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Kinesio Taping in Dysphonic Patients
ARTICLE IN PRESS Kinesio Taping in Dysphonic Patients Chiara Mezzedimi, Walter Livi, and Maria Carla Spinosi, Siena, Italy Summary: Objective. Kinesio taping (KT) is a method of elastic bandaging that produces a biomechanical effect on the organism. This study aims to evaluate its use in dysphonic patients tratment, as integrated part of speech therapy. Study Design. Randomized controlled Materials and Methods. Fifteen dysphonic patients were given the option to complement the speech therapy treatment with KT (DG1). 15 dysphonic patients suffering from similar conditions (DG2) who underwent traditional speech therapy were the control group. Results. After treatment, both DG1 and DG2 obtained a statistically significant improvement for jitter and noise-toharmonic ratio (P > 0.05) and showed an improvement in Voice Handicap Index (VHI) total (VHIt), VHI functional (VHIf), VHI emotional (VHIe), and VHI physical (VHIp). However, the improvement was statistically significant for VHIt (P = 0.0102), VHIe (P = 0.0349), and VHIp (P = 0.0366) in DG1, and only in VHIt (P = 0.0466) in DG2. In DG1, P had a lower value than in DG2 for VHIt, VHIe, and VHIp. In DG2, there were a few patients who after therapy had a VHIt higher than before therapy, whereas this did not occur in DG1. Conclusions. As expected, this study confirms the benefits of speech therapy. Although KT is not a substitute for speech therapy, our preliminary results and patients’ favorable response to KT encouraged us to continue with our studies on a larger scale. Further studies are required to better define the role of KT in speech therapy and evaluate its real effect over its placebo effect. Key Words: Kinesio taping–Taping–Speech therapy–Muscle tension dysphonia–Dysphonia.
INTRODUCTION Kinesio taping (KT) is an elastic tape that has become popular during the last 10 years, owing to its use by high-profile athletes including volleyball, soccer, and tennis players. This tape does not limit movement but supports it and activates the healing process.1 The scientific basis of KT is still to be understood. In scientific literature, an evidence-based KT efficacy is given for pain reduction, range of motion improvement, better recruitment of muscle motor units, and increased lymphatic activity.2 This technique was developed by the Japanese chiropractor Kenzo Kase in the 1970s,3 following the trail of another Japanese chiropractor, Murai, who was working in America over the possibility to facilitate tissue recovery and movements with a normal tape. KT got an international visibility during the Seoul Olympics in 1988, when it was used by the Japanese volleyball team. In recent years, KT has revolutionized physiotherapy and sports medicine. This method of elastic bandaging, thanks to its limited thickness and its particular characteristics of elasticity and adhesiveness, produces a biomechanical effect on the organism. Currently, KT is not only used in sports medicine and physiotherapy but also in gynecology, pediatrics, preventative medicine, osteopathy, neurology, and speech therapy. Human voice production is a complex mechanism that requires a perfect synchronization of laryngeal muscles and a proper glottis positioning. When this mechanism is not correctly performed, we have a vocal disorder (dysphonia) that can be classified as organic or functional. A functional voice disorder Accepted for publication January 18, 2017. From the ENT Department, Policlinico S.M. alle Scotte, Siena, Italy. Address correspondence and reprint requests to Maria Carla Spinosi, ENT Department, Policlinico S.M. alle Scotte, viale Bracci n.16, Siena, Italy. E-mail: mariacarla.spinosi@ gmail.com Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2017.01.012
occurs when vocal quality deteriorates in absence of anatomic and/or neurological factors. Today, the preferred term for functional dysphonia has become muscle tension dysphonia (MTD), because altered laryngeal muscle tension is believed to result in altered laryngeal performance despite normal anatomy.4 Individuals with MTD may have changes in cervical and perilaryngeal muscles,5,6 muscle pain at rest or during function,5,7 hyperactivity of extrinsic laryngeal muscles, limitation in the amplitude of the cervical movement,5,7 and even postural changes.8,9 Traditionally, the treatment of dysphonia related to muscle change uses body techniques, laryngeal massage and massage on the shoulder girdle, and postural changes in the neck and shoulder, besides techniques to balance the vocal production and the stabilization of voice emission.10 The objective of this study was to verify the effect of KT in the treatment of functional dysphonia, as an integrated part of speech therapy. MATERIALS AND METHODS Between September 2015 and March 2016, we enrolled consecutive patients suffering from MTD who came to the ENT Department of Policlinico S.M. alle Scotte, University Hospital Siena, and offered to them the possibility to associate KT to traditional speech therapy. We decided to exclude the following from our analysis: individuals with neurological dysphonia or who had presented with any general neurological alteration; people who underwent surgery of the larynx; individuals with reported thyroid changes (hypoor hyperthyroidism); and people reporting any sort of heart condition or gastroesophageal reflux disease, and those who smoke. Dysphonic group 1 (DG1) was composed of 15 individuals (12 women, with mean age of 27.6 years; and 3 men, with mean age of 26.6 years) who met those criteria and underwent traditional speech therapy and KT. All individuals signed the informed consent form.
