Treatment Outcomes for Professional Voice Users

Prospective Outcomes of Microlaryngoscopy Versus Office Laser Photoangiolysis for Vocal Fold Polyps

OBJECTIVE(S)

The objective of this study is to compare treatment outcomes for vocal fold polyps (VFPs) between operating room microlaryngoscopy and office-based photoangiolysis with the potassium titanyl phosphate (KTP) laser.

METHODS

Prospective nonrandomized cohort study of patients with VFPs undergoing microlaryngoscopy ("OR group") or KTP laser photoangiolysis ("KTP group"). Voice outcomes (patient-reported outcome measures [Voice Handicap Index-10 (VHI-10) and Singing VHI-10 (SVHI-10)], auditory-perceptual measures [Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)], videostroboscopic characteristics [Voice-Vibratory Assessment of Laryngeal Imaging (VALI)], and acoustic and aerodynamic measures) were performed at baseline and regular intervals after intervention.

RESULTS

Forty-four subjects (17 OR group, 27 KTP group) with VFPs were enrolled. Mean VHI-10 significantly improved from baseline to each follow-up interval in both groups, except for the 1-2-week interval in the OR group. Mean SVHI-10 improved for both groups at some intervals. Growth curve models and time-to-event analyses for patient-reported outcomes did not differ between groups. There were significant improvements in all categories of auditory-perceptual voice quality and some categories of videostroboscopic characteristics in both groups. No significant trends were identified in acoustic and aerodynamic measures. Improvements in most outcomes did not significantly differ between groups or based on polyp size. There were no major complications.

CONCLUSIONS

Significant improvements in patient-reported voice outcomes measures, auditory-perceptual voice evaluation, and videostroboscopic characteristics occur following surgical treatment of vocal fold polyps with either microlaryngoscopy or office-based KTP laser. Long-term voice outcomes do not significantly differ between treatment modalities.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:S1-S20, 2024.

Vocal Fatigue and Its Relationship with Vocal Hygiene and Work-Related Factors in Professional and Nonprofessional Voice Users: A Multiple Linear Regression Model Study

OBJECTIVES

To investigate vocal fatigue severity between professional voice users (PVUs) and nonprofessional voice users (NPVUs), and across different levels of voice users. Also to examine the relationship between vocal hygiene and work-related factors with vocal fatigue.

METHODS

This is a cross-sectional descriptive study. Four hundred one individuals from different professions were included in total. Participants were divided into four levels of voice users by classification of Koufman and Isaacson. The top three levels of voice users further identified as PVU, and level 4 voice users identified as NPVU. An online questionnaire which included vocal hygiene checklist, work-related factors, and Turkish version of vocal fatigue index (VFI) was submitted by the participants.

RESULTS

Vocal fatigue severity of PVUs were found higher than NPVUs in all VFI scores (P < 0.05). Level 2 voice users were found to have more vocal fatigue severity than all other levels of voice users. Call center workers (CCWs) had the highest means of vocal fatigue severity. Based on the multiple linear regression model vocal hygiene and the number of vocal rest breaks were found to have related with vocal fatigue the most (P < 0.05). There was also a relation with some VFI scores (P < 0.05) with voice usage duration at work and vocal rest duration. We found no relationship between working experience and vocal fatigue. The data suggests the relation between vocal fatigue and vocal hygiene, and work-related factors explain a small proportion of the association. However, in CCWs r2 was found 0.44.

CONCLUSIONS

The change in vocal fatigue severity did not match with Koufman and Isaacson's classification of voice users. We suggest that there may be other contributing factors to vocal fatigue than vocal hygiene, vocal rest, and voice usage duration even those factors may differ from profession to profession.

Prevalence of Occupational Voice Disorder Among Teachers of Kathmandu District, Nepal

The objective of this research was to identify the prevalence of voice disorders among teachers in the Kathmandu District of Nepal, with an emphasis on identifying possible risk factors that may be associated with these disorders. A cross-sectional study design was used, with both quantitative and qualitative data-gathering techniques using a mixed-methods approach. Data were collected from 95 non-teachers and 194 participating teachers from different schools in Kathmandu Valley. The analysis covered self-reported voice problem prevalence, job details, and demographic data. We examined the relationships between several variables and voice issues, including gender, class size, length of instruction, and tobacco usage. Findings: Compared with nonteachers (33.7%), teachers had a considerably greater prevalence of voice issues (69.1%). Greater class size and more than ten years of teaching experience were shown to be risk factors, while female instructors reported a greater prevalence of voice issues. Additionally, it was shown that instructors' voice issues are also linked to tobacco usage. The results of this study highlight how critical it is to provide voice therapy to educators employed in the Kathmandu District, particularly those in at-risk categories such as female instructors, more experienced educators, and educators with larger class sizes. The outcomes demonstrated important impacts on teacher well-being, job satisfaction, and academic achievement. More research and intervention strategies are needed to minimize the effects of voice problems and promote a positive teaching and learning environment.

A Systematic Review of Voice-Related Patient-Reported Outcome Measures for Use with Adults

PURPOSE

This paper's purpose is to provide a resource for clinicians and researchers of select voice-related patient-reported outcome measures (PROMs) available in the English language.

METHOD

A systematic search for voice-related PROMs was conducted between September 2020 and July 17, 2021. Databases included APA PsychInfo, Nursing and Allied Health Source, MEDLINE via the EBSCO interface, and Science Direct. Reference lists for PROMs-related articles were mined for reference to PROMs protocols.

RESULTS

Thirty voice-related PROMs were identified and categorized as either developed primarily for use in the clinic (n = 12), developed primarily for use in a specific research study (n = 6), or translated into English for publication (n = 12). Twelve PROMs were summarized: Aging Voice Index, Disease Specific Self-Efficacy in Spasmodic Dysphonia, Evaluation of the Ability to Sing Easily, Evaluating Voice Disability - Quality of Life Questionnaire, Glottal Function Index, Linear Analog Scale of Assessment of Voice Quality, Quality of Life in Recurrent Respiratory Papillomatosis, Speech Disability Questionnaire, Trans Woman Voice Questionnaire, Vocal Cord Dysfunction Questionnaire, Vocal Fatigue Index, and the Vocal Tract Discomfort Scale.

CONCLUSION

The PROMs can be categorized into English-language voice-related PROMs developed primarily for clinical use, English-language PROMs developed primarily for research use, and English-language PROMs translated into English. The extent of reliability and validity testing completed varies in the PROMs developed primarily for clinical use. A PROM's psychometric properties as well as the language in which the PROM was tested, should guide clinicians and researchers as they consider which instrument(s) to use.

Examination of Voice Perception and Voice Fatigue in Call Center Employees

OBJECTIVES

Call center employees are professional voice users and use their voices extensively while performing their professional functions. The purpose of this study is to examine whether a higher occupational voice burden among call center employees affects voice fatigue and perception.

