A Nonrandomized Trial for Student Teachers of an In-Person and Telepractice Global Voice Prevention and Therapy Model With Estill Voice Training Assessed by the VoiceEvalU8 App

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.

Remote Voice Therapy With an Oscillatory Positive Expiratory Pressure Device in Subjects With Vocal Fatigue: A Randomized Controlled Trial

PURPOSE

The present study aimed at assessing the efficacy of remote voice therapy (telepractice) implemented with Shaker Medic Plus device in subjects with vocal fatigue.

METHOD

Thirty-six participants were initially enrolled in this study. Twenty-four participants with vocal fatigue were finally randomly assigned to one of two treatment groups: (a) voice treatment with Shaker Medic Plus device plus vocal hygiene program (n = 12) and (b) voice treatment with water resistance therapy (WRT) plus vocal hygiene program (n = 12). Laryngoscopic assessment was conducted on all subjects. Before and after voice therapy, participants underwent (a) self-assessment of voice: Vocal Fatigue Index and Vocal Tract Discomfort Scale and (b) instrumental assessment with aerodynamic, acoustic, and electroglottographic measures. The treatment period included six voice therapy sessions within 6 weeks. Each session lasted 30 min. For both groups, exercises consisted of a sequence of nine phonatory tasks performed with Shaker Medic Plus (experimental group) and WRT (control group). Comparisons for all variables were performed between the experimental group and control group.

RESULTS

Significant improvements were found for self-reported variables when comparing pre- and postmeasures for both groups. No significant differences were found when comparing groups. No significant main effects or interactions were observed for any of the observed instrumental variables.

CONCLUSIONS

Remote physiologic voice therapy with Shaker Medic Plus device and water resistance therapy seem to be both effective to improve voice in subjects diagnosed with vocal fatigue. No differences should be expected between these therapeutic protocols when treating patients with vocal fatigue. Moreover, both are effective at reducing tiredness of voice, voice avoidance, physical discomfort associated with voicing, subjective perception of sensory discomfort in throat, and reduction of physical, emotional, and functional impact of voice problems.

Introduction of Voice Type Component (VTC) as an Effective Acoustic Voice Analysis Method in Tele-evaluation

OBJECTIVE

Telepractice in voice health care and evaluation services has attracted much attention in recent years. Multiple studies have proven the effectiveness of voice therapy with telepractice. However, voice evaluations are still mostly conducted in person due to the lack of sensitive acoustic analysis methods.

METHODS

This study examined various acoustic analysis methods for voice evaluation in telepractice. Eighteen female elementary school teachers with self-reported voice disorders volunteered to participate in the study. Speech samples were collected before and after the interventions using two voice sampling methods concurrently. One set of data was collected using the traditional voice sample collection method by the therapist in person. The second set of data was collected on the same speech samples using the clients' own smartphones, and the collected voice samples were later sent to the researcher for further acoustic analysis. The voice type component (VTC) measurement represented the proportion of different VTCs in a voice by measuring the chaos and intrinsic dimension.

RESULTS

Voice analyses were conducted on both sets of data, and the correlation between the two sampling procedures was analyzed. It appears that the VTC could be a more reliable method for producing acoustic analysis results with voice samples collected from smartphones compared to other objective voice assessment procedures. This reliability has been demonstrated via statistical analysis, including correlation coefficient, pairwise t test, d-prime, and area under the curve. The results of this study highlighted the VTC as an effective and accurate acoustic analysis method in tele-evaluation.

CONCLUSIONS

This feasible voice sampling method, which utilizes participants' own smartphones, will reduce barriers to accessing limited voice specialists due to distance and will decrease the cost of care by minimizing expenses associated with travel and additional equipment for voice sampling. Ultimately, this approach will enhance the effectiveness of voice care delivered through telepractice to patients in remote and underserved areas.

Rapid Implementation of Teletherapy for Voice Disorders: Challenges and Opportunities for Speech-Language Pathologists

INTRODUCTION

The COVID-19 pandemic necessitated a rapid restructuring of the clinical management of voice and upper airway disorders by speech-language pathologists (SLPs). As in-person therapy sessions were suspended, voice-specialized SLPs across healthcare settings shifted to online teletherapy. In this survey study, we queried voice therapists on their experiences with and opinions regarding the adoption of teletherapy into routine clinical practice.

METHODS

Voice-specialized SLPs were recruited nationwide to complete an online survey which included questions about the usability of software and hardware, patient management, the effectiveness of therapy, overall satisfaction, and suggestions for improvement.

RESULTS

48 participants completed the survey. The majority of respondents reported frequent technical difficulties and poor access to or understanding of appropriate equipment. Overall, participants endorsed better patient access, attendance, and compliance, as well as increased scheduling flexibility. While 95% of the respondents stated they would recommend teletherapy to another SLP, only 20% supported a shift to exclusively virtual sessions. Forty percent of respondents endorsed a hybrid model consisting of initial in-person sessions followed by virtual ones.

DISCUSSION

Incorporating teletherapy into clinical voice practice has, for the most part, followed Carl May's normalization process theory framework, in that clinicians have invested understanding, training, time and effort, and appraisal into its implementation. However, the unusually rapid pace of change necessitated by the pandemic has presented its own set of challenges. Given the inherent conveniences of virtual therapy, the online modality is likely here to stay. It is critical that we understand the facilitators and barriers to its successful adoption.

The Vocal Priorities of College Students With and Without Self-Reported Voice Problems

OBJECTIVES/HYPOTHESIS

To determine if the Vocal Priorities Questionnaire (VPQ) could be used in people who were not seeking treatment for a voice problem. To determine if the VPQ could be used to compare groups based on self-reported voice problems. To determine if vocal priorities (loudness, clarity, pitch, pitch range) vary based on self-reported voice problems.

