Is There a Relationship Between Vocal Effort and VHI?

Effects of Back Pressure on the Feasibility and Tolerability of Laryngeal Diadochokinetic Exercise: A Pilot Study

BACKGROUND

The term vocal demand response refers to how speakers meet vocal demands. Vocal loading tasks with predetermined demand parameters (duration, pitch, loudness, etc) have been used in research to study the vocal demand response; these have historically consisted of loud sustained vowel and loud speech tasks. Tasks founded on laryngeal diadochokinesis (LDDK) may be viable alternatives, especially if demand parameters such as exercise-rest ratio and fluid back pressure are concurrently modulated.

OBJECTIVES

To explore the effects of four fluid back pressure conditions (0, 5, 10, and 15 cm H2O) on several measures of subjective participant experience, feasibility, and tolerability during intervallic laryngeal diadochokinetic exercise.

METHODS

Participants (n = 12) completed 15-minute trials of LDDK in 30-second rest and exercise intervals against four counterbalanced back pressure conditions: 0, 5, 10, and 15 cm H2O. The effects of back pressure on (1) ratings of perceived vocal exertion, (2) prevalence of adverse effects such as shortness of breath or lightheadedness, (3) subjective difficulty of sustaining LDDK, (4) number of exercise intervals completed, (5) rankings of participant-preferred back pressure levels, and (6) expert ratings of auditory-perceptual diadochokinetic strength were assessed descriptively.

RESULTS

Perceived vocal exertion, lightheadedness, and subjective laryngeal diadochokinetic difficulty increased as back pressure increased. Number of intervals completed, auditory-perceptual diadochokinetic strength, and participant rankings of back pressure conditions, by contrast, decreased as back pressure increased. 0 and 5 cm H2O were the most preferred back pressure conditions overall.

DISCUSSION

Fluid back pressure was feasible and broadly tolerated during 15-minute trials of vocal exercise. However, the transition from 5 → 10 cm H2O appeared to represent an inflection point in our results: a minority of participants did not tolerate exercise at 10 cm H2O, becoming a majority at 15 cm H2O. We conclude that fluid back pressure should be restricted to values between 0 and 10 cm H2O during LDDK.

Effects of warm-up exercises on self-assessed vocal effort

PURPOSE

An elevated sense of vocal effort due to increased vocal demand is frequently reported by patients with voice disorders. However, effects of vocal warm-up on self-assessed vocal effort have not been thoroughly examined. A recently developed version of the Borg CR-10 Scale facilitates vocal effort assessments, following different vocal warm-up tasks.

METHODS

Effects of a short (5 min) vocal warm-up on self-assessed vocal effort was evaluated using the Borg CR-10. Twenty-six vocally healthy participants (13F, 13M, mean age 22.6), in two randomised groups, underwent sessions of either reading aloud or semi-occluded vocal tract exercises (SOVTE). Vocal effort was evaluated at four times: pre to post vocal warm-up and two silence periods. Non-parametric analyses for repeated measures and calculations for within-subject standard deviation were applied in group comparisons.

RESULTS

Following vocal warm-up, vocal effort ratings were increased to a statistically significant degree in both intervention groups compared to baseline ratings. After a 5-min rest in silence following completion of the vocal warm-up, vocal effort ratings returned to baseline levels in both groups. The drop in ratings immediately post warm-up compared to 5 min later was statistically significant for the SOVTE group.

CONCLUSIONS

Five minutes of vocal warm-up caused increased self-perceived vocal effort in vocally healthy individuals. The increased sense of effort dissipated faster following warm-up for the SOVTE group. When using the Borg CR-10 scale to track vocal effort, it may be beneficial to apply experience-based anchors.

Glottal Function Index: Validity and Reliability of the Persian Language Version in Patients With Voice Disorders

OBJECTIVE

To translate and cross-culturally adapt the Glottal Function Index into the Persian language (GFIp) and validate it in patients with voice disorders.

STUDY DESIGN

A cross-sectional and prospective validation design was adopted.

METHOD

The GFI was translated and culturally adapted into Persian language according to the methodology of standard forward-backward translations to obtain semantic, idiomatic, and conceptual equivalence. One hundred patients with voice disorders (53 men; mean age: 41.4 ± 13.6 years) and 40 healthy volunteers (21 women; mean age: 36.7 ± 10.0 years) completed the GFIp. Patients with voice disorders also completed the Persian Voice Handicap Index (VHIp) to assess the construct validity.

RESULTS

There were no floor and ceiling effects. Evidence for construct validity was found with a significant very good correlation between the GFIp and the VHIp total scores (r = 0.70; P < 0.001). Differences of GFIp scores between the patients and healthy participants were statistically significant (P < 0.001) confirming discriminant validity. The internal consistency reliability was acceptable for GFIp (Cronbach's α = 0.74). Absolute reliability measures of Standard Error of Measurement and the Smallest Detectable Change for GFIp were 2.5 (confidence interval 95% = ±4.9) and 6.93, respectively. Factor analysis revealed the GFIp as a single factor instrument.

CONCLUSION

The GFIp is a valid and reliable self-administered instrument for use in Persian-speaking patients with voice disorders.

Clinical Cutoff Scores for Acoustic Indices of Vocal Hyperfunction That Combine Relative Fundamental Frequency and Cepstral Peak Prominence

PURPOSE

This study examined the discriminative ability of acoustic indices of vocal hyperfunction combining smoothed cepstral peak prominence (CPPS) and relative fundamental frequency (RFF).

METHOD

Demographic, CPPS, and RFF parameters were entered into logistic regression models trained on two 1:1 case-control groups: individuals with and without nonphonotraumatic vocal hyperfunction (NPVH; n = 360) and phonotraumatic vocal hyperfunction (PVH; n = 240). Equations from the final models were used to predict group membership in two independent test sets (n = 100 each).

RESULTS

Both CPPS and RFF parameters significantly improved model fits for NPVH and PVH after accounting for demographics. CPPS explained unique variance beyond RFF in both models. RFF explained unique variance beyond CPPS in the PVH model. Final models included CPPS and RFF offset parameters for both NPVH and PVH; RFF onset parameters were significant only in the PVH model. Area under the receiver operating characteristic curve analysis for the independent test sets revealed acceptable classification for NPVH (72%) and good classification for PVH (86%).

CONCLUSIONS

A combination of CPPS and RFF parameters showed better discriminative ability than either measure alone for PVH. Clinical cutoff scores for acoustic indices of vocal hyperfunction are proposed for assessment and screening purposes.

Effect of Medialization on Dyspnea Index in Unilateral Vocal Fold Paralysis

OBJECTIVE

Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment.

STUDY DESIGN

Retrospective review.

SETTING

Academic medical center.

METHODS

Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI.

RESULTS

Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment (P < .001; 95% CI, 4.7-12.1). Twenty-eight scores decreased, 9 remained unchanged, and 6 increased. Change in DI was influenced by the presence of cardiac disease. Decreased DI persisted at 3-month follow-up. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 scores decreased and were correlated with change in DI.

CONCLUSION

Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.