Abstracts
Purpose
To verify the relationship between the occurrence of vocal discomfort and cervical complaints by using self-assessment questionnaires.
Methods
Thirty individuals (18–65 years of age) with various cervical complaints answered a translated and culturally adapted version of the self-assessment cervical questionnaire, The Copenhagen Neck Functional Disability Scale (CNFDS), titled Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC), the vocal self-assessment instruments Voice-Related Quality of Life (V-RQOL), and the Vocal Tract Discomfort Scale (VTDS). Statistical tests were used to analyze the possible relationships between the data obtained.
Results
Most of the participants reported the presence of vocal discomfort, with almost half presenting with a significant number of vocal discomfort symptoms; among these symptoms, dryness was reported most frequently and itching was reported with the highest intensity. No correlation was found between the EFIPC and V-RQOL or VTDS findings, but a negative correlation was found between the V-RQOL and VTDS findings.
Conclusion
Although the participants reported a high occurrence of vocal discomfort, no correlation was found between the selected questionnaires.
Neck pain; Questionnaires; Self-assessment; Perturbance; Voice
Objetivo
Verificar a relação entre a ocorrência de desconforto vocal e queixa cervical, a partir de questionários de autoavaliação.
Métodos
Trinta indivíduos de 18 a 65 anos de idade, todos com algum tipo de queixa cervical, responderam à versão traduzida e adaptada culturalmente do questionário de autoavaliação cervical The Copenhagen Neck Functional Disability Scale (CNFDS) - denominado em português Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC) - e dois instrumentos de autoavaliação vocal: o Questionário de Qualidade de Vida e Voz (QVV) e a Escala de Desconforto do Trato Vocal (EDTV). Testes estatísticos foram aplicados para analisar a possibilidade de relação entre os dados obtidos.
Resultados
A maioria dos participantes referiu presença de desconforto vocal, sendo que quase metade deles apresentou relevante quantidade de sintomas desse desconforto. Dentre esses, a secura foi referida com maior frequência e a coceira, o sintoma que apresentou maior intensidade. Não houve correlação entre o EFIPC e o QVV ou o EDTV. Houve correlação negativa entre QVV e EDTV.
Conclusão
Apesar dos participantes apresentarem ocorrência elevada de desconforto vocal não houve correlação entre os questionários escolhidos.
Cervicalgia; Questionários; Autoavaliação; Perturbação; Voz
INTRODUCTION
Communication supported by the use of voice is a highly individualized human ability derived from organic, emotional, and interactional aspects. Under satisfactory conditions, the voice contributes to appropriate speech intelligibility and to effective communication according to the speaker’s professional and social demands. When the voice is abnormal, it is characterized by a condition of dysphonia, a communication disorder in which the voice presents difficulty in effectively fulfilling the oral transmission of a message(11 . Behlau M, Madazio G, Feijó D, Pontes P. Avaliação de voz. In: Behlau M, organizador. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2001. p. 246-85.).
In a broad sense, it can be said that various organic, functional, and organic-functional(11 . Behlau M, Madazio G, Feijó D, Pontes P. Avaliação de voz. In: Behlau M, organizador. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2001. p. 246-85.) factors may be related to the origin of vocal disorders. These factors include the individual’s physical vulnerability, abnormalities in the respiratory tract, or personality factors, which may cause discomfort or truly interfere with an individual’s personal life(11 . Behlau M, Madazio G, Feijó D, Pontes P. Avaliação de voz. In: Behlau M, organizador. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2001. p. 246-85.,22 . Fawcus M. Disfonias: diagnóstico e tratamento. Rio de Janeiro: Revinter; 2001.).
Even before a condition characteristic of voice disorder manifests, the patient
may report the presence of vocal discomfort in some situations(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
). The term discomfort is used to
describe a subjective experience representing a condition that compromises the
optimal functionality of a structure, which is the vocal tract in this case. In
this study, the term vocal discomfort was considered a synonym of pain as well
as an indication of burning, tightness, dryness, sore throat, itching, throat
sensitivity, throat irritation, and the feeling of a lump in the throat.
Clinical experience suggests that many dysphonic individuals present with some
discomfort in the vocal tract that probably results from some type of
overexertion, such as that involving the perilaryngeal muscles(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
).
