Photobiomodulation on vocal training and rehabilitation: Delphi consensus based on experts

Pontes, Emerson Soares; Vaiano, Thays Garcia; Bastos, Roberto Sávio de Assunção; Duarte, João Marcos da Trindade; Santana, Émile Rocha; Lopes, Leonardo Wanderley

doi:10.1590/2317-1782/e20230356pt

person Emerson Soares Pontes

conceptualization · methodology · project administration · formal analysis

schoolUniversidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.

0000-0002-8455-016X

person Thays Garcia Vaiano

conceptualization · methodology · project administration · formal analysis

schoolCentro de Estudos da Voz – CEV - São Paulo (SP), Brasil.

0000-0003-2169-2723

person Roberto Sávio de Assunção Bastos

conceptualization · revision · editing of the article

schoolHospital Pronto Socorro Municipal Mário Pinotto - Belém (PA), Brasil.

0000-0002-3120-9160

person João Marcos da Trindade Duarte

formal analysis · review · editing of the article

schoolUniversidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.

0000-0003-0073-818X

person Émile Rocha Santana

formal analysis · review · editing of the article

schoolUniversidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.schoolUniversidade do Estado da Bahia – UNEB - Salvador (BA), Brasil.

0000-0002-0588-7902

person Leonardo Wanderley Lopes

conceptualization · methodology · project administration · formal analysis

schoolUniversidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.

0000-0001-9041-7114

Conflict of interests: nothing to declare.

Correspondence address: Leonardo Wanderley Lopes Departamento de Fonoaudiologia, Centro de Ciências da Saúde, Universidade Federal da Paraíba – UFPB, Cidade Universitária, Campus I, Castelo Branco, João Pessoa (PB), Brasil, CEP: 58051-900. E-mail:
lwlopes@hotmail.com

Variable	N	%
SEX
Females	06	86
Males	1	14
AGE RANGE
31-40 years	2	33
41-50 years	4	45
41-50 years	1	22
51-60 years
TIME IN THE PROFESSION
10-20 years	2	28.6
20-30 years	5	71.4
STATE WHERE THEY WORK AS A SPEECH-LANGUAGE-HEARING PATHOLOGIST
São Paulo	2	28.57
Minas Gerais	1	14.28
Bahia	1	14.28
Pernambuco	1	14.28
Paraná	1	14.28
Goiás	1	14.28
EDUCATION LEVEL
Specialization	1	22
Master’s degree	4	45
Doctoral degree	2	33
SPEECH-LANGUAGE-HEARING PROFESSOR
Teaches postgraduate programs	7	100
Total	7	100.0

