Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma

Efficacy and feasibility of a digital speech therapy for post-stroke dysarthria: protocol for a randomized controlled trial

Background

Dysarthria is a motor speech disorder caused by various neurological diseases, particularly stroke. Individuals with post-stroke dysarthria experience impaired speech intelligibility, communication difficulties, and a reduced quality of life. However, studies on the treatment of post-stroke dysarthria are lacking. Digital speech therapy applications have the advantages of being personalized and easily accessible. However, evidence for their efficacy is not rigorous. Moreover, no studies have investigated both the acute to subacute, and chronic phases of stroke. This study aims to investigate the efficacy and feasibility of digital speech therapy applications in addressing these gaps in dysarthria treatment.

Methods and design

This study is a multicenter, prospective, randomized, evaluator-blinded non-inferiority trial. We aim to recruit 76 participants with post-stroke dysarthria. Eligible participants will be stratified based on the onset period of stroke into acute to subacute, and chronic phases. Participants will be randomized in a 1:1 to receive either a personalized digital speech therapy application or conventional therapy with a workbook for 60 min daily, 5 days a week, for 4 weeks. The primary outcome is the improvement in speech intelligibility. This will be measured by how accurately independent listeners can transcribe passages read by the participants. Secondary outcomes, which include speech function, will be evaluated remotely by speech-language pathologists. This includes the maximum phonation time, oral diadochokinetic rate, and percentage of consonants correct. Participants' psychological well-being will also be assessed using self-report questionnaires, such as depressive symptoms (Patient Health Questionnaire-9) and quality of life (Quality of Life in the Dysarthric Speaker scale). The trial will also assess the feasibility, participant adherence, and usability of the application. Rigorous data collection and monitoring will be implemented to ensure patient safety.

Conclusion

This trial aims to investigate the efficacy and feasibility of digital speech therapy applications for treating post-stroke dysarthria. The results could establish foundational evidence for future clinical trials with larger sample sizes.

Clinical trial registration

Clinicaltrials.gov, identifier: NCT05865106.

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

Investigation of the Relationship Between Vocal Fatigue, Quality of Life, and Compliance With Vocal Hygiene in Professional Voice Users

PURPOSE

Intensive voice use may lead to the development of voice disorders or voice complaints, such as vocal fatigue, for professional voice users (teachers, academics, call center workers, actors, singers, speech and language therapists, voice trainers, and religious officials). Vocal fatigue has a detrimental effect on occupational, emotional, and social performance, besides the quality of life of the individual. The effect of voice hygiene interventions on voice fatigue is not fully known. The results of studies conducted with different occupational groups are inconsistent. The present study aims to analyze the relationship between vocal fatigue and voice-related quality of life (V-RQOL) in professional voice users, and the impact of vocal hygiene on vocal fatigue.

METHODS

Participants (24 male, 90 female), who were professional voice users without any diagnosis of voice disorders or voice complaints were divided into two groups low vocal hygiene compliance (LVH; n = 66) and high vocal hygiene compliance (HVH; n = 48). In this study, vocal fatigue was measured by the vocal fatigue index (VFI), and V-RQOL was measured by the voice handicap index (VHI-10) and V-RQOL.

RESULTS

VFI subscales (tiredness, avoidance, physical discomfort) have a moderate positive correlation with VHI-10 and V-RQOL, which indicates that there is a significant relationship between vocal fatigue and quality of life amongst professional voice users. While there was no significant difference between the LVH and HVH groups in terms of quality of life, it was found that the vocal fatigue level of the LVH group was higher.

CONCLUSION

This study of professional voice users with healthy voices reveals a relationship between vocal fatigue and V-RQOL. Vocal hygiene compliance may affect professional voice users' vocal fatigue symptoms; the low-compliant group has higher levels of tiredness, avoidance, and physical discomfort. The findings highlight the importance of raising awareness of the problems of professional voice users, even though they have healthy voices and the need for vocal hygiene education programs that target them.

Urica-VV Scale: A New Research Perspective of The Stage of Readiness for Treatment in Patients with Dysphonia

OBJECTIVE

To obtain evidence of validity for the URICA-V scale and estimate the psychometric properties of its items based on item response theory (IRT).

METHOD

A total of 658 individuals of both sexes over 18 years of age were allocated into two groups: with dysphonia group (WDG) and vocally healthy group (VHG). A digital database was constructed with personal and professional data and item-by-item responses on the URICA-V scale. Subsequently, Cronbach's alpha, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), application of IRT using Samejima's model and ROC curve analysis were used to obtain the cutoff point for the URICA-V scale.

RESULTS

A different version of the original URICA-V scale was obtained. Of the 32 items from the original protocol, 25 better explained the instrument and were regrouped into two domains: contemplation and maintenance. It was possible to identify which items generated higher difficulty (b) and discrimination (a) values and which contributed to the presentation of a calculation based on the theta of each participant. The ROC curve was analyzed, and a cutoff point of -0.236 was established; establishing a cutoff point facilitates the decision of which individuals are in a state of readiness for voice treatment.

CONCLUSION

The present study provided evidence that allows us to propose the URICA-Voice validated (URICA-VV) scale within a more contemporary perspective and with a reduced number of items and domains. In addition, a cutoff point was obtained based on IRT to measure, with greater accuracy, sensitivity and specificity, the stage of readiness and to differentiate individuals who have an indication for speech therapy.

An eclectic Voice Therapy Program for the Treatment of Hyperfunctional Voice Disorders (HFVD)

PURPOSE

An eclectic voice therapy program includes sequenced and structured set of exercises combining direct and indirect intervention methods. Tailor-made exercise prescription with specific cultural adaptations are needed to provide a holistic change to voice quality.1 This study detailed the construction of an exercise prescription for participants with hyperfunctional voice disorder [HFVD] in the Indian context.