The frequency of use and the conditions under which the voice is produced may
indicate how a voice disorder arose, and this is mainly applicable to cases in
which the voice is greatly influenced by the individual’s professional
activity(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
). For
example, a professor is required to use his/her voice continuously and, often,
excessively in a noisy environment. A recent study conducted in this population
(with and without vocal complaints) showed that professors who self-reported the
presence of vocal discomfort had at least 3 manifestations of this type of
discomfort. Further, even the professors who had not previously self-reported
the presence of vocal discomfort were able to identify the occurrence of 3 or
fewer manifestations of discomfort, showing the significant impact of the
demands of this profession(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
).
The shoulder girdle and, in particular, the cervical region, which houses the
larynx with the structures responsible for phonation, may also have specific
abnormalities and be the subject of varying complaints independent of dysphonia.
Evaluating symptoms present in individuals with cervical complaints requires
specific knowledge and discerning clinical ability. These symptoms may manifest
as a result of unspecific conditions (headaches and diffuse myalgia, for
example) or because of complaints from well-defined conditions (inflammatory,
degenerative, and neoplastic injuries and processes)(44 . Antônio SF, Pernambuco RA. Diagnóstico diferencial das
cervicalgias. Temas Reumatol Clín. 2001 [acesso em 9 ago 2011]; 2(1). Disponível
em:
http://www.moreirajr.com.br/revistas.asp?fase=r003&id_materia=1434
http://www.moreirajr.com.br/revistas.asp...
,55 . Manchikanti L, Singh V, Falco FJ, Cash KA, Fellows B. Comparatives
outcomes of a 2-year follow-up of cervical medial branch blocks in management of
chronic neck pain: a randomized, double-blind controlled trial. Pain Physician.
2010;13(5):437-50.).
Several studies on cervical pain(66 . Peterson C, Bolton J, Humphreys BK. Predictors of outcome in neck
pain patients undergoing chiropractic care: comparison of acute and chronic
patients. Chirop Manl Therap. 2012;20(1):27.
http://dx.doi.org/10.1186/2045-709X-20-27
https://doi.org/10.1186/2045-709X-20-27...
7 . Benyamin R, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic
review of the effectiveness of cervical epidurals in the management of chronic
neck pain. Pain Physician. 2009;12(1):137-57.
8 . Coury HJCG, Moreira RFC, Dias NB. Efetividade do exercício físico
em ambiente ocupacional para controle da dor cervical, lombar e do ombro: uma
revisão sistemática. Rev Bras Fisioter. 2009;13(6):461-79.
http://dx.doi.org/10.1590/S1413-35552009000600002
https://doi.org/10.1590/S1413-3555200900...
-99 . Cailliet R. Doenças dos tecidos moles. Porto
Alegre: Artmed; 2000.) emphasize that,
among the principal manifestations reported, pain and “neck dysfunction” in
general are only surpassed in prevalence by lumbar pathologies.
Among the characteristics related to cervicalgia, an extensive range of etiological possibilities and various consequences exist. These include an individual’s anatomical conditions, such as articular abnormalities (through injury or a degenerative process), nerve root impairment, structural abnormalities of the occipital ligaments, and neck muscle sensitivity(99 . Cailliet R. Doenças dos tecidos moles. Porto Alegre: Artmed; 2000.,1010 . Reis FJJ, Mafra B, Mazza D, Marcato G, Ribeiro M, Absalão T. Avaliação dos distúrbios do controle sensório-motor em pessoas com dor cervical mecânica: uma revisão. Fisioter Mov. 2010;23(4):617-26.).
Although the literature is a rich source of reports on cervical issues, these numerous reports confirm that neck pain is a very complex issue that may not yet be fully understood(99 . Cailliet R. Doenças dos tecidos moles. Porto Alegre: Artmed; 2000.).
A study of dysphonic women with muscular disorders(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN. Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int Otorrinolaringol. 2010;14(4):461-66.) raised some controversy regarding whether the extrinsic muscles of the larynx participate in voice production. However, the authors stated that dysphonias, particularly hyperfunctional dysphonias, may be related to misalignment in the cervical muscles, in which organic abnormalities could lead to an unsuitable functional adjustment(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN. Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int Otorrinolaringol. 2010;14(4):461-66.).