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Journal of Voice, Vol. ■■, No. ■■, 2017
TABLE 1. Distribution of the Dysphonic Groups According to Phoniatric Examination Phoniatric Physical Examination
DG1 (%)
DG2 (%)
Bilateral thickening and median-posterior chink Bilateral nodules Median-posterior triangular chink Longitudinal chink
3 (20)
3 (20)
5 (33.3) 4 (26.7) 3 (20)
5 (33.3) 4 (26.7) 3 (20)
Abbreviations: DG1, dysphonic group 1; DG2, dysphonic group 2.
Our sample was composed of adults of both genders, aged between 18 and 45. We therefore decided to exclude individuals aged over 45 to make the case and control group homogeneous and exclude any possible interferences related to aging and presbyphonia.11 Dysphonic group 2 (DG2) was composed of 15 individuals (12 women, with mean age of 20.8 years; and 3 men, with mean age of 25.3 years) who met all the criteria and underwent traditional speech therapy only. All patients had already been submitted to phoniatric examination and showed cleft, thickening, or vocal nodules (Table 1); the groups were paired according to gender and age. We followed the SIFEL (Società Italiana di Foniatria E Logopedia—Italian Society of Phoniatric and Speech Therapy) protocol,12 and carried out a complete objective examination, evaluating global posture, respiration, laryngeal palpation (including Aronson’s sign), voice perception (G.I.R.B.A.S. scale—General degree of dysphonia, degree of voice Instability, degree of voice Roughness, degree of voice Breathiness, degree of voice Asthenia, degree of voice Strain).13 We performed a spectroacoustic voice examination, and we evaluated voice quality. Patients underwent a self-evaluation (Voice Handicap Index [VHI]) that observed the impact of vocal problematics over daily activities, the psychological impact, and the perception of voice characteristics. Acoustic analysis The computerized voice analysis was conducted using PRAAT software,14 and the sample chosen for analysis was the emission of the vowel “a,” ruling out the beginning and the end of the emission and observing the following: fundamental frequency (f0), disturbance measures (jitter, shimmer), and noise measurement (noise-to-harmonics ratio [NHR]). All these evaluations were performed before and after the treatment. Speech therapy Each subject had 10 voice therapy sessions with an experienced speech therapist for a total period of 2 months, as for standard Italian National Health Care System protocol. Vocal hygiene counseling was provided as an initial step of speech therapy. Vocal hygiene education included education on how the normal voice is produced, identification of individual vocal abuse patterns, education on how to reduce or eliminate the vocal abuse, emphasis on the importance of hydration, ed-
ucation on the adverse effects of irritants, and the influence of laryngopharyngeal reflux and certain medications. The speech therapy techniques applied varied according to phonatory behavior of the patient and aimed to reduce associated hyperkinetic behavior (anterior-posterior contraction, latero-lateral shortening of vocal tract) and to obtain the best possible vocal fold vibration.14 Therapy was directed toward progressive development of optimal breathing, abdominal support, and gentle improvement of intrinsic muscle strength and agility, without supraglottic hyperfunctional compensation. Abdominal breathing was practiced to maintain appropriate subglottic air pressure, avoiding shallow, upper chest breathing, and phonation on residual air. Humming, nasal resonance exercises, yawning-sigh technique, and laryngeal manipulation were the techniques more frequently applied. KT application During their last week of speech therapy, patients of DG1 underwent KT. KT consists of a thin elastic tape that can be stretched up to 50% of its original length, resulting in lower restriction compared to conventional tapes. KT was applied in “Y” form over the anterior region of the neck (Figures 1 and 2). The literature on KT application in speech therapy is still in its infancy; thus, we found a very limited number of studies to look up while deciding on tape placement and duration of placement. Voice is the product of the synergic work of internal and external muscles (supra and infrahyoid). The cricothyroid muscle stretches as well as tenses the vocal ligaments, and it is fundamental for the creation of forceful speech. This muscle originates from the anterolateral aspect of the cricoid cartilage and attaches to the inferior margin and inferior horn of the thyroid cartilage. Because very few studies and guidelines addressed the issue of tape placement, we decided to apply KT in the anterior neck considering both the anatomy and the physiology of the
FIGURE 1. Kinesio taping application.
