Effects of vocal exercises on the treatment of dysphagia: integrative review

Original articles, case studies and/or literature reviews published in Portuguese and/or English, available electronically in full and addressing clinical treatment with vocal exercises in adults and elderly with dysphagia. Publications repeated by the databases, with a population of children, individuals who did not present the diagnosis of dysphagia, with vocal exercises without specification, with exclusive swallowing exercises, articles and/or abstracts without the possibility of access by institutional platforms, and studies with animal model were excluded.

Results

A total of 2,356 articles were found, of which, after the eligibility criteria were applied, 08 were selected for the final sample. To evaluate the effects of vocal exercises, the studies used clinical evaluation, videofluoroscopy, videoendoscopy and electromyography. Regarding the effects of vocal exercises on swallowing, it was observed that the techniques of plosive sound, buoyancy, semi-occluded vocal tract, basal sound, vocal modulation, overarticulation, the Lee Silverman Voice Treatment method® and the use of expiratory muscle strength training exercises showed positive effects in the rehabilitation of dysphagia.

Conclusion

It was observed that studies with expiratory muscle strength training (EMST), Lee Silverman method (LSVT^®) and traditional vocal exercises demonstrated positive effects in the treatment of dysphagia. However, it has not yet been possible to prove the level of evidence in all studies.

Keywords:
Voice Training; Dysphagia; Speech therapy; Swallowing; Swallowing disorders

Keywords	PubMed	LILACS	SciELO	MEDLINE
Semioccluded voice tract AND voice	46	7	4	10
Voice training AND dysphagia	62	2	0	32
Dysphagia rehabilitation AND voice	266	10	2	278
Voice therapy AND dysphagia	921	19	6	610
Voice training AND deglutition disorders	51	4	0	26
Total	1.346	42	12	956