In the literature, several questionnaires have been used to standardize vocal evaluation instruments and cervical problems. These questionnaires include the Voice-Related Quality of Life Questionnaire (V-RQOL)(1212 . Hogikyan ND, Sethuraman G. Validation of an instrument to measure Voice-Related Quality of Life (V-RQOL). J Voice. 1999;13:557-69.,1313 . Gasparini G, Behlau M. Quality of life: validation of the Brazilian version of the Voice-Related Quality of Life (V-RQOL) measure. J Voice. 2009;23(1):76-81.), known in Portuguese as the Questionário de Qualidade de Vida em Voz (QVV), which seeks to better understand how a voice problem can interfere with daily activities; the Portuguese version (not validated) of the Vocal Tract Discomfort Scale (VTDS)(1414 . Mathieson L, Hirani SP, Epstein R, Baken RJ, Wood G, Rubin JS. Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia. J Voice. 2009;23:353-66.), titled Escala de Desconforto do Trato Vocal (EDTV), which selects 8 possibilities of vocal discomfort that are marked according to the frequency and intensity of occurrence; and the Brazilian Portuguese translation of The Copenhagen Neck Functional Disability Scale (CNFDS)(1515 . Jordan A, Manniche C, Mosdal C, Hindsberger C. The Copenhagen Neck Functional Disability Scale: a study of reliability and validity. J Manipulative Physiol Ther. 1998;21(8):520-7.), titled Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC)(1616 . Badaró FAR, Araújo RC, Behlau M. Escala Funcional de Incapacidade do Pescoço de Copenhagen – EFIPC. Rev Bras Crescimento Desenvolv Hum. 2013. No prelo.), which evaluates how an individual’s cervical complaints can impair or interfere with their daily activities.
For clinical conditions in which vocal discomfort and neck problems are present, the question remains whether it is possible to establish a relationship between these questionnaires. Notably, no study making this correlation was found in a literature review.
Therefore, the aim of this study was to verify whether manifestations of vocal tract discomfort exist in individuals who present with any type of cervical complaint by applying the V-QROL, VTDS, and EFIPC questionnaires and determining whether correlations exist between these questionnaires.
METHODS
This study was approved by the Research Ethics Committee at Universidade de Taubaté (UNITAU) (opinion 269/12). All participants signed an informed consent form (Termo de Consentimento Livre e Esclarecido - TCLE).
The questionnaires were selected for this study because they are self-assessment questionnaires; this quality facilitates their application and rules out the possibility of researcher bias in the responses.
The Copenhagen Neck Functional Disability Scale (CNFDS), a cervical self-assessment questionnaire, was selected as the starting point for this study. In order to use this instrument properly, it was translated into Brazilian Portuguese and was modified to account for cultural differences, resulting in the Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC)(1616 . Badaró FAR, Araújo RC, Behlau M. Escala Funcional de Incapacidade do Pescoço de Copenhagen – EFIPC. Rev Bras Crescimento Desenvolv Hum. 2013. No prelo.).
After selecting the questionnaires, 30 individuals responded to the cervical self-assessment questionnaire (EFIPC) and the following vocal self-assessment instruments: the Voice-Related Quality of Life Measure (V-RQOL)(1212 . Hogikyan ND, Sethuraman G. Validation of an instrument to measure Voice-Related Quality of Life (V-RQOL). J Voice. 1999;13:557-69.,1313 . Gasparini G, Behlau M. Quality of life: validation of the Brazilian version of the Voice-Related Quality of Life (V-RQOL) measure. J Voice. 2009;23(1):76-81.) and the Portuguese version (not validated) of the Vocal Tract Discomfort Scale (VTDS)(1414 . Mathieson L, Hirani SP, Epstein R, Baken RJ, Wood G, Rubin JS. Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia. J Voice. 2009;23:353-66.), titled Escala de Desconforto do Trato Vocal (EDTV)(1414 . Mathieson L, Hirani SP, Epstein R, Baken RJ, Wood G, Rubin JS. Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia. J Voice. 2009;23:353-66.).