METHODS

A total of 114 adult individuals working in call centers who were not diagnosed with any voice disorder (study group, n = 57) and who were not professional voice users (control group, n = 57) were included in this study. Demographic information, the Voice Fatigue Index (VFI), and the Voice Handicap Index-10 (VHI-10) were administered to all participants. Sub-factors of the VFI, such as tiredness and avoidance of voice use (factor 1), physical discomfort after voice use (factor 2), and improvement in symptoms with rest (factor 3), were also examined.

RESULTS

Each group included 71.9% females (n = 41) and 28.1% men (n = 16). The scores of VFI factor 1, VFI factor 2, 3, VFITOTAL, and VHI-10 in the study group were statistically higher than those in the control group. The average VFI factor 2, VFI factor 3, and VFITOTAL scores of females in the study group were considerably greater than the average scores of men. The VFI and its sub-factors, as well as the VHI-10 scores of the study group whose daily working hours were 8 hours or less and 8 hours or more, did not vary significantly.

CONCLUSIONS

It has been observed that call center employees experience voice fatigue, which has an impact on voice perception in their professional functions. As a result of their heavy vocal load, contact center workers may be at a higher risk of acquiring voice disorders. Voice fatigue must be taken into account in the assessment and intervention of contact center employees by professionals and therapists working in the field of voice.

Role of Voice Handicap Index in Evaluation of Patients with Moderate to Severe Bilateral Sensorineural Hearing Loss

Background

Our ability to hear and speak enables us to communicate with others, forming an integral part of our emotional and social well-being. Vocal problems in hearing-impaired patients have yet to be assessed in terms of subjective level of disability they cause. Present study aims to assess the different Voice Handicap Index (VHI) scores among patients with moderate to severe sensorineural hearing loss and compare them to those with normal hearing.

Materials and Methods

In this prospective case control study(n = 150), study group A (n = 100) consisted of subjects with bilateral moderate to profound hearing loss on Pure tone audiometry and control group B (n = 50) with normal hearing. Both groups were asked to fill out VHI form after a normal videostroboscopic assessment.

Results

Mean VHI score in group A was 57.5 ± 12.48 and 6.0 ± 3.24 in group B, difference being statistically significant. A strong positive correlation was found between severity of hearing loss and VHI total score. The difference between both groups was also statistically significant for each of the three subscales of VHI.

Conclusion

We infer that subjects with moderate and higher bilateral sensorineural hearing loss hearing have statistically significant higher VHI scores as compared to those with normal hearing. It was observed that perception of voice handicap increased with the severity of hearing loss. These findings emphasize the need for multilateral assessment and treatment of voice disorders in subjects with hearing loss.

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.

Prevalence of Laryngopharyngeal Reflux Symptoms, Dysphonia, and Vocal Tract Discomfort in Amateur Choir Singers

INTRODUCTION

Vocal tract discomfort (VTD), dysphonia, and laryngopharyngeal reflux (LPR) symptoms are complaints frequently reported by amateur singers. There are two aims of this study. The first is to evaluate the prevalence of these symptoms using validated questionnaires. The second is to correlate singing-related variables with the questionnaire responses.

METHODS

A total of 392 amateur choir singers (ACS) and 514 control subjects completed an online survey divided into four parts: (1) clinical and demographic characteristics, (2) training in singing and singing experience, (3) history of gastroesophageal reflux disease and LPR symptoms, (4) validated questionnaires. Specifically, the reflux symptom index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) were included to analyze the actual burden related to LPR symptoms, VTD, and dysphonia.

RESULTS

ACS demonstrated a healthier lifestyle and a lower prevalence of gastroesophageal reflux disease symptoms in comparison with control subjects. ACS scored significantly higher in VTDS and VoiSS than control subjects, while no differences in the RSI results were found. Significant correlations among the questionnaires' results were demonstrated. Occasional professional singing was the variable influencing VTDS and VoiSS results the most.

CONCLUSION

ACS do not evidently manifest a higher impairment connected to LPR (RSI score), while they do report higher levels of voice (VoiSS score) and vocal tract (VTDS score) impairments, in comparison with control subjects. The relevant correlations among the PRO measures suggest that LPR symptoms, VTD, and dysphonia are related to each other. Given the relevant repercussion on the severity of VTD and dysphonia, providers should specifically ask about occasional professional singing when treating amateur singers.

It Sounds like It Feels: Preliminary Exploration of an Aeroacoustic Diagnostic Protocol for Singers

To date, no established protocol exists for measuring functional voice changes in singers with subclinical singing-voice complaints. Hence, these may go undiagnosed until they progress into greater severity. This exploratory study sought to (1) determine which scale items in the self-perceptual Evaluation of Ability to Sing Easily (EASE) are associated with instrumental voice measures, and (2) construct as proof-of-concept an instrumental index related to singers' perceptions of their vocal function and health status. Eighteen classical singers were acoustically recorded in a controlled environment singing an /a/ vowel using soft phonation. Aerodynamic data were collected during a softly sung /papapapapapapa/ task with the KayPENTAX Phonatory Aerodynamic System. Using multi and univariate linear regression techniques, CPPS, vibrato jitter, vibrato shimmer, and an efficiency ratio (SPL/PSub) were included in a significant model (p < 0.001) explaining 62.4% of variance in participants' composite scores of three scale items related to vocal fatigue. The instrumental index showed a significant association (p = 0.001) with the EASE vocal fatigue subscale overall. Findings illustrate that an aeroacoustic instrumental index may be useful for monitoring functional changes in the singing voice as part of a multidimensional diagnostic approach to preventative and rehabilitative voice healthcare for professional singing-voice users.

Vocal Fold Polyps: A Scoping Review

OBJECTIVE

This review aims to summarize the current understanding of vocal fold polyp etiology, pathophysiology, and prognosis, as well as recent developments in management.

STUDY DESIGN

Scoping literature review.

REVIEW METHODS

OVID Medline, PubMed, Google Scholar, Conference Papers Index, and Cochrane Library were searched for publications within the last 5 years using terms including "vocal," "cord," "fold," and "polyp." All abstracts were screened. Relevant studies pertaining to the etiology, pathophysiology, diagnosis, management, and prognosis of vocal fold polyps (VFPs) were included for review.

RESULTS

Eight-hundred and sixty-five citations resulted from database review. Seven-hundred and thirty citations remained after the exclusion of duplicates. One hundred and ninety-three papers underwent abstract review, with 73 citations undergoing full-text review. Fifty-nine papers were included in the review.

CONCLUSIONS

VFPs are one of the most common subtypes of benign vocal fold lesions. Phonotrauma contributes significantly to the development of these lesions, with laryngopharyngeal reflux and smoking also contributing. Correct diagnosis relies on a careful history, stroboscopy, response to voice therapy, and, in some cases, intraoperative findings. Phonosurgery is a definitive means of treatment, though more recently, in-office procedures have demonstrated efficacy and are potentially less costly and less invasive treatment options. Treatment modalities can be tailored based on the type and size of the lesion, the patient's vocal needs, medical comorbidities, and initial response to voice therapy. Voice specialists can anticipate greater emphasis placed on minimally invasive office-based procedures for the management of vocal pathology.

