Efeitos de um programa de fonoterapia da voz em grupo de pacientes com disfonia: estudo piloto / Effects of a voice therapy program in a group of patients with dysphonia: a pilot study

RESUMO Objetivo Identificar os efeitos de um programa de fonoterapia da voz em grupo de pacientes com disfonia, por meio de avaliações perceptivo-auditiva e autopercepção vocal. Métodos Estudo-piloto de ensaio clínico não controlado, com amostra de conveniência. O estudo contou com 22 participantes com diagnóstico otorrinolaringológico de disfonia. Dentre eles, 15 mulheres e sete homens, com média de idade de 59,4 ± 12,53. Foram realizadas dez sessões de terapia fonoaudiológica em grupos de cinco a seis pessoas, com abordagens diretas e indiretas, baseadas no Programa Integral de Reabilitação Vocal (PIRV). Os participantes foram avaliados individualmente, antes e após a realização do programa terapêutico. A avaliação incluiu análise de autopercepção com a Escala de Sintomas Vocais (ESV) e perceptivo-auditiva da qualidade vocal com a escala Grade, Roughness, Breathness, Asteny, Strain, (GRBAS), realizadas por fonoaudiólogos especialistas em voz. Resultados Após o programa terapêutico, observou-se diferença significativa na pontuação de grau geral de alteração da ESV (p=0,002) e também nas subescalas Limitação (p=0,002) e Emocional (p=0,006), indicando autopercepção de redução dos sintomas vocais após intervenção. No entanto, destaca-se que não foram encontrados resultados significativos na comparação pré e pós-tratamento com relação à qualidade vocal. Conclusão O programa de fonoterapia da voz teve efeitos estatisticamente significativos em relação aos sintomas vocais autorrelatados, sinalizando um caminho promissor de abordagem eclética para a terapia vocal em grupo.

ABSTRACT Purpose To identify the effects of a phonotherapy program in a group of patients with dysphonia through auditory-perceptual and vocal self-perception assessments. Methods Pilot study: an uncontrolled clinical trial with a convenience sample. Twenty-two patients with an otorhinolaryngological diagnosis of dysphonia participated in the study, including 15 women and 7 men, with a mean age of 59.4 ± 12.53, who underwent 10 speech therapy sessions in groups of 5 to 6 people, with direct and indirect therapy based on the Comprehensive Vocal Rehabilitation Program (CVRP). Patients were individually assessed before and after the therapeutic program, the assessment included auditory-perceptual analysis with the Vocal Symptoms Scale (VSS) and auditory-perceptual analysis of voice quality GRBAS, performed by speech-language pathologists specializing in voice. Results After the therapeutic program, there was a significant difference in the score for the general degree of change in the VSS (p=0.002), and also in the limitation (p=0.002) and emotional (p=0.006) subscales, indicating selfperceived reduction in vocal symptoms after intervention. However, no significant results were found in the pre- and posttreatment comparison regarding vocal quality. Conclusion The study demonstrated that the voice therapy program had statistically significant effects in relation to self-reported vocal symptoms, thus signaling a promising path for an eclectic approach to group vocal therapy.

Comparison of therapeutic effects of steroid injection by benign vocal fold lesion type.

BACKGROUND: Benign vocal fold lesions (BVFLs) can cause voice changes, including reduced loudness and pitch range. In recent times, with progression in endoscopic technology, office-based vocal fold steroid injection (VFSI) has been used as an alternative therapy for BVFLs. AIMS/OBJECTIVES: In this study, we analyzed the efficacy and safety of VFSI to investigate the mechanism underlying its therapeutic effects and determine the conditions in which VFSI will be most effective. MATERIALS AND METHODS: In this retrospective cohort study, we included 40 condition-matched patients (8 patients per lesion) with chorditis, vocal nodules, vocal polyps, Reinke's edema (RE), or vocal scars who received similar regimens of steroid injection using a commercial preparation of triamcinolone acetonide. Their phonological outcomes were evaluated 2 or 3 months after the injection. RESULTS: Significant improvements were observed in Voice Handicap Index scores, results of laboratory voice evaluation, and voice quality measured using the Grade, Roughness, Breathiness, Asthenia, Strain scale in all participants. In subgroup analysis, VFSI was highly effective against chorditis and vocal nodules, but less effective against RE and vocal scars. CONCLUSIONS: Single-dose VFSI is valuable as an alternative to voice rehabilitation and laryngo-microsurgery, but higher concentrations or repeated injections are required for intractable lesions.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study.