FIGURE 2. Kinesio taping application.
ARTICLE IN PRESS Chiara Mezzedimi, et al
KT in Dysphonic Patients
TABLE 2. DG1: Mean, Standard Deviation, and P values Before and After Voice Therapy Acoustic Analysis Jitter % Shimmer % NHR
Before Therapy
After Therapy
P Value
2.3 ± 1.27 4.8 ± 1.95 0.13 ± 0.14
1.9 ± 0.97 4.2 ± 1.29 0.10 ± 0.02
0.04 0.06 0.04
P values on Wilcoxon test are also reported. Abbreviations: DG1, dysphonic group 1; NHR, noise-to-harmonic ratio.
TABLE 3. DG2: Mean, Standard Deviation, and P Values Before and After Voice Therapy Acoustic Analysis Jitter % Shimmer % NHR
Before Therapy
After Therapy
P Value
2.2 ± 1.26 4.6 ± 1.92 0.13 ± 0.21
1.8 ± 0.96 4.1 ± 1.22 0.11 ± 0.02
0.04 0.06 0.04
P values on Wilcoxon test are also reported. Abbreviations: DG2, dysphonic group 2; NHR, noise-to-harmonic ratio.
TABLE 4. DG1 VHI Data: Mean ± Standard Deviation of Pre- and Posttherapy and P Values (alpha 0.05) on Wilcoxon SignedRank Test (Two-Tailed) Measures DG1
VHIt VHIf VHIe VHIp
Before Voice Therapy
After Voice Therapy
P Value
25.8 ± 6.3 5.7 + 2.1 4.8 + 2.1 15.3 + 4.1
22.9 ± 5.2 5.3 + 1.5 4.1 + 1.5 13.5 + 3.4
0.0102 0.1902 0.0349 0.0366
Abbreviations: DG1, dysphonic group 1; VHI, Voice Handicap Index; VHIe, VHI emotional; VHIf, VHI functional; VHIp, physical; VHIt, VHI total.
3 cricothyroid muscle, thus giving the tape a “y”-shape to be attached around the muscle and supporting its work. Statistical analysis Before and after voice therapy, the Jitter, Shimmer, and NHR means and standard deviations have been computed for both DG1 and DG2. The Wilcoxon test has been performed to evaluate any significant difference before and after voice therapy (P value). The Wilcoxon signed-rank test is a nonparametric statistical hypothesis test that compares two related samples to assess whether their population-mean ranks differ. Results are reported in Tables 2 and 3. The mean ± standard deviation of pre- and posttherapy VHI in DG1 and DG2 has been computed, too, and then the Wilcoxon signed-rank test (two-tailed) has been performed. Results are shown in Tables 4 and 5. RESULTS As expected, both DG1 and DG2 obtained an improvement after therapy evaluating acoustic analysis data (see Tables 2 and 3). This improvement was statistically significant for jitter and NHR (P > 0.05). Moreover, all patients showed an improvement (Tables 4 and 5, Figures 3 and 4) in VHI total (VHIt), VHI functional (VHIf), VHI emotional (VHIe), and VHI physical (VHIp). However, the improvement was statistically significant for VHIt (P = 0.0102), VHIe (P = 0.0349), and VHIp (P = 0.0366) in DG1, and only in VHIt (P = 0.0466) in DG2. Comparing P values, it could be noted that in DG1, P has a lower value than in DG2 for VHIt, VHIe, and VHIp. As shown in Figures 3 and 4, in DG2 there were a few patients who after therapy had a VHIt higher than before therapy, whereas this did not occur in DG1. DISCUSSION The KT approximately has the same thickness as the epidermis and is made of polymer elastic strand wrapped by 100% cotton fibers, which allow a fast evaporation of body moisture and drying.1 KT is latex free and the adhesive properties are 100% acrylic with heat-activated glue. The tape is lightweight and thin
TABLE 5. DG2 VHI Data: Mean ± Standard Deviation and P values Before and After Voice Therapy DG2
VHIt VHIf VHIe VHIp
Before Voice Therapy
After Voice Therapy
P Value
25.7 + 4.8 5.6 + 2.2 4.9 + 1.9 15.2 + 4
23.5 + 5.6 4.7 + 1.8 4.3 + 1.3 14.4 + 4.6
0.0466 0.0751 0.0784 0.1585
Abbreviations: DG2, dysphonic group 2; VHI, Voice Handicap Index; VHIe, VHI emotional; VHIf, VHI functional; VHIp, physical; VHIt, VHI total.