Self-reported Vocal Demands, Perceptions, and Knowledge of Occupational Voice Users in South Africa

OBJECTIVES

The study aimed to describe daily vocal demands, perceptions and knowledge as reported by occupational voice users.

STUDY DESIGN

A descriptive, cross-sectional research design was employed.

METHODS

A survey on vocal demands, perceptions and knowledge was distributed to 102 occupational voice users via a snowball sampling technique.

RESULTS

Slightly more than half of the participants (55%) reported using their voice for work 36.5 hours a week on average (SD = 15.5, range: 33-40). Participants reported that, on average, their daily voice use is 6.3 hours (SD = 2.7) for work and the majority (81%) reported a decrease in voice quality after work; Three-quarters (75%) also reported vocal fatigue at the end of day. Approximately one-third (33%) reported being exposed to environments where they are expected to shout, scream or cheer loudly. More than half of the participants (61%) reported that they have previously received vocal health education but 40% reported that they felt this training was insufficient. High vocal demands are significantly correlated to an increase in perceived vocal handicap rs = 0.242; (P = 0.018), tiredness of voice rs = 0.270; (P = 0.008), physical discomfort rs = 0.217; (P = 0.038) as well as how occupational voice users experience improvement of symptoms with rest rs = -0.356 (P < 0.001). Other risk factors highlighted by occupational voice users are the ingestion of liquid caffeine, alcohol, and carbonated drinks, smoking or the presence of chronic cough, chronic laryngitis, and gastroesophageal reflux disease.

CONCLUSIONS

Occupational voice users are subjected to high daily vocal demands that can be seen to be linked to vocal fatigue, changes in voice quality and vocal symptoms experienced. It is essential that occupational voice users as well as treating clinicians are aware of certain significant predictors of both vocal handicap and vocal fatigue. These findings provide insights for developing strategies for training and cultivating vocal health consciousness and preventive voice care initiatives that focus on occupational voice users in South Africa.

The Effect of Vocal Hygiene Education Programs on Voice Quality in Professional Voice Users: A Systematic Review

PURPOSE

This study aimed to critically appraise recent peer-reviewed scientific evidence on the effect of vocal hygiene education on voice quality and function directly and indirectly measured by auditory-perceptual, acoustic, and self-report measures in professional voice users.

METHOD

A systematic review was conducted utilizing the Preferred Reporting Items for Systematic review and Meta-Analyses Protocols (PRISMA-P) guidelines. Five databases were searched using the keywords "vocal hygiene," "vocal hygiene education," "vocal health," "vocal quality," and "voice quality" with Boolean phrases "AND" and "OR." Twenty-three studies that met the eligibility criteria were included. Scoring was based on the American Speech-Language-Hearing Association's levels of evidence and quality indicators, as well as the Newcastle-Ottawa Scale for assessing the risk of bias.

RESULTS

Four studies (17%) linked low awareness of vocal hygiene or insufficient vocal hygiene education to self-reported acute and chronic voice symptoms, as well as a greater perception of voice handicap among professional voice users. Numerous studies (n = 10; 43%) showed that adequate voice training or vocal hygiene education was linked to positive voice outcomes. Six studies (6.26%), however, demonstrated that vocal hygiene education is more effective when combined with direct voice therapy. When vocal hygiene education is presented in isolation, the superiority of a direct voice therapy approach, with or without vocal hygiene education, is seen over a vocal hygiene education program alone (indirect treatment).

CONCLUSIONS

Recent literature demonstrates mixed results obtained through auditory-perceptual, acoustic, and self-rating measures on the effects of vocal hygiene instruction on vocal quality and function in professional voice users. However, the compelling positive outcomes presented do warrant implementation of vocal hygiene education programs in combination with direct voice therapy for professional voice users.

Occupational diseases among call center operators needing vocal rehabilitation

BACKGROUND

Work related diseases (WRDs) and occupational diseases (ODs) greatly affect call center operators (CCOs) who experience demanding work expectations and adverse working conditions in their workplace. The aim of this study was to evaluate the sociodemographic and job characteristics of CCOs diagnosed with OD, and to describe the changes in employment status after diagnosis.

METHODS

This descriptive study is based on the electronic data records of Istanbul Occupational Diseases Hospital available from February 2007 to March 2018.

RESULTS

According to the health board reports, 122 of the 173 (70.5%) CCOs had a confirmed OD diagnosis, 85.2% were females and the mean age was 27.5 years. Vocal cord disorders were the most frequent ODs (64.8%), followed by hearing loss (12.5%), dysphonia (10.2%) and temporomandibular disorders (4.7%). Vocal cord nodules (VCN) were found to be more frequent among females compared to males (92.9% vs 62.4%, p<0.001). Although not statistically significant, the frequency of VCN was also higher in subjects working overtime (14.6% vs 6.3%), having gastroesophageal reflux disease (82.3% vs 73.9%) or thyroid nodules (100% vs 73.7%) and being current smokers (41.7% vs 13.3%). Following the OD diagnosis, 43.8% of the cases were dismissed, 18.7% quit their job, and 9.4% still held the same job position. Only 28.1% changed unit within the workplace.

CONCLUSION

Including the CCOs who were diagnosed with an OD at a very young age and at an early stage of their working life into vocational rehabilitation programs and employing them under appropriate conditions is essential to proper health and safety protocol.

Self-rated vocal complaints relationship to Vocal Tract Discomfort and Singers Voice Handicap Index in Iranian religious singers

PURPOSE

The religious singing is a popular group of professional voice users in Iran which is performed in a sadness form to persuade the audiences to cry and think to holy persons. This style has its own unique vocal demands and abuses. Therefore, the present study, for the first time, aimed to investigate the prevalence of self-reported vocal complaints, vocal discomfort symptoms, and its effects on the vocal-related life of the Iranian religious singers.

METHODS

In a cross-sectional study, 62 religious singers (28 women, 34 men) completed Singers Voice Handicap Index (SVHI), Vocal Tract Discomfort (VTD), and also a non-standard self-rated vocal complaint question. Spearman correlation test was applied to analyze correlations. Furthermore, 39 non-singers (18 women, 21 men) as a control group participated in this study.

RESULTS

The religious singer's mean score of the SVHI test was 34.84 (SD = 24.89). According to the self-rated vocal complaint question, almost 80% of the participants reported mild to the severe vocal complaints that was significantly higher than control group which was about 10%. The self-rated complaints indicated a significant positive correlation with the SVHI and the VTD reported by singers (p ≤ 0.001). The mean scores of the VTD symptoms in singers were significantly greater than control group. There was also a significant positive correlation between the two VTD and SVHI tests (p ≤ 0.001).

CONCLUSION

Religious singers are at a great risk of developing voice problems. Therefore, their vocal demands and requirements need to be followed precisely. The SVHI and VTD tests should also be considered as two efficient tools for religious singers.

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial

OBJECTIVES

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.

STUDY DESIGN

Prospective, randomized, controlled, single-blinded, non-inferiority.

MATERIALS AND METHODS

Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.

