Laryngeal Manual Therapies for Behavioral Dysphonia: A Systematic Review and Meta-analysis * , †Vanessa Veis Ribeiro, *Vanessa Pedrosa, †Kelly Cristina Alves Silverio, and * , ‡Mara Behlau, *‡São Paulo and †Bauru, Brazil Summary: Objectives. The aim of this study was to review systematically the literature and to analyze the effec- tiveness of laryngeal manual therapy in addressing the overall severity of vocal deviation, the intensity of vocal and laryngeal symptoms, and musculoskeletal pain in adults with behavioral dysphonia. Study Design. This is a systematic review and meta-analysis. Methods. Two independent authors selected clinical trials that analyzed the effectiveness of laryngeal manual therapy compared with other interventions in the treatment of adults with behavioral dysphonia from the Cochrane Library, PubMed, Web of Science, and LILACS. The analyzed outcomes were the overall severity of vocal deviation, the in- tensity of vocal and laryngeal symptoms, and musculoskeletal pain. Data analysis was conducted based on the following steps: the assessment of the risk of bias, the measures of treatment effect and descriptive data analysis, the assessment of heterogeneity, subgroup analysis, sensitivity analysis, and the assessment of reporting biases. Results. A total of 2135 studies were identified, three of which met the selection criteria. Data analysis showed an unclear risk of 100% of performance bias and 66% of detection bias, in addition to a 33% high risk of selection bias. Low statistical and clinical heterogeneities were found. In addition, no significant difference was found in the relative risk of improvement with laryngeal manual therapy and with other interventions in the analyzed outcomes. Conclusions. Various types of laryngeal manual therapies are available with similar objectives and effects, but their effectiveness is equivalent to that of other interventions involving direct voice therapy in the rehabilitation of adults with behavioral dysphonia. Key Words: Dysphonia–Therapeutics–Voice–Voice training–Voice disorders. INTRODUCTION The voice is considered to be adapted when it is produced and emitted without difficulty or effort. Any change in this process is called dysphonia. 1 The type of dysphonia that has as its eti- ology inappropriate vocal behavior, whether caused by vocal misuse or abuse, poor voice technique, or muscle tension, as pre- dominantly related to the use of voice, is classified as behavioral dysphonia. 1–3 There are still a lot of contradictions in the literature about the definition and the clinical, vocal, and laryngeal manifesta- tions of behavioral dysphonia, so the characteristics cited in the present study are based on the classification proposed by Behlau et al. 1 Thus, among the clinical manifestations of behavioral dys- phonia can be an excessive muscle tension in the cervical, facial, and laryngeal muscles; an elevated larynx; a reduction of the thy- rohyoid space; a hyperextended head; elevated shoulders; and an upper breathing pattern, among others. 4–13 In addition, vocal characteristics can be found, such as vocal quality character- ized predominantly by strain; a roughness and instability when associated with increased mass in the vocal folds, tension or stiff- ness in the vocal folds, and breathiness when associated with an incomplete glottic closure; a hard vocal attack; poor articu- lation; and laryngeal or pharyngeal resonance. 5,12–14 As for the larynx, individuals with behavioral dysphonia may present a normal larynx in the presence of vocal deviations or a larynx with organic lesions, provided that the lesions are clear consequences of vocal use. 1 These vocal deviations include changes in the mucosa of the vocal folds, such as vocal fold edema, vocal fold nodules, or other benign mass lesions; pos- tural changes, such as glottic chink; and other features related to excessive tension in the laryngeal musculature, such as an in- complete glottic closure and a hyperadduction or a constriction of the vocal folds and the laryngeal vestibule, in addition to su- praglottic alterations and minor structural alterations. 1,13–15 Thus, the condition may result in an imbalance of the laryngeal and perilaryngeal musculatures, and patients may present an in- crease in the quantity, intensity, and frequency of vocal and laryngeal symptoms and musculoskeletal pain. 4,11,14 Among the numerous possibilities of treatment for behavior- al dysphonia are the various types of laryngeal manual therapy. The term “laryngeal manual therapy” will be used in the present study in a generic way to refer to all procedures involving the digital manipulation of the neck and the cervical structures, 16,17 which are referred to in the literature by various names, such as manual circumlaryngeal therapy, 12,18 laryngeal manual therapy, 4,19 and voice massage. 20 The main objective of these in- terventions is to relax the musculature of the neck, the scapular girdle, and the larynx regions, seeking a muscular balance that enables the phonatory normofunction. 4,17 The literature on laryngeal manual therapy shows positive results for the intervention 4,14,16,17,21,22 and provides evidence that it can accelerate the improvement process and shorten the therapy Accepted for publication June 27, 2017. From the *Voice Department, Centro de Estudos daVoz (CEV), São Paulo, São Paulo, Brazil; †Speech-Language Pathology and Audiology Department, Universidade de São Paulo (USP), Bauru, São Paulo, Brazil; and the ‡Speech-Language Pathology and Audiology De- partment, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil. Address correspondence and reprints to Vanessa Pedrosa, Centro de Estudos da Voz - Rua Machado Bittencourt, 361, 10th floor, São Paulo, SP 04044-001, Brazil. E-mail: vanessa@fonoevidence.com.br Journal ofVoice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2017.06.019 ARTICLE IN PRESS