Efficacy of intensive phonatory-respiratory treatment (LSVT) for presbyphonia: two case reports

Laryngologists' Reported Decision-Making in Presbyphonia Treatment

OBJECTIVE

Decision-making regarding behavioral versus procedural intervention in the treatment of presbyphonia has not been well defined. The study objective was to survey laryngologists' reported practice patterns and decision-making in presbyphonia.

METHODS

All laryngology faculty in U.S. academic medical centers with residency programs were recruited to complete an anonymous 29-item survey regarding decision-making in presbyphonia treatment. The survey included 5 sections: demographics, first-line treatment distribution, factors that drive decision-making toward procedural intervention, treatment progression if first-line treatment is insufficient, durable treatment.

RESULTS

Of 153 laryngologists surveyed, 89 responded (58%). Voice therapy (VT) was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive VT initially. Most respondents (83%) indicated they occasionally use procedural intervention as first-line treatment. Factors driving first-line procedural intervention were severe glottal insufficiency (87%), high occupational/social voice demands (76%), voice not stimulable for change (73%), difficulty attending VT (70%), severe dysphonia (65%), and dysphagia (61%). The majority of respondents indicated the following do not affect their decision to pursue procedural intervention: patient age (88%); medical comorbidities (63%); patient's desire for a "quick fix" (55%); patient-reported outcome measures (51%). Most respondents (81%) use trial injection augmentation before durable treatment. Of durable treatments, bilateral thyroplasty was preferred (71%), followed by CaHA (15%) and lipoinjection (11%).

CONCLUSIONS

This study is the first to our knowledge to examine factors that influence decision-making in presbyphonia treatment. While VT remains the most frequent first-line treatment, study results better inform decision-making regarding first-line procedural intervention.

Evidence of Long-Term Voice Therapy Effectiveness in Patients With Presbylarynges

Evidence for long-term effectiveness of voice therapy (>2 years from previous clinic visit) is lacking from patients over 60 years who initially presented with voice complaints and subsequently demonstrated videostroboscopic signs of aging leading to voice therapy recommendations. Over the telephone, a certified speech-language pathologist enquired from those compliant and non-compliant, whether their voices were better, stable, or worse since their previous clinic visit, and asked them to rate Voice-Related Quality of Life, voice satisfaction, and Glottal Function Index to compare with their previous clinic visit ratings. Further questions focused on current voice satisfaction, and for those who were compliant, therapeutic experiences including home exercises. Twenty-four participated (16 complied; eight non-compliant), with a mean of 3.7 ± 1.2 years since the previous clinic visit. For those compliant, 0% reported better voices, 69% stable, and 31% worse. Most compliant participants (56%) attended between two and five therapy sessions. The most frequently reported therapy techniques were repeating nasal sounds/words; straw phonation; fewer words/breath group; and increasing pitch range. Eighty-one percent of compliant participants were given home exercises. They stopped regular practice a few months post-therapy but continued using them as rescue techniques. For those non-compliant, 88% reported better voices, 0% stable, and 12% worse. Most non-compliant participants (43%) reported lack of time as their reason for non-compliance. Most compliant participants reported stable voices, supporting voice therapy's role in maintaining voice function over time in the context of progressive aging. However, non-compliant participants were not associated with poorer voice quality over time.

Effect of intensive water resistance phonation therapy for people with presbyphonia: A pilot study

Purpose: The aim of this pilot study was to explore the efficacy of an intensive 3 week water resistance phonation (WRP) therapy program for people with presbyphonia.Method: Participants included 13 people with presbyphonia who received intensive WRP therapy. All participants completed eight sessions of therapy over 3 weeks. Auditory perceptual ratings, and acoustic and aerodynamic assessments were performed before and after treatment. Participants also completed the voice-related quality of life questionnaire before and after the treatment.Result: After 3 weeks of intensive voice therapy, significant improvements were demonstrated in acoustic, aerodynamic, and auditory perceptual parameters, as well as patient perceptions of voice-related quality of life. Acoustically, it was found there were significant decreases in shimmer (p = 0.019), noise-to-harmonic ratio (p = 0.016), and smoothed cepstral peak prominence (p = 0.001). Perceptually, the clients with presbyphonia showed significant reductions in the ratings of the overall grade, roughness, asthenia, and strain. Moreover, there was a significant increase in the total score of the Mandarin version of the Voice-Related Quality of Life measure post-therapy.Conclusion: The investigation provides preliminary evidence that people with presbyphonia can improve their vocal function and voice-related quality of life through intensive WRP therapy within a short period of time.

