Voice-Specialized Speech-Language Pathologist's Criteria for Discharge from Voice Therapy

Clinical Effects of Voice Therapy on Vocal Outcomes in Unilateral Vocal Fold Paralysis: Proof-of-Concept Study for Two SOVT-Based Treatment Protocols

BACKGROUND

Studies on treatment efficacy in unilateral vocal fold paralysis (UVFP) often lack a predetermined treatment protocol, and little is known about the effects of specific vocal techniques on vocal outcomes and quality of life in UVFP patients. The purpose of this preliminary proof-of-concept study is to investigate the effects and feasibility of two intensive treatment protocols based on water-resistance therapy (WRT) and vocal function exercises (VFE).

METHODS

Ten participants with acute or chronic UVFP/paresis were recruited in the study and randomly assigned to the WRT or VFE group. Three of these participants presented with aphonia and could not complete the program as prescribed. The remaining participants completed an intensive therapy program with the assigned vocal technique. Before, during, and after the program, a multidimensional voice assessment was performed. Maximum phonation time, acoustic, perceptual, and patient-reported outcome measures (PROMs) were obtained.

RESULTS

WRT and VFE had positive clinical effects on instrumental and auditory-perceptual voice quality, glottal closure, and PROMs, but interindividual variability was high. Studies with larger sample sizes are necessary to confirm or refute these findings.

CONCLUSION

The WRT- and VFE-based therapy programs are both feasible and seem to elicit positive clinical changes in UVFP patients. Suggestions on how to improve the programs are provided, as well as considerations for implementation in clinical practice. Follow-up research is needed to examine the efficacy of both programs on group level.

Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care

PURPOSE

Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice.

METHOD

Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification.

RESULTS

All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice.

CONCLUSIONS

The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24796875.

Performers With History of Voice Injury: A Survey Study of Treatment Outcomes and Vocal Function

INTRODUCTION

Past studies show that performers are more susceptible to voice injury, have higher incidence of injury, and experience greater vocal impairment than non-performers. Despite literature demonstrating otherwise, there remains fear and stigma that voice injury is a career-ending circumstance. Much of this is due to a lack of information about post-treatment vocal function.

METHODS

An anonymous online survey was distributed via email, flyer, and social media to a target audience of performers with a history of voice injury. It inquired about occupation, vocal symptoms, professionals consulted, and treatment adherence. Outcome measures included ability to perform, resolution of symptoms, and attitudes about their voices after voice injury. Findings were analyzed descriptively with statistical analysis to determine factors that may be related to favorable outcomes.

RESULTS

The survey was completed by 151 performers representing a range of genres, including musical theatre, classical, and popular genres. The most reported vocal symptoms were decreased range, singing voice quality changes, increased singing effort, and vocal fatigue. Most initially sought care from an otolaryngologist, laryngologist, or voice teacher. Diagnoses and recommendations varied, but those who adhered to treatment were more likely to report resolution of voice symptoms (P = 0.025). Those with symptoms for 2-4 weeks reported greater vocal confidence than those with a longer symptom duration (P = 0.0251). Performers working with a voice teacher were more likely to find treatment helpful (P = 0.0174). Those with neurogenic voice conditions reported less vocal reliability than participants with other pathologies (P = 0.0155).

CONCLUSION

The majority of participants continued to perform, reported resolved or improved voice symptoms after treatment, and reported positive attitudes about their voices, regardless of their injury or current presence or absence of pathology on exam. Findings of this study highlight a need for continued outreach to voice teachers, education programs, and production teams about vocal function after voice injury.

LEVEL OF EVIDENCE: 4

Examining Therapy Duration in Adults With Voice Disorders

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

An E-Survey of Current Voice Therapy Practices Amongst Speech Language Pathologists (SLPs) in India

In India, Speech Language Pathologists (SLPs) generally work with ENT surgeons and use a variety of treatment approaches, service delivery methods, feedback modes, and outcome measures in clinical practice while dealing with voice disorders. The practice preferences of the SLPs are based on theoretical and practical exposure during their graduate course, guidance from professional bodies, evidence-based practices, etc. The facilities in the work setting also determine the practice style of the SLP. This study reports information on demographics of the SLPs, nature of patients served, intervention methods, and evidence-based practices followed by the SLPs via an E-survey. Analysis of the survey from 55 SLPs in India, who work in the area of voice revealed that most SLPs had postgraduate (67.27%; n = 37) and doctorate degree (23.63%; n = 13) and worked in medical-related settings (81.81%; n = 45). Therapeutic approaches were practiced as stated in literature by 43.64% (n = 24) of SLPs. Although 56.36% (n = 31) of SLPs modified therapeutic approaches based on the client's needs (75%), literacy (16.66%) and cultural variations (8.33%). Attending Continuing Education Programs and training workshops were required to practice voice. Voice therapy methods (protocols) used by the SLPs were not uniform across India. The development of an indigenous protocol/method for voice therapy is the need of the hour.

Clinician and Patient Perception of a Voice Therapy Program Utilizing a Variably Occluded Face Mask: A Pilot Study

OBJECTIVE

The purpose of this investigation was to assess clinician and patient feedback about voice therapy using a variably occluded face mask (VOFM) and to determine if voice therapy augmented via a VOFM would result in favorable changes in patient self-perceived handicap, as well as acoustic and aerodynamic measures.