The EFIPC instrument comprises 15 questions, each of which has 3 possible answers with scores that range from 0 to 2. The sum of these scores (with a maximum of 30 points) places the individual into a classification of cervical dysfunction, according to the dysfunction classification of the original questionnaire, The Copenhagen Neck Functional Disability Scale (CNFDS)(1515 . Jordan A, Manniche C, Mosdal C, Hindsberger C. The Copenhagen Neck Functional Disability Scale: a study of reliability and validity. J Manipulative Physiol Ther. 1998;21(8):520-7.):
-
- 1 to 3 points = minimal disability;
-
- 4 to 8 points = mild disability;
-
- 9 to 14 points = mild to moderate disability;
-
- 15 to 20 = moderate disability;
-
- 21 to 26 = moderate to intense disability;
-
- 27 to 30 = intense disability.
The V-RQOL instrument comprises 10 questions (6 in the physical domain – questions 1, 2, 3, 6, 7 and 9 – and 4 in the socio-emotional domain – questions 4, 5, 8 and 10), with a maximum score of 100; the closer the score is to 100, the better the voice-related quality of life. This instrument was only used in this study to complement the information regarding the possible impact that vocal abnormalities (in this case, vocal tract discomfort) may have on an individual’s life.
The VTDS instrument comprises 8 possible manifestations of vocal tract discomfort, evaluated according to their frequency and intensity, on a scale of 0 to 6. A higher score indicates that greater vocal tract discomfort is present.
The study participants were of both genders and any race, and were between 18 and 65 years of age. Because the participants were not selected according to profession, they represented a variety of vocations, such as student, general services assistant, public servant, healthcare professional, engineer, lawyer, journalist, secretary, professor, and retiree. All of the participants were drawn from private physiotherapy offices whose main operating area is orthopedics or from the Orthopedic Clinical School at the Faculty of Physiotherapy, Universidade de Taubaté - UNITAU, all located in the city of Taubaté (SP). All participants were required to present with some type of neck complaint; none had undergone vocal rehabilitation previously, and none presented with a self-reported neurological or psychiatric impairment.
The gender distribution of the participants in this study according to the occurrence of patients with neck complaints in the selected healthcare services was random. Thus, 8 male and 22 female participants were evaluated.
In the orthopedic therapy sector, both in private practice and in the clinical school, all of the patients were screened in order to select only those who both presented with cervical complaints and began treatment in 2012. The questionnaires were administered in the same office where the individual had undergone the physiotherapy treatment, immediately at the end of their session.
Thus, the inclusion criteria were individuals complaining of cervicalgia, regardless of prior treatment at other institutions, who did not present with any neurological, cognitive, and/or psychiatric disorders, and who were capable of understanding of the instructions and/or were not illiterate, which would make it impossible to apply the protocol. The exclusion criteria were lack of availability for participation in the study, previous speech therapy, and refusal to sign the informed consent form.
After applying the three questionnaires, the collected data were analyzed statistically according to the total EFIPC score and its corresponding classification; the total V-RQOL score and the score of its physical and socio-emotional domains; and the quantity, frequency, and intensity of vocal tract discomfort from the VTDS. For statistical analysis, the variance of the means was compared by using the ANOVA test (among the cervical dysfunction classification obtained by the EFIPC, and the means of the V-RQOL and VTDS). The Pearson’s correlation test was used to verify the interrelatedness between the variables of the physical and socio-emotional domains and the total of the V-RQOL, VTDS, and EFIPC, and the Student’s t-distribution was used to calculate the p-values. The proportion of magnitudes regarding the occurrence of manifestations of vocal discomfort and the frequency and intensity were calculated in order to obtain a correlation matrix to correlate different variables.
RESULTS
Characteristics determined from the questionnaires
The Copenhagen Neck Functional Disability Scale (Escala Funcional de Incapacidade do Pescoço de Copenhagen - EFIPC)
In this study, no individual obtained an EFIPC score classified as either minimal or intense disability. The most frequent classification was “moderate disability” (50.0%), followed by “mild to moderate disability” (30.0%). However, these values were not statistically different. The original version of the CNFDS does not have a cut-off score; therefore, by following the model of the original questionnaire, the scale used herein (EFIPC) did not have a reference cut-off score.
All of the participants in this study scored higher than zero in their responses. Thus, because all of the participants presented with some type of cervical complaint, this lack of zero scores indicated that this condition reflected negatively, to a greater or lesser extent, on the cervical functional capacity of the participants (Table 1).
