The Accent Method: Behavior readjustment voice therapy

Rehabilitation Treatment Specification System: Content and Criterion Validity Across Evidence-Based Voice Therapies for Muscle Tension Dysphonia

PURPOSE

Systematically improving voice therapy outcomes is challenging as the clinician actions (i.e., active ingredients) responsible for improved patient functioning (i.e., targets) are relatively unknown. The theory-driven Rehabilitation Treatment Specification System (RTSS) and standard, voice-specific terminology based on the RTSS (RTSS-Voice) may help address this problem. This qualitative study evaluated if the RTSS and RTSS-Voice can describe four evidence-based voice therapies for muscle tension dysphonia without missing critical aspects (content validity) and identify commonalities and differences across them (criterion validity).

METHOD

Qualitative interviews were completed between the clinicians (protocol experts) who developed and/or popularized the vocal function exercises, laryngeal reposturing, circumlaryngeal massage, and conversation training therapies as well as RTSS experts to produce RTSS specifications that met two consensus criteria: (a) The protocol expert agreed that the specification represented their treatment theory, and (b) the RTSS experts agreed that the specifications correctly adhered to both the RTSS framework and the RTSS-Voice's standard terminology.

RESULTS

The RTSS and RTSS-Voice comprehensively described voice therapy variations across and within the four diverse treatment programs, needing only the addition of one new target: overall auditory-perceptual severity.

CONCLUSIONS

The RTSS and RTSS-Voice exhibited strong content validity. The standard RTSS-Voice terminology helped identify, for the first time, commonalities and differences in treatment ingredients, targets, and mechanisms of action across four treatments developed for the same patient population. In the long term, the RTSS and RTSS-Voice could provide the framework for an ever-growing collection of clinically meaningful and evidence-based therapy algorithms with potential to improve research, education, and clinical care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25537624.

The combination of accent method and phonemic contrast: an innovative strategy to improve speech production on post-stroke dysarthria

Introduction

Speech production includes segmental and suprasegmental features, which interact and cooperate with each other. Impaired speech production is common in individuals with post-stroke dysarthria. The commonly used phonemic contrast therapy and Accent Method in clinical practice can improve the segmental and suprasegmental aspects, respectively. This study aimed to explore the feasibility and immediate effectiveness of the combination of specific rhythm patterns of the Accent Method and phonemic contrast on speech production.

Methods

Fifteen poststroke dysarthria patients (12 males and three females) first received accentuation task of three rhythm patterns (Largo-slow, Andante-medium, Allegro-fast) and later received speech task in appropriate rhythm patterns combined with phonemic contrast materials and non-phonemic contrast materials. Speech parameters were analyzed by considering speech clarity and prosody.

Results

The results showed that the number of correct target syllables, sentence clarity, and standard deviation of intensity increased significantly, and the average length of pauses and abnormal pause times decreased significantly in Andante (medium) compared to other rhythms. The number of correct target syllables, sentence clarity, and standard deviation of intensity increased significantly compared with those in the non-phonemic contrast in Andante (medium).

Conclusion

The combination of phonemic contrast and Accent Method was verified to have an immediate effect on speech production in Mandarin speakers with post-stroke dysarthria and could be further validated in other diseases with impaired speech production in the clinic in the future.

Effectiveness of Semi-Occluded Vocal Tract Exercises (SOVTEs) in Patients with Dysphonia: A Systematic Review and Meta-Analysis

BACKGROUND

Dysphonia is a disorder characterized by an alteration in the overall quality of the voice which reduces quality of life. Therefore, we assessed the effectiveness of SOVTEs in the management of dysfunctional and organic dysphonia for acoustic, perceptual-auditive, aerodynamic parameters and self-perception of the disease.

METHODS

a systematic review and meta-analysis were conducted. Findings were reported according to the PRISMA statement. Five databases were searched for RCTs and non- or quasi-RCTs. Studies were independently assessed using the Cochrane Risk of bias (RoB) and ROBINS-I tools. Effect sizes (ES) were calculated only at post-treatment. GRADE criteria were used to assess the quality of evidence.

