ARTICLE IN PRESS

Effects of Voiced Gargling on the Electrical Activity of

Extrinsic Laryngeal Muscles and Vocal Self-assessment

Oliveira de Amorim,
*Amabelle Ayssa Santos da Rocha Albuquerque, †Patr
ıcia Maria Mendes Balata, ‡Geova
§ ║ ¶
Ana Clara Amorim Sarmento Vieira, Hilton Justino da Silva, and Leandro Pernambuco, *x{Paraíba, y║Recife, and
zMacei
o, Brazil

Summary: Objective. To verify the immediate effects of voiced gargling on the electrical activity of extrinsic
laryngeal muscles and vocal self-assessment.
Methods. A sample of 20 individuals of both sexes, mean age of 31.95 (§11.57) years, were equally divided in
two groups according to the presence or absence of vocal complaint. Both groups were evaluated by surface elec-
tromyography of the suprahyoid (SH) and infrahyoid (IH) muscle areas during rest, phonation of the sustained
vowel [Ɛ] in habitual and strong intensities; phonation of rising and falling glissando; and counting from 1 to 10.
Surface electromyography was assessed before and after the voiced gargling exercise, which lasted 1 minute. All
participants self-rated their voice and phonatory comfort after the exercise. Wilcoxon and Mann-Whitney tests
were applied, as well as Fisher's exact test and linear-to-linear test. The level of significance was 5%.
Results. The percentage of electrical activity of the SH muscle area decreased in the glissando and counting
tasks in the group with vocal complaint, as well as in phonation of sustained vowel in strong intensity in the group
without complaint. Decrease was also observed in the right IH muscle area at rest and during sustained vowel
phonation at habitual and strong intensities. Percentage of muscular electrical activity was lower in the group
with complaint in the following situations: IH muscle area on both sides, at rest and during habitual phonation
of sustained vowel and glissando before and after the exercise; right IH muscle area, during counting and strong
phonation of sustained vowel before and after exercise; left IH muscle area, in the counting task, just after inter-
vention. Most participants noticed improvement in voice (70%) and phonatory comfort (65%).
Conclusions. Voiced gargling during 1 minute promotes immediate effects on the electrical activity of the
extrinsic laryngeal muscles in individuals with or without vocal complaint. Most individuals reported improved
voice and phonatory comfort after exercise.
Key Words: Dysphonia−Voice−Electromyography−Self-assessment−Voice training−Larynx.

INTRODUCTION Among the various strategies proposed in voice therapy,

Voice is one of the main sources of human communication.
It can suffer environmental and/or emotional influences of
different and even significant impact on the individual's
quality of life with impairments in social, emotional, and
professional life.1
Vocal folds mobility results from the activation of com-
plex intrinsic and extrinsic muscle groups, as well as from
the participation of pulmonary airflow and the myoelastic
and aerodynamic phenomenon of phonation.2 Imbalances
in this refined mechanism, resulting from emotional and/or
environmental factors, can result in mild to severe dyspho-
nia.1 Once dysphonia is identified, voice therapy is
required.3
Accepted for publication June 8, 2020.
From the *Department of Speech, Language and Hearing Sciences, Universidade
Federal da Paraíba (UFPB), Jo~ao Pessoa, Paraíba, Brazil; yPathophysiology of the
Stomatognathic System - CNPq, Universidade Federal de Pernambuco (UFPE),
Recife, Pernambuco, Brazil; zTechnical School of Arts, Universidade Federal de Ala-
goas (UFAL), Macei
o, Alagoas, Brazil; xDepartment of Speech, Language and Hear-
ing Sciences, Universidade Federal da Paraíba (UFPB), Jo~ao Pessoa, Paraíba, Brazil;
║Department of Speech, Language and Hearing Sciences, Universidade Federal de
Pernambuco (UFPE), Recife, Pernambuco, Brazil; and the {Department of Speech,
Language and Hearing Sciences, Universidade Federal da Paraíba (UFPB), Jo~ao Pes-
soa, Paraíba, Brazil.