FIGURE 3. VHIt in DG1 before and after speech therapy. DG1, dysphonic group 1; VHIt, Voice Handicap Index total.
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FIGURE 4. VHIt in DG2 before and after speech therapy. DG2, dysphonic group 2; VHIt, Voice Handicap Index total.
to reduce patient discomfort. It is important for the material to be hypoallergenic and clinically tested. The elasticity only follows the longitudinal direction. KT is able to stretch up to 50% of its resting length and can stay on the body for about 3–5 days— showers included—without compromising the adhesive quality. The therapeutic effect is continuous during the 24 hours and part of the effect persists even after several weeks after removal.15,16 There are a variety of uses for KT, but available data for its use in voice disorders are limited.17 Because there is paucity of literature on tape placement, KT has been applied to the anterior region of the neck and has been given a “y”-shape. Alternative tape placement and alternative tape shapes should be tested both in the neck and/or in other areas. For instance, KT might be applied to the diaphragm because all DG1 patients had a pneumophonic discrepancy between highcostal respiration and frequent neck muscle contractions have been observed. The possibility of combining alternative KT placements with simultaneous or subsequent tape applications is not to exclude for future utilizations. In addition, being the first attempt to use KT, we decided to apply it for a limited time because we did not want to discourage the patient from following the standard speech therapy program or lead them to abandon the speech treatment in case of unfavorable response to KT or discomfort. Of course, our goal is to extend the application over time, especially because the patients we studied showed a remarkably good disposition toward KT treatment and a positive compliance after following the speech therapist indications correctly. As one might expect, both DG1 and DG2 obtained a significant improvement after therapy and an improvement in VHI. This improvement should be due to the speech therapy. However, according to the VHI, we noticed that in DG1 there was a general better improvement of life quality related to the impact of vocal problematics over daily activities, the psychological impact, and the perception of voice characteristics.17 The speech therapy work was also directed to improve patients’ sensibility toward a better voice self-consciousness and a better knowledge of voice characteristics.1
Journal of Voice, Vol. ■■, No. ■■, 2017
CONCLUSION The purpose of this preliminary study was to determine the potential benefit of KT in dysphonic patients. Although KT is not a substitute for speech therapy, it may increase and maintain the positive effects of speech therapy over time. KT application could accelerate the functional recovery time of patients, and also offer a better rehabilitation response to the problematics associated with dysphonia, like swallowing difficulties and neck scars. As the underlying reasons for the KT efficacy are still unclear, there are only relative contraindications: pathologies of the circulatory system, skin wounds (risk of infection), generalized edema, skin pathologies, or allergic irritation.2 A correct application, through a correct technique, on shaved and dry skin, is fundamental, otherwise symptoms might be increased by KT. In literature there are studies that support a multidisciplinary approach for a better treatment of voice disorders; for example, a study by Tomlinson and Archer and another by Craig et al suggested that physical therapy performed by a specialized expert may aid patients with MTD.18,19 According to the results of this study, we can assume that KT can have an interesting role in speech therapy. Moreover, its cost (could be bought for 6–10€) should not be a problem for the Health Care System or any patient. One problem encountered was the difficulty to distinguish between the real effect of the tape and the placebo effect regarding patient’s dysphonia. Further studies are required to asses this problem to better define the role of KT in speech therapy and its potential use in case of voice professionals (singers, actors, teachers, etc), and to better define tape placement, application frequency and duration, its use for dysphonia as well as for dysphagia, and, in general, to establish its true merits.
REFERENCES 1. Comploi G. Manuale Kinesiology Taping, 2011. 2. Comploi G. Kinesiology Taping—Applicazioni muscolari, 2011. 3. Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the Kinesio Taping Method. 2nd ed. Albuquerque, NM: Kinesio Taping Association; 2003. 4. Behlau M, Madazio G, Pontes P. Disfonias organofuncionais. In: Azevedo R, Pontes PAL, eds. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2001:296. 5. Menoncin LCM, Jurkiewicz AL, Silvério KCA, et al. Alterações musculares e esqueléticas cervicais em mulheres disfônicas. Int Arch Otorhinolaryngol. 2010;14:461–466. 6. Bigaton DR, Silvério KCA, Berni KCS, et al. Postura craniocervical em mulheres disfônicas. Rev Soc Bras Fonoaudiol. 2010;15:329–334. 7. Angsuwarangsee T, Morrison M. Extrinsic laryngeal muscular tension in patients with voice disorders. J Voice. 2002;16:333–343. 8. Hsiung MW, Hsiao YC. The characteristic features of muscle tension dysphonia before and after surgery in benign lesions of the vocal fold. ORL J Otorhinolaryngol Relat Spec. 2004;66:246–254. 9. Kooijman PG, de Jong FI, Oudes MJ, et al. Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints. Folia Phoniatr Logop. 2005;57:134–147. 10. Behlau M, Gama ACC, Cielo CA. Técnicas Vocais. In: Marchesam IQ, Silva HJ, Tomé MC, eds. Tratado das Especialidades em Fonoaudiologia. São Paulo: Guanabara-Koogan; 2014:127–152. 11. Mezzedimi C, Di Francesco M, Livi W, et al. Objective evaluation of presbyphonia: spectroacoustic study on 142 patients with PRAAT. J Voice.