RESULTS

eight articles were included. Studies investigated several SOVTEs, alone or in combination. None of the study was completely judged at low RoB. The quality of evidence resulted very low for each analysis. SOVTEs revealed to be statistically more effective than control interventions in improving F0 (ES: -14.42; CI 95%: -27.16, -1.69); P = 0.03), whereas shimmer did not change significantly (ES: -0.43; CI 95%:-02.02, 1.15; P = 0.59). Not significant changes in favor of control groups were found for jitter (ES: 0.13; CI 95%: -0.14, 0.40; P  = 0.34) and overall gravity in the perceptual-auditory evaluation (ES: 0.13 CI 95%: -0.50, 0.77; P = 0. 68). Among secondary outcomes, evidence suggested that SOVTEs are more effective than control interventions in Psub reduction (ES: -1.47; CI 95%: -2.84, -0.10; P = 0.03); self-assessment resulted not significantly in favor of SOVTEs (VHI/VRQoL: ES -0.23; CI 95% -1.14, 0.69; P = 0.63 and VTDS/VDSI: ES -4.85, CI 95% -25.13, 15.42; P = 0.64).

CONCLUSION

results obtained showed that voice therapy based on SOVTEs is not to consider significantly superior if compared to other treatments, even if a favorable trend was detected and should be taken into consideration. Further high-quality RCTs on specific SOVTEs are recommended to produce better-quality evidence.

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.

Efficacy of the Accent Method of Voice Therapy in Professional Voice Users with Minimal Associated Pathological Lesions of the Vocal Folds

Aims

Minimal associated pathological lesions (MAPLs) of the vocal folds are a group of benign disorders commonly related to phonotraumatic conditions and behaviors. Voice therapy (VT) can play a major role in readjusting these maladaptive behaviors and improve overall voice quality, thereby replace surgical intervention in some cases or act as a complementary treatment to enhance the ultimate therapeutic outcomes. This study aims to explore the short-term effect of the Accent method of VT on vocal subjective measures and acoustics in professional users with MAPLs, evaluate the responsiveness of each vocal fold lesion to the VT, and propose a simple model for providing VT to a sector of the population in great need of non-invasive management.

Materials and methods

This analytical cross-sectional included fifty professional voice users with different MAPLs were exposed to multidimensional voice assessments before and after receiving VT training in a tertiary care hospital. These assessments include GRBAS score, Multidimensional Voice Program (MDVP) and validated Arabic version Voice Handicap Index (VHI-30).

Results

This study showed variable positive effects of VT on the different types of MAPLs. Cysts had the highest level of responsiveness to VT in comparison to other lesions, followed by nodules, polyps, contact granuloma, and Reinke's edema.

Conclusions

VT is a substantial solution for managing voice disorders. It should be considered in the management plan of the various types of MAPLs, even in Reinke's edema, which showed the minimum improvement.

The Nature and Risk Factors of Minimal Associated Pathological Lesions of Vocal Folds at Two Hospitals in the Gulf Area

OBJECTIVE

To identify the possible risk factors related to etiology of the minimal associated pathological lesions (MAPLs) of the vocal folds and their impacts on the recurrence of lesion.

METHODS

This analytical cross-sectional study included 200 subjects presented with dysphonia to the Phoniatrics/Voice Clinics in two hospitals in Gulf region (KSA and UAE). Same number of matched voluntaires from the same hospitals (hospital staffs, employees and their relatives) and relatives of subjects with typical voice quality were included as well. Both groups underwent a simple questionnaire consists of 15 items related to previously accused risk factors of MAPLs.

RESULTS

The bivariant analysis by Fisher's exact test showed that male gender, presence of kids, misuse of voice, alcohol, gastroesophageal reflux diseases and voice handicapping are associated with significant risk to have MAPLs with P values < 0.001 for all except for alcohol (P = 0.015). Welch's t test revealed higher smoking index in subject than control groups with significant difference (P < 0.001). In contrast, spices, family shouting and nearby industry were not potent risk factors in our study group.

