Use of acupuncture for the treatment of adductor spasmodic dysphonia: a preliminary investigation

Ten subjects with adductor spasmodic dysphonia participated in a study examining the effects of an acupuncture treatment protocol on their voice disorder. Treatment consisted of eight sessions, and it was designed and performed by two physicians certified in acupuncture. Voice characteristics were evaluated pretreatment and posttreatment using the CSL Motor Speech Profile (MSP), Unified Spasmodic Dysphonia Rating Scale, and Voice Handicap Index (VHI). Subjects also answered a posttreatment questionnaire regarding their experience. Significant pretreatment and posttreatment differences occurred for some MSP measures. Significant differences were found on all three subtests of the VHI, and the average total scores pretreatment and posttreatment differed by 17 points (considered significant according to VHI standardization). Seven of 10 subjects reported improvements in voice production, although expert raters did not detect perceptual changes in voice quality. Possible reasons for the discrepancies between objective measures and self ratings, and implications for further research, are discussed.     

Treatment Outcomes for Professional Voice Users

Professional voice users comprise 25% to 35% of the U.S. working population. Their voice problems may interfere with job performance and impact costs for both employers and employees. The purpose of this study was to examine treatment outcomes of two specific rehabilitation programs for a group of professional voice users. Eighteen professional voice users participated in this study; half had complaints of throat pain or vocal fatigue (Dysphonia Group), and half were found to have benign vocal fold lesions (Lesion Group). One group received 5 weeks of expiratory muscle strength training followed by six sessions of traditional voice therapy. Treatment order was reversed for the second group. The study was designed as a repeated measures study with independent variables of treatment order, laryngeal diagnosis (lesion vs non-lesion), gender, and time. Dependent variables included maximum expiratory pressure (MEP), Voice Handicap Index (VHI) score, Vocal Rating Scale (VRS) score, Voice Effort Scale score, phonetogram measures, subglottal pressures, and acoustic and perceptual measures. Results showed significant improvements in MEP, VHI scores, and VRS scores, subglottal pressure for loud intensity, phonetogram area, and dynamic range. No significant difference was found between laryngeal diagnosis groups. A significant difference was not observed for treatment order. It was concluded that the combined treatment was responsible for the improvements observed. The results indicate that a combined modality treatment may be successful in the remediation of vocal problems for professional voice users.     

The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign masses

Hard or abrupt glottal attack (HGA) is one of the vocal behaviors often associated with benign lesion of the vocal folds. This study was designed to determine whether the frequency of HGA was different in hyperfunctional voice patients with and without vocal fold masses. One hundred and forty-seven subjects were studied. All subjects received a complete otolaryngological evaluation including strobovideolaryngoscopy, objective voice measures, and evaluation by a speech-language pathologist. Thirty-two patients were diagnosed with muscle tension dysphonia (19 male, 13 female) without vocal fold masses. Fifty-seven patients were diagnosed with unilateral vocal fold masses (29 male, 28 female), most of which were cysts. Fifty-eight patients were diagnosed with bilateral vocal fold masses (13 male, 45 female). Of the 45 females with bilateral vocal fold masses. 26 had a vocal cyst and reactive nodule and 19 had bilateral vocal fold nodules. The control group was balanced and matched based on sex and on percentage of singers and nonsingers. It consisted of 49 subjects with no vocal fold pathology (20 male, 29 female). The group was composed of professional speakers, singers, and nonprofessional speakers. All voice disordered groups demonstrated higher frequencies of HGA than the control group. Differences were found between the male and female subjects in this study. No differences were found between the various disorders. Differences were also found between the subgroups of bilateral masses, where the bilateral nodules group presented a higher frequency of HGA than the cyst and contralateral reactive nodule.     

The Effectiveness of a Voice Treatment Approach for Teachers With Self-Reported Voice Problems

SUMMARY: Teachers are considered the professional group most at risk of developing voice-problems, but limited treatment effectiveness evidence exists. We studied prospectively the effectiveness of a 6-week combined treatment approach using vocal function exercises (VFEs) and vocal hygiene (VH) education with 20 teachers with self-reported voice problems. Twenty subjects were randomly assigned to a no-treatment control (n = 11) and a treatment group (n = 9). Fibreoptic endoscopic evaluation was carried out on all subjects before randomization. Two self-report voice outcome measures were used: the Voice-Related Quality of Life (VRQOL) and the Voice Symptom Severity Scale (VoiSS). A Voice Care Knowledge Visual Analogue Scale (VAS), developed specifically for the study, was also used to evaluate change in selected voice knowledge areas. A Student unpaired t test revealed a statistically significant (P < 0.05) improvement in the treatment group as measured by the VoiSS. There was not a significant improvement in the treatment group as measured by the V-RQOL. The difference in voice care knowledge areas was also significant for the treatment group (P < 0.05). This study suggests that a voice treatment approach of VFEs and VH education improved self-reported voice symptoms and voice care knowledge in a group of teachers.     

