Jaime Angus, BMR (PT) & Lisa Mills-Hutton, B.Comm(Hons), BMR (PT)
Physiotherapists at Donna Sarna Physiotherapy & Rehabilitation in Winnipeg, Manitoba
“One day, you’re a high school English teacher, and then you get laryngitis and lose your voice for two weeks. The laryngitis is gone (or so you think) so you go back to work, but your voice is raspy and quite like a whisper. Your voice continues to cut out and by the end of the teaching day you have no voice left. Not a very successful first day back to work as an English teacher. You quickly return to your doctor to check if you have another infection. After some testing and a few referrals you are diagnosed with muscle tension dysphonia….”
As physiotherapists, it is always intriguing where our career and clinical direction will take us. The above story was from the first patient who was referred to us with this condition. A few years ago, Donna Sarna Physiotherapy started getting referrals from a local Speech-Language Pathologist (SLP) to provide myofascial release, breathing exercises and posture exercises to individuals who had Muscle Tension Dysphonia. The referral was part of a team approach with a Physician
and Speech-Language Pathologist (SLP) to developing a comprehensive treatment plan.
What is Muscle Tension Dysphonia (MTD)?
MTD is a change in the sound or the feel of the voice due to excessive muscle tension in and around the voice box. This tension prevents the voice from working efficiently. MTD is a pattern of muscle use that can develop during laryngitis and remain even after swelling of the vocal cords has gone. It can also be caused bystress, overuse and can co-occur with other diagnoses. Voice disorders are most commonly seen in individuals who have high vocal demands at work, such as teachers, singers, call centre employees and public speakers.
Some Signs and Symptoms a Patient May Report:
MTD generally causes the voice to sound:
Like a whisper
Other symptoms may include a voice that suddenly cuts out, breaks off, changes pitch, or fades away; a voice that "gives out" or becomes weaker the longer the voice is used. Patients may also feel pain or tension in the throat when speaking or singing, and feeling like the throat is tired when speaking or singing.
Physiological Changes That Occur
Increased muscle tension in the anterior neck and throat muscles
Restriction of cervical range of motion
Reduced voice quality
Reduced volume production
Larynx and hyoid bone are often elevated
Development of muscle imbalances, poor posture and stress 1,2
What is the Physiotherapist’s Role as Part of the Team Approach?
As physiotherapists, we consider one of our key roles as being movement detectives. What is moving and what is not moving, and why? In MTD the common picture is that the posture is less than ideal, muscles of the anterior neck and throat are tight with subsequent weakness in cervical stabilizers and scapular stabilizers. This muscle imbalance creates restrictions on the hyoid bone, jaw, cervical spine and scapula. If postural control is inadequate, then we might see decreased ability to take a deep breath as well as the alignment of the pelvis, thorax and neck and head affected. Hopefully you are starting to paint a picture on the role of the physiotherapists in MTD. Relax some muscles, strengthen others, and improve postural control and education on breathing and relaxation. As with any diagnosis, no patient follows the exact textbook pattern and many other areas need to be explored by the physiotherapist for successful patient outcomes.
Back to the patient story
The high school teacher’s examination revealed many findings. Some key items included:
Head forward posture
Inability to take a deep breath into lower lobes of lungs
Taut musculature of pectoralis major, scalenes, supra and infrahyoid, digastrics
Restricted hyoid bone
Globally weak core stabilizers of the trunk and neck
Is There Any Research or Literature on the Physiotherapy Role in MTD?
Recent research out of the Vanderbilt Voice Centre in Nashville, TN has demonstrated the positive effects of myofascial release on patients including singers, teachers, public speakers and call center employees with a diagnosis of MTD. The Vanderbilt study examined referral patients with hoarseness over a six-month period. They found that two-thirds of the patients improved with specialized therapy aimed mainly at muscle tightness of the neck and throat. The specialized therapy consisted of myofascial release, self-release techniques, posture exercises and stretches.3
Another case study in Poland examined 40 teachers with MTD aged 39-59. Their multi-disciplinary intervention included intensive voice rehabilitation carried out by a speech-language pathologists and osteopathic therapists doing voice production exercises, relaxation, aerobic activities and a variety of osteopathic myofascial techniques. The study found that the use of myofascial release therapy helped to significantly improve the functions of the vocal tract in patients with occupational dysphonia.4
What is The Treatment Plan?
Based on the research and from clinical experience, the myofascial release technique has shown to work well. Myofascial release was utilized to address the tight muscles around the neck and hyoid, as well as the postural muscles that effect vocal quality and projection. Myofascial release is a hands-on technique that involves applying gentle sustained pressure into the myofascial connective tissue restrictions. This process can help to eliminate pain and restrictions and ultimately to restore motion.
