An Exploratory Study of Voice Change Associated

With Healthy Speakers After Transcutaneous

Electrical Stimulation to Laryngeal Muscles
*Linda P. Fowler, †Mary Gorham-Rowan, and ‡Edie R. Hapner, *zAtlanta and yValdosta, Georgia

Summary: Objectives. The purpose of this study was to determine if measurable changes in fundamental frequency
(F0) and relative sound level (RSL) occurred in healthy speakers after transcutaneous electrical stimulation (TES) as
applied via VitalStim (Chattanooga Group, Chattanooga, TN).
Study Design. A prospective, repeated-measures design.
Methods. Ten healthy female and 10 healthy male speakers, 20–53 years of age, participated in the study. All partic-
ipants were nonsmokers and reported negative history for voice disorders. Participants received 1 hour of TES while
engaged in eating, drinking, and conversation to simulate a typical dysphagia therapy protocol. Voice recordings
were obtained before and immediately after TES. The voice samples consisted of a sustained vowel task and reading
of the Rainbow Passage. Measurements of F0 and RSL were obtained using TF32 (Milenkovic, 2005, University of
Wisconsin). The participants also reported any sensations 5 minutes and 24 hours after TES.
Results. Measurable changes in F0 and RSL were found for both tasks but were variable in direction and magnitude.
These changes were not statistically significant. Subjective comments ranged from reports of a vocal warm-up feeling to
delayed onset muscle soreness.
Conclusions. These findings demonstrate that application of TES produces measurable changes in F0 and RSL. How-
ever, the direction and magnitude of these changes are highly variable. Further research is needed to determine factors
that may affect the extent to which TES contributes to significant changes in voice.
Key Words: Transcutaneous electrical stimulation–Percutaneous electrical stimulation–Muscle fatigue–Delayed
onset muscle injury.

INTRODUCTION
The use of electrotherapy for treating physical ailments can be
traced back to 46 AD when a Roman physician used the shock
from electric eels to treat headaches and gout. Electrotherapy
has since endured cyclical popularity.1 In 1961, Liberson et al
demonstrated the possible benefits of using electrical stimula-
tion to improve the gait of hemiplegic patients.2 This introduc-
tion by Libeson et al marked the beginning of the current
widespread use of a variety of electrical therapy techniques, in-
cluding transcutaneous electrical stimulation (TES), in the
rehabilitation of weakened skeletal muscles. In contrast, the
use of TES to treat swallowing and voice disorders by
speech-language pathologists (SLPs) is relatively new.3 Clini-
cians who use TES to treat dysphagia have given anecdotal
reports of perceptual voice changes in their patients (VitalStim
Training, Atlanta, Georgia, 2004). Consequently, these clini-
cians have begun using TES to treat a variety of voice disorders
in the absence of coexisting dysphagia.
Accepted for publication July 21, 2009.
A portion of this research was presented at the 35th Annual Voice Symposium, titled
Voice Change in Normal Speakers Associated with Surface Electrical Stimulation, Phila-
delphia, PA, June 2006.
From the *Department of Educational Psychology and Special Education, Georgia State
University, Atlanta, Georgia; yDepartment of Communication Sciences and Disorders,
Valdosta State University, Valdosta, Georgia; and the zEmory Voice Center, Emory Uni-
versity, Atlanta, Georgia.
Address correspondence and reprint requests to Linda P. Fowler, Educational Psychol-
ogy and Special Education, Georgia State University, P.O. Box 3979, Atlanta, GA
30302-3979. E-mail: lpfowler@gsu.edu
Journal of Voice, Vol. 25, No. 1, pp. 54-61
0892-1997/$36.00
Ó 2011 The Voice Foundation
doi:10.1016/j.jvoice.2009.07.006
Although the use of TES is new to voice therapy regimes, the
practice of applying electrical stimulation to laryngeal muscles
is not new. The feasibility of using percutaneous electrical
stimulation (PES) to improve contraction in select intrinsic
laryngeal muscles was first suggested by Zealear and Dedo4
in 1977 after they successfully reanimated paralyzed laryngeal
muscles in canines. Subsequent animal studies in the field of
otolaryngology have demonstrated the effectiveness of PES in
restoring abduction and adduction in paralyzed laryngeal
muscles.5–7 Applications of PES to laryngeal muscles in
humans include using an implantable device on the posterior
cricoarytenoid muscle to help maintain glottal opening in cases
of bilateral vocal fold paralysis8 and using electrical implants to
control the laryngeal spasms of abductor spasmodic dysphonia
by stimulating the thyroarytenoid or lateral cricoarytenoid mus-
cles.9 Although current and future developments in PES are
promising, the procedure is invasive and not widely used. By
contrast, TES offers a noninvasive and cost-effective method
to treat selected voice disorders; however, there is a lack of em-
pirical evidence regarding its effectiveness.