Author and Year	Title	Casuistry	Research goal	Study design	Techniques	Result measures	Main findings	Conclusion
Brooks et al.⁽¹³13 Brooks M, McLaughlin E, Shields N. Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: a systematic review. Int J Speech Lang Pathol. 2019;21(1):89-100. http://dx.doi.org/10.1080/17549507.2017.1387285. PMid:29090601. http://dx.doi.org/10.1080/17549507.2017.... ⁾ (2019)	Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: a systematic review	Adults with communication and/or deglutition difficulties.	To investigate the effects of expiratory muscle strength training on communication and deglutition performance.	Systematic review on six databases: CINAHL, MEDLINE, Embase, SpeechBITE, AMED, and PubMed	EMST	Scale of penetration-aspiration; FOIS; EMGs of suprahyoid muscles; hyolaryngeal motion digitally analyzed by videofluoroscopy; VHI; Maximum speech time and s/z relation; questionnaire of life quality associated with deglutition.	Expiratory muscle strength training led to improved airway safety and strength of the expiratory muscles during swallowing.	Speech therapists should consider using expiratory muscle strength training to improve airway safety in adults with deglutition disorders.
Fraga et al.⁽³3 Fraga BF, Almeida ST, Santana MG, Cassol M. Efficacy of myofunctional therapy associated with voice therapy in the rehabilitation of neurogenic oropharyngeal dysphagia: a pilot study. Int Arch Otorhinolaryngol. 2018;22(3):225-30. http://dx.doi.org/10.1055/s-0037-1605597. PMid:29983759. http://dx.doi.org/10.1055/s-0037-1605597... ⁾ (2018)	Efficacy of Myofunctional Therapy Associated with Voice Therapy in the Rehabilitation of Neurogenic Oropharyngeal Dysphagia: a pilot study	10 patients diagnosed with ischemic CVA and oropharyngeal dysphagia; average age of 73.2± 7.6 years; 6 male and 4 female individuals.	To verify whether the therapy of myofunctional exercises associated with voice exercises is more efficient in the recovery of deglutition in patients with cerebrovascular accident.	Study composed of two groups: control (myofunctional exercises) and experimental (myofunctional and voice exercises)	Voice therapy by means of plosive sound exercises, thrust, semi-occluded voice tract with glottal firmness or vibrating sound, maximum phonation time, and basal sound (voice fry).	Voice assessment through GRBASI scale, oral ingestion assessment through FOIS, and sensoriomotor-orofacial assessment through MBGR protocol.	The pre-therapy FOIS levels of the experimental group were 4 and increased to 7 after therapy. The combination of myofunctional exercises and voice was more effective in improving the levels of oral ingestion than the myofunctional exercises alone.	This pilot study showed evidence that the use of voice exercises in swallowing recovery in patients with CVA was able to provide a greater increase in the level of oral ingestion.
Miles et al.⁽¹²12 Miles A, Jardine M, Johnston F, de Lisle M, Friary P, Allen J. Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson’s disease: a pilot study. J Neurol Sci. 2017;383(15):180-7. http://dx.doi.org/10.1016/j.jns.2017.11.015. PMid:29246611. http://dx.doi.org/10.1016/j.jns.2017.11.... ⁾ (2017)	Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson’s disease: A pilot study	20 participants (14 male and 6 female individuals) with Parkinson’s disease.	To investigate the effects of LSVT LOUD® on deglutition by measuring quantitative parameters of deglutition and cough in patient group referred for voice treatment.	Programs applied in 16 sessions over four weeks.	LSVT®	Participants assessed by videofluoroscopy at three stages: before the program, a week into the program, and six months later.	All participants completed the program and there was significant improvement in the expiratory flow rate of involuntary cough and in the expiratory flow increase time. All participants reported eating a normal dietary food without modification of consistency. There were no cases of aspiration.	LSVT LOUD® demonstrates effects on swallowing function and involuntary cough efficiency in individuals with mild Parkinson’s disease and voice complaints. This favors protection against respiratory and swallowing diseases, which are symptoms suffered by this population.
Laciuga et al.⁽¹⁴14 Laciuga H, Rosenbek JC, Davenport PW, Sapienza CM. Functional outcomes associated with expiratory muscle strength training: narrative review. 2014;51(4):535-46.⁾ (2014)	Functional outcomes associated with expiratory muscle strength training: narrative review	Individuals with Parkinson’s disease, multiple sclerosis, and Lance-Adams syndrome; individuals with chronic obstructive pulmonary disease; healthy young adults and the elderly.	To classify evidence on expiratory muscle strength training using a pressure limiting device applied in multiple conditions or diseases.	Literature review on the databases: PubMed, Cochrane, Google Scholar, and two international publications on the Journal of Physical Therapy Science, and one on Respiratory Medicine.	EMST	Descriptive analysis.	The analyzed studies demonstrated promising results of expiratory muscle strength training for the protection of the airways in individuals with dysphagia secondary to neuromuscular deficiency.	Expiratory muscle strength training program was successfully applied to improve the components of speech, deglutition, and breathing. The program may be further applied as therapy in cases of dysphonia and dysphagia.
