Perceived Control, Voice Handicap, and Barriers to Voice Therapy

Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care

PURPOSE

Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice.

METHOD

Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification.

RESULTS

All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice.

CONCLUSIONS

The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24796875.

The Patient Experience: The Relationship Between Vocal Handicap, Congruency, Perceived Present Control, and Mood Across Four Voice Disorders

OBJECTIVE

The potential for negative sequalae in psychosocial well-being presents clinical importance to the assessment of voice disorders. Despite the impairment voice disorders cause in the psychosocial domain, the clinical assessment of these disorders relies heavily on visual perceptual judgments of the larynx, audio-perceptual, as well as acoustic and aerodynamic measures. While these measures aid in accurate diagnosis and are necessary for standard of care, they present little insight into the patient experience of having a voice disorder.

DESIGN

Retrospective between-subject, non-experimental design.

METHODS

Data from 335 patients from the University of Pittsburgh Voice Center were collected from scores of the Voice Handicap Index-10 (VHI-10) and two recent questionnaires, the Voice Present Perceived Control scale (VPPC), and the Vocal Congruency Scale (VCS). Examining how these voice-specific scales related to three mental health screeners for stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) were also examined. Patient diagnoses included primary muscle tension dysphonia (pMTD), unilateral vocal fold paralysis (UVFP), vocal fold atrophy, and mid membranous vocal fold lesions.

RESULTS

There were significant differences in scores from the voice-specific scales between diagnostic groups with UVFP being the highest (worst) in VHI-10 and UVFP being the lowest (worst) in VCS compared to healthy controls. There was no significant difference in VPPC scores between diagnostic groups. Results showed statistically significant inverse relationships between the VHI-10 and the VPPC and between the VHI-10 and VCS for all diagnostic groups. A significant direct relationship was found between the VPPC and the VCS for patients diagnosed with MTD, UVFP and Lesions. In sum, patients with UVFP presented with the most frequent and sometimes strongest relationships between voice and mental health measures.

DISCUSSION

This study marks an initial investigation into the nuanced patient experience of having a voice disorder. Three theoretically unrelated voice constructs: handicap, perceived control, and sense of self, were measured via self-report. Results from this study describe the patient experience correlating to these constructs with weak correlations to stress, anxiety, and depression. Findings also clearly suggest that patient experience varies among diagnostic groups, as well as varying constructs. Measures of multiple constructs of patient perception provide valuable insight into a patient's experience of their voice disorder, guidance on the direction of voice treatment, and justification for such treatments.

Relationships Among Stimulability Testing, Patient Factors, and Voice Therapy Compliance

OBJECTIVE

Voice stimulability testing to determine voice therapy efficacy and prognosis is commonly used during the voice evaluation, but little is known about how patient factors (eg, voice diagnosis, dysphonia severity) can influence stimulability outcomes. The predictability of voice therapy success with different stimulability facilitating techniques (eg, hums, pitch glides) is also unknown. The goals of this study were to identify relationships between patient factors, voice therapy compliance, and stimulability testing.

METHODS

A retrospective chart review was conducted on 50 patients who were seen for their initial voice therapy evaluation at the UT Southwestern Clinical Center for Voice Care. Chart review included documentation of the stimulability tasks that yielded/did not yield voice changes, level of stimulability, voice diagnosis, clinician-rated auditory-perceptual analysis of vocal quality, therapy attendance, and compliance with voice therapy recommendations. Statistical analysis was conducted to determine whether the types of facilitating techniques, voice diagnosis, and dysphonia severity could predict how stimulable patients were and whether any stimulability techniques could predict voice therapy attendance and compliance.

RESULTS

Patients diagnosed with functional voice disorders (eg, muscle tension dysphonia) were 11 times more likely to be stimulable for voice improvements than patients with neurological voice disorders (eg, vocal fold paralysis). Patients with lower dysphonia severity were more likely to be stimulable than patients with high dysphonia severity. Specific facilitating voice tasks did not predict the level of stimulability. Stimulability level was not predictive of therapy attendance or compliance with therapy recommendations.