Address correspondence and reprint requests to Leandro Pernambuco, Jardim Uni-
versitário, S/N, Castelo Branco, Jo~ao Pessoa, PB, 58051-900, Brazil. E-mail:
leandroape@globo.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.06.008
semioccluded vocal tract exercises (SOVTE) such as finger
kazoo,4 straw phonation,5 tongue vibration,6 and high-
pitched blowing7 have already proven positive voice out-
comes. The aim of SOVTE is to increase the association
between source and filter and reduce friction between vocal
folds during phonation, then minimizing the risk of
injury.8,9 They are performed with some type of vocal tract
occlusion and support a more stable phonation through the
retroflex energy generated, with clearer vocal production
and greater phonatory comfort.8,9
Among the different variations of SOVTE is gargling,
which could be voiced or voiceless. Although the effects of
this exercise on laryngeal biomechanics are not yet fully
understood, it is assumed that water creates a barrier to air-
flow. This barrier mobilizes the vocal fold mucosa, velum,
and tongue base, resulting in vocal tract expansion and a
massage-like effect in the pharyngeal pillars. This helps to
improve the interaction between source and filter.10
Although voiced gargling is an apparently common exer-
cise in the clinical routine of voice therapy, scientific evi-
dence is lacking. The few reports in the literature about the
exclusive use of voiced gargling in voice therapy indicate
effects such as increased fundamental frequency and inten-
sity,10 besides a clearer and more comfortable emission11 in
subjects with and without vocal complaints. Voiced gargling
associated with other techniques in an eclectic approach
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2020
model promoted positive results in perceptual-auditory,
acoustic, aerodynamic, and self-assessment measures in six
patients diagnosed with muscle tension dysphonia.12
There is also reference to the use of voiced gargling as an
introductory strategy within the therapeutic model known
as flow phonation. The typical craniocervical posture during
voiced gargling favors the release of airflow when perform-
ing a nonspecific speech task to facilitate a more stress-free
phonation, which includes extrinsic laryngeal muscles.13
A physiological perspective on phonation biomechanics
demonstrates that voice is usually indirectly modified
through antagonistic actions of laryngeal stability and trac-
tion by extrinsic laryngeal muscles. Essentially, the elevation
or lowering of the hyolaryngeal apparatus by the action of
suprahyoid (SH) and infrahyoid (IH) muscles, respec-
tively.2,14 Cases of behavioral dysphonia, especially due to
intense or inadequate voice use, may be associated with
hyperfunctioning of these muscles. They may cause tension
and elevation of the larynx, increased muscle mass in the
neck, and pain in palpation.15
One of the alternatives to quantitatively evaluate the
action of extrinsic laryngeal muscles is surface electromyog-
raphy (sEMG), a procedure that measures the electrical
muscle activity of topographies of interest, including the cer-
vical area.15 Previous studies have already evaluated the
electrical activity of extrinsic laryngeal muscles in dysphonic
and nondysphonic subjects.14,16 However, there are no
records of these measures in the few studies that have
explored voiced gargling as a component of voice therapy.
Voiced gargling is characterized as an easy-to-perform exer-
cise. Thus, the study of its contribution to voice therapy will
favor the improvement of clinical management in vocal
rehabilitation, providing clinical evidence for this field of
research.
Therefore, our aim was to verify the immediate effects of
voiced gargling on the percentage of electrical activity of
SH and IH muscles in subjects with and without vocal com-
plaint. We hypothesize that voiced gargling promotes imme-
diate changes in the electromyographic measures of the
supra and IH areas in both complaining and noncomplain-
ing subjects.
METHODS
This study is a controlled pre-post design performed at the
Department of Speech, Language and Hearing Sciences of
Universidade Federal da Paraíba (UFPB), Jo~ ao Pessoa, Para-
íba, Brazil, and approved by the Human Research and Ethics
Committee of Health Sciences Center of UFPB under Opin-
ion No. 2.058.777/17 and CAAE 67111417.3.0000.5188, as
recommended by the Declaration of Helsinki and Resolution
No. 466/2012 of the National Council of Health (CNS). All
participants have voluntarily signed the Informed Consent
Form.
We selected subjects aged between 18 and 59 years, of
both sexes, with or without symptoms of vocal discomfort,
and with or without laryngeal diagnosis. We excluded those
subjects who showed the following conditions on physical
examination, medical history, or self-assessment: limited
cervical movement that impairs head extension; neurologi-
cal disorders that could compromise assessment; swallowing
disorders; hearing impairment of any degree that could
interfere with phonation control regarding voice pitch and
intensity; use of metal orthoses or prostheses; difficulty in
understanding and executing simple orders; low level of con-
sciousness; total or partial laryngectomy; and tracheostomy.