Clinicians using TES to facilitate perceptual changes have
provided anecdotal reports about the effectiveness of TES to tar-
get voice by using two of the six electrode placement patterns
suggested by VitalStim (VitalStim Training). Patterns 3a and
3b have been touted as being more likely to elicit perceptual
voice changes (Figure 1). Both of these patterns involve placing
bipolar electrodes superior to the hyoid bone and superior to the
thyroid notch. According to proponents, these patterns are more
likely to recruit cricothyroid muscle fibers and thus, increase
glottal closure. To further increase the likelihood of recruiting
cricothyroid fibers, proponents have recommended placing one
Linda P. Fowler, et al Voice Change After TES to Laryngeal Muscles
FIGURE 1. Electrode placement patterns.
set of bipolar electrodes directly over the cricothyroid muscles in
what can be termed a modified 3b pattern (VitalStim Training).
The effectiveness of cricothyroid electrode placement to im-
prove voice quality by increasing glottal closure is untested.
The claims of increased glottal closure are also questionable
considering the well-known fact that contraction of the crico-
thyroid lengthens the vocal folds. Empirical findings related
to the extent of intrinsic muscle recruitment from TES can be
gleaned from studies that investigated the effects of using
TES to treat dysphagia. Recent studies that paired TES with
videofluoroscopy reported evidence of electrical current pene-
tration to sternohyoid (SH) muscle; however, no evidence of
penetration to intrinsic laryngeal muscles was found in normal
volunteers10 or in patients with dysphagia.11 A study conducted
by Humbert et al paired TES with videonasolaryngoscopic re-
cordings.12 A statistically significant reduction in the angle of
the anterior commissure was reported when a single channel
of bipolar electrodes was placed in the submental region of
the neck. The researchers concluded that the amount of vocal
fold closure was not sufficient to prevent aspiration. Another
electrode placement pattern explored by Humbert et al resulted
in an increase in vocal fold closure when bipolar electrodes
were positioned above the hyoid bone vertically down to the cri-
coid cartilage. At first glance, the results from Humbert et al ap-
peared to support TES recruitment of intrinsic laryngeal
muscles. However, their results may reflect recruitment of
neck strap muscles, as results from other human and animal
studies have shown that PES applied to various strap muscles
during surgical operations effected changes in glottal opening
and fundamental frequency (F0).13–17 Vilkman et al18 reported
in a meta-analysis that PES applied to the SH and sternothyroid
(ST) indirectly raised F0 in some studies and lowered F0 in
other studies. The disparity between the direction of F0 change
was attributed to a variety of factors including, but not limited
to, head position; tracheal pull; whether SH and/or ST were
stimulated singularly, simultaneously, or when paired with
other muscles; and reflex responses in muscles not directly
stimulated. The extent to which TES can effect similar vocal
changes has not been fully investigated.
In an unpublished study by the authors, TES was applied to
the necks of healthy speakers. The current amplitude was in-
creased in 0.5-milliamperes (mA) increments per second while
the speakers sustained various vowel sounds. Participants were
instructed to begin phonating at a comfortable pitch level and to
55
refrain from resisting any pitch changes that occurred as the in-
tensity of the electrical current was increased. Comparisons
were made between the beginning and ending F0 levels. Similar
to the findings reported by Vilkman et al,18 some subjects dis-
played increases in F0 as the current amplitude increased while
others displayed decreases.19 The results of this study raised
the question regarding what acoustic changes occurred in the
voice after an hour of TES, because research has shown that
most SLPs apply TES to the neck for an hour when treating
dysphagia.20
The current lack of knowledge regarding the effects of TES
on voice production, coupled with increasing anecdotal reports
of TES use with voice disorders, prompted this research. The
purpose of this exploratory study was to determine if measur-
able trends of fundamental frequency (F0) and sound level
(SL) occurred in healthy volunteers after an hour of TES. F0
and SL measurements are often used clinically to judge changes
in voice associated with treatment or conditions that may affect
the voice, that is, vocal fold lesions, prolonged vocal use, vocal
fatigue, and others. F0 is an acoustic measure of the frequency
of the vocal fold vibrations. Vibratory frequency results from an
interplay between vocal fold length, mass, tension, and outgo-
ing airflow rates.21–25 Both intrinsic and extrinsic muscles can
be involved in vocal fold adjustments. Vocal loudness, or SL,
is also controlled by an interplay of physical factors that include
the degree of glottal resistance imposed by the vocal folds to
outgoing airflow, the level of subglottal pressures required to
overcome glottal resistance, the velocity of vocal fold closure
and changes in the rate of the airflow pulse at closure.26–31
Given that TES applied to the neck will cause extrinsic, and
possibly intrinsic muscles to contract, any changes in the voice
would likely be reflected in either F0 or SL.