RESULTS

Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H₂O, PhoRTE + EMST M = 32.63 cm H₂O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement.

CONCLUSION

This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

Data Collection Methods for the Voice Range Profile: A Systematic Review

Purpose To assess data collection variability in the voice range profile (VRP) across clinicians and researchers, a systematic review was conducted to evaluate the extent of variability of specific data collection points that affect the determination of frequency range and sound level and determine next steps in standardization of a VRP protocol. Method A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist. Full-text journal articles were identified through PubMed, Web of Science, Psych Info, ProQuest Dissertations and Theses Global, Google Scholar, and hand searching of journals. Results A total of 1,134 articles were retrieved from the search; of these, 463 were duplicates. Titles and abstracts of 671 articles were screened, with 202 selected for full-text review. Fifty-four articles were considered eligible for inclusion. The information extracted from these articles revealed the methodology used to derive the VRP was extremely variable across the data points selected. Additionally, there were eight common acoustic measures used for statistical analysis described in included studies that were added as a data point. Conclusions The data collection methods for the VRP varied considerably. Standardization of procedures was recommended for clinicians and researchers.

Respiratory Muscle Strength Training to Improve Vocal Function in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

The effects of presbyphonia are compounded by the decline in respiratory function that occurs with age. Commonly recommended exercises to optimize the use of respiratory muscles during speech, such as diaphragmatic breathing, are unlikely to be intensive enough to induce respiratory changes and impact vocal function. The objective of this study was to assess the effect of adding a targeted intervention, respiratory muscle strength training, to voice exercises in a sample of patients with presbyphonia.

METHODS/DESIGN

In this prospective, randomized-controlled trial, 12 participants received either (1) vocal function exercises (VFE), (2) VFE combined with inspiratory muscle strength training (IMST), or (3) VFE combined with expiratory muscle strength training (EMST). Data collected prior to and following 4 weekly intervention sessions included respiratory measures (pulmonary function and respiratory muscle strength) and voice measures (videostroboscopy, acoustic, auditory-perceptual, aerodynamic, and self-assessment measures).

RESULTS

Participants who received IMST improved their voice quality during connected speech (smoothed cepstral peak prominence and ratings of overall voice quality) and their scores on the three self-assessment questionnaires with large to very large within-group effect sizes (|d| = 0.82-1.61). In addition, participants in the IMST group reduced their subglottal pressure with a large effect size (d = -0.92). Participants who received EMST improved their maximum expiratory strength and smoothed cepstral peak prominence with large effect sizes (d = 0.80 and 0.99, respectively) but had limited improvements in other outcomes. Participants who received only VFE decreased their amount of vocal fold bowing, improved their voice quality on a sustained vowel (amplitude perturbation quotient), and improved their Glottal Function Index score with large effect sizes (|d| = 0.74-1.00).

CONCLUSION

Preliminary data indicate that adding IMST to voice exercises may lead to the greatest benefits in patients with presbyphonia by promoting improved subglottal pressure control as well as increasing air available for phonation, resulting in improved self-assessment outcomes.

Effect of Respiratory Muscle Training on Pitch Range and Sound Duration in Brass Instrument Players and Singers

OBJECTIVE

Effective use of respiratory organs is important for musicians. Therefore, the impact of Respiratory Muscle Training (RMT) on phonation is open to research. The aim of this study was to investigate the measurable effects of RMT on blowing in brass instrumental and on voice performance in singers.

METHODS

Thirty musicians were recruited and separated into a four groups. The brass instrumental and singers groups were further subdivided into control and RMT groups for a 4 week RMT intervention giving a total four groups: singers experimental (SE; n:10), singers control (SC; n:10), brass instrument players experimental (BIPE; n:5), and BIPC (n:5). The groups selected from the musicians of Samsun State Opera and Ballet Directorate and Samsun Metropolitan Municipality Band Team participated in the study.

RESULTS

After 4 weeks of RMT application in the study groups, significant increase in all parameters except Forced vital capacity/Forced expiratory volume in 1 second was observed in the values of pulmonary function tests and respiratory muscle strength in subjects with SE and BIPE (P < 0.05). The most significant results of this study are that in addition to changes in the duration of phonation (SE 36%), high-pitch (SE 79%, BIPE 27%) and low-pitch sounds (BIPE 61% and SE 42%), the SE (15%) and BIPE (3%) groups reached higher pitches in the high-pitch notes.

CONCLUSIONS

It was determined that performance of the highest and lowest pitch sounds within a vocal register in a single breath and phonation times can be improved by RMT.

Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria - a prospective randomized trial

OBJECTIVE

To examine the efficacy of combined inspiratory and expiratory respiratory muscle training (RMT) with respect to the swallowing function, pulmonary function, functional performance, and dysarthria in patients with stroke.

DESIGN

Prospective, randomized controlled trial.

SETTING

Tertiary hospital.

PARTICIPANTS

The trial included 21 subjects (12 men, 9 women) aged 35 to 80 years presenting with 6 months history of unilateral stroke, respiratory muscle weakness (≥70% predicted maximal inspiratory pressure (MIP) and/or ≤70% maximal expiratory pressure (MEP)), dysphagia, or dysarthria. These subjects were randomly assigned to the control (n = 10, rehabilitation) and experimental (n = 11, rehabilitation with RMT) groups.

INTERVENTION

Inspiratory RMT starting from 30% to 60% of MIP and expiratory RMT starting from 15% to 75% of MEP for 5 days/week for 6 weeks.

MAIN OUTCOME MEASURES

MIP, MEP, pulmonary function, peak cough flow, perception of dyspnea, Fatigue Assessment Scale, Modified Rankin Scale, Brunnstrom stage, Barthel index, Functional Oral Intake Scale (FOIS), and parameters of voice analysis.

RESULTS

Significant differences were observed between both groups in terms of MIP, forced vital capacity (FVC), and forced expiratory volume per second (FEV1) of the percentage predicted. Significant difference was found with respect to the change in fatigue, shimmer percent, amplitude perturbation quotient, and voice turbulence index (VTI) according to the acoustic analysis in the RMT group. The FEV1/FVC ratio was negatively correlated with jitter percent, relative average perturbation, pitch perturbation quotient, and VTI; the maximum mid-expiratory flow (MMEF) and MMEF% were also negatively correlated with VTI. Significant differences among participants of the same group were observed while comparing the Brunnstrom stage before and after training of the affected limbs and the Barthel scale and FOIS scores in both the groups.

CONCLUSIONS

Altogether, 6-week combined inspiratory and expiratory RMT is feasible as adjuvant therapy for stroke patients to improve fatigue level, respiratory muscle strength, lung volume, respiratory flow, and dysarthria.Clinical trial registration number (Clinical Trial Identifier): NCT03491111.