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12.
13. 14.
15.
KT in Dysphonic Patients
2016;doi:10.1016/j.jvoice.2016.05.022. pii: S0892-1997(16)30060-1. PubMed PMID: 27427181. Bergamini G, Fustos R, Ricci Maccarini A, et al. La valutazione dei risultati del trattamento logopedico delle disfonie. Il protocollo SIFEL. Acta Phoniatrica Latina, Editrice La Garangola, Padova; 2002. Magnani S. Curare la voce: diagnosi e terapia dei disturbi della voce. Milan: Editore Franco Angeli; 2013. Wirz SL, Mackenzie Beck J. Assessment of Voice Quality: The Vocal Profiles Analysis Scheme. Perceptual Approaches to Communication Disorders. London: Whurr Publisher; 1995. K-Active Europe, K-Active Therapie; Weniger Schmerz—mehr Mobilität, 2008.
5 16. Comploi G. Kinesiology taping—an evidence based method? In: Annual K, ed. Active Taping International Symposium. Frammersbach, Germany: 2009. 17. Bertini PD, Mazzocchi R, Romizi V. L’utilizzo del kinesio taping come ausilio alla terapia logopedica. LOGOPaeDIA, Vol. 1. 2011. 18. Tomlinson CA, Archer KR. Manual therapy and exercise to improve outcomes in patients with muscle tension dysphonia: a case series. Phys Ther. 2015;95:117–128. doi:10.2522/ptj.20130547. PubMed PMID: 25256740. PubMed Central PMCID: PMC4295082. 19. Craig J, Tomlinson C, Stevens K, et al. Combining voice therapy and physical therapy: a novel approach to treating muscle tension dysphonia. J Commun Disord. 2015;58:169–178. doi:10.1016/j.jcomdis.2015.05.001. PubMed PMID: 26012419. PubMed Central PMCID:PMC4653091.
INTRODUCTION Kinesio taping (KT) is an elastic tape that has become popular during the last 10 years, owing to its use by high-profile athletes including volleyball, soccer, and tennis players. This tape does not limit movement but supports it and activates the healing process.1 The scientific basis of KT is still to be understood. In scientific literature, an evidence-based KT efficacy is given for pain reduction, range of motion improvement, better recruitment of muscle motor units, and increased lymphatic activity.2 This technique was developed by the Japanese chiropractor Kenzo Kase in the 1970s,3 following the trail of another Japanese chiropractor, Murai, who was working in America over the possibility to facilitate tissue recovery and movements with a normal tape. KT got an international visibility during the Seoul Olympics in 1988, when it was used by the Japanese volleyball team. In recent years, KT has revolutionized physiotherapy and sports medicine. This method of elastic bandaging, thanks to its limited thickness and its particular characteristics of elasticity and adhesiveness, produces a biomechanical effect on the organism. Currently, KT is not only used in sports medicine and physiotherapy but also in gynecology, pediatrics, preventative medicine, osteopathy, neurology, and speech therapy. Human voice production is a complex mechanism that requires a perfect synchronization of laryngeal muscles and a proper glottis positioning. When this mechanism is not correctly performed, we have a vocal disorder (dysphonia) that can be classified as organic or functional. A functional voice disorder Accepted for publication January 18, 2017. From the ENT Department, Policlinico S.M. alle Scotte, Siena, Italy. Address correspondence and reprint requests to Maria Carla Spinosi, ENT Department, Policlinico S.M. alle Scotte, viale Bracci n.16, Siena, Italy. E-mail: mariacarla.spinosi@ gmail.com Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2017.01.012
occurs when vocal quality deteriorates in absence of anatomic and/or neurological factors. Today, the preferred term for functional dysphonia has become muscle tension dysphonia (MTD), because altered laryngeal muscle tension is believed to result in altered laryngeal performance despite normal anatomy.4 Individuals with MTD may have changes in cervical and perilaryngeal muscles,5,6 muscle pain at rest or during function,5,7 hyperactivity of extrinsic laryngeal muscles, limitation in the amplitude of the cervical movement,5,7 and even postural changes.8,9 Traditionally, the treatment of dysphonia related to muscle change uses body techniques, laryngeal massage and massage on the shoulder girdle, and postural changes in the neck and shoulder, besides techniques to balance the vocal production and the stabilization of voice emission.10 The objective of this study was to verify the effect of KT in the treatment of functional dysphonia, as an integrated part of speech therapy. MATERIALS AND METHODS Between September 2015 and March 2016, we enrolled consecutive patients suffering from MTD who came to the ENT Department of Policlinico S.M. alle Scotte, University Hospital Siena, and offered to them the possibility to associate KT to traditional speech therapy. We decided to exclude the following from our analysis: individuals with neurological dysphonia or who had presented with any general neurological alteration; people who underwent surgery of the larynx; individuals with reported thyroid changes (hypoor hyperthyroidism); and people reporting any sort of heart condition or gastroesophageal reflux disease, and those who smoke. Dysphonic group 1 (DG1) was composed of 15 individuals (12 women, with mean age of 27.6 years; and 3 men, with mean age of 26.6 years) who met those criteria and underwent traditional speech therapy and KT. All individuals signed the informed consent form.
