A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System

BACKGROUND

The prevalence of voice disorders for people aged >65 years is four times higher than for the population at large. The most common cause of dysphonia in this group is presbyphonia, the preferred first-line treatment for which is voice therapy with a speech-language pathologist. This systematic review seeks to identify how voice therapy affects multidimensional voice outcomes in people with presbyphonia.

METHODS

A systematic search of CINAHL, Embase, Emcare, MEDLINE, and Google Scholar was conducted in March 2023. Comparative and noncomparative studies of voice therapy in participants aged >50 years with presbyphonia were considered for inclusion. No limitations were placed on date or language of publication. Study quality and risk of bias were assessed with the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies. Subgroup analysis was used to compare studies based on participant sex, intervention duration, study design, and intervention content. Interventions were specified using the Rehabilitation Treatment Specification System (RTSS) employing a consensus methodology among reviewers. The results were synthesized utilizing meta-analysis when outcomes were adequately specified and narrative analysis when they were not.

RESULTS

Twenty-three studies were included with 1050 subjects (mean age: 72.5 ± 8.6 years; 51% female). The most reported intervention was vocal function exercises. Per the RTSS, 14 interventions employed a predominantly Organ Functions approach, and the 14 remaining interventions employed a Skills & Habits approach. Meta-analysis confirmed posttherapy improvement in patient-related outcome measures of 0.93 standard mean difference (P < 0.00001, 95% confidence interval [CI]: 0.70-1.17); studies with predominantly males and with longer treatment periods were associated with larger improvements, while randomized controlled trials reported more modest improvements. Meta-analysis also identified a mean posttherapy increase in maximum phonation time (MPT) of 5.37 seconds (P < 0.00001, 95% CI: 3.52-7.22). Treatments with an Organ Functions focus resulted in greater gains in MPT than those with a Skills & Habits focus (7.52 seconds versus 2.90 seconds). Finally, meta-analysis identified reductions in acoustic perturbation measures (jitter: 0.62%, P < 0.001, 95% CI: 0.26%-0.97%; shimmer 1.05%, P < 0.00001, 95% CI: 0.67%-1.44%). Narrative synthesis further identified improvement in auditory-perceptual voice quality in all active treatment groups as well as improved glottal function in most studies that reported this.

CONCLUSIONS

Despite the uncertainty around internal validity introduced by the inclusion of a wide range of study designs, there is convincing evidence that voice therapy for presbyphonia results in significant improvement in patient-reported, aerodynamic, acoustic, and expert-rated voice outcomes. Treatments with an Organ Functions focus may better address the underlying physiological deficits of presbyphonia, although future comparative studies with multidimensional voice assessment are warranted.

Effect of Practice Structure and Feedback Frequency on Voice Motor Learning in Older Adults

OBJECTIVES

The long-term goal of this research is to advance the rehabilitation of voice disorders through the study and development of efficacious treatment regimes based upon motor learning principles. This study examined the effect of contextual interference (CI) of practice structure with knowledge of results (KR) feedback on motor learning of a novel voice task, "Twang," by hypophonic, novice, and expert older adults.

STUDY DESIGN

Prospective, randomized controlled mixed design.

METHODS

A total of 92 adults, age 55-80, recruited from the following motor skill levels: 1) Hypophonic voice; 2) Novice-untrained vocalists; 3) Expert-trained vocalists were randomly assigned to four different interventions and examined during acquisition, retention, and transfer phases of motor learning. Participants from each skill-level practiced the novel task, "Twang," according to the randomly assigned Practice Structure/KR combinations: 1) Blocked practice/100%KR; 2) Blocked practice/55% KR; 3) Random practice/100%KR; 4) Random practice/55% KR.

RESULTS

During the motor performance phase, our results mirrored those reported in the limb motor learning literature for CI: A Blocked practice structure enhanced short-term effects of motor acquisition for novice, expert, and hypophonic subjects. The only significant result for KR occurred when paired with Random Practice in the hypophonic subject group: 100% KR paired with Blocked practice increased motor performance, but degraded motor learning.

CONCLUSIONS

Fundamental motor learning principles were explored within the context of a voice training paradigm. Practice with a high CI and low frequency of KR degraded performance during short-term acquisition but enhanced long-term performance effects of motor learning. Voice clinicians and teachers may benefit by implementing motor learning theory into practice during training and treatment sessions.

A Comprehensive Analysis of Age and Gender Effects in European Portuguese Oral Vowels

The knowledge about the age effects in speech acoustics is still disperse and incomplete. This study extends the analyses of the effects of age and gender on acoustics of European Portuguese (EP) oral vowels, in order to complement initial studies with limited sets of acoustic parameters, and to further investigate unclear or inconsistent results. A database of EP vowels produced by a group of 113 adults, aged between 35 and 97, was used. Duration, fundamental frequency (f0), formant frequencies (F1 to F3), and a selection of vowel space metrics (F1 and F2 range ratios, vowel articulation index [VAI] and formant centralization ratio [FCR]) were analyzed. To avoid the arguable division into age groups, the analyses considered age as a continuous variable. The most relevant age-related results included: vowel duration increase in both genders; a general tendency to formant frequencies decrease for females; changes that were consistent with vowel centralization for males, confirmed by the vowel space acoustic indexes; and no evidence of F3 decrease with age, in both genders. This study has contributed to knowledge on aging speech, providing new information for an additional language. The results corroborated that acoustic characteristics of speech change with age and present different patterns between genders.

