A Structured Pre- and Post-Operative Voice Therapy Program for Benign Vocal Fold Lesions

Benign vocal fold lesions (BVFLs) are acquired structural anomalies of the vocal folds, and these are primarily a result of vocal abuse or phonotrauma. Phonotraumatic lesions are not generally regarded as recurrent, provided that appropriate behavioral changes are made after resolution or surgical removal. Voice therapy plays a crucial role in this aspect. The aim of this article is to propose a structured pre- and post-operative voice therapy program for patients undergoing surgical intervention for BVFLs. Voice therapy post-surgery has been proven to reduce the rate of recurrence in BVFLs. Having a standard treatment protocol is a useful tool for the therapist, particularly one without extensive voice training.

Las lesiones benignas de los pliegues vocales (LBPV) son anomalías estructurales adquiridas de los pliegues vocales, y son principalmente el resultado de un abuso vocal o fonotrauma. Las lesiones fonotraumáticas generalmente no se consideran recurrentes, siempre que se realicen cambios apropiados en el comportamiento después de la resolución o la excisión quirúrgica. La terapia vocal juega un papel crucial en este aspecto. El objetivo de este artículo es proponer un programa estructurado de terapia de voz pre y postoperatorio para pacientes que son expuestos a una intervención quirúrgica para LBPV. Se ha demostrado que la terapia de voz después de la cirugía reduce la tasa de recurrencia en LBPV. Tener un protocolo de tratamiento estándar es una herramienta útil para el terapeuta, particularmente uno sin un entrenamiento extenso en patología de la voz.

Coaching Strategies for Behavioral Voice Therapy and Training.

Coaching is one of the most common words in our modern vocabulary and has many meanings depending on the setting in which it is used. Coaching facilitates positive changes to achieve a goal, usually through indirect approaches, including improving an individual's outlook on their behaviors or attitudes. Its application has spread beyond the corporate world, and many medical specialties use coaching principles. The goals of this article are to introduce coaching as a profession, and to explore the function of a vocal coach to improve communicative and vocal performance. Moreover, differences between voice therapy and voice training are highlighted, including the principles subjacent to these interventions and the use of coaching strategies. Four strategies of professional coach practitioners adapted to the training and therapy of the voice with applications to both are described. These are: powerful questions, active listening, changing habits, and implementation intention. The use of these strategies may help individuals to achieve high voice performance. Most importantly, the speech-language pathologist voice specialist can apply these strategies particularly in cases of behavioral dysphonias, which can be resistant to traditional voice therapy.

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial.

OBJECTIVES: Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone. STUDY DESIGN: Prospective, randomized, controlled, single-blinded, non-inferiority. MATERIALS AND METHODS: Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10. RESULTS: Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H2O, PhoRTE + EMST M = 32.63 cm H2O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement. CONCLUSION: This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

The influence of the low-frequency transcutaneous electrical nerve stimulation application moment in vocal quality of dysphonic women.

Objective: to compare the immediate effects of low-frequency TENS employment on vocal quality in women with behavioral dysphonia before and after vocal exercises.Methodology: 30 women (mean = 31.3 years old), diagnosed with behavioral dysphonia received low-frequency TENS before (TENS + VE Group) and after vocal exercises (VE + TENS Group) with a 1-week washout. They had their sustained vowel/a/and running speech recorded before and after each procedure for auditory-perceptual analysis and acoustic measures. The low-frequency TENS parameters applied were symmetrical biphasic quadratic pulse, 200 µs phase, 10 Hz frequency, intensity on the motor threshold, and the electrodes were positioned on the submandibular and superior fibers of the trapezius muscle region. The vocal exercises: tongue trill, humming, finger kazoo, and water resistance therapy were performed totalizing 20 min.Results: intragroup analysis of sustained vowel/a/showed reduction in both groups of strain parameter and increased the breathiness; only VE + TENS Group increased the instability parameter, decreased fundamental frequency, and increased in SPI values; the running speech analysis showed an increase in the overall degree, roughness, and breathiness parameters. However, in VE + TENS Group, there was a statistically significant decrease in the intensity of the strain and an increase in breathiness. The acoustic measures showed that VE + TENS Group had a higher variation than TENS + VE Group regarding NHR.Conclusion: vocal exercises followed by low-frequency TENS have more immediate positive effects on voice quality than the low-frequency TENS followed by vocal exercises. This is a preliminary immediate effects study, and these effects could be verified through long-term assessments.

Voiced High-Frequency Oscillation or Lax Vox Technique? Immediate Effects in Dysphonic Individuals.