ARTICLE IN PRESS 2
Journal of Voice, Vol. ■■, No. ■■, 2017
TABLE 1. Distribution of the Dysphonic Groups According to Phoniatric Examination Phoniatric Physical Examination
DG1 (%)
DG2 (%)
Bilateral thickening and median-posterior chink Bilateral nodules Median-posterior triangular chink Longitudinal chink
3 (20)
3 (20)
5 (33.3) 4 (26.7) 3 (20)
5 (33.3) 4 (26.7) 3 (20)
Abbreviations: DG1, dysphonic group 1; DG2, dysphonic group 2.
Our sample was composed of adults of both genders, aged between 18 and 45. We therefore decided to exclude individuals aged over 45 to make the case and control group homogeneous and exclude any possible interferences related to aging and presbyphonia.11 Dysphonic group 2 (DG2) was composed of 15 individuals (12 women, with mean age of 20.8 years; and 3 men, with mean age of 25.3 years) who met all the criteria and underwent traditional speech therapy only. All patients had already been submitted to phoniatric examination and showed cleft, thickening, or vocal nodules (Table 1); the groups were paired according to gender and age. We followed the SIFEL (Società Italiana di Foniatria E Logopedia—Italian Society of Phoniatric and Speech Therapy) protocol,12 and carried out a complete objective examination, evaluating global posture, respiration, laryngeal palpation (including Aronson’s sign), voice perception (G.I.R.B.A.S. scale—General degree of dysphonia, degree of voice Instability, degree of voice Roughness, degree of voice Breathiness, degree of voice Asthenia, degree of voice Strain).13 We performed a spectroacoustic voice examination, and we evaluated voice quality. Patients underwent a self-evaluation (Voice Handicap Index [VHI]) that observed the impact of vocal problematics over daily activities, the psychological impact, and the perception of voice characteristics. Acoustic analysis The computerized voice analysis was conducted using PRAAT software,14 and the sample chosen for analysis was the emission of the vowel “a,” ruling out the beginning and the end of the emission and observing the following: fundamental frequency (f0), disturbance measures (jitter, shimmer), and noise measurement (noise-to-harmonics ratio [NHR]). All these evaluations were performed before and after the treatment. Speech therapy Each subject had 10 voice therapy sessions with an experienced speech therapist for a total period of 2 months, as for standard Italian National Health Care System protocol. Vocal hygiene counseling was provided as an initial step of speech therapy. Vocal hygiene education included education on how the normal voice is produced, identification of individual vocal abuse patterns, education on how to reduce or eliminate the vocal abuse, emphasis on the importance of hydration, ed-
ucation on the adverse effects of irritants, and the influence of laryngopharyngeal reflux and certain medications. The speech therapy techniques applied varied according to phonatory behavior of the patient and aimed to reduce associated hyperkinetic behavior (anterior-posterior contraction, latero-lateral shortening of vocal tract) and to obtain the best possible vocal fold vibration.14 Therapy was directed toward progressive development of optimal breathing, abdominal support, and gentle improvement of intrinsic muscle strength and agility, without supraglottic hyperfunctional compensation. Abdominal breathing was practiced to maintain appropriate subglottic air pressure, avoiding shallow, upper chest breathing, and phonation on residual air. Humming, nasal resonance exercises, yawning-sigh technique, and laryngeal manipulation were the techniques more frequently applied. KT application During their last week of speech therapy, patients of DG1 underwent KT. KT consists of a thin elastic tape that can be stretched up to 50% of its original length, resulting in lower restriction compared to conventional tapes. KT was applied in “Y” form over the anterior region of the neck (Figures 1 and 2). The literature on KT application in speech therapy is still in its infancy; thus, we found a very limited number of studies to look up while deciding on tape placement and duration of placement. Voice is the product of the synergic work of internal and external muscles (supra and infrahyoid). The cricothyroid muscle stretches as well as tenses the vocal ligaments, and it is fundamental for the creation of forceful speech. This muscle originates from the anterolateral aspect of the cricoid cartilage and attaches to the inferior margin and inferior horn of the thyroid cartilage. Because very few studies and guidelines addressed the issue of tape placement, we decided to apply KT in the anterior neck considering both the anatomy and the physiology of the
FIGURE 1. Kinesio taping application.
