Percusión, ritmo y movimiento: facilitadores del proceso de rehabilitación del paciente laringectomizado / Percussion, rhythm and movement: Facilitators of the laringectomized patient rehabilitation process

Introducción: la voz humana en sus variadas manifestaciones, como el habla, el canto y otras producciones sonoras, es una forma de canalizar y expresar nuestras emociones, ideas, pensamientos y de vincularnos con los demás. El paciente laringectomizado total se ve privado de su voz natural. En su proceso de rehabilitación deberá aprender habilidades de comunicación funcional que le permitan desarrollar una buena calidad de vida. Material y método: 4 talleres con frecuencia trimestral, en el transcurso de un año. Participaron 21 pacientes laringectomizados, con edad promedio de 62 años. Actividades propuestas: Ejercicios de relajación activa y alineación postural, automasajes cervicofaciales y ejercitación de respiración costo-diafragmática. Percusión corporal e instrumental con variaciones rítmicas asociadas al movimiento. Ejercicios de asociación de cualidades sonoras vinculadas a la producción oral y cantada. En cada taller se administró un cuestionario escrito. Resultados: Mediante la ejercitación respiratoria se logró un mejor dominio del soplo aéreo pulmonar evitando sonidos silbantes durante la espiración. Las actividades rítmicas favorecieron el reconocimiento, la reproducción y la sincronización de movimientos corporales. Las actividades de percusión asociadas a la emisión de la palabra permitieron que el patrón rítmico acompañe a la producción de las mismas. El 100% de los pacientes manifestaron disfrute por la actividad propuesta. Entre los beneficios obtenidos mencionaron: mejoramiento del humor, sensación de bienestar corporal, mejoras en la comunicación. Conclusiones: La implementación de técnicas de relajación, alineación postural y respiración junto a actividades asociadas al ritmo y al movimiento contribuyen notoriamente a la calidad de vida de estos pacientes.

Introduction: the human voice in its varied manifestations, such as speech, singing and other sound productions are a way of channeling and expressing our emotions, ideas, thoughts and to bond with others. The total laryngectomized patient is deprived of his natural voice. In your rehabilitation process you must learn functional communication skills that allow you to develop a good quality of life. Material and method: 4 workshops with quarterly frequency, in the course of one year. 21 laryngectomized patients participated, with a mean age of 62 years. Proposed activities: Exercises of active relaxation and postural alignment, cervicofacial self-masagges and cost-diaphragmatic breathing exercises. Body and instrumental percussion with rhythmic variations associated with movement. Association exercises of sound qualities linked to the production of syllables, words, phrases, rhymes and popular songs. In each workshop, a written questionnaire was administered to respond anonymously. Results: By means of the respiratory exercises, a better control of the aerial lung breath was obtained avoiding hissing sounds during the expiration. The rhythmic activities favored the recognition, reproduction and synchronization of body movements. The percussion activities associated with the emission of the word allowed the rhythmic pattern to accompany the production of the same. 100% of patients expressed their enjoyment of the proposed activity. Among the benefits obtained mentioned: improvement of the mood, sensation of corporal well-being, improvements in the communication. Conclusions: the implementation of relaxation techniques, postural alignment and breathing along with activities associated with rhythm and movement contribute to the quality of life of these patients.

Novel esophageal speech therapy method in total laryngectomized patients: biofeedback by intraesophageal impedance.

The loss of the best communication port after total laryngectomy surgery makes speech rehabilitation an important goal. Our aim was to improve the quality of esophageal speech (ES) using online esophageal multichannel intra-luminal impedance (MII) as a new biofeedback method. Twenty-six total laryngectomized patients were included. Before ES therapy, an esophageal motility test was carried out. MII catheters were placed in all subjects who were then randomized into two groups. Group 1 included 13 cases, who were retrained according to the classical method. Group 2 included 13 cases, who were retrained according to the simplified animation of air movements within the esophagus and upper stomach resulting from the modifications of intra-esophageal air kinetics gained by MII. The level of speech proficiency was evaluated relative to pretraining levels using perceptual scales in the third and sixth months. Acoustic voice was analyzed. The number of syllables read per minute and the intelligibility of monosyllabic and dissyllabic words were calculated. In this study, MII was used for the first time in alaryngeal speech rehabilitation as a biofeedback method; an overall sufficient speech level was achieved by 68.4% at the end of therapy, whereas attendance was 90%. A statistically significant improvement was found in both groups in terms of ES level compared with the pretraining period although there was no significant difference between groups. Although we did not observe the expected difference between groups suggested by our hypothesis, MII may be used as an objective tool to show patients how to swallow and regurgitate air during training, and may thus expedite ES therapy both for the speech therapist and the patient in the future.