Vocal Tract Discomfort Scale (VTDS)
Among the eight possibilities of vocal tract discomfort contained in the VTDS, “dryness” had the highest occurrence among the individuals (76.6%), followed by “throat irritation” (63.3%) and “itching” (56.6%).
Among the possibilities of vocal tract discomfort, “dryness” was reported most frequently (53.3%), followed by “burning,” “itching,” and “throat sensitivity,” all with a frequency of 20%. Similar characteristics were found with respect to the greater intensity of discomfort, with 50% for “dryness,” 30% for “itching,” and 20% for “burning” (Table 2).
Of the population surveyed, 29 participants (96.67%) reported 1 or more manifestations of vocal tract discomfort: 13 out of these 29 (44.8%) reported 5 to 8 manifestations of vocal tract discomfort, and 6 (20.7%) reported only 1 manifestation. Only 1 individual (3.33%) reported a lack of any type of vocal discomfort. Among the 8 possibilities of vocal tract discomfort, the mean occurrence was 4.0. Regarding the frequency of manifestations, “dryness” had the highest mean (2.53) and “tightness” had the lowest mean (0.73). Consequently, with respect to intensity, “dryness” had the highest mean (2.1) and “tightness” had the lowest mean (0.66) (Table 3).
Voice-Related Quality of Life (V-RQOL)
Among those surveyed, 7 (23.3%) reported not having any problem in their voice-related quality of life. The mean obtained for the total score was 87.16. A mean of 85.41 was obtained in the physical domain, and a mean of 96.31 was obtained in the socio-emotional domain.
Correlation characteristics of the questionnaires
Among the 30 individuals surveyed, all of whom had cervical complaints, 96.67% said they experienced manifestations of vocal discomfort; 13 (43.33%) of these individuals had 5 or more manifestations, whereas 6 (20%) mentioned only 1 related manifestation. However, when measuring the extent of the relationship between the total EFIPC score, the physical and socio-emotional domain scores, the total V-RQOL score, and the number of manifestations of vocal discomfort of the VTDS, we found no correlation between the EFIPC and the other instruments used (the V-RQOL or the VTDS), demonstrating that the results of these instruments are independent. However, a negative correlation was observed between the VTDS and the V-RQOL, demonstrating that the V-RQOL result decreases as the occurrence of vocal discomfort manifestations increases, and vice-versa (Table 4).
The values obtained from our analyses indicate that although manifestations of vocal discomfort occur in participants with cervical complaints, no correlation exists among the scales used. In other words, no relationship exists between the EFIPC Disability Classification, the V-RQOL indices, and the number of manifestations of vocal discomfort (VTDS) (Table 5).
DISCUSSION
The attempt to establish a relationship between cervical and vocal abnormalities
has been shown to be a difficult undertaking. Several previous
studies(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN.
Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int
Otorrinolaringol. 2010;14(4):461-66.,1717 . Bigaton DR, Silvério KCA, Berni KCS, Distefano G, Forti F, Guirro,
RRJ. Postura crânio-cervical em mulheres disfônicas. Rev Soc Bras Fonoaudiol.
2010;15(3):329-34.
http://dx.doi.org/10.1590/S1516-80342010000300004
https://doi.org/10.1590/S1516-8034201000...
) sought to understand this
interrelationship better by using different methodologies, but they failed to
achieve this goal.
A study that measured the impact of cervical abnormalities in
Americans(1818 . Côté P, Cassidy JD, Carroll L. The Saskatchewan health and back
pain survey: the prevalence of neck pain and related disability in Saskatchewan
adults. Spine (Phila Pa 1976) 1998;23(15):1689-98.) found
that craniocervical dysfunction is a common condition, and it was estimated that
two-thirds of the population would experience neck pain at some point in life.
On the other hand, one-third of the population will experience a voice problem
at some point in life(1919 . Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES,
Gillespie MB, et al. Clinical practice guideline: hoarseness (dysphonia).
Otolaryngol Head Neck Surg. 2009;141(3 Suppl 2):S1-31.
http://dx.doi.org/10.1016/j.otohns.2009.06.744
https://doi.org/10.1016/j.otohns.2009.06...
).