OBJECTIVES: This study aims to (i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post-extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort. DESIGN: A multi-site prospective observational cohort study. PARTICIPANTS: One hundred adults with confirmed COVID-19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive. MAIN OUTCOME MEASURES: Oral intake status, level of diet modification and perceptual voice quality. RESULTS: Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018-1.112), proning (OR 3.671; 95% CI 1.128-11.943) and pre-existing respiratory disease (OR 5.863; 95% CI 1.521-11.599) were predictors of oral intake status post-extubation. Two-thirds (66%) presented with dysphonia post-extubation. Intubation injury (OR 10.471; 95% CI 1.060-103.466) and pre-existing respiratory disease (OR 24.196; 95% CI 1.609-363.78) were predictors of post-extubation voice quality. Thirty-seven per cent required dysphagia intervention post-extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge. DISCUSSION: Post-extubation dysphagia and dysphonia were prevalent amongst adults with COVID-19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Barriers to Voice Therapy Attendance in a Language-Diverse Population.

OBJECTIVES/HYPOTHESIS: Voice therapy is an effective treatment for many voice disorders, but success depends on attendance and adherence. Many factors hinder treatment attendance, and language discordance with the provider may present an additional obstacle to attending therapy. This study evaluates factors associated with voice therapy attendance at a language-diverse, safety-net hospital. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective review of adult patients referred to speech language pathology for treatment of voice disorders from January, 2018 to April, 2019. Primary spoken language, interpreter collaboration, and patient demographics were obtained from medical records. Multivariate analysis compared patient factors with voice therapy attendance versus nonattendance. RESULTS: Of 422 patients, 219 (52%) attended at least one therapy session, whereas 203 (48%) did not attend (n = 120) or schedule therapy (n = 83). In multivariate analysis, only the association between public insurance and nonattendance was statistically significant (P = .016). After adjusting for interpreter use and interval between referral and first appointment, patients with private health insurance were 2.35 times more likely to attend therapy compared to those with public insurance (95% confidence interval: 1.18-4.71). Non-English language; interpreter collaboration; distance from hospital; and patient demographics, including age, gender, ethnicity, and birthplace, did not significantly correlate with attendance. CONCLUSIONS: In a culturally and language-diverse cohort of dysphonic patients, individuals with public health insurance were significantly less likely to attend voice therapy. Language-discordant therapy and interpreter collaboration was not a statistically significant barrier to therapy attendance. Additional investigation is warranted to optimize allocation of voice therapy resources for those with public health insurance and for diverse speakers of all languages. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1835-1839, 2021.

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.

Posture and dysphonia associations in patients undergoing total thyroidectomy: stabilometric analysis.

The aim of this study is the analysis of postural changes of patients affected by vocal disorders post-thyroidectomy, in the absence of post-operative organ damage, through a stabilometry analysis, evaluating the effectiveness of a speech-language intensive treatment in phoniatric and postural quality recovery. 260 patients with vocal dysfunction after surgery without iatrogenic damage were enrolled. 130 patients were subject to post-surgical logopedic rehabilitative training (Group A); other 130 patients were not subject to any post-surgical treatment (Group B). For all patients, vocal and stabilometric parameters were evaluated before and after 2 days and 1 month from surgery. Vocal parameters evaluated were Voice Handicap Index-10, Maximum Phonation Time and objective evaluation of voice with Multidimensional Voice Program (MDVP). Stabilometric parameters evaluated were Sway area (mm2) and Sway velocity (mm/s) in firm surface and foam pad with eyes opened and closed. Regarding the stabilometric parameters, Group A obtained a statistically significant recovery of the correct posture statistically significant compared to Group B, after a month of speech therapy. Vocal parameters (VHI, MPT, MDVP) were statistically different between the two groups (p < 0.05), with a better improvement in Group A. Thanks to our study, we have shown that a logopedic rehabilitation therapy in patients with dysfunctional post-thyroidectomy dysphonia improves both the vocal and postural outcomes.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis.

