Behavioral Management of Respiratory/Phonatory Dysfunction for Dysarthria Associated With Neurodegenerative Disease: A Systematic Review.

PURPOSE: This systematic review represents an update to previous reviews of the literature addressing behavioral management of respiratory/phonatory dysfunction in individuals with dysarthria due to neurodegenerative disease. METHOD: Multiple electronic database searches and hand searches of prominent speech-language pathology journals were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. RESULTS: The search yielded 1,525 articles, from which 88 met inclusion criteria and were reviewed by two blinded co-investigators. A large range of therapeutic approaches have been added to the evidence base since the last review, including expiratory muscle strength training, singing, and computer- and device-driven programs, as well as a variety of treatment modalities, including teletherapy. Evidence for treatment in several different population groups-including cerebellar ataxia, myotonic dystrophy, autosomal recessive spastic ataxia of Charlevoix-Saguenay, Huntington's disease, multiple system atrophy, and Lewy body dementia-were added to the current review. Synthesis of evidence quality provided strong evidence in support of only one behavioral intervention: Lee Silverman Voice Treatment Program (LSVT LOUD) in people with Parkinson's disease. No other treatment approach or population included in this review demonstrated more than limited evidence, reflecting that these approaches/populations require urgent further examination. CONCLUSION: Suggestions about where future research efforts could be significantly strengthened and how clinicians can apply research findings to their practice are provided. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24964473.

Reasignación vocal: relación entre autopercepción de la voz, parámetros acústicos y función vocal en mujeres trans / Vocal reassignment: Relationship between voice self-perception, acoustic parameters and vocal function in trans women

Objetivo: Determinar aspectos anatómicos, acústicos y socioemocionales de la voz en mujeres trans.Método: Corresponde a una investigación de tipo cuantitativa con diseño observacional, análisis descriptivo de tipo transversal retrospectivo, en el que participan 10 mujeres trans que forman parte del programa de género del HSJD. Resultados: Destaca el inicio tardío del proceso de evaluación médica, terapia hormonal y acompañamiento multidisciplinario durante la transición de género. La mayor parte de las participantes perciben su voz dentro de rangos masculinos o neutros. Según los datos obtenidos en este estudio con relación a los parámetros acústicos, todas las participantes se encuentran dentro de rangos normales en la medida de Jitter, sin embargo, 2 de ellas presentan alteración en Shimmer y NHR. Además, el 70% de las participantes presentan características de disfonía músculo tensional. Conclusión: Se debe mencionar que el acompañamiento fonoaudiológico, la valoración de la voz, el estudio anatómico y la posible intervención quirúrgica por parte del especialista otorrinolaringólogo/a, son un eje fundamental a considerar en el proceso de salud global de las personas trans.(AU)

Objective: To determine anatomical, acoustic and socio-emotional aspects of the voice in trans women. Method: It corresponds to a quantitative investigation with an observational design, descriptive analysis of a retrospective cross-sectional type, in which 10 trans women who are part of the gender program of the HSJD. Results: The late start of the process of medical evaluation, hormonal therapy and multidisciplinary accompaniment during the gender transition stands out. Most of the participants perceived their voice to be within the masculine or neutral ranges. According to the data obtained in this study in relation to the acoustic parameters, all the participants are within normal ranges in the Jitter measurement, however two of them present presentations in Shimmer and NHR. In addition, 70% of the participants presented characteristics of tension muscle dysphonia. Conclusion: It should be mentioned that speech therapy monitoring, voice assessment, anatomical study and possible surgical intervention by the otorhinolaryngologist specialist are a fundamental axis to consider in the global health process of trans people.(AU)

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.

Gender-Affirming Voice Training for Trans Women: Effectiveness of Training on Patient-Reported Outcomes and Listener Perceptions of Voice.

