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National Voice Meeting 2018 – Presenter Series #3

What is Vocal Massage and could it be helpful for patients with Voice Disorders?

Vocal massage is designed to give a ‘reset’ of the muscles involved in posture and vocalization to help maintain (or help re-establish) healthy voice production. It is also increasingly being investigated as a way to decrease pain and tension from excessive contraction of the extrinsic muscles of the larynx (as found in voice disorders such as Muscle Tension Dysphonia) (Dehqan & Scherer, 2008). Vocal Massage is also starting to be used as part of a holistic treatment plan established by an ENT and Speech Pathologist by Voice centres such as the Cleveland Clinic, Vanderbilt Voice Clinic, and the Royal Throat, Nose and Ear Hospital in London.

A way to improve posture and prevent vocal problems

Singing and speaking well require a freedom and balance in the muscles around the larynx and jaw and a buoyant, free posture for the breath. A number of articles have illuminated the way in which good posture, particularly of the cervical spine, is directly related to higher levels of vocal resonance and pitch control (Arboleda & Frederick, 2008). Cardoso, Lumini-Oliveira, and Meneses (2017) have proven an effective posture allows a subject to more easily shift the tension between muscles, allowing for a free movement of the larynx without blockages and with benefits to voice production. In a study by Kooijman (2005), muscular tension and body posture were assessed in relation to voice handicap and voice quality in teachers with persistent voice complaints- the conclusion was the combination of hypertonicity of the sternocleidomastoid, the geniohyoid muscles and posterior weight bearing…[were] the most important predictor for a high voice handicap. Manual bodywork such as Vocal massage combined with rehabilitative exercises may be the way forward in helping some patients recover from a vocal disorder by addressing the body patterns contributing to the tightness in these muscles. Unfortunately, comprehensive studies on the long-term benefits of this have not yet been undertaken.

A Vocal Massage Session

The first component of a Vocal Massage is postural assessment and palpation of the area around the neck and jaw to establish if restrictions in the muscles may be affecting the patient’s ability to supply breath efficiently to the voice and vocalize well. The larynx and hyoid bone are gently assessed to establish if they are in a free, neutral position, range of motion of the jaw and head will be tested, and the therapist will check if the ribs and diaphragm are mobile and the posture is balanced. A treatment plan is then developed specific to the patient’s needs, which may include alleviating tension around the front of the neck and jaw, mobilizing the hyoid bone and larynx and addressing postural issues affecting the freedom of the breath. Myofascial techniques are used which include gentle tractioning of the muscles, trigger point work and stretches that may help reduce tension in the muscles.

May help improve respiratory function

We know that manual therapy appears to increase the respiratory function of normal individuals (Engel & Vemulpad, 2007), but more research needs to be undertaken to see if manual therapy could be helpful to those with inhibited respiratory function and voice disorders (da Cunha Pereira, de Oliveira Lemos, Gadenz, Cassol, 2017). Anecdotally many of my clients have found massage helpful after a respiratory illness such as a cough to alleviate tension and stiffness around the larynx and have found their voice more resonant and responsive after the massage session. Myofascial release techniques in this instance are used on the sternocleidomastoid and scalene muscles combined with gentle mobilization of the intercostal muscles, diaphragm attachment points and the ribcage to help free the breathing mechanism.

Countering the physical demands of workplaces- particularly for stage performers

Stage workplaces major demands on a singer’s body. Raked stages, very heavy or tight costumes, wigs, hats and high heels can all throw the alignment of the posture out and tense muscles involved in vocalisation. It can also mean the singer adjusts the position of their pelvis and neck. These adjustments may affect the singer’s capability for full breath capacity and best breath management (Staes, et al., 2011). Vocal massage used as a preventative measure to help a build-up of tension may help bring more balance back to the body and keep a voice fresh and healthy.