METHOD

The exercise program was developed based on literature related to vocal therapy approaches and delivery methods. Adaptations were introduced to a selected set of exercises. Five voice experts verified the exercises and their prescription for content and feasibility of use in the Indian context. Modification suggested by the experts were included for framing the final version of the exercise program. This structured therapy program was planned for 6 weeks (30 minutes duration/session offered individually twice per week, with a gap of two days between sessions in a week) with the goals to improve voice quality, flexibility, and endurance while speaking. Five participants with HFVD partook in the study for pilot testing. Stroboscopy, perceptual voice analysis, Dysphonia Severity Index (DSI) and Vocal Fatigue Index in Tamil (VFI-T) were used to report the therapy outcomes. Participants' report on the learning process and generalization of the program were documented. Wilcoxon-signed rank test was used to test the pre-post outcome measures.

RESULTS

An eclectic voice therapy program, i.e., Comprehensive Voice Habilitation Program [CVHP] was constructed and it included vocal hygiene instructions, warm-up & cool-down, easy onset, resonant voice, and carry over exercises. Participants completed the program in 14-18 sessions (over 7 to 9 weeks of therapy). All participants showed significant changes in vocal fold movement patterns, reduction in ventricular hyperadduction, overall grade of voice quality, DSI and VFI-T. Participants reported that pictorial illustrations, feedback, and monitoring sheets were useful in learning the exercises.

CONCLUSION

CVHP showed significant change in the voice-related outcome measures and was a viable program for treating HFVD.

Reducing Vocal Fatigue While Preserving Realism During Video Game Voice-Overs Using the Vocal Combat Technique: A Randomized Controlled Trial

OBJECTIVE

Vocal Combat Technique (VCT) teaches indirect and direct behavioral voice techniques to voice-over artists performing in violent video games. Although previous work on VCT has shown promise for mitigating dysphonia symptoms, a randomized clinical trial has yet to be undertaken. Therefore, we completed a randomized, controlled trial between a group of experienced video game voice-over actors receiving VCT and a control group comparison.

METHODS

A total of 24 video game voice-over actors completed this study. Participants were randomly assigned to receive VCT or indirect vocal hygiene training prior to completing an intensive 1-hour video game voice recording session. The primary outcome was a change in Voice Handicap Index-10 (VHI-10) preperformance/postperformance. Secondary measures included a modified version of the Evaluation of the Ability to Sing Easily (m-EASE), the Vocal Tract Discomfort Scale (VTDS), and questions regarding return to work. Participants were also rated on the realism of their vocal performance by a blinded video game director.

RESULTS

The VCT group showed a significantly smaller change in VHI-10 and m-EASE scores postperformance, and a higher increased likelihood to return to work compared to the control group. There were no group differences for VTDS or realism ratings. Four participants from the control group exhibited outlier behavior with more pronounced phonotraumatic symptoms following performance than all other participants.

CONCLUSIONS

VCT shows evidence of mitigating symptoms of dysphonia while preserving the realism of the vocal performance. More work is needed to understand performers at risk for more severe vocal symptoms following extreme voice-over work, so as to target them for preventative techniques and voice preservation.

Examining Therapy Duration in Adults With Voice Disorders

PURPOSE

This study examined the number of voice therapy sessions and the number of weeks in treatment to achieve desired voice outcomes in adults with voice disorders. Factors that may predict therapy duration were examined, as was the percentage of patients returning to the clinic for additional voice therapy after initial discharge.

METHOD

An observational cohort design was utilized. Data from 558 patients were extracted from the University of Wisconsin-Madison Voice and Swallow Outcomes Database. Patients diagnosed with muscle tension dysphonia, vocal fold paralysis, benign vocal fold lesions, laryngospasm/irritable larynx, and presbyphonia were examined. Patient demographics, auditory-perceptual assessments, acoustics, aerodynamics, videostroboscopy ratings, self-reported scales, and medical comorbidities were collected.

RESULTS

Patients required an average of 5.32 (SD = 3.43) sessions of voice therapy before voice outcomes were sufficiently improved for discharge. Average number of sessions ranged from 4.3 for presbyphonia to 6.7 for benign vocal fold lesions. Baseline overall Grade Roughness Breathiness Asthenia and Strain rating (p < .001), Dysphonia Severity Index (p < .001), Voice Handicap Index score (p < .01), age (p = .006), and occupational voice user status (p < .001) significantly predicted the number of therapy sessions required. Overall, 14.5% of patients returned for additional voice therapy following an initial discharge from treatment.

CONCLUSIONS

Findings inform our understanding of how many sessions patients with voice disorders require to achieve desired voice outcomes. Additional research is needed to optimize the efficacy of voice treatment and determine how recurrence of dysphonia might best be prevented.

Identifying Clinical Behaviors Using the Motor Learning Classification Framework: A Pilot Study

CONTEXT

Although differences in clinical interactions with patients between students and experienced clinicians are well described, differences in therapeutic training behaviors have not been explored, especially in relation to motor learning principles.

AIMS

This pilot study compared clinical behaviors between speech language pathology (SLP) students and experienced SLPs in a voice therapy task, using prepractice variables in the Motor Learning Classification Framework (MLCF).

METHODS

Using a quasi-experimental design, five final-year undergraduate SLP students and four experienced SLPs with a voice therapy caseload taught a standardized patient to produce a vocal siren. Two trained raters categorized the clinicians' behaviors using the MLCF.

RESULTS

High intrarater reliability (91.9%, 92.3%) and interrater reliability (89.6%, 82.1%) were shown across both raters. Both clinician groups used the same percentage of behaviors classified as verbal information but differed in the subtypes of these behaviors. Experienced clinicians used behaviors categorized as problem-solving and only experienced clinicians used repeated behavior sequences that included perceptual training. Both groups used significantly more talking behaviors than doing behaviors.

CONCLUSIONS

The MLCF can be reliably used to identify prepractice behaviors during client interactions in voice therapy. Students and experienced clinicians showed similarities in behaviors, but experienced clinicians used more problem solving and perceptual training behaviors than students. These differences have implications for student training. The greater use of talking behaviors than doing behaviors warrants further investigation into whether this impacts the subsequent quality of practice engaged by the client and ultimately treatment effectiveness.

The Impact of Referral Source on Voice Therapy

INTRODUCTION

Adherence to voice therapy is essential in achieving successful voice outcomes. Previous studies within the field of voice therapy have suggested that shorter wait times and utilization of an interprofessional practice (IPP) model of care have a positive effect on voice therapy completion rates. While the implementation of IPP has gained popularity, especially at academic voice centers, the majority of speech-language pathologists (SLP) practice in a traditional (T) setting where they are unaffiliated with the referring otolaryngologist.