BACKGROUND: Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice. OBJECTIVE OF REVIEW: To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model. TYPE OF REVIEW: Meta-analysis. SEARCH STRATEGY: We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered. EVALUATION METHOD: The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results. RESULTS: We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements. CONCLUSIONS: Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.

A panel of jitter/shimmer may identify functional dysphonia at risk of failure after speech therapy.

BACKGROUND: There are no reliable outcome predictors for functional dysphonia (FD) patients. OBJECTIVES: To investigate if any clinical or phoniatric characteristics could identify FD patients at risk of negative outcome after speech therapy. METHODS: We retrospectively reviewed the results of 78 FD patients treated with the proprioceptive elastic method. Before and one-month after therapy, patients underwent endoscopy, acoustic analysis with Multi-Dimensional Voice Program, and Voice Handicap Index-10 questionnaire (VHI-10). Negative outcome was the persistence of VHI-10 ≥ 13. RESULTS: 26 FD patients had negative outcome (i.e. VHI-10 ≥ 13) after speech therapy. At univariate analysis, clinical variables (i.e. sex, age, comorbidities, dysphonia duration, and professional voice use) were not associated with the outcome. Elevated Jitter% (Jitt; p = 0.03), Shimmer% (Shim; statistical trend, p = 0.06), and Noise to Harmonics Ratio (statistical trend, p = 0.06) were found in patients with poor results. At multivariate analysis, higher Jitt was an independent negative prognostic factor (p = 0.02), while a statically trend was identified for Shim (p = 0.06). A panel of Jitt >1.5 and Shim >5.1 showed an acceptable discriminatory power (AUC [ROC] = 0.76) according to Hosmer and Lemeshow scale. CONCLUSION: A panel of two acoustic analysis parameters could help in identifying FD patients at risk of speech therapy failure. Further studies in these patients are needed to evaluate the most efficient treatment protocol.

Stages of Readiness in Patients With Dysphonia: A Proposal Based on Factor Analysis Using the URICA-V Scale.

INTRODUCTION: In terms of treatment results, the readiness stage presents the best conditions for adherence to a therapeutic proposal, and it allows for an estimated disease prognosis and assistance with treatment monitoring. Patients with dysphonia who are treated using vocal rehabilitation (basically a behavioral program), regardless of disease etiology, can optimize their treatment by understanding the stages of behavioral change. OBJECTIVES: To evaluate the accuracy of the components constituting the stages of readiness to change on the University of Rhode Island Change Assessment-Voice (URICA-V) scale using confirmatory factor analysis and internal consistency indices. METHODS: This documentary study evaluated the records of 488 patients with dysphonia collected from a voice laboratory database. Most of the patients were Brazilian women with higher education who were single, nonprofessional voice users. The results of the URICA-V self-assessment questionnaire were analyzed to determine the patients' stage of readiness to change when vocal rehabilitation was proposed as a treatment. A descriptive and inferential statistical analysis was conducted using confirmatory factor analysis to determine the correlation between the questionnaire items and the stages of readiness. RESULTS: Of the eight items in the precontemplation stage, only four presented significant factor loading within that stage. Three items in the action stage did not present significant factor loading during that stage. The items in the contemplation and maintenance stages presented significant factor loadings within their respective stages. CONCLUSIONS: The results of a confirmatory factor analysis allowed us to propose an adjustment to the URICA-V scale. The objective of the adjusted scale is to improve the instrument's ability to make evaluations prethrepy and posttherapy and to more reliably assess readiness in patients undergoing voice therapy.