The Effectiveness of Group Therapy for Students With Mild Voice Disorders: A Controlled Clinical Trial

Previous studies of students studying to be teachers have indicated that these students commonly have voice disorders. Ideally, voice disorders should be treated before students start their work as teachers, but the resources for this treatment are often limited. This study examines whether group voice therapy is effective for teacher students. Accordingly, 20 teacher students with mild voice disorders received group voice therapy (in three small groups), whereas 20 students with similar voice disorders served as a control group and consequently did not receive voice therapy. Two out of three outcome measures (perceptual evaluation of voice quality and a questionnaire on the occurrence of vocal symptoms) indicated significant changes in the treatment group compared with the control group. No differences between groups were noted in the laryngeal status. The results suggest that group voice therapy seems to be an effective method to treat students with mild voice disorders.     

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.     

Preliminary study of two methods of treatment for laryngeal nodules

To date, a limited number of formal studies have assessed the efficacy of voice therapy for laryngeal nodules. The present study represents a preliminary stage of inquiry in a series of planned studies on this topic. Thirteen women with nodules participated as paid subjects. Some subjects received “confidential voice therapy,” some received “resonant voice therapy,” and some received no therapy (control condition) over a period of 2 weeks. Pre- and post-therapy measures of phonatory effort, auditory-perceptual status of voice, and laryngeal appearance provided evidence of a benefit from therapy. Baseline measures were then repeated 2 weeks after therapy was terminated. The final results indicated that, for auditory-perceptual and phonatory effort measures, the likelihood of benefiting from therapy directly covaried with compliance scores (reflecting the reported extraclinical utilization of the therapy technique), but not with therapy type (confidential vs. resonant voice therapy). At this level, the results point to the importance of assessing not only therapy type but also compliance in future, larger studies. A series of other positive and negative factors in the present research design were identified based on the results. These should be considered in future studies.     

Relationship between subjective voice complaints and acoustic parameters in female teachers'' voices

The aim of the study was to identify the acoustic correlates of female teachers' subjective voice complaints by recording their voices in their working environment. The subjects made recordings during lessons (N = 10) and breaks (N = 11). The subjects were divided into 2 groups: those with few voice complaints (FC group) and those with many voice complaints (MC group). The speech sample made in the breaks was maximally sustained /a/, from which fundamental frequency (F0), jitter, and shimmer were analyzed. The classroom samples were analyzed for F0, sound pressure level (SPL), and F0 time (the active vibration time of the vocal folds). Additionally, an index for assessing voice loading is presented. The results revealed a tendency of the MC group to have higher F0 and lower SPL and perturbation values than the FC group. The index values correlated moderately with the subjective vocal complaints.     

Adductor spasmodic dysphonia: case reports withacoustic analysis following botulinum toxin injection and acupuncture

We analyzed frequency and duration parameters of voice and speech in two men with adductor spasmodic dysphonia (SD). One was treated with botulinum toxin injection; the other received acupuncture therapy. Im provement after acupuncture therapy in terms of standard deviation of fundamental frequency, acoustic perturbation measurements, durational measurements of voice and speech, and spectrographic analysis was comparable to the results achieved with botulinum toxin injection. Voice and speech parameters were stable I year after acupuncture therapy.     

Effects of He－Ne laser irradiation on acupuncture points on Enzymic activity of SDH，3β－HSDH and 17β－HSDH of uteri and ovaria in rabbits

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Effects of He－Ne laser irradiation at acupuncture points on steroid hormone receptors of uteri in rabbits

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Psychological correlates of functional dysphonia:An investigation using the Minnesota multiphasic personality inventory

Abnormal psychological factors have been implicated in the development of functional dysphonia (FD). This investigation describes the personality and psychological characteristics of 25 female subjects who had received the diagnosis of FD. In all subjects symptoms were resolved after voice therapy. While vocally asymptomatic, these remitted subjects with FD completed the Minnesota Multiphasic Personality Inventory (MMPI), an objective personality questionnaire. When compared with a medical outpatient control group, the results showed that subjects with FD scored significantly higher on 7 of 10 clinical scales, suggesting an elevated degree of emotional maladjustment. A stepwise logistic discriminant analysis identified 2 clinical scales that provided valuable discriminatory power between the two groups. Scale I (Hs-hypochondriasis), which measures the number and type of reported somatic complaints, and scale 7 (Pt-psychasthenia), a measure of diffuse anxiety, discriminated the groups with 88% sensitivity and 89% specificity. The results suggested that in spite of symptom improvement after voice therapy, the subjects with FD continued to exhibit poor levels of adaptive functioning, which may represent trait-like vulnerability. The clinical implications of these results for voice practitioners are discussed.     