This study was purely exploratory in nature because of the
lack of previously published empirical findings concerning
the effects of TES on vocal acoustics. As such, the researchers
made no hypotheses regarding the results.
MATERIALS AND METHODS
Participants
Ten healthy female (F) and 10 healthy male (M) speakers
(n ¼ 20) between 20 and 53 years of age (mean age ¼ 26 years)
participated in this study. All participants were nonsmokers and
reported negative histories for voice, speech, phonological,
56
FIGURE 2. Posttreatment F0 and RSL changes for sustained vowel
production.
neurological, psychiatric, and swallowing disorders. All partic-
ipants were free of voice complaints on the day of testing. An
SLP with 20 years of experience in the evaluation and treatment
of voice disorders perceptually judged that voice quality was
normal on the day of testing. Hearing acuity for all participants
was judged to be within normal limits for the reception of con-
versational speech.
Procedures
TES was applied using VitalStim (Chattanooga Group, Chatta-
nooga, TN). The skin in the laryngeal and submental areas was
cleaned with alcohol, and wiped with TENS Clean-Cote Skin
Wipes (Tyco Unit-Patch Model UP220; Uni-Patch, Wabasha,
MN) to increase adherence of the bipolar electrodes to the
skin. Additionally, all male participants were clean shaven to
ensure adequate electrode adhesion. Adult-sized bipolar elec-
trodes (VitalStim REF 59000; Chattanooga Group, Chatta-
nooga, TN) with a 2.1-cm diameter and a 3.46-cm2 active
area were positioned lateral to midline in the submental region
and in the lateral cricothyroid spaces. This electrode placement
corresponded to modified 3a and 3b positions suggested by Vi-
talStim trainers (VitalStim Training). The VitalStim device had
a fixed 80-Hz pulse rate and emitted fixed biphasic pulse dura-
tions of 700 microseconds. The intensity was gradually in-
creased in 0.5-mA increments until participants reported
feeling a ‘‘grabbing’’ sensation. As per the Training Manual
for Patient Assessment and Treatment Using VitalStim Electri-
cal Stimulation,32 this ‘‘grabbing’’ sensation was associated
with muscle contraction and reflected the minimum ‘‘motor’’
level of stimulation for each participant. Stimulation was ap-
plied at the minimum motor level for 1 hour as per the standard
VitalStim dysphagia protocol recommendation. The VitalStim
device automatically cycled off 1 second each minute through-
out the hour. Participants gradually increased the intensity,
when needed, to maintain the ‘‘grabbing’’ sensation throughout
the entire hour of treatment. This protocol was consistent with
recommendations made by VitalStim educational trainers (Vi-
talStim Training). Participants engaged in conversational
speech, ate and drank during the treatment session.
To determine if the degree of cutaneous adipose tissue was re-
lated to voice changes with the use of TES, skin fold measure-
Journal of Voice, Vol. 25, No. 1, 2011
ments were made just lateral to the thyroid notch, using
a calibrated skin fold caliper (Medical Skin fold Caliper
#5028; Sammons Preston Rolyan, Bolingbrook, IL).
Voice recordings
Pre- and posttreatment voice recordings were collected in
a sound-attenuated booth. Voice recordings were obtained us-
ing an omni-directional microphone (Audio Techinca #3032,
Stow, OH) connected to a preamplifier (M-AudioMobilePre
USB, Irwindale, CA), at a mouth-to-microphone distance of
30 cm.33 This recording procedure allowed for F0 and relative
sound level (RSL) measurements. The voice samples were dig-
itized directly into a desktop PC. Each participant produced the
vowel /a/ three times for approximately 3–5 seconds, and read
the first two sentences of the Rainbow Passage (RP)34 three
times. Participants were instructed to produce the sentences at
comfortable effort and natural pitch levels.