PURPOSE

This study aims to further examine how SLP practice models (interprofessional vs traditional) affect voice therapy initiation and completion rates. The secondary aim is to determine if voice therapy attendance rates have changed since the authors' initial investigations over 10 years ago.

METHODS

A retrospective chart review of 452 patients was conducted. Data was collected on patient demographics (sex, age), diagnosis, severity of dysphonia (CAPE-V), quality of life impact (V-RQOL raw score), practice setting (IPP vs T), date of referral, date of voice therapy initial evaluation, number of therapy sessions completed, and attendance to therapy sessions defined as completion or dropout.

RESULTS/CONCLUSIONS

Initiation of voice therapy treatment was the point in the referral process that was most impacted by practice model. Over half (53%) of referrals to voice therapy in a traditional practice model did not lead to initiation of treatment, while only 23% of the referrals taking place in an IPP model failed to initiate (P < 0.001). This study also demonstrated an improving, but continued rate of noninitiation and dropout from voice therapy when compared to data that was collected 10 years prior.

Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female School Teachers With Voice Problems

BACKGROUND

Teachers suffer greater impacts of voice problems due inappropriate voice use and other contributing factors such as physiological, environmental, and individual & work related issues. Structured vocal hygiene programs (VHP) prevent/reduce the risk of vocal trauma and promote vocal health in teachers. This study aimed to estimate the outcome of instituting a sociocultural relevant vocal hygiene program in facilitating vocal health among female school teachers using a comprehensive voice assessment protocol.

METHOD

VHP was developed emphasizing adequate hydration, healthy vocal diet, posture and alignment, vocal practices while teaching, and ideal speaking environment. This was administered via a face to face session to seventeen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objective, and self-perceptual vocal measures) before and four weeks after the VHP. Inter-rater reliability for perceptual and visual examination was estimated using Intra-Class Coefficient. Wilcoxon signed ranks test was used to compare the pre- and post-treatment measures of continuous variables (acoustic, Maximum phonation time, s/z ratio, Vocal Fatigue Index [VFI] & Voice Disorder Outcome Profile [V-DOP]), and McNemar test was used for categorical variables (vocal health questionnaire, visual examination of larynx and perceptual evaluation of voice).

RESULTS

Teachers reported reduction of unhealthy vocal & nonvocal practices after VHP. Improvements in vocal and related symptoms such as sensation of heart burn (P = 0.031), discomfort around the throat (P = 0.008), inadequate breath control while speaking (P = 0.016) were noticed. Perceptually, minimal improvement was seen in voice quality (overall grade). However, MPT & s/z ratio showed no significant difference. Improvement was observed in frequency range (P = 0.004), low I₀ (P = 0.044), shimmer (P = 0.017), and DSI (P = 0.013). Changes were evident in all parameters of stroboscopic evaluation (except nonvibratory portion & ventricular fold hyper-adduction). V-DOP scores indicated positive change in the overall severity (P = 0.002), physical (P = 0.003) and functional domain (P = 0.034). VFI indicated improvement in teachers voice after a period of voice rest (P = 0.048).

CONCLUSION

Though VHP facilitated in improving the teachers' awareness of at risk phono-traumatic behaviors and vocal health, its efficiency was limited in producing physiological improvement in teachers' voice. The comparison of vocal metrics before & after the treatment provides information on changes that can be expected in teachers after guiding them through a systematic VHP.

Validation and Cross-Cultural Adaptation of Croatian Self-Evaluation of Communication Experiences after Laryngectomy Questionnaire

INTRODUCTION

The Self-Evaluation of Communication Experiences after Laryngectomy (SECEL) is a 35-item patient-reported questionnaire developed to address the communication needs of patients with laryngectomies. The aim was to translate, cross-culturally adapt, and validate the Croatian version.

METHODS

The SECEL was translated from English by two independent translators and back-translated by a native speaker, after which it was approved by an expert committee. The Croatian version of the Self-Evaluation of Communication Experiences after Laryngectomy questionnaire (SECEL:HR) was filled in by 50 laryngectomised patients who had completed their oncological treatment a year prior to inclusion in the study. Patients also filled in the Voice Handicap Index (VHI) and the Short Form Health Survey (SF-36) on the same day. All patients completed the SECEL:HR twice, the second time being 2 weeks after the initial test. Maximum phonation time and diadochokinesis of articulation organs were used for objective assessment.

RESULTS

Among the Croatian patients, the questionnaire was well-accepted and demonstrated good test-retest reliability and internal consistency for two out of three subscales. The correlations between VHI, SF-36, and SECEL:HR were moderate to strong. There were no significant differences between patients who are using oesophageal speech, tracheoesophageal speech, or the electrolarynx based on the SECEL:HR.

CONCLUSION

Preliminary findings of the research indicate that the Croatian version of the SECEL has sufficient psychometric qualities, high reliability, and good internal consistency, with a Cronbach's alpha of 0.89 for the total score. The Croatian version of SECEL can be recommended as a reliable and clinically valid measure for the assessment of substitution voices in Croatian-speaking patients.

Speaking with a KN95 face mask: a within-subjects study on speaker adaptation and strategies to improve intelligibility

Mask-wearing during the COVID-19 pandemic has prompted a growing interest in the functional impact of masks on speech and communication. Prior work has shown that masks dampen sound, impede visual communication cues, and reduce intelligibility. However, more work is needed to understand how speakers change their speech while wearing a mask and to identify strategies to overcome the impact of wearing a mask. Data were collected from 19 healthy adults during a single in-person session. We investigated the effects of wearing a KN95 mask on speech intelligibility, as judged by two speech-language pathologists, examined speech kinematics and acoustics associated with mask-wearing, and explored KN95 acoustic filtering. We then considered the efficacy of three speaking strategies to improve speech intelligibility: Loud, Clear, and Slow speech. To inform speaker strategy recommendations, we related findings to self-reported speaker effort. Results indicated that healthy speakers could compensate for the presence of a mask and achieve normal speech intelligibility. Additionally, we showed that speaking loudly or clearly—and, to a lesser extent, slowly—improved speech intelligibility. However, using these strategies may require increased physical and cognitive effort and should be used only when necessary. These results can inform recommendations for speakers wearing masks, particularly those with communication disorders (e.g., dysarthria) who may struggle to adapt to a mask but can respond to explicit instructions. Such recommendations may further help non-native speakers and those communicating in a noisy environment or with listeners with hearing loss.

