Effect of Clinical Expertise on Efficacy of Vocal Function Exercises in Individuals With Typical Voice.

OBJECTIVES/HYPOTHESIS: To determine the effect of clinical expertise on efficacy of Vocal Function Exercises (VFEs) as measured by change in percent of maximum phonation time goal attained. The hypothesis was that clinical expertise would result in greater increases in percent of maximum phonation time goal attained. STUDY DESIGN: Randomized controlled trial. METHODS: A convenience sample of 19 individuals with typical voice was recruited in a university academic clinic setting. All participants completed baseline assessment and 17 completed all study procedures. Participants were randomized to receive VFEs from an expert voice clinician with more than 40 years' experience (expert group (EG)) or from a master's student in Communication Sciences and Disorders trained in VFEs (novice group (NG)). The primary outcome measure was change in percent of maximum phonation time goal attained during VFE tasks 1 and 4. RESULTS: Mean change scores for maximum phonation time were 27.71 (P = 0.001) and 25.31 (P = 0.003) for EG and NG, respectively. Both groups improved significantly on the primary outcome measure, but the difference between groups was not statistically significant (P = 0.759). A Hedges'-g effect size of -0.14 [-1.10, 0.81] was obtained comparing EG and NG groups, indicating a small negative effect of limited clinical expertise on VFE outcomes in individuals with typical voice. CONCLUSIONS: Speech-language pathologists with varied levels of expertise are capable of efficaciously administering VFEs in individuals with typical voice.

The Effect of Maximum Phonation Time Goal on Efficacy of Vocal Function Exercises.

OBJECTIVES/ HYPOTHESIS: To determine the effect of maximum phonation time goal on efficacy of Vocal Function Exercises (VFEs) as measured by percent of maximum phonation time goal attained. The hypothesis was that provision of a maximum phonation time goal would result in greater increases in percent of maximum phonation time goal attained. STUDY DESIGN: Randomized controlled trial. METHODS: A convenience sample of individuals with normal voice were recruited in a university academic clinic setting. Of 34 participants who volunteered for the study, 28 completed baseline assessment and 19 completed all study procedures. Participants were randomized to complete VFEs with knowledge of their maximum phonation time goal (standard goal, SG), with knowledge of their maximum phonation time goal after three weeks (delayed goal, DG), or without knowledge of their maximum phonation time goal (no goal, NG). The primary outcome measure was percent of maximum phonation time goal obtained during VFE tasks one and four. RESULTS: Mean change scores for maximum phonation time were 32.50 (SG), 34.55 (DG), and 21.02 (NG). Hedges' g effect sizes of -0.10 (-1.19, 0.99) and 0.56 (-0.55, 1.67) were obtained comparing DG and SG groups, and NG and SG groups, respectively. CONCLUSIONS: Absence of maximum phonation time goal attenuates VFE efficacy; maximum phonation time goal is an active ingredient within VFEs.

Developing and Testing a Smartphone Application to Enhance Adherence to Voice Therapy: A Pilot Study.

The present study aimed to develop a smartphone application (app) that addressed identified barriers to success in voice therapy; accessibility, and poor adherence to home practice. The study objectives were (1) to investigate if app use enhanced adherence to the home practice of voice therapy and (2) to test app usability. Maximizing the effectiveness of voice therapy is vital as voice disorders are detrimental to personal and professional quality of life. A single-blinded randomized clinical trial was completed for the first objective. Participants included normophonic individuals randomly assigned to the app group or the traditional group. The primary outcome measure was adherence measured as the number of missed home practice tasks. The second objective was completed through usability testing and a focus group discussion. The app group (n = 12) missed approximately 50% less home practice tasks as compared to the traditional group (n = 13) and these results were statistically significant (p = 0.04). Dropout rates were comparable between the two groups. Usability results were positive for good usability with high perceived usefulness and perceived ease of use. App use resulted in improved adherence to home practice tasks. App usability results were positive, and participants provided specific areas of improvement which are achievable. Areas for improvement include app engagement and willingness to pay.

