Rehabilitation Treatment Specification System: Methodology to Identify and Describe Unique Targets and Ingredients.

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (ie, ingredients) actively improve specific patient functions (ie, targets). However, the RTSS does not provide methodology for standardly identifying specific unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (ie, different words describing the same treatment) or meaningfully different (eg, different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this article is to describe the challenges encountered during the project and the methodology developed to address those challenges. Because the methodology was based on the RTSS's broadly applicable framework, it can be used across all areas of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc) or impairment domain (language, cognition, ambulation, upper extremity training, etc). The resulting standard operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care.

PURPOSE: Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice. METHOD: Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification. RESULTS: All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice. CONCLUSIONS: The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24796875.

The Impact of Vocal Tremor on Deglutition: A Pilot Study.

OBJECTIVE: Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. METHODS: Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. RESULTS: Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. CONCLUSIONS: Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Rapid Implementation of Teletherapy for Voice Disorders: Challenges and Opportunities for Speech-Language Pathologists.

INTRODUCTION: The COVID-19 pandemic necessitated a rapid restructuring of the clinical management of voice and upper airway disorders by speech-language pathologists (SLPs). As in-person therapy sessions were suspended, voice-specialized SLPs across healthcare settings shifted to online teletherapy. In this survey study, we queried voice therapists on their experiences with and opinions regarding the adoption of teletherapy into routine clinical practice. METHODS: Voice-specialized SLPs were recruited nationwide to complete an online survey which included questions about the usability of software and hardware, patient management, the effectiveness of therapy, overall satisfaction, and suggestions for improvement. RESULTS: 48 participants completed the survey. The majority of respondents reported frequent technical difficulties and poor access to or understanding of appropriate equipment. Overall, participants endorsed better patient access, attendance, and compliance, as well as increased scheduling flexibility. While 95% of the respondents stated they would recommend teletherapy to another SLP, only 20% supported a shift to exclusively virtual sessions. Forty percent of respondents endorsed a hybrid model consisting of initial in-person sessions followed by virtual ones. DISCUSSION: Incorporating teletherapy into clinical voice practice has, for the most part, followed Carl May's normalization process theory framework, in that clinicians have invested understanding, training, time and effort, and appraisal into its implementation. However, the unusually rapid pace of change necessitated by the pandemic has presented its own set of challenges. Given the inherent conveniences of virtual therapy, the online modality is likely here to stay. It is critical that we understand the facilitators and barriers to its successful adoption.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets.

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357.

The Role of Oral Steroids in the Treatment of Phonotraumatic Vocal Fold Lesions in Women.

OBJECTIVES: (1) To determine the short-term effectiveness of oral steroids in women with benign vocal fold lesions and (2) to determine the effectiveness of adjuvant oral steroids in women undergoing voice therapy for benign vocal fold lesions. STUDY DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Tertiary voice care center. SUBJECTS AND METHODS: Thirty-six patients undergoing voice therapy for the treatment of phonotraumatic vocal fold lesions randomly received either a 4-day course of oral steroids or a placebo prior to initiating voice therapy. Voice Handicap Index-10 (VHI-10) scores, video and audioperceptual analyses, acoustic and aerodynamic analyses at baseline, and patient perception of improvement after a short course of steroids or a placebo and at the conclusion of voice therapy were collected. RESULTS: Thirty patients completed the study, of whom 27 (only female) were analyzed. The primary outcome measure, VHI-10, did not improve after the 4-day course of steroids or placebo. Secondary measures similarly showed no improvement with steroids relative to placebo. Voice therapy demonstrated a positive effect on both VHI-10 and patient-perceived improvement of voice in all subjects. CONCLUSION: A short course of oral steroids did not benefit women with phonotraumatic vocal fold lesions. In addition, steroids had little beneficial effect when used adjunctively with voice therapy in this patient cohort.

Laryngeal hyperfunction during whispering: reality or myth?

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.

The Development of Conversation Training Therapy: A Concept Paper.

OBJECTIVES: To introduce the conceptual, theoretical, and practical foundations of a novel approach to voice therapy, called conversation training therapy (CTT), which focuses exclusively on voice awareness and efficient voice production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. CTT is grounded in motor learning theory, focused on training target voice goals in spontaneous, conversational speech in the first session and throughout. CTT was developed by a consensus panel of expert clinical voice-specialized speech-language pathologists (SLPs) and patients with voice problems. STUDY DESIGN: This is a prospective, clinical consensus design. METHODS: A preliminary CTT approach to voice therapy was developed by the first and last authors (J.G-S. and A.I.G.) and incorporated six interchangeable tenets: clear speech, auditory/kinesthetic awareness, rapport building, negative practice, basic training gestures, and prosody. Five expert voice-specialized clinical SLPs (consensus group) were then presented CTT and a discussion ensued. Later, an informal interview by a neutral third party person occurred for further recommendations for CTT. RESULTS: The CTT approach was modified to reflect all the consensus groups' recommendations, which included the need for more detail and rationale in the program, troubleshooting suggestions, and the concern for potential challenges for novice clinicians. CONCLUSIONS: CTT is a new therapy approach based on motor learning theory, which exclusively uses patient-driven conversational narrative as the sole therapeutic stimuli. CTT is conceptually innovative because it represents an approach to voice therapy developed without the use of a traditional therapeutic hierarchy. It is also developed using input from patients with voice disorders and expert clinical providers.

Frame by frame analysis of glottic insufficiency using laryngovideostroboscopy.

OBJECTIVES/HYPOTHESIS: Glottic insufficiency (GI) can be either grossly obvious or subtle in its presentation. Subtle GI is demonstrated by various Laryngovideostroboscopic (LVS) clues, including complete but "short" phase closure of the true vocal folds (VFs) during the glottic cycle. We used the frame by frame analysis (FBFA) technique to evaluate its effectiveness in objectively contributing to the diagnosis of subtle GI in patients with atrophic and/or paretic VFs. This article intends to formally present the methods and intentions of the FBFA technique and report our findings using FBFA on subjects with clinically diagnosed GI and normal volunteers. STUDY DESIGN: Retrospective review and demonstration of technique. METHODS: Forty-four subjects with a prior clinical diagnosis of true VF atrophy (25/44) and/or paresis (19/44) and five normal volunteers were identified. Using the FBFA technique, each subject's average percentage of closed frames per glottic cycle was recorded. RESULTS: Subjects with atrophy spent 32.4% of the frames of the glottic cycle in the closed phase, subjects with paresis spent 35.7% of the frames closed, and normal subjects spent 50.2% of the frames closed. CONCLUSIONS: FBFA appears to be a simple objective method for the novice or experienced LVS interpreter, by which one can suspect subtle GI. Because of the inherent physical properties by which LVS gives an "illusionary" representation of the glottic cycle, the FBFA technique remains a theoretical tool. Future studies using high-speed digital imaging are needed to validate this useful technique.

Spasmodic dysphonia in an adolescent patient with an autoimmune neurologic disorder.

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has been primarily described in the neurology and psychiatry literature. The symptoms of this syndrome typically are a range of obsessive compulsive disorders and neuromuscular tics. The otolaryngologist occasionally becomes involved with these children when it is deemed that chronic tonsil infections are the source. We report here on a child diagnosed with PANDAS who presented with severe ventricular hyperfunction and adductor spasmodic dysphonia. She was treated with botulinum toxin, which resulted in a significant improvement in subjective voice as well as reduced jitter and shimmer on objective voice measurements.