Immediate and Short-term Effects of Straw Phonation in Air or Water on Vocal Fold Vibration and Supraglottic Activity of Adult Patients with Voice Disorders Visualized with Strobovideolaryngoscopy: A Pilot Study

Efficacy of Long-Term Intensive Straw Phonation Exercise in Air for Hyperfunctional Voice Disorders: A Preliminary Study

PURPOSE

Literature highlights the efficacy of prolonged use of straw phonation for vocally healthy individuals. Nevertheless, minimal studies have examined the prolonged use of single treatment in hyperfunctional voice disorders (HFVD), as straw phonation is used as physiological training to improve voice quality in these individuals. The present study aimed to investigate the long-term intensive training effect of straw phonation exercise in air (SPEA) for HFVD.

METHOD

In a time series design, seven females with HFVD (mean age 42.28years) participated in SPEA for 12 long sessions (30 minutes/session) intensively trained for 3weeks (4days/week). The participant-recorded voice samples were analyzed for aerodynamic measures Aerodynamic Subglottic Pressure (ASP), Airflow Rate (AFR), glottal behavior measures Contact Quotient (CQ), Contact Quotient Range (CQR), acoustic measure Acoustic Voice Quality Index (AVQI), auditory-perceptual Consensus Auditory Perceptual Evaluation of Voice - Kannada (CAPE-V-K), and self-perceptual measure Voice Handicap Index - Kannada (VHI-K) at pre-therapy, mid-therapy, post therapy, and 1-month follow-up timelines. Related Friedman's two-way analysis of variance and post hoc Wilcoxon signed-rank test were used to analyze the change in outcome measures across therapy timelines.

RESULTS

Significant reduction in ASP, CQR, AVQI, CAPE-V-K, and VHI-K measures from pre-therapy to post-therapy and follow-up timelines was observed. Although there was a decrease in AFR and CQ measures from pre therapy to post therapy and follow-up, no significant differences were observed. No significant changes were observed from pre therapy to mid-therapy in any outcome measures, indicating the need for extended therapy duration and regular practice.

CONCLUSION

These findings provide preliminary evidence of implementing the long-term intensive training of SPEA for HFVD with the support of significant outcome measures at various therapy timelines.

Toward Sham Interventions for Behavioral Voice Treatment Outcome Research in Female Students Without Dysphonia

OBJECTIVES/HYPOTHESIS

To develop sham voice treatment techniques to be used in voice treatment outcome research, and to investigate their effectiveness as sham. This entails that the techniques induce no changes in voice or voice physiology, yet still lead to a perception of efficacy.

STUDY DESIGN

Prospective randomized blinded controlled study.

METHODS

Three distinct sham intervention protocols (SIPs) were conceptualized as placebic comparators for three common voice treatment approaches with focus on vocalization (SIP1), respiration (SIP2), and manipulation (SIP3). Forty-eight female students participated in the study. Each participant attended ten 30-minute sessions over 5weeks, including a baseline evaluation, three sessions of one SIP, an inter-SIP voice assessment, three sessions of a second SIP, and a final post-SIP assessment. Auditory-perceptual and instrumental voice evaluations were used as voice treatment outcome measures. The participants' perception of voice-related quality of life was evaluated using the French Voice Handicap Index (VHIFR). Frequentist as well as Bayesian statistical methods were applied for group comparisons. The effects of combining two SIPs, the potential influence of SIP order, and experimenter/clinician effects, were also investigated.

RESULTS

The respiration-based SIP2 showed changes only in sound intensity level on a sustained vowel across the three sham intervention sessions. In contrast, the vocalization-based SIP1 impacted sound intensity level on a sustained vowel, sound intensity level on read text, and maximum phonation time. The manipulation-based SIP3 affected smoothed cepstral peak prominence on read text, Acoustic Voice Quality Index, and Dysphonia Severity Index. SIP2 thus demonstrated the highest alignment with the study's objectives, followed by SIP1 and SIP3. GRBASI ratings revealed no statistical differences for any SIP. VHIFr decreased significantly after all three SIPs. Combining the SIPs generally replicated the effects observed when each SIP was used individually. There was no order effect or experimenter/clinician effect on the results.

CONCLUSIONS

This study demonstrated significant changes in participants' perceived voice quality (measured with VHIFr) across various SIPs, despite minimal impact on objective voice function measures. Further investigation is necessary to establish one or more protocols as genuinely sham interventions.

The Immediate Impact of Targeted Exercises on Voice Characteristics in Female Speakers With Phonotraumatic Vocal Fold Lesions

OBJECTIVE

To examine the immediate impact of 30 minutes of targeted voice exercises on measures of vocal function and lesion characteristics in female speakers with phonotraumatic vocal fold lesions (PVFLs).

STUDY DESIGN

Prospective cohort study.

METHOD

Twenty-nine (n = 29) female subjects with PVFLs completed a 30 minutes targeted voice exercise protocol and a multidimensional voice analysis was conducted immediately pre and post-exercise. Analysis included expert perceptual evaluation of connected speech and stroboscopy recordings, instrumental analysis by selected aerodynamic and acoustic parameters, and self-ratings of effort and vocal function by participants. The direction and magnitude of the change from pre- to post-exercise for each individual across parameters was assessed against a Minimal Clinically Important Difference criteria.