Analysis of different performance times of the voiced trill technique in older women

PURPOSE

To analyze and compare the immediate vocal effects of the voiced trill technique in the assessment of acoustic and auditory-perceptual measures of older women with and without self-perceived vocal changes.

METHODS

Clinical, quasi-experimental study in older women, aged 60 to 70 years (n=53). A questionnaire on vocal self-perception, voice, and laryngeal assessment was applied, before and after performing the voiced trill technique. Before and during intervals of the technique, sustained vowel samples were collected, totaling four samples. Older women were divided into two groups: one with self-perceived voice changes (n=25), and the other without self-perceived voice changes (n=28). Auditory-perceptual assessments and acoustic analysis were performed. Statistical tests were used to correlate the data: ANOVA Test for repeated measures, Friedman Test, Wilcoxon Test, and Pearson's Chi-Square Test. For all tests, the significance level was set at 5%.

RESULTS

There was a predominance of moderate dysphonia in both groups, according to the auditory-perceptual judgment. There was no statistically significant difference between the groups in the assessment of the auditory-perceptual analysis regarding voice changes (improved, worsened, and unaltered voices) before and after the different technique performance times. Most older women improved their voice after 1 minute of performing the technique.

CONCLUSION

Older women often have voice changes when considering the perceptual judgment of the voice. There was no scientific evidence as to the ideal time to obtain a better effect on older women's voices.

A 4-Week Straw Phonation in Water Exercise Program for Aging-Related Vocal Fold Atrophy

PURPOSE

This study evaluated the efficacy of a 4-week straw phonation in water (SPW) exercise program on aging-related vocal fold atrophy (VFA), with a secondary objective to examine the immediate effects of SPW exercises.

METHOD

Thirty-eight older adults aged 60 years and above formally diagnosed with aging-related VFA were randomly assigned into an experimental group undergoing SPW exercises with an 8-cm depth of straw submersion into water for 4 weeks plus vocal hygiene practice (n = 20), and a control group with only vocal hygiene practice (n = 18). Outcome measures included laryngeal endoscopic measures of glottal gap, auditory-perceptual ratings of voice quality, acoustic measures, aerodynamic measures, and standardized self-assessment questionnaire scores. An additional round of acoustic and aerodynamic assessment following 20 min of SPW exercises was conducted to examine the immediate effects.

RESULTS

Significant improvements in normalized glottal gap area, perceptual rating of breathiness, smoothed cepstral peak prominence, harmonics-to-noise ratio (HNR), mean oral airflow, subglottal pressure and laryngeal airway resistance at comfortable loudness, Voice-related Quality of Life scores, and Chinese Vocal Fatigue Index Factor 3 scores were observed in the experimental group relative to the control group. There were also significant immediate effects for HNR, mean oral airflow, subglottal pressure, and laryngeal airway resistance.

CONCLUSIONS

These findings suggested significant immediate improvements in vocal function following SPW exercises, with additional significant improvements in vocal function as well as significant improvements in quality of life following the 4-week SPW exercise program. Further studies with more long-term follow-up are recommended to better understand the efficacy of SPW exercises with deep levels of straw submersion into water as an effective clinical option for the management of hypofunctional dysphonia associated with aging-related VFA.

Nonlinear analysis by phase space reconstruction of healthy elderly voices

PURPOSE

To compare the results of the non-linear acoustic analysis of elderly male and female voices, speakers of Brazilian Portuguese.

METHODS

Recordings of 14 men and 15 women were used. The voices were consensually judged to be vocally healthy by three trained speech therapists. The non-linear acoustic analysis was performed by the Phase Space Reconstruction (PSR) analysis using the Voice Analysis program.