We excluded subjects who were in use or who had received
voice therapy up to 6 months before the day of sampling.
We used convenience and non-probability samples.
The sample consisted of 20 adults aged between 20 and
56 years (mean = 31.95 § 11.57), of which 11 (55%) were
female. In this sample, 11 (55%) subjects were occupational
voice users and nine (45%) were non-occupational voice
users. Ten (50%) subjects presented without vocal complaint
and 10 (50%) presented with at least one auditory and/or
somatosensory symptom of voice-related disorders, which
included: hoarseness (n = 5); phlegm (n = 3); vocal fatigue
(n = 3); dry throat (n = 1); and cough (n = 1).
All volunteers underwent a pretest to verify the sub-
jects’ ability to perform the voiced gargling exercise. We
asked the volunteer to (1) hold an approximately 10
milliliters (mL) sip of water in the mouth; (2) inhale,
stop breathing, and then tilt the head back slightly; (3)
gargle for a minimum of 3 seconds and a maximum of 5
seconds, coupled with the emission of [u] vowel (voiced
gargling exercise). In cases of persistent choking, exacer-
bated gag reflex, inability to perform the task sequence
or refusal to remove a badly adjusted prosthesis, the sub-
ject was excluded.
For sEMG, we used a MIOTEC electromyograph (Rio
Grande do Sul, Brazil) connected to a notebook. To capture
the myoelectrical potentials (microvolts - mV) of the supra
and IH muscles, we used the software MiotecSuite 1.0 (data
acquisition system), with 32 windowing and 2000 gain for
each channel. Moreover, we used MEDTRACEÒ (Kendall,
Canada) disposable surface electrodes, consisting of a silver/
silver chloride (Ag/AgCl) plate immersed in conductive gel
for capture and conduction of the electromyographic signal.
We used a 60-Hz notch filter and a 20−500 Hz bandpass fil-
ter to avoid interference from unwanted noise and mechani-
cal artifacts.
We used three of four channels provided by the equip-
ment, all of them connected to an active sensor SDS500 by
claws. After cleaning and abrasion of sensors with gauze
and 70% ethyl alcohol, they were fixed to the skin in the
areas of interest. The electrode fixation site followed the
method proposed in the literature,2 with sites being identi-
fied through palpation of the larynx. Then, two electrodes
were fixed at each site of interest, respecting the distance of
one centimeter from center to center. The reference elec-
trode was positioned on a bone surface corresponding to the
ulna olecranon of the volunteer's right arm.2 For the SH
area, two electrodes were fixed in the central submandibular
area, towards mylohyoid muscle fibers. For the right (R-IH)
 ARTICLE IN PRESS
Amabelle Ayssa Santos da Rocha Albuquerque, et al Effects of Voiced Gargling on the Electrical Activity 3

and left (L-IH) infrahyoid areas, electrode fixation sites We applied the nonparametric Wilcoxon test to check for
were standardized at one centimeter from the thyroid notch the mean differences in PMEA before and after voiced gar-
bilaterally, with the aid of a digital caliper and a dermo- gling. Furthermore, the Mann-Whitney nonparametric test
graphic pencil. was used to analyze the mean difference of the same meas-
After electrode fixation, the volunteer was instructed to ures between groups with and without complaint, before
remain relaxed for muscle electrical activity at rest to be and after the exercise. Self-assessments of voice and phona-
analyzed. For raw signal normalization, tasks of maximum tory comfort were studied descriptively and their association
sustained voluntary electric activity were performed for with the presence or absence of complaint was analyzed by
each site of interest. Incomplete swallowing maneuver with the Fisher's exact test or linear trend test. The significance
effort was indicated for SH muscles, while retracted tongue level was 5%.
with opened mouth maneuver was indicated for R-IH and
L-IH muscles.2,14 The tasks for electromyographic signal
RESULTS
normalization using maximum sustained voluntary electric
Table 1 shows the comparison of PMEA before and after
activity were used to compare activity levels between
voiced gargling, as well as the differences between the
muscles, between tasks, and between individuals.17
groups of volunteers with or without vocal complaint. All
Subsequently, the volunteer was instructed to perform the
PMEA measures decrease after intervention, except for a
following tasks in this sequence: rest for one-minute, sus-
nonsignificant increase in the PMEA of R-IH muscles under
tained emission of vowel [Ɛ] at usual intensity, vowel [Ɛ] at
vowel emission at strong intensity in the group with vocal
strong intensity, vowel [Ɛ] in glissando and counting from 1
complaint.
to 10.