The presence of laryngeal symptoms causes discomfort that can interfere with the
act of speaking and compromise good vocal production, which can disrupt an
individual’s work or even social environment(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN.
Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int
Otorrinolaringol. 2010;14(4):461-66.). A limitation in an individual’s quality of
life because of vocal issues can affect his/her physical, emotional, and social
state. This reinforces the idea that a change in voice affects the life of a
person in different ways(1919 . Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES,
Gillespie MB, et al. Clinical practice guideline: hoarseness (dysphonia).
Otolaryngol Head Neck Surg. 2009;141(3 Suppl 2):S1-31.
http://dx.doi.org/10.1016/j.otohns.2009.06.744
https://doi.org/10.1016/j.otohns.2009.06...
).
This aspect was confirmed in the present study through the responses obtained in the V-RQOL, a protocol that allows analysis of the impact of a voice problem on an individual’s life. Most participants reported some degree of dissatisfaction with their quality of life because of vocal discomfort. In this study, the discomfort “dryness” had the highest occurrence among the participants; this was also one of the most reported vocal symptoms in another study carried out in a population presenting with cervical and vocal abnormalities(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN. Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int Otorrinolaringol. 2010;14(4):461-66.).
In a recent study conducted in professors in São Paulo, “dryness” was the
discomfort with the highest mean frequency/intensity in both the group that
self-reported vocal tract discomfort and the group that reported no vocal
discomfort(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
).
Similarly, this manifestation of vocal tract discomfort had the highest mean
frequency/intensity among the individuals surveyed in this study.
These data support the conclusion that, even though a clinic may be unable to
determine precisely how and to what extent vocal discomfort affects people’s
lives, manifestations related to the vocal tract should be taken into
consideration to provide a more relevant and comprehensive approach to the
patient’s needs because this issue can interfere with the patient’s daily
life(33 . Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract
discomfort in teachers: Its relationship to self-reported voice disorders. J
Voice. 2013;27(4):473-80.
http://dx.doi.org/10.1016/j.jvoice.2013.01.005
https://doi.org/10.1016/j.jvoice.2013.01...
).
The gender distribution of the cervicalgia cases was completely random in this study, which suggests that the higher percentage of women observed with cervicalgia was also by chance. However, a higher frequency of neck pain in women has also been observed in reports with gender distribution proportions in the studied population similar to those of this study(2020 . Conti PCR, Ferreira PM, Pegoraro LF, Conti JV, Salvador MCG. Disfunção craniomandibular (DCM). Parte II – Aspectos psicológicos e hiperatividade muscular. Rev ABO Nac. 1996;4(2):103-6.,2121 . De Vitta A, Neri AL, Padovani CR. Nível de atividade física e desconfortos musculoesqueléticos percebidos em homens e mulheres, adultos e idosos. Rev Bras Fisioter. 2003;7(1):45-52.). Nevertheless, this may not necessarily indicate that this population presents with more complaints or that women are more affected than are men, but rather that women seek treatment with greater frequency(2020 . Conti PCR, Ferreira PM, Pegoraro LF, Conti JV, Salvador MCG. Disfunção craniomandibular (DCM). Parte II – Aspectos psicológicos e hiperatividade muscular. Rev ABO Nac. 1996;4(2):103-6.). Alternatively, this can be interpreted in such a way to suggest that women do not experience more neck discomfort compared to men, but that they complain more frequently than men do because of psychosocial factors(2121 . De Vitta A, Neri AL, Padovani CR. Nível de atividade física e desconfortos musculoesqueléticos percebidos em homens e mulheres, adultos e idosos. Rev Bras Fisioter. 2003;7(1):45-52.).
In terms of vocal disorders, evidence suggests that gender does have an influence
on the manifestation of a dysphonic condition. Women have a higher
predisposition to developing vocal problems because their larynx is larger and
has a lower glottis proportion in comparison to men. Moreover, women represent
the largest portion of the population seeking speech therapy services(2222 . Putnoki DS, Hara F, Oliveira G, Behlau M. Qualidade de vida em
voz: o impacto de uma disfonia de acordo com gênero, idade e uso vocal
profissional. Rev Soc Bras Fonoaudiol. 2010;15(4):485-90.
http://dx.doi.org/10.1590/S1516-80342010000400003
https://doi.org/10.1590/S1516-8034201000...