RESULTS

A significant difference was observed in the parameter irregularity (p = 0.001) and spacing (p = 0.005), with worse results for the male group. While 93% of male voices presented degrees 2 or 3 of irregularity, these degrees were observed in 53% of female voices. In 78.6% of male voices, medium to large spacing was observed, a fact observed only in 26.7% of women.

CONCLUSION

The results of the non-linear analysis, through the Phase Space Reconstruction, using the CIS Protocol, in the voices of the elderly, showed the best result in terms of the number of curves (four or more). Regarding the irregularity of the tracing, in men, the majority presented grades 2 and 3 and in women, half presented grade 1. Regarding the spacing, 78.6% of the male voices had medium to large spacing, a fact observed only in 26.7% of women.There was a difference between the sexes in the vocal findings of the elderly by the CIS protocol with the PSR, pointing out worse results irregularity and spacing in the male population, which suggests greater vocal aperiodicity in elderly men.

Presbylarynx: Is it Possible to Predict Glottal Gap by Cut-Off Points in Auto-Assessment Questionnaires?

PURPOSE

To determine cut-off points in auto-assessment questionnaires to predict the presence and extent of presbylarynx signs.

METHOD

This case control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by Otorhinolaryngology, in a tertiary center, in 2020. Each subject underwent fiberoptic videolaryngoscopy with stroboscopy, and presbylarynx was considered when it was identified two or more of the following endoscopic findings: vocal fold bowing, prominence of vocal processes in abduction, and a spindle-shaped glottal gap. Each subject completed three questionnaires: the Voice Handicap Index (VHI), with 30 and 10 questions, and the "Screening for voice disorders in older adults questionnaire" (RAVI).

RESULTS

The studied population included 174 Caucasian subjects (60 males; 114 females), with a mean age of 73.99 years (standard deviation = 6.37; range 65-95 years). Presbylarynx was identified in 71 patients (41%). Among patients with presbylarynx, a glottal gap was identified in 22 patients (31%). The mean score of VHI-30 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. The presence of glottal gap was associated to a higher mean score of VHI-30 (41.64 ± 11.87) (P < 0.001). The mean score of VHI-10 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to higher mean score of VHI-10 (14.04 ± 3.91) (P < 0.001). There was a strong positive correlation between VHI-30 and VHI-10 (rs = 0.969; P < 0.001). The mean score of RAVI between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to a higher mean score of RAVI (11.68 ± 1.61) (P < 0.001). There was a strong positive correlation not only between RAVI and VHI-30 (rs = 0.922; P < 0.001), but also between RAVI and VHI-10 (rs = 0.906; P < 0.001). The optimal cut-off points to discriminate "no presbylarynx" from "presbylarynx", obtained by the Youden' index, were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity. The optimal cut-off points to predict glottal gap, obtained by the Youden' index, were 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10.

CONCLUSION

The optimal cut-off points do discriminate "no presbylarynx" from "presbylarynx" were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity, probably because it was designed specifically for vocal complaints of the elderly. Among patients with presbylarynx, cut-off points of 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10 were determined to predict patients with and without glottal gap. It was found a strong positive correlation between RAVI, VHI-30 and VHI-10. Thus, VHI-10 can be preferred to VHI-30 to assess voice impairment in clinical practice, because for elderly patients it is easier to answer. However, to predict endoscopic signs of presbylarynx, RAVI should be preferred.

The Effect of Pitch and Loudness Auditory Feedback Perturbations on Vocal Quality During Sustained Phonation

OBJECTIVE

Dysphonia is a reduction in vocal quality that impacts communication and is often an early sign of a voice disorder. There is little information regarding the effects of auditory feedback control of loudness and pitch on voice quality. In this study, we used both loudness-shift and pitch-shift paradigms to study the relationship between auditory feedback control and vocal quality as measured by smoothed cepstral peak prominence (CPPS), which reflects the harmonicity of the voice signal.

STUDY DESIGN

Experimental, mixed design.

