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Original research article/Artykułoryginalny
Voice rehabilitation with the application of massage
device ‘‘Medical 2VR’’ in patients after total
laryngectomy
Jarosław Markowski
1,
*, Wojciech Musialik
2
, Jarosław Paluch
1
,
Monika Świderek-Kliszewska
1
, Agnieszka Piotrowska-Seweryn
1
,
Włodzimierz Dziubdziela
3
, Wirginia Likus
4
1
Department of Otolaryngology, Medical University of Silesia, Head: Jarosław Markowski, M.D.Ph.D, Katowice,
Poland
2
Cyberbiomed Sp. z o.o., Sosnowiec, Poland
3
The Chronic Pain Clinic, Sosnowiec, Poland
4
Department of Anatomy, Medical University of Silesia, Head: Grzegorz Bajor, M.D.Ph.D, Katowice, Poland
polski przeglĄd otorynolaryngologiczny 2 (2013) 137–141
article info
Article history:
Received: 04.06.2013
Accepted: 19.06.2013
Available online: 28.06.2013
Keywords:
Laryngeal cancer
Total laryngectomy
Voice rehabilitation
Słowa kluczowe:
Nowotwór gardła
Całkowita laryngektomia
Rehabilitacja głosu
abstract
Aim: The aim of the study was to evaluate the effectiveness of a deeply invasive massa-
ger Medical 2VR, Cyberbiomed as a supportive voice rehabilitation method in patients
after total removal of the larynx. Background: Voice loss after total laryngectomy due to
laryngeal cancer seems to be the main disadvantage of that surgical procedure for majo-
rity of patients. Neck lymphoedemas, soft tissues fibrosis and restricted mobility around
the shoulder girdle due to surgical procedures and radiotherapy are the factors impeding
the process of voice rehabilitation. Materials and methods: The study was conducted on
a group of 80 patients after total laryngectomy treated in Outpatient Clinic and Depart-
ment of Otolaryngology of the Medical University of Silesia in Katowice in 2009–2011.
Assessment of voice parameters, measurements of neck circumference and pressure in
the opening of sphincter of oesophagus mouth were performed. The nature of the emit-
ted voice and speech volume was analyzed. Results: The results showed that in 90% of
patients a significant reduction of neck lymphedema was observed. Also, various voice
parameters and pressure in the opening of sphincter of oesophagus improved. Conclu-
sions: Invasive massager Medical 2VR results in reduction of the voice rehabilitation
period and shorter learning process of substitute speech in patients after total laryngec-
tomy.
© 2013 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by
Elsevier Urban & Partner Sp. z o.o. All rights reserved.
*Corresponding author at: Katedra i Klinika Laryngologii, Śląskiego Uniwersytetu Medycznego, ul. Francuska 20-24, 40-027 Katowice,
Poland. Tel.: +48 32 2591 460; fax: +48 32 2562 996.
E-mail address: jmarkow1@poczta.onet.pl (J. Markowski).
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/ppotor
2084-5308/$ –see front matter © 2013 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
http://dx.doi.org/10.1016/j.ppotor.2013.06.001
Intorduction
Voice loss after total laryngectomy due to laryngeal cancer
seems to be the main disadvantage of that surgical proce-
dure for majority of patients [1]. It has been found that in
patients, whom a complete removal of the larynx was
performed, there is a higher risk of depression in compari-
son to patients who underwent a different type of treatment
and it can result in limited social life [2]. In order to improve
the quality of life for these people, it is important to begin
voice rehabilitation as soon as possible. Many factors
influence the process. Complete removal of the larynx,
especially combined with simultaneous lymphadectomy
and radiotherapy –both primary and complementary
(postoperative) –can cause neck lymphoedemas, soft tissues
fibrosis and restricted mobility around the shoulder girdle
[3]. The occurrence of these factors significantly impedes
the process of voice rehabilitation in the patients [4].
Therefore, it is extremely important to introduce new
methods accelerating the process of voice rehabilitation in
patients after total laryngectomy.
The aim of the study was to evaluate the effectiveness of
a deeply invasive massager Medical 2VR, Cyberbiomed as
a supportive voice rehabilitation method in patients after
total removal of the larynx.
Materials and methods
The study was conducted on a group of 80 patients (68 men
and 12 women, with an average age of 67.3) who were
treated in the Outpatient Clinic and Department of Otola-
ryngology, Medical University of Silesia in the years 2009–
2011. The therapy was followed by voice rehabilitation
sessions in rehabilitation centres throughout the country.
All patients underwent rehabilitation with the application of
the deeply invasive massager Medical 2VR, Cyberbiomed.
The patients were divided into three groups:
Group I –patients before rehabilitation with the applica-
tion of the massage device,
Group II –patients directly after rehabilitation with the
application of the massage device,
Group III –patients 3 months after rehabilitation with
the application of the massage device.