Vocal ergonomics with sports coaches: Co-devised approaches to occupational voice

BACKGROUND: Work-system participation and factors are associated with occupational vocal health for vocally reliant workers, such as sports coaches. However, there is limited use of systems approaches and worker collaboration to address occupational voice. OBJECTIVE: The current research aimed to cooperatively consider coaches’ vocally reliant systems participation, including addressing vocal ergonomic factors that can create barriers for occupational vocal health and voice use. METHODS: Collaborative action inquiries explored vocal ergonomics with coaches (n = 24) from nine professional basketball teams. Across three basketball seasons, coaches and a subject matter expert identified what influenced coaches’ voices and trialed approaches to optimize vocally reliant coaching participation. Nine action inquiry methods were used, including search conferences, ergonomic approaches to enhance systems participation, and focus groups. Multi-level analyses were also undertaken. RESULTS: Participants cooperatively generated, implemented, and evaluated different strategies. A cumulative total of 57 strategies were explored within teams (team mean = 6.33, SD = 3, range = 4–14). Cross-case analysis identified 25 different strategy types. Overall, participants appraised 31.58% (18/57) strategies as supportive (i.e., enhanced facilitators for voice), 61.40% (35/57) strategies as somewhat supportive (i.e., some enhanced facilitators and some ongoing barriers), and 7.02% (4/57) strategies as unsupportive (i.e., pervasive ongoing barriers not mitigated by strategies). Further, factors across coaches’ work-systems continued to influence coaches’ voices in dynamic and complex ways. CONCLUSIONS: Collaboration with coaches enriched vocal ergonomic approaches by providing novel, context-anchored insights. Collaboration should form ‘part’ of broader mechanisms to support coaches’ voice use and vocal health at work.

Effectiveness of Breath-holding Pulling Exercise in Patients with Vocal Fold Atrophy

OBJECTIVE

In recent years, the incidence of vocal fold atrophy has increased among the elderly. Vocal function exercises (VFE) are performed in patients with age-related vocal fold atrophy; however, treatment could be challenging if the patient is unable to go to the hospital or in hospitals that do not have a speech pathologist. Breath-holding pulling exercises are simple and can be performed anywhere for the management of such patients. This study aimed to examine the effectiveness of breath-holding pulling exercises in patients with vocal fold atrophy.

STUDY DESIGN

Retrospective study METHODS: With the hands folded in front of the chest, the patients were instructed to take a deep breath, pull their hands to the left and right, and then hold their breath for 5 seconds. The physician instructed the patients to do this 10 times each morning, afternoon, and evening. Speech function, acoustic analysis, pitch range, and Voice Handicap Index-10 (VHI-10) were evaluated and compared before and 4-8 weeks after treatment.

RESULTS

Maximum phonation time (MPT), the primary endpoint, significantly improved after treatment from 14.2 ± 6.6 to 20.3 ± 9.3 seconds. Among the secondary endpoints, mean flow rate (207.5 ± 104.4 to 165.1 ± 66.5 mL/s), pitch range (22.9 ± 8.3 to 26.2 ± 8.1 semitones), VHI-10 (18.1 ± 7.2 to 12.5 ± 6.3 points) jitter (2.5±1.6 to 1.7±1.2%), and shimmer (5.9±3.5 to 4.8±3.3%) showed significant improvement.

CONCLUSION

Breath-holding pulling exercises were found to be effective in patients with vocal fold atrophy. These can be performed in hospitals with no speech pathologists, in patients who are unable to go to the hospital, and in patients who are hospitalized or unable to speak loudly. Moreover, as with conventional VFE, the training method achieves a high level of patient satisfaction.

Voice Therapy Outcome: A Comparison Between Imitation Model Voice Therapy and Verbal Instructions Model Voice Therapy

OBJECTIVES

The aim was to compare voice outcomes over time in patients treated with Imitation Model voice therapy and Verbal Instructions Model voice therapy.

METHODS

A prospective clinical trial was performed with 56 consecutive patients diagnosed with a primary or secondary functional voice disorder. Thirty-one patients were included for voice therapy following the Imitation Model and 25 patients for the Verbal Instructions Model. Assessments included a self-rated Voice Handicap Index, self-perceived hoarseness and vocal fatigue, perceptual voice evaluation by a Speech Language Pathologist, and maximum Voice Range Profiles. All assessments were completed before therapy, at end of therapy, at six-months posttherapy follow-up and 12-months posttherapy follow-up. For maximum Voice Range Profiles group differences were also compared for effects from end-of-treatment to follow-up assessments. Linear mixed models were used for analysis.

RESULTS

Comparison between treatment groups showed significantly larger long-term improvement from the baseline, for verbal instructions model as compared to imitation model for Voice Handicap Index total, and also the physical and emotional subscales, while there was no difference between groups for the functional subscale. Also, voice quality improved more after verbal instructions model, as compared to imitation model, at end of therapy. Results from self-rated hoarseness and vocal fatigue showed no difference between groups. There was no difference between treatment groups in the change of maximum Voice Range Profile from end-of-treatment to follow-up assessments.

CONCLUSIONS

The study showed that both Imitation Model voice therapy and Verbal Instructions Model voice therapy improved voice function. Compared to Imitation Model, the Verbal Instructions model showed larger long-term effect on physical and emotional aspects of voice function in everyday life. The two approaches for voice therapy might have different impacts on patients' learning.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357.