Subjective participant comments
Participants were asked to provide comments regarding the sen-
sations they felt in the laryngeal area 5 minutes after the post-
treatment voice recordings and again 24–48 hours after data
collection to determine the presence of fatigue and/or delayed
onset muscle soreness (DOMS). DOMS is characterized by ten-
derness, dull aching pain, and stiffness in muscles 24–48 hours
after unaccustomed exercise.35–38
Data analysis
The digitized voice samples were analyzed using TF32, ‘‘a
time-frequency analysis software program for 32-bit Windows
(95/98/NT/2000/XP) for the analysis of speech and other audio-
frequency waveforms.’’39 F0 was derived from the middle 1 sec-
ond of each vowel phonation. RSL for the sustained vowels was
also determined by using the middle 1-second segment to deter-
mine the average root mean square of the energy. Analysis of F0
and RSL of the connected speech samples were determined in
a similar manner used for vowel analysis with the exception
that the entire sentence production was analyzed. Each acoustic
measure was averaged across the three vowels and spoken sen-
tences for each speaker and entered as one data point per
speaker.
Statistical analysis
Twenty-four randomly selected voice recordings representing
20% of the data, evenly distributed across the four recording
conditions, were reanalyzed using TF32 to determine intrarater
and interrater measurement reliability. Pearson product-moment
reliability coefficients were calculated between the measure-
ments obtained by the first and second investigators. Interrater
reliability (r) for F0 and RSL of vowels and spoken sentences
ranged from 0.98 to 1.00 (P < 0.000).
RESULTS
Figures 2 and 3 demonstrate posttreatment changes in mean F0
for both of the vocal tasks. Posttreatment changes in F0 means
for all participants ranged from 20.6 to 31.27 Hz for /a/ and
from 5.61 to 20.93 Hz for the RP. Results of independent-
Linda P. Fowler, et al Voice Change After TES to Laryngeal Muscles
FIGURE 3. Posttreatment F0 and RSL changes for the reading
passage.
sample t tests (with a Bonferroni adjustment of P < 0.05/
4 ¼ 0.013) failed to demonstrate a significant main effect of
TES for the production of /a/ (m ¼ 1.73, standard deviation
[SD] ¼ 13.10, t(19) ¼ 0.59, P ¼ 0.562) or for the Rainbow
Passage (m ¼ 4.09, SD ¼ 6.89, t(19) ¼ 2.66, P < 0.016).
Differences in RSL between pre- and posttreatment means
for /a/ and the RP also were not statistically significant
(m ¼ 0.503, SD ¼ 3.48, t(19) ¼ 0.65, P ¼ 0.526;
m ¼ 0.407, SD ¼ 1.68, t(19) ¼ 1.08, P ¼ 0.292). Addition-
ally, no statistical differences were found in F0 and RSL
when data were parsed by gender.
A review of the participant’s posttreatment comments re-
vealed that their perceived sensory responses could be catego-
rized into one of three discrete groups. Group 1 included
participants who reported benign-to-positive posttreatment sen-
sations from 5 minutes up to 48 hours after the study. Group 2
included participants who reported symptoms consistent with
vocal fatigue. Finally, participants assigned to group 3 reported
symptoms suggestive of muscle injury (Table 1). Group 1 ex-
hibited the highest mean changes in F0 and RSL, whereas group
3 demonstrated the lowest change (Table 2). A Kruskal-Wallis
one-way analysis of variance failed to find significant posttreat-
ment group differences for F0 or RSL—vowel F0: H2,20 ¼ 3.1,
P ¼ 0.21; vowel RSL, H2,20 ¼ 0.330, P ¼ 0.848; RP F0,
H2,20 ¼ 0.211, P ¼ 0.900; or RB RSL, H2,20 ¼ 0.996, P ¼ 0.608.
The caliper measurements taken from participant’s anterior
necks were analyzed to determine whether significant differ-
ences in adipose tissue could have been a factor in posttreat-
ment sensory perceptions (Table 1). Caliper measurements
ranged from a low of 2 mm to a high of 13.5 mm (m ¼ 5.69).