Efficacy of Conversation Training Therapy for Patients With Benign Vocal Fold Lesions and Muscle Tension Dysphonia Compared to Historical Matched Control Patients.

Purpose Conversation training therapy (CTT) is the 1st voice therapy approach to eliminate the traditional therapeutic hierarchy and use patient-driven conversation as the sole therapeutic stimulus. The purpose of this investigation was to determine the efficacy of CTT compared to standard-of-care voice therapy approaches for the treatment of patients with voice disorders. Method A prospective study of CTT treatment outcomes in adults with dysphonia due to primary muscle tension dysphonia or benign vocal fold lesions compared to age, gender, and diagnosis historical matched control (HMC) patients was used. The primary outcome was change in Voice Handicap Index-10 (VHI-10); secondary outcomes included acoustic, aerodynamic, and auditory-perceptual outcomes. Data were collected before treatment (baseline), at the start of each therapy session, 1 week after the final therapy session (short-term follow-up), and 3 months after the final therapy session (long-term follow-up). Results For the CTT group, statistically significant improvements were observed for VHI-10. Though statistically significant improvements were observed for the VHI-10 for the HMC group, the CTT group saw significantly greater improvement in VHI-10. Furthermore, equivalent gains were observed following only 2 sessions of CTT compared to 4-8 sessions of traditional therapy. Significant improvements in the CTT group were observed for cepstral peak prominence in a vowel, fundamental frequency, Cepstral Spectral Index of Dysphonia in a vowel and connected speech, vocal intensity, average airflow in speech in a reading passage, number of breaths and duration of reading passage, and auditory-perceptual measurement of overall voice severity. Conclusions Results support the hypothesis that training voice techniques in the context of spontaneous conversational speech improves patient perception of voice handicap and acoustic, aerodynamic, and auditory-perceptual voice outcomes both immediately following treatment and at long-term follow-up. CTT participants also demonstrated significantly larger decreases in VHI-10 compared to HMC participants who received standard-of-care, nonconversational, hierarchical-based voice therapy.

Modificación del índice de perturbación vocal integrado mediante terapia de voz en personas con disfonía funcional en Santiago de Cali, Colombia / Modification of integrated vocal disturbance index through voice therapy in individuals with functional dysphonia in Santiago de Cali, Colombia

Introducción: La terapia de voz es una práctica que no está ampliamente fundamentada en la evidencia investigativa; la valoración y el seguimiento de los programas de rehabilitación se apoyan casi exclusivamente en el análisis perceptual y pocas evaluaciones acústicas reportan medidas que no se han interrelacionado entre sí para determinar grados de riesgo vocal en diferentes poblaciones con disfonía. El objetivo de esta investigación fue valorar acústicamente el efecto de 2tipos de terapia vocal (mixta y directa) en personas con disfonía funcional empleando el índice de perturbación vocal integrado. Método: Se seleccionó una muestra de 20 personas entre los 20 y 60 años con disfonía funcional; se evaluó toda la muestra mediante análisis acústico con el software Anagraf y se fraccionó la muestra en 2grupos, el primero recibió terapia vocal mixta y el segundo únicamente terapia vocal directa. Se evaluaron acústicamente las voces, posterior a la terapia, y se comparó el efecto de los 2tipos de intervención propuestos. Resultados: El índice de perturbación vocal integrado se encontró alterado para la mayor parte de la muestra de ambos grupos, preterapia vocal. Finalizada la terapia tanto mixta como directa, se encontró que este índice clasificó voces en rangos de normalidad y voces en riesgo disminuyendo su grado de alteración. Conclusión: El índice de perturbación vocal integrado se modificó favorablemente para ambos grupos de terapia. No obstante, esta modificación fue estadísticamente significativa para el grupo que realizó terapia vocal mixta