Subjective assessment of voice parameters, measure-
ments of pressure in the opening of sphincter of oesopha-
gus mouth as well as measurements of neck circumference
were performed in all patients. The nature of the emitted
voice with it classification into: sonorous, dull or hoarse was
analyzed. The evaluation of voice production mechanism
established two types of voice –the one produced without
effort (free voice) and forced voice (due to excessive involve-
ment of additional respiratory muscles of patient's chest in
phonation process). Speech volume in conversational
speech was analyzed in three study groups. Phonation was
categorized as soft, medium or loud. The study was conduc-
ted at the phonation of vowel 'a' Additionally, measurement
of neck circumference was taken using a tape as well as
measurement of pressure in the opening of sphincter of
oesophagus mouth with Cyberbiomed's device for graphic
visualization of pressure course in the opening of sphincter
of oesophagus mouth.
Rehabilitation was initialized 3 weeks after complete
wound healing or after minimum 3 months from the end of
radiotherapy. The rehabilitation period lasted 3–5 weeks.
Rehabilitation process was performed with the applica-
tion of deeply invasive massager Medical 2VR, Cyberbiomed
LLC (Fig. 1). It is a double –resonance device utilizing
a unique VR technology developed and applied for the first
time by an American company 'CyberBioMed LLC'. The VR
technology uses mechanical resonance of rehabilitated cen-
tre with simultaneous protection from the appearance of
standing wave by moving it inside the centre with an
electronically given frequency. The device is powered by
accelerator –type microprocessor controller, and it genera-
tes mechanical wave of regulated frequencies between 15
and 300 CPS. Parameters of the device are controlled by
microprocessor system. The application of variable diffe-
rence of frequencies in resonators protects patients from
the appearance of the harmful standing wave.
The massager was placed tightly and securely, yet
comfortably, around patient's neck without leaving any free
space after fastening. Resonators were laid evenly in areas
of the greatest oedema of a neck. In order to maintain
aseptic conditions, the device was covered with disposable
polyethylene protective items.
Patients received the massage after the removal of
tracheostomy tube ensuring that the work of the device had
not been transferred to the tube and there had been no
possibility to irritate or mechanically damage tracheostomy
hole at the same time.
Rehabilitation was divided into three stages.
Stage one –a gentle massage at low frequencies with
minimal power of the device; treatment time: maximum
1 min, twice daily, in the morning and evening; time
intervals between the treatment sessions –not less than
8 h; rehabilitation period –4–5 days.
Stage two –treatment time: 5 min, twice daily; time
intervals between the treatment sessions –not less than 1 h
–the same as in stage one; rehabilitation period –3–5 days.
Stage three –treatment time: maximally 15 min, twice
a day; time between treatment sessions the same as in
stage one; rehabilitation period up to 2 weeks.
[(Fig._1)TD$FIG]
Fig. 1 –Medical 2VR massage device, Cyberbiomed
polski przeglĄd otorynolaryngologiczny 2 (2013) 137–141138
A great attention was paid to the mucosal secretion and
sputum expectorated from tracheostomy. The appearance of
fresh blood or blood clots was an indication to the termina-
tion of the therapy. Other contraindications for using the
massager were as follows: purulent skin lesions on the neck,
pharyngocutaneous fistula, dermatoses preventing from
using any pressure on pathological changes.
Data received were analyzed by STATISTICA 9.0 program,
StatSoft Inc. Student's t-test for independent samples or
multi-way contingency tables were applied in the analysis
of variables. Correlation of the variables was analyzed with
x
2
test. The equality of variances in different samples was
assessed with Leven's test. The results were statistically
significant when p<0.05.
Results
The results showed that in 72 patients (90%), who under-
went voice rehabilitation with the application of the mas-
sage device, a significant reduction of neck lymphedema
was observed. The measurements of the neck circumference
revealed that it was (on average) up to 4.34 0.17 cm
smaller in comparison to the neck circumference before
rehabilitation ( p<0.001) (Table I). When analyzing the
results of pressure in the opening of oesophagus mouth
before and after the voice rehabilitation, a statistically
significant ( p= 0.013) increase in the number of patients
with lower pressure (Group II) was found (Table II). At the
same time, a decrease in the number of patients from group
II and III, whose pressure in the opening of oesophagus
mouth before applying the massager was average ( p= 0.003)
and high ( p= 0.002), was observed. The number of patients
with low pressure in the opening of sphincter of oesophagus
mouth increased 2.5 times in a 5-week period of rehabilita-
tion with the application of the device. The evaluation of
the voice nature in patients undergoing rehabilitation indi-
cated that the number of persons with sonorous voice had
increased 11 times immediately after using the massager
(p<0.001) (Table III). Furthermore, the number of patients
with free voice increased as well as the voice volume
increased in rehabilitated patients ( p<0.001). Only 8% of
patients did not develop substitute speech in a 5-week
period of rehabilitation (Table III).
Discussion
The treatment of laryngeal and hypopharyngeal cancer
inevitably results in iatrogenic injuries. The patient should
be aware of possible loss or reduction of voice, difficulties in
swallowing, change in the way of breathing, pain and
Table II –Measurement of pressure in the opening of
sphincter of oesophagus mouth
Study
group
Pressure in the opening of sphincter of
oesophagus mouth [number of patients]
0.7–5.3 kPa
(5–40 mmHg)
5.3–10.7 kPa
(40–80 mmHg)
10.7–12.1 kPa
(80–90 mmHg)
I20 46 14
II 35 32 8
III 51 27 2
IvsII p= 0.013 p= 0.027 NS
II vs III p= 0.011 NS NS
I vs III p<0.001 p= 0.003 p= 0.002
NS –not significant.
