Connecting Auditory-Perceptual Prompts Used in Voice Therapy to Anatomy and Physiology: Application to the Estill Voice Model and the Rehabilitation Treatment Specification System.

PURPOSE: This clinical tutorial will present the concept of applying auditory-perceptual prompts (implicit instruction) typically used in voice therapy to the anatomy and physiology of the voice production system (explicit instruction) via the Estill Voice Model (EVM) and the Rehabilitation Treatment Specification System (RTSS). METHODS: EVM offers an integrated implicit-explicit instructional approach to voice training allowing for isolated practice of vocal structures (explicit) that interact to produce functional voice qualities (implicit), such as modal speech and louder projected voice qualities. In EVM, voice quality is correlated with the specific anatomy and physiologic adjustments via 13 Estill Figures and Options (eg, Larynx Figure has three options: High, Mid, and Low). RTSS provides a framework to connect client change in functioning (ie, target) with clinician action (ie, ingredients). Mechanisms of action connect the target to the ingredients by hypothesizing how the treatment is expected to work. RESULTS: Evidence is provided for connecting auditory-perpetual voice prompts with the anatomy and physiology of voice and supporting an integrated implicit-explicit approach to voice therapy. The concept of linking commonly used implicit auditory-perceptual prompts used in voice therapy (eg, humming, loud "aahh") to explicit anatomy and physiology training (eg, 13 Estill Figures and Options) is demonstrated using EVM and the RTSS framework with case studies and video examples. CONCLUSIONS: Clinicians may choose to use anatomy and physiology of voice to define and provide explicit instruction for typically used implicit auditory-perceptual prompts. Future research is warranted to test the concept applied to voice therapy models in the literature across prevention and treatment of voice disorders.

An Assessment of Different Praat Versions for Acoustic Measures Analyzed Automatically by VoiceEvalU8 and Manually by Two Raters.

INTRODUCTION: The purpose of the study was to assess acoustic measures of fundamental frequency (fo), standard deviation of fo (SD of fo), jitter%, shimmer%, noise-to-harmonic ratio (NHR), smoothed cepstral peak prominence (CPPS), and acoustic voice quality index analyzed through multiple Praat versions automatically by VoiceEvalU8 or manually by two raters. In addition, default settings to calculate CPPS in two Praat versions manually analyzed by two raters were compared to Maryn and Weenik20 procedures for CPPS automatically analyzed by VoiceEvalU8. METHODS: Nineteen vocally healthy females used VoiceEvalU8 to record three 5-s sustained /a/ trials, the all voiced phrase "we were away a year ago," and a 15-s speech sample twice a day for five consecutive days. Two raters manually completed acoustic analysis using different versions of Praat and compared that analysis to measures automatically generated through a version of Praat used by VoiceEvalU8. One-way analyses of variance were run for all acoustic measures with post-hoc testing by the Bonferroni method. For acoustic measures that demonstrated significant differences, intraclass correlation coefficients were conducted. RESULTS: Results showed no significant differences across automatic and manual analysis for different versions of Praat for all acoustic measures during /a/, for fo, jitter%, shimmer%, and NHR during the phrase, for jitter%, shimmer%, NHR, and CPPS during speech, and for acoustic voice quality index calculated from both sustained /a/ and the phrase. The default Praat settings for CPPS were not significantly different from the Maryn and Weenik20 procedures for sustained /a/ and speech. Significant differences were present for SD of fo and CPPS during the phrase and fo and SD of fo during speech. SD of fo and CPPS in the phrase were moderately correlated and fo and SD of fo during speech demonstrated good to excellent correlations across the different versions of Praat. CONCLUSIONS: Acoustic measures analyzed through sustained /a/ and some of the acoustic measures during the phrase and speech were not different across multiple versions of Praat. Automatic analysis by VoiceEvalU8 produced similar mean values as compared to manual analysis by two raters. Even though SD of fo and CPPS in the phrase and fo and SD of fo in speech were different across the versions of Praat, the measures demonstrated moderate to excellent reliability.

Normative Values of Client-Reported Outcome Measures and Self-Ratings of Six Voice Parameters via the VoiceEvalU8 App.

