Functional Voice Disorders: The Importance of the Psychologist in Clinical Voice Assessment

The role and impact of voice physiotherapy: A qualitative study of service user perspectives

BACKGROUND

Physiotherapy has the potential to benefit people with voice and throat problems in conjunction with existing services.

PURPOSE

This study aims to explore the impact and role of physiotherapy in voice and throat care, from the perspective of people who have accessed such care. Gaining a better understanding of how physiotherapy contributes to care has the potential to improve services.

METHODS

An interpretive description design was used to explore participants perspectives of the impact and role of physiotherapy through individual semi-structured interviews with people who had accessed physiotherapy for voice or throat care through a single private practice. Transcripts were analyzed with a general inductive approach suitable for qualitative evaluation data. Data were analyzed from six interviews and four main themes emerged, with each theme further characterized by categories.

RESULTS

Two themes related to the impact of physiotherapy in voice and throat care: Offers a deeper understanding of issues affecting their voice/throat; facilitates individualized specific management. Two themes related to the role of physiotherapy in voice and throat care: Complements existing services; Valuable service. Each theme is further illustrated by categories.

CONCLUSION

This study indicates that physiotherapy for voice and throat problems can complement existing services while adding value, providing people with a deeper understanding of their problem and facilitating specific management. There is great potential for physiotherapy to benefit voice users. Future research should further evaluate the potential to include physiotherapy in the voice care team and consider how best to capture the broad impacts illustrated.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of the Effectiveness of Resonant Voice Therapy in Patients with Functional Voice Disorder

OBJECTIVE

This study aims to determine the effectiveness of resonant voice therapy (RVT) in patients with functional voice disorder and to examine the subjective and objective voice changes after the therapy.

STUDY DESIGN

This study adopted an experimental research design with a pretest-posttest control group.

METHOD

Thirty-four women participated in the study-17 in the experimental group and 17 in the control group. Voice hygiene training and RVT were applied to the experimental group. The Turkish version of the Voice Handicap Index (VHI-10) and GRBAS (Grade, Roughness, Breathiness, Asthenia, and Strain) scale were used for subjective voice assessment. Voice recordings were subjected to acoustic analysis on the PRAAT program. After an 8-week therapy program, the same process was repeated for post-test assessment.

RESULTS

In the voice analyses performed after RVT, which was applied to patients with functional voice disorders, the results of the acoustic analysis showed statistically significant differences in jitter, PPQ5, RAP, shimmer, APQ11, and NHR parameters. Subjective voice analysis indicated a statistically significant decrease in VHI-10 scores from 20.88 ± 5.33-9.06 ± 3.3 in the experimental group. The GRBAS score was 4.29 ± 1.2 before the therapy and 1.71 ± 1.1 after the therapy, which is a statistically significant decrease. The results point out that RVT has been effective in improving the objective and subjective parameters of patients with functional voice disorders.

CONCLUSION

RVT applied to patients with functional voice disorders provides significant improvement in acoustic and perceptual voice parameters. The RVT is an effective therapy method in the treatment of patients with functional voice disorders and should be considered as a therapeutic option.

Applied Machine Learning Techniques to Diagnose Voice-Affecting Conditions and Disorders: Systematic Literature Review

BACKGROUND

Normal voice production depends on the synchronized cooperation of multiple physiological systems, which makes the voice sensitive to changes. Any systematic, neurological, and aerodigestive distortion is prone to affect voice production through reduced cognitive, pulmonary, and muscular functionality. This sensitivity inspired using voice as a biomarker to examine disorders that affect the voice. Technological improvements and emerging machine learning (ML) technologies have enabled possibilities of extracting digital vocal features from the voice for automated diagnosis and monitoring systems.

OBJECTIVE

This study aims to summarize a comprehensive view of research on voice-affecting disorders that uses ML techniques for diagnosis and monitoring through voice samples where systematic conditions, nonlaryngeal aerodigestive disorders, and neurological disorders are specifically of interest.

