VOCAL REHABILITATION or VOICE THERAPY at JOURNAL OF VOICE: A 30-YEAR ANALYSIS ON PUBLICATIONS

BEHLAU M. (1), CARROLL L. (2)
(1). Director at “Centro de Estudos da Voz” - CEV, São Paulo, Brazil; permanent professor at the Graduate Program in Human Communicative Disorders at “Universidade Federal de São Paulo – UNIFESP”, São Paulo, Brazil.
(2). Private Practice (New York, NY and Newington, NH, USA) and Senior Voice Scientist, Children’s Hospital of Philadelphia (Philadelphia, PA, USA)

INTRODUCTION

Voice as a new specialty was the aim of the opening article of Journal of Voice – JoV (SATALOFF, 1987a). This peer-review journal highlighted the success of all efforts that started in 1971 with the 1st The Voice Foundation Symposium at Juilliard School in New York, USA, and attributed to an interdisciplinary cooperation in voice. All professionals involved in the care of individuals with voice problems, particularly the professional voice users, were recognized in this position paper. This was the beginning of a very successful journal, recognized worldwide by specialists as one of the most important periodicals to further the advance of the voice science.

The present review will deal with vocal rehabilitation, which achieved an impressive evolution during these last 30 years. Rehabilitation is a word originally from the medieval Latin rehabilitationem (nominative rehabilitation; re- "again" + habilitare "make fit") which means "restoration", while the word therapy comes from the Greek therapeia, which means "curing, healing, service done to the sick”. In this text, rehabilitation will be used as a synonym of therapy. Vocal rehabilitation (VR) or voice therapy (VT) is a complex process which may encompass one or more aspects related to breathing, phonating, resonating or effectively using the voice in different environments and with different communication purposes, such as singing, acting, teaching or preaching.  At the most mechanical point, rehabilitation may involve muscle adjustments. At the opposite end, rehabilitation can include a psychodynamic analysis of the impact of certain preferred vocal parameters on the listeners. Vocal self-image, competent use of voice for challenging communications, and vocal behavior are other aspects frequently involved in VR. The focus of any method or program to rehabilitate patients with voice problems is to improve vocal production, regardless the diagnosis, and to reduce the negative impact of the given vocal disorder on the patient’s quality of life. In a simple way, VR aims to improve vocal functionality for the purpose of communication.

The origin of vocal rehabilitation is usually credited to an adaption of singing exercises, used to improve faulty behaviors, described in classical manuals, such as CACCINI (1601). However, the scientific era of the vocal rehabilitation is credited to an Austrian poet, physician and philosopher, Emil Froeschels (1884-1972), the founder and honorary president of the International Association of Logopedics and Phoniatrics – IALP (1924). Froeschels coined the word “logopedics” to identify the area of the science responsible to rehabilitate patients with voice, speech, language and hearing problems. The name logopedics-logopedician still used in most European countries to refer to the speech language pathologist (BRODNITZ, 1972).

Froeschels introduced the terms hyper and hypofunction to identify conditions in which there is an excessive force of the muscles of the larynx and vocal tract (hyperfunction) or an exhaustion of such musculature and the condition of paratetic hoarseness (hypofunction) (FROESCHELS, 1943). The beginning of the scientific voice is recognized with the publication of two of his seminal articles, one on the pushing technique (FROESCHELS, 1943) and the other on the chewing method (FROESCHELS, 1952).

Journal of Voice is considered the most important compilation for publication of studies related to vocal rehabilitation. This article offers a panoramic view on the evolution of such publications and highlights important achievements in the field. A review of the complete collection of JOV was made both by analyzing the printed volumes from the CEV library and also by consulting the electronic archives of the periodical by a team of graduate students in SLP using PubMed and the Journal of Voice archives (www.jvoice.org), from volume 1 (1987) to volume 31 (2017). The first search was conducted by analyzing title and abstracts for inclusion in this analysis. Secondly, all articles were checked and the whole text was read to confirm that the content was related to VR; 20% of issues were re-checked by the first author and divergences were discussed in group. A collection of 286 articles were grouped and a second analysis was made in order to eliminate articles that were not directly related to the topic of vocal rehabilitation, such as impact of vocal exercises and specific training in normal voice and larynx subjects. It is understood that vocal rehabilitation must be used only when dealing with a disorder in order to restore or treat a person with dysphonia and not when the purpose is to improve vocal function in normal voice subjects.  A total of 167 articles remained after the second analysis. After a detailed analysis of the manuscripts, by reviewing the content of each contribution, the amount was reduced to 144 manuscripts, which are the subject of the present paper.

The most evident outcome is a clear development of experimental design, parallel to a more precise scientific writing, with the use of concrete and measurable terms to testify positive changes after an intervention (evidence-based practice). Methodological description has improved, and more details are presented particularly at the last decade. The literature offers multiple approaches, specific programs and customized treatments, all of them with some level of scientific evidence of positive results. Effect size has only been taken into consideration recently as well as interference factors such as coping strategies and adherence to treatment.  Other variables in reviewed manuscripts include the number of sessions, dosage of exercises, and home practice as well as the type of philosophical orientations, from a symptomatic approach to a holistic intervention.

 

CATEGORIZATION OF ARTICLES

Articles dealing with VR were classified into 4 general groups: theoretical articles (N=10), review articles (N=12), outcome studies with dysphonic patients (N=75) and effects of vocal rehabilitation and related factors (N=47).

Group 1. Theoretical articles were more common in the previous years and these types of publications include comments on the importance of VR or on the role of the SLP Voice Specialist in treating patients with vocal problems as well as presentation of specific programs.

 

Group 2. Review articles include simple revision or clarification of the literature, mainly to highlight an improvement in a specific area of treatment but also integrative and systematic reviews, and  more modern approaches to understand the real contribution of certain treatments for specific conditions.

 

Group 3. Outcome studies with dysphonic patients is a large group that includes case studies, immediate effect of exercises/techniques, and studies with defined methods, programs or protocols. Case reports and studies focusing on the immediate effect of a specific exercise or technique, such as the LAX VOX or resonance tube exercise open this group. Then, studies with defined interventions of rehabilitation, with several designs (case-control, clinical trials and others) are listed, considering that the main goal of these publications is to analyze the effect of a specific method/program of treatment, such as VFE, laryngeal massage/manipulation, comprehensive method, PROEL, among others, applied in different treatment modalities: VR only or combined VR plus (pre, post or pre-post) surgery or botulinum toxin.

 

Group 4. The last group, effects of vocal rehabilitation and related factors, encompasses all articles that give attention not to a specific method but to different aspects that can interfere in the outcome of treatment, such as clinicians’ and patients’ characteristics, personality traits, psychological features, and also therapy administration factors, such as number and duration of sessions, adherence, and withdrawal from treatment.

 

GROUP 1 ARTICLES: THEORETICAL ARTICLES ON VOICE REHABILITATION

Ten articles were included in this group, published from 1987 to 2016, all coming from the United States (Figure 1).  The first mention of VR appears at the first volume of JoV, on an article by SATALOFF (1987b). The author explores common diagnoses and treatment of professional voice users and plainly calibrates the tone of some fundamental stones in our inter and multidisciplinary specialty: in the presence of a voice problem, it is not generally needed to restrict the professional voice user from performing; complete voice rest should be rarely used and laryngeal surgery has to be avoided whenever possible. Moreover, as a warning sign and a clarification to the scientific and naïve community, it is stated that a general SLP may not be the adequate professional to deal with voice problems. The SLP who decides to work with voice problems will need to have a unique combination of knowledge in arts and sciences, merging background in medical sciences, culture and vocal arts. VR is the responsibility of SLP voice specialist and this review will focus on this perspective.

The second article appears on the second volume of the JoV collection and it is authored by one of the icons of our field, the speech-language pathologist, Daniel Boone. This paper presents the basis of respiratory training in voice therapy (BOONE, 1988). Boone states that patients with dysphonia do not always need to modify their respiratory patterns, however, when needed, a simple 4-point program can be administered, connecting breathing to phonation. This article started to put an ending to the myth that all voice problems are the cause of respiratory faults, which was a common belief in those days.

The third article is an editorial signed by ARONSON (1988) where he summarized observation on several cases of patients with “normal” laryngeal examination and a variety of abnormal voices, running from office to offices, with an apparently calm attitude on the outside and ambivalent feelings on the inside, collecting frustrated treatment attempts. The author proposes a psychosocial history taken in order to correctly assess these individuals, perform a proper treatment, and to restore a normal vocal function. Aronson pinpoints that a voice problem may not always be in the larynx and the clinician needs to be aware and sensible of the patient’s psychosocial factors.

The concept of coping is brought to the voice scenario by GATES (1992). He reinforces that becoming ill can be a strategy to overcome difficulties and this cannot be neglected when analyzing an individual with a voice disorder. Moreover, the author defines dysphonia as a “defective use of voice” and claim the need of having the three major professional areas under the name vocology (teachers of singing and performing arts, speech pathologists and scientists, and laryngologists) in order to improve the advance of knowledge and to reduce bias.

The possible dissonance between the clinician's perspective and the concerns of the young dysphonic client with a professional career is discussed by ANDREWS (1993). The struggle between the request of short-term solutions and the long-term consequences of vocal misuse and abuse are explored. The recognized author came back later in JoV (ANDREWS, 1997) with a special focus on the singing/acting child. The later text reinforces the benefit of a team approach when dealing with children, recognizing the emotional investment needed from the part of the child and the fact that early in life the voice of this young professional becomes an important part of their overall identity. Both articles offer interesting appendixes with several tips to use in rehabilitation.

Alternative medicine for treating voice problems is explored at the article by D’ANTONI et al (1995), with attention in behavioral therapies such as massage therapy, creative visualization, Alexander, mindfulness, and meditation. The authors urged for empirical studies with these approaches, but little has been done to enhance the knowledge regarding these alternative practices. Similarities between these alternative practices and some common voice therapy techniques were presented, such as: meditation and resonance voice therapy; mindfulness and awareness of the tactile-kinesthetic feedback system; visualization and using the visual-motor images to facilitate coordination of voice; and finally, massage and Alexander Technique which are closely related to laryngeal/strap muscle massage and body alignment.