Despite a statistical tendency observed in almost all meas-
After these tasks, the individuals performed voiced gar-
urements, PMEA decreased significantly only in the SH
gling exercise, according to the following guidelines and
area in the glissando and counting tasks for the complaining
commands: (1) remain seated, following the Frankfurt plan;
group. In the group without complaint, the PMEA was sig-
(2) place in the mouth a comfortable volume of water at
nificantly reduced at rest and during sustained vowel tasks
room temperature; (3) inhale, stop breathing, and then tilt
at usual and strong intensities in the R-IH area. In the group
the head back slightly; (4) gargle for a minimum of 3 sec-
without complaint, PMEA also decreased in the SH area
onds and a maximum of 5 seconds, coupled with the emis-
during strong vowel emission.
sion of vowel [u]; (5) return the head to the usual position,
When comparing sEMG measures between the groups
swallow or spit out the water. The process was repeated for
with or without complaint, all PMEA were lower in the
one minute and could be performed up to three times with
group with complaint, although only a few differences were
the same volume of water, which was then swallowed or
significant (Table 1). At rest and during the usual vowel
spitted it out. The performance time for one minute was
emission and glissando tasks, the PMEA of R-IH and L-IH
used to avoid risk of choking and cervical discomfort and
areas was significantly lower in the complaining group both
because it is supposed to be a minimum time to produce any
before and after intervention. During counting and vowel
effect based on other studies that investigated immediate
emission at strong intensity, PMEA was significantly lower
effects of SOVTE.4−8 The exercise was performed exclu-
in the complaint group of R-IH area, both before and after
sively on its voiced version and the whole procedure was
the exercise. In the counting task, the PMEA of L-IH was
monitored by a researcher to control the individual perfor-
significantly lower in the complaint group only after voiced
mance in the sequence of tasks and to avoid voiceless gar-
gargling has been performed.
gling.
Table 2 shows that most volunteers reported improve-
After intervention, the whole sEMG procedures were per-
ment in voice (70%) and phonatory comfort (65%) after
formed again. In addition, the volunteer answered two ques-
voiced gargling. There was no self-report of worsening of
tions related to self-assessment of voice and phonatory
the voice sound after the exercise. No association was found
comfort, respectively: “Do you think the sound of your
between self-assessment and vocal complaint, ie, both
voice has improved, worsened, or not changed after exer-
groups perceived greater voice quality and phonatory com-
cise?” and “Do you think the feeling of comfort while speak-
fort after the exercise.
ing has improved, worsened, or not changed after
exercise?”.
The analysis of sEMG signals was performed later with DISCUSSION
the software MiotecSuite 1.0. In the sustained vowel emis- Dysphonia is a disorder that limits communication and
sion tasks, at least the three central seconds were selected interferes with the individual's quality of life in a negative
because they are considered as more stable. In the other way.18 Thus, it is necessary to better understand the effects
tasks, the entire signal was selected, with the onset and offset of therapeutic strategies used in vocal rehabilitation, as it
of emissions recorded simultaneously with the sEMG. The involves complex changes in respiratory, phonatory, and
mean microvolts (mV) of each task was converted to a per- resonant adjustments, as well as in inappropriate vocal
centage of muscle electrical activity (PMEA) according to behaviors and in the use of intrinsic and extrinsic laryngeal
the specific normalization task for each site of interest. muscles.19
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2020

TABLE 1.