Introduction: Voice therapy is a practice that is not extensively based on research evidence; the assessment and monitoring of rehabilitation programmes are generally based on perceptual analysis, and few acoustic measures have not been correlated with each other to determine the extent of vocal risk among different kinds of populations with dysphonia. The aim of this research was the acoustic assessment of the effect of 2types of voice therapy (mixed and direct) in individuals with functional dysphonia using the integrated vocal disturbance index. Method: A sample of 20 functional dysphonic individuals aged between 20 and 60 years was selected. The individuals were assessed through an acoustic analysis using Anagraf software. The sample was split into 2groups; the first one received mixed voice therapy and the second only received direct voice therapy. The post-therapy voices were acoustically assessed, comparing the effect of the techniques proposed. Results: The integrated vocal disturbance index was found to be altered for most of the individuals in both groups before receiving voice therapy. On completion of the mixed and direct voice therapy, it was found that the index classified the voices into normal and at risk, decreasing their extent of disturbance. Conclusion: The integrated vocal disturbance index was favourably modified for both therapy groups. However, this was statistically more significant for the group that received mixed voice therapy

Consideraciones para la intervención de los apoyos de la comunicación y el lenguaje en la escuela inclusiva / Considerations for the intervention on communication and language supports in the inclusive school

La evolución de la integración educativa hacia el paradigma de la inclusión representa un cambio radical en la perspectiva de análisis de la realidad de las escuelas, en cuanto a la diversidad del alumnado, y de las propuestas de intervención que se centran ahora no en los déficits y limitaciones del individuo, sino en las oportunidades y alternativas que les ofrece el contexto. La puesta en práctica del modelo inclusivo requiere la creación de equipos docentes, que incluyan al profesorado de apoyo como elemento clave para el desarrollo del proyecto. Miembros de este equipo de apoyo son los especialistas en comunicación y lenguaje, que plantean, en un modelo de educación inclusiva, una intervención no de carácter clínico ni terapéutico ni aislado, sino integral que considera el entorno natural del aula como clave para el proceso de adquisición y desarrollo de la capacidad lingüística y comunicativa de todos los alumnos. Este modelo de intervención tiene en el trabajo en equipo y la colaboración el elemento fundamental para garantizar el éxito en la implementación y desarrollo del modelo de la educación inclusiva, que plantea la necesidad de ofrecer propuestas coordinadas entre el apoyo y el tutor a partir de dimensiones y áreas curriculares comunes para trabajar la diversidad del alumnado en cuento a la comunicación y el lenguaje, que potencien y trabajen elementos válidos para todos e imprescindibles para algunos

The evolution of educational integration towards a paradigm of inclusiveness represents a radical change in the perspective of analysing school reality with regard to student diversity and intervention proposals, focused now not on individual shortcomings and limitations, but on the opportunities and alternatives offered to them in this context. Putting an inclusive model into practice requires setting up teaching teams, including support for teachers as a key element to implement the project. Members of this support team are specialists in communication and language which they suggest, in an inclusive education model, an intervention without a clinical, therapeutic or isolated nature, but rather as an integral part that takes into account the natural setting of the classroom as key for the process of acquiring and developing linguistic and communication skills amongst all students. Teamwork and collaboration are the key elements of this intervention model to ensure the inclusive education model is successfully implemented and rolled out. It includes the need to offer coordinated proposals between the support and tutor staff based on curricular dimensions and areas to work on student diversity regarding communication and language, which strengthen and work on elements that are valid for all students and which are essential for some

Voice therapy associated with a decrease in the reflux symptoms index in patients with voice complaints.

