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129.e10
it was possible to consider the procedure proper to subjects classification in groups. The sEMG results corroborated the group
classification because it showed differences between the
groups, which will be presented and discussed as follow.
It was adopted convenience simple random sample, using table of random numbers, by the premise of homogeneous sample
exhaustion identified for the absence of discrepancy in sEMG
evaluation (outliers), as well for the Altman nomogram, considered the significance level adjustments, of test power and effect
to be identified by the research.
The MIOTOOL 200 (Miotec, Brazil) electromyography
was used to collect the electrical potentials of SH and IH muscles
groups in microvolt (mV), with the possibility to select four independent channels, with 32 windowing and 2000 gain for each
channel. Because there are no references about the gain range
used to capture the electrical activity of these muscles, the gain
range previously mentioned was adopted, which allowed the
adjustment of signal to muscles reaching 574.93 mV, according
to the manufacturers instruction. Three channels were used,
each one connected to an active sensor SDS500 by claws; reference cable; calibrator; universal serial bus communication cable;
all from Miotec, Brazil, and disposable child surface electrodes from MEDITRACE (Kendall, Canada). The sign analysis was performed using the Miograph 2.0 software.
The sEMG equipment was connected to an LG notebook (LG
Electronics, S~ao Paulo, Brazil), with main configurations
160 GB HD, Intel Dual-Core Inside 1.7 GHz processor (Intel Corporation, USA), Windows Vista Premium operational system.
Voice assessment was made by digitally recording voice in a
portable computer (Sony Vaio, Intel 2.3 GHz processor; Sony,
Brazil). Voice was captured by a unidirectional head set microphone, Sennheiser PC-20 (Sennheiser, Germany), placed
3 cm at the side of the mouth, to avoid exhale noise interference.
To catalog the voice recordings, the register were processed in
VoxMetria software, 4.7 h version (CTS Informatica, Brazil).
Considering the interest of this research in acoustic data was to
assess mean fundamental frequency and loudness in usual and
strong intensities, the voice analysis mode was chosen to register
sustained vowel // and counting numbers from 20 to 30.
All participants were guided about their rights and duties in
this research, purpose of the study and then signed the informed
consent. Later, all of them passed through a structured interview
to identify the complaints and the evident signs indicating voice,
hearing, and cervical disturbances, to reduce selection bias.
The electromyography and voice recording were made in the
speech-language room, where the study took place, with the
TABLE 1.
Criteria for Classifying the Individuals According to Groups of Analysis
Criteria
Count of 20 to 30 in usual intensity
Vocal complaint
Emission of vowel // in usual intensity
Group D
(Dysphonic)
Group D
(Dysphonic)
Group ND
(Nondysphonic)
Group ND
(Nondysphonic)
VAS > 1
+ or
VAS 1
+
VAS > 1
VAS 1
VAS 1
+
VAS 1
Abbreviations: VAS, degree of vocal change assessed by visual analog scale; +, present; , absent; + or , present or absent.
environment temperature of 18 C maintained by airconditioner. The subject was requested to remain seated
straight, with eyes opened, feet on the ground, arms resting
on lower members, with the back to the equipment, to avoid
any attempt to visual feedback. It was not necessary to shave
the participants. After cleaning the place with gauze and 70%
ethyl alcohol, for which abrasion is higher than cotton, the electrodes were placed: one channel with two electrodes in submandibular region, to obtain signs mainly from milohyoid and
digastrics muscles considered as mouth floor, toward anterior
venter of digastrics muscle; and two channels placed bilateral
to larynx, 1 cm from the thyroid notch,10 measured using a digital caliper rule. The distance between the electrodes was 1 cm,
center from center.
Assessment started following the order presented in Figure 1.
To capture maximum voluntary sustained activity (MVSA) it
was required of the subject to perform incomplete swallowing
maneuver with effort and retracted tongue with opened mouth
maneuver, as recommended by Balata et al.10 Each procedure
was performed taking 10 seconds rest between tasks, and the
researcher always provided an explanation about the task to
be performed, afterward the voice and electromyography signs
were recorded.
