Behind the Headset: Predictive Accuracy of Patient-Reported Outcome Measures for Voice Symptoms in Call Centers

Objective: This study examines factors predicting self-reported voice symptoms in call center workers. Methods: Multivariate analysis and predictive modeling assess personal, work-related, acoustic, and behavioral factors. Generalized Linear Models (GLMs) and Receiver Operating Characteristic (ROC) curves are employed. Results: Age and sleep patterns impacted voice quality and effort, while workplace factors influenced symptom perception. Unhealthy vocal behaviors related to tense voice and increased effort, while hydration was protective. Voice acoustics showed diagnostic potential, supported by ROC data. These findings emphasize voice symptom complexity in call center professionals, necessitating comprehensive assessment. Limitations: This study recognizes its limitations, including a moderate-sized convenience sample and reliance on PROM metrics. Future research should incorporate more objective measures in addition to self-reports and acoustic analysis. Value: This research provides novel insights into the interplay of personal, occupational, and voice-related factors in developing voice symptoms among call center workers. Predictive modeling enhances risk assessment and understanding of individual susceptibility to voice disorders. Conclusion: Results show associations between various factors and self-reported voice symptoms. Protective factors include sleeping more than six hours and consistent hydration, whereas risk factors include working conditions, such as location and behaviors like smoking. Diagnostic models indicate good accuracy for some voice symptom PROMs, emphasizing the need for comprehensive models considering work factors, vocal behaviors, and acoustic parameters to understand voice issues complexity.

Objetivo: Este estudio examina los factores que predicen los síntomas de voz en los trabajadores de call centers. Métodos: Se utilizan análisis multivariados y modelos predictivos para evaluar factores personales, laborales, acústicos y de comportamiento. Se emplean Modelos Lineales Generalizados (GLM) y curvas ROC. Resultados: La edad y los patrones de sueño afectaron la calidad vocal y el esfuerzo, mientras que los factores laborales influyeron en la percepción de síntomas. Los comportamientos vocales no saludables se relacionaron con voz tensa y mayor esfuerzo, mientras que la hidratación fue protectora. Los parámetros acústicos de voz mostraron potencial diagnóstico respaldado por datos de ROC. Los hallazgos subrayan complejidad de síntomas vocales en profesionales de centros de llamadas, requiriendo una evaluación integral. Limitaciones: Este estudio reconoce sus limitaciones, que incluyen una muestra de conveniencia de tamaño moderado y la dependencia de medidas PROMs. Futuras investigaciones deberían incorporar medidas objetivas, además de los autorreportes y análisis acústico. Importancia: Esta investigación aporta nuevos conocimientos sobre factores personales, laborales y síntomas de voz en trabajadores de call centers. El modelado predictivo mejora la evaluación de riesgos y la comprensión de la susceptibilidad individual a trastornos de la voz. Conclusión: Los resultados muestran asociaciones entre diversos factores y los síntomas vocales reportados. Los factores de protección incluyen dormir más de seis horas y una hidratación constante; los factores de riesgo incluyen las condiciones de trabajo, como la ubicación y comportamientos como fumar. Los modelos de diagnóstico indican una buena precisión para algunas PROMs de síntomas de la voz, lo que subraya la necesidad de modelos integrales que tengan en cuenta los factores laborales, los comportamientos vocales y los parámetros acústicos para comprender la complejidad de los problemas de la voz.

Voice self-assessment in individuals with Parkinson's Disease as compared to general voice disorders.

BACKGROUND: Individuals with Parkinson's Disease (IwPD) often fail to adjust their voice in different situations, without awareness of this limitation. Clinicians use self-report questionnaires that are typically designed for individuals with General Voice Disorders (GVD) in the vocal assessment of IwPD. However, these instruments may not consider that IwPD have a reduced self-perception of their vocal deficits. This study aimed to compare self-reported vocal symptoms and voice loudness between IwPD and GVD. METHODS: 28 IwPD and 26 with GVD completed the Voice Symptom Scale (VoiSS) questionnaire to evaluate their voice self-perception. Vocal loudness (dB) was also assessed. Univariate and multivariate analyses were used to compare the outcomes from these measures between the two groups. Principal Component Analysis and Hierarchical Clustering Analysis were applied to explore data patterns related to voice symptoms. RESULTS: IwPD reported significantly fewer vocal symptoms than those with GVD in all VoiSS questionnaire domains. Multivariate principal component analysis found no significant correlations between VoiSS scores and participant similarities in voice measures. Despite experiencing hypophonia, IwPD scored lower in all VoiSS domains but still fell in the healthy voice range. Hierarchical Clustering Analysis grouped participants into three distinct categories, primarily based on age, vocal loudness, and VoiSS domain scores, distinguishing between PD and GVD individuals. CONCLUSIONS: IwPD reported fewer vocal symptoms than GVD. The voice self-assessment seems to be unreliable to assess vocal symptoms in IwPD, at least regarding loudness. New self-report instruments tailored to PD individuals are needed due to their particular voice characteristics.