Percentage of Electrical Activity of Extrinsic Laryngeal Muscles Pre and Post Voiced Gargling Exercise and Between
Subjects With or Without Voice Complaint (n = 20)
Vocal Complaint p†
Yes (n = 10) No (n = 10)
Mean Standard Deviation Mean Standard Deviation
Resting SH pre 11.79 3.52 13.05 7.31 0.705
Resting SH post 10.31 4.19 10.94 7.42 0.762
p* = 0.169 p* = 0.093
Resting R-IH pre 11.06 10.88 22.35 12.40 0.023
Resting R-IH post 8.66 8.12 18.56 11.17 0.028
p* = 0.721 p* = 0.017
Resting L-IH pre 11.54 11.26 21.65 13.65 0.034
Resting L-IH post 9.10 8.16 18.77 12.38 0.041
p* = 0.508 p* = 0.139
Vowel SH pre 21.59 8.79 38.72 47.18 0.45
Vowel SH post 20.09 9.89 26.93 17.23 0.597
p* = 0.646 p* = 0.333
Vowel R-IH pre 28.27 38.76 46.58 24.46 0.028
Vowel R-IH post 21.84 32.05 36.13 19.03 0.023
p* = 0.203 p* = 0.017
Vowel L-IH pre 36.09 58.25 41.27 19.65 0.041
Vowel L-IH post 26.00 42.77 35.08 20.16 0.034
p* = 0.285 p* = 0.139
Strong vowel SH pre 31.11 14.55 42.97 25.96 0.199
Strong vowel SH post 23.19 12.23 35.40 23.89 0.174
p* = 0.114 p* = 0.007
Strong vowel R-IH pre 34.14 33.65 55.20 24.06 0.049
Strong vowel R-IH post 35.99 46.19 43.09 21.46 0.096
p* = 0.799 p* = 0.013
Strong vowel L-IH pre 41.59 46.73 54.48 29.15 0.151
Strong vowel L-IH post 39.07 47.84 44.10 24.26 0.257
p* = 0.646 p* = 0.203
Glissando SH pre 32.57 25.65 39.41 34.42 0.496
Glissando SH post 27.61 20.34 32.48 21.72 0.762
p* = 0.047 p* = 0.093
Glissando R-IH pre 38.60 47.30 91.21 51.60 0.005
Glissando R-IH post 34.04 36.71 67.08 22.02 0.016
p* = 0.575 p* = 0.114
Glissando L-IH pre 41.91 49.21 86.72 51.45 0.023
Glissando L-IH post 33.49 37.37 62.75 20.24 0.013
p* = 0.445 p* = 0.169
Counting SH pre 53.97 35.16 61.76 56.41 0.821
Counting SH post 37.71 20.67 54.61 36.98 0.364
p* = 0.047 p* = 0.646
Counting R-IH pre 40.29 38.02 70.97 27.73 0.013
Counting R-IH post 34.11 33.59 59.58 21.66 0.016
p* = 0.508 p* = 0.059
Counting L-IH pre 46.83 48.49 77.55 40.02 0.07
Counting L-IH post 38.13 41.57 65.47 27.52 0.019
p* = 0.386 p* = 0.139
* Wilcoxon test.
†
Mann-Whitney test; bold values = p < 0.05.
Abbreviations: R-IH, right infrahyoid muscle area; L-IH, left infrahyoid muscle area; SH, suprahyoid muscle area.
 ARTICLE IN PRESS
Amabelle Ayssa Santos da Rocha Albuquerque, et al
TABLE 2.
Self-assessment of Voice Quality and Phonatory Comfort in Individuals With and Without Voice Complaint (n = 20)
Question Voice Complaint n (%)
Yes (n = 10)
Do you think the sound of your voice (...)?*
has not 3 (30.0)
changed
has 7 (70.0)
improved
Do you think the feeling of comfort while speaking (...)?
has 2 (20.0)
worsened
has not 2 (20.0)
changed
has 6 (60.0)
improved
* The option “has worsened” was not answered.
†
Fisher’s Exact Test.
‡
Linear trend test; p < 0.05.
The extrinsic laryngeal musculature consists of SH and
IH muscle and acts to maintain the stability and traction of
the anterior or posterior cranial or caudal hyolaryngeal
apparatus.20 It generates an indirect but comprehensive par-
ticipation in vocal production, whether supporting intrinsic
musculature in vocal fold stretching and shortening or par-
ticipating in resonant adjustments.20,21
Voiced gargling exercise promotes the controlled passage
of transglottic airflow and requires elongated neck posture
during its performance, concurrently promoting stretching
of supra and IH muscle fibers.13 Therefore, it can be sup-
posed that voiced gargling promotes immediate effect in the
muscular electrical activity in the SH and IH areas, which
are the focus of this study. However, there are no previous
publications with converging objective or method for direct
discussion. Our results were articulated with other findings
related to voiced gargling based on correlations and analo-
gies.