FIGURE 2. Kinesio taping application.
ARTICLE IN PRESS Chiara Mezzedimi, et al
KT in Dysphonic Patients
TABLE 2. DG1: Mean, Standard Deviation, and P values Before and After Voice Therapy Acoustic Analysis Jitter % Shimmer % NHR
Before Therapy
After Therapy
P Value
2.3 ± 1.27 4.8 ± 1.95 0.13 ± 0.14
1.9 ± 0.97 4.2 ± 1.29 0.10 ± 0.02
0.04 0.06 0.04
P values on Wilcoxon test are also reported. Abbreviations: DG1, dysphonic group 1; NHR, noise-to-harmonic ratio.
TABLE 3. DG2: Mean, Standard Deviation, and P Values Before and After Voice Therapy Acoustic Analysis Jitter % Shimmer % NHR
Before Therapy
After Therapy
P Value
2.2 ± 1.26 4.6 ± 1.92 0.13 ± 0.21
1.8 ± 0.96 4.1 ± 1.22 0.11 ± 0.02
0.04 0.06 0.04
P values on Wilcoxon test are also reported. Abbreviations: DG2, dysphonic group 2; NHR, noise-to-harmonic ratio.
TABLE 4. DG1 VHI Data: Mean ± Standard Deviation of Pre- and Posttherapy and P Values (alpha 0.05) on Wilcoxon SignedRank Test (Two-Tailed) Measures DG1
VHIt VHIf VHIe VHIp
Before Voice Therapy
After Voice Therapy
P Value
25.8 ± 6.3 5.7 + 2.1 4.8 + 2.1 15.3 + 4.1
22.9 ± 5.2 5.3 + 1.5 4.1 + 1.5 13.5 + 3.4
0.0102 0.1902 0.0349 0.0366
Abbreviations: DG1, dysphonic group 1; VHI, Voice Handicap Index; VHIe, VHI emotional; VHIf, VHI functional; VHIp, physical; VHIt, VHI total.
3 cricothyroid muscle, thus giving the tape a “y”-shape to be attached around the muscle and supporting its work. Statistical analysis Before and after voice therapy, the Jitter, Shimmer, and NHR means and standard deviations have been computed for both DG1 and DG2. The Wilcoxon test has been performed to evaluate any significant difference before and after voice therapy (P value). The Wilcoxon signed-rank test is a nonparametric statistical hypothesis test that compares two related samples to assess whether their population-mean ranks differ. Results are reported in Tables 2 and 3. The mean ± standard deviation of pre- and posttherapy VHI in DG1 and DG2 has been computed, too, and then the Wilcoxon signed-rank test (two-tailed) has been performed. Results are shown in Tables 4 and 5. RESULTS As expected, both DG1 and DG2 obtained an improvement after therapy evaluating acoustic analysis data (see Tables 2 and 3). This improvement was statistically significant for jitter and NHR (P > 0.05). Moreover, all patients showed an improvement (Tables 4 and 5, Figures 3 and 4) in VHI total (VHIt), VHI functional (VHIf), VHI emotional (VHIe), and VHI physical (VHIp). However, the improvement was statistically significant for VHIt (P = 0.0102), VHIe (P = 0.0349), and VHIp (P = 0.0366) in DG1, and only in VHIt (P = 0.0466) in DG2. Comparing P values, it could be noted that in DG1, P has a lower value than in DG2 for VHIt, VHIe, and VHIp. As shown in Figures 3 and 4, in DG2 there were a few patients who after therapy had a VHIt higher than before therapy, whereas this did not occur in DG1. DISCUSSION The KT approximately has the same thickness as the epidermis and is made of polymer elastic strand wrapped by 100% cotton fibers, which allow a fast evaporation of body moisture and drying.1 KT is latex free and the adhesive properties are 100% acrylic with heat-activated glue. The tape is lightweight and thin
TABLE 5. DG2 VHI Data: Mean ± Standard Deviation and P values Before and After Voice Therapy DG2
VHIt VHIf VHIe VHIp
Before Voice Therapy
After Voice Therapy
P Value
25.7 + 4.8 5.6 + 2.2 4.9 + 1.9 15.2 + 4
23.5 + 5.6 4.7 + 1.8 4.3 + 1.3 14.4 + 4.6
0.0466 0.0751 0.0784 0.1585
Abbreviations: DG2, dysphonic group 2; VHI, Voice Handicap Index; VHIe, VHI emotional; VHIf, VHI functional; VHIp, physical; VHIt, VHI total.