All tasks were timed, assuming the command emission by the
researcher as zero for the subject to start. Total time to collect
data varied from 45 to 60 minutes, depending on subjects
comprehension to perform the tasks and the electric sign quality
captured by the electrodes.
Data analysis had three moments. The first was the electromyography data preparing, that is, selection, filtering, and
analyzing the sign. The second was perceptual and acoustic
vocal analysis; and the third was the statistic data analysis.
At the first moment, electromyography normalization sign of
SH and IH was started by the raw sign register in microvolt (mV).
129.e11
For the signs of MVSA, sustained vowel //, and rest, the first and
last second of each recording were eliminated. In muscle maneuvers, the register of the three middle seconds were considered the
most stable ones, and, therefore selected to be analyzed. At rest,
the selected register was at 58 seconds interval.
At the analysis of electromyography signs during counting
numbers in habitual and loud volumes, the whole register was
selected and its duration varied according to speed rate and/or
voice disorders which could cause pauses along the speech. After
the interval selection, each one of them was doubled to posterior
mean square root analysis (Root Mean SquareRMS).
Online Butterworth digital filter was used to avoid noises and
mechanic artifacts of electromyography (EMG) sign. This is a
band pass filter in 20500 Hz frequency, configured as superior
and inferior filtering cut point. Frequency spectrum through
Fourier Fast Transform was used which allows the manual
filtering using Notch, at 60 Hz frequency the same of energy
supply interference.
Once the sign was filtered and the interferences taken off, the
software module that allows RMS values extraction, was used
to obtain maximum and minimum statistic parameters, and the
mean electric activity in microvolt (mV). Muscle electric activities
were captured during sustained vowel and speech, in usual and
strong intensities, converted to microvolt in percentage of normalization parameter, previously defined,11 according to Table 2.
At second analysis moment, GRBASI international scale, in
Likert, was used to measure general dysphonia grade, which allowed quantifying and qualifying the impact of general voice
deviation (G parameter) as follows: 0 , absence of dysphonia;
1 , slight deviation; 2 , moderate deviations; and 3 , severe
deviations.
Assuming MVSA as standard for electric activity sign
normalization, associations between electromyography and
acoustic analysis were searched, comparing dysphonic and
129.e12
TABLE 2.
Statement of Criteria and Formulas for Converting the Electrical Activity of the Extrinsic Laryngeal Muscles from Microvolts
to Percentage
Task
MVSA
Emission of
vowel //
Count emission
Normalizing
Parameter
Mean
Peak
Emission
Formula for Calculation
EA of emission %
EA of emission mV3100
EA of parameter admitted as 100%mV
Peak
Vowel //
Count
FIGURE 2. Box-plot of the overall median time of vocal complaints, according to study groups.
129.e13
TABLE 3.
Distribution of Mean and Standard-Error of the Mean Normalized Electrical Activity by MVSA of Muscle Groups, According
to the Task and Comparison Groups
Means and Standard Errors of the Mean
Normalized Electrical Activity by MVSA
According to Comparison Group
Tasks
D (n 19) (M Sem)
ND (n 22) (M Sem)
P Value
Vocal rest
Vowel // in usual intensity
Vowel // in strong intensity
Count of 20 to 30 in usual intensity
Count of 20 to 30 in strong intensity
Vocal rest
Vowel // in usual intensity
Vowel // in strong intensity
Count of 20 to 30 in usual intensity
Count of 2030 in strong intensity
17.30 2.32
63.33 11.72
69.62 11.83
87.63 13.28
95.41 15.44
14.48 3.08
27.92 2.77
41.57 6.37
45.32 5.02
63.69 7.94
30.54 5.83
71.69 12.61
100.29 16.00
91.34 14.50
128.06 17.36
17.51 4.07
44.96 6.09
80.16 10.49
73.24 11.14
107.97 14.54
0.053
0.622
0.142
0.866
0.174
0.567
0.016
0.003
0.030
0.012
Muscle Evaluated
IH
SH
DISCUSSION
The results of this article had broken a paradigm: dysphonics
would have major electric activity (EA) because they recruit
more muscles fibers during sustained vowels emissions and
TABLE 4.