The influence of body position (supine and upright) on breathing pattern according to the performance activity (resting tidal breathing or speech breathing), is theoretically explored in the article by HOIT (1995).  Breathing for speaking and singing is usually done at the upright position and is influenced by many variables. There are clinical consequences, particularly with hyperfunctional voice disorders patients, and a three-step treatment approach is presented to help patients to alleviate vocal symptoms due to faulty respiratory patterns.

An intensive approach in vocal rehabilitation, the so-called Boot Camp, is proposed by PATEL, BLESS and THIBEAULT (2011) in order to treat recalcitrant dysphonias that failed to previous traditional approaches. The proposed protocol consists of one to four successive days with different therapists and simultaneous methods and an average of 5 hour per day of rehabilitation. Laryngeal examination is performed at the beginning and ending of each day. Information from multiple areas of knowledge, such as neurobiology, exercise physiology, motor learning theory and psychotherapy are used to justify this regimen of treatment that offer an alternative to previous failure in a short period of time.

 The most recent article from this group is a theoretical presentation with clinical applications of a novel method for voice disorders treatment, named Conversation Training Therapy (CTT) (GARTNER-SCHMIDT et al 2016), based on patient-driven conversational narrative, without the traditional therapeutic hierarchy.  

FIGURE 1. GROUP 1. THEORETICAL ARTICLES ON VOICE REHABILITATION

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1987

Robert T Sataloff . The professional voice: Part III. Common diagnoses and treatments. J Voice 1987b; 283-292.

 

The SLP working in the voice area will need knowledge in both arts and sciences, merging background in medical sciences, culture and vocal arts; VR is the responsibility of SLP voice specialist.

USA

1988

Daniel R. Boone. Respiratory training in voice therapy, In Journal of Voice, Volume 2, Issue 1, 1988, Pages 20-25

Presentation of a 4-point program to correct breathing when faulty in dysphonic patients.

USA

1990

Arnold E. Aronson. Importance of the psychosocial interview in the diagnosis and treatment of “functional” voice disorders, In Journal of Voice, Volume 4, Issue 4, 1990, Pages 287-289

A psychosocial interview can help to properly assess and treat patients with normal larynges and deviant voices.

USA

1992

George A. Gates. Coping with dysphonia, In Journal of Voice, Volume 6, Issue 1, 1992, Pages 22-26

Three important points: vocal disorders are complex; vocal pathology and treatment views need to be refined and reconciled; and integrated treatment protocols and teaching programs need to be used for positive coping.

USA

1993

Moya L. Andrews. Intervention with young voice users: A clinical perspective, In Journal of Voice, Volume 7, Issue 2, 1993, Pages 160-164

The young artist as a voice patient and the struggle between the clinician and the patients’ view.

USA

1995

Maria L. D'Antoni, Pamela Lynn Harvey, Marvin P. Fried. Alternative medicine: Does it play a role in the management of voice disorders? In Journal of Voice, Volume 9, Issue 3, 1995, Pages 308-311

Alternative medicine can help patients with voice problems and need to be scientifically studied.

USA

1995

Jeannette D. Hoit. Influence of body position on breathing and its implications for the evaluation and treatment of speech and voice disorders, In Journal of Voice, Volume 9, Issue 4, 1995, Pages 341-347

Detailed information on breathing and body posture with clinical implications to help patients with voice problems related to faulty respiratory patterns.

USA

1997

Moya L. Andrews. The singing/acting child: a speech-language pathologist's perspective, In Journal of Voice, Volume 11, Issue 2, 1997, Pages 130-134

Psychosocial aspects to deal with the artistic child and the uniqueness of the young patient.

USA

2011

Rita R. Patel, Diane M. Bless, Susan L. Thibeault. Boot Camp: A Novel Intensive Approach to Voice Therapy. Journal of Voice. Volume 25, Issue 5, 2011, Pages 562–569.

An intensive regimen for vocal rehabilitation has basis in neurobiology, exercise physiology, motor learning theory and psychotherapy and can produce learning and behavioral changes in recalcitrant dysphonic patients. This method is valuable for patients who have not responded to traditional voice therapy models, as well as those patients who have significant time limits with recovery of voice function. 

USA

2016

Jackie Gartner-Schmidt, Shirley Gherson, Edie R. Hapner, Jennifer Muckala, Douglas Roth, Sarah Schneider, Amanda I. Gillespie. The Development of Conversation Training Therapy: A Concept Paper, In Journal of Voice, Volume 30, Issue 5, 2016, Pages 563-573

Concept paper proposing a novel approach to voice therapy, called conversation training therapy (CTT), which single focus on voice awareness in conversational voice.

USA

GROUP 2 ARTICLES. REVIEW OF THE LITERATURE

Twelve articles were included in this group, from 1993 to 2017, four of them from 2017; 5 from the USA, 2 from Belgium, 1 from Brazil, 1 from China, 1 from The Netherlands, 1 from both Australia and UK and another from both Brazil and USA (Table 2). The international representation can be explained by the fact that review articles suffer fewer financial limitation resources than experimental studies.

Behavioral treatment for spasmodic dysphonia was reviewed by HEUER (1992) who considered classical books, selected articles and congress presentations. The author concluded that only mild cases can benefit from VR. An excellent article reviewed the progress made during the last 25 years in the voice area was produced by STEMPLE (1993); the author recognize the outstanding contributions of the clinician of the early history and highlights changes made by the interdisciplinary cooperation supported by powerful associations including The Voice Foundation  (TVF), the International Association of Logopedics and Phoniatrics  (IALP), the American Speech-language and Hearing Association  (ASHA) and the Acoustics Society of America  (ASA); a particular session is dedicated to voice therapy and the future. The amount of data accumulated have helped to understand vocal function, however, current VR techniques, exercises and methods have not been properly examined yet, even if there is clinical evidence of its effectiveness. The approaches described until the beginning of the 1990’s were classified by the author in 4 philosophical orientations: symptomatic voice therapy (focus on correcting deviant aspects of voice), psychogenic voice therapy (dealing with the emotional and psychosocial status of the patient), etiologic voice therapy (discovering and changing/modifying/eliminating the causes of the voice problems), and eclectic voice therapy (combination of some or all previous orientations to treat the patient with dysphonia). The scientific advances obtained to understand the vocal function led the author to propose a new philosophical orientation of voice therapy named physiologic voice therapy, based on the knowledge on how the voice is produced. This review article is a seminal contribution and can be considered the fundamental column of the modern VR era.

A very interesting historical review manuscript by GILMAN and GILMAN (2008) deeply explored the use of electrotherapy starting more than 150 years ago, the sudden abandonment of the approach, and the reemergence of this option of treatment recently presented as “innovative” without any scientific reliable data to support its use. Electrical stimulation methods have contributed to advance the knowledge on the laryngeal physiology.

Regarding direct vs. indirect voice therapy, an extensive systematic review was performed by SPEYER (2008) who identified 47 articles dealing specifically to voice therapy for behavioral or organic dysphonias. In general, positive but modest effects were observed with the rehabilitation with direct therapy seeming to be more effective than indirect approaches; the analysis showed that a restricted patient population and a well-defined therapy offers better results. Methodological problems have interfered on the robustness of the results, which limits generalization. Diversity of types of dysphonia, different modalities of therapy as well as different assessment dimensions and instruments make this analysis very complex. This article is an excellent resource, not only to be aware of methodological problems but also to understand the complexity of voice problems and the current scenario of all types of therapy.

The pros and cons of voice rest after laryngeal surgery is a traditional discussion without scientific consensus. The review article by ISHIKAWA and THIBEAULT (2010) is an excellent source of scientific provocation by presenting detailed clinical and basic science review of the literature, presenting biological aspects of vocal rest, characteristics of scar (general, ligament and vocal fold) and the process of tissue healing. Vocal rest versus exercise is presented with some comparison to the orthopedic knowledge on complete immobilization versus controlled mobilization. The current knowledge is that voice rest facilitates healing better than non-controlled use of voice. However, there is still limited information on the impact of controlled exercises, such as resonance techniques to improve tissue remodeling. Vocal fold cells respond positively to mechanical stimulus. It is plausible to hypothesize that a well-designed protocol can offered good results in patients after surgery, but this has to be proved. This article is a must-read text to help clinicians to manage patients not only after laryngeal surgery but also after post-traumatic events.

Two articles deal with muscle tension dysphonia. The first one on the current knowledge on the pathophysiology and treatment of this condition, by Van HOUTTE et al (2011), highlights that this condition is among a spectrum of voice disorders with a common base including increasing tension at the (para-)laryngeal muscles and etiological factors, such as psychological/personality disorders, vocal misuse/abuse, compensatory vocal habits due to the presence of laryngopharyngeal reflux, upper airway infections, and organic lesions. Treatment is multidisciplinary and requires indirect and direct vocal rehabilitation techniques, medical treatment and sometimes even surgical approaches. One systematic review with meta-analysis on laryngeal manual therapies for behavioral dysphonia (RIBEIRO et al, 2017) conclude that the many laryngeal manual therapies described share similar objectives and effects, but their effectiveness is equivalent to that of other interventions involving direct voice therapy in the rehabilitation of adults with behavioral dysphonia. MTD is complex condition that needs more investment and has still a long way to go before achieving consensus. All approaches need to be used with caution, even if effects seem to be positive.

Two other articles analyzed vocal fold paralysis, the most common neurological conditions of the larynx. One is a systematic review and meta-analysis by CHEN et al (2014), considering types and timing of therapy for vocal fold paresis/paralysis after thyroidectomy. The study reveals that cases are very heterogenous but there is possible bias involved in the conclusion. However, timing seems to play an important role.  Reversible interventions should be performed during the first 12 months after the paralysis and irreversible interventions afterwards. Moreover, combined approaches with material injections and VR are frequently used but details on VR are offered. On the other hand, the review by WALTON et all (2017) study specify the role of VR for these neurological cases and conclude that all articles in the review present positive results with this type of intervention, but with low level of evidence mainly due to lack of methodological rigor. Reduced efficacy can be the consequence of a non-standardized assessment and intervention parallel to a large variability of case presentations and inconsistent timing, frequency, and dosage of treatment.