Toward a Consensus Description of Vocal Effort, Vocal Load, Vocal Loading, and Vocal Fatigue

Purpose The purpose of this document is threefold: (a) review the uses of the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" (as found in the literature) in order to track the occurrence and the related evolution of research; (b) present a "linguistically modeled" definition of the same from the review of literature on the terms; and (c) propose conceptualized definitions of the concepts. Method A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scientific Electronic Library Online. Four terms ("vocal fatigue," "vocal effort," "vocal load," and "vocal loading"), as well as possible variants, were included in the search, and their usages were compiled into conceptual definitions. Finally, a focus group of eight experts in the field (current authors) worked together to make conceptual connections and proposed consensus definitions. Results The occurrence and frequency of "vocal load," "vocal loading," "vocal effort," and "vocal fatigue" in the literature are presented, and summary definitions are developed. The results indicate that these terms appear to be often interchanged with blurred distinctions. Therefore, the focus group proposes the use of two new terms, "vocal demand" and "vocal demand response," in place of the terms "vocal load" and "vocal loading." We also propose standardized definitions for all four concepts. Conclusion Through a comprehensive literature search, the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" were explored, new terms were proposed, and standardized definitions were presented. Future work should refine these proposed definitions as research continues to address vocal health concerns.

The Effect of Superficial Hydration, With or Without Systemic Hydration, on Voice Quality in Future Female Professional Singers

OBJECTIVE

The aim of this study was to describe the effect of superficial hydration, with or without systemic hydration, on voice quality in future female professional singers by assessing acoustic and perceptual parameters of voice production as well as symptoms of vocal fatigue.

STUDY DESIGN

This is an experimental design study.

METHODS

A study was performed on a sample of 24 female voice majors to ascertain the effect of superficial hydration, with or without systemic hydration, on acoustic parameters and perception of vocal fatigue. The study replicated a prior study by van Wyk et al (2016) with some modifications; we looked at the effect of both systemic and superficial hydration independently and together on voice quality and vocal fatigue. Acoustic measurements including GRBASI, jitter, shimmer, F₀ MPT, frequency min and max, intensity min and max, and dysphonia severity index were measured along with perceived vocal fatigue using the Vocal Fatigue Index.

RESULTS

A statistically significant increase in MPT values were obtained when comparing pre- and post-test results of the hypo hydrated (P = 0.015) and superficial hydration condition (P = 0.004). A significant increase in frequency min (Hz) within the hypo hydrated condition was also observed (P = 0.019). A significant increase was observed in the intensity min (dB) (P = 0.010) and F₀ min (Hz) (P = 0.002) within the combined hydration condition. Also, when superficial hydration was applied, mean shimmer % (P = 0.016), MPT (sec) (P = 0.003) and dysphonia severity index (P = 0.020) scores increased significantly in a between-group, post-test comparison. A significant reduction in mean intensity max (dB) (P = 0.049) and intensity min (dB) (P = 0.018) was also observed.

CONCLUSIONS

This study demonstrates that the use of superficial hydration results in positive outcomes of perceptual parameters of voice quality and symptoms of vocal fatigue in future female professional singers. However, mixed results were observed regarding the acoustic parameters of voice. The superficial hydration data is compelling enough to warrant implementing in a vocal hygiene protocol for singers.

The Therapeutic Effects of Straw Phonation on Vocal Fatigue

OBJECTIVES

Straw phonation has been investigated for its vocal warm-up effects on healthy populations and therapeutic effects on voice patients. The purpose of this article was to determine whether it is beneficial for vocal fatigue.

STUDY DESIGN

Prospective cohort study METHODS: Twenty-five healthy participants were recruited into 1-hour vocal loading tasks followed by 10-minute vocal rest or straw phonation on 2 different days. Various parameters including phonation threshold pressure (PTP), mean airflow, closed quotient (CQ), current speaking effort level (EFFT), and laryngeal discomfort (DISC) were acquired at baseline, after vocal load, and after the intervention.

RESULTS

Increased PTP, EFFT, and DISC were observed after vocal load. Decreased PTP, EFFT, and DISC were then acquired after both vocal rest or straw phonation. More significant improvements were obtained in straw phonation when compared with vocal rest. Additionally, significantly increased mean flow and decreased CQ were obtained after straw phonation when compared to vocal rest.

CONCLUSIONS

Straw phonation has the potential to adjust aerodynamics within the vocal tract leading to improved vocal efficiency, optimized vibration mode, and attenuated vocal fatigue. This study provided a promising treatment for vocal fatigue that could have wide clinical relevance to voice users with high voice demands.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E674-E679, 2020.

Effects of Humidification of the Vocal Tract and Respiratory Muscle Training in Women With Voice Symptoms-A Pilot Study

OBJECTIVE

The aim of this study was to determine the efficacy of a 4-week breathing exercise intervention in participants with voice symptoms.

METHODS

Six nonsmoking women (mean age 49) experiencing voice symptoms used a novel device WellO₂ for respiratory exercises that provides counter pressure during both inspiration and expiration and warms and humidifies the breathing air. Speech samples were acoustically (Acoustic Voice Quality Index) and perceptually (grade, roughness, breathiness, asthenia, and strain scale) analyzed, and perceived voice symptoms and self-reported effort in breathing and phonation were obtained. Respiratory measurements included breathing frequency and pattern, peak expiratory flow, forced vital capacity, and forced expiratory volume in 1 minute.

RESULTS

The total scores of Acoustic Voice Quality Index and some of its subcomponents (shimmer and harmonic-to-noise ratio), and the grade, roughness, and strain of the GRBAS scale indicated significantly improved voice quality. However, neither the nature or frequency of the experienced voice symptoms nor the perceived phonatory effort changed as the function of intervention. According to the participants, their breathing was significantly less effortful after the intervention, although no significant changes were observed in the objective respiratory measurements with a spirometer.

CONCLUSION

Training with the WellO₂ device has the potential to improve voice quality. The combination of inspiratory and expiratory training and warmed, humidified air is a multifaceted entity influencing several parts in the physiology of voice production. The effects of using WellO₂ need to be confirmed by further studies with a larger number of participants.

Voice Quality and Auditory Processing in Subjects with and Without Musical Experience

INTRODUCTION

The relationship between voice and auditory processing is complex and has aroused increasing scientific interest in the last decades. Little is known about the relationship between voice quality and auditory processing in individuals with and without musical experience.

OBJECTIVES

To assess voice quality and auditory processing in subjects with and without musical experience.

METHODS

Total 120 individuals were split into three groups: GS = singers (N = 47), GI = instrumentalists (N = 43), and NM = nonmusicians (N = 30); group GS was subdivided into GS = 20 singers only and GSI = 27 singers and instrumentalists at the same time. Subjects were undertaken vocal assessment by means of Perceptual Assessment of voice recording followed by self-assessment of a potential voice problem using the Brazilian validated version of the Voice Symptom Scale (VoiSS) (Escala de Sintomas Vocais - ESV). The central auditory processing was carried out following such temporal processing tests: Frequency Pattern Test (FPT), Random Gap Detection Test (RGDT), and auditory-perceptual analysis of distorted speech as indicated: Synthetic Sentence Identification (SSI) test, with Ipsilateral Competing Message.