Distribution of the Differences of Means Normalized Electrical Activities by MVSA of Extrinsic Laryngeal Muscles Between
Emissions in Usual and Strong Intensities
Differences of Means Normalized Electrical Activities Between
Emissions in Usual and Strong Intensities
Muscle
Emission
P Value
IH
Vowel //
Count
Vowel //
Count
11.47 6.52
14.90 4.69
13.66 5.17
18.37 4.17
22.66 9.05
42.01 6.15
35.20 7.60
34.73 6.73
<0.001
<0.001
0.029
0.054
SH
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TABLE 5.
Distribution of Means and Standard Errors of Acoustic Parameters Measured in Emissions in Usual and Strong Intensities
Means and Standard-Errors
Acoustic Parameters
Fundamental frequency (Hz)
Intensity (dB)
Emission
P Values
195.08 14.10
244.77 10.88
194.66 7.59
262.52 12.48
0.979
0.297
184.86 10.67
255.14 11.13
180.97 7.64
264.99 8.91
0.764
0.489
64.20 1.05
79.54 1.36
68.74 1.23
83.38 0.94
0.009
0.023
50.22 1.15
61.70 1.38
53.32 1.40
66.24 1.15
0.101
0.015
Vowel //
Usual intensity
Strong intensity
Count of 20 to 30
Usual intensity
Strong intensity
Vowel //
Usual intensity
Strong intensity
Count of 20 to 30
Usual intensity
Strong intensity
TABLE 6.
Distribution of 19 Dysphonic Subjects According to the Vocal Deviation
Electric Activity (mV) by Dysphonic Grade
Muscles
Dysphonic in vowel // in usual intensity
Dysphonic in count of 20 to 30
Measurements in MSVA
IH
SH
Measurements in vocal rest
IH
SH
Emissions
5 (26.32)
6 (31.58)
9 (47.36)
9 (47.36)
5 (26.32)
4 (21.06)
Vowel//
Count of 20 to 30
Vowel//
Count of 20 to 30
43.50 14.11
40.78 11.79
56.25 13.12
50.62 12.10
35.59 5.54
35.34 5.60
43.38 9.60
43.27 9.63
20.27 3.13
19.56 3.99
39.37 7.42
46.87 7.63
Vowel//
Count of 20 to 30
Vowel//
Count of 20 to 30
5.28 1.24
4.84 1.07
4.22 1.60
3.98 1.33
4.30 0.64
4.30 0.64
1.45 0.48
3.97 0.49
3.61 0.51
3.85 0.60
3.58 0.69
3.22 0.77
Notes: Correspondence was maintained between the emission in usual intensity of vowel // and the emission of count of 20 to 30 by respective G consensus.
skeletal muscle tissue in variable portions. Slow contraction fibers are entitled type I, and fast contraction fibers, type II. These
last ones are subdivided into three subgroups: IIa, IIb, and
IId/x.24,25
Type I fibers are involved in aerobic and resistance activities
once they have major quantity of mitochondria, higher blood
flow, and more myoglobin, characterizing them as red fibers
and are, therefore, more resistant to fatigue. Type II fibers
have lower expressed myoglobin, therefore characterized as
white fibers. Type IIa has fast oxidative contraction and higher
contraction speed, but low resistance to fatigue. Type IIb has
fast glycolytic contraction and has lower mitochondria, activated when short and intense activity shots are necessary.
Type IId/x has intermediate properties between IIa and IIb.24,25
Hoh25 revised the reason of intrinsic laryngeal muscles to
have hybrid fiber type. It was identified that these muscles
composed by dynamic tissues, which characteristics may be
altered to attend the complexity of laryngeal functions (protection, breathing, swallowing and phonation, and last one phylogenetic) and therefore present different standards that may
suffer adaptive change with hormone and neural regulation.
However, the study does not research the extrinsic muscles.
