In humans, speech is a complex process that requires the coordinated involvement of various components of the phonatory system, which are monitored by the central nervous system. The larynx in particular plays a crucial role, as it enables the vocal folds to meet and converts the exhaled air from our lungs into audible sounds. Voice production requires precise and sustained exhalation, which generates an air pressure/flow that creates the pressure in the glottis required for voice production. Voluntary vocal production begins in the laryngeal motor cortex (LMC), a structure found in all mammals, although the specific location in the cortex varies in humans. The LMC interfaces with various structures of the central autonomic network associated with cardiorespiratory regulation to allow the perfect coordination between breathing and vocalization. The main subcortical structure involved in this relationship is the mesencephalic periaqueductal grey matter (PAG). The PAG is the perfect link to the autonomic pontomedullary structures such as the parabrachial complex (PBc), the Kölliker–Fuse nucleus (KF), the nucleus tractus solitarius (NTS), and the nucleus retroambiguus (nRA), which modulate cardiovascular autonomic function activity in the vasomotor centers and respiratory activity at the level of the generators of the laryngeal-respiratory motor patterns that are essential for vocalization. These cores of autonomic structures are not only involved in the generation and modulation of cardiorespiratory responses to various stressors but also help to shape the cardiorespiratory motor patterns that are important for vocal production. Clinical studies show increased activity in the central circuits responsible for vocalization in certain speech disorders, such as spasmodic dysphonia because of laryngeal dystonia.

The dorsomedial hypothalamus nucleus (DMH) plays a pivotal role in the orchestration of sympathetic nervous system activities. Through its projections to the brainstem and pontomedullary nuclei, it controls heart rate, contractility, blood pressure, and respiratory activity, such as timing and volumes. The DMH integrates inputs from higher brain centers and processes these signals in order to modulate autonomic outflow accordingly. It has been demonstrated to be of particular significance in the context of stress responses, where it orchestrates the physiological adaptations that are necessary for all adaptative responses. The perifornical region (PeF), which is closely associated with the DMH, also makes a contribution to autonomic regulation. The involvement of the PeF region in autonomic control is evidenced by its function in coordinating the autonomic and endocrine responses to stress, frequently in conjunction with the DMH. The DMH and the PeF do not function in an isolated manner; rather, they are components of a comprehensive hypothalamic network that integrates several autonomic responses. This neural network could serve as a target for developing therapeutic strategies in cardiovascular diseases.

Vocal production requires the coordinated control of respiratory, laryngeal, and autonomic systems. In individuals with high vocal demand, this physiological load may influence autonomic regulation, even in the absence of voice disorders. This scoping review systematically mapped current evidence on the relationship between voice production and autonomic nervous system (ANS) activity in adults, focusing exclusively on studies that assessed both systems simultaneously. A systematic search was conducted in PubMed, Scopus, Web of Science, Embase, and CINAHL, following PRISMA-ScR guidelines. Eligible studies included adults performing structured vocal tasks with concurrent autonomic measurements. Data were extracted and synthesized descriptively. Fifteen studies met the inclusion criteria. Most involved healthy adults with high vocal demand, while some included participants with subclinical or functional voice traits. Vocal tasks ranged from singing and sustained phonation to speech under cognitive or emotional load. Autonomic measures included heart rate (HR), heart rate variability (HRV), and electrodermal activity (EDA), among others. Four thematic trends emerged: autonomic synchronization during group vocalization; modulation of autonomic tone by vocal rhythm and structure; voice–ANS interplay under stress; and physiological coupling in hyperfunctional vocal behaviours. This review’s findings suggest that vocal activity can modulate autonomic function, supporting the potential integration of autonomic markers into experimental and clinical voice research.