Within-talker and within-session stability of acoustic characteristics of conversational and clear speaking stylesa).

In speech production research, talkers often perform a speech task several times per recording session with different speaking styles or in different environments. For example, Lombard speech studies typically have talkers speak in several different noise conditions. However, it is unknown to what degree simple repetition of a speech task affects speech acoustic characteristics or whether repetition effects might offset or exaggerate effects of speaking style or environment. The present study assessed speech acoustic changes over four within-session repetitions of a speech production taskset performed with two speaking styles recorded in separate sessions: conversational and clear speech. In each style, ten talkers performed a set of three speech tasks four times. Speaking rate, median fundamental frequency, fundamental frequency range, and mid-frequency spectral energy for read sentences were measured and compared across test blocks both within-session and between the two styles. Results indicate that statistically significant changes can occur from one repetition of a speech task to the next, even with a brief practice set and especially in the conversational style. While these changes were smaller than speaking style differences, these findings support using a complete speech set for training while talkers acclimate to the task and to the laboratory environment.

Systematic Review of Literature on Vocal Demand Response: Understanding Physiology, Measurements, and Associated Factors.

PURPOSE: Considering the conceptual migration from vocal load and vocal loading to vocal demand and vocal demand response, this review of literature aimed to identify physiological explanations, reported measurements, and associated factors (vocal demands) reported in the literature when considering the phonatory response to a vocal demand. METHODS: A systematic review of literature, following the PRISMA Statement, was conducted using Web of Science, PubMed, Scopus, and ScienceDirect. Data were analyzed and presented in two parts. First, a bibliometric analysis, co-occurrence analysis, and content analysis were performed. Three criteria that got article inclusion were defined: (1) written in English, Spanish, and Portuguese; (2) published between 2009 and 2021; and (3) focused on vocal load and loading, vocal demand response, and voice assessment parameters. A total of 54 publications met the criteria and were included in this review. The second part included a conceptual framework based on the content analysis of three aspects of vocal demand response: (1) physiological explanations, (2) reported measurements, and (3) vocal demands. RESULTS AND CONCLUSION: As would be expected since vocal demand response is a relatively new term and not yet commonly used in literature when discussing way that the speakers respond to communicative scenarios, most of the studies reviewed (both historical and recent) still use the term of vocal load and vocal loading. Although there is a broad variety of literature discussing a wide range of vocal demands and voice parameters used to characterize the vocal demand response, results show that there is consistency across the studies. While vocal demand response is unique and intrinsic to the talker, associated factors that contribute to this response include both internal talker and external talker factors. Internal factors include muscle stiffness, viscosity in the phonatory system, vocal fold tissue damage, elevated sound pressure levels during occupational voice demands, extended periods of voice use, suboptimal body posture, difficulties in breathing technique, and sleep disturbances. Associated external factors include the working environment (noise, acoustics, temperature, humidity). In conclusion, although vocal demand response is intrinsic to the speaker, the speaker's response is affected by external vocal demands. However, due to the wide methods to evaluate vocal demand response, it has been difficult to establish its contribution to voice disorders in the general population and, specifically, among occupational voice users. This literature review identified commonly reported parameters and factors that may help clinicians and researchers define vocal demand response.

Screening of Voice Pathologies: Identifying the Predictive Value of Voice Acoustic Parameters for Common Voice Pathologies.

