Voice Therapy Outcome—A Randomized Clinical Trial Comparing Individual Voice Therapy,Therapy in Group,and Controls Without Therapy

ObjectiveA stumbling-block in voice therapy is how the patient will be able to apply the new voice technique in everyday life. Possibly this generalization process could be facilitated by giving voice therapy in group because of the natural forum for training voice-to-speech early in communication between the patients in a group setting. The aim of the study was to compare treatment results from individual voice therapy and voice therapy in group, at several time points and in comparison to patients with no voice therapy.MethodsA randomized treatment study was performed with 77 consecutive patients diagnosed with a functional voice disorder. Thirty-one patients were randomized to individual and group therapy, respectively, and 15 patients to no therapy. The assessments included standardized voice recording and registration of voice range profile (VRP), answering Voice handicap index (VHI) and visual analogue scales for self-hoarseness and self-vocal fatigue, and perceptual voice evaluation by speech-language pathologist. The assessments were performed before, direct after therapy, and three months later in all groups. The 2 therapy groups were also assessed 12 months after therapy.ResultsAll VHI scores as well as the self-ratings of hoarseness and vocal fatigue, and the perceptual evaluation of voice quality and maximum VRP improved significantly in both therapy groups 3 months after treatment and at 12 months follow-up. There were no significant changes in the control group, with the exception of decreased self-rated hoarseness and increased maximum VRP. Comparisons between treatment groups showed significant larger improvement after group therapy for VHI physical subscale at 12 months, as well as significant lower VHI total score at all measurement sessions and lower subscale scores at 12 months. There were no differences between treatment groups in self-hoarseness or self-vocal fatigue and no difference in perceptual voice quality or VRP. Comparison between controls and treatment groups showed significant larger change in treatment groups from baseline to three months in VHI total and to end of therapy in functional subscale. Treatment groups also showed significant lower scores than controls at each measurement session, for VHI total and physical subscale as well as lower degree of perceptual aberration of voice quality and vocal fatigue, at three months follow-up.ConclusionsThis study shows long-term improvement from behavioral voice therapy, particularly in a group setting. The results indicate the importance of early transfer-to-speech and late posttherapy test to capture whether the goal of voice therapy was fulfilled or not for the patients.     

Expanding perspectives in care of the speaking voice

The effective voice clinician has always had to borrow from various disciplines: voice science, otolaryngology, psychology, and speech-language pathology. Such eclecticism requires, however, that the clinician integrate the perspectives of these various disciplines into some kind of theoretical clinical bias. One bias might be that with greater use of instrumentation in voice therapy, the voice clinician must not substitute data collection for attending to the feelings of the patient. By using the clinical input from various disciplines, for example, voice clinicians might develop a useful clinical perspective that vocal hyperfunction is one of the primary causes of many voice disorders. Consequently, from such a clinical view might come a treatment perspective that can clearly define the problem (too much effort while speaking) and offer a rationale for voice remediation.     

G. Paul Moore lecture: unifying the disciplines of our voice smorgasbord

A look at the many disciplines working with voice over the past 50 years is provided from the perspective of a speech-language pathologist (SLP). Some of the earliest collaborations between medicine and speech-language pathology were seen in the management of cleft palate and velopharyngeal inadequacy problems and observed, also, in laryngectomee rehabilitation. The earlier concern of the SLP for the emotional and psychological aspects of patients with voice disorders appeared replaced with the rise of symptomatic therapy. Dramatic improvement in instrumentation assisted by computer analyses increased our awareness and understanding of both normal and disordered phonation. Although instrumentation today allows for many forms of visual feedback in voice training and therapy, this may be often at the expense of providing needed kinesthetic-proprioceptive and auditory feedback. Particular voice therapy approaches (cognitive, gestalt-holistic, imagery, resonant therapy, muscle training, and symptomatic therapy) used today are described. Suggestions are given for improving educational requirements and clinical experience in voice for SLPs.     

Preparation of the Speech-LanguagePathologist Specializing in Voice: An Educational Survey

This study investigates the academic and clinical preparation a speech-language pathologist receives in the area of voice. The purpose is to determine how to structure continuing education and specialty training in vocology, defined as the science and practice of voice habilitation. Surveys were sent to the graduate programs in speech-language pathology accredited by the American Speech-Language-Hearing Association (ASHA) in 1994, and again in 1999. Results from the 1994 survey indicated that students received limited information and clinical experience in handling typical voice cases. Although most programs required a voice disorders course, fewer mandated coursework in normal voice production or clinical experience with voice patients. The follow-up survey showed that the educational environment in 1999 is similar to that in 1994. It is evident that the programs are in compliance with the Educational Training Board model developed by ASHA for basic clinical competence, but no structure for specialty training has yet emerged.     

Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules

The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules. Perceptual and physiological progressive changes were examined during a strictly structured, behaviorally based voice therapy protocol in which 11 women with vocal nodules participated. Randomized audio recordings from pretherapy and from each of the therapy approaches (vocal hygiene, respiration, direct facilitation, carryover) were used for perceptual evaluations. Six speech-language pathologists rated ten voice quality parameters. Two evaluation procedures were performed and compared. Interlistener reliability was sufficiently high in both tests. Significant effects of therapy were found for decreased overall dysphonia, press, instability, gratings, roughness, vocal fry, and "scrape." Nonsignificant group effects were found for breathiness, aphonic instances, and lack of sonority. No significant parameter changes occurred between baseline assessment and the completion of the initial (vocal hygiene) phase of therapy. Significant changes were found following the direct facilitation and respiration phases of therapy. Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved. However, the nodules had decreased in size and edema was reduced after therapy for all clients, but one. Combined results suggest: (1) Alterations in vocal function were reflected in perceptual parameters, and (2) the voice therapy had a positive effect on voice quality, vocal status, and vocal function for the majority of the vocal nodule clients.     

Treatment of laryngeal contact ulcers and granulomas: A 12-year retrospective analysis

Multiple etiological factors including gastroesophageal reflux, hyperfunctional voice use, and endotracheal intubation have been implicated in the development of posterior laryngeal ulcers and granulomas. The optimal approach to treatment of these lesions remains controversial. The mainstay of treatment at Vancouver General Hospital has been aggressive medical management of gastroesophageal reflux, with complimentary voice therapy offered to patients suspected of having significant hyperfunctional phonation. The authors reserve Botulinum toxin injection or surgical excision for patients who fail initial therapy. They conducted a retrospective analysis of their voice clinic records from 1985–1997 to examine the efficacy of this approach. They identified 76 patients with the diagnosis of contact ulcer or granuloma. Fifty-two patients had follow-up data available for review. Ninety-four percent of patients were treated nonsurgically: 35 patients were treated solely by dietary and medical therapy to control gastroesphageal reflux, 10 patients were treated by a combination of medical gastroesophageal reflux control and voice therapy, 3 patients had Botox injections, 2 patients had surgical excision of granuloma, 1 patient had a Kenalog injection, and 1 patient underwent laparoscopic fundoplication. Overall, 77% of patients had complete resolution, whereas 11% had partial resolution and another 11% had no significant improvement. The data supports control of gastroesophageal reflux as a central component in treatment of posterior laryngeal ulcers and granulomas.     

Reliability in Perceptual Analysis of Voice Quality

This study focuses on speaking voice quality in male teachers (n = 35) and male actors (n = 36), who represent untrained and trained voice users, because we wanted to investigate normal and supranormal voices. In this study, both substantial and methodologic aspects were considered. It includes a method for perceptual voice evaluation, and a basic issue was rater reliability. A listening group of 10 listeners, 7 experienced speech-language therapists, and 3 speech-language therapist students evaluated the voices by 15 vocal characteristics using VA scales. Two sets of voice signals were investigated: text reading (2 loudness levels) and sustained vowel (3 levels). The results indicated a high interrater reliability for most perceptual characteristics. Connected speech was evaluated more reliably, especially at the normal level, but both types of voice signals were evaluated reliably, although the reliability for connected speech was somewhat higher than for vowels. Experienced listeners tended to be more consistent in their ratings than did the student raters. Some vocal characteristics achieved acceptable reliability even with a smaller panel of listeners. The perceptual characteristics grouped in 4 factors reflected perceptual dimensions.     