Changes in the Daily Phonotrauma Index Following the Use of Voice Therapy as the Sole Treatment for Phonotraumatic Vocal Hyperfunction in Females

Purpose The aim of this study was to use the Daily Phonotrauma Index (DPI) to quantify group-based changes in the daily voice use of patients with phonotraumatic vocal hyperfunction (PVH) after receiving voice therapy as the sole treatment. This is part of an ongoing effort to validate an updated theoretical framework for PVH. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and posttreatment data from 52 female patients with PVH. Normative weeklong data were also obtained from 52 matched controls. Each week was represented by the DPI, which is a combination of neck-surface acceleration magnitude skewness and the standard deviation of the difference between the first and second harmonic magnitudes. Results Compared to pretreatment, the DPI statistically decreased towards normal in the patient group after treatment (Cohen's d = -0.25). The posttreatment patient group's DPI was still significantly higher than the control group (d = 0.68). Conclusions The DPI showed the pattern of improved ambulatory voice use in a group of patients with PVH following voice therapy that was predicted by the updated theoretical framework. Per the prediction, voice therapy was associated with a decreased potential for phonotrauma in daily voice use, but the posttreatment patient group data were still significantly different from the normative control group data. This posttreatment difference is interpreted as reflecting the impact on voice use of the persistence of phonotrauma-induced structural changes to the vocal folds. Further validation of the DPI is needed to better understand its potential clinical use.

Acoustic Variability in the Healthy Female Voice Within and Across Days: How Much and Why?

Purpose The aims of this study were (1) to quantify variability in voice production (as measured acoustically) within and across consecutive days in vocally healthy female speakers, (2) to identify which acoustic measures are sensitive to this variability, and (3) to identify participant characteristics related to such voice variability. Method Participants included 45 young women with normal voices who were stratified by age, specifically 18-23, 24-29, and 30-35 years. Following an initial acoustic and auditory-perceptual voice assessment, participants performed standardized field voice recordings 3 times daily across a 7-day period. Acoustic analyses involved 32 cepstral-, spectral-, and time-based measures of connected speech and sustained vowels. Relationships among acoustic data and select demographic, health, and lifestyle (i.e., participant-based) factors were also examined. Results Significant time-of-day effects were observed for acoustic analyses within speakers (p < .05), with voices generally being worse in the morning. No significant differences were observed across consecutive days. Variations in voice production were associated with several participant factors, including improved voice with increased voice use; self-perceived poor voice function, minimal or no alcohol consumption, and extroverted personality; and worse voice with regular or current menstruation, depression, and anxiety. Conclusions This acoustic study provides essential information regarding the nature and extent to which healthy voices vary throughout the day and week. Participant-based factors that were associated with improved voice over time included increased voice use, self-perceived poor voice function, minimal or no alcohol consumption, and extroverted personality. Factors associated with worse voice production over time included regular or current menstruation, and depression and anxiety.

Effect of an iOS App on Voice Therapy Adherence and Motivation

Purpose Patients commonly report difficulties adhering to voice therapy. An iOS app was developed in our lab that assists practice via reminder notifications, instructional recordings, and cepstral peak prominence analysis results. The purpose of this study was to assess the effect of such homework support modality on adherence behavior and associated motivation in a comparison of app support and written homework instructions and to assess the usability and utility of the app. Method Thirty-four individuals exhibiting adducted hyperfunction were randomized to receive either written homework instructions or the app when practicing resonant voice exercises for 3 weeks. All patients digitally audio-recorded all home practice, provided self-reported estimates of generalization, and completed weekly motivation scales. Results App support significantly increased practice frequency but did not affect self-reported generalization or motivation. Practice was significantly predicted by System Usability Scale scores. Utility of reminders and instructions were good, but cepstral peak prominence feedback was considered useful to only a subset of participants. Conclusion Interactive mobile therapy support can significantly increase practice of resonant voice homework without influencing motivation.

Muscle Tension Dysphagia: Contributing Factors and Treatment Efficacy

OBJECTIVE

To determine factors contributing to disease etiology and treatment efficacy.

STUDY DESIGN

Original Report.

SETTING

Tertiary academic center.

METHODS

IRB approved prospective study of 20 patients with reported dysphagia who exhibited normal oropharyngeal and esophageal swallowing function as evidenced by videofluoroscopic swallow study, esophagogastroduodenoscopy, high-resolution esophageal manometry with stationary impedance, and Bravo pH probe off proton pump inhibitor. Patients underwent speech-language pathology intervention.

RESULTS

Atypical laryngeal muscle tension was present in 100% of patients. Forty percent of patients had diagnosed positive gastroesophageal reflux disease. Sixty-five percent of patients showed signs of non-specific laryngeal inflammation and laryngeal hyperresponsiveness during strobolaryngoscopy. All patients reported a mean of 90% recovery by the completion of voice therapy directed toward unloading muscle tension.

CONCLUSION

The study results suggest an association between laryngeal muscle tension and these patients' dysphagia symptoms regardless of associated conditions. Speech-language pathology intervention showed high treatment efficacy.

LEVEL OF EVIDENCE

2c- Outcomes research.

Steam and/or Semi-occluded Vocal Tract Exercise as Morning Vocal Warm-up Strategy

OBJECTIVE

This study was designed to evaluate the effectiveness of either steam, semi-occluded vocal tract (SOVT) exercises, or a combination of both as a speaking voice warm-up strategy to be used at the start of the day.

METHODS/DESIGN

This prospective study assessed the impact of three different vocal warm-up conditions on phonatory threshold pressure (PTP). The three conditions were: (1) Steam - breathing steam for 3 minutes; (2) SOVT exercise - blowing bubbles through a straw into a cup of water while phonating /u/ for 3 minutes; and (3) Steam + SOVT - both conditions 1 and 2. Participants were 12 females with a mean age of 24. They were assessed on three different mornings, with one condition being tested each morning. Condition order and combination order were counterbalanced. Each morning prior to arriving, participants were asked to be up for about an hour, with no shower, no hot drinks or food, minimal voice-use, and no exercise. PTP was measured prior to each condition and immediately after. Participants also qualitatively described the experience of each condition and provided their subjective impression of how their voice felt after each condition.