OBJECTIVES/HYPOTHESIS: Patients with muscle tension dysphonia often demonstrate an elevation in Reflux Symptom Index (RSI) and 10-item Voice Handicap Index (VHI-10) scores, and may be erroneously diagnosed with laryngopharyngeal reflux disease. In this study we assessed the effects of voice therapy on RSI and VHI-10 scores in patients with voice complaints not responsive to antireflux medications. STUDY DESIGN: Retrospective cohort study. METHODS: A study of patients was conducted at a single tertiary-care center over 1 year (January 2012-January 2013). Patients were included if they had dysphonia not responsive to proton pump inhibition, did not have neurologic or neoplastic disease, and participated in at least three voice-therapy sessions in the absence of antireflux therapy. Primary analysis assessed change in RSI scores between the initial and follow-up visits with a laryngologist. RESULTS: A total of 18 patients were included (mean age = 49.9 ± 14.5 years, 89% female, 83% with a primary complaint of dysphonia). From initial to follow-up visit, the median RSI score (18.5 [interquartile range {IQR}, 9.5-22.8] vs. 10.5 [IQR, 4.5-14]; P = .02) and median VHI-10 score (25.5 [IQR, 11.3-30.0] vs. 13.5 [IQR, 9.5-20.8]; P = .03) significantly decreased. A significant inverse correlation was found between the number of voice therapy sessions/month and change in RSI score (r = -0.4; P = .05). CONCLUSIONS: In this study of patients with muscle tension dysphonia or vocal hyperfunction not responsive to antireflux therapy, RSI and VHI-10 scores improved following voice therapy. Results suggest that self-reported symptoms typically attributed to laryngopharyngeal reflux disease may actually be secondary to inefficient voice use patterns or anxiety about dysphonia that are responsive to voice therapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1169-1173, 2019.

Surface electromyographic biofeedback for behavioral dysphonia in adult people: a systematic review.

PURPOSE: To review systematically the literature and to analyze the effectiveness of surface electromyographic biofeedback in the rehabilitation of adults with behavioral dysphonia. RESEARCH STRATEGIES: Two authors performed an independent search in the following databases: Clinical Trials, Cochrane Library, Embase, LILACS, PubMed, and Web of Science. A specific search strategy was developed for each database. SELECTION CRITERIA: The review included studies that examined the effectiveness of surface electromyographic biofeedback compared to other direct vocal therapy intervention in adults with behavioral dysphonia. There were no restrictions in regard to language or date of publication. DATA ANALYSIS: Analysis of the risk of bias, heterogeneity, quantitative and qualitative data, sensitivity, subgroups, and publication bias. RESULTS: 51 studies were identified, but only two cohort studies remained as prospects for analysis. The studies showed 100% uncertain risk of selection, performance, and detection bias. There was a high degree of clinical heterogeneity. The descriptive analysis showed a reduction in muscle electrical activity and improvement in vocal self-assessment using electromyographic biofeedback; however, it was not possible to calculate the effect size of the interventions. The present study was limited by the fact that it was unable to show a consensus for the majority of data analyzed. CONCLUSION: The available literature does not support a conclusive finding about the effectiveness of surface electromyographic biofeedback compared to other direct interventions used in the rehabilitation of adults with behavioral dysphonia. The studies analyzed vary widely in their clinical procedures and methodology, making it impossible to determine the procedure's effectiveness.

Incidence of dysphagia and dysphonia after Hangman's fractures: Evidence from 93 patients.

This research aims to explore the accurate incidence, severity and outcomes of dysphagia and dysphonia after Hangman fractures.A total of 93 patients were included in this study and clinical data were reviewed. The Bazaz grading system (0-None; 1-Mild; 2-Moderate; 3-Severe) was used for dysphagia evaluation and the Voice Handicap Index-10 used to evaluate dysphonia. In all of the patients, evaluation of dysphagia and dysphonia was performed preoperatively and at 1 week, 1 month, 3, 6, and 12 months after surgery. SPSS 22.0 software (SPSS Inc, Chicago, IL) was used for all statistical analyses.Posttraumatic immediate dysphagia was found in 8 patients and posttraumatic immediate dysphonia was observed in 3 patients. The incidence of dysphagia was 22.6% at the 1st week, 16.1% at the 1st month, and 9.7% at the 3rd month of follow-up. The incidence of dysphonia was 24.5% at the 1st week, 11.3% at the 1st month, and 3.8% at the 3rd month of follow-up.Posttraumatic immediate dysphagia and dysphonia occurred and the anterior surgical approach was associated with a higher incidence of dysphagia compared to posterior surgery and nonoperative patients. Most dysphagia and dysphonia were mild and gradually decreased during the subsequent 3 months after surgery. Future prospective, randomized studies with larger sample sizes are required to validate these data.