A unique article with an international perspective is presented by De BODT et al (2015). Temporal voice therapy data (frequency and duration of sessions) was analyzed for scientific literature from 1975 to 2013, considering both qualified publications and scientific textbooks. This added a clearer panorama on this issue.  Temporal aspects information on VR are important not only for financial insurance purposes, but also to deal with compliance issues and to understand dosage of treatment. The results of the review of 140 texts showed that voice therapy lasts an average of 9.25 weeks distributed over 10.87 sessions of mostly 30 (36.36%) or 60-minute sessions (27.27%) and occurs once (34.55%) or twice (28.18%) per week, with substantial geographical differences. Few articles have achieved the JoV reader an international picture such this one and this is a mandatory reading to all professional involved in the treatment of patients with voice disorders.

An interesting recent article by MOREIRA et al (2017) analyzed dropout rates and reasons for dropout on clinical trials for VR. Clinical trials are sophisticated, prospective experiments designed to answer specific questions about different types of interventions. Costs involved are usually high, and patient involvement, time commitment and statistical analysis are usually demanding. Therefore, clinical studies produce scientific validity and are crucial to advocate the use of a certain treatment approach. It is common to report problems in maintaining patients’ adherence to assessment and treatment, which can compromise the results. This intriguing article reveals that the overall dropout rate for clinical trials for VR is 15%. Reasons include methodological aspects, such as refusal to be present at sessions, incomplete data and technical errors, and also clinical reasons such as dissatisfaction or satisfaction with the result obtained and self-termination of the program. Adverse effects related to vocal therapy were seldom reported. Studies with reduced dropout were those that included quality of life self-assessment. These studies may have helped the individual to reflect on his/her condition, and therefore generated more adherence to treatment. The higher quality studies (the ones that adhered to the CONSORT statement) showed reduced dropout rates, thereby obtaining more reliable results regarding efficacy in VR.

Finally, the article by DESJARDINS et al (2017) studied the effectiveness of direct VR analyzing 15 randomized clinical trials which involved patients from five different etiologies of dysphonia (functional, Parkinson induced, GERD induced, presbyphonia and unilateral vocal fold paresis), treated by eight specific  voice therapy approaches: Laryngeal Manual Therapy (LMT), Lee Silverman Voice Treatment (LSVT), Vocal Function Exercises  (VFE), Resonant Voice Therapy (or Lessac-Madsen Resonant Voice Therapy), Stretch and Flow Phonation, Comprehensive Voice Rehabilitation program  (CVRP), Phonation Resistance Training Exercises (PhORTE) and Direct Techniques (relaxation and breathing exercises and facilitating techniques). Significant positive improvements were found post 14 programs (all but LMT were used for patients with bilateral benign lesions) on at least one outcome variable. The results are superior to those produced by alternative approaches (such as vocal hygiene) or no intervention at all.  Discrepancies in reported outcome measures limit comparisons of different interventions and drawing more robust conclusions. The article highlights the lack of uniform definition for “effectiveness” of VR. Authors use the terms effectiveness or effective, but also efficacy, non-inferiority, complementary treatment method, utility, practical clinical effect, and viable delivery option without any clear criteria for their use.

 

FIGURE 2. GROUP 2. REVIEW OF THE LITERATURE ARTICLES

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1992

Reinhardt J. Heuer. Behavioral therapy for spasmodic dysphonia, In Journal of Voice, Volume 6, Issue 4, 1992, Pages 352-354

This article reviewed the most frequently used techniques for spasmodic dysphonia listed in books, articles and congress presentations and conclude that only mild cases can benefit from VR.

USA

1993

Joseph C. Stemple. Voice research: So What? A clearer view of voice production, 25 years of progress; the speaking voice, In Journal of Voice, Volume 7, Issue 4, 1993, Pages 293-300

An excellent review on how the scientific information has impacted the clinical practice in the voice area. This is the chief resource regarding the physiological philosophical orientation in VR.

USA

2008

Marina Gilman, Sander L. Gilman. Electrotherapy and the Human Voice: A Literature Review of the Historical Origins and Contemporary Applications, In journal of Voice, Volume 22, Issue 2, 2008, Pages 219–231

A review on the early stages of application on electrotherapy (more than 150 years ago), the fall of these procedures, and the recent reappearance of these procedures with only inconclusive results.

USA

2008

Speyer R. Effects of voice therapy: a systematic review. J Voice. 2008;22:565-80.

A review of 47 articles on voice rehabilitation, excluding pharmacological and surgical treatment, indicated positive but modest effect with VR. Several methodological problems and the inherent complexity of the voice area are discussed.

 

THE NETHERLANDS

2010

Keiko Ishikawa, Susan Thibeault. Voice Rest Versus Exercise: A Review of the Literature, In Journal of Voice, Volume 24, Issue 4, 2010, Pages 379–387

Review of the current clinical and basic science literature on the use of vocal rest after laryngeal surgery. A clear comparison with the orthopedic research on rest versus controlled exercise habilitation is offered, with a list of similarities and differences.

USA

2011

Evelyne Van Houtte, Kristiane Van Lierde, Sofie Claeys. Pathophysiology and Treatment of Muscle Tension Dysphonia: A Review of the Current Knowledge, In Journal of Voice, Volume 25, Issue 2, 2011, Pages 202–207

Review on knowledge on MTD with special consideration to treatment of this condition.

BELGIUM

2014

Xuhui Chen, Ping Wan, Yabin Yu, Ming Li, Yanyan Xu, Ping Huang, Zaoming Huang. Types and Timing of Therapy for Vocal Fold Paresis/Paralysis After Thyroidectomy: A Systematic Review and Meta-Analysis, In Journal of Voice, Volume 28, Issue 6, 2014, Pages p799–808

Systematic review considering unilateral or bilateral paralysis and timing of intervention by material injection and VR.

CHINA

2015

Marc De Bodt, Tine Patteeuw, Athenais Versele. Temporal Variables in Voice Therapy, In Journal of Voice, Volume 29, Issue 5, 2015, Pages p611–617

A unique review of articles and textbooks regarding temporal aspects of VR, offering an international panorama with some general trends and many geographical particularities.

BELGIUM

2017

Tais C. Moreira, Camila D. Gadenz, Dirce M. Capobianco, Luciana R. Figueiró, Maristela Ferigolo, Joao Ricardo N. Vissoci, Helena M.T. Barros, Mauriceia Cassol, Ricardo Pietrobon. Factors Associated With Attrition in Randomized Controlled Trials of Vocal Rehabilitation: Systematic Review and Meta-Analysis, In Journal of Voice, Volume 31, Issue 2, 2017, Pages 259.e29–259.e40

Systematic review and meta-analysis on dropout rates and reasons for dropout on clinical trials for VR has associate higher scores to low methodological quality design

BRAZIL and USA

2017

Maude Desjardins, Lucinda Halstead, Melissa Cooke, Heather Shaw Bonilha. A Systematic Review of Voice Therapy: What “Effectiveness” Really Implies, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 392.e13–392.e32

Review on the effectiveness of direct voice therapy, considering only randomized clinical trials

USA

2017

Chloe Walton, Erin Conway, Helen Blackshaw, Paul Carding. Unilateral Vocal Fold Paralysis: A Systematic Review of Speech-Language Pathology Management, In Journal of Voice, Volume 31, Issue 4, 2017, Pages 509.e7 - 509.e22

Systematic review of VR for unilateral vocal fold paralysis showed positive effects, however with low level of evidence

AUSTRALIA and UNITED KINGDOM

2017

Vanessa Ribeiro, Vanessa Pedrosa, Kelly Silverio, Mara Behlau. Laryngeal Manual Therapies for Behavioral Dysphonia: A Systematic Review and Meta-analysis, In Journal of Voice, Volume 31, 2017 /epub - ahead of print

Systematic review and meta-analysis revealed similarities among approaches and results.

BRAZIL

 

 


GROUP 3 ARTICLES: OUTCOME STUDIES ON VOICE REHABILITATION

This group encompasses 74 articles, the largest category of studies. In order to facilitate the reader to find the information needed, a subgrouping in three types was adopted: Group 3A includes case-reports, Group 3B immediate effects of vocal techniques/exercises or duration of exercises, and Group 3C studies with defined methods/programs/protocols.

Group 3A CASE REPORT STUDIES

Seven articles on case reports that included VR were published from 1997 to 2014, four from the USA, two from Brazil and one from Austria. These are unique cases with all but one (FU et all, 2013) handled by multidisciplinary approaches. PINHO et al (1997) describe a case of paradoxical vocal fold movement, which was not well understood at that time and propose a VR program based in respiratory retraining.  BEHLAU et al (2009) present a unique case of vocal fold self-disruption with VR and not vocal rest as main treatment during the acute traumatic phase. FRIEDRICH et al (2010) present two cases of persistent vestibular fold phonation treated by transitory surgical approach and VR. PATEL et al (2012) showed that VR using Vocal Function Exercises on a granuloma case produced a better vocal efficiency attested by high speed digital imaging. GOFFI-FYNN and CARROLL (2013) present a difficult case of a singer with MTD treated by a combination of voice teacher and speech pathologist approach. LU et all (2013) used LSVT method to treat two cases of presbyphonia, with good results and no secondary negative consequences.

 

FIGURE 3a. GROUP 3A CASE REPORT STUDIES

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1997

Sílvia M.R. Pinho, Domingos H. Tsuji, Luis Sennes, Marcia Menezes. Paradoxical vocal fold movement: A case report, In Journal of Voice, Volume 11, Issue 3, 1997,  Pages 368-372

Single case of patient with paradoxical vocal fold movement, positively treated by VR with focus on breathing control.

BRAZIL

2009

Mara Behlau, Gisele Oliveira, Paulo Pontes. Vocal Fold Self-Disruption After Phonotrauma On a Lead Actor: A Case Presentation, In Journal of Voice, Volume 23, Issue 6, 2009, Pages 726-32

Single case of an elite actor with extensive rupture of vocal fold after a phonotraumatic event treated by medications and intensive VR during the acute period.

BRAZIL

2010

Gerhard Friedrich, Karl Kiesler, Markus Gugatschka. Treatment of Functional Ventricular Fold Phonation by Temporary Suture Lateralization, In Journal of Voice, Volume 24, Issue 5, 2010, Pages 606–609

2 cases of resistant functional vestibular phonation treated by temporary surgical lateralization of the vestibular fold followed by VR and reversion of the suture.