METHODS

This systematic literature review (SLR) investigated the state of the art of voice-based diagnostic and monitoring systems with ML technologies, targeting voice-affecting disorders without direct relation to the voice box from the point of view of applied health technology. Through a comprehensive search string, studies published from 2012 to 2022 from the databases Scopus, PubMed, and Web of Science were scanned and collected for assessment. To minimize bias, retrieval of the relevant references in other studies in the field was ensured, and 2 authors assessed the collected studies. Low-quality studies were removed through a quality assessment and relevant data were extracted through summary tables for analysis. The articles were checked for similarities between author groups to prevent cumulative redundancy bias during the screening process, where only 1 article was included from the same author group.

RESULTS

In the analysis of the 145 included studies, support vector machines were the most utilized ML technique (51/145, 35.2%), with the most studied disease being Parkinson disease (PD; reported in 87/145, 60%, studies). After 2017, 16 additional voice-affecting disorders were examined, in contrast to the 3 investigated previously. Furthermore, an upsurge in the use of artificial neural network-based architectures was observed after 2017. Almost half of the included studies were published in last 2 years (2021 and 2022). A broad interest from many countries was observed. Notably, nearly one-half (n=75) of the studies relied on 10 distinct data sets, and 11/145 (7.6%) used demographic data as an input for ML models.

CONCLUSIONS

This SLR revealed considerable interest across multiple countries in using ML techniques for diagnosing and monitoring voice-affecting disorders, with PD being the most studied disorder. However, the review identified several gaps, including limited and unbalanced data set usage in studies, and a focus on diagnostic test rather than disorder-specific monitoring. Despite the limitations of being constrained by only peer-reviewed publications written in English, the SLR provides valuable insights into the current state of research on ML-based voice-affecting disorder diagnosis and monitoring and highlighting areas to address in future research.

Presbyphonia as an Individual Process of Voice Change

OBJECTIVE

The aim of the study was to determine the individual variability of the severity of dysphonia in the population of older women and men using the initial perceptual voice assessment (GRBAS) and objective diagnosis of the clinical form of Presbyphonia with laryngeal visualization technique (High-Speed Digital Imaging [HSDI]) and acoustic voice analysis (Diagnoscope Specjalista).

METHODS

The study included 302 elderly women and men. Application of perceptual GRBAS scale allowed to extract 230 subjects with voice disorders (Group I). Remaining 72 elderly subjects without the symptoms of dysphonia consisted Group II. Group III included 50 subjects with euphonic voice. In the assessment of dysphonia, visualization technique (HSDI) as well as acoustic method (Diagnoscope Specjalista). The observation of real vibration of vocal folds using HSDI technique and HS camera allowed to examine symmetricity (Shaw-Deliyski scale), periodicity and amplitude of vibration, Mucosal Wave (MW) morphology, Glottal Closure Type, and value of Open Quotient (OQ). Acoustic analysis allowed to assess value of Fundamental Frequency (F0), Maximum Phonation Time (MPT) as well as Jitter, Shimmer, Noise-to-Harmonics Ratio (NHR) parameters. Narrowband Spectrography was performed.

RESULTS

HSDI technique allowed to register in elderly women with voice disorders a mild asymmetry and aperiodicity of vibrations, MW reduction, amplitude increase and glottal insufficiency in the posterior segment of glottis which indicated edematous changes in the larynx. In 90% of men in this group, moderate asymmetry and aperiodicity were observed as well as amplitude decrease, significant limitation of MW and glottal insufficiency in the middle segment of the glottis which indicated atrophic changes in the larynx. In remaining 10% of men, amplitude of vibration was increased which indicated the existence of hypofunctional dysphonia. Objective confirmation of glottal insufficiency in women with edematous changes was high value of OQ in posterior segment of the glottis registered with HSDI technique. In men with larynx atrophy, the value of OQ was the highest in the middle segment of the glottis. Glottal insufficiency, especially in the middle segment, coexisted with the increase of NHR parameter observed in acoustic examination and with numerous nonharmonic components in the scope of high frequencies revealed in narrowband spectrography, especially in men with larynx atrophy. What is more, in men, the increase of F0 and reduction of MPT was registered. In women with edematous changes of the larynx, acoustic analysis revealed decrease of F0 value, increase of Jitter, Shimmer, NHR as well as reduction of MPT. Narrowband sopectrography revealed not only harmonic components but also nonharmonics in the range of low, medium, and high frequencies.