Table I –Measurements of the neck circumference in the
patients
Study group Neck circumference
Mean SD [cm]
I 47.02 2.62
II 44.85 2.26
III 42.68 2.45
DI vs II 2.17 0.36
DI vs III 4.34 0.17
IvsII p= 0.002
I vs III p<0.001
Table III –Subjective voice assessment
Study group Nature of the voice
[number of patients]
Voice production
mechanism
[number of
patients]
Phonation volume
[nubmer of patients]
Lack of
substitute
speech
[number
of patients]
Sonorous Flat Hoarse Strained Easy Silent Medium Laud
I 5 (6%) 35 (44%) 40 (50%) 70 (88%) 10 (12%) 55 (69%) 23 (29%) 2(2%) 16 (20%)
II 54 (68%) 10 (12%) 16 (20%) 48 (60%) 32 (40%) 32 (40%) 36 (45%) 12 (15%) 10 (12%)
III 55 (69%) 9 (11%) 16 (20%) 50 (61%) 30 (39%) 32 (40%) 37 (46%) 11 (14%) 7 (8%)
IvsII p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p= 0.033 p= 0.012
II vs III NS NS NS NS NS NS NS NS
I vs III p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p= 0.022 p<0.001
NS –not significant.
Dźwięczny matowy ochrypły party swobodny cicha średnia głośna.
polski przeglĄd otorynolaryngologiczny 2 (2013) 137–141 139
psychological tensions associated with operative treatment.
Voice loss seems to be the most intolerable of all mentioned
problems [5, 6].
About 10–20% of patients after total removal of the
larynx are unable to learn to speak despite the voice
rehabilitation (the learning of oesophageal speech, voice
prostheses, electronic larynx) [7, 8]. The learning process of
substitute speech can by delayed or even totally reduced by
excessive thickness of tissues in the neck and submandibu-
lar region due to lymphostasis (lymphoedema) [9]. In order
to improve the quality of voice rehabilitation after total
laryngectomy, it is important to minimize the effects of an
extensive surgical treatment, radiotherapy or chemotherapy.
The application of mechanical resonance technique in
deeply invasive massager Medical 2VR improves blood and
lymph flow. Therefore, it supports better blood supply and
nourishment of the tissues and reduces lymphoedemas and
venostasis. Accelerating the process of metabolism in basal
layer of the skin leads to faster regeneration of damaged
epidermal cells. An increase of temperature in the areas of
laryngeal tissues results in haemangiectasia, efficient blood
supply in muscular tissue and its enhanced elasticity and
resilience. It particularly concerns nape and neck muscles,
muscular coat of oesophagus as well as mimical and tongue
muscles. The massage allows to comminute and remove fat
cells from excessively developed subcutaneous tissue of
submandibular region [10]. In our study, 90% of patients
showed a significant reduction of the neck circumference
after rehabilitation with the application of massager. The
values of pressure in the opening of sphincter of oesopha-
gus mouth, which do not extend 80 mmHg, are crucial in
voice rehabilitation [11]. It has been found that the better
quality of substitute speech is an effect of greater expres-
sion of mouth and face movements [5]. Muscles relaxation
by reducing physiological stress effects not only supports
rehabilitation process, but it also improves physical endu-
rance and self-confidence [4, 5]. The application of massager
Medical 2VR, Cyberbiomed not only refines voice rehabilita-
tion, but it also leads to faster return to active social life in
patients after total laryngectomy. Deeply invasive massager,
if regularly used, tones the skin, decreases tension of the
oesophageal muscles and significantly improves blood
supply in the operated area. Possible complications after the
use of the massager include pharyngocutaneous fistula and
irritation of mucous membrane of the tracheostomy. Howe-
ver, none of above side effects were observed in the study.
Conclusions
The application of the invasive massager Medical 2VR in
voice rehabilitation in patients after complete removal of
the larynx:
1. Reduces lymphoedema of the neck.
2. Improves elasticity and blood supply in soft tissues of the
neck.
3. Decreases pressure in the opening of sphincter of oesop-
hagus.
4. Reduces the period of voice rehabilitation and accelerates
the learning process of substitute speech.
5. Improves general physical endurance and the quality of
life.
Authors' contributions/Wkład autorów
According to order.
Conflict of interest/Konflikt interesu
The work was not funded by the Clinic of Otolaryngology of
the Medical University of Silesia. The device concept was
developed by Cyberbiomed. The costs of development and
implementation were incurred by Cyberbiomed.
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article has been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments invol-
ving humans; EU Directive 2010/63/EU for animal experi-
ments; Uniform Requirements for manuscripts submitted to
Biomedical journals.
Acknowledgements/Podziękowania
We are grateful to Wojciech Musialik for his technical
assistance.
references/pi
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