The voice handicap index with post-laryngectomy male voices.

BACKGROUND: Surgical treatment for advanced laryngeal cancer involves complete removal of the larynx ('laryngectomy') and initial total loss of voice. Post-laryngectomy rehabilitation involves implementation of different means of 'voicing' for these patients wherever possible. There is little information about laryngectomees' perception of their changed voice quality and communication status. Surgical voice restoration (SVR) has become the 'gold standard' rehabilitation, but there continue to be patients who use other methods of communication. There is no clear evidence comparing patients' perception of their voice handicap across different types of alaryngeal communication. AIMS: To compare the self-assessed vocal handicap of laryngectomees using SVR with those using non-SVR methods of post-laryngectomy communication. METHODS & PROCEDURES: Potential participants were identified from one Head and Neck cancer centre in South Wales. They included both male and female participants using all methods of post-laryngectomy communication. Each patient's Voice Handicap Index (VHI) score, sub-set scores, and group means were calculated. Two major confounding factors: age and time since surgery, and communication method (SVR/non-SVR), were considered to identify factors, other than method of communication, which may influence rehabilitation outcomes. OUTCOMES & RESULTS: A total of 71 questionnaires were sent out and 62 (82%) were returned from 35 patients who had undergone SVR and 27 patients who used non-SVR methods of communication. Of the non-SVR group, twelve used oesophageal voice, eleven an electrolarynx, two writing and two mouthing for communication. The gender ratio (53:9), age (43-90 years) and time since surgery (1-40 years) were broadly representative of this population, but because of the small number of females, we excluded the women from further analysis. Individual VHI scores ranged from 4 to 106. Both the SVR and non-SVR group mean scores: 44.7 and 50.9, were within the range of moderately severe voice handicap. There was no significant difference between the groups for total VHI scores or two of the three sub-domains, nor any significant effect on voice handicap due to the confounding factors assessed: age or time since surgery. The total VHI score was better by 6.5 ( - 4.9 to 17.9) points in the SVR group (p = 0.3), probably reflecting the literature reporting superior voice in SVR. CONCLUSIONS & IMPLICATIONS: The data suggest that where patient-assessed quality of life is concerned, SVR and non-SVR outcomes are comparable. This is an important consideration when planning and carrying out treatment recommendations. The study has clear clinical implications; understanding the potential of all methods of post-laryngectomy communication is essential for holistic patient management.

Estimation of influence of myofascial release techniques on esophageal pressure in patients after total laryngectomy.

In patients after total laryngectomy, increased tension in myofascial neck and arm areas might be observed. Via fascial continuity it has an adverse impact on the superior esophageal constrictor forming the "mouth of the oesophagus", which hinders learning of esophageal speech. The aim is to assess the effect of manual myofascial release techniques on esophageal pressure in patients after total laryngectomy. Forty patients (12 F, 28 M), aged 43-75 (mean 56.8 years), 9 months to 13 years (average 3 years) after total laryngectomy, 35 patients (87.5%) after neck lymph node resection, 38 patients (95%) after radiotherapy. Esophageal pressure was assessed using modified Seeman's method. Manual myofascial release techniques were applied within head, neck, arms, upper trunk and upper limb areas. Wilcoxon and Shapiro-Wilk's test was used for the purpose of statistical analysis. Statistically significant decrease of the mean esophageal pressure was observed after the physiotherapy treatment. The average pressure among the examined patients decreased from 37.9 to 26.6 mmHg. The application of myofascial manual techniques decreases esophageal pressure, thus allowing patients to learn esophagus speech at a faster pace.