We observed a PMEA statistical tendency to decrease in
all requested tasks after the exercise, in both analyzed top-
ographies, regardless of the presence or absence of vocal
complaint. Thus, we assume that one-minute voiced gar-
gling generally reduces the recruitment of muscle fibers in
the SH and IH areas, which may contribute to a more com-
fortable and less stressed phonation.
The literature highlights some aspects of voiced gargling
that may justify this finding. During voiced gargling, the
onset of transglottic flow release occurs without the negative
effects of intra and extralaryngeal tension already common
in speech situations.13 In addition, extended head posture
during exercise inhibits laryngeal elevation beyond the
desired.13 The inclusion of voiced gargling at the beginning
of a therapeutic program that uses the principles of flow
phonation13 also denotes the intention to promote muscle
relaxation and consequent smoother and more comfortable
phonation. All these aspects converge to the effect of
Effects of Voiced Gargling on the Electrical Activity 5
Total p
No (n = 10)
3 (30.0) 6 (30.0) 1.00†
7 (70.0) 14 (70.0)
0 (0.0) 2 (10.0) 0.32‡
3 (30.0) 5 (25.0)
7 (70.0) 13 (65.0)
PMEA reduction observed in this study for SH and IH
areas.
Although statistical analysis of the relationship between
PMEA and self-assessment was not feasible due to the sam-
ple size, we assume that the reduction of PMEA in the SH
and IH areas after voiced gargling may have contributed to
the improvement of self-reported voice quality and phona-
tory comfort, with or without vocal complaint. It is reason-
able to suppose that neck stretching itself impact the PMEA
of the SH and IH areas, but it is likely a greater positive
impact when associated with voiced gargling. The smooth
and consistent release of airflow during voiced gargling
assists in the relaxation of extralaryngeal muscles, which in
turn induces a clearer vocal quality.12 Therefore, it is possi-
ble to understand the perception of improvement in voice
and phonatory comfort after exercise, even when vocal com-
plaint is absent.
A previous study on a sample of subjects with and
without vocal complaints also found high rate of positive
judgment of the effect of voiced gargling on voice.11
Among those who had vocal complaint, voice improve-
ment was perceived by 91.66% (n = 22), while this pro-
portion was 94.11% (n = 16) in the other group. Some
effects such as “more open voice,” “clearer voice,” and
“easier to speak” have been reported by volunteers. Fur-
thermore, the authors hypothesize that the exercise causes
indirect effects that can positively impact the self-assess-
ment of voice quality and phonation comfort, such as
greater water intake and cleaning of the oropharynx.
Although t questions and the exercise dosimetry method
were not similar, both studies highlight the potential of
voiced gargling to improve self-assessment both in the
auditory-perceptual and sensory dimensions.
In the particular case of phonatory comfort, it is empha-
sized the importance of self-assessing effort, which was used
for many years in Sports Medicine to help the knowledge of
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2020
muscle demand to a certain exercise load, providing subjec-
tive estimates of fatigue and contributing to therapeutic
decisions by adjusting exercise frequency, duration, and
intensity.9
It is noteworthy that the few studies on the effects of
voiced gargling on voice are heterogeneous in their applica-
tion format, which is a limitation in the comparison of
results. Two Brazilian studies10,11 exclusively applied 3
series of 10 repetitions of voiced gargling exercises, each
series lasting approximately 1 minute, with 30-second inter-
vals.
In a North American study,12 whose therapeutic program
consisted of three exercises, gargling was performed in four
stages: unvoiced; voiced; voiced with glissando; and voiced
with head return to the usual position accompanied by sub-
sequent emission of various nasal sounds. In the first 3
stages, 10 repetitions of 5−6 seconds each were performed.
In a case study reported by a North American researcher,13
gargling was also part of a therapeutic program, applied
under the following sequence: unvoiced; voiced; and voiced
with head return to the usual position.
As our study is the first one to investigate the immediate
effects of voiced gargling on the electrical activity of SH and
IH areas, the choice was the voiced variation of the exercise
for 1 minute. We considered the reduction of fatigue impact
on muscular electrical activity and the use of a task that pro-
moted not only transglottic airflow, but also the greater acti-
vation of glottic resistance through a voiced activity.