Vocal Function Exercises With and Without Maximally Sustained Phonation: A Randomized Controlled Trial of Individuals With Normal Voice.

OBJECTIVES: To determine the effect of maximally sustained phonation on efficacy of Vocal Function Exercises as measured by percent of maximum phonation time goal attained. The hypothesis was that maximally sustained phonation would result in greater improvements in percent of maximum phonation time goal attained. STUDY DESIGN: Randomized controlled trial. METHODS: A convenience sample of individuals with normal voice were recruited in a university academic clinic setting. Of 34 participants who volunteered for the study, 31 completed baseline assessment and 23 completed all study procedures. Participants were randomized to complete Vocal Function Exercises (traditional group TG), modified Vocal Function Exercises with reduced requirement for maximally sustained phonation (midpoint group MG), or modified Vocal Function Exercises with removed requirement for maximally sustained phonation (baseline group BG). The primary outcome measure was percent of maximum phonation time goal obtained during Vocal Function Exercises. RESULTS: The MG (p = 0.008) and TG (p = 0.001) groups significantly improved percent of maximum phonation time goal attained after six weeks of exercise, while the BG group (p = 0.0202) did not (ɑ = 0.0125). Difference among groups was not statistically significant (p = 0.67, ɑ = 0.0125). Hedges' g effect sizes of 0.29 (-0.66, 1.25) and 0.51 (-0.57, 1.58) were obtained comparing MG and TG groups, and BG and TG groups, respectively. CONCLUSIONS: Greater requirements for maximally sustained phonation improved efficacy of Vocal Function Exercises in enhancing normal voice as measured by percent of maximum phonation time goal attained. Maximally sustained phonation may be modified to some extent while preserving efficacy of Vocal Function Exercises, however complete elimination of maximally sustained phonation may attenuate improvement. Additional research in a clinical population is warranted.

Defining Roles and Responsibilities for School-Based Tele-Facilitators: Intraclass Correlation Coefficient (ICC) Ratings Of Proposed Competencies.

The primary purpose of this study was to craft and validate a set of core competencies necessary for a tele-facilitator to possess in the school setting. Competencies were created through literature review and qualitative analysis. Following expert review, the competencies were revised and formatted into an online survey which was sent to respondents in four target groups: (a) school administrators who had adopted telepractice as a service delivery model; (b) speech-language pathologists (SLPs) experienced in telepractice within a school setting; (c) current tele-facilitators, and (d) scholars experienced in telepractice. Fifty-seven percent (20 out of 35) of the competencies were rated as "Essential Skills." The remaining competencies could be more or less important depending on workplace requirements.

Cultural and Linguistic Adaptation of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) Into Hindi.

Aim The purpose of this study was to develop and assess the reliability of a Hindi version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Reliability was assessed by comparing Hindi CAPE-V ratings with English CAPE-V ratings and by the Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale. Method Hindi sentences were created to match the phonemic load of the corresponding English CAPE-V sentences. The Hindi sentences were adapted for linguistic content. The original English and adapted Hindi CAPE-V and GRBAS were completed for 33 bilingual individuals with normal voice quality. Additionally, the Hindi CAPE-V and GRBAS were completed for 13 Hindi speakers with disordered voice quality. The agreement of CAPE-V ratings was assessed between language versions, GRBAS ratings, and two rater pairs (three raters in total). Pearson product-moment correlation was completed for all comparisons. Results A strong correlation (r > .8, p < .01) was found between the Hindi CAPE-V scores and the English CAPE-V scores for most variables in normal voice participants. A weak correlation was found for the variable of strain (r < .2, p = .400) in the normative group. A strong correlation (r > .6, p < .01) was found between the overall severity/grade, roughness, and breathiness scores in the GRBAS scale and the CAPE-V scale in normal and disordered voice samples. Significant interrater reliability (r > .75) was present in overall severity and breathiness. Conclusions The Hindi version of the CAPE-V demonstrates good interrater reliability and concurrent validity with the English CAPE-V and the GRBAS. The Hindi CAPE-V can be used for the auditory-perceptual voice assessment of Hindi speakers.