PURPOSE: Although speech-language pathologists have provided gender-affirming voice training for trans women since the 1970s, evidence for this training's effectiveness remains weak. Our study aimed to redress limitations of earlier studies and evaluate voice training effects on outcomes important to trans women. METHOD: Seventy-four trans women (19-54 years old) who wanted a more female-sounding voice were recruited through two health facilities and provided with an eight- to 12-session voice training program based on contemporary literature, usual clinical practice, and client-centered care principles. Self-reported outcomes and an audio-recorded reading sample were collected 3 months before, immediately before and after, and 3 months after training. Forty cisgender speakers were audio-recorded reading the same sample material as comparison voices. Seventy-nine naive listeners made gender-related voice ratings of an extract from these audio recordings. Training effectiveness was evaluated using group-level analyses (linear mixed-effects models) and individual-level analyses to establish what proportion of participants improved to a predetermined relevant degree. RESULTS: Group-level analyses demonstrated positive training effects, maintained 3 months posttraining, for trans women's vocal satisfaction, perceptions of voice-related social participation, and self- and listener perceptions of their voices. Individual-level analyses also demonstrated positive effects. Two thirds of trans women increased vocal satisfaction to a relevant degree, one third who reported restricted social participation before training reduced this restriction to a relevant degree, and all were rated more female-sounding after training (although not all to a relevant degree). CONCLUSIONS: All trans women participants made progress toward their voice goals and maintained those gains at follow-up. These findings provide evidence that gender-affirming speech-language pathology services warrant prioritization. Further research is warranted to investigate factors predicting outcomes of voice training for trans women.

A 4-Week Straw Phonation in Water Exercise Program for Aging-Related Vocal Fold Atrophy.

PURPOSE: This study evaluated the efficacy of a 4-week straw phonation in water (SPW) exercise program on aging-related vocal fold atrophy (VFA), with a secondary objective to examine the immediate effects of SPW exercises. METHOD: Thirty-eight older adults aged 60 years and above formally diagnosed with aging-related VFA were randomly assigned into an experimental group undergoing SPW exercises with an 8-cm depth of straw submersion into water for 4 weeks plus vocal hygiene practice (n = 20), and a control group with only vocal hygiene practice (n = 18). Outcome measures included laryngeal endoscopic measures of glottal gap, auditory-perceptual ratings of voice quality, acoustic measures, aerodynamic measures, and standardized self-assessment questionnaire scores. An additional round of acoustic and aerodynamic assessment following 20 min of SPW exercises was conducted to examine the immediate effects. RESULTS: Significant improvements in normalized glottal gap area, perceptual rating of breathiness, smoothed cepstral peak prominence, harmonics-to-noise ratio (HNR), mean oral airflow, subglottal pressure and laryngeal airway resistance at comfortable loudness, Voice-related Quality of Life scores, and Chinese Vocal Fatigue Index Factor 3 scores were observed in the experimental group relative to the control group. There were also significant immediate effects for HNR, mean oral airflow, subglottal pressure, and laryngeal airway resistance. CONCLUSIONS: These findings suggested significant immediate improvements in vocal function following SPW exercises, with additional significant improvements in vocal function as well as significant improvements in quality of life following the 4-week SPW exercise program. Further studies with more long-term follow-up are recommended to better understand the efficacy of SPW exercises with deep levels of straw submersion into water as an effective clinical option for the management of hypofunctional dysphonia associated with aging-related VFA.

[Troubleshooting with difficult replacement of voice prostheses and a novel retrograde procedure]. / Tipps und Tricks beim erschwerten Stimmprothesenwechsel und ein neues retrogrades Wechselverfahren.

The implantation of a voice prosthesis has become a standard procedure during a laryngectomy. A voice prostheses enables patients to develop speech shortly after surgery, which strongly improves rehabilitation and quality of life.The lifetime of a voice prosthesis is limited and highly variable due to different causes. A replacement is usually necessary several times a year and can easily been done in an outpatient setting with surface anesthesia. In some cases, replacing the prosthesis becomes difficult. This article will take a closer look at different reasons that can lead to difficulties in prostheses replacement and discuss possible solutions, thereby focusing especially on a retrograde technique. The aim of this article is to help colleagues that already have experience with voice prostheses and want to expand their therapeutic armamentarium.

COVID-related dysphonia and persistent long-COVID voice sequelae: A systematic review and meta-analysis.

