Laryngeal manipulation, not for the fainthearted

Laryngeal manipulation

A growing number of singers are turning to laryngeal manipulation and massage to relieve muscle tension around the larynx. A curious LINE HILTON attended a two-day Laryngeal Manual Therapy workshop so she could learn more about the practice.

Let me start with an admission: I’m a total voice geek. And when I heard that the Voice Workshop were hosting a course on Laryngeal Manipulation Therapy (LMT) with the renowned Jacob Lieberman I jumped at the chance to attend.

Lieberman is an osteopath and psychotherapist who specialises in voice. He’s quite a forthright character, not afraid to express his opinions in public. For instance, he doesn’t believe gastric reflux can affect the vocal folds – a controversial viewpoint in the world of voice.

Over many years he developed a specific protocol for examining and manipulating the larynx, releasing laryngeal muscle tension and mobilising the joints of the larynx. This treatment has become known as LMT. Many other practitioners massage the larger extrinsic muscles in the throat area, but Lieberman spent many years figuring out how to get into the deeper intrinsic muscles of the larynx and to release them through manipulation. He believes that LMT helps to change the neural pathways by interrupting the signal and retraining the muscle to perform optimally.

The reason why muscle tension is such a concern for singers is that contraction of these muscles can cause the larynx to be immobilised and pulled up into a higher position. This stops the vocal folds from functioning optimally and can result in a raised speaking pitch, loss of upper range, vocal fatigue and hoarseness. If left untreated, muscle tension can cause a host of other, more serious problems such as loss of voice and acute pain.

With many of my fellow singers reporting that LMT had worked wonders for them, I wanted to know more and to experience it myself. I was also eager to learn how to palpate. This is when the practitioner inspects an area of the body using their fingers or hands to gauge size, tension, movement and to identify any abnormalities of the anatomy.

I was joined at the workshop by variety of professionals including speech therapists, osteopaths, singing teachers, sports masseuses and even a musical director from the West End – all fellow voice geeks with a desire to understand the vocal instrument and mechanism more intimately.

We covered a wide variety of areas including the breathing mechanism, the larynx, neck anatomy, the temporal mandibular joint, the extrinsic and intrinsic muscles of the larynx, the tongue and the psyche. The workshop was a mix of theory, demonstrations and practice.

Here is some of what I learnt.

LMT can be painful

As part of the workshop we practised on each other and at times Lieberman worked on us, one particular maneouvre was surprisingly painful for me. I hadn’t realised that I had any tension until Lieberman went to work on my thyrohyoid muscle. This is the muscle that connects the hyoid bone and thyroid cartilage. It’s one of the muscles that brings the larynx back down during the swallowing process.

Thyrohyoid muscle
Thyrohyoid muscle.
By User:Mikael Häggström – Transferred from en.wikipedia to Commons by IngerAlHaosului using CommonsHelper., Public Domain, https://commons.wikimedia.org/w/index.php?curid=8984662

Following this manipulation, I felt more freedom of movement but after the workshop and for about three days the larynx area was painful to touch, though there was no discomfort when swallowing. Given my experience, I’d advise that singers avoid LMT just before a gig. Give yourself three to five days between treatment and performing to ensure any discomfort has subsided.

Be prepared for immediate results

Once tension is released, the larynx will drop. After some LMT from Lieberman, one guy’s speaking pitch dropped noticeably, and became richer and warmer.

While this is a good thing in the long term, it could cause pitching issues until the singer has adjusted to the lower larynx position. Another good reason not to get LMT done too close to a performance or recording.

How to palpate

Lieberman taught us how to use our fingers to find the various laryngeal structures such as the hyoid bone and the thyroid and cricoid cartilages.

When palpating you’re not just looking to identify the relevant structures, but the spaces between them. The smaller these spaces are, the greater the likelihood of muscle tension.

By the end of the two days I felt confident that I could identify the relevant structures and obvious muscle tensions. This will help me to know when to refer a singer on for treatment – which as a singer teacher was my aim.

Obviously, it would take much longer than two days to become proficient in LMT, you need a lot more training and practice. Singing teachers are not insured or deemed professionally qualified to manipulate, this would require a qualification such as massage (minimum level 3), professional indemnity for physical treatment, and membership of a professional body such as the NAMMT.

Jacob Lieberman demonstrating on vocal coach, Ian Nicholas
Consider the cause or causes of muscle tension

LMT relieves muscle tension but not necessarily the cause of the tension. If, for example, bad posture, anxiety or an inflammatory process caused the tension in the first place, you’d need to address the underlying problem otherwise the tension is likely to return.

As with so much to do with singing, it’s important to look at the big picture. This leads me to my next point…

Get a good history

Lieberman emphasised the importance of getting a detailed history. If you want to get to the root cause of the problem, consider issues such as past car accidents or neck, head or spinal injuries, sleeping patterns, medications, posture, chronic and acute illnesses, anxiety, stress and general health.

If the vocal problem is simply down to primary muscle tension, then manual therapy can be like a miracle cure – as soon as you release the tension, bingo, the voice is normal again.

But if there is something more complicated going on (and let’s face it, we singers are complex creatures) then you need to address the problem.

If for example the tension is caused by constantly clearing your throat due to a respiratory infection, the infection needs to be treated. If it’s caused by anxiety or neuroses, then that issue needs to be tackled. There could be more than one issue at play.

Testimonial

Fellow vocal coach and iSingmag contributor, Chris Johnson also attended the workshop. He says of the workshop: “Jacob’s class was just what I needed. The palpation skills I learnt have allowed me to feel how the larynx, and everything else attached to it, is working. Or, more to the point, how it’s overworking.

“When I combine that knowledge with what I hear in the vocal tone and with the behaviour of the singer, my ability to figure out the true cause of the problem grows massively. That can only mean that my clients are able to overcome blocks and develop even quicker, which ultimately benefits their careers and well-being. That’s makes me happy!”

Conclusions

LMT can be used to treat laryngeal tension when it arises, but I can also see it being part of a singer’s overall health and well-being strategy. Just as a sportsperson uses regular sports massages to stay in good shape to perform, I could see LMT being used on a regular, proactive basis by the pro singer. But it’s not a cure-all for bad technique, poor posture or ill health.

Referrals

After the workshop I asked leading ENT/Laryngologist, Nicholas Gibbons, based at the Lewisham Hospital, for his views on LMT. I was curious to learn if, and when, he would refer a singer for this kind of treatment.

His says he would do so, “when there is a history of, or evidence (from a voice clinic), of a feeling of tension and tightness in the neck that appears to increase with singing.”. He also says, “If LM doesn’t work, then further investigation would be required.”

Gibbons says a number of specialised physiotherapists and osteopaths do very similar things to Lieberman (who unfortunately is rarely in the UK). He name-checked Ed Blake at Physio Ed, Lyndsay Mudford and Nikki Moss.

Website: jacob-lieberman.co.uk

http://www.linehilton.com

iSing founder Line, is passionate about creating a place where singers can gain knowledge, skills, advice and support. Something she wishes she had when she first started. In her private practice she helps pro and semipro singers, artists and voice teachers with their voice, performance, mindset and teacher training. Her speciality areas include Performing Arts Medicine, anatomy, health, technique and mindset. She pulls on a wide range of qualifications, experiences and interests to assist her clients to build and develop the knowledge and skills they require for their craft. She is a member of the BVA, PAVA, PAMA, is an MU she.grows.X mentor and Education Section committee member and Advisor to Vocology In Practice, and a BAST singing teacher trainer.