AUSTRIA

2012

Rita R. Patel, Jack Pickering, Joseph Stemple, Kevin D. Donohue. A Case Report in Changes in Phonatory Physiology Following Voice Therapy: Application of High-Speed Imaging, In Journal of Voice, Volume 26, Issue 6, 2012, Pages 734-741

 

1 case, man with granuloma, multiple assessments, perceptual auditory, stroboscopic, acoustic, aerodynamic, high speed digital imaging were performed pre-and post-vocal function exercises program of rehabilitation. HSDI demonstrated the efficiency of vocal function after VR, including vibratory motion, closure and impact stress; all other analysis offered almost no information.

USA

2013

Jeanne C. Goffi-Fynn, Linda M. Carroll. Collaboration and Conquest: MTD as Viewed by Voice Teacher (Singing Voice Specialist) and Speech-Language Pathologist, In Journal of Voice, Volume 27, Issue 3, 2013, Pages 391.e9-391.e14

1 qualitative case report, soprano singer with muscle tension dysphonia treated by a medical voice team; the article addresses the challenges involved in the correct diagnosis and treatment of this difficult case.

USA

2013

Fang-Ling Lu, Shannon Presley, Becky Lammers. Efficacy of Intensive Phonatory-Respiratory Treatment (LSVT) for Presbyphonia: Two Case Reports, In Journal of Voice, Volume 27, Issue 6, 2013, Pages 786.e11-786.e23

2 cases, LSVT applied to presbyphonia, with better glottic competence and vocal function, with neither laryngeal trauma nor maladaptive laryngeal hyperfunction.

USA

2014

Amanda I. Gillespie, Leah B. Helou, John W. Ingle, Maria Baldwin, Clark A. Rosen. The Role of Voice Therapy in the Treatment of Dyspnea and Dysphonia in a Patient With a Vagal Nerve Stimulation Device, In Journal of Voice, Volume 28, Issue 1, 2014, Pages 59-61

Case study, man with dyspnea and dysphonia after vagal nerve stimulation device implantation for treatment refractory epileptic seizures, treated with a multidisciplinary approach via respiratory retraining therapy, similar to paradoxical vocal fold movement disorder treatment.

USA

 

GROUP 3B. IMMEDIATE EFFECTS OF VOICE EXERCISES or DURATION OF EXERCISES

Nine articles were included in this group, six dealing with immediate effects of certain vocal exercises and two specifically on duration of performance of vocal exercises.  Brazil contributed with three articles; Sweden, Chile and Japan with one article each, and joint international efforts are observed in three articles (one signed by authors from Chile, Finland, Czech Republic and Egypt, another by colleagues from Brazil and Finland, and the third one from The Netherlands and Japan). The number of subjects in these studies range from one (GUZMAN, CASTRO, TESTART et al, 2013) to 49 (VLOT et al 2017). Prolonged /b/ technique to displace a high larynx to a better vertical position in the neck was examined by ELLIOT, SUNDBERG and GRAMMING (1997). Several types of semi-occluded vocal tract exercises, including tube in the water, in the air, phonation into straw, lip trills and hand-over mouth were tested in several studies (MENEZES et al 2011; GUZMAN et al, 2013a; GUZMAN et al, 2013b; PAES et al 2013; RAMOS et al, 2017; YAMASAKI et al 2017), using not only traditional but also sophisticated analysis, such as computerized tomography  (GUZMAN et al, 2013b) and magnetic resonance imaging (YAMASAKI et al, 2017). The traditional humming exercise was submitted to two studies, one on immediate EGG and acoustic effects in patients with muscle tension dysphonia. Proving that regularity of vocal fold vibration can be improved rapidly (OGAWA et al, 2013) and another with auditory, EGG and HSDI analysis proved that nasal exercises help to stabilize vocal fold oscillation even in the presence of benign mass lesions (VLOT et al, 2017). Two articles specifically studied the duration of exercises and concluded that 5 minutes of tongue trills produced best auditory and acoustic results for women with vocal nodules (MENEZES et al, 2011) and 3 to 5 minutes was the best dosage for children with benign vocal lesion for semi-occluded vocal tract exercises with a straw (RAMOS et al, 2017). Even if there are only few studies of this subcategory, they seem to offer useful clinical information and can be produced with moderate financial investment.

 

TABLE 3b.  GROUP 3B IMMEDIATE EFFECTS OF VOICE EXERCISES or DURATION OF EXERCISES ARTICLES

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1997

Ninni Elliot, Johan Sundberg, Patricia Gramming. Physiological aspects of a vocal exercise, In Journal of Voice, Volume 11, Issue 2, 1997, Pages 171-177

7 subjects with normal and dysphonic voices. Prolonged /b/ exercise successfully changes vertical positioning of the larynx to a lower level as indicated by multichannel electroglottograph analysis.

SWEDEN

2011

Marcia H.M. Menezes, Maysa T. Ubrig-Zancanella, Maria Gabriela B. Cunha, Gislaine F. Cordeiro, Kátia Nemr, Domingos H. Tsuji. The Relationship Between Tongue Trill Performance Duration and Vocal Changes in Dysphonic Women, In Jornal of Voice, Volume 25, Issue 4, 2011, Pages e167–e175

 

27 women with vocal fold nodules performed tongue trills at different durations: 1, 3, 5 and 7 minutes, with best results at minute 5, according to auditory and acoustic analysis

BRAZIL

2013a

Marco Guzman, Christian Castro, Alba Testart, Daniel Muñoz, Julia Gerhard. Laryngeal and Pharyngeal Activity During Semioccluded Vocal Tract Postures in Subjects Diagnosed With Hyperfunctional Dysphonia, In Journal of Voice, Volume 27, Issue 6, 2013, Pages 709-716

20 subjects with hyperfunctional dysphonia performed eight different semi occluded exercises: lip trills, hand-over-mouth technique, phonation into four different tubes, and tube phonation into water using two different depth levels. All exercises produced a low larynx, narrow aryepiglottic opening, and wide pharynx. Tube in the water, narrow tube in the air and loud phonation exercises produced more evident changes.

CHILE

2013b

Marco Guzman, Anne-Maria Laukkanen,Petr Krupa,Jaromir Horáček, Jan G. Švec, Ahmed Geneid. Vocal Tract and Glottal Function During and After Vocal Exercising With Resonance Tube and Straw, In Journal of Voice, Volume 27, Issue 4, 2013, Pages 523.e19–523.e34

1 subject, normal voice, male classically trained singer; resonance tube and phonation into straw exercise improve vocal efficiency and economy, as indicates by computerized tomography and acoustic analysis. Straw exercise produces more evident changes.

CHILE, FINLAND, CZECH REPUBLIC and EGYPT

2013

Sabrina Mazzer Paes, Fabiana Zambon, Rosiane Yamasaki, Susanna Simberg, Mara Behlau. Immediate Effects of the Finnish Resonance Tube Method on Behavioral Dysphonia, In Journal of Voice, Volume 27, Issue 6, 2013, Pages 717-722

25 female teachers with behavioral dysphonia; resonance tube in water. Exercise increased phonatory comfort and produced better vocal quality. Spectrographic data confirmed auditory impression. Mean fundamental frequency decreased after the exercise.

BRAZIL and FINLAND

2014

Makoto Ogawa, Kiyohito Hosokawa, Misao Yoshida, Toshihiko Iwahashi, Michiko Hashimoto, Hidenori Inohara. Immediate Effects of Humming on Computed Electroglottographic Parameters in Patients With Muscle Tension Dysphonia. In Journal of Voice, Volume 28, Issue 6, 2014, Pages p733–741

21 patients with muscle tension dysphonia and 20 controls performed the humming exercise without and with pitch changes. Results from EGG and acoustic analysis showed positive immediate effect in adjusting the regularity of vocal fold vibration and augmenting the degree of glottal contact in MTD patients as well as non-dysphonic speakers.

JAPAN

2017

Carien Vlot, Makoto Ogawa, Kiyohito Hosokawa, Toshihiko Iwahashi, Chieri Kato, Hidenori Inohara. Investigation of the Immediate Effects of Humming on Vocal Fold Vibration Irregularity Using Electroglottography and High-speed Laryngoscopy in Patients With Organic Voice Disorders, In Journal of Voice, Volume 31, Issue 1, 2017, Pages 48–56

49 dysphonic patients with benign mass lesions and 49 normal voice subjects recorded acoustic and EGG signal during humming; 11 from both groups had simultaneous EGG and HSDI video recordings. Humming can stabilize vocal fold oscillation and 

 immediately improves the voice quality and the EGG perturbation parameters,

THE NETHERLANDS and JAPAN

2017

Lorena de Almeida Ramos, Ana Cristina Côrtes Gama. Effect of Performance Time of the Semi-Occluded Vocal Tract Exercises in Dysphonic Children, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 329–335

27 children with vocal fold nodules and cysts performed 1, 3, 5 and 7 minutes of phonation into straw exercises and were also recorded after the same time duration of vocal rest. Auditory and acoustic analysis showed that 3 to 5 minutes yield the best results when compared to control condition.

BRAZIL

2017

Rosiane Yamasaki, Emi Z. Murano, Eloisa Gebrim, Adriana Hachiya, Arlindo Montagnoli, Mara Behlau, Domingos Tsuji. Vocal Tract Adjustments of Dysphonic and Non-Dysphonic Women Pre- and Post-Flexible Resonance Tube in Water Exercise: A Quantitative MRI Study, In Journal of Voice, Volume 31, Issue 4, 2017, Pages 441-454

10 dysphonic and 10 normal voice women underwent magnetic resonance imaging analysis, pre-and post-3-minute exercise, at rest and during phonation. The flexible resonance tube in water exercise promoted positive changes in both groups. Moreover, vocal tract adjustments were different for both groups at rest and during phonation.

BRAZIL

  

GROUP 3C. STUDIES WITH DEFINED METHODS/PROGRAMS/PROTOCOLS

Several studies were presented with the goal of understanding the impact of a specific program of VR in specific types of dysphonia or populations, or also on combined types of treatment, such as toxin botulinum injection and vocal rehabilitation or phonosurgery and voice therapy. In this subcategory, 59 studies are presented chronologically and by method or program of intervention. The approaches are identified by several names, and the preference of the author(s) was respected at the entries. The number of subjects is these studies range from 4 to 171. The international participation is evident. The approaches number almost 50, which reflects the variety of options available for treatment.