).
Regardless of the propensity for vocal abnormalities, women are predisposed to the presence of pain, cervical discomfort, and fatigue in this region. However, reports that refer to the symptom of cervical spine pain in dysphonic individuals are sparse in the literature(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN. Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int Otorrinolaringol. 2010;14(4):461-66.).
A great variety of cervical evaluation instruments are available to clinics, such
as those that were selected as instruments in this study(2323 . Fejer R, Hartvigsen J. Neck pain and disability due to neck pain:
what is the relation? Eur Spine J. 2008;17(1):80-8.
http://dx.doi.org/10.1007/s00586-007-0521-9
https://doi.org/10.1007/s00586-007-0521-...
24 . Schellingerhout JM, Heymans MW, Verhagen AP, Vet HC, Koes BW,
Terwee CB. Measurement properties of translated versions of neck-specific
questionnaires: a systematic review. BMC Med Res Methodol. 2011;11:87-101.
http://dx.doi.org/10.1186/1471-2288-11-87
https://doi.org/10.1186/1471-2288-11-87...
-2525 . Soklic M, Peterson C, Humphreys BK. Translation and validation of
the German version of the Bournemouth Questionnaire of Neck Pain. Chiropr Man
Therap. 2012;20(2):1-8.
http://dx.doi.org/10.1186/2045-709X-20-2
https://doi.org/10.1186/2045-709X-20-2...
). The EFIPC, which was the cervical self-assessment
instrument used for this research, is a questionnaire that has been translated
and culturally adapted for Brazilian Portuguese; however, it has not been
validated. This tool was shown to be inadequate for establishing a correlation
between cervical complaints and vocal discomfort based on the V-RQOL and VTDS,
which may have been due to the sample size and the methodology used or because
the instruments have different ranges of magnitude and are therefore not
comparable.
The published studies tended to utilize practical means to evaluate cervical
dysfunction, such as clinical postural assessment(2626 . Nelli EA. Estudo da postura corporal em portadores da disfonia
[tese]. Bauru: Hospital de Reabilitação de Anomalias Craniofaciais da
Universidade de São Paulo; 2006.), photogrammetry(1717 . Bigaton DR, Silvério KCA, Berni KCS, Distefano G, Forti F, Guirro,
RRJ. Postura crânio-cervical em mulheres disfônicas. Rev Soc Bras Fonoaudiol.
2010;15(3):329-34.
http://dx.doi.org/10.1590/S1516-80342010000300004
https://doi.org/10.1590/S1516-8034201000...
), and photometric analysis(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN.
Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int
Otorrinolaringol. 2010;14(4):461-66.), in order to extract a
clinical analysis. However, another possibility is to link this analysis to
instruments, and, in most cases, these instruments are questionnaires to measure
cervical dysfunction. In contrast to the studies mentioned above, this study
attempted to compare self-assessment questionnaires (from the areas of physical
therapy and speech therapy) without resorting to clinical evaluations in order
to verify the possibility of an interrelationship between cervical complaints
and vocal discomfort.
Two other studies attempted to relate cervical and vocal abnormalities by
investigating cervical abnormalities in dysphonic women(1111 . Menoncin LCM, Jurkievicz AL, Silvério KCA, Camargo, PM, Wolf NMN.
Alterações musculares e esqueléticas em mulheres disfônicas. Arq Int
Otorrinolaringol. 2010;14(4):461-66.) or craniocervical posture in
dysphonic women(1717 . Bigaton DR, Silvério KCA, Berni KCS, Distefano G, Forti F, Guirro,
RRJ. Postura crânio-cervical em mulheres disfônicas. Rev Soc Bras Fonoaudiol.
2010;15(3):329-34.
http://dx.doi.org/10.1590/S1516-80342010000300004
https://doi.org/10.1590/S1516-8034201000...
). These
studies reported that dysphonia cannot be regarded as a trigger for postural
change and that dysphonic women present with greater craniocervical dysfunction
compared to women without dysphonia. Along these lines, the authors of one of
these studies stated that no research has been published that objectively
analyzed posture and dysfunction of the cervical region in patients with
dysphonia; further, the authors found that dysphonia is more related to
dysfunction in the cervical region than it is to postural changes in this
region(1717 . Bigaton DR, Silvério KCA, Berni KCS, Distefano G, Forti F, Guirro,
RRJ. Postura crânio-cervical em mulheres disfônicas. Rev Soc Bras Fonoaudiol.