Extrinsic laryngeal muscle has participation in voice modulation, contributing to size of vocal folds variations and resonant
characteristics.23,26 They act indirectly in phonation because
of its anchor in neck, pulling larynx and hyoid bone in four
directions: anterior, posterior, cranial, and caudal. These
muscles fixated on hyoid and other structures as jaw, mastoid,
and thorax bones are divided into SH and IH muscles.23
These muscles are theoretically antagonists because the first
has mainly the function to raise and the second the function to
lower the larynx. Muscle dynamics may favor change in function allowing that the antagonist muscle, for example, act as
synergist in other movement, but there is no evidence if this
biomechanics happens during phonation.
In cases of hyperfunction of extrinsic laryngeal muscles,
because of intensive or inappropriate use of voice, this tension
may raise the larynx, increase muscle mass in the neck, cause
pain during palpation of the regions, and therefore collaborating
to functional dysphonia or its worsening.27
Studying vocal tremor in six subjects using laryngeal EMG
by needle in two intrinsic muscles and two extrinsic: thyroid
and sternothyroid, during sustained vowel /i/ task, Finnegan
et al28 verified that even showing unsystematic responses
among the subjects, there was electric activity in these muscles
during emission.
Although the function of extrinsic muscles during phonation
is recognized, some aspects still require research. They act in
fixation of hyoid bone. However, looking to topographic dynamics of hyoid bone in laryngeal functions, because of its
importance in cranium-cervical stability, German et al29 identified the existence of an information gap about aspects as resistance to fatigue, contraction time, and hysteresis of muscles
fibers related to passive or active balance. Furthermore, the
lack of knowledge about the fiber composition disfavor inferences about muscle condition related to strength, resistance,
and fatigue.
129.e15
129.e16
Dysphonia severity seems to produce the worst muscle performance. It is interesting to remember that extrinsic muscles have
a direct relation to phonation, especially to fundamental
frequency.
Acoustic analysis of the mean loudness values showed lower
variability in the dysphonic group, which agree to the argument
that it is a necessary major energetic and metabolic support to
increase loudness and these subjects could not do it as normal
ones can.
Analyzing acoustic parameters of fundamental frequency
and loudness, finding lower value between dysphonics when
compared with normal seems to reinforce the hypothesis that
lower electric activity of extrinsic laryngeal muscles may
have contributed to its reduction.
To detect significant difference between dysphonic and
normal exclusively in loudness, P-values between 0.002 and
0.02, it is a strong indicative of association between dysphonia
and the difficulty to control loudness.
The results of rest test were also surprising. It was expected
that basal activity was increased due to muscle tension maintenance which is verified at dysphonic phonation. However, physiologically, it would be odd if this happened in this research
because of the lowest value of electric activity detected during
phonation. It is myoelectric principle that once a lower functional recruitment happens, the same must happen at basal activity, pointing out that evaluated muscle has low action
potential, limiting the contraction process.
It is necessary to suggest possible explanations to the presented results. The most likely as the methodology adopted,
which was based on previous studies that did not exclusively
evaluate SH and IH groups. Task repetitions, common in
myoelectric evaluations, were not arbitrary; the electromyography assessment method respected proper technical
directions.
MVSA normalization of SH and IH muscles also constitute a
differential, because it promoted the maximum contraction of
muscles directly involved in vocal function, differing from
other studies where normalization was performed using
maximum or submaximum contraction of muscles with indirect
relation to phonation.
CONCLUSION
Dysphonic subjects showed lower electric activity of extrinsic
laryngeal muscles when compared with nondysphonic. The
fact that the studied muscles groups had lower electric activity
in this population may be indicative of a reduction in muscle
resistance.
Another factor to be considered is the possibility of muscle
fatigue in dysphonics, perhaps by the excessive use of these
muscles, thus this finding may indicate the need to change the
voice therapy for these subjects. It seems reasonable to admit
that this therapy should invigorate these muscles instead of promote its relaxation.
Biochemical and histological analysis of these muscles
would better explain these results, because of the relation of
electric activity with the kind of muscle fiber and its conditions
Acknowledgments
The authors thanks the National Council of Technological and
Scientific Development (CNPq), which had a financial support
with Universal Edictal MCT/CNPQ 14/2009, area B, process
476412/2009. There are no conflicts of interest.
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