PURPOSE: Dysphonia is a common symptom due to the coronavirus disease of the 2019 (COVID-19) infection. Nonetheless, it is often underestimated for its impact on human's health. We conducted this first study to investigate the global prevalence of COVID-related dysphonia as well as related clinical factors during acute COVID-19 infection, and after a mid- to long-term follow-up following the recovery. METHODS: Five electronic databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and Web of Science were systematically searched for relevant articles until Dec, 2022, and the reference of the enrolled studies were also reviewed. Dysphonia prevalence during and after COVID-19 infection, and voice-related clinical factors were analyzed; the random-effects model was adopted for meta-analysis. The one-study-removal method was used for sensitivity analysis. Publication bias was determined with funnel plots and Egger's tests. RESULTS: Twenty-one articles comprising 13,948 patients were identified. The weighted prevalence of COVID-related dysphonia during infection was 25.1 % (95 % CI: 14.9 to 39.0 %), and male was significantly associated with lower dysphonia prevalence (coefficients: -0.116, 95 % CI: -0.196 to -0.036; P = .004) during this period. Besides, after recovery, the weighted prevalence of COVID-related dysphonia declined to 17.1 % (95 % CI: 11.0 to 25.8 %). 20.1 % (95 % CI: 8.6 to 40.2 %) of the total patients experienced long-COVID dysphonia. CONCLUSIONS: A quarter of the COVID-19 patients, especially female, suffered from voice impairment during infection, and approximately 70 % of these dysphonic patients kept experiencing long-lasting voice sequelae, which should be noticed by global physicians.

Programa Condicionamento Vocal e Respiratório (CVR II): nova proposta para profissionais da voz / Vocal and Respiratory Conditioning Program (CVR II): new proposal for voice professionals / Programa de Acondicionamiento Vocal y Respiratorio (CVR II): nueva propuesta para profesionales de la voz

Proposta recente de apresentação de Programa de Condicionamento Vocal e Respiratório (CVR I) incentivou a continuidade (CVR II), considerando novas estratégias de treinamento muscular vocal e respiratório que pudessem contribuir para melhor desempenho de profissionais da voz. Para a condução da ação, mais uma vez, houve a participação integrada de fonoaudiólogos e fisioterapeutas e, no papel de participantes, profissionais da voz. Planejada para dez encontros, em que dois deles (início e fim) foram destinados à coleta de dados, a proposta teve como objetivo aumentar ainda mais a resistência vocal e respiratória dos participantes, promovendo melhor rendimento profissional. Exercícios de trato vocal semiocluído e respiratórios foram realizados com o uso dos incentivadores denominados New Shaker® e Respiron Athletic 2®. Trata-se de mais uma experiência relatada na direção de convocar outros profissionais a colocarem em prática ações para o condicionamento vocal e respiratório de profissionais da voz. O uso de incentivadores respiratórios e a parceria com a Fisioterapia são apresentados e recomendados para melhor entendimento e consequente atendimento das questões da voz e da respiração. (AU)

This is a continuation (VRC II) of a recent proposal to present a Vocal and Respiratory Conditioning (VRC I) Program using new vocal and respiratory muscle training strategies aimed at contributing to a better performance of voice professionals. Once again, the initiative included the integrated participation of speech-language pathologists and physiotherapists, as well as voice professionals as participants. Ten meetings were planned in the initial proposal, with the first and last meeting focused on data collection, the proposal aimed to further increase the vocal and respiratory resistance of the participants, promoting better professional performance. Semi-occluded vocal tract and respiratory exercises were performed with using the New Shaker® and Respiron Athletic 2® boosters. This is an experience reported in order to encourage other professionals to put into practice actions for vocal and respiratory conditioning. The use of respiratory boosters and the partnership with Physiotherapy are recommended, aiming at a better understanding and consequent care of voice and breathing issues in voice professionals. (AU)

Una propuesta reciente de presentar un Programa de Acondicionamiento Vocal y Respiratório (CVR I) fomentó la continuidad (CVR II), considerando nuevas estratégias para el entrenamiento de los músculos vocales y respiratórios que podrían contribuir a un major desempeño de los profesionales de la voz. Para conducir la acción, una vez más, se contó con la participación integrada de fonoaudiológos y kinesiológos, y en el papel de participantes, profesionales de la voz. Planificada para diez encuentros, en los que dos de ellos (inicio y final) están destinados a la recolección de datos, la propuesta tiene como objetivo aumentar aún más la resistência vocal y respiratoria de los participantes, promoviendo un mejor desempeño profesional. Se realizaron ejercicios de tracto vocal y respiratorio semiocluidos con el uso de incentivos denominados New Shaker® y Respiron Athletic 2®. Esta es una experiencia más reportada en la dirección de invitar a otros profesionales a poner en práctica acciones para el acondicionamiento vocal y respiratório de los profesionales de la voz. Se presenta y recomienda el uso de soportes respiratórios y la asociación con Kinesiología para una mejor comprensión y consecuente atención de problemas de voz y respiración. (AU)

Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation.