CONCLUSIONS

Voice diagnosis and severity of dysphonia influenced stimulability levels. However, voice stimulability was not predictive of voice therapy attendance or compliance, and no specific facilitative task predicted the level of stimulability. Future investigations should focus on other means of measuring a patient's motivation for change and on the predictive power of stimulability testing on voice therapy outcomes.

Clinical Psychology and Voice Disorders: A Meta-Analytic Review of Studies Assessing Psychological Characteristics Across Individuals With and Without Voice Disorders

OBJECTIVES

Clinical voice disorders are heterogenous conditions capturing problems with voice production and control. Psychological conceptualizations of voice disorders posit that mood, anxiety, and personality characteristics contribute to the development and maintenance of voice symptoms. This review brings together research comparing these psychological characteristics across groups with and without voice disorders, with the aim of profiling group differences.

METHODS

A systematic search of PubMed, CINAHL, Ovid (PsycInfo, MEDLINE, Embase), and Web of Science databases was conducted, with studies required to assess psychological characteristics between samples with and without voice disorders. Relative study quality and risk of bias were formally evaluated, synthesizing results via meta-analysis (estimating standardized mean difference; SMD) and narrative synthesis.

RESULTS

Thirty-nine studies (N = 4740) were reviewed. Marked psychological differences were observed between case-control groups, including significantly higher self-reported features of depression (SMD = 0.50), state anxiety (SMD = 0.58), trait anxiety (SMD = 0.52), health anxiety (SMD = 0.57), and neuroticism (SMD = 0.47) in voice disorder groups. However, less consistent patterns of difference were observed between voice disorder types, including minimal quantitative differences between functional and organic diagnoses.

CONCLUSIONS

Findings underline and formulate the psychological features associated with experiencing a voice disorder, indicating individuals with voice disorders present with considerable psychological needs that may benefit from clinical psychology input.

A Review of Factors Associated with Voice Problems in the Fitness Instructor Population

There is a high prevalence of reported dysphonia symptomology in the fitness instructor population. This is concerning as these reported symptoms of dysphonia, aphonia, and vocal fatigue can significantly compromise quality of life. The purpose of this review is to explore key factors that may contribute to voice problems in the fitness instructor population. Voicing with concurrent phonation and exercise may be influenced by (1) the increased cardiovascular requirement during exercise, (2) the increased cognitive load associated with dual tasking, (3) the altered hydration state associated with prolonged exercise, and (4) the phonatory dose associated with continued voicing with loud background music. This manuscript will explore the literature on these key factors (ie, phonatory dose, dehydration, metabolic bioenergetics, cognitive load, and psychosocial stress) as they pertain to fitness instructors.

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.

Exploring Personality and Perceived Present Control as Factors in Postsurgical Voice Rest: A Case Comparison

OBJECTIVE

This case comparison explored the relation between personality, perceived present control, and postoperative voice rest (as estimated by self-report and objective voice use) following surgery for benign vocal fold lesions.

METHOD

Two participants were included. Both participants were diagnosed with benign vocal fold pathology, underwent phonosurgery, and were assigned to either complete voice rest (CVR) or relative voice rest (RVR) postoperatively. During voice rest (VR), a visual analog scale (VAS) and a dosimeter (the Vocalog2) were used daily to estimate self-perceived and objective voice use, respectively. The participants also completed questionnaires on voice-related demographics, the Voice Handicap Index (VHI), Ten-Item Personality Inventory (TIPI), and Perceived Present Control (PPC). After 7 days of CVR or RVR, participants completed a postoperative questionnaire and a final VAS for overall voice use.

RESULTS

A wide discrepancy was observed in one of two participant's subjective perception of voice use (using the VAS) versus objective dosimetry data wherein she reported significantly more voice use than was observed objectively. Differences in personality and PPC between the participants did not appear to affect their voice use following the VR protocols.