Results of a Kruskal-Wallis one-way analysis of variance failed
to demonstrate a significant differences in the caliper measure-
ments between the three groups, H2,20 ¼ 1.102, P ¼ 0.58.
DISCUSSION
This study investigated whether there were measurable differ-
ences in F0 and RSL after 1 hour of TES in 20 healthy speakers.
Measurable changes were found for nearly all participants for
both vocal tasks. The largest posttreatment differences occurred
in F0; however, the extent and direction of the changes varied
57
greatly across participants. This variability contributed to
a nonsignificant statistical finding for the aggregated data.
The variability in acoustic findings was consistent with those
reported in the Vilkman et al18 meta-analysis. Accordingly,
these results suggested that the TES only penetrated to the level
of participant’s extrinsic muscles. This deduction is further
supported by Humbert et al,12 who reported that high-current-
amplitude TES applied to the anterior neck showed little
evidence of recruiting intrinsic laryngeal muscles. Most of
the participants in this study chose low-to-moderate current
intensities as demonstrated by beginning and ending mean
levels that ranged from 4.7 to 9.27 mA. Consequently, the SH
and, to a lesser degree, the ST probably received the greatest
amount of stimulation.
One possible cause for the variability in the findings could be
related to the differences in how participant’s muscles responded
to TES as suggested by the disparity in the participant’s posttreat-
ment perceptual sensations. Participants placed in group 1 col-
lectively described sensations that suggested decreased
laryngeal height, easier phonation, and a ‘‘warm-up’’ feeling.
Vocal warming has been described as muscular adjustments
that occur 10 to 30 minutes after phonation begins in response
to physiological demands placed on the voice.39,40 According
to Safran et al, warm-up increases temperature and decreases
the viscosity of muscle tissue.41 The factors that caused these par-
ticipants to sense a warm-up effect were unclear. Neither the cur-
rent amplitudes used nor their neck fat measurements suggested
that less stimulation was applied to their muscles.
Participants in group 2 reported sensory changes that were
characteristic of fatigue 5 minutes after TES was removed.
These seven participants described sensations of tingling, neck
tightness, neck stiffness, neck pain, increased throat clearing,
and muscle fatigue in the laryngeal area. Symptoms of laryngeal
aching and tightness in the neck, as well as a sensation of fullness
in the throat have been associated with laryngeal fatigue.42
These comments were similar to those made by speakers in a vo-
cal loading study after engaging in 45 minutes of loud, oral read-
ing.43 Vocal loading has been described as the stress placed on
speech musculature when speaking for a prolonged period of
time.44 Vocal loading results in higher F0s and a higher rate of
glottal closure as evidenced by voice source parameters and
more gradual spectral slopes.42,43,45–51 Laukkanen et al found
a correlation between acoustic changes and symptoms of fatigue
after loud reading in a group of teachers who had marginally
healthy vocal folds.52 Laukkanen et al suggested that
increasing F0 may be a mechanism of compensating for the
added stress of a loading task, especially when the vocal folds
are not completely healthy. Although no significant acoustic
changes were found in the current study, it should be noted
that the frequency data tended to trend in an upward direction
as evidenced by 15 of the participants displaying posttreatment
increases in F0 during production of the conversation speech
sample. This trend, coupled with the perceptual comments sug-
gested that group 2 experienced a vocal loading effect that
caused muscle fatigue. All participants in our study reported
negative histories for voice disorders; however, some may
have had mild, undiagnosed mucosal changes. Therefore,
58 Journal of Voice, Vol. 25, No. 1, 2011

TABLE 1.