RESULTS

GSI reported a higher number of voice symptoms compared to the other groups for the VoiSS. Throughout the groups, most individuals did not present voice disorders and, when presented, were mild. Subgroup GSI showed the best auditory abilities of temporal ordering for the FPT-Humming and FPT-Verbal, whereas NM had the worst performance. Negligible correlation strength alone was found between the different central auditory processing tests, the overall degree of vocal deviation in the auditory-perceptual analysis of voice quality, and the total score of the Voice Symptom Scale protocol.

CONCLUSION

The voice quality of musicians and nonmusicians was correlated with their auditory processing; although with negligible strength. It was verified that singers-instrumentalist reported more voice symptoms compared to the other groups. Despite the large variation throughout the groups concerning auditory processing, musicians, especially singers-instrumentalists, have shown better auditory abilities of temporal ordering, suggesting that musical training and experience may account for such performance.

The Effects of Respiratory Muscle Training on Phonatory Measures in Individuals with Parkinson's Disease

INTRODUCTION

In individuals with Parkinson's disease (PD), respiratory muscle weakness and rigidity, bradykinesia of abdominal muscles and stiffness of the chest wall, affect the respiratory component of voice intensity due to reduced pulmonary capacity and airflow needed to vibrate the vocal folds. It may be possible to improve voice production by strengthening respiratory muscles. The purpose of this study was to evaluate the effects of inspiratory and expiratory muscle training on voice production outcomes in individuals with PD.

METHOD

Thirty-one participants with PD were randomly allocated to three study groups (control group n = 10, inspiratory training group, n = 11, and expiratory training group, n = 11). The inspiratory and expiratory group performed a home-based inspiratory and expiratory muscle training program, respectively (five sets of five repetitions). Both groups trained six times a week for 2 months using a progressively increased resistance. The control group performed expiratory muscle training using the same protocol and a fixed resistance. Phonatory measures, maximum inspiratory/expiratory pressure, and spirometric indexes were assessed before and at 2 months after training.

RESULTS

Differences in peak subglottic pressure were moderate (d = 0.59) between expiratory and inspiratory groups, large between inspiratory and control groups (d = 1.32), and large between expiratory and control groups (d = 1.96). Differences in maximum phonation time were large (d = 1.26) between inspiratory and control groups, moderate (negative) between expiratory and inspiratory groups (d = -0.60), and moderate between expiratory and control groups (d = 0.72). Differences in peak sound pressure level were large (d = 1.27) between inspiratory and control groups, trivial between expiratory and inspiratory groups (d = -0.18), and large between expiratory and control groups (d = 1.10).

CONCLUSIONS

Inspiratory muscle training is effective in improving maximum phonation time, and expiratory muscle training is more effective for improving peak subglottic pressure, and peak sound pressure level in individuals with PD.

The usefulness of the acoustic and the capacity analysis of singing voice

Abstract Introduction: The aim of the study was to assess the acoustic and capacity analysis of singing voice using DiagnoScope Specialist software. Material and methods: The study was conducted in 120 adults subjects, including 74 women and 46 men aged 21-5, were divided into 3 groups: I -40 subjects (treatment group) – professional vocalists, II- 40 subjects (treatment group) – semiprofessional vocalists, III- 40 subjects (control group) – students of The Military Medical Faculty at Medical University of Lodz – nonsingers. The research methodology included: primary medical history, physical examination (otolaryngological), vdeolaryngoscopic examination, the GRBAS scale for subjective voice evaluation, diagnostic voice acoustic and capacity analysis using DiagnoScope Specialist software, survey on lifestyle patterns which may affect voice quality. Results: Average value of the fundamental frequency F0 was the highest in professional vocalists’ group was 316,46 Hz in women and 165,09 Hz in men, in semiprofessional vocalists’ group was accordingly 260,50 Hz and 149,26 Hz, in nonsingers’ group was accordingly 261,23 Hz and 159, 27 Hz. Average value of Jitter parameter in professional vocalists’ group was 0,30% in women and 0,54% in men, in semiprofessional vocalists’ group was accordingly 0,31% and 0,57%, in nonsingers’ group was 0,31% and 0,56%. Average value of Shimmer parameter in professional vocalists’ group was 3,27% in women and 3,75% in men, in semiprofessional vocalists’ group was accordingly 3,46% and 3,77%, in nonsingers’ group was 4,33% and 4,39%. Average value of NHR index in professional vocalists’ group was 3,28% in women and 6,00% in men, in semiprofessional vocalists’ group was accordingly 3,23% and 6,72%, in nonsingers’ group was 3,89% and 6,13%. Conclusions: Values of the parameters which are measuring the character of the voice, relative period-to-period fundamental frequency perturbations, relative period-to-period amplitude perturbation and level of buzzing together with other methods have diagnostic and predictive value in early detection of voice disorders. Capacity analysis in singing voice showed very low values of the following parameters: phonation time, true phonation time, no phonation coefficient, voice efficiency coefficient and voice capacity. Key words: The acoustic and capacity analysis, singing voice

Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: A systematic review

PURPOSE

To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in adults with acquired motor based communication and/or swallowing difficulties of any aetiology.

METHOD

A systematic review was conducted. Six databases (CINAHL, MEDLINE, EMBASE, SPEECHBYTE, AMED and PUBMED) were searched from inception until end of May 2016. Randomised and non-randomised controlled studies and pre-test/post-test studies published in English that investigated the effects of expiratory muscle strength training were included. Study quality was assessed using the PEDro scale. Data were analysed descriptively and effect sizes and associated 95% confidence intervals were calculated.

RESULT

Seven articles reporting data from five studies were included. Preliminary data suggests expiratory muscle strength training improved airway safety during swallowing in people with dysphagia and increased the strength of the expiratory muscles in all patient groups. There was little evidence to suggest changes in communication outcomes after expiratory muscle strength training.

CONCLUSION

Speech-language pathologists might consider using expiratory muscle strength training to improve airway safety in adults with swallowing disorders.

Effect of expiratory muscle strength training intervention on the maximum expiratory pressure and quality of life of patients with Parkinson disease

PURPOSE

The purpose of this study was to investigate the effects of 4-weeks expiratory muscle strength training (EMST) on the maximum expiratory pressure (PEmax) and quality of life (QoL) in patients with Parkinson disease (PD).

METHODS

Thirteen outpatients diagnosed with PD participated in this study, and were assigned into either a 5DE training group (5DE group; n = 4; 75% PEmax for 5-d/wk), 3DE training group (3DE group; n = 5; 75% PEmax for 3-d/wk) and control group (3DC group; n = 4; 0% PEmax for 3-d/wk) by matching their Hoehn and Yahr scale, genders, and age. The PEmax and Parkinson disease questionnaire-39 item (PDQ-39) were evaluated pre- and post-intervention.

RESULTS

The posttest PEmax of the 5DE was significantly higher than that of the 3DC (P < 0.05). Moreover, 5DE and 3DE but not 3DC significantly increased PEmax after training. There were no differences in the overall quality of life in PD patients measured by PDQ-39 among three groups, but the 5DE group significantly improved the mobility constructs of PDQ-39 compared with 3DC (P < 0.05).