BACKGROUND: Voice acoustic analysis is important for objectively assessing voice production and diagnosing voice disorders. AIM: This study aimed to investigate the sensitivity of various voice acoustic parameters in differentiating common voice pathology types. METHODS: Data from the publicly available Perceptual Voice Qualities Database were analyzed; the database includes recordings of participants with and without voice disorders. A wide range of acoustic parameters was estimated from the recordings, such as alpha ratio, harmonics-to-noise ratio (HNR), cepstral peak prominence smoothed (CPPS), pitch period entropy (PPE), fundamental frequency, jitter, shimmer, and sound pressure levels. The predictive capabilities of the parameters were evaluated using receiver operating characteristic curves. Linear regression analysis determined the associations between parameters and voice disorders. Principal component analysis was conducted to identify important parameters for distinguishing voice disorders. RESULTS AND CONCLUSION: This study has identified significant differences in acoustic parameters between those with and without voice disorders. Notably, the combination of five parameters-namely, PPE, shimmer, jitter, CPPS, and HNR-was identified as a strong predictor in voice disorder screening. These findings contribute substantially to the field of voice disorders, offering valuable insights for screening and diagnosis.

Exploring the Feasibility of a Comprehensive Screening for Voice and Swallowing Function in Post-Extubation Patients: A Pilot Study

Objectives: This pilot study aimed to identify and test a battery of time-efficient and cost-effective voice and swallowing screening tools for post-extubated patients in Chile. Methods: A panel of four experts selected and rated voice and swallowing screening tools. Seven measures were selected: smoothed cepstral peak prominence (CPPS) and maximum phonation time (MPT) for voice assessment, Volume-Viscosity Swallow Test (V-VST) for swallowing, voluntary and reflex peak cough flow for cough assessment, Eating Assessment Tool-10 (EAT-10), and Vocal Symptom Scale (VoiSS) for patient-reported outcomes. These tools were applied to four post-extubation patients within 48-72 hours post-hospital discharge, alongside the assessment of 17 matched controls. Results: Post-extubation patients showed significantly shorter MPT, lower CPPS values, increased V-VST dysphagia signs, reduced voluntary peak cough flow, and more pronounced symptoms on both the VoiSS and EAT-10 compared to controls. Limitations: The study had a modest sample size and relied solely on clinical screening tools. Value: This pilot study suggests a feasible and cost-effective approach to voice and swallowing screening for post-extubation patients, valuable in resource-constrained settings. Conclusion: While these accessible tools are not gold-standard assessments, they offer valuable insights and can guide future research. This study underscores the potential of selected tools in facilitating early detection of voice and swallowing disorders in post-extubation patients.

Objetivos: Este estudio piloto tuvo como objetivo identificar y probar una batería de herramientas de detección de problemas de voz y deglución que fueran eficientes en cuanto a tiempo y costo para pacientes chilenos postextubados. Métodos: Un panel de cuatro expertos seleccionó y evaluó herramientas de detección de voz y deglución. Se seleccionaron siete medidas: prominencia de pico cepstral suavizado (CPPS) y tiempo máximo de fonación (TMF) para la evaluación de la voz, prueba de volumen-viscosidad (V-VST) para la deglución, flujo máximo voluntario y reflejo de la tos para evaluar la tos, Eating Assessment Tool-10 (EAT-10) y la Escala de Sintomas Vocales (ESV) para los resultados informados por los pacientes. Estas herramientas se aplicaron a cuatro pacientes postextubados (48-72 horas), junto con la evaluación de 17 controles pareados. Resultados: Los pacientes postextubados mostraron un TMF y CPPS significativamente más bajos, aumento de los indicios de disfagia en la V-VST, reducción del flujo máximo de la tos y síntomas más pronunciados tanto en la ESV como en la EAT-10 en comparación con los controles. Limitaciones: El estudio tuvo un tamaño de muestra reducida y se basó únicamente en herramientas de detección clínica. Valor: Este estudio piloto sugiere un enfoque factible y rentable para la detección de problemas de voz y deglución en pacientes postextubados, valioso en entornos con recursos limitados. Conclusión: Aunque ese abordaje no sustituye a las evaluaciones de referencia, ofrece información valiosa y puede guiar futuras investigaciones que busquen facilitar la detección temprana de los trastornos de la voz-deglución en pacientes postextubados.

Immediate Effects of Semi-Occluded Vocal Tract Exercises on Acoustic, Auditory-Perceptual, and Self-Perceptual Measures of Voice Production.