Rationale and structure of a curriculum in vocology

A proposal is presented for formal academic training in vocology, the science of vocal habilitation and voice disorders. Rationale is given for expanding current methods of intervention offered in speech-language pathology classes to include more of the techniques offered in theatre arts and music. Formally, this can be accomplished by establishing a specialty track (vocology) in an M.A. program. The primary focus of vocal habilitation should be to meet the vocational and recreational needs of a particular individual, not simply to achieve a normal voice     

Reliability of Clinician-Based (GRBAS and CAPE-V) and Patient-Based (V-RQOL and IPVI) Documentation of Voice Disorders

This study examined the reliability of two methods for documenting voice quality by clinicians and compared the methods for documenting patients' perceptions of voice quality. It involved a prospective reliability study and a retrospective chart review. Reliability of two clinician-based voice assessment protocols-Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) and Consensus Auditory Perceptual Evaluation-Voice (CAPE-V)-was evaluated. These two protocols were then compared after use in voice assessments of 42 males and 61 females performed by a certified speech-language pathologist specializing in the assessment of voice disorders. In addition, two patient-based scales (Voice Related Quality of Life, or V-RQOL, and Iowa Patient's Voice Index, or IPVI) obtained from the same patients were compared with each other and with the clinician-based scales. Reliability of clinicians' ratings of overall severity of dysphonia using GRBAS and CAPE-V scales was very good (r>0.80). Agreement between V-RQOL Total scores and IPVI ratings of the patient's perceptions of impact of dysphonia was less strong (Spearman's r=-0.76). There was relatively weak agreement between patient-based and clinician-based scales. Clinician's perceptions of dysphonia appeared to be reliable and unaffected by rating tool, as indicated by the high level of agreement between the two rating systems when they were used together. The CAPE-V system appeared to be more sensitive to small differences within and among patients than the GRBAS system. The V-RQOL and IPVI approaches to documenting patient's perceptions of dysphonia agreed less well possibly due to differences in patient dependence on voice and on interpretation of the rating tool items. The differences between clinician-based and patient-based data support the conclusion that clinicians and patients experience and consider dysphonia very differently.     

Voice Problems of Future Speech-Language Pathologists

Students training to be educators frequently exhibit voice disorders prior to employment. To date, there exist no similar studies of future speech-language pathologists (SLPs). The study is designed as a prospective, nonrandomized survey. The objective of this study is to determine the voice problems of first year graduate students training to be SLPs. Participants were 104 first year graduate students majoring in speech-language pathology at two universities. The Quick Screen for Voice was administered. Participants who failed completed a questionnaire regarding voice problems, medical history, daily habits, and voice use. When responses further indicated voice-related problems, endoscopic examination was completed. Fourteen percent (N=15) of the participants failed the screening by demonstrating two or more abnormal voice characteristics. These included persistent glottal fry (present in all who failed), low habitual pitch, juvenile resonance, hoarse, breathy, or strained phonation, abnormally low pitch on sustained vowels, and voice breaks during the frequency range. Twelve percent (N=12) failed both the screening and follow-up questionnaire. Responses included self-reported dysphonia, medical history with voice-related side effects, difficulty with excessive voice use, and voice problems occurring daily or weekly. Endoscopic evaluation showed one participant with bilateral vocal nodules. The results suggest that voice problems among future SLPs (12%) are more common than the 3-9% reported in the general population and similar to the 11% previously reported for teachers. However, future SLP voice problems are less frequent than those reported among education majors (21%) and all college students (17%). Faculty should identify students with voice problems and emphasize optimal voice use in classroom and clinical settings.     

Prevalence of voice disorders in African American and European American preschoolers

Several studies have reported prevalence rates for voice disorders in school-aged children. Less is known, however, about such prevalence in preschoolers, and whether racial, ethnic, or cultural diversity may influence it. The presence of voice disorders in a total of 2445 African-American and European-American preschool children, 1246 males and 1199 females, from 2 to 6 years of age is reported here. Presence of a voice disorder characterized by hoarseness was identified by a three-prong approach including teacher identification, investigator screening, and parent identification. Speech-language pathologists listened individually to each child's speech as they engaged each child in play-conversation activities. A voice disorder was identified on the basis of the judgment of two speech-language pathologists. Voice disorders characterized by hoarseness were identified in 95 children or 3.9% of the total sample by the investigators. Statistical analysis revealed no significant differences for age, gender, or race.     

Coaching Strategies for Behavioral Voice Therapy and Training

Coaching is one of the most common words in our modern vocabulary and has many meanings depending on the setting in which it is used. Coaching facilitates positive changes to achieve a goal, usually through indirect approaches, including improving an individual's outlook on their behaviors or attitudes. Its application has spread beyond the corporate world, and many medical specialties use coaching principles. The goals of this article are to introduce coaching as a profession, and to explore the function of a vocal coach to improve communicative and vocal performance. Moreover, differences between voice therapy and voice training are highlighted, including the principles subjacent to these interventions and the use of coaching strategies. Four strategies of professional coach practitioners adapted to the training and therapy of the voice with applications to both are described. These are: powerful questions, active listening, changing habits, and implementation intention. The use of these strategies may help individuals to achieve high voice performance. Most importantly, the speech-language pathologist voice specialist can apply these strategies particularly in cases of behavioral dysphonias, which can be resistant to traditional voice therapy.     

