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.

Lessons Learned: Large-Scale Perfused Cadaver Training in Three Different Curricular Environments.

BACKGROUND: Perfused cadavers are viable training models for operating room surgical skills, increasing fidelity of vascular anatomy, dissection, and tissue handling. In addition, perfused cadavers may have benefits in military medical training environments with a focus on hemorrhage control and vascular access. OBJECTIVES: We created a large-scale training exercise with perfused cadavers in three different environments and aim to share the curricular design and feedback from the exercise. METHODS: We conducted a 4-day simulation training exercise with 13 perfused cadavers in 3 different environments: hospital environment, the austere echelons of care environment, and a controlled-settings tent for hemorrhage control and needle decompression training. Through an anonymous online survey and an after-action review (AAR), we elicited feedback on advantages, disadvantages, costs, and comparison to models of porcine and fresh cadavers for procedures and existing courses. RESULTS: A total of 324 participants were trained with 13 perfused cadavers for over 4 days from a variety of specialties and on different procedures and surgical skills. Based on 130 respondents to the survey and the AAR, perfused cadavers were rated to have realistic arterial bleeding and bleeding control training. In addition, perfused cadavers provided increased realism and fidelity for surgical skills. There were disadvantages of logistical requirements, cleanup, costs, and mobility. CONCLUSION: Perfused cadavers can be implemented effectively for hemorrhage control training, surgical and procedure skills, and even exercises in austere environments, but require significant logistical and planning considerations. The training value is maximized with a progressive curriculum from hemorrhage control iterations to more invasive surgical procedures, such as thoracotomy and exploratory laparotomy.

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.

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.

Patient-Reported Factors Associated with the Onset of Hyperfunctional Voice Disorders.

OBJECTIVES: Prevention, diagnosis, and treatment of hyperfunctional voice disorders would be improved by better understanding their etiological contributing factors. Therefore, this study estimated the prevalence of etiological factors using self-reported data about disorder onset from a large cohort of patients with Phonotraumatic Vocal Hyperfunction (PVH) and Non-Phonotraumatic Vocal Hyperfunction (NPVH). METHODS: Retrospective chart review extracted the self-reported rate (gradual, sudden) and events associated (voice use, anxiety/stress, upper respiratory infection [URI]) with disorder onset from 1,577 patients with PVH and 979 patients with NPVH. RESULTS: Both patient groups reported a gradual onset more than a sudden onset. Voice use was the most frequently reported event for PVH and the NPVH group self-reported all three events at equal frequency. The largest PVH subgroups were associated with voice use while the NPVH subgroups were associated with only voice use, only URI, or only anxiety/stress. CONCLUSION: The results support the general clinical view that PVH is most strongly related to the gradual accumulated effects of phonotrauma, while NPVH has a more heterogeneous etiology. The identified PVH and NPVH subgroups may have clinical relevance and future work could investigate differences in treatment and outcomes among these subgroups.

Differences in Daily Voice Use Measures Between Female Patients With Nonphonotraumatic Vocal Hyperfunction and Matched Controls.

Purpose The purpose of this study was to obtain a more comprehensive understanding of the pathophysiology and impact on daily voice use of nonphonotraumatic vocal hyperfunction (NPVH). Method An ambulatory voice monitor collected 1 week of data from 36 patients with NPVH and 36 vocally healthy matched controls. A subset of 11 patients with NPVH were monitored after voice therapy. Daily voice use measures included neck-skin acceleration magnitude, fundamental frequency (f o), cepstral peak prominence (CPP), and the difference between the first and second harmonic magnitudes (H1-H2). Additional comparisons included 118 patients with phonotraumatic vocal hyperfunction (PVH) and 89 additional vocally healthy controls. Results The NPVH group, compared to the matched control group, exhibited increased f o (Cohen's d = 0.6), reduced CPP (d = -0.9), and less positive H1-H2 skewness (d = -1.1). Classifiers used CPP mean and H1-H2 mode to maximally differentiate the NPVH and matched control groups (area under the receiver operating characteristic curve of 0.78). Classifiers performed well on unseen data: the logit decreased in patients with NPVH after therapy; ≥ 85% of the control and PVH groups were identified as "normal" or "not NPVH," respectively. Conclusions The NPVH group's daily voice use is less periodic (CPP), is higher pitched (f o), and has less abrupt vocal fold closure (H1-H2 skew) compared to the matched control group. The combination of CPP mean and H1-H2 mode appears to reflect a pathophysiological continuum in NPVH patients of inefficient phonation with minimal potential for phonotrauma. Further validation of the classification model is needed to better understand potential clinical uses. Supplemental Material https://doi.org/10.23641/asha.14390771.

Changes in the Daily Phonotrauma Index Following the Use of Voice Therapy as the Sole Treatment for Phonotraumatic Vocal Hyperfunction in Females.

