Intervention Outcomes of Two Treatments for Muscle Tension Dysphonia: A Randomized Controlled Trial

Efficacy of Voice Therapy in Rehabilitation of Muscle Tension Dysphonia in Patients of Nonlaryngeal Head and Neck Cancer: A Sequelae of Chemoradiotherapy

The association of voice disorders in laryngeal cancers has been studied extensively; however Dysphonia associated with chemo-radiation in non laryngeal Head and Neck cancer (HNC) is a new area of practice in voice clinics. This study thus aimed to evaluate the efficacy of voice rehabilitation among non-laryngeal HNC survivors who were treated with curative RadioTherapy (RT)/Chemoradiotherapy (CRT) in adjunct with or without surgery. This tertiary institutional assessor blinded quasi experimental study after inclusion and exclusion criteria consisted of a study cohort of 128 patients who within 1-3 months of completion of treatment for HNC reported to the laryngology clinic for voice complaints and throat discomfort. All patients underwent documentation of laryngeal endoscopic imaging, acoustics assessment, Aronson's Laryngeal Palpatory Method (LPM) and Voice Handicap Index (VHI). Thereafter they were subjected to Vocal Rehabilitation Therapy (VRT) which constituted of Manual circumlaryngeal therapy, SOVTE, and vocal hygiene program. Re-evaluation of the vocal parameters was done at 6 weeks and 3 months from the start of the VRT. All parameters were significantly altered at 6 weeks and 3 months follow-up. Post VRT the videolaryngoscopic findings showed reduction in abnormal supraglottic MTPs with subsequent good approximation of true cords and reduction of involvement of supralaryngeal activities. The Dysphonia Severity Index (DSI) impairment levels and VHI scores showed significant improvement from the baseline to both at 6 weeks and 3 months of VRT (p < 0.001). DSI and VHI scores even showed significant improvement between 6 weeks to 3 months of therapy. There was highly significant correlation of VRT with/without surgery, with CRT and in non-smokers at 6 weeks and 3 months of VRT. In non-laryngeal head and neck malignancies, VRT offered as early as within 1-3 months of completion of treatment of HNC ameliorates surgical and chemo-radiation induced Muscle Tension Dysphonia.

Bi-Weekly Voice Therapy Versus Weekly Voice Therapy for Muscle Tension Dysphonia

OBJECTIVES

To compare the outcomes of bi-weekly voice therapy (BWVT) with weekly voice therapy on perception, acoustics, and quality of life for individuals with muscle tension dysphonia (MTD).

METHODS

Thirty participants with MTD were enrolled either BWVT (40 min/session, two sessions per week for 4 weeks) or weekly voice therapy (40 min/session, once a week for 8 weeks). Auditory perceptual ratings, acoustic parameters, and the Mandarin version of the voice-related quality of life questionnaire (MV-RQOL) scores were statistically analyzed before and after treatment.

RESULTS

There were significant improvements in the voice qualities such as overall grade, roughness, asthenia, and strain in both groups after treatment. Acoustics analyses showed that fundamental frequency, speaking fundamental frequency, jitter, shimmer, and cepstral peak prominence significantly improved in both groups after treatment. For the MV-RQOL questionnaire scores, the result also demonstrated that both groups felt significant improvements in voice-related quality of life after treatment. However, there were no significant differences between the two groups of treatment effects.

CONCLUSIONS

Patients with MTD can restore voice qualities and quality of life if they are able to complete a full course of voice therapy, regardless of the intensity of voice therapy. However, if they can receive the BWVT, they would be able to regain their voice faster. The results of this study can be provided as a reference for clinicians when treating patients with MTD.

Comparative Analysis of Two Methods of Perceptual Voice Assessment

OBJECTIVES

The primary aim was to compare two methods for perceptual evaluation of voice - paired comparison (PC) and visual analog scale (VAS) ratings. Secondary aims were to assess the correspondence between two dimensions of voice- overall severity of voice quality and resonant voice, and to investigate the influence of rater experience on perceptual rating scores and rating confidence scores.

STUDY DESIGN

Experimental design.