Objectives: This investigation aimed to propose a new rehabilitation technique that combines voice exercises and instrumental postural rehabilitation for patients with muscle tension dysphonia (MTD). Methods: We enrolled nine dysphonic patients (8 women and 1 man, aged 22-55 years). Voice assessment included strobovideolaryngoscopy, Maximum Phonation Time (MPT), perceptual evaluation by GRBAS scale and patient's self-rating by Italian version of the Voice Handicap Index (VHI). Vestibular function was evaluated by the Bed Side Examination and Video Head Impulse test (VHIT). Postural control was evaluated by Dynamic Posturography (DP) using the Sensory Organization Test (SOT) and analysing the Equilibrium Score (ES) and balance subsystems (somatosensorial, visual, vestibular). Results: All cases underwent different types of voice exercises combined with balance training based on NeuroCom Balance Master Protocols, once a week for six 35-minutes sessions. After therapy, an improvement in MPT, VHI, GRBAS scores and endoscopic laryngeal features was obtained. DP results at baseline were normal and after therapy we showed a slight improvement of ES (somatosensorial and visual components). Conclusions: A combined rehabilitation technique for MTD, by improving the attention to postural control, allows for significant improvement in vocal symptoms.

Immediate effects of a semi-occluded water-resistance ventilation mask on vocal outcomes in women with dysphonia.

INTRODUCTION: Semi-occluded vocal tract exercises (SOVTEs) are frequently used exercises in voice therapy. An important shortcoming to most SOVTEs is the inability to include continuous speech in these exercises. A variation of water-resistance therapy (WRT), during which a patient phonates through a resonance tube ending in water, was developed to include continuous speech: the semi-occluded water resistance ventilation mask (SOVM-WR). The current study investigated the immediate effects of this innovative technique on vocal outcomes of women with dysphonia. METHODS: A pretest-posttest randomized controlled trial was performed. Twenty female participants were randomly assigned to the experimental SOVM-WR group or the WRT (control) group. A blinded multidimensional voice assessment was conducted before and after a 30-minute therapy session with the assigned technique. RESULTS: No significant changes were found in acoustic or auditory-perceptual vocal outcomes in either of the groups, except for a significant increase in lowest frequency in both groups. Patient-reported outcomes (PROMs) showed significant improvements of vocal comfort, vocal effort, and voice quality in both groups, and participants indicated that they would use the techniques at home. CONCLUSIONS: The similar results of the SOVM-WR to WRT and promising PROMs confirm its suitability as an alternative to the latter technique. Potential reasons for a lack of improvement of objective and auditory-perceptual vocal outcomes are vocal fatigue, tube dimensions and immersion, and the small sample size. Large-scale and longitudinal research is needed to examine whether the SOVM-WR has a higher transfer to spontaneous speech than WRT after a full therapy program.

Crowdsourced Perceptual Ratings of Voice Quality in People With Parkinson's Disease Before and After Intensive Voice and Articulation Therapies: Secondary Outcome of a Randomized Controlled Trial.

PURPOSE: Limited research has examined the suitability of crowdsourced ratings to measure treatment effects in speakers with Parkinson's disease (PD), particularly for constructs such as voice quality. This study obtained measures of reliability and validity for crowdsourced listeners' ratings of voice quality in speech samples from a published study. We also investigated whether aggregated listener ratings would replicate the original study's findings of treatment effects based on the Acoustic Voice Quality Index (AVQI) measure. METHOD: This study reports a secondary outcome measure of a randomized controlled trial with speakers with dysarthria associated with PD, including two active comparators (Lee Silverman Voice Treatment [LSVT LOUD] and LSVT ARTIC), an inactive comparator (untreated PD), and a healthy control group. Speech samples from three time points (pretreatment, posttreatment, and 6-month follow-up) were presented in random order for rating as "typical" or "atypical" with respect to voice quality. Untrained listeners were recruited through the Amazon Mechanical Turk crowdsourcing platform until each sample had at least 25 ratings. RESULTS: Intrarater reliability for tokens presented repeatedly was substantial (Cohen's κ = .65-.70), and interrater agreement significantly exceeded chance level. There was a significant correlation of moderate magnitude between the AVQI and the proportion of listeners classifying a given sample as "typical." Consistent with the original study, we found a significant interaction between group and time point, with the LSVT LOUD group alone showing significantly higher perceptually rated voice quality at posttreatment and follow-up relative to the pretreatment time point. CONCLUSIONS: These results suggest that crowdsourcing can be a valid means to evaluate clinical speech samples, even for less familiar constructs such as voice quality. The findings also replicate the results of the study by Moya-Galé et al. (2022) and support their functional relevance by demonstrating that the effects of treatment measured acoustically in that study are perceptually apparent to everyday listeners.