OBJECTIVES: Ecological momentary assessments (EMA) and interventions (EMI) have the potential to assess and offer interventions repeatedly within the client's daily life through mobile app technology. Considering the development of the EMA VoiceEvalU8, the current work provided normative data by comparing traditional (i.e., paper and pencil) and electronic (i.e., VoiceEvalU8 app) administration modalities of client-reported outcome measures and client self-ratings of six voice parameters twice a day in their functional environment. METHODS: In Experiment 1, 50 vocally healthy cisgender women and men completed the Voice Handicap Index (VHI)-30, VHI-10, and Vocal Fatigue Index (VFI) with paper and pencil and the VoiceEvalU8 app. The order of administration modality and perceptual scales was randomized for each participant. In Experiment 2, 104 vocally healthy cisgender women and men used the VoiceEvalU8 app across five days in the morning before talking all day and in the evening after talking all day to self-rate six voice parameters (i.e., overall quality, roughness, breathiness, strain, pitch, and loudness) on a scale from 0 - 100. Mann Whitney U tests were run for all measures. Means and standard deviations are reported for descriptive analysis and normative values. RESULTS: In Experiment 1, results showed no significant differences between paper and pencil and VoiceEValU8 app administration for the VHI-30, VHI-10, and VFI for vocally healthy adults. Normative values in the current study were consistent with previous literature for the VHI-10 and VFI factor 1 and 2, but slightly higher for the VHI-30 and slightly lower for the VFI factor 3. In Experiment 2, results demonstrated significant differences for all six voice parameters between the morning and evening log sessions. Normative values demonstrated higher self-ratings in the morning as compared to the evening. CONCLUSIONS: For vocally healthy adults, completing the VHI-30, VHI-10, and VFI via paper and pencil and the VoiceEvalU8 app yielded the same results. Client self-ratings of six voice parameters on a scale from 0 - 100 twice a day demonstrated that vocally healthy adults perceived voice to be worse in the morning before talking all day as compared to the evening after talking all day. The results from the current work are promising for EMA via the VoiceEvalU8 app and support the need for continued investigations with clients with voice differences, problems, and/or disorders.

A Nonrandomized Trial for Student Teachers of an In-Person and Telepractice Global Voice Prevention and Therapy Model With Estill Voice Training Assessed by the VoiceEvalU8 App.

Purpose This study investigated the effects of the in-person and telepractice Global Voice Prevention and Therapy Model (GVPTM) treatment conditions and a control condition with vocally healthy student teachers. Method In this single-blinded, nonrandomized trial, 82 participants completed all aspects of the study. Estill Voice Training was used as the stimulability component of the GVPTM to train multiple new voices meeting all the vocal needs of the student teachers. Outcomes were assessed using acoustic, perceptual, and aerodynamic measures captured by the VoiceEvalU8 app at pre and post in fall and during student teaching in spring. Results Significant improvements were achieved for several acoustic and perceptual measures in the treatment conditions, but not in the control condition. The in-person and telepractice conditions produced similar results. The all-voiced phrase and connected speech were more successful in demonstrating voice change for some of the perturbation measures as compared to sustained /a/. Conclusions The treatment conditions were successful in improving the participants' voices for fundamental frequency and some acoustic perturbation measures while maintaining the improvements during student teaching. In addition, the treatment conditions were successful in decreasing the negative impact of voice-related quality of life and vocal fatigue during student teaching. Future research should address the effectiveness of the various components of the GVPTM, the application of the GVPTM with patients with voice disorders, the relevance of defining auditory-perceptual terms by the anatomy and physiology of the voice production system (i.e., Estill Voice Training), and the continued use of the VoiceEvalU8 app for clinical voice investigations. Supplemental Material https://doi.org/10.23641/asha.13626824.

Functional Voice Assessment and Therapy Methods Supported by Telepractice, VoiceEvalU8, and Estill Voice Training.

Functional assessment and therapy methods are necessary for a client-centered approach that addresses the client's vocal needs across all environments. The purpose of this article is to present the approach with the intent to encourage discussion and implementation among educators, clinicians, researchers, and students. The functional approach is defined and its importance is described within the context of the World Health Organization's International Classification of Functioning, Disability, and Health with support provided by synchronous and asynchronous telepractice, the VoiceEvalU8 app, server, and web portal, and a framework that defines voice qualities (e.g., resonance, twang, loud, and others) by the anatomy and physiology of the voice production system (i.e., Estill Figures for Voice). Case scenarios are presented to highlight application of the functional voice approach.

A phrase captures aerodynamic and acoustic data in healthy voice users and in patients with voice disorders.

