G. Paul Moore lecture: Rational thought: The impact of voice science upon voice care

Recent evolution in scientific knowledge and technology has led to monumental improvement in the standard of care for patients with voice disorders. New concepts in anatomy, physiology, measurement, and analysis have provided voice care professionals with not merely better understanding, but moreover an extensive vocabulary with which to think about voice function and dysfunction. Previously, we had to depend too much upon anecdote and “the art of medicine.” Thanks to scientific advances, we now have the tools we need for rational thought about the human voice. This is the fundamental change responsible for recent great advances in voice care.     

Acoustic Changes in Student Actors' Voices After 12 Months of Training

This study was to evaluate acoustic changes in student actors' voices after 12 months of actor training. The design used was a longitudinal study. Eighteen students enrolled in an Australian tertiary 3-year acting program (nine male and nine female) were assessed at the beginning of their acting course and again 12 months later using a questionnaire, interview, maximum phonation time (MPT), reading, spontaneous speaking, sustained phonation tasks, and a pitch range task. Samples were analyzed for MPT, fundamental frequency across tasks, pitch range for speaking and reading, singing pitch range, noise-to-harmonic ratio, shimmer, and jitter. After training, measures of shimmer significantly increased for both male and female participants. Female participants' pitch range significantly increased after training, with a significantly lower mean frequency for their lowest pitch. The finding of limited or negative changes for some measures indicate that further investigation is required into the long-term effects of actor voice training and which parameters of voicing are most targeted and valued in training. Particular investigation into the relationship between training targets and outcomes could more reliably inform acting programs about changes in teaching methodologies. Further research into the relationship between specific training techniques, physiological changes, and vocal changes may also provide information on implementing more evidence-based training methods.     

Impact and Prevention of Voice Problems in the Teaching Profession: Embracing the Consumers'' View

Teachers are vulnerable to developing voice problems due to their specific occupational demands during teaching. Information on how the teaching profession is impacted by voice problems and what the profession perceives to be useful information for preventing voice problems is important for health care service providers. A total of 122 subjects from the teaching profession (55 practicing teachers and 67 prospective teachers) were therefore surveyed to ascertain their perception of their voice condition and the impact of voice problems on their communication, social life, personal emotions, and occupation. The results showed that the practicing teachers perceived their voice to be significantly worse than the prospective teachers. In addition, the teachers also faced significantly more difficulties in their daily communication than the prospective teachers. These two groups of subjects believed that information on breathing exercises and specific vocal hygiene strategies would help them prevent voice problems.     

Boot Camp: A Novel Intensive Approach to Voice Therapy

It is well known in the disciplines of neurobiology, exercise physiology, motor learning, and psychotherapy that desirable learning and behavior changes occur primarily from practice that involves high-intensity overload, variability, and specificity of training. We propose a novel treatment approach called intensive short-term voice therapy that uses these practice parameters for recalcitrant dysphonia. Intensive short-term voice therapy involves multiple sessions with a variety of clinicians, incorporating multiple simultaneous therapeutic approaches. The intensive short-term voice therapy approach is characterized by voice therapy for 1–4 successive days each with an average of 5 hours of therapy and five clinicians. This form of intensive voice therapy provides rigorous practice, involving not only overload but also opportunities for specificity and individuality thereby facilitating better transfer of learned skills. This article discusses the conceptual, theoretical, and practical foundations of this novel therapy approach.     

Changes in Objective Acoustic Measurements and Subjective Voice Complaints in Call Center Customer-Service Advisors During One Working Day

SUMMARY: The aim of this study was to investigate how different acoustic parameters, extracted both from speech pressure waveforms and glottal flows, can be used in measuring vocal loading in modern working environments and how these parameters reflect the possible changes in the vocal function during a working day. In addition, correlations between objective acoustic parameters and subjective voice symptoms were addressed. The subjects were 24 female and 8 male customer-service advisors, who mainly use telephone during their working hours. Speech samples were recorded from continuous speech four times during a working day and voice symptom questionnaires were completed simultaneously. Among the various objective parameters, only F0 resulted in a statistically significant increase for both genders. No correlations between the changes in objective and subjective parameters appeared. However, the results encourage researchers within the field of occupational voice use to apply versatile measurement techniques in studying occupational voice loading.     