METHODS/DESIGN

This pilot study used a prospective, pre-post single group design. Eleven patients with dysphonia due to primary muscle tension dysphonia (8) or benign vocal fold lesions (3) were recruited. Data collected included patient and clinician feedback of voice therapy using a VOFM, voice handicap index (VHI)-10, acoustic and aerodynamic measures. Data were collected before treatment (baseline) and 1-week post-therapy. Wilcoxon signed-rank tests were used to compare data pre- and post-therapy.

RESULTS

Statistically significant improvement was observed for the VHI-10 with a median delta of -7. Clinician feedback generally reported that patients liked the VOFM, using the VOFM within the first two sessions of therapy, and within less than 10 min of use. All clinicians ranked the conversation level of the hierarchy as the most effective level. Three themes emerged from the Therapy Feedback Form: the VOFM was a (1) "Facilitator for Sensation," (2) a "Physical Tool," and that there was (3) "No Program Needed" to use the VOFM in voice therapy. There was a statistically significant improvement in cepstral peak prominence (p = 0.0329) and cepstral spectral index of dysphonia (p = 0.0164) in sustained vowels.

DISCUSSION

This pilot study represents the first investigation into clinician and patient perceptions of using a VOFM. Reported measures via patient perception, as well as clinician perceptions, and some acoustic and aerodynamic measures showed that participants got better with VOFM voice therapy. Last, in general, both clinicians and patients liked utilizing a VOFM in voice therapy.

Associations Between Voice and Gestural Characteristics of Transgender Women and Self-Rated Femininity, Satisfaction, and Quality of Life

Purpose Client-based subjective ratings of treatment and outcomes are becoming increasingly important as speech-language pathologists embrace client-centered care practices. Of particular interest is the value in understanding how these ratings are related to aspects of gender-affirming voice and communication training programs for transgender and gender-diverse individuals. The purpose of this observational study was to explore relationships between acoustic and gestural communication variables and communicator-rated subjective measures of femininity, communication satisfaction, and quality of life (QoL) among transfeminine communicators. Method Twelve acoustic and gestural variables were measured from high-fidelity audio and motion capture recordings of transgender women (n = 20) retelling the story of a short cartoon. The participants also completed a set of subjective ratings using a series of Likert-type rating scales, a generic QoL questionnaire, and a population-specific voice-related QoL questionnaire. Correlational analyses were used to identify relationships between the communication measures and subjective ratings. Results A significant negative relationship was identified between the use of palm-up hand gestures and self-rated satisfaction with overall communication. The acoustic variable of average semitone range was positively correlated with overall QoL. No acoustic measures were significantly correlated with voice-related QoL, and unlike previous studies, speaking fundamental frequency was not associated with any of the subjective ratings. Conclusions The results from this study suggest that voice characteristics may have limited association with communicator-rated subjective measures of communication satisfaction or QoL for this population. Results also provide preliminary evidence for the importance of nonverbal communication targets in gender-affirming voice and communication training programs.

Conversation Training Therapy: Let's Talk It Through

This article introduces a novel approach to voice therapy called conversation training therapy (CTT). CTT is the first voice therapy approach to remove the therapeutic hierarchy common in most treatment programs. Rather, CTT uses patient-driven conversation as the sole stimuli in therapy to increase perceptual awareness of voice production in conversational speech. The genesis as to why CTT was developed, as well as the conceptual, theoretical, and component parts of CTT, will be explained. In addition, this article will offer examples of the language of therapy, as it applies to CTT and how to trouble-shoot if problems arise. Medical documentation relevant to CTT will also be outlined. Last, results from a recent efficacy study on CTT will be reported.

Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic

OBJECTIVES

Voice therapy is administered by speech-language pathologists in multiple practice settings, including private practice community voice clinics. However, the evidence for diagnosis patterns and voice treatment outcomes in community voice clinics is very limited. The purpose of this study was to extend knowledge from a previous investigation by assessing the epidemiological patterns of patient referrals to a private practice community voice clinic across a 4-year period (50 months) and to measure the effectiveness of treatment outcomes for patients who were followed up with voice therapy in the same setting.

STUDY DESIGN

Retrospective case series.

METHODS

Consecutive patient records from November 2014 through January 2019 were reviewed. Patients were grouped into seven categories of distinctive diagnoses. Descriptive data for each group were extracted to determine epidemiological patterns of disorder diagnosis, voice handicap, voice quality severity, age, and gender. For patients who completed at least three treatment sessions, pre- and posttreatment measurements of two assessments, the Voice Handicap Index (VHI) and the Acoustic Voice Quality Index (AVQI), were extracted and compared using a multivariate analysis of variance.

RESULTS

Records from 454 consecutive patient referrals over a 50-month time period were reviewed. The most frequent diagnoses were multifactorial etiologies or those with only a few cases, categorized collectively as an "other" diagnosis category. Diagnoses of nonspecific dysphonia and mid-membranous lesions were also common. Consensus Auditory Perceptual Evaluation of Voice-scale scores were not different among disorders; however, group differences were found for VHI and AVQI. Treatment data were available for 292 patients, with 47 of those patients completing at least three treatment sessions and with data for pre- and posttreatment VHI and AVQI. A mixed multivariate analysis of variance showed a significant effect of treatment (Wilks' Lambda = 0.42, F[2] = 27.58, P < 0.001, ƞ_p² = 0.58), where both AVQI and VHI improved significantly across the pre- to posttreatment measurements.

CONCLUSIONS

Patient characteristics and diagnosis patterns across a 50-month period were similar when compared to a previous study that investigated epidemiological patterns in this clinic across 28 months. Voice therapy administered in this community voice clinic to patients with varied diagnoses was found to be effective based on changes in VHI and AVQI measurements.