Instrumental and Perceptual Evaluations of Two Related Singers

The primary goal of this study was to characterize a performer's singing and speaking voice. One woman was not admitted to a premier choral group, but her sister, who was comparable in physical characteristics and background, was admitted and provided a valuable control subject. The perceptual judgment of a vocal coach who conducted the group's auditions was decisive in discriminating these 2 singers. The singer not admitted to the group described a history of voice pathology, lacked a functional head register, and spoke with a voice characterized by hoarseness. Multiple listener judgments and acoustic and aerodynamic evaluations of both singers provided a more systematic basis for determining: 1) the phonatory basis for this judgment; 2) whether similar judgments would be made by groups of vocal coaches and speech-language pathologists; and 3) whether the type of tasks (e.g., sung vs. spoken) would influence these judgments. Statistically significant differences were observed between the ratings of vocal health provided by two different groups of listeners. Significant interactions were also observed as a function of the types of voice samples heard by these listeners. Instrumental analyses provided evidence that, in comparison to her sister, the rejected singer had a compromised vocal range, glottal insufficiencies as assessed aerodynamically and electroglottographically, and impaired acoustic quality, especially in her speaking voice.     

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.     

Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy.

An important clinical issue concerns the efficacy of current voice therapy approaches in treating voice disorders, such as vocal nodules. Much research focuses on finding reliable methods for documentation of treatment results. In this second treatment study of ten patients with vocal nodules, who participated in a behaviorally based voice therapy program, 11 aerodynamic (transglottal air pressure and glottal waveform) and acoustic (spl, f0, and spectrum slope) measures were used. Three pretherapy baseline assessments were carried out, followed by one assessment after each of five therapy phases. Measurements were made of two types of speech materials: Strings of repeated /pae/ syllables and sustained /ae/ phonations in two loudness conditions: comfortable loudness and loud voice. The data were normalized using z-scores, which were based on data from 22 normal subjects. The results showed that the aerodynamic measures reflected the presence of vocal pathology to a higher degree than did the acoustic spectral measures, and they should be useful in studies comparing nodule and normal voice production. Large individual session-to-session variation was found for all measures across pretherapy baseline recordings, which contributed to nonsignificant differences between baseline and therapy data.     

Vocal loudness and frequency capabilities of the voice

A phonetogram is a graph showing the sound pressure level (SPL) of softest and loudest phonation over the entire fundamental frequency range of a voice. A physiological interpretation of a phonetogram is facilitated if the SPL is measured with a flat frequency curve and if the vowel /a/ is used. It was found that in soft phonation, the SPL is mainly dependent on the amplitude of the fundamental, while in loud phonation, the SPL is mainly determined by overtones. The short-term SPL variation, i.e., the level variation within a tone, was about 5 dB in soft phonation and close to 2 dB in loud phonation. For two normal voices the long-term SPL variation, calculated as the mean standard deviation of SPL for day-to-day variation, was found to be between 2.4 and 3.4 dB in soft and loud phonation. Speakers who raise their loudness of phonation also tend to raise their mean voice fundamental frequency. Measures obtained from speaking at various voice levels were combined so that typical pathways could be introduced into the phonetogram. The average slope of these pathways was 0.3–0.5 st/dB for healthy subjects. Averaged phonetograms for male singers and male nonsingers did not differ significantly, but averaged phonetograms for female singers and female nonsingers did, in that the upper contour was higher for the female singers. Averaged phonetograms for female patients with non-organic dysphonia showed significantly lower SPL values in loudest phonation as compared to healthy female subjects, while no corresponding difference was seen for males in this regard. With respect to the SPL values for softest phonation, male dysphonic patients showed significantly higher SPL values than healthy male subjects, while no corresponding difference was seen in female subjects. The subglottal pressure mirrored these phonetogram differences between healthy and pathological voices. The averaged phonetograms of female patients after voice therapy showed an increased similarity with those of normal voices. For the male patients the averaged phonetogram did not change significantly after therapy.     

Effects of voice therapy on the voice range profiles of dysphonic patients

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.     

Twelve-Month Clinical Follow-Up Study of Voice Patients' Recovery Using the Voice Activity and Participation Profile (VAPP)

Objective

To study the effects of voice treatment including brief voice therapy for 12 months in two groups of voice patients: organic and functional.