OBJECTIVES: To analyze the immediate effects of voiced high-frequency oscillation (VHFO) and Lax Vox technique on vocal quality and self-reported intensity of vocal and laryngeal symptoms in individuals with behavioral dysphonia. METHODS: This experimental, prospective, randomized cross-over study, investigated thirty adults (15 women and 15 men) with behavioral dysphonia (vocal complaints, altered voice on auditory-perceptual evaluation, vocal nodules or mucosal thickening, and incomplete glottic closure). The outcome variables analyzed were auditory-perceptual analysis, acoustic analysis (voice quality characteristics), and self-reported intensities of vocal and laryngeal symptoms. Each participant performed two exercises-VHFO and Lax Vox technique-in a random sequence for 3 minutes. A 7-day washout period was provided between the exercises. The data were analyzed using the paired t-test and Wilcoxon test (P < 0.05). RESULTS: After VHFO, no significant difference was observed on auditory-perceptual evaluation in all participants, whereas the Lax Vox technique worsened breathiness among women (P = 0.027). VHFO significantly increased the fundamental frequency (P = 0.014) and decreased the noise harmonic ratios for women (P = 0.026). Among men, there was a decrease in shimmer parameter (P = 0.035). Moreover, symptoms such as "lump in the throat" (P = 0.005), "voice loss" (P = 0.017), and "high-pitched voice" (P = 0.023) decreased in women after VHFO, whereas in men, "itchiness" and "hoarseness" (P < 0.001) decreased after VHFO. The Lax Vox technique decreased "hoarseness" (P = 0.003) in women, without any effect in men. CONCLUSION: The VHFO exercise provided more positive immediate effects results than the Lax Vox technique regarding vocal quality and self-reported symptom intensity in participants with behavioral dysphonia.

Estructura de los objetivos terapéuticos en la intervención fonoaudiológica de usuarios con necesidades vocales: una revisión sistemática exploratoria / Structure of therapeutic goals in the speech therapy intervention of users with vocal needs: an exploratory systematic review

Esta revisión tiene como finalidad identificar y describir la estructura de los objetivos terapéuticos incluidos en aquellas investigaciones que explicitan una intervención fonoaudiológica vocal durante los últimos cinco años. La búsqueda estratégica se lleva a cabo en las bases de datos PubMed, Science Direct y Web Of Science y se obtienen 3.974 registros, de los cuales 12 artículos cumplen con todas las condiciones declaradas en los criterios de inclusión. La tendencia mayoritaria en la literatura del área es la omisión de los objetivos terapéuticos y la alusión solo a los procedimientos empleados. En el análisis cualitativo de los objetivos hallados, se evidencia la ausencia de una estructura textual estándar y falta de diferenciación entre los tipos de objetivos, lo que provoca un alto grado de heterogeneidad en su redacción. En relación con la noción de usuario, su rol es más bien secundario y pasivo. Existe insuficiente atención a la determinación de criterios de logro y una escasa operacionalización de los contenidos a abordar en la intervención fonoaudiológica. La enunciación de los contenidos de intervención desde su naturaleza conceptual impide una medición concreta asociada a la tarea terapéutica propuesta debido a su pobre operacionalización. Se concluye que no existe una estructura común en la formulación de objetivos terapéuticos para la intervención vocal.

This review aims to identify and describe the structure of the therapeutic objectives included in research reporting vocal therapy procedures during the last five years. The strategic search was carried out on three databases: PubMed, ScienceDirect and WebOf Science and 3,974 records were obtained. After the analysis, 12 articles met the inclusion criteria. The general trend in the literature of the area is the omission of the objectives and the exclusive reference to the therapeutic procedures used. The qualitative analysis shows an absence of a standard textual structure and a lack of differentiation between levels of objective hierarchy, which causes a high degree of heterogeneity in their writing. The role of client is rather secondary and passive. The setting of achievement criteria and the contents operationalization to be addressed in the voice therapy session are insufficientlyattended. The enunciation of the therapy contents from their conceptual nature hinders a concrete measurement to the therapeutical task proposed, due to its lack of operationalization. It is concluded that there is no common structure in the vocal therapy objectives formulation.

