Manual Voice Therapy

Professional voice users are very familiar with the symptom of voice fatigue. This can be described as

• Achiness
• The feeling of something stuck in the throat/globus sensation
• Soreness in the throat

It is so common that some may consider it a normal feeling. Singers may expect this feeling after a performance or tour. Other professions with heavy voice use, such as teachers and lawyers, regularly feel the need to stop talking after work due to the discomfort in their throat. 

Why does my voice hurt? Why does it feel tight? 

Voice production is a muscular task. It requires the coordination of many muscle groups. There are tiny groups of muscles in the larynx (voice box), which are the final step in producing voice. The tiny laryngeal muscles have a maximum ability. Like any other muscle in the body, there is a point after which it becomes fatiguing to continue to use the vocal muscles. However, unlike other muscles, because we need our vocal system to communicate, we can, and often do, push our laryngeal muscles past their natural limitations. This results in the recruitment of compensatory muscles. Rather than primarily using the tiny laryngeal vocal muscles, which are designed for the purpose of vocalization, we use other muscles. These other muscles compensate for the fatigued vocal muscles. However, because they are not designed for vocalization, they are poorly designed for that task. This results in discomfort, misalignment or chronically inefficient voice use. Chronic inefficiency comes about when the body has “learned” a compensatory muscle use pattern and relies on this predominantly rather than a normal, healthful production pattern. Once the voice is pushed past its natural limitations and compensatory muscle use starts, it can be difficult for the body to undo this. Ligaments and fascia can shorten and tighten. It is often difficult for the patient to relax this again and restore healthful voice. Because these muscles are in the neck and encircle the throat, tightness produces symptoms of a sore throat, achy throat, voice fatigue, or painful voice use. Singers commonly exhibit this because their voice use is so extreme. Even the most trained singer will have to push the voice past its natural limitations at some point. This may be singing when you have a cold, working the extremes of your range, having inadequate monitors to hear yourself, singing 8 shows a week… the list goes on because singing puts such high demand on the larynx that the tipping point is easy to reach. Most singers have some muscular inefficiency because of this. When muscular health is restored, efficiency increases and nearly all singers note improvement in vocal quality, range, and sensation. 

What symptoms occur when there is muscular compensation of the voice? 

The earliest symptoms are due to voice fatigue. These include:

• Tiring after a shorter period of time
• An achy feeling during singing
• Achiness or pain after singing

As more time passes without diagnosis and treatment, symptoms will worsen:

• Loss of vocal range, particularly at the top of the range
• Wider vocal break
• Pain while singing
• Discomfort with swallowing
• Need for voice rest

Why does tightness occur? Tightness most commonly occurs when the voice is used past its natural limitations. This is most common when the voice’s capacity is diminished. The voice’s capacity can be lowered by:

• Illness (upper respiratory illness, a cold)
• Smoking
• Previous significant voice use (i.e., singing the night before)
• Other inflammatory conditions of the larynx

Tightness can also occur with stressors and anxiety. This as a form of laryngeal protectiveness. Any event can put the larynx into a state of protectiveness that needs manipulation to correct and relax the larynx. Voice artists in particular seem to manifest stress and anxiety around the larynx. Many singers have voice symptoms after a stressful event, such as a breakup, car accident, contract negotiations, etc. Similar to how some will develop tightness in the shoulders or heartburn when they experience stress, singers often get laryngeal tightness. This results in:

• Voice fatigue
• Loss of vocal range
• Loss of resonance
• Pain with singing
• Prolonged hoarseness
• Increased effort of projection and voice production

How does it work?

The larynx is surrounded by numerous muscles that provide anchoring, support, and mobility. As seen in the above picture, the three major laryngeal structures are the hyoid bone, the thyroid cartilage, and the cricoid cartilage. Numerous muscles and ligaments attach to these structures. At any of these points of attachment, a voice user may have a problem. The location of symptoms is extremely individual, as each person will compensate in a different way. By manually releasing each individual person’s target area, symptoms of vocal fatigue, inefficiency, and discomfort will decrease. Manual therapy works in many ways that are not fully understood. Release may be due to relaxation of the fascia around a muscle, the release of neurochemicals, the release of scar tissue, or other mechanisms. While it is not clear why these methods work, relief occurs quite quickly when done correctly. When alignment improves and the primary vocal muscle use pattern is restored, the professional voice user will notice this. They will feel and sing better. 

What is manual therapy? 

Manual therapy is an approach used to release tension around the larynx and restore functionality. We use several techniques, customizing the care to the problems that are identified. This may include myofascial release, manual adjustment, and massage according to the needs of the patient. The vocal system includes the laryngeal muscles as well as the muscles of the neck, chest, back, and abdomen. Therefore, any of these muscles and their ligaments may require manual therapy to alleviate tension and discomfort. 

Will symptoms recur after manual therapy? 

Manual treatments works on the idea that the muscles have tightened and engaged in a suboptimal or inefficient way. This can happen any time the larynx is put through a strenuous period. This can include a cold, going on tour, or a stressful life event. Muscular tension will develop in different places for different people but artists often have muscular tension develop in muscles in and around the throat. Some patients respond very well to one session, and only need one treatment. Most, however, will require periodic treatment as stressors occur. For example, the touring performer will often require a session after each tour. Treatment is individualized and can be discussed with the patient to find the right balance between treatment frequency and self-sufficiency. Stretches and other techniques will also be taught to the patient to encourage self-reliance. 

Why does this technique work? 

The science behind why myofascial techniques work is not definitive. There is significant evidence that simply laying hands on a patient has a therapeutic effect. However, prolonged gentle pressure in specific locations can result in significant relaxation of muscular tension and patient perception of pain. The singer relies on their muscles to do their job. Similar to how an athlete will need occasional manual therapy, including stretching, pressure, and myofascial release, singers need mobilization with careful targeting of zones of laryngeal compensation. Treatment of primary and surrounding muscles is used to relax the primary movers and alleviate pain. Is it painful? Most patients who undergo manual therapy do not experience pain. The techniques that are incorporated are designed to take patients to a point of awareness without overpowering them with pain. However, given the proven effect of the mind on the body, some will experience the technique as pain. The underlying principle is that the brain must process the sensation of pressure and determine that it not necessary to feel pain at that site. Leaving the hands in place for a longer time allows for that processing so that what might begin as a pain sensation will resolve. By communicating throughout the procedure, it is simple to avoid complications and worsening. The procedure can be terminated at any point if the patient feels it is not helping. 

How do I know if I need manual therapy? 

When the voice is not working, there are many symptoms that may occur, including

• Loss of vocal range
• Voice fatigue: not being able to sing for as long
• Discomfort or pain while singing or afterwards
• Prolonged recovery time
• Hoarseness

Singers live in fear of these symptoms, attributing them to nodules or some other organic vocal cord injury. However these symptoms may also occur in patients with muscular injury of the larynx. The only way to ensure you need laryngeal mobilization is to have an evaluation with a laryngologist. Through careful analysis of your history, voice, and videostroboscopy, the need for manual therapy will be assessed. This consultation is lengthy and should include a rigid scope in the mouth (not the nose) to assess the vocal folds carefully. It is of vital importance that a singer not have manual therapy prior to a laryngology evaluation. It is common for vocal cord injury to be missed by others who care for the voice in their haste to start manual therapy. In this way, the singer’s undiagnosed injury will progress while an essentially useless manual technique is performed. After clearance for manual therapy, you will receive a treatment plan to determine what is needed. Most patients experience significant benefit within 1-2 sessions.