The Impact of Referral Source on Voice Therapy.

INTRODUCTION: Adherence to voice therapy is essential in achieving successful voice outcomes. Previous studies within the field of voice therapy have suggested that shorter wait times and utilization of an interprofessional practice (IPP) model of care have a positive effect on voice therapy completion rates. While the implementation of IPP has gained popularity, especially at academic voice centers, the majority of speech-language pathologists (SLP) practice in a traditional (T) setting where they are unaffiliated with the referring otolaryngologist. PURPOSE: This study aims to further examine how SLP practice models (interprofessional vs traditional) affect voice therapy initiation and completion rates. The secondary aim is to determine if voice therapy attendance rates have changed since the authors' initial investigations over 10 years ago. METHODS: A retrospective chart review of 452 patients was conducted. Data was collected on patient demographics (sex, age), diagnosis, severity of dysphonia (CAPE-V), quality of life impact (V-RQOL raw score), practice setting (IPP vs T), date of referral, date of voice therapy initial evaluation, number of therapy sessions completed, and attendance to therapy sessions defined as completion or dropout. RESULTS/CONCLUSIONS: Initiation of voice therapy treatment was the point in the referral process that was most impacted by practice model. Over half (53%) of referrals to voice therapy in a traditional practice model did not lead to initiation of treatment, while only 23% of the referrals taking place in an IPP model failed to initiate (P < 0.001). This study also demonstrated an improving, but continued rate of noninitiation and dropout from voice therapy when compared to data that was collected 10 years prior.

Immediate Effects of Mindfulness Meditation on the Voice.

OBJECTIVES: The benefits of mindfulness meditation are well documented. This study evaluated the immediate effects of mindfulness meditation (MM) on the voice and voice user. STUDY DESIGN: Prospective experimental study. METHODS: Participants: 19 vocally healthy (VH) individuals, and 26 individuals with common voice disorders (CVD; benign lesions and hyperfunctional muscle tension) deemed stimulable for voice therapy. Exclusionary criteria: prior training or regular meditation practice. Participants recorded speech samples before and after a 11.5-minute prerecorded session of MM. PRIMARY OUTCOMES: phonatory aerodynamics and participants' self-reported experience of voice. SECONDARY OUTCOMES: self-reported anxiety, vocal acoustics, speech breathing patterns, and auditory-perceptual outcomes. Baseline self-reported measures of voice (Voice Handicap Index-10 - VHI-10), breathing (Dyspnea Index - DI), stress (Perceived Stress Scale - PSS), and trait mindfulness (Cognitive and Mindfulness Scale - Revised, CAMS-R, Five Facet Mindfulness Questionnaire - FFMQ) were compared between groups. RESULTS: At baseline, CVD had significantly higher VHI-10 (P< 0.001) and DI (P= 0.0014), and lower trait mindfulness (CAMS-R, P= 0.02). No difference between groups for PSS or FFMQ. Changes postMM: decreased CPP for all-voiced sentences for VH (P= 0.003), decreased mean SPL (P= 0.012) on sustained vowel for VH, increased mean phonatory airflow during sustained vowel for CVD (P = 0.012). VH demonstrated a decrease in CPP on the all-voice sentence, and CVD demonstrated an increase, resulting in a significant between group difference (P= 0.013). Participants reported improvements in voice, emotional and physical states. State anxiety decreased for both groups (= < 0.001). No other objective outcomes reached significance. CONCLUSIONS: After a brief MM, participants experienced improvement in physical, emotional, and cognitive states, and in their perceptions of their voice. Results indicate that a brief, single session of MM may be beneficial for some, but not sufficient to override habitual voice and speech patterns. Given the benefits of MM, future work should evaluate MM in a standard voice therapy protocol.

Airflow Patterns of Running Speech in Patients With Voice Disorders.

OBJECTIVE: Aerodynamic measures of voice have historically been acquired using sustained phonation tasks. This study seeks to determine whether there are differences in airflow during sustained phonation (MFs), in running speech (MFrs), or during phonation in running speech (MFvrs). We also seek to determine whether these patterns are diagnostically significant. METHODS: Data were collected on 40 subjects (15 men, 25 women), ages 20-79, with a mean age of 53 in this prospective study. All participants received a comprehensive videostroboscopic evaluation and were deemed appropriate for voice evaluation and trial therapy. The Phonatory Aerodynamic System 6600 was used for data collection. The Comfortable Sustained Phonation and Running Speech protocols were used for data acquisition. Patient diagnoses were divided into five subgroups: benign lesions, vocal fold paralysis or paresis, muscle tension dysphonia, edema or laryngitis, and chronic cough. Statistical methods such as analysis of variance and Tukey tests assessed pairwise differences in the airflow rate. Pairwise Tukey multiple comparisons of means testing using a 95% family-wise confidence level were completed to determine the interrelationships of the pairs. RESULTS: Differences were found among airflow measures (P value = 0.0152), pairwise comparisons of MFs-MFvrs pair (P value = 0.012), and diagnosis. No significance was found in MFs-MFrs (P = 0.051) or MFvrs-MFrs (P = 0.94) pairs. Mean flow rates were higher than the norms in MFs. The overall range of mean airflow was similar to those of published norms. CONCLUSION: Assumptions about mean airflow of connected speech should not be made based on sustained phonation tasks alone. No salient diagnostic characteristics were found by diagnosis.