METHODS

We applied 200 ms loudness-shifts (± 0, 3, or 6 dB) and pitch-shifts (± 0, 50, and 100 cents) to auditory feedback during sustained vowel production in 25 healthy adults. We then measured CPPS before and after the loudness-shift or pitch-shift to investigate the effect of changes in auditory feedback on vocal harmonicity.

RESULTS & CONCLUSIONS

Results showed that, on average, CPPS significantly decreased between the first half of the measured segment and the last half of the segment in the absence of auditory feedback shifts, suggesting that voice quality may be reduced across longer vowels over time. Upward and downward shifts in loudness auditory feedback caused a relative increase in CPPS, indicating an improvement in vocal harmonicity, even in cases when vocal intensity was reduced. Pitch alterations had inconsistent and minimal effects. We propose that there may be a control mechanism for voice quality that increases harmonicity of the voice signal to improve voice audibility (ie, ability to be heard) in the presence of unpredictable variability in voice intensity.

Objective Laryngoscopic Measures From Older Patients With Voice Complaints and Signs of Aging

PURPOSE

The purpose of this study was to use objective measures of glottal gap, bowing, and supraglottic compression from selected images of laryngoscopic examinations from adults over 60 years of age with voice complaints and signs of aging to test current hypotheses on whether degree of severity impacts treatment recommendations and potential follow-through with treatment.

METHOD

Records from 108 individuals 60 years or older with voice complaints and signs of aging were reviewed. Three objective measures (normalized glottal gap area [NGGA], total bowing index, and normalized true vocal fold width) were derived. Each measure was subsequently divided into three categories by severity: absence, small degree, or large degree. Nonparametric statistics tested associations between severity and treatment recommendations as well as potential follow-through.

RESULTS

Noninvasive treatments (observation/voice therapy) were marginally associated with no glottal gap (p = .09). More invasive treatments (injection/bilateral thyroplasty) were associated with glottal gaps being present (p = .026), but bilateral thyroplasty recommendations were not significantly associated with the largest gaps. Treatment modalities were not characterized by specific severity categories for any of the objective measures. No significant differences were found for any of the three objective measures between those who followed through with recommended treatment and those who did not.

DISCUSSION

Results demonstrated some support for current hypotheses on how degrees of severity of objective measures relate to treatment recommendations. Of the three measures, NGGA appears to be more informative regarding treatment recommendations and follow-through, but due to low power, larger sample sizes are needed to confirm clinical relevance.

Intensive voice treatment (the Lee Silverman Voice Treatment [LSVT®LOUD]) for individuals with Wilson's disease and adult cerebral palsy: two case reports

Objective: In this case report, we aimed to examine the effects of an intensive voice treatment (the Lee Silverman Voice Treatment [LSVT^®LOUD]) for Wilson's disease (WD), and adult cerebral palsy (CP), and dysarthria.Method: The participants received LSVT^®LOUD four times a week for 4 weeks. Acoustic, perceptual (GRBAS) analyses were performed and data from the Voice Handicap Index (VHI) were obtained before and after treatment.Results: Besides the Harmonics-to Noise Ratio (HNR) value (dB) of the participant with WD, for both participants' fundamental frequencies (Hz), jitter (%), and shimmer (%) values showed significant differences (p < .05) after therapy. Both participants showed significant improvements (p < .05) in the duration (s) and the sound pressure level (dB, SPL) of sustained vowel phonation (/a/), in SPL (dB) of pitch range (high and low /a/) and reading and conversation (p < .01). There was a positive improvement in the high-frequency values (Hz) of both participants but not in the low-frequency values (Hz) in the participant with WD. Perceptual analysis with GRBAS judgements of sustained vowel (/a/) and paragraph reading of two participants also showed improvement. After therapy, perceived loudness of the participants' voice increased.Conclusions: The findings provide some preliminary observations that the individuals with WD and the adult individuals with CP can respond positively to intensive speech treatment such as LSVT^®LOUD. Further studies are needed to investigate speech treatments specific to WD and adult CP.