PURPOSE: This study examined the immediate acoustic, auditory-perceptual, and self-perceptual effects of two semi-occluded vocal tract exercises (SOVTs): straw phonation and straw phonation into a cup of water, delivered in a remote setting. METHOD: 36 participants (19 females and 17 males) completed a baseline battery of acoustic recordings, followed by one of two SOVTs, and an identical post-task battery. The procedure repeated itself to include the other SOVT. Participants were also asked to rate their self-perceived vocal effort and quality following each condition. Recordings were presented to three expert listeners for completion of auditory-perceptual analysis. RESULTS: Acoustically, a significant decrease in shimmer was noted following straw phonation. Auditory-perceptual analysis revealed a significant increase in the perception of strain following straw phonation into a cup of water. While no significant differences were found between SOVT tasks in self-perception of vocal effort, a significant increase in self-perception of vocal loudness was reported following straw phonation into a cup of water. CONCLUSIONS: SOVTs have a varied, yet significant short-term impact across acoustic, auditory-perceptual, and self-perceptual measures of voice production. Straw phonation provided consistently significant acoustic results, with nearly every variable improving to some degree. Results also support the notion that shimmer is an acoustic measure that is particularly susceptible to change following modest manipulation. These results, in addition to the auditory-perceptual and self-perceptual findings, have a direct impact on how SOVTs are being used clinically and may generalize to inform the way voice metrics are collected and analyzed.

Clinical Utility and Validation of the Acoustic Voice Quality and Acoustic Breathiness Indexes for Voice Disorder Assessment in English Speakers.

BACKGROUND: While several acoustic voice metrics are available for clinical voice assessment, there remains a significant need for reliable and ecologically valid tools. The Acoustic Voice Quality Index version 03.01 (AVQI-3) and Acoustic Breathiness Index (ABI) hold potential due to their comprehensive assessment approach, incorporating diverse voice aspects. However, these tools still need to be validated in English-speaking populations. METHODS: This study assessed the discriminatory accuracy and validity of AVQI-3 and ABI in 197 participants, including 148 with voice disorders. Voice samples were collected, followed by AVQI-3 and ABI calculations. Additionally, auditory-perceptual assessments were conducted by a panel of speech-language pathologists. RESULTS: AVQI-3 and ABI effectively identified disordered voice quality, evidenced by high accuracy (AUCs: 0.84, 0.89), sensitivity, and specificity (thresholds: AVQI-3 = 1.17, ABI = 2.35). Strong positive correlations were observed with subjective voice quality assessments (rs = 0.72, rs = 0.77, p < 0.001). CONCLUSIONS: The study highlights AVQI-3 and ABI as promising instruments for clinically assessing voice disorders in U.S. English speakers, underscoring their utility in clinical practice and voice research.

Association Between Bilingualism, Vocal Effort, and Background Noise With Voice Fundamental Frequency and LTAS Among Spanish-English Bilingual Teachers.

BACKGROUND: As the world becomes increasingly interconnected, the demand for bilingual teachers has grown exponentially. However, the unique combination of being a bilingual occupational voice user establishes challenges that warrant careful examination. OBJECTIVE: To investigate the association between bilingualism, vocal effort, and background noise with fundamental frequency and long-term spectrum average among Spanish-English bilingual teachers. METHODS: Exploratory cross-sectional correlational study with the participation of eight Spanish-English proficient bilingual teachers (native Spanish speakers) who were teaching online classes during the quarantines established to mitigate the propagation of COVID-19. Participants were asked to read two standardized texts (one in English and one in Spanish) under two background noise conditions (with and without background white noise). RESULTS: There was a significant interaction between language and vocal effort considering that the association of vocal effort with fo was different for Spanish and English. There was also a significant main effect of background noise on fo. There were significant differences in voice spectral characteristics between productions in Spanish and English and between productions with and without background noise. The alpha ratio was significantly higher in productions in English and with background noise compared with productions in Spanish without background noise. The mid to high spectral energy ratio (1-5 K/5-8 K) was significantly lower in productions in English and with higher perceived vocal effort compared with productions in Spanish and with lower scores on the Borg Scale. CONCLUSION: Our findings introduce a need perspective by emphasizing the impact of speaking a second language on the work-relatedness of voice disorders among teachers. These findings stress the necessity to factor in language and environmental conditions for the comprehensive evaluation and management of work-related voice disorders.

Mapping the Landscape of Voice Complaints among Teachers: A Bibliometric Investigation.