A study examining the effectiveness of Vocal Massage in relation to Reflux

While much more research needs to be undertaken, in a recent study by Gaelyn Garrett, M.D., and Duke researcher Seth Cohen, M.D. at the Vanderbilt Voice Institute (Cohen & Garrett, 2008) it was found that around 67 per cent of patients who had hoarseness over a six-month period were either on reflux medication or had been prescribed reflux medication without improvement. Two-thirds of those patients improved with specialized manual therapy aimed at muscle tightness of the neck and throat. “Medical Director Gaelyn Garrett, M.D., and her staff of speech-language pathologists had previously treated the condition with voice therapy alone for the muscles around the larynx, which include the swallowing muscles. Some patients, however, did not respond to only doing voice therapy.” “In these people who weren’t responding, we started asking a lot of questions about their daily habits and we started realizing that people talk on the phone and it affects their posture; people are at a computer and it affects their posture,” Garrett said. It was also found that typically these patients had experienced some kind of physical or emotional trauma which had begun a process of excess tension throughout the body “… they were in a car wreck, they went through a divorce, they had back surgery” (Cohen & Garrett, 2008). Cohen and Garrett (2008) report how a more holistic view revealed other causes of tension: “And you start asking people, too, about where they focus stress and if they have any cervical spine issues, neck or shoulder issues, tension headaches. It all fell in place that if we address this whole musculoskeletal area, from the backup, it would help patients relax their voice,” she said. In conclusion, while anecdotally vocal massage helps certain patients and small studies have proven its effectiveness (Rubin, Lieberman, & Harris, 2000), more comprehensive studies are needed to establish the long-term effects and benefits, the type of patient it might help and how it might be best implemented in a multidisciplinary setting.

References

Arboleda, B. M. W., & Frederick, A. L. (2008). Considerations for maintenance of postural alignment for voice production. Journal of Voice, 22(1), 90-99.

Cardoso, R., Lumini-Oliveira, J., & Meneses, R. F. (2017). Associations between Posture, Voice, and Dysphonia: A Systematic Review. Journal of Voice.

Cohen, S. M., & Garrett, C. G. (2008). Hoarseness: is it really laryngopharyngeal reflux? The Laryngoscope, 118(2), 363-366.

da Cunha Pereira, G., de Oliveira Lemos, I., Gadenz, C. D., & Cassol, M. (2017). Effects of voice therapy on muscle tension dysphonia: a systematic literature review. Journal of Voice.

Dehqan, A., & Scherer, R. C. (2018). Positive Effects of Manual Circumlaryngeal Therapy in the Treatment of Muscle Tension Dysphonia (MTD): Long Term Treatment Outcomes. Journal of Voice.

Engel, R. M., & Vemulpad, S. (2007). The effect of combining manual therapy with exercise on the respiratory function of normal individuals: a randomized control trial. Journal of Manipulative and Physiological Therapeutics, 30(7), 509-513.

Kooijman, P. G. C., De Jong, F. I. C. R. S., Oudes, M. J., Huinck, W., Van Acht, H., & Graamans, K. (2005). Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints. Folia Phoniatrica et Logopaedica, 57(3), 134-147.

Rubin, J. S., Lieberman, J., & Harris, T. M. (2000). Laryngeal manipulation. Otolaryngologic Clinics of North America, 33(5), 1017-1034.

Staes, F. F., Jansen, L., Vilette, A., Coveliers, Y., Daniels, K., & Decoster, W. (2011). Physical therapy as a means to optimize posture and voice parameters in student classical singers: a case report. Journal of Voice, 25(3), e91-e101.

To contact Rachael about Vocal Massage please email her at rachael@vocalease.com.au

Rachael Cunningham is a Vocal Massage Therapist in Sydney. She is a qualified Remedial Massage therapist and has undertaken extensive training in myofascial techniques for the Neck, Jaw and Head and Vocal Massage. Rachael is also very aware of demands placed upon singers in the performing arts as she has sung in the chorus of Opera Australia for the past 20 years. Currently she is performing in Aida at the Sydney Opera House and is about to travel to China to tour with Madama Butterfly. Her website is www.vocaleasemassage.com.au

“Unless stated otherwise, this article represents only the views of the author and not the views of the AVA”

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National Voice Meeting 2018 – Presenter Series #2

The Australian Voice Association

By Cecilia Pemberton

I am very much looking forward to returning to Adelaide to present at the 2018 Australian Voice Association’s National Voice Meeting: Voice on! The Road to Recovery.