 

A summary of each intervention, organized by alphabetic order, with some introductory remarks is presented here. In the case of adapted programs or protocols designed specially by the authors, the explanation offered is derived from the own manuscript. When needed, information from the original source of the method, program or protocol was included.

 

  • ACCENT METHOD: Proposed by Smith and Thyme (1976), it is a holistic approach for behavior modification that includes vocal hygiene recommendation and correction of faulty behaviors. It aims directly to a better speech and voice production, using relaxing body position, diaphragmatic breathing and natural optimal pitch obtained through rhythmic vowel play (slow, largo, andante and allegro). After achieving vowel control, the patient is directed to articulated speech utterances and then to spontaneous speech. It is usually delivered twice weekly in a 20 minute session. Two studies are included in this series of articles.

 

  • ACUPUNCTURE: A key component of the traditional Chinese medicine, acupuncture is an alternative medicine approach, commonly used for pain relief, with the insertion of many thin needles in the skin, for several minutes. It has been practiced at the Far East for at least 3,000 years but  only in the last 30 years has scientific research been produced to understand its principles and results (PYNE, SENKER, 2008).

 

  • BEHAVIORAL VOICE INTERVENTION PROTOCOL FOR PREMATURES: It is a specific protocol designed by the authors (REYNOLDS et al, 2017) with the following components: information provision (diagrams with description of respiratory, laryngeal, and resonance systems), abdominal breathing, abdominal breathing plus speech (voiceless fricatives), relaxation exercises (yawn-sigh, easy onset and silent giggle), and resonant voice/forward focus (humming and hierarchy of speech samples).

 

  • BEHAVIORAL VOICE THERAPY PROTOCOL: This specific protocol developed by HOLMBERG et al (2001) has five basic behaviorally based approaches or phases: vocal hygiene (education, identification of vocal and non-vocal abuses, etiology of nodules and reduction/elimination of vocal abuse habits), respiration (speech breathing free of excessive effort and improvement on use of air supply for voice production), direct facilitation (reduction of loudness and use of yawn-sigh technique), relaxation (progressive technique, imagery and instruction for management of stress), and carry-over exercises (client mimicking specific speaking situations and feedback on communication outside the therapy room).

 

  • BERNESE BRIEF DYNAMIC INTERVENTION (BBDI): A new and not validated model of short term therapy based on a three-generation view of the emergence of pediatric dysphonia (grandparents-parents-child), BBDI was developed at the Division of Phoniatrics at the ENT Clinic of Berne University between 2000 to 2010 for children with non-organic voice disorder (KOOLBRINNER 2006). It is a short-term treatment with play therapy and psychodynamic counseling of the parents, to resolve the nodes of attachment (nodes of feeling, thinking, and behaving) that need to be addressed (usually seen in all psychosomatic diseases).

 

  • BODY ALIGNMENT: Alignment refers to how the head, neck, shoulder, spine, hips, legs, ankle and feet line up with each other.  There is a general agreement that postural alignment is important for optimizing voice production (ARBOLEDA, FREDERICK, 2008). Several techniques can be used in order to improve posture to facilitate to reduce tension in order to achieve a better muscular length-tension balance to facilitate voice production with less effort. Posture affects directly body tension and respiration, and this needs to be addressed in some patients. The help of a physical therapist may be necessary.

 

  • BREATHING TECHNIQUES: A series of exercises to help regulate the flow of air, removing any constriction from the nostrils to the lungs which can be done standing, sitting or in laying position, with or without vocalization. They were frequently used in the early days of voice therapy due to the influence of singing techniques in vocal rehabilitation. Classical books present several options of dealing with breathing (COOPER, 1966; BOONE, 1971; ARONSON, 1990; BOONE et al, 2010). A more inferior or complete breathing is preferred over clavicular or superior type. Nasal breathing when silent is incentivized as well as coordination of  regular pacing of inspiration and expiration. These exercises are almost never used alone in VR.

 

  • COMBINED FUNCTIONAL VOICE THERAPY (FSVT): Use of a functional singing voice therapy program was proposed by  Sielska-Badurek et al (2016). All tasks of therapy are mainly addressed through singing.  The program has 7 steps: (1) Discussion about examination results, indication of incorrect movements, and tension of the singer's vocal tract structures; (2)  Improvement of the body posture (Feldenkreis Method); (3)  Learning how to control and influence the tension and movements of the abdominal walls, shoulders, neck, and mandible muscles (manual techniques, stretching and relaxing of muscles; chewing method); (4)  Improvement of breathing patterns (Lax Voice therapy and techniques related to the singer's imagination); (5)  Improvement of the coordination of respiration and phonation (Accent method); and (6) Creation of conscious appoggio (increasing the sensorimotor self-awareness of the vocal tract).  If incorrect functions where noticed during speaking, therapy deals also with this modality of use of voice.

 

  • COMBINED TREATMENTS: Some studies present a combination of different types of treatment, such as surgery and rehabilitation approaches, or botulinum toxin injection and voice therapy. Sometimes the studies compared different groups with or two modalities of treatment.

 

  • COMPREHENSIVE VOICE REHABILITATION PROGRAM (CVRP): This holistic program, structured and progressive,  was developed by BEHLAU in the 90’s (BEHLAU ET AL 2013),  that includes perception, vocal psychodynamics, awareness and changing negative vocal habits, body-voice association techniques, glottal competence, and resonance exercises with the final goal to improve oral communication. The program focuses on five characteristics: body-voice integration, glottal source, resonance, coordination of subsystems, and communicative attitude.

 

  • CONFIDENTIAL VOICE THERAPY (CVT): The approach to reduce tension and to increase airflow while phonating was proposed by CASPER (2000). The patient is guided to speak with minimum intensity, low effort and a breathing vocal quality, using short phrases for 3 to 4 weeks, and then to builds to normal voicing. It was initially developed to treat vocal folds nodules. The patient is instructed to produce voice as if speaking confidentially at close range. It can be used as a strategy to reduce the size of benign mass lesions and muscular tension before using a more active approach, such as resonant voice. One study compares resonant voice and confidential voice therapy.

 

  • CONVENTIONAL VOICE THERAPY: Defined by DEMMINK-GEERTMAN and DEJONCKERE (2010), this approach is a combination of different techniques, including respiratory retraining, coordination of breathing with vocalization, resonant voice therapy, accent method, and vocal function exercises on a customized exercise program for each patient.

 

  • COORDINATION THERAPY (CTh):  This holistic approach addressing functional, personal and emotional aspects was proposed by Elfriede Öcker (Demmink-Geertman and Duits-Schouten 2006). The goal is to develop the ability to eliminate persistent negative emotions, inhibitions, anxieties, emotional impulsiveness, fears, conscious and unconscious self-defeating actions or reactions, and even physical pain and symptoms when there is an underlying problem of emotional stress. This is done via counseling, which includes stress management. Besides the behavioral aspects, body posture is observed and corrected to optimize the tonus of the muscles, with a particular focus on relaxing the oral, pharyngeal, and extrinsic laryngeal muscles by massage, jaw movements, and yawning. Cranial and caudal laryngeal motion is actively trained to facilitate lowering of the larynx.

 

  • COUNSELING OF PARENTS: Counseling is a professional relationship used to help people make changes. It is a collaborative effort between a clinician and a patient, using a structured interview to support people to help with a problem, and improve communication and coping skills. It is a technique used by several health professionals but can be also a profession itself (counseling.org).

 

  • DIRECT AND INDIRECT VOCAL REHABILITATION: Direct rehabilitation is a modality of treatment that includes all techniques that can be used to modify aspects of faulty voice production, from breathing to resonance. The individual learns a healthier pattern of voice production to replace his faulty one. Indirect rehabilitation is a group of techniques that do not work directly on the voice but focus on the contributing and maintaining aspects of the voice problem. Vocal hygiene recommendations, voice ergonomics and vocal abuse patterns modification are usually listed in this type of intervention. The patient is instructed to be able to identify both the contributing psychological and social factors in the voice problem. Coping strategies and dealing with stress are also usually included in this category. Direct and indirect modalities are not mutually exclusive and have been recognized as important aspects in VR since the classical books.

 

  • EXPIRATORY MUSCLE SPEECH TRAINING (EMST):  This is a specific breathing training program with the goal of improving respiratory strength during phonation. Exercises are made with an external device to mechanically overload the expiratory muscles. A one-way, spring-loaded valve that blocks the flow of air until the targeted expiratory pressure is produced. Levels of blockage can be changed to improve the maximum expiratory pressures. The most common device is the EMST 150, developed by Sapienza, Davenport and Martin (PITTS et al., 2009).

 

  • FUNCTIONAL VOICE PROGRAM (FVP): An original rehabilitation program specially developed by the authors (SIELSKA-BADUREK et al, 2017) to treat singers that includes the combination of the following methods of exercises: Lessac Method, Alexander Technique, Froeschels' chewing method, accent method, relaxation techniques, Feldenkrais method, Lax Vox, laryngeal manual therapy, and auditory training.

 

  • HYDRATION THERAPY: Hydration treatments are often adopted in the clinical management of voice disorders using general recommendations such as commercial ambient humidifiers, direct steam inhalations, taking mucolytic drugs, using mostly nose breathing or simply by elevating intake of water or other hydrating fluids. According to TITZE (19), hydration helps to reduce vocal fold viscosity, improve conditions to a better mucosal vibration, and may also minimize the risk of edema-based laryngeal lesions. Only one study has specifically addressed hydration as therapy method in this series.

 

  • HYGIENIC, SYMPTOMATIC AND PHYSIOLOGICAL VOICE THERAPY: According to SENKAL and ÇIYILTEPE (2013), hygienic voice therapy techniques can improve behaviors that contribute to injury of the vocal folds. Identification and subsequent elimination of poor vocal behaviors, followed by the development of proper vocal behaviors are part of this program as well as others. Symptomatic voice therapy techniques are used to treat abnormal voice quality according to voice symptoms (Chewing exercise, Yawn-sigh technique, EMG biofeedback, and Manual Circumlaryngeal Therapy). Physiological voice therapy techniques are designed to optimize voice production by rebalancing the 3 subsystems (breathing, phonation and resonance) through use of maximum vowel prolongations and pitch glides using specific pitch and phonetic contexts.