[An influence of myofascial release techniques on the esophagus pressure for patients after total laryngectomy]. / Wplyw manualnych technik miesniowo-powieziowych na poziom cisnienia przelykowego u chorych po calkowitym usunieciu krtani.

UNLABELLED: The increase of patients after total laryngectomy myofascial neck and arms area tension might be observed. Via fascial continuity it has an adverse impact on superior oesophageal constrictor, forming the "mouth of oesophagus", which hinders learning oesophagus speech. THE AIM: The assessment of manual myofascial release techniques influence on the patients' oesophagus pressure after total laryngectomy. MATERIAL: 40 patients (12 F, 28 M), aged 43-75 (middle 56, 8 years), 9 months to 13 years (average 3 years) after total laryngectomy, 35 patients (87.5%) after neck lymph node's resection, 38 patients (95%) after radiotherapy. METHODS: The oesophagus pressure was checked by modified Seeman's method. Manual myofascial release techniques were applied within head, neck, arms, upper trunk and upper limbs area. Wilcoxon and Shapiro-Wilk's test was used for the purpose of statistical analysis. RESULTS: A statistical significant decrease of the mean of oesophagus pressure was observed after physiotherapy treatment. The average pressure among the examined group decreased from 37.9 to 26.6 mm Hg. CONCLUSIONS: The application of myofascial manual techniques decreased an oesophagus pressure which allows patients to obtain faster oesophagus speech.

New approaches in the rehabilitation of the traumatic high level quadriplegic.

The use of noninvasive alternatives to tracheostomy for ventilatory support have been described in the patient management of various neuromuscular disorders. The use of these techniques for patients with traumatic high level quadriplegia, however, is hampered by the resort to tracheostomy in the acute hospital setting. Twenty traumatic high level quadriplegic patients on intermittent positive pressure ventilation (IPPV) via tracheostomy with little or no ability for unassisted breathing were converted to noninvasive ventilatory support methods and had their tracheostomy sites closed. Four additional patients were ventilated by noninvasive methods without tracheostomy. These methods included the use of body ventilators and the noninvasive intermittent positive airway pressure alternatives of IPPV via the mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were used to adjust ventilator volumes and to document effective ventilation during sleep. No significant complications have resulted from the use of these methods over a period of 45 patient-years. Elimination of the tracheostomy permitted significant free time by glossopharyngeal breathing for four patients, two of whom had no measurable vital capacity. We conclude that noninvasive ventilatory support alternatives can be effective and deserve further study in this patient population.

Effects of auditory feedback and phonetic context on stomal noise in laryngectomized speakers.

Stomal noise intensity during esophageal speech was measured in 7 laryngectomized subjects during amplified monaural auditory feedback and during control conditions without feedback. A significant (5-10 dB) reduction in stomal noise was observed when auditory feedback was applied. The conditions without feedback were designed to provide additional information regarding the effects of the initial phonetic element in the esophageal speech token on stomal noise. During the control conditions, esophageal speech tokens beginning with voiceless consonants resulted in significantly more stomal noise than was present for the other speech tokens. Clinical implications of the findings are discussed.

Acoustic and physiologic correlates of the voicing distinction in esophageal speech.

This study was designed to compare high- and low-intelligibility productions of /t/ and /d/ in esophageal speakers by using a combination of acoustic, perceptual, and physiologic measurements. Observations from these comparisons were incorporated into clinical strategies for modifying a single subject's low-intelligibility utterances. Acoustic comparison indicated that esophageal speakers used voice onset and phonation off-times but not vowel durations to differentiate /t/ and /d/ in high-intelligibility productions. Intraoral pressure measures during /t/ and /d/ production demonstrated excessively high intraoral pressures in both consonants for a low-intelligibility speaker and did not suggest systematic differences in intraoral pressure between /t/ versus /d/. Two weeks of biofeedback treatment with a low-intelligibility speaker were associated with a reduction in intraoral pressures for /t/ and /d/ productions, improved intelligibility, and changes in acoustic characteristics for /t/.