Normative Voice Range Profiles of Male and Female Professional Voice Users

Normative voice range profiles (VRP) are calculated for a group of male and female teachers, based on 43 and 46 recordings, respectively. All individuals had healthy voices. These normative VRPs contain 95% prediction intervals for both frequency and intensity. They are based on a series of mathematical transformations of the original individual VRPs in order to maintain in the normative VRPs the typical oval VRP shape, including the dip between modal and falsetto register. The normative VRPs presented are directly applicable in the clinical practice of otolaryngologists and speech-language pathologists.     

Voice profiles and standard voice profile of untrained children

Voice profiles were taken of 277 healthy children between the ages of 5 and 14 years. The measured phonetograms were grouped according to sex and years of age. In each group, the means and standard deviations of maximal and minimal volume of each frequency were calculated. The median was used to establish the upper and lower limits of the voice range of each group. No age-dependent changes of the group voice profiles were shown in the groups of 7 to 10 year olds. Out of that emerged a standard childhood voice profile of the untrained voice. After age 10, an increase of the dynamic range over the lowest frequencies was found. Because of the voice changes in puberty, a profile for 13- and 14-year-old boys could not be established.     

Vocal Evaluation in Teachers With or Without Symptoms

The aim of this study was to perform voice evaluation in teachers with and without vocal symptoms, identifying etiologic factors of dysphonia, voice symptoms, vocal qualities, and laryngeal lesions. Eighty teachers were divided into two groups: GI (without or sporadic symptoms, 40) and GII (with frequent vocal symptoms, 40). They answered a specific questionnaire, and were subject to a perceptual vocal assessment (maximum phonation time, glottal attack, resonance, coordination of breathing and voicing, pitch, and loudness), GIRBAS scale, and to videolaryngoscopy. Females were predominant in both groups, and the age range was from 36 to 50 years. Elementary teachers predominated, working in classes with 31-40 students. Voice symptoms and alterations in the perceptual vocal analysis and in the GIRBAS scale were more frequent in GII. In 46 teachers (GI-16; GII-30), videolaryngoscopy exams were abnormal with the vocal nodules being the most frequent lesions. These results indicate that a teacher's voice is compromised, and requires more attention including control of environmental factors and associated diseases, preventive vocal hygiene, periodic laryngeal examinations, and access to adequate specialist treatment.     

Vocal Range and Intensity in Actors: A Studio Versus Stage Comparison

A voice range profile (VRP) was obtained from each of eight professional actors and compared with two speech range profiles (SRPs). One speech profile was obtained during the dramatic reading of a scene in the laboratory and the other during a performance on stage in a professional theater. The objective was to determine the pitch and loudness ranges used by the actors in speech relative to the VRP. The principal question of interest was whether the actors stayed within the center of the VRP, or whether they tended to drift toward the boundaries of intensity and frequency. A second question was whether the performance within the laboratory accurately reflects that of a stage performance. The results suggest that some subjects tend to exceed the center of the VRP during the stage performance. It is hypothesized that these actors may stress their vocal mechanism during performance and are more likely candidates for vocal injury.     

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.     

Perceptual evaluation of voice quality and its correlation with acoustic measurements

To determine whether a correlation exists between the Grade, Roughness, Breathiness, Aesthenia, Strain (GRBAS) scale (a subjective measure of voice) and the Multi-Dimensional Voice Program (MDVP) scale (an objective measure of voice). A retrospective review of 37 voice patients (12 male/25 female) was conducted. Each voice was perceptually evaluated using the GRBAS scale by an experienced speech pathologist and acoustically analyzed using the MDVP scale. Statistical analysis using a multivariate regression model identified a significant correlation between the noise-related parameters of MDVP and the components of the GRBAS scale. Grade correlated with voice turbulence index (VTI), noise harmonic ratio (NHR), and soft phonation index (SPI). Roughness correlated with NHR only. Breathiness correlated with SPI only. Aesthenia also correlated with SPI only. Of the 19 acoustic variables measured by the MDVP system, only three noise parameters significantly correlated with the GRBAS perceptual voice analysis. Perhaps "noise" is the perceived acoustical quality of the dysphonic voice. A voice quantifying measure such as a "voice index score" could be proposed using the GRBAS scoring and the three clinically relevant MDVP values following further studies.     