In combination with myofascial release, physiotherapists should address posture and strength to ensure optimal positioning of the diaphragm, rib cage, throat and head. Wherever appropriate, we use a team approach to work with other health care professionals including doctors, massage therapists, vocal coaches and speech-language pathologists.
Brief treatment plan for the high school teacher:
The plan was to see the patient once a week for eight weeks. Treatment consisted of myofascial release, postural awareness and exercises, home myofascial release stretches and a Pilates-based core and scapular stabilization program. The patient was also referred to an instructor for private Pilates reformer work.
The patient saw a speech-language pathologist (SLP) every second week to work on vocal quality, vocal projection and vocal hygiene. The physician was informed of progress and monitored the patients overall health. The patient was given a microphone to use while teaching for two months until sufficient progress was achieved. The patient has returned to teaching full time with no complaints of vocal issues. The patient continues with the private Pilates reformer sessions, but has been discharged from physiotherapy and SLP with a home program.
Since that first referral from the SLP, treatment has been provided to dozens of patients. In April 2016, Donna Sarna Physiotherapy was invited to present a half day workshop at the annual conference for the College of Audiologists and Speech-Language Pathologists of Manitoba. This area of practice is not somewhere any of us would have predicated our career would lead us to. With further post graduate training in myofascial release, cranial sacral therapy and visceral mobilization; and reading as much literature as possible we have been able to get many people back to work and talking!
If you are interested in this area of practice be sure to read the literature below and team up with a speech-language pathologist to learn as much as you can about MTD. We highly recommend taking several courses from John Barnes on myofascial release and cranialsacral therapy by the Upledger Institute. We also suggest connecting with the Vanderbilt Voice Centre in Nashville, TN.
1. The John Hopkins University. Muscle Tension Dysphonia: What You Need to Know. Retrieved from http://www.hopkinsmedicine.org/otolaryngology/specialty_areas/voice_center/conditions/muscle_tension_dysphonia.html.
2. Van Houte, E., Van Lierde, K., Claeys, S. (2009). Pathophysiology and Treatment of Muscle Tension Dysphonia: A review of Current Knowledge. Journal of Voice, 25(2), 202-207.
3. Tomilson, C., Archer, K. (2014). Manual Therapy and Exercise to Improve Outcomes in Patients with Muscle Tension Dysphonia: A case series. Journal of the American Physical Therapy Association, 95(1), 117-128.
4. Marszalek S., Niebudek-Bogusz, E., Woznicka, E., Malinska, J., Golusinska, W., Sliwinska-Kowalska, M. (2012). Assessment of the Influence of Osteopathic Myofascial Techniques on Normalization of the Vocal Tract Functions in Patients with Occupational Dysphonia. International Journal of Occupational Medicine and Environmental Health, 225-235
5. McLean, L. (2005). The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Journal of Electromyography and Kinesiology, 15, 527-535.
6. Roy, N., Bless, D., Heisy, D., Ford, C. (1997). Manual Circumlaryngeal Therapy for Functional Dysphonia: An evaluation of short and long term treatment outcomes. Journal of Voice, 11(3), 321-331.
7. Rubin, S., Blake, E., Mathieson, L., (2005). Musculoskeletal Patterns in Patients with Voice Disorders. Journal of Voice, 21(4), 477-484.
Jaime Angus, BMR (PT)
Jaime graduated from the University of Manitoba in 2000 with a Bachelor of Medical Rehabilitation in Physiotherapy. She has completed course work in the management of incontinence, pelvic pain disorders, pelvic organ prolapse, prenatal and postpartum health and fitness as well as post-mastectomy care. She has also undergone extensive training in the areas of myofascial release, visceral manipulation and acupuncture. Combining Jaime’s training in myofascial release, cranial sacral therapy and Pilates she has taken an interest in working with individuals with vocal disorders secondary to muscle tension or scar tissue.
Lisa Mills-Hutton, B.Comm (Hons), BMR (PT)
Lisa graduated from the University of Manitoba in 2009 with a Bachelor of Medical Rehabilitation in Physiotherapy. She is certified in acupuncture and has taken several post-graduate courses in myofascial release, cranial sacral therapy, acupuncture, movement dysfunction, neurological rehabilitation and chronic pain management. Working with several speech-language pathologists and vocal coaches Lisa has enjoyed combining her myofascial release, Pilates and exercise knowledge to provide a team treatment approach for individuals with vocal disorders and post-surgical neck and throat scar tissue.