 

  • INDIRECT VOCAL REHABILITATION: see DIRECT AND INDIRECT VOCAL REHABILITATION

 

  • KINESIO® TAPING METHOD (KT):  Developed by the Japanese chiropracticioner and acupuncturist KASE in the 1970’s (KASE et al, 2002), this method is used in physiotherapy and sports medicine, as well as clinical applications in osteopathy and neurology. It uses elastic bandaging with certain thickness and characteristics of elasticity and adhesiveness, made by polymer elastic strand wrapped by 100% cotton fibers, in order to produce a biomechanical effect on the organism with the release of muscle limitations. Only one study exists in this series of articles.

 

  • LEE SILVERMAN VOICE TREATMENT (LSVT®): This intensive method proposed in the 1980’s by Ramig (RAMIG 1995) has good scientific documentation for treatment of voice problems in individuals with Parkinson Disease with the goal of restoring functional oral communication based solely on phonatory effort. The method has a single focus on loudness of voice, with high-effort productions, multiple repetitions, 16 sessions, 4 per week and calibration of voice to speech.

 

  • LIPS AND TONGUE TRILLS – see SEMI-OCCLUDED VOCAL TRACT EXERCISES (SOVT)

 

  • MANUAL LARYNGEAL MUSCULOSKELETAL TENSION REDUCTION TECHNIQUE or MANUAL CIRCUMLARYNGEAL THERAPY (MCT) and LARYNGEAL MANUAL THERAPY  (LMT): Laryngeal manipulation for reducing the muscle tension was proposed by ARONSON (1990) and consists of kneading the laryngeal musculature and lowering the position of the larynx in the neck to release musculoskeletal tension and improve the voice. There are several options of manipulation but the two more frequently used are the MCT, a strong one hand deep massage approach with the patient producing voice during the procedure (push-back maneuver, pull-down maneuver and median compression and downward traction) and the LMT, a less vigorous and more superficial approach using two hand soft manipulation with vocalization only afterward. Four studies were found, two with MCT, one with LMT and the last one with a combination of laryngeal manipulation techniques.

 

  • ORAL RESONANCE PROGRAM: Specifically created by the authors (CAREW et al, 2007), this program is based on the techniques of oral resonance suggested by BOONE (1971) and MARTIN AND DARNLEY (1992) to achieve a more feminine voice in transsexuals. Two therapy goals were used to develop the desired oral resonance: (1) lip spreading during speech and forward tongue carriage; (2) auditory and visual discrimination of techniques from clinician-provided models and positive and negative practice of each technique. Hierarchy tasks from isolated vowels were progressively used to reach conversational level speech.

 

  • PLANNED VOCAL REHABILITATION FOR UNILATERAL VOCAL FOLD PARALYSIS: Three techniques commonly used for treating vocal fold paralysis were associated in this planned program: the vocal function exercises, hard glottal attack, and resonance voice therapy. The program has 3 stages with an average of 4 weeks per stage: 1st stage includes breathing control, vocal hygiene, relaxation exercise, and VFE; 2nd stage includes relaxation exercise, VFE programs on longer maximum phonation time, and hard glottal attack; 3rd stage focuses on VEF programs and RVT, using frontal focus and soft voice without cuing, MPT over 15 seconds; and speech using forward resonance and easy phonation.

 

  • PROEL METHOD: This is a multidimensional and holistic approach developed by the Spanish phoniatrician Borragan in the 1990’s (DIAS GOMES et al, 1999) and further developed in Italy (BORRAGAN et al, 2008). The goal of this method is to rebalance the phonatory system by eliminating muscle tension in an attempt to seek greater elasticity in the body. The method is divided in 5 progressive phases: (1) Control of vocal risk factors; (2) Vocal proprioceptive awareness; (3) Elimination of the mechanisms of stress, tension, and muscular stiffness; (4) Projection and resonance of the voice; and (5) Research into the feeling of freedom and well-being. Only one study was found in this series of articles.

 

  • PUSHING PROGRAM: First proposed by FROESCHELS (1955) to treat vocal fold paralysis, this method aims to reduce glottic insufficiency by increasing glottal closure using the sphincteric function of the larynx. The exercises use the synchronous responsive adduction of the vocal folds when the neck and arms are consciously strained which requires intrathoracic pressure build up. Many body maneuvers can be used. Only one study was found in this series of articles.

 

  • RELAXATION TECHNIQUES: Once very popular, several techniques can be used to reduce vocal hyperfunction considering both the whole body or head, neck and shoulders (laryngeal area). Structured progressive muscle relaxation or body movements with or without vocalizations can be used. Relaxation techniques are almost never used alone and are frequently associated with breathing or visualization exercises or for improving body awareness. Classical books that mention breathing also mention relaxation strategies (COOPER, 1966 ARONSON, 1990; BOONE, 1971 and 2010; COLTON and CASPER, 1996).

 

  • RESONANT VOICE THERAPY (RVT):  This method of treatment has its root on performance scenarios such as theatre and classical music.  RVT is described in traditional theatre literature (LESSAC, 1967) and in speech language pathology manuals (BOONE, 1971; COOPER, 1973; ARONSON, 1990; COLTON & CASPER, 1996; BOONE et al, 2010). Almost all international literature and clinical practice involve a version of resonant voice therapy (BEHLAU, MURRY, 2012) with nasal sounds produced in isolation, prolonged or in staccato, with vowels, words and sentences with the majority of nasal sound to improve voice. The use of nasal sounds helps to tune the supraglottic cavities to the glottal source. Semi-occluded vocal tract interaction effect is also observed here.  Resonant voice usually corresponds to complete vocal fold closure. A structure version of the resonant strategy for VR is the Lessac-Madsen Resonant Voice Therapy (LMRVT), developed by Verdolini in the early 2000 (VERDOLINI, 2000; VERDOLINI, 2005), with the goal of correcting both hypo- or hyperadducted vocal fold closure by implementing a barely-abducted or barely-adducted laryngeal configuration.      

 

  • RESPIRATORY EFFORT TREATMENT (RET): This is a high effort method focused on breathing, which includes maximum inspiration and expiration, maximum prolongation of the voiceless fricatives /s/ and /f/ and sustained intraoral air pressure using the Iowa Oral Performance Instrument (IOPI). Origin of this approach began in 1980 with Hartman et al (1980) and Robin et al (1992).

 

  • SEMI-OCCLUDED VOCAL TRACT EXERCISES (SOVTE): This large group of exercises involves narrowing at any supraglottic region or an artificial extension of the vocal tract in order to maximize interaction between source (vocal folds vibration) and filter (vocal tract). The effect is a resonant voice due to a better coupling. Several sounds can be used to create this effect, such as closed vowels (/i/ and /u/), tongue and lips trills. and artificial extensions such as phonation in straw (small or larger) or tubes (rigid or flexible) in the water or in the air. Resistance can be manipulated by varying the length, the diameter of the straw or tube or by inserting in the water (superficially or deeply). Straw phonation was proposed by Titze (2006) and it is one of the most frequent SOVT exercises used both in training and treatment. A non-differentiated sustained sound is the starting vocalization that can be followed by pitch glides, humming sounds, music or reciting poetry. A foam cup with a whole or a ventilation mask or simply by almost closing the mouth with the hand are other options to produce the semi-occluded effect. Two studies were present, one with lips and tongue trills and another comparing phonation on water resistance tube versus on tube in the air.

 

  • SEONG-TAE KIM’S MULTIPLE VOICE THERAPY TECHNIQUE (SKMVT®): The authors broadly classify this program as a method for alleviating laryngeal tension and enhancing laryngeal contact. The program includes yawn-sigh, change of loudness, singing voice, establishing a new tone, and multi-voice therapy techniques. It is reported to be effective for patients with psychogenic or functional dysphonia, with initial studies on benefit of SKMVT for patients with unilateral vocal fold polyp.

 

  • SPEECH PATHOLOGY INTERVENTION PROGRAM FOR CHRONIC COUGH (SpeICh-C):  A multidimensional speech pathology treatment program proposed by VERTIGAN et l (2006)is based on approaches used to treat hyperfunctional voice disorders and paradoxical vocal fold movement. The SPEICH-C includes four components:  education about the nature of chronic cough, strategies to control the cough, psycho‐educational counselling, and vocal hygiene education to reduce laryngeal irritation. Only one study is present in this series of articles.

 

  • STRETCH-AND-FLOW VOICE THERAPY - (SnF): Also known as Casper-Stone Flow Phonation, this program was proposed in the 1980’s (STONE & CASTEEL, 1982) to treat functional dysphonia or aphonia. It is a structural, progressive physiological intervention, with tasks designed to rebalance the respiratory, phonatory, and resonatory subsystems of voice production. A unique characteristic of this method is the use of voiceless sounds. The main focus of therapy is airflow management to interrupt the tendency of breath-holding. Various feedback strategies such as placing a piece of tissue in front of the mouth or holding one's hand in front of the mouth to monitor airflow are used to make the airflow concrete to the patient. Voicing is introduced only after mastering the continuous airflow during exhalation, starting with voicing in vowels, words, phrases and then conversation.

 

  • STRUCTURED PROTOCOL FOR VOICE REHABILITATION ATHER RADIOTHERAPY: This protocol created according to the Swedish Standard Voice Training (IWARSON, 2007) was proposed by TUOMI et al (2014) to treat dysphonia after radiotherapy for laryngeal cancer. The program has 10 specified VR sessions, including: basic exercises for relaxation, posture, and breathing, starting with sounds and progressing to words and short phrases. Phonation is used with simultaneous physical movement, focusing on resonance, articulation exercises (to achieve relaxation), reading and conversation with appropriate pausing, eye contact, repetition of most patient-relevant techniques, and on volume and voice projection.