RESULTS

There were 36 data points, reflecting change in PTP from before to after each condition. Results reflected high variability within each individual and condition. Due to this variability, means and standard deviations for each separate condition are meaningless, requiring deeper investigation into trends in the data. The investigators eliminated all data points where the sound pressure level (SPL) in the pre-experimental measure exceeded 67 dB; this was interpreted as the participant not performing the PTP task as softly as possible. First, data were examined within each participant, excluding all data from any participant who exceeded 67 dB SPL in any of the three pre-experimental measures. Of the seven participants remaining, steam was the best condition for one, SOVT was the best for three, and Steam + SOVT was the best for three. Of these, only two people experienced an improvement in PTP of greater than or equal to 0.5 cm H 2 O, both under the SOVT condition. Of the same seven participants, steam was the worst condition for three, SOVT was the worst for one, and Steam + SOVT was the worst for two. The three participants for whom steam was the worst reported strongly disliking the condition. Only three people experienced a worsening of PTP greater than or equal to 0.5 cm H 2 O: one in the SOVT condition; and two in the Steam + SOVT. It is typically expected that increases or decreases in PTP and SPL will be systematically related. Since the goal of a warm-up is to increase phonatory efficiency, and improve the viscosity of the vocal folds, a reduction in PTP after any condition was interpreted favorably. For the 9 data points across all conditions where PTP and SPL both decreased, there was a mean decrease in PTP of 0.34 cm H₂O (SD = 0.28 cm H₂O ). Mean decrease in SPL was 2.00 dB (SD = 0.88 dB). This indicates that individuals were able to decrease PTP and SPL as expected after a warm-up strategy. Finally, a trend appeared in six data points, where despite an increase in SPL, PTP decreased, potentially indicating improvement in vocal efficiency. Of these data points the mean decrease in PTP was 0.36 cm H₂O ( SD = 0.17 cm H₂O ), with a mean increase in SPL of 1.70 dB (SD = 1.21 dB). Of these six data points, indicating increased efficiency, three were with steam, two with Steam + SOVT, and one with SOVT.

CONCLUSION

This study revealed that these strategies are not universally successful, and clinicians should recommend them only after assessing their effectiveness for their client. Clinicians need to be custom tailoring these exercises to their client's goals and proclivities. Another consideration is the importance of teaching proper SOVT technique, so it is done correctly without added tension. Even blowing bubbles into a cup of water with phonation can be done poorly, in some cases yielding counterproductive results. Another interesting trend suggests that the inclusion of steam in vocal warm-up may increase vocal efficiency. Future studies should explore how time of day and vocal condition impact each strategy's effectiveness, and which strategy may be most appropriate for different desired outcomes, such as vocal warmup versus vocal rescue.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis

BACKGROUND

Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice.

OBJECTIVE OF REVIEW

To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered.

EVALUATION METHOD

The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results.

RESULTS

We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements.

CONCLUSIONS

Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.

Impact of Remnant Nodules on Immediate and Long-term Outcomes of Voice Therapy for Vocal Fold Nodules

OBJECTIVES

In this study, we aimed to assess whether remnant vocal fold nodules (VFN) influence immediate and long-term voice outcomes after voice therapy.

STUDY DESIGN

This is a retrospective cohort study evaluating immediate and long-term voice outcomes.

METHODS

Twenty-five adult patients with VFN who completed voice therapy were included in this study. Patients were classified into remnant (n = 18) and nonremnant (n = 7) groups according to the presence of remnant nodules immediately after completion of voice therapy. Acoustic and perceptual parameters, as well as voice handicap index (VHI), were compared between groups immediately (immediate outcome) and more than 3 months (long-term outcome) after completion of voice therapy.

RESULTS

Immediately after voice therapy, there were no significant differences between groups in grade-roughness-breathiness-asthenia-strain (GRBAS) score, jitter, shimmer, noise-to-harmonics ratio, voice range profile, or s/z ratio. Postvoice therapy VHI scores did not significantly differ between the two groups (9.29 ± 8.94 in the nonremnant group vs. 12.78 ± 9.01 in the remnant group, P = 0.392). The overall GRBAS grade of all patients was maintained at 0 or 1 during long-term follow-up. There was no significant difference between the long-term VHI scores of the remnant group (10.00 ± 8.58) and the nonremnant group (5.67 ± 8.71) (P = 0.306).

CONCLUSIONS

Immediately after voice therapy, perceptual scores, acoustic parameters, and VHI scores all significantly improved regardless of presence of remnant nodules. Favorable outcomes of voice therapy were maintained during long-term follow-up regardless of presence of remnant nodules after voice therapy.

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

OBJECTIVE

A 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.

METHODS

A 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.

RESULTS

All 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.

CONCLUSIONS

This 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.

Long-term Surveillance Following Intralesional Steroid Injection for Benign Vocal Fold Lesions

Importance

The short-term outcomes of vocal fold steroid injection (VFSI) are well documented. However, few studies have reported the long-term outcomes following VFSI.

Objective

To investigate the incidence rates of symptom recurrence and secondary interventions following VFSI for benign vocal fold lesions.

Design, Setting, and Participants

This prospective cohort study was conducted at a tertiary referral medical center in Taipei, Taiwan. The cohort included 189 patients with vocal fold lesions who had received VFSI as the primary treatment between August 2011 and September 2013.

Exposures

All participants underwent VFSI.

Main Outcomes and Measures

Long-term surveillance was conducted through structured telephonic interviews and by reviewing medical charts every 6 months over a 2-year period. We assessed the 10-item voice handicap index, dysphonic symptoms, and whether the patients had received any additional interventions after the initial VFSI.

Results

The 189 participants (32 men and 157 women; mean [SD] age, 39 [10] years [range, 20-74 years] included patients who had undergone VFSI for vocal fold nodules (n = 72), polyps (n = 72), or mucus-retention cysts (n = 45). Following VFSI, 141 patients (74.6%; 23 men and 118 women; mean age, 39 years [range, 20-70 years]) showed positive response (ie, clinically significant symptom resolution without the need for additional procedures) and received long-term surveillance. The median follow-up period was 19.4 months, and 2 patients were lost to follow-up postoperatively within 1 year. The cumulative failure rates (subjective symptom recurrence plus secondary treatments) at 6, 12, 18, and 24 months after VFSI were 12%, 17%, 24%, and 32%, respectively. When the initial response rate to VFSI (141 of 189, 74.6%) was considered altogether, VFSI remained effective after 2 years in 50% of the initially recruited 189 patients. The highest rate of long-term effectiveness of VFSI occurred in vocal polyps (54%), followed by nodules (49%) and cysts (43%).