Amateur choir singers - Does good vocal health matter?

BACKGROUND: Many amateur singers enjoy singing in choirs. They are likely to lack the training and expertise of professional singers and this may have an impact on their vocal health. AIMS: To assess the experiences of amateur singers, their use of warm-up and cool-down sessions, their vocal health, their sources of help and advice and their reactions to receiving a diagnosis and treatment. METHODS AND PROCEDURES: A questionnaire was sent to amateur choir singers. Quantitative data on their use of warm-up and cool-down activities were collected and the singers rated how frequently they experienced adverse voice symptoms after singing. Qualitative data were collected from singers who had sought advice about their voice and from those who had received a diagnosis and treatment. OUTCOME AND RESULTS: Most choirs used warm-up sessions but few used cool-down. Singers who participated in choir warm-ups experienced significantly less vocal symptoms. Individual warm-ups were ineffective. Singers who had previously had a diagnosis continued to have significantly higher symptom scores. A quarter of the singers who had neither sought help nor had a diagnosis had high scores. Singers appeared uncertain about who to consult for help. Those who saw a speech and language therapist were much more likely to receive a diagnosis and treatment either by the therapist or by referral to an ear, nose and throat specialist. Those receiving treatment were mainly positive about it and likely to complete a course of therapy. CONCLUSIONS AND IMPLICATIONS: Warm-up sessions performed by choirs are helpful in avoiding voice symptoms and are recommended. The presence of singers who are unaware of potential damage to their voices is a concern. A simple rating system, as used in this research, may act to alert them to the dangers. Choir leaders could be more active in advising singers and refer them to professionals where necessary. Speech and language therapists appear more sensitive to their problems and could be a first point of contact. WHAT THIS PAPER ADDS: What is already known on this subject Poor vocal health may occur in amateur singers and lead to voice disorders which will reduce the demonstrated benefits of regular singing. They may be less aware than professional singers of potential hazards and may not know how to sing in a way that ensures good vocal health. There has been less research on the extent of voice problems in amateurs or of the actions they may take to resolve the vocal difficulties they encounter. What this paper adds to the existing knowledge This survey demonstrates that choir warm-ups were effective in helping to avoid common symptoms associated with voice problems. A large minority of singers who had not sought help for voice problems had high symptom scores on our assessment. Singers frequently turned to a singing teacher for help. Those who consulted a speech and language therapist were much more likely to be referred for further investigation and treatment. What are the potential or actual clinical implications of this work? We present a simple subjective measure of symptom severity which succeeds in distinguishing between singers who warm up their voices and those who do not and between singers who have received a past diagnosis and those who have not. There are a number of indications in this research that amateur singers are unsure if they need help and are uncertain who can offer it. In these circumstances the use of a simple measure of the severity of vocal abuse may be useful.

Immediate effects of straw phonation in air or water on the laryngeal function and configuration of female speech-language pathology students visualised with strobovideolaryngoscopy: A randomised controlled trial.

