Surface electromyographic biofeedback for behavioral dysphonia in adult people: a systematic review

Ribeiro, Vanessa Veis; Vitor, Jhonatan da Silva; Honório, Heitor Marques; Brasolotto, Alcione Ghedini; Silverio, Kelly Cristina Alves

doi:10.1590/2317-1782/20182018031

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Sumário

Systematic Review • CoDAS 30 (6) • 2018 • https://doi.org/10.1590/2317-1782/20182018031 copy

Surface electromyographic biofeedback for behavioral dysphonia in adult people: a systematic review

Biofeedback eletromiográfico de superfície para disfonia comportamental em adultos: revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To review systematically the literature and to analyze the effectiveness of surface electromyographic biofeedback in the rehabilitation of adults with behavioral dysphonia.

Research strategies

Two authors performed an independent search in the following databases: Clinical Trials, Cochrane Library, Embase, LILACS, PubMed, and Web of Science. A specific search strategy was developed for each database.

Selection criteria

The review included studies that examined the effectiveness of surface electromyographic biofeedback compared to other direct vocal therapy intervention in adults with behavioral dysphonia. There were no restrictions in regard to language or date of publication.

Data analysis

Analysis of the risk of bias, heterogeneity, quantitative and qualitative data, sensitivity, subgroups, and publication bias.

Results

51 studies were identified, but only two cohort studies remained as prospects for analysis. The studies showed 100% uncertain risk of selection, performance, and detection bias. There was a high degree of clinical heterogeneity. The descriptive analysis showed a reduction in muscle electrical activity and improvement in vocal self-assessment using electromyographic biofeedback; however, it was not possible to calculate the effect size of the interventions. The present study was limited by the fact that it was unable to show a consensus for the majority of data analyzed.

Conclusion

The available literature does not support a conclusive finding about the effectiveness of surface electromyographic biofeedback compared to other direct interventions used in the rehabilitation of adults with behavioral dysphonia. The studies analyzed vary widely in their clinical procedures and methodology, making it impossible to determine the procedure's effectiveness.

Keywords
Dysphonia; Feedback; Therapeutics; Voice; Voice Training

Database	Uniterms	Search strategies
Clinical Trials	MeSH	((“Dysphonia” OR “Voice Disorders”) AND (“Therapeutics” OR “therapy” OR “Rehabilitation” OR “Exercise Therapy” OR “Rehabilitation of Speech and Language Disorders” OR “Voice Training”) AND (“Biofeedback, Psychology” OR “Feedback” OR “Neurofeedback” OR “electromyographic biofeedback”))
Cochrane Library	MeSH	(((“clinical” AND “trial”) OR “clinical trials as topic” OR “clinical trial” OR “random*” OR “random allocation” OR “therapeutic use”) AND (“Dysphonia” OR “Voice Disorders”) AND (“Therapeutics” OR “therapy” OR “Massage” OR “Musculoskeletal Manipulations” OR “Rehabilitation” OR “Rehabilitation of Speech and Language Disorders” OR “Voice Training”))
LILACS	DeCS	dysphonia OR voice disorders AND therapeutics OR rehabilitation OR rehabilitation of speech and language disorders OR voice training AND feedback OR biofeedback, psychology OR electromyography OR biofeedback electromyography
PUBMED	MeSH	((((((clinical[Title/Abstract] AND trial[Title/Abstract]) OR “clinical trials as topic”[Mesh] OR (clinical trial [Publication Type]) OR “random”*[Title/Abstract] OR “random allocation”[Mesh] OR “therapeutic use”[MeSH Subheading])))) AND ((“Voice Disorders”[Mesh] OR “Dysphonia”[Mesh]))) AND ((“Therapeutics”[Mesh] OR “therapy”[Subheading] OR “Rehabilitation”[Mesh] OR “rehabilitation” [Subheading] OR “Exercise Therapy”[Mesh]) OR “Rehabilitation of Speech and Language Disorders”[Mesh] OR “Voice Training”[Mesh]))) AND ((“Biofeedback, Psychology”[Mesh] OR “Feedback”[Mesh] OR “Neurofeedback”[Mesh] OR “electromyographic biofeedback”[Title/Abstract])))
Web of Science	MeSH	(“clinical” AND “trial”) OR “clinical trials as topic” OR “clinical trial” OR “random*” OR “random allocation” OR “therapeutic use” AND “Dysphonia” OR “Voice Disorders” AND “Therapeutics” OR “therapy” OR “Rehabilitation” OR “Exercise Therapy” OR “Rehabilitation of Speech and Language Disorders” OR “Voice Training” AND “Biofeedback, Psychology” OR “Feedback” OR “Neurofeedback” OR “electromyographic biofeedback”
Embase	Emtree	'clinical trial'/exp OR 'clinical trial' OR 'clinical study'/exp OR 'clinical study' OR 'clinical article'/exp OR 'clinical article' OR 'clinical trial (topic)'/exp OR 'clinical trial (topic)' OR 'controlled clinical trial'/exp OR 'controlled clinical trial' OR 'controlled clinical trial (topic)'/exp OR 'controlled clinical trial (topic)' OR 'randomized controlled trial'/exp OR 'randomized controlled trial' OR 'controlled study'/exp OR 'controlled study' OR 'pretest posttest control group design'/exp OR 'pretest posttest control group design' OR 'intervention study'/exp OR 'intervention study' AND ('dysphonia'/exp OR 'dysphonia') OR 'voice disorder'/exp OR 'voice disorder' AND ('therapy'/exp OR 'therapy') OR 'rehabilitation'/exp OR 'rehabilitation' OR 'exercise'/exp OR 'exercise' OR 'speech and language rehabilitation'/exp OR 'speech and language rehabilitation' OR 'voice training'/exp OR 'voice training' AND ('feedback system'/exp OR 'feedback system') OR 'neurofeedback'/exp OR 'neurofeedback' AND ('electromyograph'/exp OR 'electromyograph')