CONCLUSION

Both 5 d/wk and 3 d/wk of EMST effectively enhance respiratory muscle strength and improve mobility construct measured by PDQ-39 in patients with PD.

Magnitude of Neck-Surface Vibration as an Estimate of Subglottal Pressure During Modulations of Vocal Effort and Intensity in Healthy Speakers

PURPOSE

This study examined the relationship between the magnitude of neck-surface vibration (NSVMag; transduced with an accelerometer) and intraoral estimates of subglottal pressure (P'sg) during variations in vocal effort at 3 intensity levels.

METHOD

Twelve vocally healthy adults produced strings of /pɑ/ syllables in 3 vocal intensity conditions, while increasing vocal effort during each condition. Measures were made of P'sg (estimated during stop-consonant closure), NSVMag (measured during the following vowel), sound pressure level, and respiratory kinematics. Mixed linear regression was used to analyze the relationship between NSVMag and P'sg with respect to total lung volume excursion, levels of lung volume initiation and termination, airflow, laryngeal resistance, and vocal efficiency across intensity conditions.

RESULTS

NSVMag was significantly related to P'sg (p < .001), and there was a significant, although small, interaction between NSVMag and intensity condition. Total lung excursion was the only additional variable contributing to predicting the NSVMag-P'sg relationship.

CONCLUSIONS

NSVMag closely reflects P'sg during variations of vocal effort; however, the relationship changes across different intensities in some individuals. Future research should explore additional NSV-based measures (e.g., glottal airflow features) to improve estimation accuracy during voice production.

The Measurement and Effects of Vocal Load in Singing Performance. How Much Singing Can a Singer Sing if a Singer Can Sing Songs?

Singing as both an art form and physical activity demands a level of health and skill fitness to meet performance demands. The determination of performance fitness relies on performers' self-evaluations of their vocal capacity for performance, based, amongst other factors, on the current vocal status and ability to manage the associated vocal load. Measurement of load and the impact on the vocal mechanism is complex and influenced by many intrinsic and extrinsic factors. Researchers have attempted to quantify vocal load effects by measuring physical impact stress on the vocal folds, self-reported perceived exertion, and/or clinical evaluation of physiologic, acoustic, or perceptual changes. Most studies have been conducted in laboratory rather than in performance contexts and studies on singers are substantially lacking. Heavy vocal load has been causally associated with the development of voice disorders, although the exact relationship and thresholds for acquiring laryngeal pathology require further elucidation, and little is also known about the development of voice disorders among singers. Further understanding of the short-term and cumulative effect on the vocal folds of performing as a singer and the nature and prevalence of voice problems among singers is crucial to the determination of appropriate prevention and therapeutic management.

The Vocal Tract Discomfort Scale: Validity and Reliability of the Persian Version in the Assessment of Patients With Muscle Tension Dysphonia

OBJECTIVE

To cross-culturally adapt of Persian Vocal Tract Discomfort (VTDp) scale and evaluate its validity and reliability in the assessment of patients with muscle tension dysphonia (MTD).

STUDY DESIGN

A cross-sectional and prospective cohort design was used to psychometrically test the VTDp.

METHODS

The VTD scale was cross-culturally adapted into Persian language following standard forward-backward translations. The VTDp scale was administrated to 100 patients with MTD (54 men and 46 women; mean age: 38.05 ± 10.02 years) and 50 healthy volunteers (26 men and 24 women; mean age: 36.50 ± 12.27 years). Forty-five patients with MTD completed the VTDp 7 days later for test-retest reliability. Patients also completed the Persian Voice Handicap Index (VHIp) to assess construct validity.

RESULTS

The results of discriminative validity demonstrated that the VTDp was able to discriminate between patients with MTD and healthy participants. The internal consistency was confirmed with Cronbach α .77 and 0.73 for VTDp frequency and severity subscales, respectively. The test-retest reliability was excellent with an intraclass correlation coefficient (ICC_agreement) of 0.93 for the frequency subscale and 0.91 for the severity subscale. Construct validity of the VTDp was shown with significant correlations between the VTDp frequency and severity subscales and the VHIp total scores (0.36 and 0.37, respectively). The standard error of measurement and smallest detectable change values for VTDp frequency (2.11 and 5.85, respectively) and severity (2.25 and 6.23, respectively) were acceptable. The Bland-Altman analysis for assessing the agreement between test and retest measurements showed no systematic bias.

CONCLUSION

The VTDp is a valid and reliable self-administered scale to measure patient's vocal tract sensations in Persian-speaking population.

Effects of fast expiration exercises without pressure on the respiratory muscle strength of healthy subjects

[Purpose] The aim of this investigation was to determine the effects of 4 weeks of fast expiration exercises performed without pressure on respiratory muscle strength. [Subjects and Methods] Respiratory muscle strength of the training group that performed fast expiration exercises (n=12) was compared with that of a control group that performed no exercises (n=12). The fast expiration exercises were performed using a peak expiratory flow meter device and consisted of 20 fast expiration exercises performed 3 times per week for 4 weeks. Maximal expiratory and inspiratory pressures were evaluated as respiratory muscle strength using a spirometer pre- and post- intervention. [Results] There were significant increases in maximal expiratory pressure from 76.9 ± 29.1 to 96.1 ± 37.5 cmH₂O and maximal inspiratory pressure from 80.8 ± 36.6 to 95.3 ± 37.6 cmH₂O in the training group, but there was no significant difference in respiratory muscle strength between pre- and post-intervention in the control group. [Conclusion] Fast expiration exercises may be beneficial for increasing respiratory muscle strength. The findings of this study should be considered when prescribing a variation of the expiratory muscle strength training, as part of a pulmonary rehabilitation program.

Vocal warm-up and breathing training for teachers: randomized clinical trial

OBJECTIVE To compare the effectiveness of two speech therapy interventions, vocal warm-up and breathing training, focusing on teachers' voice quality.METHODS A single-blind, randomized, parallel clinical trial was conducted. The research included 31 20 to 60-year old teachers from a public school in Salvador, BA, Northeasatern Brazil, with minimum workloads of 20 hours a week, who have or have not reported having vocal alterations. The exclusion criteria were the following: being a smoker, excessive alcohol consumption, receiving additional speech therapy assistance while taking part in the study, being affected by upper respiratory tract infections, professional use of the voice in another activity, neurological disorders, and history of cardiopulmonary pathologies. The subjects were distributed through simple randomization in groups vocal warm-up (n = 14) and breathing training (n = 17). The teachers' voice quality was subjectively evaluated through the Voice Handicap Index (Índice de Desvantagem Vocal, in the Brazilian version) and computerized voice analysis (average fundamental frequency, jitter, shimmer, noise, and glottal-to-noise excitation ratio) by speech therapists.RESULTS Before the interventions, the groups were similar regarding sociodemographic characteristics, teaching activities, and vocal quality. The variations before and after the intervention in self-assessment and acoustic voice indicators have not significantly differed between the groups. In the comparison between groups before and after the six-week interventions, significant reductions in the Voice Handicap Index of subjects in both groups were observed, as wells as reduced average fundamental frequencies in the vocal warm-up group and increased shimmer in the breathing training group. Subjects from the vocal warm-up group reported speaking more easily and having their voices more improved in a general way as compared to the breathing training group.CONCLUSIONS Both interventions were similar regarding their effects on the teachers' voice quality. However, each contribution has individually contributed to improve the teachers' voice quality, especially the vocal warm-up.TRIAL RECORD NCT02102399, "Vocal Warm-up and Respiratory Muscle Training in Teachers".