Long-Term Outcome of Hyperfunctional Voice Disorders Based on a Multiparameter Approach

SUMMARY: The purpose of this study is to determine the long-term voice outcome (6.1 years after a well-defined voice treatment program) of hyperfunctional voice disorders in 27 subjects. All patients showed a muscle tension pattern type I (MTP I). Perceptual ratings, aerodynamic and acoustical analyses, Voice Handicap Index (VHI) value, and a determination of the Dysphonia Severity Index (DSI) were performed. The laryngovideostroboscopic images indicated that 51% of the subjects still show pathological laryngological findings. The negative evolution of the DSI from -1 to -3.2 is in agreement with this finding. Analysis of the components of the DSI shows that the main responsible variable for this negative change is the lowest intensity (I-low) that increased with 8.1 dB, indicating that subjects generally speak too loud, which is a typical problem for vocal hyperfunction. The VHI-score indicates an unimportant psychosocial impact of the voice disorder. The more objective and laryngostroboscopic findings indicate a chronic situation for a substantial part of the subjects and even a worse situation for some of them. Whether the long-term voice outcome results can be changed with the insertion of several follow-up voice rehabilitation sessions over the years remains unanswered and is a subject for further research.     

Applying the Voice Handicap Index (VHI) to Dysphonic and Nondysphonic Hebrew Speakers

OBJECTIVE: To evaluate a translated version of the Voice Handicap Index (VHI) as a diagnostic tool for people with and without a laryngeal pathology, among Hebrew speakers. STUDY DESIGN: Parallel group design. METHODS: The VHI was translated and adapted to Hebrew. The translated version was, then, administered to a group of 182 patients with various laryngeal pathologies and a control group of 171 people with no laryngeal pathology. Based on the participants' responses to the VHI, statistical analyses were, initially, performed to assess validity and reliability, and then to evaluate group differences between the pathological and control groups and among the different pathological groups included in the study. RESULTS: Statistical analyses showed high reliability values of the Hebrew version of the VHI (overall Cronbach's alpha r = 0.976). Participants' scores were not affected by their age (P = 0.156) or gender (P = 0.261). The participants in the control group obtained significantly lower scores on the overall VHI score, as well as on all three subscale scores, in comparison with the pathological group (P < 0.001). In addition, within the pathological group, patients with neurogenic pathologies received higher scores than all other pathological groups, whereas patients with laryngeal inflammation received lower scores than all other pathological groups (P < 0.05). CONCLUSION: The VHI is a powerful tool for quantifying patients' perceptions of their voice handicaps, and it maintained its power across translation. The VHI was shown to be valuable for the assessment of speakers with, as well as without laryngeal pathologies.     

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.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy     

The effect of low-dose β-blockade on performance anxiety in singers

Thirteen singing students received placebo or 20 mg of nadolol prior to their end-of-semester jury performance. The performance was repeated 48 h later with the cross-over drug regimen. Subjects' musical performances were evaluated by a panel of judges (comprised of the subjects' voice faculty). No statistically significant difference could be detected in the overall quality of the performance whether students were taking drug or placebo. Although the small number of subjects in this study precludes a definitive conclusion, these data, together with previous information, lead us to suggest that β-blockers are not useful in coping with nervousness in singing students.     

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.     

Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints-particularly those ones that have no obvious relation to voice function-decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints-voice related and not related-are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.     

Influence of glottal closure configuration on vocal efficacy in young normal-speaking women

Posterior closure insufficiency of the glottis is often mentioned in connection with permanent voice disorders. Recently published studies have revealed that an incomplete closure of the glottis can be found also in normal-speaking voices, especially in women. However, the effect of glottal closure configuration on vocal efficacy is not sufficiently clarified. The purpose of this study was to determine the effect of glottal closure configuration on singing and speaking voice characteristics. Overall, 520 young female normal-speaking subjects were examined by videostroboscopy for different phonation conditions in the combination of soft, loud, low, and/or high phonation and by voice range profile measurements. According to the videostroboscopic analysis, the subjects were subdivided into four groups: complete closure of the vocal folds already in soft phonation (group 1), closure of the vocal fold with increasing intensity (group 2), persistent closure insufficiencies despite increasing intensity (group 3), and hourglass-shaped closure in subjects with vocal nodules (group 4). Subjects in which the glottal closure could not be evaluated sufficiently were subclassified into group 5 (missing values).

Selected criteria of the singing and speaking voice were evaluated and statistically processed according to the mentioned subclassification. Group 1 reached significantly the highest sound pressure levels (SPL_max) for the singing voice as well as for the shouting voice. Group 3 showed a limited capacity to increase the intensity of the singing and speaking voice. The results gathered in this study objectify the relationship of insufficient glottal closure and reduced vocal capabilities. As long as no conclusive data on long-term consequences of insufficient glottal closure are available, a prophylactic improvement of the laryngeal situation especially in female professional voice users by voice therapy should be recommended.