Design and Methods

A clinical prospective follow-up study with repeated measurements in five phases: medical session, first voice therapy session, last voice therapy session, and 6 months and 12 months after voice therapy. The mean number of voice therapy sessions was 3.4. The main outcome measures were the Voice Activity and Participation Profile (VAPP) and the Symptom Questionnaire.Of consenting patients (n = 141) with chronic voice disorders, 46 dropped out during follow-up. Ninety-five patients formed the study group. Forty-one of them received only voice therapy, but the rest of them received combined treatment (medication, amplifiers, and voice massage), but also experienced life events affecting voice. Patients with any laryngeal pathology formed the organic group (n = 47), others had a functional voice disorder.

Results

Using the improvement criterion that the change of the VAPP score should exceed standard error of measurement, the percentage of individual patients achieving improvement was 47% in the mild, 59% in the moderate, and 75% in the severe disorder groups. Effect size for VAPP total score was 0.89. The positive effect continued to progress after the therapy ended. Patients with functional or organic voice disorder improved almost equally, although minor findings indicate that functional patients benefited more.

Conclusions

Voice treatment had a progressive effect for 1 year in half of our patients. No statistical difference was found between the functional and organic patient groups.     

Intensive voice treatment in parkinson disease: Laryngostroboscopic findings

As part of ongoing research to investigate and document the efficacy of intensive voice therapy to improve functional communication in patients with idiopathic Parkinson disease, 45 patients were enrolled in a controlled, randomized, prospective study. Pre- to posttreatment comparisons are presented here on 22 of those patients who underwent laryngeal imaging examination. Of the 22 patients, 13 patients received intensive therapy aimed at increasing vocal and respiratory effort (VR), whereas nine received intensive therapy aimed at increasing respiratory effort (R) only. All patients had a pretreatment evaluation that included two (but sometimes only one) voice recordings and an otolaryngologic examination with laryngostroboscopy. At the completion of 4 weeks of therapy (16 sessions), two voice recordings were made, and laryngostroboscopy was again performed. The pre- and posttherapy videolaryngostroboscopy tapes were then randomized and rated by four judges. Raters' findings were then compared with vocal intensity measured before and after therapy. The VR therapy group showed improvements on laryngostroboscopic variables: less glottal incompetence and no significant change in supraglottal hyperfunction after therapy. No differences were observed in the R-only group. The mean intensity increase in the VR therapy group was 12.5 dB, compared with a decrease of 1.9 dB in the R-only group. These findings suggest that in patients with Parkinson disease, intensive therapy focusing on phonatory effort improves adduction of the vocal folds as assessed by laryngostroboscopy. Differences in laryngeal function in these patients observed with fiberoptic laryngoscopy and rigid telescopic laryngoscopy are discussed.     

Inhaled Corticosteroids: Hazardous Effects on Voice—An Update

Inhaled corticosteroids (ICS) have become the prevalent treatment in asthmatics. Hazards to voice are under-recognized. A total of 38 patients with voice complaints associated with the use of ICS were assessed by 79 strobovideolaryngoscopy (SVL) examinations, 24 single and 14 multiple SVL. Hoarseness and dysphonia were the primary reasons for referral. The ICS initially used most frequently was Advair Diskus (fluticasone propionate and salmeterol-inhalation powder-[IP]) in 22 patients, followed by Flovent (fluticasone propionate inhalation aerosol-pressurized metered-dose inhaler-[PMDI]) in 11. Duration of ICS usage varied from 2 weeks to 4-5 years. Higher dosage and frequency of use exacerbated problems. Hazards to voice previously unrecognized by real-time indirect mirror or fiberoptic laryngoscopy were identified by meticulous attention to SVL abnormalities. There was essentially no difference in occurrence of abnormalities whether analyzed from the perspective of the initial 38 or all 79 examinations. These included abnormal mucosal wave symmetry/periodicity (76-63%), phase closure (74-63%), glottic closure (63-59%), mucosal wave amplitude/magnitude (50-35%), supraglottic hyperactivity (39-25%), mucosal quality (34-34%), and glottic plane (10-5%).Candidiasis of the larynx was infrequently observed. Fluticasone ICS were a cause of steroid inhaler laryngitis, and the best treatment was their avoidance or cessation. Further prospective studies ideally might include SVL documented as a pretherapy baseline and then repeated in each ICS patient who developed hoarseness/dysphonia.