Effects of Vocal Training on Thyroarytenoid Muscle Neuromuscular Junctions and Myofibers in Young and Older Rats

The purpose of this investigation was to determine the effects of vocal training on neuromuscular junction (NMJ) morphology and muscle fiber size and composition in the thyroarytenoid muscle, the primary muscle in the vocal fold, in younger (9-month) and older (24-month) Fischer 344 × Brown Norway male rats. Over 4 or 8 weeks of vocal training, rats of both ages progressively increased their daily number of ultrasonic vocalizations (USVs) through operant conditioning and were then compared to an untrained control group. Neuromuscular junction morphology and myofiber size and composition were measured from the thyroarytenoid muscle. Acoustic analysis of USVs before and after training quantified the functional effect of training. Both 4- and 8-week training resulted in less NMJ motor endplate dispersion in the lateral portion of the thyroarytenoid muscle in rats of both ages. Vocal training and age had no significant effects on laryngeal myofiber size or type. Vocal training resulted in a greater number of USVs with longer duration and increased intensity. This study demonstrated that vocal training induces laryngeal NMJ morphology and acoustic changes. The lack of significant effects of vocal training on muscle fiber type and size suggests vocal training significantly improves neuromuscular efficiency but does not significantly influence muscle strength changes.

Exercise Science and the Vocalist

The application of exercise science training knowledge has been of growing interest to voice professionals. This tutorial, derived from the authors' invited presentations from the "Exercise and the Voice" Special Session at the 2018 Voice Foundation Symposium, proposes a foundational theoretical structure based in exercise science, clarifies the wide range of variables that may influence voice training, and summarizes our present understanding of voice physiology from the perspective of muscle training. The body of literature on voice exercise was then analyzed from the perspective of this framework, identifying what we currently know and what we still have yet to learn.

Effects of Intensive Voice Treatment (The Lee Silverman Voice Treatment [LSVT LOUD]) in Subjects With Multiple Sclerosis: A Pilot Study

AIM

The rehabilitation of voice disorders is an unmet need in multiple sclerosis (MS). The Lee Silverman Voice Treatment (LSVT LOUD) is a well-documented and effective speech treatment, developed to treat voice disorders in Parkinson Disease. The purpose of the present study was to examine the viability of applying the LSVT LOUD to individuals with MS and verify short- and long-term improvements in acoustic and perceptual voice parameters.

METHODS

A single subject design was performed in a consecutive sample of 8 subjects with MS. The subjects' voice was recorded with PRAAT software for 5 days at baseline during the 16  treatment sessions, and at follow-up (FU) 6/12 months later. PRAAT provided data on sustained /a/ (SPL/a/) voice intensity and maximum phonation time (MPT/a/) of sustained /a/, and on functional sentences voice intensity. In addition, self-assessment questionnaire Voice Handicap Index, the perceptual GIRBAS scale and intensity of monologue were collected at first day of baseline, post-treatment and at FU. In the treatment phase each subject received treatment according to LSVT LOUD protocol. Visual analysis calculated for daily acoustic variables was used to determine baseline stability and analyse changes following treatment. The Wilcoxon test was used to assess statistically significant differences between baseline and post treatment.

RESULTS

All participants completed the LSVT LOUD programme; one participant dropped out at FU. Improvements in acoustic analysis were found: SPL/a/ improved on average (± standard deviation) 11.64 ± 4.19 dB with 7 subjects showing statistically significant improvement (P < 0.05); MPT/a/ improved on average 1.2 ± 1.53seconds, while intensity of functional sentences improved on average 8.11 ± 3.46  dB with 4 and 5 subjects showed statistically significant improvement, respectively. Intensity of monologue improved 14.90 ± 3.33 dB. Acoustic values are maintained or increased at FU respect to baseline. All subjects improved perceptual ratings at Voice Handicap Index and results were maintained at FU. These changes were associated with improvements on five parameters on the GIRBAS scale at post-treatment, however no further improvement were observed at FU.

CONCLUSION

Intensive LSVT LOUD treatment is a viable approach to treat hypophonia in MS. LSVT LOUD improved both quantitative-instrumental and perceptive-subjective assessments. Randomised controlled trials are needed to provide a firm support on the effectiveness of LSVT LOUD in MS.