PURPOSE: With the significant and growing interest in voice disorders among teachers over the last several decades, there is value in having a comprehensive overview of the current state of the field and its related research productivity. This study aims to provide an updated and comprehensive mapping of the intellectual structure and research evolution in the field of occupational voice complaints among teachers. METHODS: A systematic review of scientific articles on occupational voice complaints among teachers published in the last two decades was conducted using the preferred reporting items for systematic reviews and meta-analyses statements. A retrospective bibliometric analysis was then performed using the Web of Science core collection and VOSviewer to identify scientific productivity indicators, including publications per year, productivity by country, journals, and most cited articles. RESULTS: Based on the search eligibility criteria, a total of 473 articles were initially screened, and from this selection, 157 articles were identified as meeting the inclusion criteria and therefore included in the analysis. The analysis revealed a strong trend in scientific productivity, with a 300% increase in the number of publications during the last decade. The leading countries in publications on this field were Brazil, the United States, and Finland. The Journal of Voice, CoDAS, and Folia Phoniatrica et Logopaedica were the most frequently published journals. Additionally, the literature on voice complaints among teachers primarily focused on five conceptual clusters: vocal demand response, voice disorders, vocal health promotion, individual-associated factors, and voice symptoms. CONCLUSION: This study examines the growing literature on voice complaints among teachers over the past 20 years, identifying key countries, journals, and thematic clusters. The findings have important implications for researchers, policymakers, and practitioners, providing insights for collaboration and guiding future advancements in the field.

Bilingualism and Voice Production. Differences Between Bilingual Latin-American Spanish- English Female Speakers and Monolingual Spanish Female Speakers During Spanish Productions.

BACKGROUND: Speaking a second language influences jitter and shimmer when comparing monolingual English speakers with bilingual English-Spanish speakers. However, there is little information about differences on voice acoustic parameters when comparing monolingual Spanish speakers with bilingual Spanish-English speakers during their productions in Spanish. AIM: Determine differences in five voice acoustic parameters commonly used in voice assessments (fundamental frequency, jitter, shimmer, Harmonics-to-Noise Ratio and Cepstral Peak Prominence Smoothed) which may be influenced by bilingualism. METHODS: Exploratory cross-sectional study with two groups of female participants: monolingual Spanish speakers (n = 17), and bilingual Spanish-English speakers (n = 11). Participants filled out a questionnaire and recorded two voice samples (sustained vowel /a/ and reading). For this study, all the participants reported that their native language was Spanish. RESULTS: Being a female bilingual speaker had a significant effect on Shimmer (%) with a Beta = -0.7. Similar tendency was found on harmonics-to-noise ratio (B = 0.2) and cepstral peak prominence smoothed (B = 0.2). CONCLUSIONS: Our results indicate that being a native Spanish female speaker, speaking English as a second language, has significant small effects on voice acoustic parameters, such as shimmer, harmonics-to-noise ratio and cepstral peak prominence smoothed, during their productions in Spanish. This information is of interest for assessment and intervention plans of bilingual speakers at clinical and work-related settings.

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.

Tracking Occupational Voice State with a Visual Analog Scale: Voice Quality, Vocal Fatigue, and Effort.

BACKGROUND: Due to elevated vocal health risk in industries such as call centers, there is a need to have accessible and quick self-report tools for voice symptoms. This study aimed to determine if the concurrent and construct validity of three visual analog scales (VASs) of voice quality and symptoms could be used as a screening tool in call center agents. METHODS: A cross-sectional study was carried out in three call center companies. The Voice Handicap Index-10 (VHI-10) and a vocal hygiene and symptoms survey were administered to 66 call center workers. Further, acoustic parameters including harmonics-to-noise ratio (HNR), smoothed cepstral peak prominence (CPPs), L1-L0 slope, and Alpha ratio were collected. Finally, workers completed three VASs capturing self-perception of vocal effort (VAS-1), voice quality (VAS-2), and vocal fatigue (VAS-3). Linear regression models with bootstrapping evaluated the possible relationship between the three VASs measurements, self-perceived vocal symptoms, and acoustic parameters. RESULTS: VAS-1 scores were associated with HNR and voice breaks, VAS-2 with voice breaks, and VAS-3 with Alpha ratio. Using the area under a receiver operating characteristic curve (AUC), the highest AUC for detecting an altered VHI-10 questionnaire score was observed for the three VASs. Also, the highest AUC for detecting altered CPPs was reached for the VAS-1. CONCLUSIONS: VAS as a self-report instrument of vocal symptoms is related to psychosocial voice impairment and alterations of acoustic voice parameters in call center workers. Such instruments could be easily implemented to identify voice complaints in these populations. LEVEL OF EVIDENCE: 2 (Diagnosis research question) Laryngoscope, 133:1676-1682, 2023.