Auditory-vocal integration impairment: New challenges and opportunities for voice assessment and therapy / Alteración de la integración auditivo-vocal: nuevos retos y oportunidades para la evaluación y la terapia de la voz

This reflection paper addresses the importance of the interaction between voice perception and voice production, emphasizing the processes of auditory-vocal in-tegration that are not yet widely reported in the context of voice clinicians. Given the above, this article seeks to 1) highlight the important link between voice pro-duction and voice perception and 2) consider whether this relationship might be exploited clinically for diagnostic purposes and therapeutic benefit. Existing theories on speech production and its interaction with auditory perception provide context for discussing why the evaluation of auditory-vocal processes could help identify associ-ated origins of dysphonia and inform the clinician around appropriate management strategies. Incorporating auditory-vocal integration assessment through sensorimotor adaptation paradigm testing could prove to be an important addition to voice assess-ment protocols at the clinical level. Further, if future studies can specify the means to manipulate and enhance a person's auditory-vocal integration, the efficiency of voice therapy could be increased, leading to improved quality of life for people with voice disorders

Este artículo de reflexión aborda la importancia de la interacción entre la percepción y la producción de la voz, haciendo hincapié en los procesos de integración auditivo-vocal, los cuales aún no han sido muy divulgados en el contexto de los clínicos de voz. Dado lo anterior, este articulo busca: 1) destacar la importante relación entre la producción y la percepción de la voz y 2) considerar si esta relación pudiese explotarse clínicamente con fines diagnósticos y terapéuticos. Las teorías existentes sobre la producción de la voz y su interacción con la percepción auditiva proporcionan el contexto para discutir por qué la evaluación de los procesos auditivo-vocales podría ayudar a identificar los orígenes asociados a cierto tipo de disfonías e informar al clínico sobre las estrategias de abordaje adecuadas. La incorporación de la evaluación de la integración auditivo-vocal a través de la prueba del paradigma de adaptación sensoriomotora podría ser una importante adición a los protocolos de evaluación de la voz a nivel clínico. Además, si los estudios futuros pueden especificar los medios para manipular y mejorar la integración auditivo-vocal de una persona, la eficacia de la terapia de la voz podría aumentar, lo que llevaría a mejorar la calidad de vida de las personas con trastornos de la voz

Rehabilitación vocal fisiológica con ejercicios de tracto vocal semiocluido / Physiologic voice rehabilitation with semi-occluded vocal tract exercises

Introducción. Los ejercicios de tracto vocal semiocluido (ETVSO) son herramien-tas utilizadas en la rehabilitación fisiológica de la voz. Los ETVSO son ejercicios vocales producidos por la semioclusión del tracto vocal, a través de una serie de posturas que buscan alargar y/o ocluir el tracto vocal, generando un cambio en el patrón vibratorio de los pliegues vocales, grado de aducción y el patrón respiratorio. Los ETVSO pueden dividirse, según el tipo de semioclusión, en sostenida, transitoria y oscilatoria, así como en ejercicios de mayor resistencia a menor resistencia.Objetivo. Describir los diferentes tipos de ejercicios de tracto vocal semiocluido, el tipo de semioclusión, el grado de resistencia y sus efectos en los pliegues vocales, patrón respiratorio y configuración del tracto vocal. Metodología. Se realizó una revisión de la literatura en las bases de datos PubMed, Medline y Science Direct, usando los siguientes términos: "Semi-Occluded Vocal Tract Postures", "tract vocal semiocclude" y "ejercicios de tracto vocal semiocluido". Se utilizaron operadores booleanos "AND" y "OR" para especificar la búsqueda.Resultados. Los beneficios de estos ejercicios impactan positivamente en variables aerodinámicas, en la función glótica y en la configuración del tracto vocal. Conclusiones. Los ejercicios de tracto vocal semiocluido son una familia de ejerci-cios vocales producidos por semioclusión sostenida, transitoria y oscilatoria del tracto vocal, a través de una serie de posturas que buscan alargar y/o ocluir el tracto vocal, cuyos beneficios impactan positivamente los pliegues vocales y el tracto vocal

Introduction. Semi-occluded vocal tract exercises (SOVTE) are tools used in physiologic voice rehabilitation. Semi-occluded vocal tract exercises are vocal exer-cises produced by the semi-occlusion of the vocal tract through a series of postures that seek to lengthen and/or occlude the vocal tract, generating a change in the vibratory pattern of vocal folds, degree of vocal folds adduction, and the respira-tory pattern. SOVTE can be divided, according to the type of semi-occlusion, into sustained, transient and oscillatory, as well as exercises with high and low degree of airflow resistance.Objective. To describe the different types of semi-occluded vocal tract exercises, the type of semi-occlusion, the type of resistance, and their effects on the vocal folds, respiratory pattern, and configuration of the vocal tract.Methodology. A literature review was performed in the PubMed, Medline, and Science Direct databases, using the following terms: "Semi-occluded vocal tract pos-tures", "Semi-occluded vocal tract" and "Semi-occluded vocal tract exercises". Boo-lean operators "AND" and "OR" were used to specify the search.Results. The benefits of these exercises positively impact aerodynamic variables, glottal function, and configuration of the vocal tract.Conclusions. The semi-occluded vocal tract exercises are a family of vocal exerci-ses produced by the sustained, transitory, and oscillatory semi-occlusion of the vocal tract, through a series of postures that seek to lengthen and/or occlude the vocal tract, whose benefits positively impact on vocal folds and vocal tract.