RESULTS

Variability was observed among participants in their response to exercise and across parameters. Multidirectional change in function was demonstrated across instrumental parameters, with observations of both improvement and decline. The most consistent change observed was a reduced PTP post-exercises for 38% of participants (n = 11), and the greatest magnitude of change was observed in aerodynamic measures of airflow and pressure, and the acoustic parameter semitone range. Variability in the direction of change across instrumental measures was observed for 24% of participants (n = 7), while consistent improved function was seen for 45% (n = 13), declined function for 17% (n = 5) and no change for 14% (n = 4). Participant's self-reported effort and function post-exercise was also multidirectional, with the greatest number reporting improvement. Comparatively little change was observed in perceptual evaluation of speech and stroboscopy recordings. Findings suggest that individuals with all lesion types, sizes and liabilities have the potential to improve vocal function immediately post-exercises according to instrumental measures, with the greatest magnitude of change observed in participants with large lesions. Although participants' characteristics did not differentiate, those with nodules or polyps tended to report improvement in function and reduced effort post-exercise, whereas those with a diagnosis of pseudocyst/s or a unilateral lesion appeared to report no change or declined function.

CONCLUSION

Change in measures of vocal function was observed in female speakers with PVFLs immediately following a 30 minutes targeted exercises protocol. Many demonstrated improvement but a high degree of variability was observed in the way speakers respond, and it is likely an individual's response is influenced by a range of factors. Self-rating scales, along with key instrumental parameters sensitive to the presence of PVFLs, may prove most useful in tracking initial change in the immediate and short-term duration in this population, and in assessing stimulability and candidacy for therapy. Further exploration is warranted of stimulability for immediate and cumulative change to achieve sustained improvement in function and efficiency across time.

Connecting Auditory-Perceptual Prompts Used in Voice Therapy to Anatomy and Physiology: Application to the Estill Voice Model and the Rehabilitation Treatment Specification System

PURPOSE

This clinical tutorial will present the concept of applying auditory-perceptual prompts (implicit instruction) typically used in voice therapy to the anatomy and physiology of the voice production system (explicit instruction) via the Estill Voice Model (EVM) and the Rehabilitation Treatment Specification System (RTSS).

METHODS

EVM offers an integrated implicit-explicit instructional approach to voice training allowing for isolated practice of vocal structures (explicit) that interact to produce functional voice qualities (implicit), such as modal speech and louder projected voice qualities. In EVM, voice quality is correlated with the specific anatomy and physiologic adjustments via 13 Estill Figures and Options (eg, Larynx Figure has three options: High, Mid, and Low). RTSS provides a framework to connect client change in functioning (ie, target) with clinician action (ie, ingredients). Mechanisms of action connect the target to the ingredients by hypothesizing how the treatment is expected to work.

RESULTS

Evidence is provided for connecting auditory-perpetual voice prompts with the anatomy and physiology of voice and supporting an integrated implicit-explicit approach to voice therapy. The concept of linking commonly used implicit auditory-perceptual prompts used in voice therapy (eg, humming, loud "aahh") to explicit anatomy and physiology training (eg, 13 Estill Figures and Options) is demonstrated using EVM and the RTSS framework with case studies and video examples.

CONCLUSIONS

Clinicians may choose to use anatomy and physiology of voice to define and provide explicit instruction for typically used implicit auditory-perceptual prompts. Future research is warranted to test the concept applied to voice therapy models in the literature across prevention and treatment of voice disorders.

Vocal Effort and Acoustic Analysis of Gargle Phonation Versus Water Swallow in Patients With Muscle Tension Dysphonia: A Clinical Trial

PURPOSE

To determine the effects of gargle phonation (GP) on self-perceived vocal improvement, vocal effort, acoustic parameters, and speech rate in patients with muscle tension dysphonia (MTD). We hypothesized that GP would improve voice, reduce phonatory effort, and alter acoustic and speech measures.

STUDY DESIGN

Prospective randomized, single-blind cross-over clinical trial METHODS: Thirty-four participants (26 females, 8 males; average age 53 years) who were diagnosed with MTD completed the Voice Handicap Index-10 (VHI-10) and were assigned three study conditions: Baseline (B), GP, and Water Swallow (WS; sham), presented in one of two counterbalanced orders B-WS-GP (WS1st) or B-GP-WS (GP1st). Participants recorded stimuli from the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and rated their perceived vocal effort and vocal improvement. F0, vocal intensity, cepstral peak prominence (CPP), and speaking rate were measured.

RESULTS

Average VHI-10 scores by group were 16 (min/max 2-29) for WS1st and 15 (min/max 3-40) for GP1st. About 73.5% reported more vocal improvement after GP, 17.65% after WS, and 8.8% noted no difference between conditions. Reduced effort was reported after GP, compared to B (P < 0.001) and WS (P = 0.005). Lower effort was also reported after the WS condition, compared to B (P = 0.011). Key acoustic findings included an increase in F0 after GP for sustained /i/ for females. CPP was significantly higher for females reading CAPE-V sentences after GP, when GP preceded WS, compared to B (P = 0.004) and WS (P = 0.003). Speech rate was faster for females after GP versus B (P = 0.029).

CONCLUSIONS

GP may be beneficial in the treatment of MTD. CPP may be a useful marker for vocal improvement after GP for women with mild MTD. Further studies would benefit from having more male participants and those with moderate and severe MTD.