Musculoskelatal Issues and the Voice: Treating Somatic Dysfunction as a Part of Voice Therapy

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1 Musculoskelatal Issues and the Voice: Treating Somatic Dysfunction as a Part of Voice Therapy Benjamin Asher, MD, FACS New York, NY ASHA Orlando 11/21/14

2 No financial disclosures Nothing to declare

3 Case 1 18 year old voice student with a 2 month history of pain in her throat after singing. Normal laryngeal stroboscopy. Trigger points in her scalene, suboccipital, and trapezius muscles. Treated with a combination of neuromuscular therapy, and osteopathic techniques.

4 How do I work and what is it called? B;end of Osteopathy and Muscular releases Energy medicine If you put your hands on people, you practice energy medicine Listening with my hands Open mind/open heart

5 Attitude Meeting the patient where they are Cannot force will Allowing and creating the space for the patient to recognize the imbalance and allowing their mind to engage and let it go.

6 Sternomastoid Trigger Points

7 Osteopathy Founded by Andrew Taylor Still Disturbances of the spinal column result in disease in the organs fed by the nerves coming from that area

8 Osteopathy Cranial Field William Garner Sutherland internal bevel of the suture between the squama of the temporal bone and the greater wing of the sphenoid and the external bevel of the suture between the temporal bone and the inferior border of the parietal bone-joint designed for motion

9 Osteopathy cranial Primary respiratory mechanism 5 types of intrinsic motion associated with the cranium, central nervous system, and sacrum

10 Osteopathy cranial articular mobility of the cranial bony mechanism mobility of the sacrum betwen the ilia inherent mobility of the CNS fluctuations of the CSF inherent motion of the dural membranes Restriction in motion results in disease

11 Osteopathy cranial Osteopathy in the Cranial Field vs. Cranio-sacral Therapy (Upledgger)

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13 Myofascial Pain Pain caused by a trigger point Myofascial Trigger Point-(Travell) A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle s fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness and autonomic phenomena.(active and latent)

14 Sternomastoid Trigger Points

15 Discussion Myofascial pain-trigger point concept extends the understanding of many non-specific pharyngeal and laryngeal symptoms. Pain, burning, pressure, fullness, tightness Improvement is not only from muscular relaxation but from the disruption of the dysfunctional trigger point pathway

16 Brief Overview of Myofascial Pain and Trigger Points

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20 Myofascial Pain Trigger points Myofascial pain is referred from trigger points in specific patterns characteristic of each muscle

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24 Myofascial Pain Patterns of pain do not follow neural pathways Crossover Distant Trigger Points Not associated with acupuncture meridians Activation and Propagation

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27 Myofascial Pain Trigger points arise from multiple causes; Indirect activation by other trigger points Acute or chronic overload stress Exposure to cold Visceral disease Arthritic joints Emotional distress

28 Myofascial Pain Diagnosis of TP s Hx of sudden onset during or shortly after acute overload stress, or hx of gradual onset with chronic overload of the affected muscle Characteristic patterns of pain, specific to individual muscles (trigger point maps have not been made for larynx and pharynx) Weakness and restriction in the stretch ROM of the affected muscle

29 Myofascial Pain DX TP s (cont) Taut palplable band in affected muscle Exquisite, focal tenderness to digital pressure in the band of taut muscle Local twitch response of the tender spot Reproduction of the patients pain by pressure on the tender spot

30 Typical Symptoms Throat pain (burning, sharp, or ache) Loss of vocal range Pain with singing, speaking, or shouting Globus TMD

31 Trigger points in the following muscles: SCM Scalenes Sub-occipitals Trapezius Digastric Strap muscles

32 Treatment modalities Myofascial Release Muscle Energy Technique Cranial Osteopathy Balanced Membranous and Balanced Ligamentous releases Deep penetrating heat with active stretching

33 Most patients note improvement immediately or within 24 hours, but duration of improvement was variable depending upon multiple factors: Recurrent stress (physical and emotional) Nutritional deficiencies Generalized inflammatory status (lyme disease, fibromyalgia, etc) Food intolerances Xenobiotic exposure (Mercury, VOC s, etc.)

34 Resources Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 1, Upper Half of Body, David Simmons, Janet Travell, Lois Simmons, Williams and Wilkins