Does a Systematic Vocal Exercise Program Enhance the Physiologic Range of Voice Production in Classical Singing Graduate-Level Students?

Purpose The purpose of this study was to assess the effects of vocal function exercises (VFEs) on the physiologic range of the operatic voice. The primary outcome measure was total voice range profile (VRP) area. Method Forty graduate-level opera majors were randomly assigned to experimental (training with VFE + vocal hygiene) and control (vocal hygiene only) groups. All participants underwent an acoustic voice assessment (modified VRP) pre and post 10 weeks of the assigned intervention. VRP total area was calculated and compared between and within the two groups. The total VRP area was subsequently divided into three area thirds (low, medium, and high). Results A significant improvement (increase) was observed in the VFE group for the primary outcome measure of VRP area when pre- and postvoice conditions were compared for total area, upper third, and middle third. No significant improvement was found in the vocal hygiene-only group. Conclusion Vocal training with VFEs over a 10-week period demonstrated positive effects on physiologic voice range as evidenced by an increase in the total VRP area and therefore may enhance the potential of those who already have professional voice training.

Biobehavioral Measures of Presbylaryngeus.

OBJECTIVE: The objective of this observational study was to assess the relationship between established aging biobehavioral measures and voice decline in normally aging adults. STUDY DESIGN: Cross-sectional study. METHODS: Participants 60-85 years of age were divided into two age and sex-matched groups, based on the presence or absence of presbylaryngeus. Both groups underwent a battery of tests measuring anthropometric variables, inflammatory markers, general health measures, and vocal function parameters. Differences from the norm were calculated for all variables. Parametric and nonparametric tests were performed to assess group differences. In addition, variable selection analysis was performed to determine variables that were most influential in predicting the occurrence of presbylaryngeus in our current sample. RESULTS: Fifty-three participants were divided into age and sex-matched groups of "presbylaryngeus" (n = 26) and "non-presbylaryngeus" (n = 27). The two groups were statistically different in select measures of inflammatory markers, general health measures, and vocal function parameters. Anthropometric measures were not statistically different. Based on variable selection, the variables most predictive of the presence of presbylaryngeus were measures of the Physical Activity Scale of the Elderly, C-reactive protein, laryngeal airway resistance, and vocal roughness. CONCLUSIONS: In addition to group differences in vocal function measures, results for the presbylaryngeus group consistently trended sub-optimally on anthropometric measures, two inflammatory markers, and general health measures. These results suggest that this sample of individuals with presbylaryngeus demonstrated greater biobehavioral deficits associated with aging as compared to age and sex-matched non-presbylaryngeus individuals.

Efficacy of Voice Therapy in Improving Vocal Function in Adults Irradiated for Laryngeal Cancers: A Pilot Study.

BACKGROUND: Radiation therapy (XRT) for laryngeal cancers causes acute and chronic vocal dysfunction. Although these deleterious effects of XRT are well-established, there is a dearth of research with respect to effective voice rehabilitation following XRT for laryngeal cancers. OBJECTIVE: To obtain preliminary data on the efficacy of voice rehabilitation, using vocal function exercises (VFEs) in improving vocal function in adults irradiated for laryngeal cancer. The comparison treatment group (VH) received vocal hygiene counseling. STUDY DESIGN: Randomized clinical trial. METHODS: Participants were randomized to the VFE + VH or VH group. Both interventions lasted 6 weeks. The primary outcome measure was improvement in VHI scores. Secondary outcome measures included auditory-perceptual assessments, acoustic and aerodynamic measures, and laryngeal imaging. RESULTS: Ten participants were recruited for the study. The VFE + VH (n = 6) group demonstrated a statistically significant improvement in the primary outcome measure (P = 0.03), as well as select parameters of all secondary outcome measures. The VH (n = 4) group did not demonstrate a statistically significant improvement in primary or secondary outcome measures. CONCLUSIONS: This study offers preliminary data for the utility of VFEs in the irradiated laryngeal cancer population. However, findings in the VFE + VH group lack generalizability, secondary to sample heterogeneity, and limited sample size.