 

  • SYMPTOMATIC VOICE THERAPY: This voice management approach, introduced by Daniel Boone in the 1960’s (BOONE, 1971), is based on the premises of modifying symptoms of voice production, such as pitch, loudness, articulation, breathing patterns, resonance, among others, to remediate voice disorders. Once identified, these deviated components can be modified through the use of one or many voice therapy facilitating techniques, such as tongue position, change of loudness, chewing exercises, digital manipulation, ear training, elimination of abuses, elimination of hard glottal attack, establishment of new pitch, explanation of the problem, feedback, hierarchy analysis, negative practice, open mouth exercises, pitch inflections, pushing approach, relaxation, respiration training, target voice model, voice rest, yawn-sigh approach, chant talk, inhalation phonation, and half-swallow boom, among others.

 

  • THERAPY MODEL FOR PSYCHOGENIC VOICE DISORDER: COMBINED BEHAVIORAL AND COGNITIVE THERAPY: This model, proposed by ANDERSSON and SHALÉN (1998), includes traditional vocal exercises, communicative exercises, and interactive therapeutic discourses. The goal of the treatment is to obtain a normal vocal behavior and awareness of the connection between vocal dysfunction and psychosocial factors. Particular attention is given to direct the body as a tool for the expression of emotions.

 

  • THORACO-ABDOMINAL VOCALIZATION: Proposed by Van Lierde et al (2010), this program consists of a progressive series of breathing exercises, starting with theoretical information about breathing patterns/limited breath support, and identification of the breathing pattern of the subject. Subjects practice abdominal/diaphragmatic breathing without phonation at rest while sitting, and then during phonation at rest while sitting, with the use of tactile and visual feedback of the abdominal breathing pattern. This is followed by practicing during production of the consonants /z/ and /v/, in isolation, in syllables, with short and long words, and counting numbers.

 

  • TRADITIONAL VOICE THERAPY: This label usually offers a program that includes vocal hygiene and several symptomatic facilitating approaches, as suggested by BOONE (1971).

 

  • TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS): This form of electrotherapy, a simple  technique to reduce muscle pain, involves the application of percutaneous electrodes in the laryngeal region. A current of low frequency and high intensity is suggested to be used, placing surface electrodes on suprahyoid muscles and superior fibers of trapezius muscles, with the goal of promoting muscle relaxation of the perilaryngeal and cervical areas (SILVERIO et al, 2015). TENS can also improve vascularization in addition to assisting in muscle relaxation which leads to an analgesic purpose.

 

  • TWANG THERAPY: This method is presented by LOMBARD and STEINHEUER (2007) as an alternative approach to treat hypophonic voices by increasing vocal power working on the sound filter via twang quality. Results are obtained through constriction of the epilarynx in order to enhance vocal power. Only one study is present in this series of articles.

 

  • VOCAL FUNCTION EXERCISES: Proposed by STEMPLE (1984), this series of 4 physiological exercises facilitates the return of a healthy voice function by improving the interaction between the 3 subsystems: breathing, phonation and resonance. The exercises are presented as: warm-up (sustained /i/ for as long as possible on a comfortable note), vocal folds stretching (glide from the lowest to the highest note in the frequency range, using /o/), vocal fold contracting (glide from the highest to the lowest note in the frequency range, using /o/) , and power exercises (sustained notes middle C and D, E, F, G above middle C for as long as possible, using /o/). This whole sequence is done twice a day, in sets of two. Maximum phonation time goals are set on an individual basis. The voice for all exercises, particularly for the warm up, has to be soft and engaged. Semi-occluded vocal tract (lip buzz, lips or tongue trills) can also be used.

 

  • VOCAL HYGIENE (VH): This program is considered indirect vocal therapy and consists of several orientations regarding best practices to use the voice. It includes what should be avoided and the alternatives for challenging situations such as yelling, screaming, speaking for a long time and over competing noise. Vocal rest and hydration tips are often offered. Traditional voice hygiene recommendations are published in many books, but a good list is available at ROY et al (2001). More modern approaches include items such as lifestyle, environmental factors and coping with stress and emotions.

 

  • VOCAL WARM-UP PROTOCOL: Warming up the voice is a series of exercises as a practical vocal routine to make the voice ready for a specific use, such as singing, acting and teaching. It is usually performed by professional voice users and it is consider important to set up the mechanism and to prevent injuries. A warm-up of 15 to 20 minutes is considered as adequate time to perform the exercises but individuals with voice problems may take a longer period to prepare the vocal apparatus. It is hypothesized that warming up the voice allows the muscles to be more relaxed and balanced, secretions are thinned, and the mind is focused on the performance to follow. Vocal warm-up routines can be specific designed for certain purposes (BEHLAU et al 2015).

 

  • VOICE AMPLIFICATION (VA): Amplification was suggested by ROY et al (2002) in order to ease voice production, reduce vocal fatigue, and prevent hyperfunction when increased volume or extended periods of voice usage are needed. It is a supportive tool that can be implemented when waiting for VR, or to prevent dysphonia when teaching with poor room acoustic conditions.

 

  • VOICE THERAPY EXPULSION TECHNIQUE (VTE): This technique was originally proposed by  ARNOUX-SINDT (1991) as a rehabilitation protocol for treatment of postintubation granulomas. The technique aims first to induce ischemia of the lesion peduncle, and then expel the mass through a series of “repeated microtraumas” produced with specific vocal exercises with sharp, strong glottal closure and high airflow. All exercises are repeated in order to induce excision of the lesion, by expulsion out of the patient's mouth through coughing. The program was modified to treat vocal fold polyps by BARILLARI et al (2017) and has two parts: pars destruens and parts construens. Parts destruens consists of 5 to a maximum of 10 sessions of 30 minutes each, twice a week, with exercises to produce microtrauma and expulsion of the lesion, through coughing, scraping, vigorous and fast inspiration and expiration. Vowels with aspirated attack and then saccadized, as well as inspiration and expiration of sonorized vowels are used. In case of failure, the patient is sent to standard voice therapy. If expulsion occurs, the patient proceeds to the pars construens, with 10 more sessions of 30 minute duration, similar to the standard therapy, twice a week, to develop awareness on voice control, recognition of deviant vocal behaviors, and production of correct vocal emission in various communicative settings. No special precautions are necessary, and no significant risks were reported in the literature. 

 

  • VOICE TRAINING METHOD: This particular group of exercises proposed by the authors (LIANG et al 2017) consists of five components of exercise: abdominal breath exercise, breath control exercise, rapid breathing exercise, relaxation exercise, and reciting vocal exercise. The program is delivered during a period of 4 months.

 

Table 3c presents 39 different entries with articles sorted by type of method of treatment, according to year of publication, followed by important information and country of authorship. The main conclusion is that patients usually benefit from VR. In almost all types of intervention, even if long-term results and size of effect lack strong statements. Moreover, multidimensional multiparametric approach to evaluation outcome results seems to be a good strategy to evaluate outcomes. Different dimensions of assessment, such as auditory-perceptual analysis of the degree of voice deviation, aerodynamic, acoustic, laryngeal and self-assessment evaluation of impact of dysphonia change in different pacing are only poorly correlated among themselves. Some methods, such as Focal Function Exercises (VFE), with clear and easy instructions for administration are the treatment option of many studies. Combined treatments, with a mixture of modalities of treatment, methods and exercises, are used in some studies, without a clear rationale on the benefit of these combined approaches. Programs developed by the authors with a specific purpose or to fulfill specific patient groups, such as transgender individuals or premature children have also shown positive outcomes. Dysphonias with a behavioral etiological basis, with or without benign lesions have more studies than organic/neurological cases. The voice, even at intense deviated degrees, seems to be mobile and benefits from vocal hygiene, counseling and several types of exercises, therapies, program or methods.

 

Figure 3c. GROUP 3C. STUDIES WITH DEFINED METHODS/PROGRAMS/PROTOCOLS ARTICLES

 

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1.    1. ACCENT METHOD: two studies

1991

M.N; Kotby, S.R. El-Sady, S.E. Basiouny, Y.A. Abou-Rass, M.A. Hegazi. Efficacy of the accent method of voice therapy, In Journal of Voice, Volume 5, Issue 4, 1991, Pages 316-320

28 patients with functional voice disorders, vocal fold nodules and vocal fold paralysis; 20 to 25 sessions to complete the program, intensive twice a day format may be used. Perceptual auditory, laryngeal analysis and aerodynamic parameters showed improvements, less evident for the paralysis cases.

EGYPT

1994

Bibi Fex, Sören Fex, Osamu Shiromoto, Minoru Hirano. Acoustic analysis of functional dysphonia: Before and after voice therapy (accent method), In Journal of Voice, Volume 8, Issue 2, 1994, Pages 163-167

10 patients with functional voice disorders, 10 sessions of 30 minutes, with different spacing. Acoustic analysis showed that perturbation, noise and fundamental frequency measures improved after VR.

SWEDEN and JAPAN

2.    2. COMBINED TREATMENTS: nine studies were identified, combining:

  PHONOSURGERY AND VOCAL REHABILITATION

  BOTULINUM TOXIN INJECTION AND VOCAL REHABILITATION

  SURGERY AND VOICE THERAPY EXPULSION TECHNIQUE  (VTE)

1992

Thomas Murry,.Gayle E. Woodson, A comparison of three methods for the management of vocal fold nodules, In Journal of Voice, Volume 6, Issue 3, 1992, Pages 271-276

 

 59 patients with vocal folds nodules were treated with one of 3 options: therapy, therapy following surgery, or combined management by an otolaryngologist-speech pathologist. Pre-and post-treatment analysis showed that all options produced positive changes, however, the greatest improvement was obtained with the combined management group. This was followed by those treated by voice therapy only, and finally by the group that had surgery before VR. VR included posture, relaxation, breathing control, reduction of hard glottal attack, opening of the vocal apparatus by relaxing the tongue, and reducing facial and neck squeeze. Vocal hygiene and reduced voice usage were also implemented.

USA

1993

Paulo Pontes, Mara Behlau. Treatment of sulcus vocalis: Auditory perceptual and acoustical analysis of the slicing mucosa surgical technique, In Journal of Voice, Volume 7, Issue 4, 1993, Pages 365-376

10 subjects with severe dysphonia due to deep sulcus vocalis submitted to a combined approach, which included vocal fold slicing mucosa technique followed by intensive vocal rehabilitation. Laryngeal, auditory-perceptual and acoustic analysis showed a good anatomical result, a better vibratory pattern, and an improvement in overall vocal quality. VR consisted of several therapeutic probes with facilitating techniques in order to select the best approach to restore phonation after aphonia post-surgery due to extensive intervention.