CONCLUSION

Vocal trauma especially in females and children is a potent risk factor for vocal fold nodules and cysts. The gastroesophageal reflux is a suggested risk factor for Reinke's edema and contact granuloma. Smoking is the risk factor for MAPLs particularly polyp, contact granuloma, and Reinke's edema. Also, alcohol consumption is a possible risk factors for Reinke's edema. Identification of risk factors of the MAPLs is an important step in planning therapy. Risk factors which are highly related to a specific type of MAPLs should be involved in any planned program for protection, voice rehabilitation and/or prevention of recurrence of that lesion.

Effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia: A randomized controlled trial

PURPOSE

The present study aimed to assess the effectiveness of a physiologic voice therapy program based on different semioccluded vocal tract exercises in subjects with behavioral dysphonia.

METHODS

Thirty-four participants with behavioral dysphonia were randomly assigned to one of two treatment groups: 1) voice treatment with physiologic voice therapy plus vocal hygiene program (n=20), and 2) vocal hygiene program only (n=14). Laryngoscopic assessment was performed in all subjects. Before and after voice therapy, participants underwent aerodynamic, electroglottographic, and acoustic assessment. The Voice Handicap Index (VHI), Voice symptom scale (VoiSs), Vocal tract discomfort scale (VTDS), and self-assessment of resonant voice quality were also performed. The treatment included eight voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with four different semioccluded vocal tract exercises (SOVTE). Comparison for all variables were performed between experimental group and control group.

RESULTS

Wilcoxon test showed significant improvements for experimental group for VHI, VoiSs, VTDS (decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental groups was observed on subglottic pressure, phonation threshold pressure, and glottal airflow across the implemented tasks.

CONCLUSION

Physiologic voice therapy based on semioccluded vocal tract exercises seems to be an effective tool to improve voice in subjects diagnosed with behavioral dysphonia. Apparently, most changes should be expected in variables related to physical and functional aspects compared to objective variables. Subglottic pressure and phonation threshold pressure seem to be the most change-sensitive parameters and they may reflect a reduction in phonatory effort reported by patients after voice therapy.

Resonance Effects and the Vocalization of Speech

Studies of the respiratory and laryngeal actions required for phonation are central to our understanding of both voice and voice disorders. The purpose of the present article is to highlight complementary insights about voice that have come from the study of vocal tract resonance effects.

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

Purpose The aim of this study was to test the hypothesis that stretch-and-flow voice therapy (SnF) is noninferior to resonant voice therapy (RVT) for speakers with muscle tension dysphonia. Method Participants with primary muscle tension dysphonia were randomly assigned to 1 of 2 treatment groups. Participants received 6 sessions of either SnF or RVT for 6 weeks (1 session per week). Pretreatment and posttreatment audio recordings of sustained vowels and connected speech were acquired. Response to treatment was assessed using the voice handicap index (VHI) as the primary outcome measure. Secondary outcome measures included the acoustic voice quality index, the smoothed cepstral peak prominence, and scales from the Consensus Auditory-Perceptual Evaluation of Voice instrument. Data were analyzed for 21 participants who completed the study (12 in the SnF group, 9 in the RVT group). Results Direction of change for the primary outcome measure and all 3 secondary outcome measures at posttreatment was in the direction of improvement for both SnF and RVT. Confidence intervals for VHI measures did not cross the null effect line on forest plots, suggesting significant effects for both treatments on the primary outcome measure. The effect sizes for pretreatment to posttreatment changes in VHI were large for both treatment groups. Similar results were found for the secondary acoustic outcome measures. There were statistically significant pretreatment to posttreatment changes in the primary and secondary outcome measures for patients receiving both treatments, indicating significant improvement in response to both RVT and SnF. There were no statistically significant differences in pretreatment to posttreatment changes in the primary outcome measure or any secondary outcome measure between the two groups. The within-group pretreatment to posttreatment changes in Consensus Auditory-Perceptual Evaluation of Voice scales did not reach statistical significance for either RVT or SnF. Conclusions Both SnF and RVT produced positive treatment response in speakers with muscle tension dysphonia, with no statistically significant difference in the outcome measures between the two treatments. This suggests that SnF is noninferior to RVT and that both are effective options for treating vocal hyperfunction. Results from this study also support previous findings documenting the sensitivity of multidimensional acoustic measurements to treatment response.