Concentration of Fibroblasts in the Vocal Fold of Elderly

OBJECTIVE

To study the concentration of fibroblasts in the vocal folds of elderly people.

MATERIAL AND METHODS

The vocal folds of 13 cadavers were removed and divided into two age groups: Control group: n-5, 18-40 years; Elderly group: n-8, ≥75 years). The vocal folds were dissected and prepared for immunohistochemical analysis using the SA100 antibody to fibroblasts. The sites analyzed were maculae flavae and medial (or vibrating) portion of the vocal folds. The AVsoft program was used to count the cells.

RESULTS

A higher concentration of fibroblasts was identified in the maculae flavae of the larynx of young adults and in the medial portion of the vocal folds of the elderly. However, these results did not determine statistically significant differences, allowing us to conclude that there was no effect of age on the concentration of fibroblasts in the vocal folds.

CONCLUSION

In the larynx of the elderly, the fibroblast population remains similar to the young adults, both in the maculae flavae and in the body of the vocal folds, possibly being responsible for the constant production of fibrous matrix in the lamina propria. Functional changes in these cells are probably more marked than quantitative ones.

Injection laryngoplasty as an effective treatment method for glottal insufficiency in aged patients

PURPOSE

The purpose of the study was to assess outcomes of injection laryngoplasty (IL) for treating glottal insufficiency in elderly patients with presbyphonia or unilateral vocal fold paralysis (UVFP).

METHODS

A single-center retrospective study was performed. The study group consisted of 34 patients with glottal insufficiency aged between 60 and 82 years who had been treated with injection laryngoplasty. Of them, 16 patients were diagnosed with presbyphonia and 18 with UVFP.

RESULTS

After IL, glottal closure improved in both groups. The change was statistically significant in the patients with presbyphonia (marginal homogeneity test MH = 3.80; p < 0.001) and in the UVFP patients (MH = 4.04; p < 0.001). Voice quality improved after IL and 12 months after surgical intervention remained significantly better compared to before augmentation (MH tests were statistically significant at p < 0.05 for R, B, A, and S parameters). In the patients with UVFP, significant improvement was observed in 7 of 12 evaluated parameters (Jitt, RAP, PPQ, Shim, APQ, sAPQ, and NHR) but in the patients with presbyphonia only average fundamental frequency (F0) improved significantly. Comparison of the Voice Handicap Index outcomes before and 12 months after surgery showed improvement of subjectively assessed voice quality in both groups; however, the change was statistically significant only in the UVFP patients.

CONCLUSIONS

Injection laryngoplasty is a safe and effective treatment method for glottal insufficiency in the elderly. This study shows a significant and clinically relevant improvement to at least12 months, especially in patients with UVFP.

The effect of nasal septum deviation on voice aging

PURPOSE

The aging process of the voice differs among individuals, and the factors that affect age-related changes in voice are not well-defined. In this study, we investigated the difference between older people with nasal septum deviation (NSD) and older people without NSD in terms of degree of aging voice using objective and subjective voice assessment tools.

METHODS

The study included 94 patients (47 women, 47 men) aged >65 years. Nasal septum deviation was determined in 45 patients (NSD group), and 49 patients had no nasal pathology (control group). Maximum phonation time (MPT), GRBAS scale, and acoustic voice analysis parameters were compared between the NSD and control groups; sub-group analysis disaggregated by sex was also performed.

RESULTS

No significant difference was observed between the NSD and control groups with respect to MPT, GRBAS scale, and acoustic voice analysis parameters in the total study population and among male subjects. The only parameter that showed a significant difference between sub-groups of female subjects was soft phonation index (SPI) (p=.03).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze the effect of NSD on the voice aging. With the findings of the present study, NSD does not seem to have an effect on voice aging, and also it can be suggested that septoplasty will not have an effect on preventing presbyphonia. Further studies on larger groups of patients are required to provide more definitive evidence on this subject.

Self-Perceived Voice Problems in a Nontreatment Seeking Older Population in Hong Kong

OBJECTIVE

To evaluate the prevalence of self-perceived voice problems and voice-related quality of life in a nontreatment seeking older population in Hong Kong.

STUDY DESIGN

Prospective, cross-sectional survey.

METHODS

One hundred and one older individuals aged 65 years or above were recruited from senior citizen community centers in Hong Kong. Each participant received a face-to-face interview with the researcher. The participants were asked to report the presence of voice problems and the voice symptoms that they experienced. They were also asked to complete the Cantonese version of the Voice Handicap Index to ascertain their voice-related quality of life.

RESULTS

Over one-fourth (27.7%) of participants reported having current voice problems. Perceived voice problems were found to pose significant negative impacts on the older individuals' voice-related quality of life. The prevalence of voice problems and extent of impacts of voice-related quality of life were similar across the young-old, old-old, and the oldest-old groups of participants.