The effects of intensive speech treatment on intelligibility in Parkinson's disease: A randomised controlled trial

BACKGROUND

More than 6,000,000 individuals worldwide are diagnosed with Parkinson's disease (PD). Nearly 90% develop speech signs that may substantially impair their speech intelligibility, resulting in losses in their communication and quality of life. Benefits of intensive speech treatment have been documented for a range of speech signs. However, the critical question of whether speech is more intelligible after treatment has not been investigated in a randomised controlled trial (RCT). We hypothesised that intensive speech treatment would improve speech intelligibility in PD.

METHOD

Sixty-four patients with hypokinetic dysarthria secondary to PD participated in this single-centre, parallel arm, statistically-powered RCT. Reporting follows CONSORT guidelines for non-pharmacological treatment. Patients were recruited from US clinics and randomised using a statistician-derived minimisation algorithm, to intensive speech treatment (16 1-hour sessions/1 month) targeting voice (voice group) or targeting articulation (articulation group) or to an untreated group (no treatment group). Speech treatments were delivered by speech clinicians who specialised in treating patients with PD. Trial design minimised bias and supported equipoise. For intelligibility assessment, blinded listeners (n = 117) orthographically transcribed 57 patients' recorded, self-generated narrative speech samples, randomly presented in multi-talker babble noise. Listeners were American-English speakers, ages 18-35 years, with normal hearing. The primary outcome was baseline (pre-treatment) to post-treatment change in transcription accuracy (TA), recognised as the most objective measure of intelligibility. TA was defined as the percentage of words transcribed correctly. Listeners, data collectors, and data managers were blinded to treatment conditions and groups. Reliability was evaluated using intraclass correlation coefficients and differences amongst groups were evaluated by mixed-effects models, in accordance with the intention-to-treat approach.This trial was registered with ClinicalTrials.gov Identifier: NCT00123084.

FINDINGS

Between June 23, 2016 and August 14, 2017, blinded listeners transcribed baseline and post-treatment speech samples for intelligibility assessment of 57 patients in the voice (n = 19), articulation (n = 19) and no treatment (n = 19) groups. Between-group differences (d) in changes from baseline to post-treatment in TA indicated significantly greater increases following treatment targeting voice than treatment targeting articulation (d = 26·2%, 95% CI 1·5 - 51·0; p = 0·04; ES=1·0). Differences between TA changes in the treatment targeting voice and in the no treatment group were significant (d = 42·8%, 95% CI 22·4 - 63·2; p = 0·0002; ES=1·8). Differences between TA changes in the treatment targeting articulation and in the no treatment group were not significant (d = 16·5%, 95% CI -6·1 - 39·2; p = 0·147; ES=0·9).

INTERPRETATION

These findings provide the first RCT evidence that intensive speech treatment targeting voice improves speech intelligibility in PD. Thus, this evidence-based treatment may positively impact health-related quality of life for patients with PD globally when it is included in patient management.

FUNDING

Comparison of the immediate effect of voiced oral high-frequency oscillation and flow phonation with resonance tube in vocally-healthy elderly women

PURPOSE

To verify and compare the immediate effects of the voiced oral high-frequency oscillation (VOHFO) technique and the phonation into a silicone resonance tube in the elderly self-perception of vocal and laryngeal symptoms and in their voice quality.

METHODS

14 elderly women, over 60 years old, performed the VOHFO and phonation into a resonance tube technique (35cm in length and 9mm in diameter) with one-week interval between both to avoid carry-over effect. Initially, all participants answered questions regarding the frequency and intensity of their vocal/laryngeal symptoms. Recordings of the sustained vowel /a/ and counting numbers were performed for posterior perceptual and acoustic analyses of the voice quality. The maximum phonation time (MPT) for /a/, /s/, /z/ and counting numbers were also obtained. After that, a draw lot established which technique (VOHFO or resonance tube) would be initially applied for three minutes. After the exercise performance the same procedures were carried out and the elderly women answered a self-assessment questionnaire about the effect of the techniques in her voice, larynx, breathing and articulation. Comparison pre and post each technique were analyzed using ANOVA, Wilcoxon and Mann-Whitney tests. The sensations after the techniques were assessed using the Chi-square test (p<0.05).