Purpose: A voice evaluation typically involves aerodynamic and acoustic measures captured through repeated /pi/s. The current study addresses the need for a more functional utterance that better approximates connected speech.Methods: Healthy voice users and patients with voice disorders produced repeated /pi/s and a phrase, "Pooh, pay Pia pea pie," into the Phonatory Aerodynamic System across two trials.Results: In Experiment 1 with healthy voice users, subglottic pressure (Ps), airflow, fundamental frequency (F0), and sound pressure level (SPL) demonstrated strong reliability for speech tasks and trials. Laryngeal resistance (LR) demonstrated inconsistent reliability. In Experiment 2, patients with voice disorders completed pre and post voice therapy measures of Ps, airflow, LR, F0, SPL, and the Voice Handicap Index. Results demonstrated that all of the measures captured a significant difference from pre to post except LR in both women and men and F0 in women.Conclusions: The study suggests that the phrase was successful in capturing reliable aerodynamic and acoustic data in healthy voice users and significant changes from pre to post in patients with voice disorders. In addition, analyzing Ps and airflow independently may be more clinically useful than the combination of the two in LR.

Building a Successful Voice Telepractice Program.

PURPOSE: Telepractice offers prevention, assessment, treatment, and consultation at a distance. This article provides an overview of telepractice with specific considerations and examples related to voice across licensure requirements, state and federal laws, reimbursement, documentation, and telepractice methods. CONCLUSION: As technology continues to advance and as client demand for telepractice services increases, practitioners need to create successful telepractice programs.

Results of a Voice-Related Survey of Physical Education Student Teachers.

The current study investigated physical education (PE) student teachers' understanding of the vocal demands of their future profession, interest in participating in a voice-training program, and the current impact of the voice on quality-of-life by the Voice Handicap Index (VHI, Jacobson et al., 1997). Seventy-four PE student teachers completed a voice-related survey and the VHI. Forty-three percent of participants indicated that teaching will negatively affect the voice and 29% of participants reported that they may develop a voice problem because of teaching; however, only 17% of participants indicated that a voice training program was needed to learn healthy and effective voice use for teaching. Based on the results, participants knew that teaching may negatively impact the voice, but they were not convinced that a voice training program was necessary. In addition, the student teachers' voices were not negatively impacting quality- of-life, as determined by the VHI.

Results of a Survey Offering Clinical Insights into Speech-Language Pathology Telepractice Methods.

A telepractice survey was administered to the American Speech-Language-Hearing Association Special Interest Group 18 Telepractice affiliates and attendees of the Waldo County General Hospital Speech-Language Pathology Telepractice Training program in Maine, USA over the summer of 2016. Sixty-seven respondents completed the survey. The survey explored demographics of clients and clinicians, costs and equipment, learning opportunities, use of the client's environment and caregivers/e-helpers, and method adaptations in telepractice. The results of the survey provide information on the current state of telepractice methods in speech-language pathology from experienced practitioners. This information may be used to develop telepractice models and to prepare speech-language pathology graduate students in the delivery of telepractice methods.

An Online Telepractice Model for the Prevention of Voice Disorders in Vocally Healthy Student Teachers Evaluated by a Smartphone Application.

This article describes the Global Voice Prevention Model (GVPM) facilitated with student teachers at West Chester University and the VoiceEvalU8 smartphone application (app) used to assess the effectiveness of the GVPM. Twenty-one participants completed 1 of 3 conditions (i.e., in-person GVPM, telepractice GVPM, and control). The in-person and telepractice conditions ran for 4 weeks during fall 2016, with 1 week dedicated to vocal education and vocal hygiene and 3 weeks spent in vocal training. The control condition ran for 1 week and included only vocal education and vocal hygiene. The VoiceEvalU8 app was used at pre- and post-condition twice a day for 5 days to record acoustic, perceptual, and aerodynamic voice measures. The study is ongoing; therefore, preliminary acoustic results for fundamental frequency (F0) and jitter% are presented from pre- to post-condition. During spring 2017, the participants were student teaching and using the VoiceEvalU8 app to record the voice measures before and after teaching all day. A new group of participants will be enrolled fall 2017 for selection into 1 of the 3 conditions and then continue on to student teaching spring 2018.

Influence of Smartphones and Software on Acoustic Voice Measures.