CONCLUSION

The amount of voice use in both VR protocols for these two participants suggests that personality and PPC did not affect their adherence to recommendations of VR. Patients may perceive their voice use differently across time, which might play a role in their adherence to voice rest recommendations: voice use measured as instances versus a unit of time (seconds).

The Effects of Drowsiness Detection Technology and Education on Nurses' Beliefs and Attitudes Towards Drowsy Driving

Background: Drowsy driving is prevalent among night-shift nurses, yet there is a gap in understanding nurses' beliefs and attitudes that may affect their intention to avoid drowsy driving.Objectives: The objectives of the study were twofold: 1) investigate how behavioral constructs such as beliefs and attitudes may affect nurses' intention to avoid drowsy driving; and 2) assess changes in such beliefs and attitudes during a study that evaluated the effectiveness of educational and technological interventions.Methods: Three-hundred night-shift nurses were recruited from a large hospital in Texas to participate in a randomized control trial. Participants were randomly assigned to three groups: 1) control; 2) educational intervention; and 3) combined educational and technological intervention. The study utilized an integrated model drawing from the constructs of the Theory of Planned Behavior and the Health Belief Model to elicit attitudes, beliefs, and intentions to use in-vehicle drowsiness detection technologies. Each group was surveyed pre- intervention and at post-intervention around 3 months later to assess changes in beliefs and attitudes. Structural equation models and path analysis were used to analyze changes in beliefs.Results: Seventy-nine participants completed the pre-intervention questionnaire, and 44 nurses completed the pre- and post-intervention surveys. Intention was predicted primarily by attitude and perceived health threat. Perceived health threat also mediated the relationship between behavioral intention and the influence of subjective norms as well as perceived behavioral control. Participants who received education about drowsy driving had positive changes in beliefs.Conclusions: Nurses' perceived health threat from driving drowsy and their attitude towards our intervention were important motivators to avoid drowsy driving. Interventions aiming at raising awareness of the risks associated with drowsy driving may be effective at motivating nurses to avoid drowsy driving.

Association Between Communicative Participation and Psychosocial Factors in Patients With Voice Disorders

IMPORTANCE

Communicative participation can be conceptualized as taking part in life situations in which people are socially engaged. Communicative participation is an important aspect in the lives of patients with voice disorders, although it has not been formally assessed among a broad sample of patients with voice disorders. The associations between communicative participation and associated concepts (vocal impairment, psychosocial distress, and voice-specific perceived control) are unknown yet important for integrated treatment approaches.

OBJECTIVE

The primary objective was to examine the associations between communicative participation and vocal impairment, psychosocial distress, and voice-specific perceived control. The secondary objective was to examine whether perceived control moderates the association of distress with communicative participation and vocal impairment, the latter of which would replicate previous research. The hypotheses were that communicative participation would be associated with lower vocal impairment, lower distress, and higher perceived control and that higher perceived control would moderate the association between communicative participation and both vocal impairment and psychosocial distress.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted from June 2014 to May 2017 among a consecutive sample of adult patients with voice disorders at an academic voice clinic affiliated with the University of Minnesota. Of the 744 patients approached to participate in the survey study, 590 patients agreed. Data analysis was performed from January to June 2020.

MAIN OUTCOMES AND MEASURES

Communicative participation (measured by the 10-item general short form of the Communicative Participation Item Bank), vocal impairment (measured by the 10-item version of the Voice Handicap Index), psychosocial distress (measured by the 18-item version of the Brief Symptom Inventory), and voice-specific perceived control (measured by the 8-item present control subscale of the Perceived Control Over Stressful Events Scale).