Orientaciones filosóficas en la intervención fonoaudiológica de voz. El desafío actual de dar el alta / Philosophical orientations in voice therapy. The current challenge of discharge

El presente artículo corresponde a una reflexión sobre las orientaciones filosóficas en la terapia vocal actual. Cuando existe alguna alteración o trastorno vocal, se habla comunmente de un desequilibrio entre los subsistemas involucrados en el proceso fonatorio, es decir, fuelle (sistema respiratorio), fuente (pliegues vocales) y filtro (tracto vocal). Si no hay un correcto balance, entonces el sistema no tiene un correcto funcionamiento y pueden aparecer síntomas como ronquera, sensación de cuerpo extraño, prurito, fatiga vocal o bien disfonía o incluso afonía. Como con-secuencia de estas dificultades, se generan compensaciones que durante el proceso de la intervención fonoaudiológica el profesional debe volver a "equilibrar". Para lograr este objetivo, se desarrollan y analizan las diversas herramientas que entregan las filosofías de pensamiento a lo largo de la historia de la rehabilitación vocal, don-de se encuentran la orientación higiénica, psicológica, sintomatológica, fisiológica y ecléctica. En este mismo sentido, el profesional debe buscar lo que percibe como más idóneo para cada paciente o grupo a intervenir, centrado en mejorar la calidad vocal y las necesidades actuales de estos, basándose en el contexto mundial actual, con el objetivo de lograr un buen proceso de entrenamiento o rehabilitación y final-mente lograr el alta.

The present article corresponds to a reflection about the philosophical orientations in the current vocal therapy. When there are some vocal alterations or disorders, we usually talk about an imbalance between the sub-sysmtems involved in the fonatory process, which are bellows (respiratory system), source (vocal folds) and filter (vocal tract). When there is not a correct balance, the system does not work properly and as a consequence, it is possible to experiment symptoms such as hoarseness, foreign body sensation, pruritus, vocal fatigue, dysphonia or even aphonia. As a result of these difficulties, it is possible to generate compensations through the intervention of speech therapy. By virtue of this therapy the professional must 'balance'. In order to achieve this, it is necessary to develop and analyze the different tools that philoso-phical studies offer through the history of vocal rehabilitation. Some of these tools are hygienic orientation, psychological, symptomatological, physiological and eclec-tic. Thinking on that, the professional must search what it is most suitable for every patient or group of people that he/she will be working with. This must be focus on improving vocal quality and the actual necessities of the patient, based on the current global context. The final purpose of the professional is to achieve a good and healthy process of training and/or rehabilitation to accomplish medical discharge.

Objetivos de intervención en voz: Una propuesta para su análisis y redacción / Voice therapy goals: a proposal for analysis and writing

Este artículo de reflexión aborda aspectos que dan cuenta de la complejidad en el planteamiento de objetivos en torno a los marcos de abordaje vocal contemporáneos. Se plantea la complejidad de la selección y redacción de objetivos para la interven-ción en voz holística y ecléctica, y desde ella, la necesidad de incorporar el modelo CIF y las recomendaciones de la ASHA para el desarrollo de objetivos centrados en la persona, tanto a corto como a largo plazo. Se propone la utilización del método de análisis SMART y su aplicación específica para objetivos de intervención de la voz. Además, se abordan los aspectos formales que se deben considerar para una redacción precisa. Finalmente, se ejemplifica la propuesta mediante un caso clínico. Esta propuesta pretende ser de utilidad para fines terapéuticos y/o para el ámbito académico, tanto en la discusión de la formulación y diseño de planes terapéuticos como en el pensamiento reflexivo asociado al abordaje vocal.

This reflective article addresses aspects that deal with the complexity of objective setting in contemporary vocal approach frameworks. It addresses the complexity in selecting and writing objectives for holistic and eclectic voice therapy and the need to incorporate the ICF model and ASHA recommendations for the development of person-centered goals in both the short and long term. The use of the SMART analysis method is proposed and its specific application for voice therapy goal. Also, the formal aspects to be considered for precise wording are addressed. Finally, the proposal is exemplified through a clinical case. This proposal is intended to be useful for therapeutic and/or academic purposes, both in discussing the formula-tion and design of therapeutic plans and the reflective thinking associated with the vocal approach.