CONCLUSIONS

The course of Presbyphonia varies individually in the elderly. In many subjects, the process of aging does not influence the quality of voice. Crucial importance in the diagnosis of Presbyphonia is assigned to High-Speed Digital Imaging technique which confirms the existence of edematous changes in the larynx in women as well as atrophy and hypofunctional dysphonia in men. The acoustic examination of voice confirmed the individual variability of the severity of Presbyphonia in the elderly depending on the clinical form of dysphonia determined by the gender of the diagnosed person.

Psychological Distress in a Sample of Adult Italian Patients Affected by Vocal Nodules and Muscle-Tension Dysphonia: Preliminary Results

OBJECTIVES

To evaluate the correlation between voice disorders and psychological distress, in terms of anxiety, stress, and depression, in a sample of adult Italian patients and to compare our results with those obtained in a group of adult healthy controls matched by age, sex, geographic distribution, and occupation.

METHODS

This prospective-controlled study included 100 adults with Vocal nodules (VN) and Muscle Tension Dysphonia (MTD1), aged between 18 and 65 years, as Experimental Group (EG) and 100 age-matched subjects without any voice disorders as a Control Group (CG). All patients in the EG underwent a phoniatric evaluation, including the administration of the Voice Handicap Index (VHI) and laryngeal examination. Both patients of EG and CG underwent a Psychological evaluation by means of standardized tests; Beck's Depression Inventory, State Anxiety Inventory (STAI 1-State Anxiety), Trait Anxiety Inventory (STAI 2- Trait Anxiety), and Perceived Stress Scale (PSS-10) were completed by patients. Fisher's exact test and chi-squared test were used to compare all categorical variables, whereas numerical variables were compared either with the nonparametric Mann-Whitney-Wilcoxon or with Kruskal Wallis test. General linear models were used to study continuous variables between patients and controls and between different groups within the sample.

RESULTS

In the study group, the Physical domain (P score) of the VHI was more affected than the Emotional (E score) and Functional ones (F score) both in patients with MTD1 and VN; patients with VN presented a significant difference in P score, E score and VHI total score than patients with isolated MTD 1 (P < 0.005). Psychological assessment showed a significant difference (P < 0.005) between VN and MTD 1 regarding PSS-10 and STAI-1 scores. Low Beck's Depression Inventory scores were present in our sample without significant differences between patients with VN and those with MTD 1. Scores related to psychological distress in the EG were far superior to those obtained by the healthy CG, with markedly significant values especially for PSS-10 (P < 0.0001) and STAI 2 (P < 0.01). Finally, younger patients (18-35 years) with VN showed a highest risk of psychosocial distress.

CONCLUSION

the present study identified a high prevalence of psychological distress among patients with vocal disorders without any prior specific psychiatric diagnosis, especially in terms of anxiety and perceived stress. For this reason both these symptoms should be taken into consideration in the diagnostic, therapeutic, and follow-up process of patients with MTD1 and VN.

Integrative Review and Framework of Suggested Mechanisms in Primary Muscle Tension Dysphonia

PURPOSE

Despite the high prevalence of primary muscle tension dysphonia (MTD-1), its underlying mechanisms and their interrelationships have yet to be fully identified. The objectives of this integrative review were (a) to describe and classify the suggested underlying mechanisms for MTD-1, (b) to appraise the empirical evidence supporting each of the proposed mechanisms, and (c) to summarize the information in an integrative model.

METHOD

PubMed, Scopus, and CINAHL were searched for all publications pertaining to muscle tension dysphonia. Papers were retained if they included theoretical or empirical data pertaining to underlying mechanisms of MTD-1. A total of 921 papers initially qualified for screening, of which 100 remained for consideration in this review. Underlying mechanisms of MTD-1 were extracted using a consensus approach.

RESULTS

Seven broad categories of putative mechanisms involved in MTD-1 were identified: psychosocial, autonomic, sensorimotor, respiratory, postural, inflammatory, and neuromuscular. These categories were further divided into 19 subcategories detailed in the body of this review article. Based on the reviewed evidence, our proposed integrative model presents MTD-1 as an idiosyncratic motor adaptation to physiological perturbation or perceived threat. Under this model, physiologically or psychologically aversive stimuli can instigate a series of motor adaptations at multiple levels of the nervous system, ultimately disturbing muscle activation patterns and their biomechanical outcomes. Importantly, these adaptations appear to have the potential to become chronic even after threatening stimuli are withdrawn.