Immediate Effects of the Semi-Occluded Ventilation Mask on Subjects Diagnosed With Functional Dysphonia and Subjects With Normal Voices

PURPOSE

The present study was designed to assess the immediate effects of the semi-occluded ventilation mask (SOVM) in subjects with functional dysphonia and subjects with normal voice.

METHODS

Sixty-four participants were included in this study (48 women and 16 men). Thirty-one of them were diagnosed with functional dysphonia and 33 with normal voice. All subjects were randomly assigned to one of two conditions: an experimental condition using the SOVM (n = 33) and a control condition with participants not using the SOVM (n = 31). Thus, within both conditions, participants could be either dysphonic or normal-voiced. This produced a total of four different groups: (1) subjects with normal voice with SOVM (n = 17), (2) subjects with normal voice without SOVM (n = 16), (3) dysphonic subjects with SOVM (n = 16), and (4) dysphonic subjects without SOVM (n = 15). All participants underwent aerodynamic, electroglottographic (EGG), and acoustic assessments, and were also asked to assess their own voice, before and after voice exercises.

RESULTS

Significant differences were found for aerodynamic, EGG, and acoustic variables when comparing SOVM conditions (dysphonic and normal) against control. Cepstral peak prominence and EGG contact quotient showed an increase among dysphonic participants with SOVM. L1-L0 showed an increase for all participants in SOVM condition (dysphonic and normal). Self-perceived resonant voice quality showed an increase for both groups in SOVM condition. Glottal airflow showed a decrease for the dysphonic participants in SOVM condition. Phonation threshold pressure and subglottic pressure showed a decrease for both groups in SOVM condition.

CONCLUSION

The present study suggests that immediate positive effect could be produced by connected speech phonatory tasks using the SOVM in both dysphonic subjects and subjects with normal voice, the change being greater among the former. SOVM seems to promote an easy voice production and a more efficient phonation.

A Randomized Controlled Trial of Two Semi-Occluded Vocal Tract Voice Therapy Protocols

PURPOSE

Although there is a long history of use of semi-occluded vocal tract gestures in voice therapy, including phonation through thin tubes or straws, the efficacy of phonation through tubes has not been established. This study compares results from a therapy program on the basis of phonation through a flow-resistant tube (FRT) with Vocal Function Exercises (VFE), an established set of exercises that utilize oral semi-occlusions.

METHOD

Twenty subjects (16 women, 4 men) with dysphonia and/or vocal fatigue were randomly assigned to 1 of 4 treatment conditions: (a) immediate FRT therapy, (b) immediate VFE therapy, (c) delayed FRT therapy, or (d) delayed VFE therapy. Subjects receiving delayed therapy served as a no-treatment control group.

RESULTS

Voice Handicap Index (Jacobson et al., 1997) scores showed significant improvement for both treatment groups relative to the no-treatment group. Comparison of the effect sizes suggests FRT therapy is noninferior to VFE in terms of reduction in Voice Handicap Index scores. Significant reductions in Roughness on the Consensus Auditory-Perceptual Evaluation of Voice (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hillman, 2009) were found for the FRT subjects, with no other significant voice quality findings.

CONCLUSIONS

VFE and FRT therapy may improve voice quality of life in some individuals with dysphonia. FRT therapy was noninferior to VFE in improving voice quality of life in this study.

Intraoral pressures produced by thirteen semi-occluded vocal tract gestures

The use of semi-occluded vocal tract (SOVT) exercises as habilitative and rehabilitative tools has grown substantially in the past two decades. As the use of these exercises has grown, so too has the number of variations of the phonatory gestures used to create oral semi-occlusions. While much of the research on SOVT exercises to this point has been conducted using straw phonation, there has been little discussion or investigation regarding how other phonatory gestures that are considered to be SOVT compare to one another. The current study sought to measure the intraoral pressure produced by 13 phonatory gestures generally thought of as oral semi-occlusions. Twenty subjects (10 male, 10 female) produced three tokens of each gesture, and intraoral pressure was recorded via a thin, flexible-cannula pressure transducer. Pressures ranged between 0.1 and 1.0 kPa, but varied significantly between gestures and between subjects.