Efectos del entrenamiento respiratorio aislado en las variables respiratorias y vocales / Effects of isolated respiratory training on breathing and voice variables

La implementación del entrenamiento respiratorio aislado en la rehabilitación y el entrenamiento de la voz es una práctica común en los países de habla hispana. Ac-tualmente, no existe ningún manuscrito en español que revise la información teórica y empírica del entrenamiento respiratorio en este contexto. El propósito de la presente revisión es entregar la evidencia actualizada del efecto del entrenamiento respiratorio aislado en la voz. El entrenamiento de la fuerza respiratoria ha demostrado tener consecuencias positivas en los parámetros medidos; no obstante, los datos disponibles hasta ahora no reporta efectos significativos en la voz, exceptuando los casos de personas con trastornos neurológicos de base y presbifonía. Si el entrenamiento respiratorio con el uso de dispositivos no ha demostrado impactar favorablemente sobre otras disfonías (no neurológicas ni presbifonía) ni en sujetos sanos profesionales de la voz, no existiría razón para esperar que los ejercicios respiratorios aislados que se suelen incluir en las rutinas de entrenadores vocales, fonoaudiólogos, logopedas y foniatras tengan un efecto positivo. Considerando que el entrenamiento de la fuerza muscular respiratoria parece actuar sobre algunos parámetros vocales en personas con alteraciones neurológicas y presbifonía, futuras investigaciones deberían considerar la exploración del posible efecto positivo en otros parámetros vocales no medidos aún en este tipo de población

Isolated breathing training in rehabilitation and voice training is a common prac-tice in Spanish-speaking countries. Currently, there are no documents in Spanish that study the theoretical and empirical information related to respiratory training in this context. The purpose of the present review is to provide updated information regarding the current evidence of the possible effect of isolated respiratory training on voice. Respiratory strength training has been shown to have positive effects on respiratory parameters, however, the available evidence does not report significant effects on the voice, except for people with underlying neurological disorders and presbyphonia. If respiratory training using devices designed for these purposes has not been shown to positively impact vocal characteristics of subjects with dyspho-nia (not neurological or presbyphonia) or of healthy professional voice users, there is no reason to expect that the isolated breathing exercises that are often included in the routines of vocal trainers and speech therapists will have a positive effect on voice variables. Considering that respiratory muscle strength training seems to positively affect some vocal parameters in people with neurological disorders and presbyphonia, future research should consider exploring the possible effect on other vocal parameters not yet measured in this type of population

Telepráctica de la Terapia Vocal: una ref lexión sobre su aplicación a partir del COVID-19 / Telepractice of voice therapy: a ref lection on its application from the beginning of COVID-19

El manejo de la pandemia por COVID-19 ha generado grandes cambios sociales y mundiales. Uno de ellos, debido al distanciamiento social, ha sido la incorporación de la telepráctica de la terapia vocal en países que tenían poco o nulo conocimiento de ella. Este artículo tiene el propósito de reflexionar sobre la aplicación de la teleprác-tica de la terapia vocal, considerando los beneficios, barreras y oportunidades que surgen de ella. Además, se plantea que la aplicación de la telepráctica requiere de una política, de un marco legislativo y de aspectos éticos para asegurar una terapia vocal exitosa. ¿Es efectiva la telepráctica? ¿es posible aplicarla? ¿qué requiere su aplicación?

The management of the COVID-19 pandemic has generated huge changes socially and worldwide. One of these, due to social distancing, has been the incorporation of telepractice to voice therapy in countries where the knowledge of it was very little or there was none. The purpose of this article is to reflect about the usage of tele-practice in voice therapy by considering the benefits, barriers and opportunities that emerge from it. The paper also poses that the application of telepractice requires po-licies, a legislative framework and ethical aspects to ensure a successful voice therapy. Is the telepractice effective? Can it be implemented? What does its appliance require?

Intervención fonoaudiológica en artistas: hacia una mirada completa de intervención vocal / Voice Therapy Intervention on artists: towards a complete look at vocal intervention

Hoy en día el conocimiento avanza a pasos agigantados. Cada vez hay más fonoau-diólogos en diversas áreas de la profesión. Llama la atención de muchos el área ar-tística, pues es un área poco explorada y amplia. Este artículo tiene el objetivo de reflexionar sobre la intervención vocal en artistas (cantantes, actores y otros). Su im-plementación debe comprender una mirada completa de la persona: voz, fisiología, fisiopatología, emociones, rol, aspectos médicos, farmacológicos y características in-dividuales. Esto promueve la adherencia de un profesional de la voz a su área de conocimiento y genera un espacio de sanidad, exploración y libertad artística en términos actuales, incluso en medio de una pandemia

Nowadays the knowledge is advancing by leaps and bounds. The number of Speech Pathologists in different areas of the profession has increased. The artistic area calls the attention of many, because it is a hardly explored and wide area. This article aims to reflect on vocal intervention on artists (singers, actors and others). Its imple-mentation should include a thorough overview of the person: voice, physiology, phy-siopathology, emotions, role, medical and pharmacological aspects and individual characteristics. This promotes the adhesion of a voice professional to their area of its own knowledge, thus allowing a space for healing, exploration and artistic freedom in current terms, even in the midst of a pandemic

The Effect of a Voice Therapy Program Based on the Taxonomy of Vocal Therapy in Women with Behavioral Dysphonia.