Voice Quality Changes Following Phonatory-Respiratory Effort Treatment (LSVT®) Versus Respiratory Effort Treatment for Individuals with Parkinson Disease

Perceptual ratings of hoarseness and breathiness were used to assess the efficacy of two intensive methods for treating dysarthrophonia in individuals with idiopathic Parkinson disease. One method emphasized phonatory-respiratory effort (the Lee Silverman Voice Treatment, LSVT®) and the other emphasized respiratory effort alone (RET). Perceptual ratings were performed by two expert listeners based on random order presentation of the patients' pretreatment and posttreatment recordings of the “Rainbow Passage.” The listeners were blinded to the patients and their treatment group. Statistically significant pretreatment to posttreatment improvement in hoarseness and breathiness was observed in the LSVT® group but not in the RET group. The present findings are consistent with acoustic and physiologic findings reported previously, providing further evidence for the efficacy of the LSVT®.     

The young adult voice

Young adulthood is notable for rapid physical changes and psychosocial instability. Care of the young adult professional voice requires knowledge of the specific anatomic and physiologic changes associated with the mutational voice, as well as the effects of general growth and maturation on the vocal mechanism. The effects of psychological stresses common to young adulthood, such as educational commitments and early career choices, must also be understood. Upper respiratory infection and allergies are common in this age group. Treatment of these conditions must be tailored in the professional voice user because of the potential side effects of some medications and the performance imperatives of the patient. Surgical indications for tonsillectomy in the young voice patient are discussed. There are no special considerations in the evaluation and treatment of laryngeal pathology in the young adult, with the exception of limiting the use of sedative anesthesia. However, conservatism in surgical decision-making is advised. The development of a stable, efficient vocal technique and a mature professional background requires time, patience, and hard work.     

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.     

Throaty Voice Quality: Subglottal Pressure, Voice Source, and Formant Characteristics

"Throaty" voice quality has been regarded by voice pedagogues as undesired and even harmful. This study attempts to identify acoustic and physiological correlates of this quality. One male and one female subject read a text habitually and with a throaty voice quality. Oral pressure during p-occlusion was measured as an estimate of subglottal pressure. Long-term average spectrum analysis described the average spectrum characteristics. Sixteen syllables, perceptually evaluated with regard to throaty quality by five experts, were selected for analysis. Formant frequencies and voice source characteristics were measured by means of inverse filtering, and the vocal tract shape of the throaty and normal versions of the vowels [a,u,i,ae] of the male subject were recorded by magnetic resonance imaging. From this material, area functions were derived and their resonance frequencies were determined. The throaty versions of these four vowels all showed a pharynx that was narrower than in the habitually produced versions. To test the relevance of formant frequencies to perceived throaty quality, experts rated degree of throatiness in synthetic vowel samples, in which the measured formant frequency values of the subject were used. The main acoustic correlates of throatiness seemed to be an increase of F1, a decrease of F4, and in front vowels a decrease of F2, which presumably results from a narrowing of the pharynx. In the male subject, voice source parameters suggested a more hyperfunctional voice in throaty samples.     

Movement of the velum during speech and singing in classically trained singers

The present study addresses two questions: (a) Is the action and/orposture of the velopharyngeal valve conducive to allow significant resonance during Western tradition classical singing? (b) How do the actions of the velo-pharyngeal valve observed in this style of singing compare with normal speech? A photodetector system was used to observe the area function of the velopharyngeal port during speech and classical style singing. Identical speech samples were produced by each subject in a normal speaking voice and then in the low, medium, and high singing ranges. Results indicate that in these four singers the velopharyngeal port was closed significantly longer in singing than in speaking samples. The amount of time the velopharyngeal port was opened was greatest in speech and diminished as the singer ascended in pitch. In the high voice condition, little or no opening of the velopharyngeal port was measured.