Revisión sistemática de la literatura sobre medidas aerodinámicas de la fonación / Systematic literature review on aerodynamic measures of the phonation

Objetivo: El presente estudio muestra una revisión sistemática de la literatura relacionada con las aplicaciones clínicas e investigativas de las medidas aerodinámicas de la fonación: presión subglótica, flujo transglótico y resistencia glótica. Metodología: La revisión se realizó en las bases de datos PubMed y Web Of Science con una ventana temporal 2000-2017. Todos los artículos revisados obtuvieron nivelI. Luego de realizar una evaluación crítica de la evidencia científica, fueron catalogados como estudios clínicos aleatorizados con diseños experimentales. Resultados: Se entregan a partir de la asociación de las medidas aerodinámicas con seis categorías de análisis: a)como método objetivo de evaluación clínica; b)estudios con profesionales de la voz cantada y hablada; c)aplicaciones clínicas e investigativas en patologías laríngeas funcionales; d)investigaciones en diferentes grupos etarios; e)estudios en laringes caninas, y f)estudios en ejercicios con tracto vocal semiocluido. Conclusiones: Se demuestra la objetividad de aplicar medidas aerodinámicas en los estudios de la voz patológica y profesional; las medidas aerodinámicas de la fonación pueden aplicarse en población tanto pediátrica como adulta, y en adultos mayores

Objective: The present study shows a systematic review of the literature, related to the clinical and investigative implementations of aerodynamic measurements of phonation: subglottic pressure, transglottic airflow and glottal resistance. Method: The review was performed in PubMed and Web of Science databases with a time window 2000-2017. All articles reviewed obtained levelI. After performing a critical assessment of the scientific evidence, articles were classified as randomized clinical studies with experimental designs. Results: They are delivered from the association of aerodynamic measurements with six categories of analysis: a)as an objective method for clinical evaluation; b)studies with professional singing and speaking voice users; c)clinical and research implementations in functional laryngeal pathologies; d)research in different age groups; e)studies in canine larynx; and f)studies in voice exercises with semi-occluded vocal tract. Conclusions: The objectivity of implementing aerodynamic measures in pathological and professional voice studies is demonstrated; the aerodynamic measures of phonation can be applied in the pediatric population, as well as in adults and the elderly

Effect of the comprehensive voice rehabilitation program in teachers with behavioral dysphonia. / Efeito do programa integral de reabilitação vocal em professoras com disfonia comportamental.

PURPOSE: Analyze the effects of the Comprehensive Vocal Rehabilitation Program (CVRP) and the motivational stages during speech therapy in teachers with behavioral dysphonia. METHODS: Retrospective, longitudinal, observational study using data from the medical records of 33 teachers regarding auditory-perceptual, acoustic, self-perception analyses and the Voice Handicap Index (VHI-10) protocol in pre- and post-speech therapy situations, and motivational stages of adherence to treatment. RESULTS: Auditory-perceptual assessment of the voice showed that 64.7% of the participants improved voice quality post-speech therapy. Comparison between the pre- and post-speech therapy moments showed that 82.4% of the teachers improved their voice according to self-perception. The VHI-10 showed no statistically significant difference between the pre- and post-speech therapy moments (p=0.879). Acoustic analysis of the voice showed improvement in the means of all evaluated parameters. Statistically significant correlation was observed in the analysis between the pre- and post-speech therapy moments only for the variables maximum phonation time and shimmer. Most of the teachers were at the stage of contemplation on the URICA-VOICE scale. No statistical significance was observed in the correlation analysis between VHI-10, auditory-perceptual assessment of the voice, maximum phonation time, and parameters of acoustic analysis with vocal self-perception of teachers and with auditory-perceptual assessment of voice. CONCLUSION: The use of CVRP for the treatment of behavioral dysphonia presented positive results in the pre- and post-speech therapy evaluation. As for motivation, the teachers strongly believed in the possibility of facing the problem, but still without much effort to change this situation.