2010;15(3):329-34.
http://dx.doi.org/10.1590/S1516-80342010000300004
https://doi.org/10.1590/S1516-8034201000...
). Thus, this
suggests that speech therapy focused on dysphonia should be carried out in
combination with treatment for craniocervical dysfunction in an effort to reduce
muscle tension as well as regain functional mobility in this region.
Further, reports regarding vocal abnormalities in individuals with cervical complaints are scarce in the literature, indicating that further scientific studies are required in this field.
This research was conducted without considering the occurrence of cervicalgia
according to the afflicted cervical levels. Cervical abnormalities related to
the cervical plexus and/or high cervical levels (C1 to C4) are believed to be
most likely to cause dysphonia(2727 . Virk JS, Majithia A, Lingam RK, Singh A. Cervical osteophytes
causing vocal fold paralysis: case report and literature review. J Laryngol
Otol. 2012;126(9):963-5.
http://dx.doi.org/10.1017/S0022215112001259
https://doi.org/10.1017/S002221511200125...
,2828 . Rocabado M. Cabeça e pescoço: tratamento articular. Seção 2. São
Paulo: Oclusivo; 1999.); however,
these are not the major causes of cervicalgia(2828 . Rocabado M. Cabeça e pescoço: tratamento articular. Seção 2. São
Paulo: Oclusivo; 1999.
29 . Onyewu O, Manchikanti L, Falco FJE, Singh V, Geffert F, Helm II S,
et al. An update of the appraisal of the accuracy and utility of cervical
discography in chronic neck pain. Pain Physician.
2012;156):E777-806.-3030 . Rosa R. Prevalência de cervicalgia em pacientes submetidos ao
tratamento quiroprático: um estudo retrospectivo [trabalho de conclusão de
curso]. Novo Hamburgo: Universidade Feevale; 2007.).
One possible method for obtaining further evidence of vocal complaints in individuals with cervical abnormalities is to relate the cervical levels to dysphonia; this suggestion is a possible topic for future research. In addition, dysphonia should be investigated further in these cases; such an assessment was not performed in this study because only vocal discomfort was considered. This methodological limitation may explain the absence of correlation among the aspects addressed. Thus, for future research with a similar intent, we suggest performing a complete voice evaluation, which is possible with a methodology that defines the cervical levels, and choosing a cervical self-assessment questionnaire other than the EFIPC.
A limitation regarding the applicability of this research is that the questionnaires used were not adjusted sufficiently to permit their comparison.
Despite the lack of correlation found in this study, the usefulness of this research lies in its contribution to the literature in the field of studies that correlate vocal abnormalities with cervical complaints. Thus, we have suggested one possible method for determining this correlation, and we have shown that addressing the areas in question requires rigorous methodological criteria with careful selection of the evaluation instruments to be used.
CONCLUSION
Although most of the participants presented with cervical complaints and manifested vocal discomfort, the VTDS and V-RQOL were not correlated with the EFIPC. A negative correlation was observed between the VTDS and V-RQOL.
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27Virk JS, Majithia A, Lingam RK, Singh A. Cervical osteophytes causing vocal fold paralysis: case report and literature review. J Laryngol Otol. 2012;126(9):963-5. http://dx.doi.org/10.1017/S0022215112001259
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29Onyewu O, Manchikanti L, Falco FJE, Singh V, Geffert F, Helm II S, et al. An update of the appraisal of the accuracy and utility of cervical discography in chronic neck pain. Pain Physician. 2012;156):E777-806.
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30Rosa R. Prevalência de cervicalgia em pacientes submetidos ao tratamento quiroprático: um estudo retrospectivo [trabalho de conclusão de curso]. Novo Hamburgo: Universidade Feevale; 2007.
-
Study conducted at the Centro de Estudos da Voz – CEV – São Paulo (SP), Brazil, as a pre-requisite for the completion of a specialization in Voice Area.
Publication Dates
-
Publication in this collection
Sept 2014
History
-
Received
7 Aug 2013 -
Accepted
10 Dec 2013