Participants Divided Into Groups Based on Posttreatment Sensory Sensations, Current Amplitude, Neck Fat, Sensations 5
Minutes After TES, and Sensations 27–48 Hours After TES
F0 RSL
Current Sensations 5 min Sensations 24/48 hr
Part Amplitude Neck Fat After TES After TES /a/ RP /a/ RP
Group 1: warm-up
F3 4.5–6.5 4.33 Pitch seemed higher, noticed Three twitches later + +  +
a ‘‘warm-up’’ feeling the same night
F6 6–7 7.00 Voice sounded lower in pitch. No sensation +  + +
F7 6–8 6.83 Neck felt loose; voice sounded No sensation + + + +
a little clearer
M2 4.5–10 2.17 Noticeable contractions in chest No sensations    
during TES; no sensations
afterward
M5 4.5–7 3.67 Neck felt slightly less tense. No sensations +  + 
No change in voice
M10 4.5–9.5 2.00 Easier to maintain sounds Muscles in neck felt more relaxed  +  +
Group 2: fatigue
F1 4.5–8.5 13.50 Voice felt higher and less nasal; Voice continued to feel ‘‘a little + + + +
neck felt tighter; ‘‘voice tight’’ that same night
felt more closed’’
F10 4–7.5 4.17 Voice sounded clearer, felt No sensations + +  +
‘‘rejuvenated.’’ Neck felt stiff on
the sides and sore for 30 min
M3 5–8 3.83 Head movements felt like different No sensations  +  +
muscles needed to be used;
neck felt loose and stretched out
M6 5–7.5 6.83 Felt a little numbness No sensations  +  +
and slight tingling
M7 4–16 2.50 Neck felt tired; felt sensation No sensations + +  +
of choking during stimulation
M8 4.5–22.5 3.67 Neck felt tired; more relaxed; Neck felt more relaxed    
voice sounded clearer
M9 3.5–8.5 2.00 No change in voice or neck; No sensation + + + +
frequently needed
to clear throat
Group 3: delayed onset muscle soreness
F2 4.5–8 12.30 Twitching and tingling under Soreness on left side under chin  + + +
chin that lasted about 30 min
F4 5.5–9 13.50 Some tingling Neck muscles feel like they  +  
have been through a workout
F5 5–10 2.83 Numb spot on neck Voice seems to be husky.    +
Neck muscles feel like they have
been through a workout
F8 4.5–10 9.33 Voice smoother and clearer; No change in voice; + + + +
neck felt relaxed neck quite sore
F9 4.5–7.5 3.67 Skin felt raw Neck felt sore as after a workout + +  +
M1 5–7 3.17 Neck felt tired; muscles been Throat felt sore during swallows +   +
through workout
M4 4.5–7.5 6.50 Neck felt fatigued, as if subjected Not very sore the next day, but on  + + 
to talking for a long duration the second day, very sore.
+: Indicates a posttreatment increase; : indicates a posttreatment decrease.
Abbreviation: RP, Rainbow Passage.

subsequent investigations should include laryngoscopic Muscle fatigue has been described as a ‘‘failure to maintain
evaluations to verify vocal health before applying TES. the required or expected force’’ after repeated activity.55 The
It has long been known that skeletal muscles fatigue more rap- rapid fatigue associated with TES has been attributed to
idly from electrically induced than volitional contractions.53,54 synchronous recruitment of the motor units, imprecise motor
Linda P. Fowler, et al Voice Change After TES to Laryngeal Muscles 59

damage, ruptured sarcolemma, damage to the actin and myosin

TABLE 2.
Changes in F0 (Hz) and RSL (dB)
contractile filaments, and damaged z disc configurations.62,63
Loss of strength in skeletal muscles after exercise-induced in-
/a/ RB jury can be as great as 40% with full recovery taking as long
F0 RSL F0 RSL as 5–6 weeks. Other associated responses in skeletal muscles in-
clude swelling and muscle stiffness.64 Another theory posits that
Group 1
DOMS is a symptom of ‘‘myofibrillary remodeling’’ that occurs
Mean 6.85 1.20 4.28 1.00
in muscles after undergoing unaccustomed levels of eccentric
SD 14.10 2.80 9.00 1.60
contractions. Thus, the muscle fibers hypertrophy in response
Group 2 to greater demands.65Although all participants were instructed
Mean 4.50 0.20 4.45 1.32 to freely allow their voices to respond to TES, it is possible
SD 12.20 3.50 6.30 1.10 that participants in group 3 unconsciously attempted to maintain
Group 3 their habitual pitch and loudness levels. Doing so may have
Mean 5.50 0.60 3.60 0.02 caused hyolaryngeal elevators to apply external lengthening
SD 11.50 2.80 6.50 2.00 forces on muscle fibers that were simultaneously being electri-
cally induced to contract, and thus produced eccentric contrac-
tions. Another similar hypothesis is that these participants had
force control, and higher activation frequencies used with elec- more reflexive responses in muscles not directly stimulated,
trically elicited contractions.56 Cranial muscles are uniquely a possible response reported by Vilkman et al.18 Such reactions
different from skeletal muscles57; however, some inferences could also result in eccentric contractions, particularly if reflex-
can be made between the two. Mammalian skeletal muscles ive responses occurred in agonistic hyolaryngeal elevators. Fi-
are classified by their motor neurons, motor units, and the func- nally, the possibility of marginally healthy vocal folds may
tional properties of the muscle fibers. The muscle fiber types also have contributed to these participants developing DOMS.