Conclusions and Relevance

This study demonstrates that VFSI can be beneficial in managing benign vocal lesions, especially when first-line treatments are unsuitable. However, the long-term results of this study clarify that a substantial number of patients experience symptom recurrence or receive subsequent interventions within 2 years after VFSI; this should be considered in medical decision making.

Factors Associated With Attrition in Randomized Controlled Trials of Vocal Rehabilitation: Systematic Review and Meta-Analysis

OBJECTIVES/HYPOTHESIS

This study aimed to determine the dropout rates and the reasons for dropout in randomized clinical trials of vocal rehabilitation.

STUDY DESIGN

This study used systematic review and meta-analysis (CRD42013003807).

METHODS

We included randomized controlled trials for voice disorders. In June 2015, we searched the following databases: MEDLINE, EMBASE, Cochrane, Clinical Trials, and AJSLP. The titles and abstracts or full texts of articles were independently analyzed by two reviewers. Study quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scale. Our initial research base included more than 8491 articles.

RESULTS

A total of 51 articles were obtained using our eligibility criteria. The low-quality studies evaluated had higher dropout rates (odds ratio: 3.3, 95% confidence interval: 1.04-12.9). Studies with healthy patients (45%) or vocal training versus no training (25%) also had higher dropout rates. Methodological issues seemed to have a greater influence on the dropout rates of the studies included in the co-occurrence matrix.

CONCLUSIONS

Dropout rates of approximately 15% occur in randomized clinical trials of speech therapy when assessed by the Grading of Recommendations Assessment, Development and Evaluation. Studies with lower methodological quality had higher patient loss rates. Methodological and clinical reasons accounted for the highest dropout rates in the studies included in this meta-analysis.

Long-term effects of an intensive voice treatment for vocal fold nodules

PURPOSE

The purpose of the current study was to examine the long-term effects of intensive voice treatment for vocal fold nodules, compared to outcomes for patients treated with traditional voice therapy. It was hypothesised that intensive treatment would provide comparable maintenance of vocal function, voice quality, and patients' perception of quality-of-life when compared with traditional treatment at 6 month follow-up.

METHOD

Thirty-six women diagnosed with bilateral vocal fold nodules who were treated with either traditional (n = 20; once a week for 8 weeks) or intensive (n = 16; eight sessions within 3 weeks) therapy. Each participant completed voice, stroboscopic, and acoustic assessments and the Voice Handicap Index before, immediately post and 6 months post-treatment.

RESULT

Results revealed most improved perceptual, stroboscopic and acoustic parameters were maintained in both groups at 6 months post-treatment, with no significant differences between the two groups. In addition, both groups maintained satisfaction on their perception of vocal function, with no significant difference between the two groups.

CONCLUSION

The investigation provided further evidence that individuals with vocal fold nodules are able to maintain improved voice quality and vocal health following intensive voice treatment to a similar degree to traditional voice treatment.

Cross-activation and detraining effects of tongue exercise in aged rats

Voice and swallowing deficits can occur with aging. Tongue exercise paired with a swallow may be used to treat swallowing disorders, but may also benefit vocal function due to cross-system activation effects. It is unknown how exercise-based neuroplasticity contributes to behavior and maintenance following treatment. Eighty rats were used to examine behavioral parameters and changes in neurotrophins after tongue exercise paired with a swallow. Tongue forces and ultrasonic vocalizations were recorded before and after training/detraining in young and old rats. Tissue was analyzed for neurotrophin content. Results showed tongue exercise paired with a swallow was associated with increased tongue forces at all ages. Gains diminished after detraining in old rats. Age-related changes in vocalizations, neurotrophin 4 (NT4), and brain derived neurotrophic factor (BDNF) were found. Minimal cross-system activation effects were observed. Neuroplastic benefits were demonstrated with exercise in old rats through behavioral improvements and up-regulation of BDNF in the hypoglossal nucleus. Tongue exercise paired with a swallow should be developed, studied, and optimized in human clinical research to treat swallowing and voice disorders in elderly people.

Average Ambulatory Measures of Sound Pressure Level, Fundamental Frequency, and Vocal Dose Do Not Differ Between Adult Females With Phonotraumatic Lesions and Matched Control Subjects

OBJECTIVES

Clinical management of phonotraumatic vocal fold lesions (nodules, polyps) is based largely on assumptions that abnormalities in habitual levels of sound pressure level (SPL), fundamental frequency (f0), and/or amount of voice use play a major role in lesion development and chronic persistence. This study used ambulatory voice monitoring to evaluate if significant differences in voice use exist between patients with phonotraumatic lesions and normal matched controls.

METHODS

Subjects were 70 adult females: 35 with vocal fold nodules or polyps and 35 age-, sex-, and occupation-matched normal individuals. Weeklong summary statistics of voice use were computed from anterior neck surface acceleration recorded using a smartphone-based ambulatory voice monitor.

RESULTS

Paired t tests and Kolmogorov-Smirnov tests resulted in no statistically significant differences between patients and matched controls regarding average measures of SPL, f0, vocal dose measures, and voicing/voice rest periods. Paired t tests comparing f0 variability between the groups resulted in statistically significant differences with moderate effect sizes.

CONCLUSIONS

Individuals with phonotraumatic lesions did not exhibit differences in average ambulatory measures of vocal behavior when compared with matched controls. More refined characterizations of underlying phonatory mechanisms and other potentially contributing causes are warranted to better understand risk factors associated with phonotraumatic lesions.

A taxonomy of voice therapy

PURPOSE

Voice therapy practice and research, as in most types of rehabilitation, is currently limited by the lack of a taxonomy describing what occurs during a therapy session (with enough precision) to determine which techniques/components contribute most to treatment outcomes. To address this limitation, a classification system of voice therapy is proposed that integrates descriptions of therapeutic approaches from the clinical literature into a framework that includes relevant theoretical constructs.

METHOD

Literature searches identified existing rehabilitation taxonomies/therapy classification schemes to frame an initial taxonomic structure. An additional literature search and review of clinical documentation provided a comprehensive list of therapy tasks. The taxonomy's structure underwent several iterations to maximize accuracy, intuitive function, and theoretical underpinnings while minimizing redundancy. The taxonomy was then used to classify established voice therapy programs.