Question 1 PBM is a therapeutic procedure for habilitation and rehabilitation that has been studied and reviewed in the academic field, as it holds the power of biostimulation. In general, what benefits and advances has PBM brought to Speech Therapy and to the voice area?	Determine PBM advances specifically for the Voice area.
Question 2 One of the goals of vocal therapy is to modify/manage an individual's vocal behavior and develop functional muscular adjustments adapted to the patient's vocal demands. Do you often use PBM in your clinical practice in the area of voice? In which cases do you generally use PBM the most?	Highlight the use of PBM in the Voice area.
Question 3 CFFa resolution no. 541, of March 15, 2019, provides for the use of the Low-Intensity Laser device as a therapeutic device associated with conventional clinical speech-language pathology procedures, and can be used for speech-language pathology purposes. Given this prerogative, is PBM indicated for the voice area? Have you completed any training/qualification on PBM in Speech-Language Pathology with clinical parameters in the voice area? Respectively, what would the pre-practice (requirements) be for the recommendation and application of PBM in the voice area?	Denote the indication of PBM for speech therapy practice, and the prerequisites for use in the Voice area.
Question 4 Voice disorders are multidimensional and may be caused by behavioral or organic factors, or a combination of these. They represent any difficulty in vocal emission that prevents the voice from fulfilling its purpose, which is to transmit the individual's verbal and emotional message. I would like to consider three major groups of dysphonia here: behavioral dysphonia without laryngeal injury; behavioral dysphonia with laryngeal injury; and organic dysphonia. Considering these conditions, where have you used PBM most frequently?	List the cases in which the use of PBM can bring more results.
Question 5 Some studies show that speech therapy is the treatment of choice for dysphonia, especially those related to vocal behavior. The key steps for a positive treatment outcome should include guidance, awareness, and vocal training with specific techniques and exercises. Therefore, I would like to ask two questions related to the use of PBM in vocal rehabilitation: a) at what point in the rehabilitation process do you use PBM: at the beginning of the process (first patient monitoring sessions), as a complementary device to vocal training (exercises), or as an alternative for cases in which vocal training is not achieving the expected results? b) At what point in the session do you use PBM – before, during, or after performing the exercises? What are the criteria for this choice?	Highlight the moment of use of PBM in the therapeutic process.
Question 6 Regarding the use of PBM in dysphonic individuals, we have the experience of clinicians and the self-reporting of positive results from patients, but there is no scientific evidence to support the hypothesis of the effects of PBM on the voice area. What clinical guidelines do you use regarding the recommended dose for patients with inflammatory processes in the VFP? How many points per application are used in the laryngeal region? How is the effect of PBM verified: is any specific task requested before and after? Self-reporting by the client? Acoustics?	To infer which clinical parameters are related to the dose, number of points, and verification of the effect of PBM for dysphonic individuals.
Question 7 The vocal folds have distinct geometry, histology and viscoelasticity, with a complex structure that includes the lamina propria (in three layers) and the thyroarytenoid muscle, which support their biomechanical structure and phonation capacity. Regarding the wavelength, power of action and penetration of PBM, which wavelength do you use most in the larynx region?	Define the wavelength that you consider most appropriate and effective for PBM in the laryngeal region.
Question 8 The larynx is lined with mucous membrane tissue, and its walls are made of connective tissue, muscle, and cartilage. Cartilage provides support and maintains the elasticity of the larynx. According to the PBM clinical guidelines, what is the most commonly used irradiation method in the laryngeal region and what is the most commonly used anatomical site of application in the laryngeal region? Why?	Highlight the method of irradiation of PBM in the laryngeal region and the anatomical site of application.
Question 9 Regarding the use of PBM for vocal improvement/conditioning for voice professionals, studies show that the chromophores sensitized by PBM regulate components of the respiratory chain, altering their redox potential, promoting enzymatic activation and prolonging the biochemical activity of the muscle fiber. What clinical guidelines do you use regarding the recommended dose for patients undergoing vocal improvement/conditioning? I would like to consider two groups of vocal improvement/conditioning – spoken voice and improvement/conditioning – singing voice. Considering these groups, where have you used PBM most frequently? How many points per application are used in the laryngeal region? How is the effect of biomodulation verified: is any specific task requested before and after? Client self-report? Acoustics?	List the cases in which the use of PBM can bring more results. Infer the clinical parameters related to the dose, number of points, and verification of the effect of PBM for vocal improvement/conditioning.
Question 10 At what point in the qualification process do you use PBM for individuals with high vocal performance? At the beginning of the process (first patient monitoring sessions), as a complementary device to vocal training (exercises), or as an alternative for cases in which vocal training is not achieving the expected results? b) At what point in the session do you use PBM – before, during or after the exercises are performed? What are the criteria for this choice?	Outline the moment of use of PBM in the therapeutic process.
Question 11 What irradiation method and anatomical site of application of PBM do you generally use in the laryngeal region for vocal improvement/conditioning? And why?	Identify the method of irradiation of PBM in the laryngeal region and the anatomical site of application.
Question 12 The modified ILIB technique or systemic laser therapy consists of the non-invasive, continuous and indirect application of red therapeutic laser (660nm) in the region of the radial artery, continuously. This absorption by the blood leads to an increase in the metabolism and synthesis of the main physiological protein that regulates the body's oxidative system (superoxide dismutase). This enzyme inhibits the action of reactive oxygen species (ROS), leading to the protection of cells against mutations and aging, thus combating free radicals that are so harmful to health. Do you use the ILIB technique on dysphonic patients? Or for vocal conditioning/improvement?	Check the use of the ILIB technique or systemic laser therapy in the Voice area.