Aerodynamic Patterns in Patients With Voice Disorders: A Retrospective Study.

OBJECTIVE: A recently published retrospective chart review of aerodynamic profiles of women with primary muscle tension dysphonia by Gillespie et al (2013) identified various relationships between mean airflow rate (MFR) and estimated subglottal pressure (est-Psub). The current retrospective study expanded the diagnostic categories to include all voice disorders referred for voice therapy. Three research questions were proposed: (1) Are there differences in the MFR and the est-Psub compared with the normal control group? (2) Within the disordered population, are there different variations in the pairing of MFR and est-Psub? (3) If these variations exist, are they diagnosis specific? METHODS: A retrospective chart review of patients seen for acoustic and aerodynamic voice assessment at the Emory Voice Center between January 1, 2013 and December 31, 2014, were examined for aerodynamic measures of est-Psub and MFR; of these, 192 met the inclusion criteria. Simple t test, two-step cluster analysis, and analysis of variance, as well as Tukey multiple comparisons, were performed using R and SPSS. RESULTS: Mean est-Psub was significantly greater in the group with voice disorder than in the control group (P value < 0.001). However, no statistical significance was found when comparing the MFR with the control group (P value <0.59). Nine possible pairings of MFR and est-Psub were found. Sufficient evidence was not found to detect significant differences in these pairings across diagnostic groups. CONCLUSION: With regard to the rate and interrelationships of MFR and est-Psub, the findings of this study are similar to those of Gillespie et al, that is, MFR and est-Psub are not determinate of diagnosis.

Differences in temporal variables between voice therapy completers and dropouts.

OBJECTIVES: The aim of this study was to examine temporal variables thought to be associated with voice therapy completion. STUDY DESIGN: Retrospective chart review of 197 cases (120 dropouts and 77 completers) seen at two voice centers. METHODS: Cases included males and females aged 15-90 years presenting with a chief complaint of dysphonia who were referred by an otolaryngologist to a speech-language pathologist for voice therapy. Cases were analyzed from the date of physician referral through the final therapy session. The dependent variable was completion of voice therapy. Independent variables included selected temporal variables related to the timing, frequency, and duration of voice therapy. A binary logistic regression was performed to evaluate the relationship between the dependent variable and the temporal variables. Differences between groups were assessed with independent t tests and post hoc analysis. RESULTS: There were significant differences between groups for the number of sessions attended and the wait time between otolaryngology referral and speech-language pathology evaluation, which were also the strongest predictors of therapy completion. CONCLUSIONS: There was a strong relationship found between selected temporal variables and therapy completion. Future research directions will examine methods to use these findings to effect a reduction in voice therapy dropout.

A study of voice therapy dropout.

Treatment dropout is a consistent problem among behavior change therapies. A recent study by the authors demonstrated that 38% of patients did not attend a voice evaluation after referral by the otolaryngologist. Further, 47% of patients who attended a voice evaluation did not return for therapy. No previous study has set out to document completion/dropout rates for voice therapy, but high rates of attrition are reported as problematic within voice therapy research studies. The purpose of this study was to quantify the problem of voice therapy dropout over the course of voice therapy and to analyze factors that may predict dropout using a retrospective chart review. Data were collected at two voice centers and included demographics (gender, age, and race/ethnicity), quality-of-life impact (Voice Handicap Index [VHI]), severity of dysphonia (Consensus Auditory Perceptual Evaluation of Voice [CAPE-V] overall severity score), diagnosis, and completion/dropout status. Results indicated a 65% voice therapy dropout rate in this study. There was no significant difference in dropout rates for gender, age, race, VHI, CAPE-V, or diagnosis. No factor studied was strongly associated with dropout. The 65% dropout rate in this study was consistent with literature published in other behavior change fields. The variables analyzed in this study were not predictive of dropout. Future research should examine methods to effect a reduction in dropout, from otolaryngologist referral through completion of therapy.