Further experiments are suggested to broaden the electro-
myographic investigation of the SH and IH areas after
voiced gargling in different sequences and dosimetries in the
short, medium, and long term, especially from randomized
controlled trials.
Significant differences found before and after voiced gar-
gling in intragroup comparisons revealed that the effects of
exercise have idiosyncratic characteristics inherent to the
complexity of the action of extrinsic laryngeal muscles on
voice. Although this muscle group does not act directly on
phonation, its indirect mechanism is essential, since it main-
tains the larynx stabilization in the neck, which results in
muscle balance, vocal stability, and greater phonatory
comfort.3
In the group with complaint, the PMEA decreased in the
SH area in the glissando and counting tasks. Individuals
with vocal complaint develops laryngeal adjustments, nota-
bly larynx in higher position and with higher degree of ten-
sion, conditions associated with the action of SH muscles,
responsible for the upward traction of the hyolaryngeal
joint.22
Our hypothesis is that voiced gargling promoted greater
relaxation of the SH area in the group with complaint. In
addition, less recruitment of motor units in this topography
was observed in phonatory tasks that require a more diverse
laryngeal demand. Glissando mainly requires vertical plas-
ticity of the hyolaryngeal apparatus, whereas counting
requires greater respiratory support, activation of the orofa-
cial muscles for articulatory activity, supraglottic
adjustments, and rapid, synchronous, and refined move-
ments of constant contrast between stability and traction in
the most diverse directions; thus being more complex com-
pared to sustained vowel emission.16 It can be assumed that,
voiced gargling may lead to different PMEA values when
performed in ascending and descending glissando, which is
a research proposal for future studies.
In the group without complaint, muscle electrical activity
decreased significantly in the SH area only during vowel
emission in strong intensity. Compared to the vowel emis-
sion in habitual intensity, the strong intensity requires a
higher larynx position, more muscular and respiratory sup-
port, as well as more mandibular and laryngeal stability. In
the group without vocal complaint, it is assumed that the
larynx is naturally more stable in the middle neck, ie, these
individuals may need more effort and, consequently, greater
muscle recruitment to produce vowels at a high intensity. It
is supposed that the voiced gargling helps to induce PMEA
decrease in SH muscles and this reverted into a more dis-
crete motor unit recruitment to perform the same task.
The fact that only one side of the IH area showed a signif-
icant decrease in PMEA in some phonatory tasks draws
attention to the asymmetric effect caused by the exercise in
this site. Symmetry in the activation of extrinsic laryngeal
muscles during phonation is still an underexplored topic in
the field of voice research, different from what occurs in
other areas of speech-language therapy.23 In symmetry, the
activation of bilateral muscles is expected to be similar so
that there is harmony between both sides. However, in the
case of extrinsic laryngeal muscles, symmetry is dependent
on a complex interaction between the various muscles acting
in the paralaryngeal area. In sEMG, this may result in cross-
talk, a simultaneous uptake of electrical activity of muscles
adjacent to those of interest.15 It is not ruled out that some
results of this study, particularly those that revealed signifi-
cant changes on only one side of the IH area, may find sup-
port in this phenomenon.
It is also worth highlighting the possible effect of muscle
synergies between the SH and IH muscle areas. Normaliza-
tion of the electromyographic signal enables the evaluation
of antagonistic or synergistic muscles, as is the case of sites
studied here.24 The behavior of electromyographic results
suggests a possible balance between the different topogra-
phies assessed. It is necessary to explore these relationships
in future studies to investigate the hypothesis of a greater
muscle synchrony after voiced gargling.
The effects of voiced gargling on the electrical activity
of the IH area were another relevant topic of this study.
All significant differences in intergroup analysis were
found only in the PMEA of R-IH, L-IH, or both. All of
these measures are lower in the group with vocal com-
plaint, even after intervention. Previous research has
shown that there is lower electrical activity in the SH
area in dysphonic subjects compared to that of those
nondysphonic.16 Therefore, the group with vocal com-
plaint was expected to show significantly lower electrical
potentials in this area compared to the group without
 ARTICLE IN PRESS
Amabelle Ayssa Santos da Rocha Albuquerque, et al
complaint, but it is only occurred in the IH area in this
sample.