ITEMS
1. – I consider photobiomodulation (PBM) indicated for use in voice.
2. – I apply PBM at the beginning of the vocal rehabilitation process.
3. – I use PBM as a complementary device to vocal training.
4. - I apply PBM as a complementary alternative only in cases where I have limitations in the results obtained using conventional vocal therapy.
5. - I believe that having training/qualification in PBM is essential for its effective use and clinical application in the voice area.
6. - I use PBM on voice professionals without dysphonia.
7. - I only use PBM in cases of vocal improvement.
8. - I use PBM in the vocal rehabilitation of dysphonic patients.
9. - I use PBM in the Voice area to improve the client/patient's muscular performance.
10. - I use PBM in the Voice area to modulate inflammation.
11. - I use PBM with voice professionals to improve muscle performance.
12. - I use PBM with voice professionals to improve muscle recovery.
13. - I use PBM with voice professionals to reduce symptoms of vocal fatigue.
14. - I use PBM in cases of patients with dysphonia due to muscle tension.
15. - I use PBM in cases of patients with laryngeal paralysis.
16. - I use PBM in cases of patients with behavioral dysphonia without laryngeal injury.
17. - I use PBM in cases of patients with behavioral dysphonia with laryngeal injury.
18. - I use PBM in cases of patients with dysphonia of organic origin.
19. - I use PBM in cases of patients with dysphonia of neurological origin.
20. - I use PBM in cases of patients with dysphonia due to sequelae of head and neck cancer.
21. - I use PBM in cases of patients with dysphonia resulting from laryngitis due to laryngopharyngeal reflux.
22. - I use PBM in the laryngeal region before performing vocal exercises.
23. - I use PBM in the laryngeal region during vocal exercises.
24. - I use PBM in the laryngeal region after performing vocal exercises.
25. - I use infrared wavelengths in the laryngeal region of patients with inflammatory processes in the vocal folds.
26. - I use point contact as a method of irradiation in the laryngeal region in patients with inflammatory processes in the vocal folds.
27. - I apply PBM to the thyroid cartilage lamina in patients with inflammatory processes in the vocal folds.
28. - I apply PBM to the anterior commissure and the thyroid cartilage lamina in patients with inflammatory processes in the vocal folds.
29. - I apply 4J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.
30. - I apply 4-6J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.
31. - I apply 6J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.
32. - I apply PBM at 3 points in the hemilarynx of patients with inflammatory processes in the vocal folds.
33. - I apply PBM at 4 points in the hemilarynx of patients with inflammatory processes in the vocal folds.
34. - I apply PBM to 5 points on the hemilarynx of patients with inflammatory processes in the vocal folds.
35. - I request a specific vocal task before and after application, to check the effect of PBM on the voice.
36. - I use patient/client self-reporting to check the effect of PBM on vocal production.
37. - I use acoustic analysis before and after applying PBM to check its effect on the voice.
38. - I use PBM as a complementary device for vocal conditioning in speaking voice professionals.
39. - I use PBM as a complementary device for vocal conditioning in singing voice professionals.
40. - I use doses lower than 4J (Joules) when my goal is to improve vocal conditioning in voice professionals.
41. - I use doses between 4-6J (Joules) when my goal is to improve vocal conditioning in voice professionals.
42. - I use doses between 6-9J (Joules) when my goal is to improve vocal conditioning in voice professionals.
43. - I use infrared wavelengths in the laryngeal region when my goal is to improve the client/patient's vocal conditioning.
44. - I use point contact as a method of irradiation in the laryngeal region when my objective is to improve the client/patient's vocal conditioning.
45. - I apply PBM at 3 points in the hemilarynx when my goal is to improve the client/patient's vocal conditioning.
46. - I apply PBM to 4 points on the hemilarynx when my goal is to improve the client/patient's vocal conditioning.
47. - I apply PBM to 5 points in the hemilarynx when my goal is to improve the client/patient's vocal conditioning.
48. - I use PBM in the laryngeal region before performing vocal exercises when my goal is vocal conditioning for voice professionals.
49. - I use PBM in the laryngeal region during vocal exercises when my goal is vocal conditioning for voice professionals.
50. - I use PBM in the laryngeal region after performing vocal exercises when my goal is vocal conditioning for voice professionals.
51. - I use point contact as a method of irradiation in the laryngeal region when my objective is vocal conditioning for voice professionals.
52. - I apply PBM to the thyroid cartilage lamina when my goal is vocal conditioning for voice professionals.
53. - I apply PBM to the anterior commissure and the keel of the thyroid cartilage in the laryngeal region when my objective is vocal conditioning for voice professionals.
54. - I use the ILIB technique on dysphonic patients.
55 - I use the ILIB technique on clients whose goal is vocal conditioning/improvement.

CVC formula
$1 -_{i} \frac{(\frac{{\sum_{}^{}}_{i}}{n})}{_{m a x}} 2 -_{i} {(\frac{}{n})}^{n} 3 -_{i} {_{i}}_{i}$