Purpose The aim of this study was to use the Daily Phonotrauma Index (DPI) to quantify group-based changes in the daily voice use of patients with phonotraumatic vocal hyperfunction (PVH) after receiving voice therapy as the sole treatment. This is part of an ongoing effort to validate an updated theoretical framework for PVH. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and posttreatment data from 52 female patients with PVH. Normative weeklong data were also obtained from 52 matched controls. Each week was represented by the DPI, which is a combination of neck-surface acceleration magnitude skewness and the standard deviation of the difference between the first and second harmonic magnitudes. Results Compared to pretreatment, the DPI statistically decreased towards normal in the patient group after treatment (Cohen's d = -0.25). The posttreatment patient group's DPI was still significantly higher than the control group (d = 0.68). Conclusions The DPI showed the pattern of improved ambulatory voice use in a group of patients with PVH following voice therapy that was predicted by the updated theoretical framework. Per the prediction, voice therapy was associated with a decreased potential for phonotrauma in daily voice use, but the posttreatment patient group data were still significantly different from the normative control group data. This posttreatment difference is interpreted as reflecting the impact on voice use of the persistence of phonotrauma-induced structural changes to the vocal folds. Further validation of the DPI is needed to better understand its potential clinical use.

Changes in a Daily Phonotrauma Index After Laryngeal Surgery and Voice Therapy: Implications for the Role of Daily Voice Use in the Etiology and Pathophysiology of Phonotraumatic Vocal Hyperfunction.

Purpose This study attempts to gain insights into the role of daily voice use in the etiology and pathophysiology of phonotraumatic vocal hyperfunction (PVH) by applying a logistic regression-based daily phonotrauma index (DPI) to predict group-based improvements in patients with PVH after laryngeal surgery and/or postsurgical voice therapy. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and postsurgery data from 27 female patients with PVH; 13 of these patients were also monitored after postsurgical voice therapy. Normative weeklong data were obtained from 27 matched controls. Each week was represented by the DPI, standard deviation of the difference between the first and second harmonic amplitudes (H1-H2). Results Compared to pretreatment, the DPI significantly decreased in the patient group after surgery (Cohen's d effect size = -0.86) and voice therapy (d = -1.06). The patient group DPI only normalized after voice therapy. Conclusions The DPI produced the expected pattern of improved ambulatory voice use across laryngeal surgery and postsurgical voice therapy in a group of patients with PVH. The results were interpreted as providing new objective information about the role of daily voice use in the etiology and pathophysiology of PVH. The DPI is viewed as an estimate of potential vocal fold trauma that relies on combining the long-term distributional characteristics of two parameters representing the magnitude of phonatory forces (neck-surface acceleration magnitude) and vocal fold closure dynamics (H1-H2). Further validation of the DPI is needed to better understand its potential clinical use.

Integration of Motor Learning Principles Into Real-Time Ambulatory Voice Biofeedback and Example Implementation Via a Clinical Case Study With Vocal Fold Nodules.

PURPOSE: Ambulatory voice biofeedback (AVB) has the potential to significantly improve voice therapy effectiveness by targeting one of the most challenging aspects of rehabilitation: carryover of desired behaviors outside of the therapy session. Although initial evidence indicates that AVB can alter vocal behavior in daily life, retention of the new behavior after biofeedback has not been demonstrated. Motor learning studies repeatedly have shown retention-related benefits when reducing feedback frequency or providing summary statistics. Therefore, novel AVB settings that are based on these concepts are developed and implemented. METHOD: The underlying theoretical framework and resultant implementation of innovative AVB settings on a smartphone-based voice monitor are described. A clinical case study demonstrates the functionality of the new relative frequency feedback capabilities. RESULTS: With new technical capabilities, 2 aspects of feedback are directly modifiable for AVB: relative frequency and summary feedback. Although reduced-frequency AVB was associated with improved carryover of a therapeutic vocal behavior (i.e., reduced vocal intensity) in a patient post-excision of vocal fold nodules, causation cannot be assumed. CONCLUSIONS: Timing and frequency of AVB schedules can be manipulated to empirically assess generalization of motor learning principles to vocal behavior modification and test the clinical effectiveness of AVB with various feedback schedules.

Coupling centrifuge modeling and laser ablation inductively coupled plasma mass spectrometry to determine contaminant retardation in clays.

Quantifying the retardation (Rd) of reactive solutes as they migrate through low-permeability clay-rich media is difficult, thus motivating this study to assess the viability of combining centrifuge modeling and laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) techniques. An influent solution containing Cl-, trace metals, and lanthanide species flowed at 1.0 mL x h(-1) through an undisturbed clay-rich core sample (33 mm diameter x 50 mm long) mounted in a UFA Beckman centrifuge operating at 3000 rpm (N factor = 876 g). During the 87 day experiment the hydraulic conductivity of the core was 3.4 x 10(-10) m x s(-1). Effluent breakthrough data indicate the Rd of Tl to be 10; incomplete breakthrough (non-steady-state) data for 145Nd and 171Yb suggest Rd values of >>75 and >>85, respectively. At the completion of the transport experiment, longitudinal sections of the core solid were analyzed for 145Nd and 171Yb using a Cetac laser ablation system coupled with an ICP-MS. The longitudinal core sections yielded Rd values of >10000 for 145Nd and 171Yb. This study demonstrates coupling these techniques can provide Rd values for a wide range of reactive solutes with relatively rapid testing of small-scale, low hydraulic conductivity core samples.