Area A5 is a noradrenergic cell group in the brain stem characterised by its important role in triggering sympathetic activity, exerting a profound influence on the sympathetic outflow, which is instrumental in the modulation of cardiovascular functions, stress responses and various other physiological processes that are crucial for adaptation and survival mechanisms. Understanding the role of area A5, therefore, not only provides insights into the basic functioning of the sympathetic nervous system but also sheds light on the neuronal basis of a number of autonomic responses. In this review, we look deeper into the specifics of area A5, exploring its anatomical connections, its neurochemical properties and the mechanisms by which it influences sympathetic nervous system activity and cardiorespiratory regulation and, thus, contributes to the overall dynamics of the autonomic function in regulating body homeostasis.

Ehlers–Danlos syndromes (EDS) are heritable connective tissue disorders caused by defects in collagen and related extracellular-matrix proteins. Because the vocal fold (VF) lamina propria is a collagen-dependent structure, the voice might be expected to be affected, yet laryngeal involvement has received comparatively little attention. This scoping review, conducted according to the Joanna Briggs Institute framework and reported following the PRISMA extension for Scoping Reviews (PRISMA-ScR), mapped the available evidence on voice and laryngeal manifestations in adults with EDS. PubMed, Scopus and Web of Science were searched to 11 March 2026, and thirteen studies were included: four questionnaire-based and nine clinical or instrumental. Self-reported voice problems were common across EDS and hypermobility spectrum disorder populations, ranging from mild-to-moderate handicap in large cohorts to frequent, fluctuating difficulties in professional singers, although their prevalence varied with population and assessment method. Direct laryngeal examination revealed a recurring substrate of cricoarytenoid joint subluxation or fixation, arytenoid prolapse and hyolaryngeal instability, together with microvascular and mucosal fragility, characteristically accompanied by preserved VF mobility. Muscle tension dysphonia was the most frequent diagnosis in high-vocal-demand cohorts. Reflux, vocal load and autonomic comorbidities such as postural orthostatic tachycardia syndrome were frequently reported and may modulate the clinical picture. Taken together, the evidence indicates that voice and laryngeal involvement is a genuine, multi-level manifestation of EDS that remains under-recognised. The current literature is limited by small, heterogeneous and largely uncontrolled studies; prospective research using standardised multimodal assessment is needed to clarify its prevalence, mechanisms and management.

Teaching Human Physiology in undergraduate medical education requires more than the acquisition of conceptual knowledge; it demands that students develop causal explanatory frameworks linking physiological mechanisms to their clinical manifestations. Problem-Based Learning (PBL) has been proposed as a strategy to promote this integrative form of reasoning, yet evidence in preclinical physiology, particularly among first-year medical students without prior formal clinical exposure, remains limited. This quasi-experimental pre–post study evaluated the impact of a two-session PBL intervention on physiological reasoning in 135 first-year medical students at the University of Málaga. The intervention comprised six contact hours delivered across five small-group classes (25–30 students per class) organized into teams of five students and was triggered by two real cardiovascular events involving elite athletes. Written responses to two open-ended questions administered before (PRE) and after (POST) the intervention were coded using an ordinal framework (N0–N4) that independently assessed mechanistic conceptual complexity (P1: physiological model of the heart as an effective pump) and physiological cause–effect integration (P2: physiological rationale underlying healthcare intervention following loss of effective blood flow). Both dimensions improved significantly after the intervention. The effect on physiological cause–effect integration was large (P2: Z = −7.723, p < 0.001, r = 0.68), with the proportion of students reaching advanced integrative reasoning levels (N3–N4) increasing from 3.8% to 53.8%. The effect on mechanistic conceptual complexity was moderate (P1: Z = −4.683, p < 0.001, r = 0.41). Improvements in the two dimensions were independent of one another (rs = 0.128, p > 0.05), indicating that they represent distinct cognitive constructs. These findings suggest that brief, carefully designed PBL sequences anchored in authentic clinical problems can produce substantial gains in causal physiological reasoning among first-year medical students, even before the formal introduction of cardiovascular physiology in lecture-based teaching.