ITEM	CVC
1. I consider photobiomodulation (PBM) indicated for use in voice.	1.00*
2. I apply PBM at the beginning of the vocal rehabilitation process.	0.86*
3. I use PBM as a complementary device to vocal training.	1.00*
4. I apply PBM as a complementary alternative only in cases where I have limitations in the results obtained using conventional vocal therapy.	0.52
5. I believe that having training/qualification in PBM is essential for its effective use and clinical application in the voice area.	1.00*
6. I use PBM on voice professionals without dysphonia.	1.00*
7. I only use PBM in cases of vocal improvement.	0.71
8. I use PBM in the vocal rehabilitation of dysphonic patients.	0.86*
9. I use PBM in the Voice area to improve the client/patient's muscular performance.	0.95*
10. I use PBM in the Voice area to modulate inflammation.	0.71
11. I use PBM with voice professionals to improve muscle performance.	0.90*
12. I use PBM with voice professionals to improve muscle recovery.	0.90*
13. I use PBM with voice professionals to reduce symptoms of vocal fatigue.	1.00*
14. I use PBM in cases of patients with dysphonia due to muscle tension.	0.71
15. I use PBM in cases of patients with laryngeal paralysis.	0.62
16. I use PBM in cases of patients with behavioral dysphonia without laryngeal injury.	0.81*
17. I use PBM in cases of patients with behavioral dysphonia with laryngeal injury.	0.52
18. I use PBM in cases of patients with dysphonia of organic origin.	0.57
19. I use PBM in cases of patients with dysphonia of neurological origin.	0.48
20. I use PBM in cases of patients with dysphonia due to sequelae of head and neck cancer.	0.43
21. I use PBM in cases of patients with dysphonia resulting from laryngitis due to laryngopharyngeal reflux.	0.71
22. I use PBM in the laryngeal region before performing vocal exercises.	1.00*
23. I use PBM in the laryngeal region during vocal exercises.	0.48
24. I use PBM in the laryngeal region after performing vocal exercises.	0.81*
25. I use infrared wavelengths in the laryngeal region of patients with inflammatory processes in the vocal folds.	0.86*
26. I use point contact as a method of irradiation in the laryngeal region in patients with inflammatory processes in the vocal folds.	0.95*
27. I apply PBM to the thyroid cartilage lamina in patients with inflammatory processes in the vocal folds.	0.81*
28. I apply PBM to the anterior commissure and the thyroid cartilage lamina in patients with inflammatory processes in the vocal folds.	0.86*
29. I apply 4J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.	0.76*
30. I apply 4-6J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.	0.86*
31. I apply 6J (Joules) per point in the laryngeal region in patients with inflammatory processes in the vocal folds.	0.95*
32. I apply PBM at 3 points in the hemilarynx of patients with inflammatory processes in the vocal folds.	0.62
33. I apply PBM at 4 points in the hemilarynx of patients with inflammatory processes in the vocal folds.	0.71
34. I apply PBM to 5 points on the hemilarynx of patients with inflammatory processes in the vocal folds.	0.43
35. I request a specific vocal task before and after application, to check the effect of PBM on the voice.	1.00*
36. I use patient/client self-reporting to check the effect of PBM on vocal production.	1.00*
37. I use acoustic analysis before and after applying PBM to check its effect on the voice.	0.71
38. I use PBM as a complementary device for vocal conditioning in speaking voice professionals.	1.00*
39. I use PBM as a complementary device for vocal conditioning in singing voice professionals.	0.95*
40. I use doses lower than 4J (Joules) when my goal is to improve vocal conditioning in voice professionals.	0.33
41. I use doses between 4-6J (Joules) when my goal is to improve vocal conditioning in voice professionals.	1.00*
42. I use doses between 6-9J (Joules) when my goal is to improve vocal conditioning in voice professionals.	0.95*
43. I use infrared wavelengths in the laryngeal region when my goal is to improve the client/patient's vocal conditioning.	0.81*
44. I use point contact as a method of irradiation in the laryngeal region when my objective is to improve the client/patient's vocal conditioning.	0.90*
45. I apply PBM at 3 points in the hemilarynx when my goal is to improve the client/patient's vocal conditioning.	0.76*
46. I apply PBM to 4 points on the hemilarynx when my goal is to improve the client/patient's vocal conditioning.	0.76*
47. I apply PBM to 5 points in the hemilarynx when my goal is to improve the client/patient's vocal conditioning.	0.62
48. I use PBM in the laryngeal region before performing vocal exercises when my goal is vocal conditioning for voice professionals.	0.95*
49. I use PBM in the laryngeal region during vocal exercises when my goal is vocal conditioning for voice professionals.	0.43
50. I use PBM in the laryngeal region after performing vocal exercises when my goal is vocal conditioning for voice professionals.	0.33
51. I use point contact as a method of irradiation in the laryngeal region when my objective is vocal conditioning for voice professionals.	0.90*
52. I apply PBM to the thyroid cartilage lamina when my goal is vocal conditioning for voice professionals.	0.90*
53. I apply PBM to the anterior commissure and the keel of the thyroid cartilage in the laryngeal region when my objective is vocal conditioning for voice professionals.	0.81*
54. I use the ILIB technique on dysphonic patients.	0.62
55. I use the ILIB technique on clients whose goal is vocal conditioning/improvement.	0.71
Total	0.78*

[1] Caption: PBM = photobiomodulation; ILIB = intravascular laser irradiation of blood