BACKGROUND: A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed. AIMS: The aim of this study was to investigate and compare the immediate effects of straw phonation (SP) in air, SP in 2 cm water, and SP in 5 cm water (with stirring straws), on the laryngeal function and configuration of a homogeneous group of vocally healthy female speech-language pathology students, visualised with flexible SVL. METHODS & PROCEDURE: A randomised controlled trial was used. Fifty-two female speech-language pathology students (mean age: 18.7 years, SD: 0.6) were assigned randomly to one of three experimental groups or a control group: (1) SP in air, (2) SP in 2 cm water, (3) SP in 5 cm water or (4) [u] phonation with similar soft onset and slightly pursed lips as in SP but without a straw (control group). The participants underwent flexible SVL during habitual [u] phonation, followed by the specific SOVT exercise of their group assignment. All video samples were evaluated randomly and blindly by two experienced investigators using the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form, first independently and then by consensus. OUTCOME & RESULTS: Compared to habitual phonation, the vibrational amplitude decreased during SP in 5 cm water and SP in 2 cm water, being more prominent in the first, more flow-resistant exercise. The mucosal wave also decreased during SP in 5 cm water. The anteroposterior (AP) supraglottic compression similarly increased during SP in air, SP in 2 cm water, and SP in 5 cm water. Further, a rise in mediolateral (ML) compression and a decrease in phase symmetry and regularity were found during SP in 2 cm water. A similar decrease in regularity was observed during SP in 5 cm water. CONCLUSIONS & IMPLICATIONS: Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More AP supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation. WHAT THIS PAPER ADDS: What is already known on the subject A promising way to obtain vocal economy and efficiency is by semi-occluding the vocal tract while phonating. Current knowledge about the immediate effects of semi-occluded vocal tract (SOVT) phonation on the laryngeal function and configuration is based mainly on computer modelling or excised larynges studies. In in vivo SOVT studies, electroglottography (EGG) has been the most commonly used laryngeal outcome, showing contradictory results between studies. Therefore, exploring these aspects by direct visualisation of the human larynx during SOVT phonation using strobovideolaryngoscopy (SVL) is needed. What this paper adds to existing knowledge Group results of the current study generally support earlier computer modelling and in vivo studies, strengthening the current SOVT knowledge. Both SP in air and SP in water cause positive immediate laryngeal effects for voice training opportunities. More anteroposterior (AP) supraglottic activity found during each SP exercise might indicate epilarynx narrowing, an economic phenomenon associated with SOVT. Immersing the straw in water additionally diminished the vibrational amplitude, lowering vocal fold impact stress and risk for phonotrauma during the exercise. The decreased regularity of the vibrational cycles during SP in water might be due to the varying back pressure created by the water bubbling. The impact of SP in water on ML supraglottic compression needs further investigation. What are the potential or actual clinical implications of this work? Current results support that both SP in air and SP in water can be useful exercises in voice training. SP in water has shown the additional gain of lowering the vibrational amplitude during the exercise, hence supporting its appropriateness for vocal warm-ups by minimising vocal fold impact stress and the risk of phonotrauma. In the future, large-scale randomised controlled trials in other subgroups of voice users, including dysphonic patients, are needed to support evidence-based practice. SVL can facilitate the search for individualised training and therapy approaches.

Effects of sensorimotor voice training on event-related potentials to pitch-shifted auditory feedback.

The pitch perturbation technique is a validated technique that has been used for over 30 years to understand how people control their voice. This technique involves altering a person's voice pitch in real-time while they produce a vowel (commonly, a prolonged /a/ sound). Although post-task changes in the voice have been observed in several studies (e.g., a change in mean fo across the duration of the experiment), the potential for using the pitch perturbation technique as a training tool for voice pitch regulation and/or modification has not been explored. The present study examined changes in event related potentials (ERPs) and voice pitch in three groups of subjects due to altered voice auditory feedback following a brief, four-day training period. Participants in the opposing group were trained to change their voice fo in the opposite direction of a pitch perturbation stimulus. Participants in the following group were trained to change their voice fo in the same direction as the pitch perturbation stimulus. Participants in the non-varying group did not voluntarily change their pitch, but instead were asked to hold their voice constant when they heard pitch perturbations. Results showed that all three types of training affected the ERPs and the voice pitch-shift response from pre-training to post-training (i.e., "hold your voice pitch steady" task; an indicator of voice pitch regulation). Across all training tasks, the N1 and P2 components of the ERPs occurred earlier, and the P2 component of the ERPs occurred with larger amplitude post-training. The voice responses also occurred earlier but with a smaller amplitude following training. These results demonstrate that participation in pitch-shifted auditory feedback tasks even for brief periods of time can modulate the automatic tendency to compensate for alterations in voice pitch feedback and has therapeutic potential.

Short Implicit Voice Training Affects Listening Effort During a Voice Cue Sensitivity Task With Vocoder-Degraded Speech.