It is interesting to reflect how far the AVA has come, since the Inaugural Voice Symposium was held in Adelaide in May 1991 at the Queen Elizabeth Hospital. I was on the organising committee for that symposium along with Alison Russell, Jan Baker, David Close and Alison Bagnall.

The Keynote speaker was Dr Robert Bastian, then Professor of Otolaryngology at Loyola University School of Medicine, Washington. He is the Founder and President of the Bastian Voice Institute. Professor Bastian’s interests in the field of laryngology encompassed both voice and swallowing with a special interest in the needs of professional voice users. What a wonderful choice of speaker he was, so generous in his knowledge and time. He had an infectious enthusiasm for the idea of collaboration of all the professionals interested in voice.

As a committee we were impecunious, but Professor Bastian generously agreed to present with no remuneration. We were indeed very fortunate. He was so encouraging of our endeavours not only for the symposium but also to build an association to foster collaboration.  We did of course have some anxious moments, especially as we were spending money we didn’t actually have and weren’t sure anyone would attend! We were soon rewarded when registration opened, the response was overwhelming. We quickly broke even and had soon made a profit.  200 delegates attended that inaugural symposium; speech pathologists, ENTs, teachers of singing and voice coaches.

The success of the symposium was the impetus for the formation of the AVA. By the end of 1991, Alison Russell, Jan Baker and I had established the AVA with a charter to foster collaboration between all voice professionals in the education, research and care of voice users.

The financial success of the inaugural symposium meant that, from then on, seeding funds were available for future AVA organising committees.

So it is, many successful symposia later, that the current AVA committee have put together a very exciting, diverse programme which will encompass care and rehabilitation of the singing and spoken voice in both the adult and paediatric fields.

We are so fortunate to have Leda Scearce as the keynote speaker. I recently watched an interview that Liz Johnson Schafer did of Leda as part of “Interviews on Voice Matters”. Leda talks about her background as a professional singer before retraining as a speech pathologist and also her philosophy for the rehabilitation of the singing voice. I highly recommend watching the video https//you.be/0bpwU-Fjr50 .

I also saw a webinar of Leda presenting as part of the 2018 Performance Voice Conference at The University of Utah, Voice Disorders Centre. Leda ran a very successful master class. It was so interesting to see her at work with some young singers. I’m sure she will be a treat to have at the 2018 AVA National Voice Meeting.

Also on the programme this year is Nicole Free. For those of you who don’t know Nicole, check out her 3-minute thesis: https://youtu.be/3ebmlZbJgcQ. She is now through to the Asia Pacific finals.

I look forward to seeing you in Adelaide.

Also on the programme this year is Nicole Free. For those of you who don’t know Nicole, check out her 3-minute thesis: https://youtu.be/3ebmlZbJgcQ. She is now through to the Asia Pacific finals.

Cecilia Pemberton is a speech pathologist in her private practice, Voice Care

Australia and at the Voice Assessment Centre at St Vincent’s Clinic, Sydney. In 1991, she co-founded the Australian Voice Association after the Inaugural Australian Voice Symposium in Adelaide.
Her research has covered the normative data for endoscopic examination of the larynx, changes in speaking fundamental frequency in women’s voice with age and intergenerational and most recently the effectiveness of prevention and early intervention programmes for voice problems in teachers. Cecilia is co-author of Voice Care for Teachers DVD.

In 2009 she was awarded Fellowship by Speech Pathology Australia for her contribution to the profession. Her voice care programme for teachers with the Catholic Education Diocese of Wollongong has been a finalist in both the NSW Safe Work Awards (2009) and the Australian Human Resources Institute, Martin Seligman Award for Health and Wellbeing (2015). In 2014 she won the British Voice Association Van Lawrence Prize for her paper “Efficiently and Cost Effectively Managing Teachers’ Voice Problems”.

To register for the AVA National Voice Meeting and AGM 2018 click here:

“Unless stated otherwise, this article represents only the views of the author and not the views of the AVA”