CONCLUSIONS

The proposed model highlights the importance of personalized rehabilitation in MTD-1 treatment. Limitations of the literature are discussed to provide guidance for future research aimed at improving our understanding of MTD-1.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19586065.

Self-perception of quality of life in patients with functional voice disorders: the effects of psychological and vocal acoustic variables

PURPOSE

Functional voice disorders (FVD) are multifactorial and may have a significant impact on the patients' quality of life (QOL). The aim of this study was to explore and analyze the relationship between the VHI scores, psychological variables, and objective voice measurements, and to develop a psychological and/or vocal acoustic model for the overall self-perceived evaluation of quality of life for three different types of FVD.

METHODS

After ENT examination, 83 women were classified into three groups: psychogenic voice disorder (PVD = 39), primary muscle tension voice disorder (MTVD1 = 16), and secondary muscle tension voice disorder (MTVD2 = 28). All patients were evaluated according to a multidisciplinary assessment protocol, which included the self-evaluation of quality of life (Voice Handicap Index, VHI), psychological evaluation (Hamilton Rating Scales for Depression (HAM-D) and for Anxiety (HARS), and Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Auto questionnaire (TEMPS-A)), and vocal acoustic analysis [mean fundamental frequency (F0, Hz), jitter (local, %), shimmer (local, %), and harmonic-to-noise ratio (HNR, dB)].

RESULTS

Our findings revealed a moderate impact on QOL, regardless of the type of FVD. There were significant correlations between VHI scores, psychological variables, and voice perturbation parameters, with the exception of the MTVD1 and MTVD2 groups. The stepwise multiple linear regression analysis suggested that QOL could be explained by: anxious temperament together with shimmer in PVD group, jitter in the MTVD1 group, and depressive temperament in the MTVD2 group.

CONCLUSIONS

Affective temperaments and/or voice perturbation parameters were meaningful predictors of self-evaluation of quality of life in patients with different types of FVD.

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

OBJECTIVE

A stumbling-block in voice therapy is how the patient will be able to apply the new voice technique in everyday life. Possibly this generalization process could be facilitated by giving voice therapy in group because of the natural forum for training voice-to-speech early in communication between the patients in a group setting. The aim of the study was to compare treatment results from individual voice therapy and voice therapy in group, at several time points and in comparison to patients with no voice therapy.

METHODS

A randomized treatment study was performed with 77 consecutive patients diagnosed with a functional voice disorder. Thirty-one patients were randomized to individual and group therapy, respectively, and 15 patients to no therapy. The assessments included standardized voice recording and registration of voice range profile (VRP), answering Voice handicap index (VHI) and visual analogue scales for self-hoarseness and self-vocal fatigue, and perceptual voice evaluation by speech-language pathologist. The assessments were performed before, direct after therapy, and three months later in all groups. The 2 therapy groups were also assessed 12 months after therapy.

RESULTS

All VHI scores as well as the self-ratings of hoarseness and vocal fatigue, and the perceptual evaluation of voice quality and maximum VRP improved significantly in both therapy groups 3 months after treatment and at 12 months follow-up. There were no significant changes in the control group, with the exception of decreased self-rated hoarseness and increased maximum VRP. Comparisons between treatment groups showed significant larger improvement after group therapy for VHI physical subscale at 12 months, as well as significant lower VHI total score at all measurement sessions and lower subscale scores at 12 months. There were no differences between treatment groups in self-hoarseness or self-vocal fatigue and no difference in perceptual voice quality or VRP. Comparison between controls and treatment groups showed significant larger change in treatment groups from baseline to three months in VHI total and to end of therapy in functional subscale. Treatment groups also showed significant lower scores than controls at each measurement session, for VHI total and physical subscale as well as lower degree of perceptual aberration of voice quality and vocal fatigue, at three months follow-up.

CONCLUSIONS

This study shows long-term improvement from behavioral voice therapy, particularly in a group setting. The results indicate the importance of early transfer-to-speech and late posttherapy test to capture whether the goal of voice therapy was fulfilled or not for the patients.