OBJECTIVES: Understanding speech in real life can be challenging and effortful, such as in multiple-talker listening conditions. Fundamental frequency ( fo ) and vocal-tract length ( vtl ) voice cues can help listeners segregate between talkers, enhancing speech perception in adverse listening conditions. Previous research showed lower sensitivity to fo and vtl voice cues when speech signal was degraded, such as in cochlear implant hearing and vocoder-listening compared to normal hearing, likely contributing to difficulties in understanding speech in adverse listening. Nevertheless, when multiple talkers are present, familiarity with a talker's voice, via training or exposure, could provide a speech intelligibility benefit. In this study, the objective was to assess how an implicit short-term voice training could affect perceptual discrimination of voice cues ( fo+vtl ), measured in sensitivity and listening effort, with or without vocoder degradations. DESIGN: Voice training was provided via listening to a recording of a book segment for approximately 30 min, and answering text-related questions, to ensure engagement. Just-noticeable differences (JNDs) for fo+vtl were measured with an odd-one-out task implemented as a 3-alternative forced-choice adaptive paradigm, while simultaneously collecting pupil data. The reference voice either belonged to the trained voice or an untrained voice. Effects of voice training (trained and untrained voice), vocoding (non-vocoded and vocoded), and item variability (fixed or variable consonant-vowel triplets presented across three items) on voice cue sensitivity ( fo+vtl JNDs) and listening effort (pupillometry measurements) were analyzed. RESULTS: Results showed that voice training did not have a significant effect on voice cue discrimination. As expected, fo+vtl JNDs were significantly larger for vocoded conditions than for non-vocoded conditions and with variable item presentations than fixed item presentations. Generalized additive mixed models analysis of pupil dilation over the time course of stimulus presentation showed that pupil dilation was significantly larger during fo+vtl discrimination while listening to untrained voices compared to trained voices, but only for vocoder-degraded speech. Peak pupil dilation was significantly larger for vocoded conditions compared to non-vocoded conditions and variable items increased the pupil baseline relative to fixed items, which could suggest a higher anticipated task difficulty. CONCLUSIONS: In this study, even though short voice training did not lead to improved sensitivity to small fo+vtl voice cue differences at the discrimination threshold level, voice training still resulted in reduced listening effort for discrimination among vocoded voice cues.

Indirect Vocal Therapy as a Treatment Program for Behavioral Dysphonia: A Pilot Study.

INTRODUCTION: Indirect vocal therapy (IVT) has tools that aim to modify an individual's behavior, emotional factors, and physical environment for restoring vocal quality. Then, vocal health guidance may promote the desire for caring about the voice and prevent or treat behavioral dysphonia. However, studies that used parts of IVT have shown conflicting results. Hence, the main objective of this study was to introduce an IVT program based on the taxonomy of Van Stan et al. [Am J Speech Lang Pathol. 2015;24(2):101-25]. The second objective of this study was to analyze the preliminary effects of the IVT program on vocal comfort through the self-assessment of vocal fatigue, vocal symptoms, vocal handicap, and vocal quality in patients diagnosed with behavioral dysphonia. METHOD: This is an experimental, analytical, and prospective pilot study. Nine participants (five women; four men) aged between 18 and 50 years with behavioral dysphonia participated in this study. They underwent the IVT program with guidance about vocal health, general health, emotional factors, and motivation. The therapy was implemented twice per week, totalizing eight sessions, each lasting 35 min. Participants were assessed before therapy started (M1), after it ended (M2), and 1 month after as a follow-up (M3). As assessment, participants filled in the Vocal Fatigue Index (VFI), Voice Symptoms Scale (VoiSS), and Vocal Handicap Index-30 (VHI-30). Additionally, they had their voices recorded for acoustic measures (i.e., cepstral peak prominence-smoothed, alpha ratio, and L1-L0) and auditory-perceptual analysis using the GRBASI scale. RESULTS: The acoustic measures and auditory-perceptual analysis showed no significant differences between the assessment moments. The auditory-perceptual analysis showed a mild deviation in participants' vocal quality. The participants' scores of the VFI, VoiSS, and VHI were lower in M2 and remained lower in M3. CONCLUSION: The IVT program had positive results in voice-related self-assessment and vocal comfort. However, further studies are necessary to elucidate its effects on the vocal quality of participants with behavioral dysphonia.

Indexing Cognitive Resource Usage for Acquisition of Initial Voice Therapy Targets.