A videofluoroscopic study has shown that, besides
stretching the neck, voiced gargling makes the tongue base
reach its closest point of contact with the posterior pharyn-
geal wall; thus reaching its most retracted position, even
when compared to the position assumed during swallow-
ing.25 During voiced gargling, IH muscles not only anchor
and stabilize the larynx, but are also stimulated by the maxi-
mum retraction of the tongue base. Therefore, it is possible
that the continuous and repetitive movements provided by
voiced gargling over the IH area may lead to muscle activa-
tion with less effort during phonatory tasks and even during
rest.
The effects of voiced gargling on the PMEA of the IH
area seem to occur regardless of the presence or absence of
vocal complaint. This is because before the intervention, the
group with complaint showed lower PMEA than the group
without complaint. After exercise, PMEA decreased in both
groups and the group with vocal complaints remained with
lower electrical potentials. It is possible to assume that in
the group with complaint, the IH area is under muscle
fatigue, as there may be low resistance with consequent
decrease in muscle fiber recruitment due to incorrect phona-
tion patterns or greater effort to perform laryngeal lowering,
as opposed to the more accentuated activation of SH
muscles. This may correlate with the time and degree of dys-
phonia, as observed by other authors.16 These hypotheses
should be investigated in future studies.
Moreover, we should not reject the effect of head postural
control. During the execution of the exercise, the head may
incline, even slightly, to one side, which may differently
affect the cervical musculature. The return of the head to
the usual 90° posture after exercise can cause slight adjust-
ment micromovements that may reflect what has been con-
ferred as asymmetry of this area. Another aspect is that
possible discrete and clinically undetectable cervical asym-
metries (as they were not observed in this investigation) may
have interfered with the muscle balance captured by sEMG.
Thus, it is recommended that during gargling, the thera-
pist stabilizes the individual's head. In this research, the vol-
unteers were instructed to keep their heads tilted to perform
the exercise, but this postural control was not rigorously
controlled. It is suggested that researchers be vigilant to
avoid this measurement bias in future studies.
At this point, we should also consider that the results of
voiced gargling may be influenced by the fact of, when per-
forming the exercise, the individual returns his/her head to
the natural position and inevitably needs to swallow, even if
it is saliva, which promotes ascension and decline of the lar-
ynx and consequently interfere with the adjustment pro-
moted by stretching the anterior neck during voiced
gargling.10,11
It is also relevant the study of the physiology of voiced
gargling alongside the concepts of hydrostatics. It was
reported that the effects of voiced gargling may resemble
those of a hydrotherapeutic exercise, as water density
Effects of Voiced Gargling on the Electrical Activity 7
produces mechanical reactions that require greater strength
of the musculoskeletal system to perform the move-
ments.10,11 However, the transposition of these physical
concepts into voice therapy practice still needs to be studied
more deeply. Another hypothesis is a that voiced gargling
produces a massage-like effect with improvement in muscle
relaxation, especially in larger vocal tract volumes, an effect
already found in water resistance therapy due to water
bubbling.26
The limitations of this study are related to the sample size
and the nonprobabilistic convenience sampling, which limits
the external validity of the data. Laryngeal diagnosis, con-
figuration of vocal tract and other aspects of multidimen-
sional voice assessment were not controlled in this study
because they are not the focus of our investigation, but may
have been confounding variables. The effects of a therapeu-
tic program on voice outcomes and the results of a perfor-
mance time for up to one minute should be investigated in
future studies.
Simultaneously, this study stands out for being the first in
the investigation of the immediate effects of voiced gargling
in the PMEA of the SH and IH areas. The findings may
contribute to improve decision-making in voice therapy and
to highlight the therapeutic clinical evidence in the field of
voice research. This study also contributes to a better under-
standing of muscle dynamics involved in phonation, espe-
cially in the pre- and post-exercise comparative analysis
through quantitative measurements of muscle recruitment
obtained by sEMG.
CONCLUSION
Voiced gargling promotes immediate effects on the PMEA
of the SH and IH areas in subjects with or without vocal
complaint. Most subjects perceive improvement in voice
quality and phonatory comfort after voiced gargling. How-
ever, there is no association between self-assessment and
vocal complaint.
Acknowledgments
The authors thank the Brazilian National Council for Sci-
entific and Technological Development (Conselho Nacio-
nal de Desenvolvimento Científico e Tecnol
ogico − CNPq)
for the scholarship granted to the authors AASRA and
ACASV.
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