RESULTS

The sample comprised 590 patients (mean [SD] age, 51.9 [17.1] years; 390 women [66.1%]) with voice disorders. Communicative participation was associated with lower vocal impairment (r = -0.73; 95% CI, -0.77 to -0.69), lower overall psychosocial distress (r = -0.22; 95% CI, -0.30 to -0.14), and higher voice-specific perceived control (r = 0.30; 95% CI, 0.23-0.37). Moderation analyses indicated that communicative participation was negatively associated with distress at all levels of perceived control and, replicating previous findings, greater vocal impairment was associated with higher psychosocial distress only in patients with lower perceived control.

CONCLUSIONS AND RELEVANCE

In this study, communicative participation was associated with, but distinct from, vocal impairment and was also associated with psychosocial distress and voice-specific perceived control. The study's results suggest that communicative participation is an important addition to voice research and clinical care.

Voice and Self-Regulation: Integrating Review of the Literature

OBJECTIVE

To verify the relationship between self-regulation and voice behavior according to national and international literature.

METHODS

A literature survey was performed using the PubMed, LILACS, and SciELO databases. The search terms used were the following: self-regulation, self-control, combined with voice, voice disorders, and dysphonia, in Portuguese, English, and Spanish. Articles that addressed self-regulation and voice behavior or voice disorders published in English, Spanish, or Portuguese were included, without restriction of date. The variables preselected for the data organization were authors, database, country, impact factor, journal, type of study, sample size, sample characteristics, methods for data collection, group comparison, objective, and outcome.

RESULTS

A total of 10,176 articles were identified in the databases, of which 10 were selected based on title, read in full, and kept for data analysis. The studies were found predominantly in American journals and were published between 2013 and 2019. The United States published most articles, and the predominant methodological aspect was observational and cross-sectional.

CONCLUSION

Despite the small number of articles, the studies analyzed can show self-regulation as an important factor in vocal behavior and call attention to its performance in voice disorders.

Perceptual and acoustic voice analysis in patients with glottis cancer after endoscopic laser cordectomy

<b>Introduction:</b> Treatment of glottis cancer, despite oncological safety, should consider postoperative voice quality. CO<sub>2</sub> laser endoscopic cordectomy allows radical removal of the tumor while maintaining respiratory, defensive and phonatory functions. <br><b>The aim:</b> The aim of the study is perceptual and acoustic evaluation of voice in patients after endoscopic CO2 III-Va laser cordectomy due to glottis cancer. <br><b>Material and method:</b> The study included 30 men after CO<sub>2</sub> cordectomy. 13 (43%) patients underwent type III cordectomy, 6 (20%) - type IV; 11 (37%) - type Va. Voice quality has been assessed 6 months after the surgery. Control group included 30 healthy men of the same age. GRBAS scale has been used in perceptual evaluation of voice. Acoustic analysis has been performed using DiagnoScope Specjalista software. Narrowband spectrography and Maximum Phonation Time (MPT) measure has been performed. <br><b>Results:</b> In study group, voice has been classified as G<sub>1</sub>R<sub>1</sub>B<sub>0</sub>A<sub>0</sub>S<sub>0</sub> after type III cordectomy; as G<sub>1</sub>R<sub>1</sub>B<sub>1</sub>A<sub>1</sub>S<sub>2</sub> in type IV and as G<sub>2</sub>R<sub>1</sub>B<sub>1</sub>A<sub>0</sub>S<sub>3</sub> in type Va. Acoustic evaluation revealed the highest values of F0, Jitter, Shimmer and NHR after Va cordectomy as well as non-harmonic components in narrowband spectrography and reduction of MPT. <br><b>Conclusions:</b> Postoperative voice quality depends on the type of cordectomy. Perceptual assessment indicates that type IV and Va cordectomy cause intensification of voice disorders. Parameters of acoustic evaluation increase with the extent of the procedure. The presence of non-harmonic components in narrowband spectrography increases with the extent of cordectomy, such as the reduction of MPT. Preservation of anterior commissure influences good voice quality in perceptual and acoustic assessment.