METHODS

Voice samples from six children (pre and post therapy) were rated by 15 Speech-Language Pathologists specialized in voice. Raters completed four tasks corresponding to the two rating methods and voice qualities: PC-severity, PC-resonance, VAS-severity, and VAS-resonance. For PC tasks, raters chose the better of two voice samples (better voice quality or better resonance, depending on the task) and indicated the degree of confidence in each choice. Rating and confidence score were combined to produce a number on a 1-10 scale (PC-confidence adjusted). VAS ratings involved rating voices on a scale for degree of severity and resonance, respectively.

RESULTS

PC-confidence adjusted and VAS ratings were moderately correlated for overall severity and also vocal resonance. VAS ratings were normally distributed and had greater rater consistency than PC-confidence adjusted ratings. VAS scores reliably predicted binary PC choices (choice of voice sample only). Overall severity and vocal resonance were weakly correlated and rater experience was not linearly related to rating scores or confidence.

CONCLUSIONS

Results suggest that the VAS rating method holds advantages over PC, including normally distributed ratings, superior consistency of ratings, and the ability to provide more finely grained detail regarding the auditory perception of voice. Overall severity and vocal resonance were not redundant in the current data set, suggesting that resonant voice and overall severity are not isomorphic. Finally, the number of years of clinical experience was not linearly related to perceptual ratings or rating confidence.

A Clinician's Guide to Critically Appraising Randomized Controlled Trials in the Field of Speech-Language Pathology

PURPOSE

When considering original research articles, randomized controlled trials (RCTs) provide the highest level of research evidence. Given this, RCTS are often used by clinicians performing evidence-based practice to determine the most effective intervention for a specific patient or patient population. Although RCTs represent a high level of research evidence, it is important for clinicians to critically appraise RCTs to determine the validity of the study methods deployed, the statistical and clinical significance of treatment effects, and whether or not the results generalize to a particular patient, patient population, and/or clinical setting. Therefore, this tutorial will provide clinicians with an overview of what an RCT is, the various types of RCTs, when RCTs are appropriate to conduct and/or use to inform clinical practice, and the advantages and limitations of RCTs. Additionally, this tutorial will provide clinicians with practical tools to employ when reading an RCT, including checklists with questions, definitions of important terminology frequently used in RCTs, and demonstrations of how to critically appraise RCTs using literature examples from the speech-language pathology literature.

CONCLUSIONS

Learning how to interpret and apply the results from RCTs to inform clinical practice for purposes of improving patient care is a critical evidence-based practice skill for clinicians to develop. This tutorial will assist clinicians in the field of speech-language pathology by furthering their fundamental knowledge of RCTs and by providing them with pragmatic tools to critically appraise RCTs to inform their clinical practice.

A randomized controlled trial of the effects of flow phonation voice treatment for primary muscle tension dysphonia

OBJECTIVE

The purpose of the study was to investigate the effects of flow phonation voice therapy on laryngeal physiology and vocal quality in persons with primary Muscle Tension Dysphonia (MTD1).

METHODS

Seventeen participants with a diagnosis of MTD1 completed the study. Participants were randomized to two groups. Group 1 (9 participants) received flow phonation treatment and individualized vocal hygiene education for 12 sessions over six weeks. Group 2 (8 participants) received vocal hygiene education only for three weeks (6 sessions), followed by another three weeks (6 sessions) of both vocal hygiene instruction and flow phonation therapy. Treatment consisted of cup-bubble blowing, gargling, and stretch and flow exercises. Visual-perceptual. auditory-perceptual, acoustic, aerodynamic and voice-related quality-of-life measures were obtained at three time points: before treatment, three weeks after initiation of treatment and after completion of treatment.

RESULTS

Voice quality was perceived to be significantly improved in both groups. Voice related quality-of-life trended toward improvement for both groups across time points. Changes in aerodynamic and acoustic measures did not reach statistical significance compared to baseline for both groups. Visual comparisons of laryngeal closure patterns demonstrated comparably better outcomes for Group 1.