RESULTS

The comparison of both techniques showed decrease in roughness and improvement in resonance for counting numbers after the resonance tube and same outcomes post VOHFO. There were no significant differences for the other analyzed variables between groups.

CONCLUSION

The phonation into a resonance tube exercise improves the vocal quality of elderly women. In addition, both exercises are similar regarding self-perception of vocal / laryngeal symptoms and sensations post three minutes of the technique, suggesting that VOHFO can be safely applied in voice therapy for this population.

Exercise Science and the Vocalist

The application of exercise science training knowledge has been of growing interest to voice professionals. This tutorial, derived from the authors' invited presentations from the "Exercise and the Voice" Special Session at the 2018 Voice Foundation Symposium, proposes a foundational theoretical structure based in exercise science, clarifies the wide range of variables that may influence voice training, and summarizes our present understanding of voice physiology from the perspective of muscle training. The body of literature on voice exercise was then analyzed from the perspective of this framework, identifying what we currently know and what we still have yet to learn.

A Tutorial of the Effects of Sex Hormones on Laryngeal Senescence and Neuromuscular Response to Exercise

Purpose The purpose of this tutorial is to summarize how sex hormones affect both laryngeal senescence and neuromuscular response to exercise, highlighting the importance of considering sex differences in developing treatment for the senescent voice. Conclusion Men and women's voices are sexually dimorphic throughout the life span, including during the laryngeal adaptations observed during senescence. Therefore, presbyphonia (age-related dysphonia) likely clinically manifests differently for men and women due to differences in how the male and the female larynx change in response to aging. Because sexual dimorphism is evident in both laryngeal aging and response to exercise, voice therapy programs aimed at treating the typical and disordered aged voice should consider sex differences in their design.

Voice therapy for the elderly with progression of intensity, frequency, and phonation time: case reports

This study aims to verify the immediate and medium-term effects of an intensive voice therapy, with progression of vocal intensity and frequency and phonation time, on the voice and larynx of two elderly. A 79-year-old male and an 82-year-old female with vocal complaints and presbylarynx characteristics underwent 12 sessions of intensive voice therapy, with progression of voice intensity and frequency and phonation time, for three weeks. To analyze the therapeutic effects, the following assessments were performed pre-, post-immediately, and one month after voice therapy: auditory-perceptual analyses of the voice, acoustic analysis, and evaluation of maximum phonation time (MPT), self-reference voice-related quality of life, and laryngeal behavior. Most results of these measurements indicated positive changes immediately after voice therapy. There was reduction in the measures of vocal quality deviation, perturbation, and harmonics-to-noise pre-, post-immediately, and one month after voice therapy, which indicates vocal improvement. There was increase in fundamental frequency, maximum phonation time and self-reference voice-related quality of life. Assessment of the laryngeal images showed no consistent difference. One month after voice therapy, worsening of some results was observed compared with the post-immediate assessment, but improvements were maintained in relation to the initial evaluation. The results of this therapeutic proposal are promising, and their effects should be investigated in controlled clinical trials to verify their efficacy.

Vocal Dose in Older Adults with Presbyphonia: An Analytic, Cross-Sectional Study

PURPOSE

Older patients with age-related voice changes (presbyphonia) are considered vocal under-doers due to a reportedly low a amount and intensity of voice use (ie, low vocal dose). This low voice use may be consequential to negative effects of presbyphonia like throat discomfort, as well as anxiety and frustration from difficulty communicating. Causally speaking, vocal fold atrophy (presbylaryngis) may indicate inadequate intrinsic laryngeal muscle loading with low voice use, though research is lacking. As a first step, this study examined voice use objectively using vocal dosimetry in older adults with presbyphonia. We hypothesized participants, especially if retired, would exhibit low vocal doses, and lower than reported for other populations.