Vocal function exercises for normal voice: The effects of varying dosage.

PURPOSE: This study examined the effect of varying dosage of vocal function exercise (VFE) home practice on attainment of pre-established maximum phonation time (MPT) goals in individuals with normal voice. High dosage VFE practice was expected to result in greatest MPT. The overarching goal of this study was to contribute to a VFE dosage-response curve, potentially including a point of observable toxicity. METHOD: Twenty-eight females ages 18-25 with normal voice participated in this pre-post longitudinal group study. Participants were randomly assigned to one of three experimental groups and completed a six-week VFE protocol with practice twice daily. The low dosage group performed each exercise once, the traditional group twice, and the high dosage group four times. The primary outcome measure was MPT as performed on the fourth VFE using the prescribed semi-occluded vocal tract posture. RESULT: No toxic effects were observed. MPT increased for all participants, with significant improvement for traditional and high dosage groups. CONCLUSION: High dosage VFEs may yield more rapid improvement in MPT, however benefits must be weighed against the risk of increased attrition. Low dosage VFEs insufficiently improved MPT. Further research on dosage is warranted, and should include individuals with disordered voice.

Effects of Vocal Function Exercises: A Systematic Review.

OBJECTIVES: The purpose of the present review was to systematically analyze the evidence for the effectiveness of vocal function exercises (VFEs) in improving voice production. METHODS: A systematic literature search was performed by two independent reviewers using PubMed and EBSCOHost to access relevant databases and to locate outcome studies that used VFEs as an intervention. Articles that met inclusion criteria were appraised based on the American Speech-Language and Hearing Association's levels of evidence. Effect sizes for outcomes were calculated using Hedge's g. Voice outcomes were categorized according to the five domains of voice assessment: visual perceptual analysis, acoustic analysis, aerodynamic analysis, auditory-perceptual analysis, and patient self-report measures. RESULTS: Twenty-one articles were included for the final appraisal. All studies demonstrated positive effects of VFEs as demonstrated by effect sizes across selected voice parameters. Effect sizes across parameters ranged from -0.59 to 1.55. None of the included studies reported adverse voice outcomes as a result of VFEs. CONCLUSIONS: Outcome studies demonstrate that VFEs are efficacious in enhancing vocal function in individuals with normal and disordered voices, presbylaryngeus, and professional voice users. The available research suggests moderate to strong evidence to support the use of VFEs for a variety of voice disorders.

Vocal function exercises for normal voice: With and without semi-occlusion.

PURPOSE: This study examined the effect of varying degrees of vocal tract (VT) occlusion used during Vocal Function Exercises (VFEs) on attainment of maximum phonation time (MPT) goals in normal voice. Greater VT occlusion was expected to result in increased MPT. The overarching goal was to determine whether the semi-occluded vocal tract (SOVT) posture used during VFEs could be modified while preserving efficacy. METHOD: Twenty-six females ages 18-30 participated in this pre-post longitudinal group study. Participants were randomly assigned to three experimental groups and completed a six-week VFE protocol. The first group performed exercises using the prescribed SOVT posture; the second group used the vowel /o/; group three used the vowel /a/. The primary outcome measure was MPT as performed on the exercise tasks using the assigned vocal tract posture. RESULT: MPT significantly improved in the prescribed SOVT group, but did not significantly improve in the modified /o/ and /a/ groups. CONCLUSION: The SOVT posture used during VFEs is modifiable to a small extent without significantly undermining efficacy. Changes in MPT are less robust with reduced VT occlusion. Research in a clinical population is warranted.