Parameters analyzed	Subgroups	n	%
Surface electromyographic biofeedback program combined with direct vocal therapy	Exercise	1	50.00
	Function	2	100.00
Surface electromyographic biofeedback program combined with indirect vocal therapy	Vocal counseling	1	50.00
	Vocal psychodynamics	0	0.00

AUTHORS	Wong AY, Ma EP, Yiu EM ¹⁸18 Wong AYH, Ma EPM, Yiu EML. Effects of practice variability on learning of relaxed phonation in vocally hyperfunctional speakers. J Voice. 2011;25(3):e103-13. http://dx.doi.org/10.1016/j.jvoice.2009.10.001. PMid:20456910. http://dx.doi.org/10.1016/j.jvoice.2009...	Andrews S, Warner J, Stewart R ²⁸28 Andrews S, Warner J, Stewart R. EMG biofeedback and relaxation in the treatment of hyperfunctional dysphonia. Br J Disord Commun. 1986;21(3):353-69. http://dx.doi.org/10.3109/13682828609019847. PMid:3307882. http://dx.doi.org/10.3109/1368282860901...
Surface electromyography of the oral-facial region during habitual phonatory activity	Group 1 (biofeedback combined with constant practice)—pre: 37.53 ± 9.03; post: 30.78 ± 8.76; Group 2 (biofeedback combined with masked practice)—pre: 34.13 ± 11.96; post: 30.98 ± 12.78; Group 3 (biofeedback combined with randomized practice)—pre: 32.81 ± 15.19; post: 28.86 ± 9.82	NA
Surface electromyography of the thyroid-hyoid region during habitual phonatory activity	Group 1 (biofeedback combined with constant practice)—pre: 20.24 ± 4.11; post: 14.71 ± 3.82; Group 2 (biofeedback combined with masked practice)—pre: 16.98 ± 3.62; post: 12.33 ± 1.90; Group 3 (biofeedback combined with randomized practice)—pre: 21.10 ± 3.80; post: 15.00 ± 3.26	NA
Surface electromyography of the cricothyroid-hyoid region during habitual phonatory activity	NA	Group 1 (biofeedback)—pre: 204.20 ± 147.34; post: 12.60 ± 3.97; Group 2 (program of progressive relaxation)—pre: 138.6 ± 95.84; post: 24.40 ± 4.92
Auditory-perceptive assessment	NA	NA
Vocal self-assessment	NA	Group 1 (biofeedback)—Improved= 5; No change/Worse= 0; Group 2 (program of progressive relaxation)—Improved= 4; No change/Worse= 1

Authors	Wong AY, Ma EP, Yiu EM ¹⁸18 Wong AYH, Ma EPM, Yiu EML. Effects of practice variability on learning of relaxed phonation in vocally hyperfunctional speakers. J Voice. 2011;25(3):e103-13. http://dx.doi.org/10.1016/j.jvoice.2009.10.001. PMid:20456910. http://dx.doi.org/10.1016/j.jvoice.2009...	Andrews S, Warner J, Stewart R ²⁸28 Andrews S, Warner J, Stewart R. EMG biofeedback and relaxation in the treatment of hyperfunctional dysphonia. Br J Disord Commun. 1986;21(3):353-69. http://dx.doi.org/10.3109/13682828609019847. PMid:3307882. http://dx.doi.org/10.3109/1368282860901...
Database	Cochrane and PubMed	Manual search
Journal	Journal of Voice	British Journal of Disorders of Communication
Year	2011	1986
Design	Prospective cohort	Prospective cohort
Country	China	England
Sample	Group 1 (biofeedback combined with constant practice): 7 participants; Group 2 (biofeedback combined with practice): 7 participants; Group 3 (biofeedback combined with randomized practice): 7 participants	Group 1 (biofeedback): 5 participants; Group 2 (program of progressive relaxation): 5 participants
Pathology	Hyperfunctional dysphonia	Hyperfunctional dysphonia
Gender	Both sexes	Female
Age	18-48 years	20-54 years
Number of sessions	8 sessions	4-15 sessions
Frequency of sessions	Twice per week	Once per week
Duration of session	ND	45 minutes
Muscles of electromyographic biofeedback	Muscle of the thyroid-hyoid region	Muscle of the cricothyroid region
Format of electromyographic biofeedback presentation	Visual feedback in the form of the electrical activity reading in RMS appearing on the computer screen after every two sentences	Visual feedback in the form of electrical activity reading as registered by a needle on a scale
Activity performed during the electromyographic biofeedback	Reading aloud a set of 24 sentences in three ways: constant number, increasing number, and random number of characters	Reading with maximum electrical activity below 30 µV in four of five consecutive tests to pass to phonation tasks; in subsequent stages, reading with electrical activity varying by no more than 10µV from a resting state in four of five tests

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[1] Conflict of interests: nothing to declare.