Muscle Activity and Aerodynamic Voice Changes at Different Body Postures: A Pilot Study.

OBJECTIVE: Body posture is a commonly discussed component of voice training and therapy. However, body postures, postural changes, related posturing muscle monitoring, and the potential changes in voice production (eg, glottal aerodynamic changes, acoustic differences) have been inconsistently described in the literature, leaving room for free interpretation and possible misunderstandings. The primary purpose of this pilot study was to compare the magnitude of electromyographical activation of muscles involved in phonation-breathing functions and their changes due to four standardized body postures in experienced singers. Secondly, to identify which body posture produces greater changes in aerodynamic parameters, vocal pitch, and loudness. METHODS: Eight healthy adults with experience in singing voice performed a vocal task during different body postures commonly used in both voice training and therapy. A 3D-capture system was used to control and quantify the alignment of each posture. During the performances, surface electromyography (sEMG) was used to measure the muscular activity involved in the breathing/phonation and posture processes. A nonparametric Kruskal-Wallis test was used to compare the sEMG activity of phonatory muscles and aerodynamic voice variables between postures. RESULTS: Our study did not reveal significant differences in sEMG activity, aerodynamic parameters, vocal pitch, and loudness among body postures during vocal task productions. However, the vocal pitch (in semitones) revealed significant differences in the unstable surface when compared to the upright posture, modified upright, and leaning postures. CONCLUSION: The body postures selected did not generate voice aerodynamic modifications of the voice nor in the levels of activation of muscles involved in the phonation-breathing process in individuals with experience in singing voice. Modifications of body posture as a tool for voice therapy should be further investigated, considering the population with voice problems and no voice training experience.

Self-Perception of Vocal Effort in Response to Modeled Communication Demands.

OBJECTIVES: The optimization of vocal effort given a response to a voice demand is a common clinical and vocal performance goal. Increases in vocal effort are often in response to communication limitations from both the interlocutors and the communication environment. This study investigates the relationship between vocal effort and vocal demands from changes and limitations imposed by the communication environment. METHODS: Thirty-seven participants rated their vocal effort associated with a map description task in a range of communication demands. These demands included communication distance (from 1 m to 4 m), loudness goal (54 dB-66 dB), and excess background noise (53 dBA-71 dBA). The vocal effort ratings were compared across the different types and extents of vocal demand conditions. RESULTS: As would be expected, there were significant increases in vocal effort levels from the control condition to the extremes of the distance and loudness goal vocal demands. Each increase in background noise resulted in distinct increases in vocal effort level. Participants were able to use the vocal effort scale to efficiently quantify expected increases in vocal demands. CONCLUSIONS: Increases of vocal effort level accompany increases to vocal demands that exceed the habitual or expected communication. While voice training and vocal therapy are essential for reducing internal vocal demands, clients with a goal to reduce vocal effort should also consider external vocal demands such as communication distance and background noise.

A Semiautomated Protocol Towards Quantifying Vocal Effort in Relation to Vocal Performance During a Vocal Loading Task.

To increase the reliability and comparability of vocal loading studies, this paper proposes the use of a standardized approach with experiments that are [1] grounded on consistent definitions of terms related to vocal fatigue (vocal effort, vocal demand, and vocal demand response), and [2] designed to reduce uncertainty and increase repeatability. In the approach, a semi-automated vocal loading task that also increases efficiencies in collecting and preparing vocal samples for analysis was used to answer the following research question: To what extent is vocal effort and vocal demand response sensitive to changes in vocal demands (ie, noise only, noise plus duration)? Results indicate that the proposed protocol design consistently induced change in both vocal effort and vocal demand response, indicating vocal fatigue. The efficacy of future vocal loading studies would be improved by adopting a more consistent methodology for quantifying vocal fatigue, thus increasing interstudy comparability of results and conclusions.