OBJETIVO: analisar os efeitos do Programa Integral de Reabilitação Vocal (PIRV) e os estágios motivacionais durante a terapia de voz em professoras com disfonia comportamental. MÉTODO: estudo observacional longitudinal retrospectivo com dados de prontuários de 33 professoras referente à análise perceptivo-auditiva, acústica, autopercepção vocal e Protocolo de Índice de Desvantagem Vocal (IDV-10) nas situações pré e pós-fonoterapia e estágios motivacionais de adesão ao tratamento. RESULTADOS: Na avaliação perceptivo-auditiva da voz, 64,7% das participantes melhoraram a qualidade vocal pós-fonoterapia. Quando comparados os momentos pré e pós-fonoterapia, observou-se que 82,4% das professoras melhoraram a voz segundo a autopercepção. O IDV-10 não mostrou diferença entre os momentos pré e pós-fonoterapia (p=0,879). Na análise acústica da voz, observou-se melhora da média de todos os parâmetros avaliados. Houve associação estatisticamente significante na análise entre os momentos pré e pós-fonoterapia apenas nas variáveis tempo máximo de fonação e shimmer. A maioria das professoras encontrou-se no estágio de contemplação na escala URICA-VOZ. Não houve significância estatística na análise de associação entre o IDV-10, análise perceptivo-auditiva, tempo máximo de fonação e parâmetros da análise acústica com a autopercepção vocal das professoras e com a avaliação perceptivo-auditiva da voz. CONCLUSÃO: o uso do PIRV para tratamento de disfonias comportamentais promoveu resultados positivos quando comparada a avaliação vocal antes e após tratamento. Quanto à motivação, as professoras acreditavam com firmeza na possibilidade de enfrentar o problema, mas ainda sem muito esforço para mudar essa situação.

Voice Changes in the Elderly.

The impact of aging is as inevitable in the larynx as on all biologic systems. The muscles of larynx have the potential to atrophy, the elastin fibers of lamina propria thin with age, and mucous production diminishes. As a result, vocal folds fail to approximate appropriately and the stress on once-robust vocal folds increases. These changes present as poor voice quality, vocal tension, tremor, and altered fundamental frequency. Rather than consider presbyphonia as an immutable diagnosis, we must see it as an opportunity to elevate our standard of care and set goals to work for therapeutic improvement of voice quality.

Assessment of short-term functional voice therapy in patients with unilateral paralysis of the larynx.

Introduction Laryngeal paralysis deteriorates all laryngeal functions. Therefore the therapeutic process must include restoration of respiratory, defensive and vocal function. Selection of a proper rehabilitation path plays a key role. Appropriate research protocol that includes objective methods of voice evaluation is an important element of monitoring the return of vocal efficiency. Voice efficiency is important for the patient particularly due to psychological and social reasons. Aim The aim of the study was the assessment of short-term functional voice therapy (FVT) in patients with unilateral paralysis of the larynx with the usage of objective parameters describing the glottis and voice quality. Material and Method During the last 10 years 355 patients with laryngeal paralysis were hospitalized in the Audiology and Phoniatrics Clinic due to dysphonia. All patients undergone 5-day FVT. From 2015 we unified diagnostic protocol measuring parameters obtained from videostrobokymography (VSK), electroglottography (EGG), perceptual and acoustic voice analysis before and after 5 day hospitalization. Results After FVT patients improved voice quality and glottal compensation. The majority of patients achieved a statistically significant improvement in the VSK, EGG, MDVP and perceptual analysis. Group of patients with unsatisfactory voice improvement after therapy required a prolonged rehabilitation or has been qualified for laryngeal microsurgery. Potential factors that could have cause insufficient effects of FVT were analysed. Conclusions The complexity of voice rehabilitation is crucial for the success of therapy. Interdisciplinary therapeutic team plays a significant role during voice rehabilitation in patients with vocal fold paralysis.