FIGURE 3. VHIt in DG1 before and after speech therapy. DG1, dysphonic group 1; VHIt, Voice Handicap Index total.
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FIGURE 4. VHIt in DG2 before and after speech therapy. DG2, dysphonic group 2; VHIt, Voice Handicap Index total.
to reduce patient discomfort. It is important for the material to be hypoallergenic and clinically tested. The elasticity only follows the longitudinal direction. KT is able to stretch up to 50% of its resting length and can stay on the body for about 3–5 days— showers included—without compromising the adhesive quality. The therapeutic effect is continuous during the 24 hours and part of the effect persists even after several weeks after removal.15,16 There are a variety of uses for KT, but available data for its use in voice disorders are limited.17 Because there is paucity of literature on tape placement, KT has been applied to the anterior region of the neck and has been given a “y”-shape. Alternative tape placement and alternative tape shapes should be tested both in the neck and/or in other areas. For instance, KT might be applied to the diaphragm because all DG1 patients had a pneumophonic discrepancy between highcostal respiration and frequent neck muscle contractions have been observed. The possibility of combining alternative KT placements with simultaneous or subsequent tape applications is not to exclude for future utilizations. In addition, being the first attempt to use KT, we decided to apply it for a limited time because we did not want to discourage the patient from following the standard speech therapy program or lead them to abandon the speech treatment in case of unfavorable response to KT or discomfort. Of course, our goal is to extend the application over time, especially because the patients we studied showed a remarkably good disposition toward KT treatment and a positive compliance after following the speech therapist indications correctly. As one might expect, both DG1 and DG2 obtained a significant improvement after therapy and an improvement in VHI. This improvement should be due to the speech therapy. However, according to the VHI, we noticed that in DG1 there was a general better improvement of life quality related to the impact of vocal problematics over daily activities, the psychological impact, and the perception of voice characteristics.17 The speech therapy work was also directed to improve patients’ sensibility toward a better voice self-consciousness and a better knowledge of voice characteristics.1
Journal of Voice, Vol. ■■, No. ■■, 2017
CONCLUSION The purpose of this preliminary study was to determine the potential benefit of KT in dysphonic patients. Although KT is not a substitute for speech therapy, it may increase and maintain the positive effects of speech therapy over time. KT application could accelerate the functional recovery time of patients, and also offer a better rehabilitation response to the problematics associated with dysphonia, like swallowing difficulties and neck scars. As the underlying reasons for the KT efficacy are still unclear, there are only relative contraindications: pathologies of the circulatory system, skin wounds (risk of infection), generalized edema, skin pathologies, or allergic irritation.2 A correct application, through a correct technique, on shaved and dry skin, is fundamental, otherwise symptoms might be increased by KT. In literature there are studies that support a multidisciplinary approach for a better treatment of voice disorders; for example, a study by Tomlinson and Archer and another by Craig et al suggested that physical therapy performed by a specialized expert may aid patients with MTD.18,19 According to the results of this study, we can assume that KT can have an interesting role in speech therapy. Moreover, its cost (could be bought for 6–10€) should not be a problem for the Health Care System or any patient. One problem encountered was the difficulty to distinguish between the real effect of the tape and the placebo effect regarding patient’s dysphonia. Further studies are required to asses this problem to better define the role of KT in speech therapy and its potential use in case of voice professionals (singers, actors, teachers, etc), and to better define tape placement, application frequency and duration, its use for dysphonia as well as for dysphagia, and, in general, to establish its true merits.
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