Is There a Role for Exercise in the Management of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis?

PURPOSE

The role of exercise in the management of people with amyotrophic lateral sclerosis (PALS) is controversial and currently unclear. The purpose of this review article is to review literature examining the impact of limb, respiratory, and oral motor exercise on function, disease progression, and survival in PALS and the transgenic ALS animal model.

METHOD

A literature review was conducted to examine relevant studies published in peer-reviewed journals between 1960 and 2014. All studies were appraised for quality of research and were assigned a level of evidence, and treatment outcomes were classified as either positive, negative, or neutral.

RESULTS

A total of 18 exercise-based intervention studies on limb (13), respiratory (3), or speech (2) function were identified. Of the human clinical trials, 6 were experimental and 4 were exploratory. No experimental studies were identified examining the impact of targeted exercise on speech or swallowing function. Mild to moderate intensity limb or respiratory exercise, applied early in the disease, was noted to have a beneficial impact on motor function and survival.

CONCLUSION

Insufficient data exist to support or refute the role of exercise in the management of bulbar dysfunction in PALS. This represents a critical area of future investigation.

Emirati Teachers' Perceptions of Voice Handicap

OBJECTIVES

The purpose of the study was to explore Emirati teachers' perceptions of voice handicap and to analyze their acoustic characteristics to determine whether acoustic measures of teachers' voice would verify their perceptions of voice handicap.

METHODS

Sixty-six Emirati school teachers (33 men and 33 women), with different years of teaching experience and age, and 100 control participants (50 men and 50 women) underwent vocal assessment that included the Voice Handicap Index (VHI-Arab) and acoustic measures (F0, jitter%, shimmer%, signal to noise ratio [SNR]).

RESULTS

Significant differences between the teachers' group scores and the control group scores on the following subscales of VHI-Arab: physical (P = 0.006), emotional (P = 0.004), and total score of the test (P = 0.002). No significant differences were found among teachers in the three VHI subscales, and the total score regarding gender (functional P = 0.307; physical P = 0.341; emotional P = 0.126; and total P = 0.184), age (functional P = 0.972; physical P = 0.525; emotional P = 0.772; and total P = 0.848), and years of teaching experience (functional P = 0.319; physical P = 0.619; emotional P = 0.926; and total P = 0.638). The significant differences between the teacher's group and the control group in three acoustic measures: F0 (P = 0.000), shimmer% (P = 0.000), and SNR (P = 0.000) were further investigated. Significant differences were found among female and male teachers in F0 (P = 0.00) and SNR (P = 0.007). As for teachers' age, significant differences were found in SNR (P = 0.028). Teachers' years of experience did not show significant differences in any of the acoustic measures.

CONCLUSIONS

Teachers have a higher perception of voice handicap. However, they were able to produce better voice quality than control participants were, as expressed in better SNRs. This might have been caused either by manipulation of vocal properties or abusive overloading the vocal system to produce a procedurally acceptable voice quality.

Functional outcomes associated with expiratory muscle strength training: narrative review

This review presents the available evidence for the effects of expiratory muscle strength training (EMST) with the use of a pressure threshold device. The investigators used computerized database searches for studies reporting the outcomes of pressure threshold EMST published after 1994. A total of 24 selected articles presented outcomes related but not limited to respiratory function, such as speech, swallow, voice, and cough function in persons with neurologic conditions such as Parkinson disease, multiple sclerosis, and Lance-Adams syndrome; in persons with respiratory diseases, such as chronic obstructive pulmonary disease; and in healthy young adults and sedentary and active elderly. Several studies demonstrated promising outcomes of EMST as a non-task-specific training for airway protection in persons with dysphagia secondary to neuromuscular impairments; however, further research is needed to confirm and generalize the reported findings.

Efeitos da reabilitação fonoaudiológica na desvantagem vocal de cantores populares profissionais

Objetivo Verificar o efeito de um programa de reabilitação de voz na desvantagem vocal autorrelatada por um questionário, em cantores populares profissionais com disfonia. Métodos Quarenta e nove cantores populares profissionais, entre 18 e 45 anos, avaliados pelo otorrinolaringologista e diagnosticados como portadores de disfonia comportamental, com ou sem lesão de massa, relacionada, em maior ou menor grau, ao comportamento vocal, foram encaminhados para fonoterapia. Os cantores foram distribuídos em dois grupos: Experimental (GE), com 29 cantores submetidos à fonoterapia imediata e Controle (GC), com 20 cantores aguardando em fila de espera do serviço para terapia fonoaudiológica, atendidos após a finalização da pesquisa. Todos os participantes responderam ao protocolo de Índice de Desvantagem para o Canto Moderno (IDCM) e autoavaliaram suas vozes falada e cantada, na primeira e na última sessão de atendimento (avaliação e reavaliação). Resultados Houve diferença entre o GE e o GC no momento pós-terapia, para todos os escores do protocolo IDCM. Não houve mudanças em relação ao número de aulas de canto, após a intervenção. O GE relatou melhoria na qualidade da voz falada e cantada. Conclusão Cantores populares profissionais que realizaram terapia fonoaudiológica apresentaram redução na desvantagem vocal autorrelatada no canto, quando comparados aos cantores com queixas vocais e sem tratamento.

Singing voice handicap mapped by different self-assessment instruments

PURPOSE: To map voice handicap of popular singers with a general voice and two singing voice self-assessment questionnaires. METHODS: Fifty singers, 25 male and 25 female, 23 with vocal complaint and 27 without vocal complaint answered randomly the questionnaires. For the comparison of data, the following statistical tests were performed: Mann-Whitney, Friedman, Wilcoxon, Spearman and Correlation. RESULTS: Data showed that the VHI yielded a smaller handicap when compared to the other two questionnaires (VHI x S-VHI - p=0.001; VHI x MSVH - p=0.004). The S-VHI and MSVH produced similar results (p=0.723). Singers with vocal complaint had a VHI total score of 17.5. The other two instruments showed more deviated scores (S-VHI - 24.9; MSVH - 25.2). There was no relationship between gender and singing style with the handicap perceived. A weak negative correlation between the perceived handicap and the time of singing experience was found (-37.7 to -13.10%), that is, the smaller the time of singing experience, the greater the handicap is. CONCLUSION: The questionnaires developed for the assessment of singing voice, S-VHI and MSVH, showed to be more specific and correspondent to each other for the evaluation of vocal handicap in singers. Findings showed that the more the time of singer's singing experience, the smaller the handicap is. Gender and singing styles did not influence the perception of the handicap.