STUDY DESIGN

Prospective cross-sectional study.

METHODS

An online survey that contained demographic questions, questions about self-reported voice problems, and the VPQ was distributed to undergraduate university students. Confirmatory factor analyses (CFA) and exploratory factor analysis (EFA) were completed to determine if the VPQ was appropriate for use in this population. Invariance testing determined if the VPQ could be used to compare groups. Cronbach's alpha determined internal consistency. An analysis of variance was conducted to compare the scores for each vocal priority across three self-reported voice problem categories: never, current, and past.

RESULTS

Responses from 285 participants were analyzed. An initial CFA found that the four-priority VPQ originally proposed did not have adequate fit indices. An EFA and modified CFA revealed that four priorities were still present, but "not having a gravelly voice" fit better with the priority of pitch, not clarity. With this model, invariance was verified and Cronbach's alpha indicated internal consistency. Loudness was the top vocal priority for 34.8%. In those with a past voice problem, clarity was scored higher compared to those with a current voice problem, F(2, 284) = 5.298, P = 0.006, and pitch range was scored higher compared to those who had never experienced a voice problem, F(2, 284) = 5.431, P = 0.005.

CONCLUSIONS

A modified four-priority version of the VPQ presented with acceptable dimensionality and invariance for college students with and without self-reported voice problems. Scores for clarity and pitch range were influenced by experiences with voice problems.

Effect of Practice Structure and Feedback Frequency on Voice Motor Learning in Older Adults

OBJECTIVES

The long-term goal of this research is to advance the rehabilitation of voice disorders through the study and development of efficacious treatment regimes based upon motor learning principles. This study examined the effect of contextual interference (CI) of practice structure with knowledge of results (KR) feedback on motor learning of a novel voice task, "Twang," by hypophonic, novice, and expert older adults.

STUDY DESIGN

Prospective, randomized controlled mixed design.

METHODS

A total of 92 adults, age 55-80, recruited from the following motor skill levels: 1) Hypophonic voice; 2) Novice-untrained vocalists; 3) Expert-trained vocalists were randomly assigned to four different interventions and examined during acquisition, retention, and transfer phases of motor learning. Participants from each skill-level practiced the novel task, "Twang," according to the randomly assigned Practice Structure/KR combinations: 1) Blocked practice/100%KR; 2) Blocked practice/55% KR; 3) Random practice/100%KR; 4) Random practice/55% KR.

RESULTS

During the motor performance phase, our results mirrored those reported in the limb motor learning literature for CI: A Blocked practice structure enhanced short-term effects of motor acquisition for novice, expert, and hypophonic subjects. The only significant result for KR occurred when paired with Random Practice in the hypophonic subject group: 100% KR paired with Blocked practice increased motor performance, but degraded motor learning.

CONCLUSIONS

Fundamental motor learning principles were explored within the context of a voice training paradigm. Practice with a high CI and low frequency of KR degraded performance during short-term acquisition but enhanced long-term performance effects of motor learning. Voice clinicians and teachers may benefit by implementing motor learning theory into practice during training and treatment sessions.

An Assessment of Different Praat Versions for Acoustic Measures Analyzed Automatically by VoiceEvalU8 and Manually by Two Raters

INTRODUCTION

The purpose of the study was to assess acoustic measures of fundamental frequency (f_o), standard deviation of f_o (SD of f_o), jitter%, shimmer%, noise-to-harmonic ratio (NHR), smoothed cepstral peak prominence (CPPS), and acoustic voice quality index analyzed through multiple Praat versions automatically by VoiceEvalU8 or manually by two raters. In addition, default settings to calculate CPPS in two Praat versions manually analyzed by two raters were compared to Maryn and Weenik²⁰ procedures for CPPS automatically analyzed by VoiceEvalU8.

METHODS

Nineteen vocally healthy females used VoiceEvalU8 to record three 5-s sustained /a/ trials, the all voiced phrase "we were away a year ago," and a 15-s speech sample twice a day for five consecutive days. Two raters manually completed acoustic analysis using different versions of Praat and compared that analysis to measures automatically generated through a version of Praat used by VoiceEvalU8. One-way analyses of variance were run for all acoustic measures with post-hoc testing by the Bonferroni method. For acoustic measures that demonstrated significant differences, intraclass correlation coefficients were conducted.

RESULTS

Results showed no significant differences across automatic and manual analysis for different versions of Praat for all acoustic measures during /a/, for f_o, jitter%, shimmer%, and NHR during the phrase, for jitter%, shimmer%, NHR, and CPPS during speech, and for acoustic voice quality index calculated from both sustained /a/ and the phrase. The default Praat settings for CPPS were not significantly different from the Maryn and Weenik²⁰ procedures for sustained /a/ and speech. Significant differences were present for SD of f_o and CPPS during the phrase and f_o and SD of f_o during speech. SD of f_o and CPPS in the phrase were moderately correlated and f_o and SD of f_o during speech demonstrated good to excellent correlations across the different versions of Praat.

CONCLUSIONS

Acoustic measures analyzed through sustained /a/ and some of the acoustic measures during the phrase and speech were not different across multiple versions of Praat. Automatic analysis by VoiceEvalU8 produced similar mean values as compared to manual analysis by two raters. Even though SD of f_o and CPPS in the phrase and f_o and SD of f_o in speech were different across the versions of Praat, the measures demonstrated moderate to excellent reliability.