RESULTS

The taxonomy divided voice therapy into direct and indirect interventions delivered using extrinsic and/or intrinsic methods, and Venn diagrams depicted their overlapping nature. A dictionary was developed of the taxonomy's terms, and 7 established voice therapy programs were successfully classified.

CONCLUSION

The proposed taxonomy represents an important initial step toward a standardized voice therapy classification system expected to facilitate outcomes research and communication among clinical stakeholders.

Predicting and influencing voice therapy adherence using social-cognitive factors and mobile video

PURPOSE

Patient adherence to voice therapy is an established challenge. The purpose of this study was (a) to examine whether adherence to treatment could be predicted from three social-cognitive factors measured at treatment onset: self-efficacy, goal commitment, and the therapeutic alliance, and (b) to test whether the provision of clinician, self-, and peer model mobile treatment videos on MP4 players would influence the same triad of social cognitive factors and the adherence behavior of patients.

METHOD

Forty adults with adducted hyperfunction with and without benign lesions were prospectively randomized to either 4 sessions of voice therapy enhanced by MP4 support or without MP4 support. Adherence between sessions was assessed through self-report. Social cognitive factors and voice outcomes were assessed at the beginning and end of therapy. Utility of MP4 support was assessed via interviews.

RESULTS

Self-efficacy and the therapeutic alliance predicted a significant amount of adherence variance. MP4 support significantly increased generalization, self-efficacy for generalization, and the therapeutic alliance. An interaction effect demonstrated that MP4 support was particularly effective for patients who started therapy with poor self-efficacy for generalization.

CONCLUSION

Adherence may be predicted and influenced via social-cognitive means. Mobile technology can extend therapy to extraclinical settings.

Vocal Hygiene Habits and Vocal Handicap Among Conservatory Students of Classical Singing

OBJECTIVES

This study sought to assess classical singing students' compliance with vocal hygiene practices identified in the literature and to explore the relationship between self-reported vocal hygiene practice and self-reported singing voice handicap in this population. The primary hypothesis was that increased attention to commonly recommended vocal hygiene practices would correlate with reduced singing voice handicap.

STUDY DESIGN

This is a cross-sectional, survey-based study.

METHODS

An anonymous survey assessing demographics, attention to 11 common vocal hygiene recommendations in both performance and nonperformance periods, and the Singing Voice Handicap Index 10 (SVHI-10) was distributed to classical singing teachers to be administered to their students at two major schools of music.

RESULTS

Of the 215 surveys distributed, 108 were returned (50.2%), of which 4 were incomplete and discarded from analysis. Conservatory students of classical singing reported a moderate degree of vocal handicap (mean SVHI-10, 12; range, 0-29). Singers reported considering all 11 vocal hygiene factors more frequently when preparing for performances than when not preparing for performances. Of these, significant correlations with increased handicap were identified for consideration of stress reduction in nonperformance (P = 0.01) and performance periods (P = 0.02) and with decreased handicap for consideration of singing voice use in performance periods alone (P = 0.02).

CONCLUSIONS

Conservatory students of classical singing report more assiduous attention to vocal hygiene practices when preparing for performances and report moderate degrees of vocal handicap overall. These students may have elevated risk for dysphonia and voice disorders which is not effectively addressed through common vocal hygiene recommendations alone.

Measuring vocal function in professional music theater singers: construct validation of the Evaluation of the Ability to Sing Easily (EASE)

OVERVIEW

Working music theater singers (MTS) typically have a heavy vocal load and little is known about their perception of vocal function. The Evaluation of the Ability to Sing Easily (EASE) was used to assess professional MTS' perceptions of current singing voice status and to compare scores across demographic and performance characteristics and to evaluate the construct validity of the EASE and its subscales (VF = Vocal Fatigue, PRI = Pathologic-Risk Indicators).

METHODS

Professional MTS (n = 284) completed an online survey including the EASE and two additional Vocal Concern (VC) items. Scores were compared across age, gender, whether currently working, role, perceived vocal load over the past 24 h and self-reported voice problem.

RESULTS

For the whole cohort, statistically significant differences were found on all subscales according to whether or not singers perceived themselves to have a voice problem (p < 0.001). Currently performing singers were significantly different from those not performing in a show on the EASE Total (p = 0.014) and VF (p = 0.002), but not for PRI and VC. In the currently performing singer group, significant differences were found for gender, role and perceived voice problem on the EASE Total and all subscales (p < 0.01). Significantly higher VF scores were recorded for singers with heavy vocal load (p = 0.01), but there were no differences on the EASE Total (p = 0.57), PRI (p = 0.19) or VC subscales (p = 0.53). Among these performing singers, no significant age differences were found for any EASE subscales.

CONCLUSIONS

These findings provide further validation of the EASE as a useful tool for measuring singers' perceptions of vocal function and suggest that the subscales should be scored separately. Future evaluation of the EASE against objective clinical assessments (e.g., videostroboscopy) is recommended.

Vocal fold epithelial barrier in health and injury: a research review

PURPOSE

Vocal fold epithelium is composed of layers of individual epithelial cells joined by junctional complexes constituting a unique interface with the external environment. This barrier provides structural stability to the vocal folds and protects underlying connective tissue from injury while being nearly continuously exposed to potentially hazardous insults, including environmental or systemic-based irritants such as pollutants and reflux, surgical procedures, and vibratory trauma. Small disruptions in the epithelial barrier may have a large impact on susceptibility to injury and overall vocal health. The purpose of this article is to provide a broad-based review of current knowledge of the vocal fold epithelial barrier.

METHOD

A comprehensive review of the literature was conducted. Details of the structure of the vocal fold epithelial barrier are presented and evaluated in the context of function in injury and pathology. The importance of the epithelial-associated vocal fold mucus barrier is also introduced.

RESULTS/CONCLUSIONS

Information presented in this review is valuable for clinicians and researchers as it highlights the importance of this understudied portion of the vocal folds to overall vocal health and disease. Prevention and treatment of injury to the epithelial barrier is a significant area awaiting further investigation.