CONCLUSION

The results suggest that voice problems are common in the older population and should not be underestimated. The study urges the need to allocate more resources to provide voice-related services from the young-old group for promoting positive aging.

Effects of Aging on Vocal Fundamental Frequency and Vowel Formants in Men and Women

PURPOSE

This study reports data on vocal fundamental frequency (f_o) and the first four formant frequencies (F1, F2, F3, F4) for four vowels produced by speakers in three adult age cohorts, in a test of the null hypothesis that there are no age-related changes in these variables. Participants were 43 men and 53 women between the ages of 20 and 92 years.

RESULTS

The most consistent age-related effect was a decrease in f_o for women. Significant differences in F1, F2, and F3 were vowel-specific for both sexes. No significant differences were observed for the highest formant F4.

CONCLUSIONS

Women experience a significant decrease in f_o, which is likely related to menopause. Formant frequencies of the corner vowels change little across several decades of adult life, either because physiological aging has small effects on these variables or because individuals compensate for age-related changes in anatomy and physiology.

The ageing voice and voice therapy in geriatrics

BACKGROUND

Although voice therapy is commonly used as an initial treatment for geriatric dysphonia, its role in the treatment for different organic voice disorder is less defined.

AIMS

The goal of this study was to investigate dysphonia and therapy modalities in this cohort.

METHODS

This study analyzes the demographics, Voice Handicap Index questionnaires, and acoustic voice measures including fundamental frequency, jitter and shimmer by using Kay Elemetrics Computerized Speech Lab Multidimensional voice program which were obtained in all patients before and after treatment. A total of 91 (55 men and 36 women) patients with voice complaints, age ranging from 50 to 91 years (mean 64.11 ± 7.2) diagnosed of any vocal fold pathology were made via strobovideolaryngoscopy.

RESULTS

Vocal nodules in 23.9 % (N = 22) was the most common diagnosis associated with the voice complaints, followed by laryngopharyngeal reflux in 10.8 % (N = 10) and paresis in 9.78 % (N = 9). VHI scores varied greatly, ranging from 4 to 92, with an average score of 42.7. Multidimensional voice program scores showed that fundamental frequency (F0) tends to rise as a function of age in men (mean 283.66 ± 23.7).

DISCUSSION

Fundamental frequency perturbation may be affected in ageing, both genders same values detected. Of these patients, 80 % received hygienic voice therapy and % 20 symptomatic voice therapies. This study identified fundamental frequency alteration for ageing voice and dysphonia in all elderly patients presenting with voice complaints.

CONCLUSION

Additional research is needed to determine normative values for multidimensional voice program scores and other assessments in the elderly population.

Vocal Loading and Environmental Humidity Effects in Older Adults

The goal of this study was to investigate the effects of a vocal loading challenge that combined prolonged speaking, in child-directed voice within a noisy environment, in older adults. An additional goal was to determine whether increased environmental humidity would attenuate the negative effects of this vocal loading challenge.

METHOD

Thirteen healthy subjects (five males and eight females; >65 years) completed a vocal loading challenge. The challenge involved 45 minutes of child-directed speech in the presence of 65 dB multitalker babble background noise. Subjects completed this challenge in both low humidity and moderate humidity in counterbalanced order. Vocal function was assessed before and after the challenge using phonation threshold pressure (PTP), cepstral peak prominence (CPP), low/high spectral ratio (LHR), perceived phonatory effort (PPE), and perceived vocal tiredness.

RESULTS

Negative changes were observed in the aging larynx following the 45-minute vocal loading challenge. Measures of PTP, PPE, and perceived vocal tiredness demonstrated statistically significant loading effects. Increased ambient humidity significantly alleviated the negative changes observed in PPE and perceived vocal tiredness. Increased humidity significantly improved CPP measures both before and after the vocal loading challenge.

CONCLUSIONS

This study furthers our understanding of how older adults respond to a vocal loading challenge of prolonged nonhabitual speech in a noisy environment. Our data suggest that the aging voice is negatively affected by prolonged loud speaking and that humidification may be beneficial in reducing some of these negative effects.

Evolving Spiking Neural Networks for Recognition of Aged Voices

The aging of the voice, known as presbyphonia, is a natural process that can cause great change in vocal quality of the individual. This is a relevant problem to those people who use their voices professionally, and its early identification can help determine a suitable treatment to avoid its progress or even to eliminate the problem. This work focuses on the development of a new model for the identification of aging voices (independently of their chronological age), using as input attributes parameters extracted from the voice and glottal signals. The proposed model, named Quantum binary-real evolving Spiking Neural Network (QbrSNN), is based on spiking neural networks (SNNs), with an unsupervised training algorithm, and a Quantum-Inspired Evolutionary Algorithm that automatically determines the most relevant attributes and the optimal parameters that configure the SNN. The QbrSNN model was evaluated in a database composed of 120 records, containing samples from three groups of speakers. The results obtained indicate that the proposed model provides better accuracy than other approaches, with fewer input attributes.