PURPOSE: The purpose of this study was to index cognitive resource usage for acquisition of initial targets of two common voice therapy techniques (resonant voice therapy [RVT] and conversation training therapy [CTT]) based on the theorized depletion effect (i.e., when an initial task requiring high cognitive load leads to poorer performance on a subsequent task). METHOD: Eleven vocally healthy participants, ages 23-41 years, read aloud the Rainbow Passage and produced consonant-vowel resonant targets (/mi, ma, mu/) followed by a baseline computerized Stroop task and a 15-min washout. Following this baseline period, participants watched and interacted with two videos instructing them in RVT or CTT initial targets. After viewing each video and practicing the associated vocal skills, participants rated the degree of mental effort required to engage in the target vocal technique on a modified Borg scale. Participants recorded their attempts at RVT on /mi, ma, mu/ and CTT on the Rainbow Passage, which were later rated by three voice-specialized speech-language pathologists as to how representative they were of each respective target technique. Changes in fundamental frequency and average auditory-perceptual ratings from baseline were examined to determine if participants adjusted their technique from RVT and CTT baseline to acquisition. RESULTS: Performance on the Stroop task was, on average, worse post CTT than post RVT, but both post-CTT and post-RVT Stroop scores were poorer than baseline. These results suggest that both treatment techniques taxed cognitive resources but that CTT was more cognitively taxing than RVT. However, despite differences in raw averages, no statistically significant differences were found between the baseline, post-CTT, and post-RVT Stroop scores, likely due to the small sample size. Participant ratings of mental effort for CTT and RVT were statistically similar. Likewise, poorer post-RVT Stroop scores were associated with participants' greater perceived mental effort with RVT acquisition, but there was no significant association between mental effort ratings for CTT acquisition and post-CTT Stroop scores. Significantly higher fundamental frequency and perceived ratings of the accuracy of technique from baseline to acquisition for both CTT and RVT were found, providing evidence of vocal behavior changes as a result of each technique. CONCLUSIONS: Brief exposure to initial treatment tasks in CTT is more cognitively depleting than initial RVT tasks. Results also indicate that vocally healthy participants are able to make a voice change in response to a brief therapy prompt. Finally, participant-rated measures of mental effort and secondary measures of cognitive depletion do not always correlate.

The role of patient perceptions and hyperfunctional voice disorders in predicting voice therapy attendance.

OBJECTIVES/HYPOTHESIS: Attendance is essential to voice therapy's effectiveness in the treatment of voice and laryngeal disorders. With such high rates of drop-out and non-attendance, it is important to understand the factors that influence this behavior. This study sought to identify potential predictors of attendance to voice therapy at an interdisciplinary voice clinic. STUDY DESIGN: Single-institution retrospective cohort study. METHODS: In this retrospective cohort study, patients evaluated at an interdisciplinary voice clinic who received a referral for voice therapy were identified. Age, gender, voice-related diagnoses, Voice Handicap Index-10 scores, Reflux Symptom Index scores, and measures of patient perceptions (self-rated severity, importance of voice in one's life, and "feelings about voice therapy") were recorded to evaluate associations with attendance to at least one therapy session. Standard statistical analysis and logistic regressions were performed. RESULTS: Of 168 subjects included, 111 (66.1 %) attended at least one session of voice therapy. Patients diagnosed with primary hyperfunctional voice disorders had a significantly higher attendance rate than other groups. Attenders had higher self-ratings of severity and more positive "feelings about voice therapy" compared to non-attenders. Regression models found three significant predictors of therapy attendance: primary diagnosis of hyperfunctional voice disorder, self-rated severity, and "feelings about voice therapy." CONCLUSION: In this cohort, patients with more positive feelings about voice therapy, higher self-rated severity, and a diagnosis of primary hyperfunctional voice disorder were more likely to attend voice therapy.

Patient Satisfaction and Acoustic Changes in Trans Women after Gender Affirming Voice Training.

OBJECTIVES: Gains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women. METHODS: Retrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre-therapy, immediate post-therapy, and extended post-therapy time intervals. RESULTS: A total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5-7) over an average of 13.14 weeks (range 6-16). Average time between completing GVT and presenting for extended follow-up was 11.37 months (range 6-31). Compared to initial presentation prior to therapy, at extended follow-up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post-therapy and extended post-therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post-therapy and extended post-therapy. CONCLUSIONS: In self-selected patients who present for extended follow-up, GVT alone can result in sustained pitch elevation and voice-related quality life in trans women. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2340-2345, 2023.