CONCLUSIONS

Results of this study indicate flow phonation exercises can potentially be favorably employed for individuals with MTD1. In particular, it appears that the exercises aid in alleviating vocal hyperfunction, as evidenced by visual perceptual stroboscopic analysis, and clinically improved auditory-perceptual measures.

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.

Effects of low-frequency repetitive transcranial magnetic stimulation in adductor laryngeal dystonia: a safety, feasibility, and pilot study

PURPOSE

The effects of neuromodulation are virtually unexplored in adductor laryngeal dystonia (AdLD), a disorder characterized by involuntary contraction of intrinsic laryngeal muscles. Recent findings indicated that intracortical inhibition is reduced in people with AdLD. Low-frequency repetitive transcranial magnetic stimulation (rTMS) induces prolonged intracortical inhibition, but the effects in AdLD are unexplored. This pilot and feasibility study aimed to examine the safety, feasibility, and effects of a single session 1 Hz rTMS over the laryngeal motor cortex (LMC) in people with AdLD and healthy individuals.

METHODS

The stimulation location was individualized and determined through TMS-evoked responses in the thyroarytenoid muscles using fine-wire electrodes. 1200 pulses of 1 Hz rTMS were delivered to the left LMC in two groups: Control (n = 6) and AdLD (n = 7). Tolerance, adverse effects, intracortical inhibition, and voice recordings were collected immediately before and after rTMS. Voice quality was assessed with acoustic-based and auditory-perceptual measures.

RESULTS

All participants tolerated the procedures, with no unexpected adverse events or worsening of symptoms. No significant effects on intracortical inhibition were observed. In the AdLD group, there was a large-effect size after rTMS in vocal perturbation measures and a small-effect size in decreased phonatory breaks.

CONCLUSIONS

One rTMS session over the LMC is safe and feasible, and demonstrated trends of beneficial effects on voice quality and phonatory function in AdLD. These preliminary findings support further investigation to assess clinical benefits in a future randomized sham-controlled trial. CLINICALTRIALS.GOV: NCT02957942, registered on November 8, 2016.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357.

Measuring Stakeholder Perceptions: A Review of Social Validity Reporting in ASHA Journals

Purpose Intervention research in speech-language pathology is growing; however, there remains a gap between research and clinical practice. To promote evidence-based practice, stakeholder input may be solicited during the development and evaluation of treatments. One method of evaluating stakeholder input is by subjectively measuring social validity. Social validity probes end users' satisfaction and acceptability of a treatment. Method This review article explores the type and frequency of subjective social validity measures reported in speech-language pathology treatment literature published in American Journal of Speech-Language Pathology; Journal of Speech, Language, and Hearing Research; and Language, Speech, and Hearing Services in Schools from January 2017 through April 2019. In total, 93 treatment studies were included and coded descriptively. Results Of the 93 treatment studies included in this review, 20 reported subjective measures of social validity. The most common method of measurement was questionnaires (n = 19), followed by interviews (n = 5), and direct observation (n = 1). Conclusions Only 21.5% of reviewed speech-language pathology treatment articles from American Speech-Language-Hearing Association journals reported measures of social validity, although it is a crucial component of implementation of evidence-based practice. We urge researchers and journal editors to include social validity measures in treatment literature as we promote the uptake of evidence-based practices and the involvement of stakeholders during the development of evidence-based practices. We also encourage the development of social validity measures that can be validated on individuals with communication disorders.

Mapping Meta-Therapy in Voice Interventions onto the Rehabilitation Treatment Specification System