A Multidimensional Study of Vocal Function Following Radiation Therapy for Laryngeal Cancers.

BACKGROUND: Radiation therapy (XRT) has proven to be an effective curative modality in the treatment of laryngeal cancers. However, XRT also has deleterious effects on vocal function. AIM: To demonstrate the multidimensional nature of deficits in vocal function as a result of radiation therapy for laryngeal cancer. STUDY DESIGN: Cohort study. METHODOLOGY: Vocal function parameters were chosen from the 5 domains of voice assessment to complete a multidimensional assessment battery. Adults irradiated (XRT group) for laryngeal cancers were compared to a control group of individuals with no history of head and neck cancers or radiation therapy. The control group was matched in age, sex, and pack years of smoking. RESULTS: Eighteen participants were recruited for the study. The XRT group demonstrated significantly worse clinical values as compared to the control group across select parameters in the each of the 5 domains of voice assessment. DISCUSSION: Radiation therapy for laryngeal cancers results in multidimensional deficits in vocal function. Notably, these deficits persist long term. In the present study sample, multidimensional deficits were persistent 2 to 7 years following completion of XRT. The observed multidimensional persistent vocal difficulties highlight the importance of vocal rehabilitation in the irradiated larynx cancer population.

Contribution of Glottic Insufficiency to Perceived Breathiness in Classically Trained Singers.

Breathiness in the singing voice is problematic for classical singers. Voice students and singing teachers typically attribute breathiness to breath management issues and breathing technique. The present study sought to determine whether glottic insufficiency may also contribute to breathiness in a singer's voice. Studies have revealed a relationship between insufficient vocal fold closure and inefficiency in the speaking voice. However, the effect of insufficient vocal fold closure on vocal efficiency in singers has yet to be determined. Two groups of voice students identified with and without breathiness issues underwent aerodynamic and acoustic voice assessment as well as laryngeal stroboscopy of the vocal folds to quantify the prevalence of insufficient vocal fold closure, also known as glottic insufficiency. These assessments revealed four groups: 1) those with glottic insufficiency and no perceived voice breathiness; 2) those with glottic sufficiency and perceived voice breathiness; 3) those with glottic insufficiency and perceived breathiness; and 4) those with glottic sufficiency and no perceived breathiness. Results suggest that previously undiscovered glottal insufficiency is common in young singers, particularly women, though the correlation with identified breathiness was not statistically significant. Acoustic and aerodynamic measures including noise-to-harmonics ratio, maximum phonation time, airflow rate, subglottal pressure, and laryngeal airway resistance were most sensitive to glottic insufficiency.

Enhancement of aging rat laryngeal muscles with endogenous growth factor treatment.

Clinical evidence suggests that laryngeal muscle dysfunction is associated with human aging. Studies in animal models have reported morphological changes consistent with denervation in laryngeal muscles with age. Life-long laryngeal muscle activity relies on cytoskeletal integrity and nerve-muscle communication at the neuromuscular junction (NMJ). It is thought that neurotrophins enhance neuromuscular transmission by increasing neurotransmitter release. We hypothesized that treatment with neurotrophin 4 (NTF4) would modify the morphology and functional innervation of aging rat laryngeal muscles. Fifty-six Fischer 344xBrown Norway rats (6- and 30-mo age groups) were used to evaluate to determine if NTF4, given systemically (n = 32) or directly (n = 24), would improve the morphology and functional innervation of aging rat thyroarytenoid muscles. Results demonstrate the ability of rat laryngeal muscles to remodel in response to neurotrophin application. Changes were demonstrated in fiber size, glycolytic capacity, mitochondrial, tyrosine kinase receptors (Trk), NMJ content, and denervation in aging rat thyroarytenoid muscles. This study suggests that growth factors may have therapeutic potential to ameliorate aging-related laryngeal muscle dysfunction.