found in most human skeletal muscles are type I, IIa, IIX, and When viewed comparatively, the symptoms reported by the
IIb isoforms. The latter two are fast-contracting, fast-fatiguing three groups appear to represent a continuum of responses. Aside
fibers, with type IIX having slightly lower force production from the possibility that some of the participants may have had
and a longer duration of use than type IIb.58 The percentage of mild mucosal changes of the vocal folds, the variability in the
each fiber type contained within a muscle varies from muscle level of muscle sensations could have been due to the fact that
to muscle. Unlike many skeletal muscles, the suprahyoid and in- participants did not engage in standardized speech and swallow-
frahyoid cranial muscles in humans contain a higher percentage ing tasks during TES application. Therefore, varying amounts of
of myocin heavy chain type IIa fibers.59 These fast-twitch fibers muscle load experienced by participants may have accounted for
have an intermediate resistance to fatigue when compared with their reported symptoms of warm-up versus fatigue or DOMS.
slow-twitch type I fibers and the other type II subtypes. The However, regardless of the specific causes for the variability in
suprahyoid and infrahyoid muscles receive the majority of elec- reported symptoms, the possibilities of muscle fiber injury, tem-
trical stimulation when TES is applied to the neck.60 Theoreti- porary loss of muscle strength, muscle stiffness and swelling, and
cally, the higher preponderance of type II subtypes in extrinsic muscle hypertrophy need to be factored into therapeutic proto-
laryngeal muscles could account for the reports of neck fatigue cols using TES to treat voice disorders. Alternately, reported
made by participants in this group 5 minutes after the stimula- symptoms of warm-up and feeling ‘‘rejuvenated’’ gave promise
tion ended. As has been found with skeletal muscles, the efficacy for positive therapeutic results that could be gained from perfect-
of treatment protocols designed to treat cranial muscles with ing the use of TES as a treatment modality.
TES will be limited by the duration of time the recruited muscle
fibers continue to respond. Accordingly, comparative studies of
volitional and electrically induced muscle fatigue in cranial CONCLUSION
muscles would be needed to help determine effective treatment The quantitative and qualitative data in this study suggest pos-
protocols when applying TES to the neck. sible mechanisms by which TES may contribute to physiolog-
The need for determining effective and safe treatment proto- ical changes in voice. The variable posttreatment acoustic
cols became evident when responses from group 3 were exam- changes displayed and sensory perceptions reported by the par-
ined. These participants made various descriptions of neck pain, ticipants shed light on how subsequent studies should be de-
short-term anesthesia, and/or DOMS 24–48 hours after TES signed to increase understanding of cranial muscle responses
was removed. Participants in this group did not use markedly to TES. Questions that need to be meticulously studied to
higher current amplitudes nor did they have significantly lower help establish safe and effective treatment protocols include,
levels of adipose tissue in their necks that posed less resistance but are not limited to
to the current flow.
The actual pathophysiology of DOMS has not been clearly 1. Can TES applied to the neck and submental area cause
identified. Most researchers believe DOMS is caused by strenu- vocal fatigue and/or DOMS?
ous eccentric muscle contractions.61 Reported muscle responses 2. If so, how long can TES be applied before muscle fatigue
to vigorous eccentric contractions included significant cell and/or DOMS occur?
60
3. What current amplitude levels should be applied to pre-
vent muscle fatigue and/or DOMS?
4. Should TES be used simultaneously with vocal exercises
or should it not be applied during vocal production?
5. If voice exercises can be paired with TES, which ones
will be the most effective and safe?
6. What types of voice disorders are most appropriate to in-
clude TES as a treatment modality?
7. Is hypertrophy in extrinsic laryngeal muscles a desired
outcome when treating some voice disorders?
Review of the participants’ comments from 24 hours after
their TES sessions reinforced the importance of investigating
the possible positive and deleterious effects of TES through
the aforementioned questions. In addition, this study’s data
were from participants with healthy voices, and as such, the
muscle and sensory responses of people with diagnosed voice
disorders could be dissimilar to the findings reported here.
The results from this study demonstrate the need for further em-
pirical investigation before TES is adopted as a common ap-
proach SLPs use to treat voice disorders.
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