Meta-therapy refers to the clinical dialogue via which direct and indirect voice treatments are introduced and discussed, and which helps build a useful conceptual framework for voice therapy. Meta-therapy was idiosyncratically defined in previous work. However, the current colloquial narrative of meta-therapy is not standardized or specific enough to be reliably taught, rigorously studied, or clinically delivered with high fidelity. Therefore, this article uses a standard framework (the Rehabilitation Treatment Specification System or RTSS) to further articulate and operationalize meta-therapy in vocal rehabilitation. Meta-therapy's conceptual framework generally aligns with the RTSS's treatment theory and associated concepts; e.g., the treatment component and its underlying ingredients, mechanisms of action, and target. Because the treatment theories in meta-therapy most frequently involve mechanisms of action related to information processing, they primarily map onto the RTSS's Representations treatment components. The treatment targets in meta-therapy are often focused on changes in the patient's cognitions, knowledge, beliefs, attitudes, intentions, and/or awareness regarding voice-related modifications. The ingredients in meta-therapy are frequently clinician actions conveying information with the goal of appropriately shaping the patient's mental representations, and are delivered with verbal cues, stories, analogies, etc. This manuscript provides specific examples of how meta-therapy is applied in clinical voice practice. Considerations for future investigation of meta-therapy are proposed.

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.

Does More Compression Mean More Pressure? A New Classification for Muscle Tension Dysphonia

Objective The aims of this study were to test the hypothesis that greater supraglottic compression (anteroposterior or lateral) correlates with higher subglottic pressure (SGP) and to develop a classification of muscle tension dysphonia (MTD), based on the degree of supraglottic compression during speech. Method A prospective, cross-sectional study was conducted in a series of 37 consecutive patients diagnosed with MTD with an altered aerodynamic profile characterized by high SGP (more than 90 mmH₂O). Supraglottic anteroposterior and lateral compression were categorized in three grades and assessed during the laryngoscopic examination. All patients completed the Spanish Voice Handicap Index (VHI) questionnaire and completed an acoustic and aerodynamic voice assessment. The relationship between compression grade and VHI with SGP was analyzed. Results More than 90% of patients demonstrated some degree of anteroposterior compression, and 67% had some degree of lateral compression. The mean (SD) SGP was 111.03 (16.7) mmH₂O, and the mean VHI was 27.86 (12.5). The degree of SGP was statistically different in the different grades of anteroposterior compression, and also anteroposterior compression correlated with an SGP (p < .05). The degree of lateral compression was not correlated with SGP. Neither the degree of anteroposterior or lateral compression nor the value of SGP was found to correlate with VHI. Conclusions Because grade of anteroposterior compression correlates with SGP, these grades can be used for diagnosis and follow-up of MTD patients. To this end and on this basis, we propose a new classification for MTD. Unlike the established classification, our proposed one makes it possible to combine different laryngoscopic features, improving the description of the larynx during phonation.

Isolated and Combined Respiratory Training for Muscle Tension Dysphonia: Preliminary Findings

PURPOSE

The purpose of this study was to determine the feasibility of altering speech breathing patterns and dysphonia severity through training increased levels of lung volume use during speech. It was hypothesized that respiratory-based training would increase lung volume levels during speech as well as improve acoustic voice measures, and that the addition of laryngeal-based treatment would further improve voice acoustics by treatment completion.

METHOD

A multiple baseline, single subject design was replicated over six participants with primary muscle tension dysphonia as a preliminary investigation of novel respiratory treatment methods. Following four baseline probes (1-4), two phases of treatment were implemented over 6 weeks. Respiratory lung volume-based training (RLVT) and subsequent performance was probed at sessions 5 to 7 and laryngeal-based training was added to the RLVT and probed at sessions 8 to 10. Visual biofeedback was used during RLVT to assist the motor learning process. Respiratory outcome measures of lung volume initiation, termination and excursion were objectively measured using respiratory plethysmography (InductoTrace), and cepstral and spectral-based acoustic measures were also determined at each time point.

RESULTS

All participants showed improvement in one or more respiratory measures as well as reduced acoustic dysphonia severity following phase 1 of RLVT alone. Two participants achieved further marked improvement in acoustic voice measures after laryngeal-based training was added in phase 2 of treatment, but this was generally also accompanied by further improvement or stabilization of respiratory measures.

CONCLUSION

Results from this preliminary study support the feasibility of RLVT for improving speech breathing behavior, and suggest that RLVT alone can improve objectively measured dysphonia severity.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis

BACKGROUND

Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice.

OBJECTIVE OF REVIEW

To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered.

EVALUATION METHOD

The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results.

RESULTS

We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements.

CONCLUSIONS

Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.