Rodrigues et al.⁽¹⁰10 Rodrigues KA, Menezes FT, Nerto ICO, Lederman HM, Manrique D, Chiari BM. Dysphagia associated to psychogenic dysphonia: case report. Distúrb Comun. 2012;24(3):415-20.⁾ (2012)	Dysphagia associated to psychogenic dysphonia: case report	Female patient, 47 years old, with complaint of gradual difficulty deglutition of saliva and foods.	To report the evolution of a oropharyngeal dysphagia case associated with psychogenic dysphonia.	Patient subjected to weekly speech therapy (1 session a week). Exercises at a frequency of 3 series of 10 repetitions, with a total of 6 sessions. Each session lasted 30 minutes.	Scales with voice modulation; Over articulation exercises; isometric tongue base exercises.	Deglutition videofluoroscopy.	Fluoroscopy of the deglutition revealed normal results. The patient reported improvement in voice modulation scales, over articulation exercises, and stasis sensation in the pharyngeal area and in swallowing. However, the patient started to present aphonia condition, with present and audible cough, diagnosed as psychogenic dysphonia.	The speech therapy contributed to the patient's deglutition recovery.
Maffei et al.⁽⁹9 Maffei C, Gonçalves MI, de Mello MM, Kluppel J Jr, Camargo PA. Pharyngeal cervical neurinoma: dysphonia and dysphagia. Braz J Otorhinolaryngol. 2007 Out;73(5):718. http://dx.doi.org/10.1590/S0034-72992007000500021. PMid:18094817. http://dx.doi.org/10.1590/S0034-72992007... ⁾ (2007)	Pharyngeal cervical neurinoma: dysphonia and dysphagia	A patient with post-resection of neck and pharyngeal neuroma.	To analyze the effects of speech recovery, chewing, and deglutition on a case of neck and pharyngeal neuroma.	Clinical case of a 38-year-old patient with complaint of dysphonia, dysphagia, and chewing difficulty. Videolaryngoscopy indicated right hemilarynx paralysis and breathy tone. Electromyography showed a reduction in the electrical activity of the temporalis and masseter muscles on the right side. Speech therapy performed in 24 sessions.	Isotonic and isometric myofunctional exercises for the tongue, emission of sustained vowel / i / with hooked hands associated with neck flexion.	Vdeolaryngoscopy, videofluoroscopy and electromyography of the masticatory muscles.	Improvement in tongue strength, tonus, and mobility; decrease in food leakage; increased constriction of the pharynx muscles, with reduced residues in piriform sinuses; increased activity of temporal and masseter muscles on the right side, reduction in the glottal gap and decreased breathy tone.	The exercises promoted improvement in deglutition function and voice quality.
Fox et al.⁽²¹21 Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, Farley BG. The science and practice of LSVT/LOUD: neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders. Semin Speech Lange. 2006;27(4):283-99.⁾ (2006)	The science and practice of LSVT®/LOUD: neural plasticity-principled approach to treating individuals with Parkinson’s disease and other neurological disorders	Individuals with Parkinson’s disease, cerebrovascular accident, and cerebral palsy	To clarify the importance of a key-element as a recovery target for the improvement of various motor control systems.	Literature review.	LSVT®/LOUD	Descriptive analysis.	The studies demonstrated that the treatment with voice fold adduction and respiratory drive generated an effect on the voice sound pressure level, with improvement in speech (articulation), facial expression, and deglutition. The alterations in tongue function and base, prolonged oral and pharyngeal transit time, difficulty in bolus formation and lingual and pharyngeal stasis were resolved after the technique was applied.	Treatment focused on loudness (volume) is an effective tool for recovery, with results in disorders in oral communication and tract Vocal tract function in individuals with Parkinson’s disease. Improvements in voice, speech and deglutition functions indicate a neural plasticity mechanism after LSVT®/LOUD technique.
Sharkawi et al.⁽¹¹11 El Sharkawi A, Ramig L, Logemann JA, Pauloski BR, Rademaker AW, Smith CH, et al. Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT®): a pilot study. J Neurol Neurosurg Psychiatry. 2002;72(1):31-6. http://dx.doi.org/10.1136/jnnp.72.1.31. PMid:11784821. http://dx.doi.org/10.1136/jnnp.72.1.31... ⁾ (2002)	Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT®): a pilot study	8 patients with Parkinson’s disease: 6 male (aged between 57 and 77) and 2 female (aged between 48 and 57).	To define the effects of Lee Silverman Voice Treatment (LSVT®) on deglutition and voice.	Each patient received modified barium for swallowing and voice recording before and after a month of LSVT®.	LSVT®	Voice assessment with measurements of voice intensity, fundamental frequency, and the patient's perception of speech change.	Before LSVT, the deglutition disorders in the oral phase, tongue control and strength were reduced, and in the pharyngeal phase, tongue base retraction decreased, resulting in vallecula residues. Oral transit time and pharyngeal transit time were prolonged. After LSVT®, there was a reduction in the number of deglutition disorders and in the oral residue after swallowing liquids.	LSVT® improved neuromuscular control of the whole upper aerodigestive tract, improved tongue and tongue base function during the oral and pharyngeal phases of deglutition, and improved voice intensity.

Academia Brasileira de Audiologia Rua Itapeva, 202, conjunto 61, CEP 01332-000, Tel.: (11) 3253-8711, Fax: (11) 3253-8473 - São Paulo - SP - Brazil
E-mail: revista@audiologiabrasil.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Conflict of interests: No.