Immediate and long-term effects of speech treatment targets and intensive dosage on Parkinson's disease dysphonia and the speech motor network: Randomized controlled trial.

This study compared acoustic and neural changes accompanying two treatments matched for intensive dosage but having two different treatment targets (voice or articulation) to dissociate the effects of treatment target and intensive dosage in speech therapies. Nineteen participants with Parkinsonian dysphonia (11 F) were randomized to three groups: intensive treatment targeting voice (voice group, n = 6), targeting articulation (articulation group, n = 7), or an untreated group (no treatment, n = 6). The severity of dysphonia was assessed by the smoothed cepstral peak prominence (CPPS) and neuronal changes were evaluated by cerebral blood flow (CBF) recorded at baseline, posttreatment, and 7-month follow-up. Only the voice treatment resulted in significant posttreatment improvement in CPPS, which was maintained at 7 months. Following voice treatment, increased activity in left premotor and bilateral auditory cortices was observed at posttreatment, and in the left motor and auditory cortices at 7-month follow-up. Articulation treatment resulted in increased activity in bilateral premotor and left insular cortices that were sustained at a 7-month follow-up. Activation in the auditory cortices and a significant correlation between the CPPS and CBF in motor and auditory cortices was observed only in the voice group. The intensive dosage resulted in long-lasting behavioral and neural effects as the no-treatment group showed a progressive decrease in activity in areas of the speech motor network out to a 7-month follow-up. These results indicate that dysphonia and the speech motor network can be differentially modified by treatment targets, while intensive dosage contributes to long-lasting effects of speech treatments.

The Effect of Upper Airway Ailments on Teachers' Experience of Vocal Fatigue.

BACKGROUND: Teachers have been found to have a higher than normal risk to develop voice disorders. One common symptom of voice problems among teachers is the report and occurrence of vocal fatigue, often associated with different individual, physical, environmental, and professional factors. AIM: The aim of this study was to provide insight into the potential effect of sinus infections, laryngitis, colds, seasonal allergies, and reflux on reported vocal fatigue, as quantified by the Vocal Fatigue Index (VFI). METHOD: An exploratory cross-sectional design was implemented via an online survey sent by email to teachers of kindergarten through 12th-grade in 31 states throughout the USA. RESULT: The main result of this study was that teachers with self-reported reflux and seasonal allergies had statistically significant higher scores on VFI Factor 1 (performance), VFI Factor 2 (pain), and VFI Factor 3 (recovery) when compared to those without self-reported reflux and seasonal allergies. CONCLUSIONS: It may be likely that an individuals' change in reported vocal fatigue over time may be also associated with health-related factors, such as reflux and seasonal allergies rather than just changes in voice production. These associated factors should be considered and potentially controlled for in future research and clinical practice surrounding teachers' experience of vocal fatigue.

Acoustic Effects of Vocal Warm-Up: A 7-Week Longitudinal Case Study.

OBJECTIVE: A case study was used to determine which acoustic parameters would be sensitive to a SOVT-based vocal warm-up over the duration of a standard voice treatment. METHODS: The longitudinal research design consisted of repeated voice measures during 7 weeks from a single subject, a 48-year-old male occupational voice user with a history of voice disorders. A steady phonation and running speech tasks were performed before and after an intensive 1-minute water-resistance voice exercise (WRT). Acoustic assessment of the pre-and postrecordings from each session was obtained with freely accessible software (e.g., Audacity, PRAAT) and acoustic measures (e.g., fundamental frequency, jitter, shimmer, alpha ratio, NHR, HNR, L1L0, Cepstral Peak Prominence smoothed). RESULTS: After WRT, the analysis indicated that jitter, shimmer, and NHR had a small but statistically significant decrease, while alpha ratio, CPPS, and HNR had a statistically significant increase. For the days where there were six repetitions, there was a larger effect in the later repetitions in the day for some metrics (i.e., alpha ratio, shimmer, NHR, CPPS), while others had the biggest effect in the first two repetitions in a day (i.e., jitter, HNR). CONCLUSIONS: A short vocal water-resistance voice task had a positive effect on the short-term acoustic voice metrics after each repetition of the exercise, independent of the number of repetitions throughout the day. When five repetitions of this exercise routine occurred, there was a more substantial influence on the proportion of acoustic voice changes.