taut m. - muscles that are actively contracting. tautness feels stiff. -extent of laryngeal elevation: is the larynx and hyoid held in an elevated position?

what's another reposturing maneuver?

pull down place hands in thyrohyoid space

last reposturing maneuever

pull down and squeeze

what's the first reposturing maneuver?

push back on the hyoid -patient needs to be vocalizing

main thing trying to do mutational falsetto

release the larynx -get a degree of shortening of vocal fold by perturbing the larynx -pushback in and down is helpful for mutational falsetto

pMTD are patients who are free of

structural or neurological pathology

Basic principles of CLM locate sites of focal ____, ____ ,&_______ progress from ___ to ____ pressure vary according to ____ of patient patient _____ concurrently increase ___ of voice stimuli

tenderness, nodularity, tautness superficial to deep tolerance vocalizes complexity

what's a pivotal point for the larynx?

the hyoid bone -wherever the hyoid goes the larynx follows -balancing point for the larynx-can be impacted by suprahyoid muscles, infrahyoid muscles, or some combination hyoid: imp. sweet spot within the larynx -want to do something to hyoid to reposture (interfere with any muscle activity being imposed on the hyoid)

why are a lot of patients stuck?

they're active in the way they're recruiting muscles -a lot of patients didn't need massage but needed to reset their system

what do we do with the hyoid "push back" technique

vary height and pressure, I.e. suprahyoid (BOT), hyoid, infrahyoid, T-H space, thyroid notch, and thyroid prominence apply pressure above, on, and slightly below (patient is vocalizing)

how long does it take to see effects of manual circumlaryngeal techniques?

video examples: can see major improvements in the same exact session

what is mutational falsetto (MF)?

voice mutation in males occurs over a 6 to 12 month period and is typically completed by 15 years of age -failure of male high pitched preadolescent voice to transition to lower pitch of adolescence and adulthood -AKA puberphonia, adolescent voice, adolescent transitional, dysphonia, persistent falsetto, incomplete voice mutation, pubescent falsetto

in circumlaryngeal massage, make sure patient

voices how we see if patient benefits from massage or reposturing

why do we just want them to say "ah" while we're talking to them?

we don't want them to go back to their old voice--they have to practice better voice and attend to it

otehr features of mutational falsetto?

weak, thin, breathy, hoarse, effeminate, immature voice with inadequate resonance -frequent voice cracks and/or pitch breaks -only high pitch voice may be present or mixed high/low pattern (large pitch breaks) -left untreated, MF can become chronic and persist into adulthood

what's the calibrated amount of pressure during palpation?

when fingernail begins to blanch (whitening on tip)

when should we do focal palpation?

when patient is at rest -also contrast to when patient is producing voice -check passive range of motion of limb and sometimes there will be resistance (passing tone of muscle) -can check passive range of larynx by trying to move side to side when at rest -in some cases patients produce a lot tension when producing voice and recruit a whole bunch of muscle activity

what is stimulability testing?

whether the patient has the capacity to produce a better sound in voice where can they get the complexity in the diagnostic session