OBJECTIVE: This study aims to propose and analyze the effect of a voice therapy program (VTP) in women with behavioral dysphonia. MATERIALS AND METHODS: This is a controlled, blinded, and nonrandomized cohort study. Participants of this study were 22 women with behavioral dysphonia divided into two groups: G1, 11 women with behavioral dysphonia who received the VTP, and G2, 11 women with behavioral dysphonia who did not receive any intervention. Before and after 6 weeks, the outcome variables evaluated in both groups were auditory-perceptual evaluation of the global degree of vocal quality (vowel /a/ and counting), instrumental acoustic parameters, Voice-Related Quality of Life, vocal and larynx symptoms, and musculoskeletal pain. The statistical analysis used the Wilcoxon, chi-square, and Mann-Whitney tests (P < 0.05). RESULTS: After 6 weeks, we observed a significantly higher improvement in the general degree of vocal deviation in vowels, a reduced F0 and symptom of "fatigue while talking" in G1, and an increased "shoulder" pain intensity in G2. Both groups showed improvement in the socioemotional domain of Voice-Related Quality of Life. In addition, the comparison between the groups showed a significantly greater reduction in fundamental frequency and the "voice loss" symptom in G1 compared with G2. CONCLUSIONS: The VTP using semioccluded vocal tract exercises obtained a positive effect on voice quality, symptoms, and musculoskeletal pain in women with behavioral dysphonia. The proposal, based on the taxonomy of voice therapy, seems to have promoted a phonatory balance, muscle relaxation, and improvement in the vocal resistance of this population.

Effectiveness of Voice Therapy Associated With Electromyographic Biofeedback in Women With Behavioral Dysphonia: Randomized Placebo-Controlled Double-Blind Clinical Trial.

OBJECTIVE: To analyze the effectiveness of vocal therapy associated with electromyographic biofeedback in women with behavioral dysphonia. MATERIALS AND METHODS: This is a randomized placebo-controlled double-blind clinical trial. Twenty-two adult women with behavioral dysphonia were randomly divided into two groups: Experimental Group-11 women participated in vocal therapy associated with the application of electromyographic biofeedback; Placebo Group-11 women participated in vocal therapy associated with the application of placebo electromyographic biofeedback. Both groups performed eight therapy sessions, twice a week, lasting 30 minutes. The vocal therapy of both groups was composed of semioccluded vocal tract exercises (trill, humming, and fricative). The evaluations were performed at four time points-before, after, one, and three months after the vocal therapy-and will consist of the following assessments: auditory-perceptual evaluation of voice, acoustic evaluation of voice, and surface electromyographic. The data were analyzed statistically comparing the groups and the time of evaluation (P < 0.05). RESULTS: The proposed vocal therapy promoted positive results in vocal quality and muscular electrical activity during rest in women with behavioral dysphonia for both groups. Electromyographic biofeedback promoted additional positive results in muscle electrical activity during phonatory tasks in women with behavioral dysphonia. CONCLUSION: In this study, the vocal therapy associated with electromyographic biofeedback had equivalent efficacy to traditional therapy in the voice. The biofeedback was more effective than traditional therapy on muscular electrical activity and had effects that remained for a longer time in women with behavioral dysphonia.

Voiced High-frequency Oscillation and LaxVox: Analysis of Their Immediate Effects in Subjects With Healthy Voice.

OBJECTIVES: The aim of this study was to analyze the immediate effects of voiced high-frequency oscillation (VHFO) and LaxVox exercises in vocally healthy subjects. METHODS: Thirty adult subjects (15 women, 15 men) with no history of dysphonia or vocal complaints participated in the study. The subjects performed VHFO and LaxVox techniques for 3 minutes in a random order, with a washout period of 7 days. They answered a questionnaire for vocal/laryngeal intensity symptoms, and had maximum phonation time (MPT) /a/, /s/, /z/, and number counting measured. The vowel /a/ was also recorded before and after both techniques for acoustic analysis. After both techniques, the subjects answered a questionnaire about vocal, laryngeal, respiratory, and articulatory sensations. Data were analyzed using the Wilcoxon, and paired t and chi-square tests were used (P < 0.05), as required. RESULTS: There was an increase in high loudness symptom after LaxVox in women, whereas there was a decrease in painful throat, irritated throat, and low loudness symptoms after VHFO in men. After LaxVox, the MPT of /z/ increased in women and after VHFO, the MPT of /s/, /z/, and number counting increased in men. The fundamental frequency variability increased in women after VHFO. The sensations remained unchanged in both groups following the two exercises in women and men. CONCLUSIONS: VHFO and LaxVox techniques had similar effects on vocal and laryngeal symptoms, as a matter of fact, in terms of phonatory and acoustic measures. With regard to vocal symptoms, VHFO showed better immediate effects in men than in women. As a result, the hypothesis H0 is partially refuted.

Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer / Efeitos multidimensionais da terapia vocal em pacientes com paralisia unilateral daprega vocal por câncer

Abstract Introduction: Patients with unilateral vocal fold paralysis may demonstrate different degrees of voice perturbation depending on the position of the paralyzed vocal fold. Understanding the effectiveness of voice therapy in this population may be an important coefficient to define the therapeutic approach. Objective: To evaluate the voice therapy effectiveness in the short, medium and long-term in patients with unilateral vocal fold paralysis and determine the risk factors for voice rehabilitation failure. Methods: Prospective study with 61 patients affected by unilateral vocal fold paralysis enrolled. Each subject had voice therapy with an experienced speech pathologist twice a week. A multidimensional assessment protocol was used pre-treatment and in three different times after voice treatment initiation: short-term (1-3 months), medium-term (4-6 months) and long-term (12 months); it included videoendoscopy, maximum phonation time, GRBASI scale, acoustic voice analysis and the portuguese version of the voice handicap index. Results: Multiple comparisons for GRBASI scale and VHI revealed statistically significant differences, except between medium and long term (p < 0.005). The data suggest that there is vocal improvement over time with stabilization results after 6 months (medium term). From the 28 patients with permanent unilateral vocal fold paralysis, 18 (69.2%) reached complete glottal closure following vocal therapy (p = 0.001). The logistic regression method indicated that the Jitter entered the final model as a risk factor for partial improvement. For every unit of increased Jitter, there was an increase of 0.1% (1.001) of the chance for partial improvement, which means an increase on no full improvement chance during rehabilitation. Conclusion: Vocal rehabilitation improves perceptual and acoustic voice parameters and voice handicap index, besides favor glottal closure in patients with unilateral vocal fold paralysis. The results were also permanent during the period of 1 year. The Jitter value, when elevated, is a risk factor for the voice therapy success.

Resumo Introdução: Pacientes com paralisia unilateral de prega vocal podem apresentar diferentes graus de distúrbios da voz, dependendo da posição da prega vocal paralisada. A compreensão da eficácia da terapia vocal nesta população pode ser um coeficiente importante para definir a abordagem terapêutica. Objetivo: Avaliar a eficácia da terapia vocal em curto, médio e longo prazos em pacientes com paralisia unilateral de prega vocal e determinar os fatores de risco para falha na reabilitação da voz. Método: Estudo prospectivo, no qual 61 pacientes com paralisia unilateral de prega vocal foram recrutados. Cada participante foi submetido a terapia vocal com um fonoaudiólogo experiente duas vezes por semana. Um protocolo de avaliação multidimensional foi utilizado no pré-tratamento e em três momentos após o início da terapia da voz: curto prazo (1-3 meses), médio prazo (4-6 meses) e longo prazo (12 meses); incluiu videoendoscopia, tempo máximo de fonação, escala GRBASI, análise de voz acústica e a versão em português do Voice Handicap Index. Resultados: Os dados comparativos temporais das avaliações revelaram diferenças estatisticamente significativas, exceto entre médio e longo prazo (p < 0,005). Os dados sugerem que há melhora vocal ao longo do tempo com resultados de estabilização após seis meses (médio prazo). Dos 28 pacientes com paralisia unilateral permanente da prega vocal, 18 (69,2%) atingiram o fechamento glótico completo após a terapia vocal (p = 0,001). O método de regressão logística indicou que o Jitter entrou no modelo final como um fator de risco para melhora parcial. Para cada unidade de aumento de Jitter, houve um aumento de 0,1% (1,001) da chance de melhora parcial, o que significa um aumento na chance de não ocorrer melhora completa durante a reabilitação. Conclusão: A reabilitação vocal melhora os parâmetros de voz perceptiva e acústica e o índice de incapacidade vocal, além de favorecer o fechamento glótico em pacientes com paralisia unilateral da prega vocal. Além disso, os resultados também foram permanentes durante o período de um ano. O valor de Jitter, quando elevado, é um fator de risco para sucesso parcial da terapia vocal.

Aerodynamic, Electroglottographic, and Acoustic Outcomes after Tube Phonation in Water in Elderly Subjects.