METHOD

This research used an analytic, cross-sectional design with subgroup analyses to determine feasibility of vocal dosimetry in older adults with presbyphonia. Thirteen older adults with presbyphonia (7 males) completed vocal dose monitoring using an ambulatory phonation monitor (APM). The APM measured vocal parameters over a day of monitoring, from which time, cycle, and distance doses were calculated. Data also were gathered on demographics, vocal handicap, and vocal effort.

RESULTS

Descriptively, the group showed a low mean time dose as compared to published vocal dose data from other populations. Females exhibited significantly higher mean values of time dose, cycle dose, and fundamental frequency than males. Time dose for males was negatively correlated with vocal effort. Subgroup analyses failed to detect an effect of age group, but found significantly a higher mean value for time dose in employed, compared to retired, participants.

CONCLUSIONS

Consistent with self-report, we found older adults with presbyphonia exhibit low time doses, which were in contrast to high vocal doses published on teachers, patients with dysphonia, and even office workers. We found differences in vocal dose as a function of sex and employment status. Though a limited sample, findings suggest patients with presbyphonia may demonstrate low vocal dose, which may be a useful target in treatment.

Effect of Laryngopharyngeal Neuromuscular Electrical Stimulation on Dysphonia Accompanied by Dysphagia in Post-stroke and Traumatic Brain Injury Patients: A Pilot Study

Objective

To investigate the effect of laryngopharyngeal neuromuscular electrical stimulation (NMES) on dysphonia in patients with dysphagia caused by stroke or traumatic brain injury (TBI).

Methods

Eighteen patients participated in this study. The subjects were divided into NMES (n=12) and conventional swallowing training only (CST, n=6) groups. The NMES group received NMES combined with CST for 2 weeks, followed by CST without NMES for the next 2 weeks. The CST group received only CST for 4 weeks. All of the patients were evaluated before and at 2 and 4 weeks into the study. The outcome measurements included perceptual, acoustic and aerodynamic analyses. The correlation between dysphonia and swallowing function was also investigated.

Results

There were significant differences in the GRBAS (grade, roughness, breathiness, asthenia and strain scale) total score and sound pressure level (SPL) between the two groups over time. The NMES relative to the CST group showed significant improvements in total GRBAS score and SPL at 2 weeks, though no inter-group differences were evident at 4 weeks. The improvement of the total GRBAS scores at 2 weeks was positively correlated with the improved pharyngeal phase scores on the functional dysphagia scale at 2 weeks.

Conclusion

The results demonstrate that laryngopharyngeal NMES in post-stroke or TBI patients with dysphonia can have promising effects on phonation. Therefore, laryngopharyngeal NMES may be considered as an additional treatment option for dysphonia accompanied by dysphagia after stroke or TBI.

Fonoterapia vocal e fisioterapia respiratória com idosos saudáveis: revisão de literatura

RESUMO Este estudo tem como tema a fonoterapia vocal e a fisioterapia respiratória no idoso saudável. O objetivo do presente estudo foi revisar a literatura sobre fonoterapia vocal e sobre fisioterapia respiratória com idosos saudáveis. Foi realizado um levantamento bibliográfico de artigos publicados entre 2004 e 2014 nas bases de dados Lilacs, Bireme, MedLine, PubMed e Scielo. Descritores utilizados: physical therapy specialty; breathing; speech therapy; aged; therapeutics e voice. A literatura sobre fonoterapia vocal com idosos saudáveis mostrou que as intervenções têm sido feitas por meio de orientação vocal; terapia vocal tradicional para presbifonia, independente do tipo de intervenção; exercícios vocais específicos; e programas terapêuticos padronizados, havendo evidências de melhora de medidas vocais perceptivoauditivas, acústicas, de autoavaliação vocal e de imagem laríngea. Quanto à fisioterapia respiratória, a literatura evidenciou que as técnicas ou procedimentos utilizados com idosos saudáveis foram: uso do aparelho Threshold, técnicas de terapia manual, espirometria de incentivo, exercícios respiratórios associados ao movimento do tronco e membros inferiores e atividade física em geral, apresentando evidências de melhora na força muscular respiratória, função pulmonar e autonomia funcional dos idosos.