This study assessed the within-subject variability of voice measures captured using different recording devices (i.e., smartphones and head mounted microphone) and software programs (i.e., Analysis of Dysphonia in Speech and Voice (ADSV), Multi-dimensional Voice Program (MDVP), and Praat). Correlations between the software programs that calculated the voice measures were also analyzed. Results demonstrated no significant within-subject variability across devices and software and that some of the measures were highly correlated across software programs. The study suggests that certain smartphones may be appropriate to record daily voice measures representing the effects of vocal loading within individuals. In addition, even though different algorithms are used to compute voice measures across software programs, some of the programs and measures share a similar relationship.

Clinical investigation of the Global Voice Therapy Model.

The purpose of this study was to investigate the effect of the Global Voice Therapy Model (GVTM) on acoustic, aerodynamic, and perceptual voice measures of four adults seeking voice therapy for a voice disorder. A speech-language pathologist facilitated speaking voice therapy with the four participants using the GVTM. Participants completed acoustic, aerodynamic, and perceptual voice measures at pre- and post-therapy time points. Differences were seen in the voice measures from pre- to post-therapy. The GVTM was successful in facilitating an improvement in the acoustic, aerodynamic, and perceptual measures of the participants.

Voice characteristics of female physical education student teachers.

In this study, the subjective and objective voice measures of seven female physical education student teachers during a semester of student teaching were investigated. The participants completed the voice measures at three data collection time points: baseline, middle, and end of the semester. The voice measures included acoustic and aerodynamic data, perceptual rating scales of vocal quality and vocal fatigue, an end-of-semester questionnaire, and the Voice Handicap Index. Results demonstrated that the subjective and objective voice measures changed at the middle and the end of the semester as compared with those at baseline. The change in the voice measures may suggest that the vocal mechanism was adapting to the increased vocal demands of teaching physical education.

Effects of masking noise on laryngeal resistance for breathy, normal, and pressed voice.

PURPOSE: The purpose of the present study was to explore the effects of masking noise on laryngeal resistance for breathy, normal, and pressed voice in vocally trained women. METHOD: Eighteen vocally trained women produced breathy, normal, and pressed voice across 7 fundamental frequencies during a repeated CV utterance of /pi/ under normal and masked auditory feedback. Dependent variables were mean and standard deviation of laryngeal resistance (LR; cmH2O/l/s). RESULTS: LR values for breathy and normal voice remained constant across normal and masked auditory feedback, whereas LR values for pressed voice increased significantly from normal to masked auditory feedback. CONCLUSIONS: The results suggest that both voice pattern and feedback condition influenced the stability of the LR data. Specifically, the pressed voice pattern may be more susceptible to auditory feedback influence because it was less stable than the breathy and the normal voice patterns. Future investigation should continue to explore the relevance of auditory feedback for theoretical and clinical issues surrounding voice.

Laryngeal resistance distinguished pressed, normal, and breathy voice in vocally untrained females.

The purpose of this study was to determine if pressed, normal, and breathy voice can be distinguished by laryngeal resistance (LR) in vocally untrained females. Twelve adult females, with no vocal expertise or training, produced each of the voice qualities on the pitch A3 (220 Hz) during a repeated consonant-vowel utterance of /pi/ into a Rothenberg vented face-mask with attached microphone, pressure, and air-flow transducers. Results indicated that LR was successful in distinguishing pressed, normal, and breathy voice in vocally untrained females. The results are consistent with previous research and further support the suggestion that LR is a useful measure for studying the co-ordinative interactions across respiratory and laryngeal subsystems of voice production.

Evidence for distinguishing pressed, normal, resonant, and breathy voice qualities by laryngeal resistance and vocal efficiency in vocally trained subjects.

The purpose of this study was to determine if pressed, normal, resonant, and breathy voice qualities can be distinguished from one another by laryngeal resistance (LR; cm H(2)O/l/s) and/or vocal efficiency (VE; dB/cm H(2)O x l/s) in vocally, trained subjects. The experimental design was a within-subjects repeated measures design. Independent variables were pressed, normal, resonant, and breathy voice qualities. Dependent variables were LR and VE. Participants were 13 women of age 18-45 years with established vocal expertise. After a brief training phase, subjects were asked to produce each of the voice qualities on the pitch A3 (220 Hz) at a constant, individually identified comfortable dB level (+/-1 dB), during a repeated consonant-vowel utterance of /pi pi pi pi pi/. Results indicated that LR but not VE reliably distinguished pressed, normal, and breathy voice. Neither of the measures, however, distinguished normal from resonant voice, which were distinguished perceptually. The results suggest that LR may provide a useful tool for studying the coordinative dynamics of pressed, normal, and breathy voice qualities.