OBJECTIVE: The present study aimed at observing the influence of tube phonation into water on objective voice characteristics in elderly subjects. METHODS: Thirty elderly subjects with presbyphonia were randomly assigned to one of two voice exercise groups: (1) voice exercises with water resistance therapy at 4 and 8 cm of water depth (experimental group), and (2) voice exercises with vowel [a:]. Aerodynamic, electroglottographic, and acoustic voice assessments were conducted before and after exercises. RESULTS: The experimental group showed a significant increase in contact quotient, subglottic pressure (Psub), glottal resistance, and sound pressure level (SPL) when comparing the pre-post 8 cm and the post 4 cm-post 8 cm conditions. No significant differences were found for the control group. Moreover, significant differences for all variables (except for glottal airflow) when comparing condition post (for the control group) and condition post 8 cm (for the experimental group) were found. CONCLUSION: Tube phonation into water might improve vocal function in the geriatric population. This semioccluded vocal tract exercise seems to promote an increase in Psub and vocal fold adduction immediately after exercise. This in turn might cause an increase in SPL. The effect should become manifest when a deep level of submersion (e.g., 8 cm water) is used. Shallower submersion produced negligible or no effects.

Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer.

INTRODUCTION: Patients with unilateral vocal fold paralysis may demonstrate different degrees of voice perturbation depending on the position of the paralyzed vocal fold. Understanding the effectiveness of voice therapy in this population may be an important coefficient to define the therapeutic approach. OBJECTIVE: To evaluate the voice therapy effectiveness in the short, medium and long-term in patients with unilateral vocal fold paralysis and determine the risk factors for voice rehabilitation failure. METHODS: Prospective study with 61 patients affected by unilateral vocal fold paralysis enrolled. Each subject had voice therapy with an experienced speech pathologist twice a week. A multidimensional assessment protocol was used pre-treatment and in three different times after voice treatment initiation: short-term (1-3 months), medium-term (4-6 months) and long-term (12 months); it included videoendoscopy, maximum phonation time, GRBASI scale, acoustic voice analysis and the portuguese version of the voice handicap index. RESULTS: Multiple comparisons for GRBASI scale and VHI revealed statistically significant differences, except between medium and long term (p<0.005). The data suggest that there is vocal improvement over time with stabilization results after 6 months (medium term). From the 28 patients with permanent unilateral vocal fold paralysis, 18 (69.2%) reached complete glottal closure following vocal therapy (p=0.001). The logistic regression method indicated that the Jitter entered the final model as a risk factor for partial improvement. For every unit of increased Jitter, there was an increase of 0.1% (1.001) of the chance for partial improvement, which means an increase on no full improvement chance during rehabilitation. CONCLUSION: Vocal rehabilitation improves perceptual and acoustic voice parameters and voice handicap index, besides favor glottal closure in patients with unilateral vocal fold paralysis. The results were also permanent during the period of 1 year. The Jitter value, when elevated, is a risk factor for the voice therapy success.

The Impact of Double Source of Vibration Semioccluded Voice Exercises on Objective and Subjective Outcomes in Subjects with Voice Complaints.

PURPOSE: The present study reports the effects of double source of vibration semioccluded vocal tract exercises (SOVTEs) on subjective and objective variables in subjects with voice complaints. METHODS: Eighty-four participants with voice complaints were randomly assigned to one of four treatment groups: (1) water resistance therapy, (2) tongue trills, (3) lip trills, and (4) raspberry (tongue and lip trills at the same time). Before and after voice therapy, participants underwent aerodynamic, electroglottographic, and acoustic assessments. Measures for the Vocal Tract Discomfort Scale (VTDS), self-assessment of resonant voice quality, and sensation of muscle relaxation were also obtained. Three assessment sessions were conducted: (1) before the therapy session (Pre), (2) immediately after the voice therapy session (Post 1), and (3) 1 week after home practice (Post 2). RESULTS: Significant differences between baseline (Pre) and both post measures were found for the perception of muscle relaxation and resonant voice quality. No significant differences between Post 1 and Post 2 for any exercises were observed. This indicates that all voice exercises improved subjective self-perceived voice quality immediately after exercises and that improvement remained stable after 1 week of practice. Water resistance therapy and raspberry attained the highest effect. A significant decrease for all exercises was also observed for VTDS values after 1 week of practice. Although some significant changes were observed in objective variables, no clear patterns could be detected. CONCLUSIONS: SOVTEs with secondary source of vibration may reduce vocal symptoms related to physical discomfort in subjects with voice complaints. Objective variables apparently do not fully reflect subjective positive outcomes, or they are not sensitive enough to capture changes. No significant differences between four observed SOVTEs were observed.