BRAZIL

1995

Michael S. Benninger, Barbara Jacobson. Vocal nodules, microwebs, and surgery, In Journal of Voice, Volume 9, Issue 3, 1995, Pages 326-331

115 patients with vocal folds nodules were evaluated; eight anterior commissure microwebs were identified. The majority had complete resolution or sufficient improvement of their lesions and avoided surgery. Nine patients required surgery, two of these with anterior commissure microwebs. In total, 94% of patients achieved normal voice function, while the 6% of failures either did not receive or were noncompliant with voice therapy. Microwebs may be associated with failure in voice therapy. VR consisted of voice instruction, voice hygiene and behavior modification.

USA

1995

Thomas Murry, Gayle E. Woodson. Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy, In Journal of Voice, Volume 9, Issue 4, 1995, Pages 460-465

17 patients with adductor spasmodic dysphonia, 10 were treated by botulinum toxin and 7 received the toxin and voice therapy directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing during a 4-session program to reduce tension and control flow of air, beginning 3 weeks post-injection. The combined modality of treatment yielded better results, with a higher mean airflow rates for longer periods.  Botulinum toxin reduced or eliminated intrinsic laryngeal muscle spasms while VR treated the extrinsic hyperfunctional vocal behaviors.

USA

1997

Reinhardt J. Heuer, Robert Thayer Sataloff, Kate Emerich, Rhonda Rulnick, Margaret Baroody, Joseph R. Spiegel, Gursel Durson, John Butler. Unilateral recurrent laryngeal nerve paralysis: The importance of “preoperative” voice therapy, In Journal of Voice, Volume 11, Issue 1, 1997, Pages 88-94

41 patients with unilateral recurrent lesions, retrospective study with 14 patients requiring surgery and 27 treated by VR only. Decision on surgical treatment was based primarily on the patient's satisfaction with VR. VT consisted of education on voice, vocal fold paralysis, and vocal hygiene. Vocal exercises included avoidance of hyperfunctional compensation, use of optimal breathing and abdominal support, improvement of intrinsic laryngeal muscle strength, and agility. Aerodynamic measurements, such as maximum phonation time and acoustic analysis of breathiness may predict the need of surgery. Preoperative VR for these patients is a good option of treatment.

USA and TURKEY

1999

Lisa N. Kelchner, Joseph C. Stemple, Bernice Gerdeman, Wendy Le Borgne, Stewart Adam. Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective, In Journal of Voice, Volume 13, Issue 4, 1999, Pages 592-601

117 patients with unilateral adductor vocal fold paralysis, retrospective study. 25 patients had pre-and post-treatment data available. Patients were treated with medialization procedures or with VR. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.

USA

1999

A.J. Emami, Murray Morrison, Linda Rammage, Douglas Bosch. Treatment of laryngeal contact ulcers and granulomas: A 12-year retrospective analysis, In Journal of Voice, Volume 13, Issue 4, 1999, Pages 612-617

76 patients with contact ulcer or granuloma, retrospective study. 52 has pre and post-treatment data available.  94% of patients were treated non-surgically by dietary and medical therapy to control gastroesophageal reflux, or medical reflux control and voice therapy, or botulinum toxin injections, or surgical excision of granuloma, or Kenalog injection, or laparoscopic fundoplication. 77% of patients had complete resolution, 11% had partial resolution and 11% had no significant improvement. Control of gastroesophageal reflux is a central component in treatment of posterior laryngeal ulcers and granulomas. VT may be instituted as an adjunct measure and when it was administered, it included  exercises to reduce laryngeal and supralaryngeal tension by improving speech, breathing, and resonance as well as providing specific exercises to relax jaw, tongue, neck, and face. Vocal abuse awareness and reduction of voice use was also addressed.

CANADA

2015

Mirjana Petrovic-Lazic, Nadica Jovanovic, Milan Kulic, Snezana Babac, Vladimir Jurisic. Acoustic and Perceptual Characteristics of the Voice in Patients With Vocal Polyps After Surgery and Voice Therapy, In Journal of Voice, Volume 29, Issue 2, 2015, Pages p241–246

41 patients with vocal fold polyps submitted to endolaryngeal phonomicrosurgery  and voice therapy. 21 patients with healthy voice served as control group. 2 sessions of VR pre surgery and  intensive voice therapy with 16 sessions, 3 times per week, beginning10 days after surgery.  both auditory-perceptual and  acoustic  analysis improved after the combined approach. VR included vocal hygiene, reducing/stopping vocal abusive behaviors, and direct voice treatment to alter pitch, loudness, or breath support. Stress reduction techniques and relaxation exercises were also used

SERBIA and BOSNA AND HERZEGOVINA

2017

Maria R. Barillari, Umberto Volpe, Giuseppina Mirra, Francesco Giugliano, Umberto Barillari. Surgery or Rehabilitation: A Randomized Clinical Trial Comparing the Treatment of Vocal Fold Polyps via Phonosurgery and Traditional Voice Therapy with “Voice Therapy Expulsion” Training, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 379.e13–379.e20

randomized controlled trial of 150 patients with vocal fold polyps, treated by  phonosurgery (CO2 laser surgery)  plus 16 sessions of  standard voice therapy, or with the  “Voice Therapy Expulsion” protocol with 5 to a maximum of 10 sessions, followed by 10 sessions of voice therapy to raise awareness on voice control, in recognizing deviant vocal behaviors, and in producing correct vocal emission in various communicative settings., 3 assessments:  pre-treatment, at  the end of the treatment and  1 year after treatment. Multidimensional analysis with laryngeal, auditory-perceptual, acoustics and self-assessment protocol showed no significant differences between the two groups in terms of clinical outcomes and personal satisfaction. However, the Voice Therapy Expulsion was associated with higher scores for quality of life after treatment. The "Voice Therapy Expulsion” technique is a valid, noninvasive, and well-tolerated option for  vocal fold polyps’ treatment. VTE was done through repetitive microtrauma exercises. Standard voice treatment consisted of voice counseling, relaxation training, vocal function exercises, breath support, and vocal hygiene management (prevention of misuse and abuse of the voice), as well as respiratory and phonatory exercises to prevent exaggerated vocal fold contact to facilitate relaxed phonation.

ITALY

2017

Sunali Vij, Ashok K. Gupta, Dharam Vir. Voice Quality Following Unilateral Vocal Fold Paralysis: A Randomized Comparison of Therapeutic Modalities.

In Journal of Voice, Volume 31, Issue 3, 2017, Pages 379.e13–379.e20

 

 20 patients with UVFP, randomly divided into two groups: Group I received VR with pushing-pulling exercises, half-swallow boom, head tilt method,  digital manipulation/manual circumlaryngeal therapy, neck relaxation exercises, vocal function exercises and humming exercises.  Group II underwent thyroplasty type I and type IV. Pre, post 1 and 3-month of treatment; auditory-perceptual and acoustic parameters were obtained. Group 1: patients improved significantly for all parameters, except for shimmer, for seven out of ten patients. Group 2: voice quality improved in 70% of the patients with all the parameters. Shimmer did not improve in patients receiving voice therapy.

INDIA

3.    3. MANUAL LARYNGEAL MUSCULOSKELETAL TENSION REDUCTION TECHNIQUE or MANUAL CIRCUMLARYNGEAL THERAPY  (MCT) and LARYNGEAL MANUAL THERAPY  (LMT): four studies, two with MCT, one with LMT and the last one with a combination of laryngeal techniques.

1993

Nelson Roy, Herbert A. Leeper. Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: Perceptual and acoustic measures, In Journal of Voice, Volume 7, Issue 3, 1993, Pages 242-249

17 patients with functional dysphonia were treated by a single approach, the manual laryngeal musculoskeletal tension reduction technique. Later, this method was  simply called MCT, using a single session, with positive results shown by auditory and acoustic analysis. The treatment protocol is included in the appendix.

CANADA

1997

Nelson Roy, Diane M. Bless, Dennis Heisey, Charles N. Ford. Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes, In Journal of Voice, Volume 11, Issue 3, 1997, Pages 321-331

25 patients with functional dysphonia treated by MCT with positive results for short and long-term by auditory, acoustic and interview. Occasional partial and temporary recurrence can occur, but long-term results proved the stability of the outcome. Clarification on the use of the word functional to indicate a disturbance of physiological vocal function. The protocol at the appendix shows more details. 

USA

2009

L. Mathieson, S.P. Hirani, R. Epstein, R.J. Baken, G. Wood, J.S. Rubin. Laryngeal Manual Therapy: A Preliminary Study to Examine its Treatment Effects in the Management of Muscle Tension Dysphonia, In Journal of Voice, Volume 23, Issue 3, 2009, Pages 353–366

Pilot study on 10 patients with MTD, positively treated by LMR on a single session. A Vocal Tract Discomfort Scale  (VTD) was presented to evaluate pre and post-treatment symptoms. A palpatory Evaluation Protocol is also introduced to assess muscle tensions and positioning of the larynx in the neck. Auditory, acoustic analysis and the VTD scale showed improvements.

UNITED KINGDOM

2016

Çağıl Gökdoğan, Ozan Gökdoğan, Hakan Tutar, Utku Aydil, Metin Yılmaz. Speech Range Profile (SRP) Findings Before and After Mutational Falsetto (Puberphonia), In Journal of Voice, Volume 30, Issue 4, 2016, Pages p448–451

16 male patients with mutational falsetto, treated by a combination of voice techniques including larynx manipulation, larynx-depressing exercise, and producing vegetative voice, over 4 sessions, once per week, 20-minute duration each. Auditory and acoustic analysis show good results in changing fundamental frequency to a lower frequency.

TURKEY

4.       PUSHING PROGRAM

1993

Hiroya Yamaguchi, Yoshie Yotsukura, Hirosaku Sata, Yoko Watanabe, Hajime Hirose, Noriko Kobayashi, Diane M. Bless. Pushing exercise program to correct glottal incompetence, In Journal of Voice, Volume 7, Issue 3, 1993, Pages 250-256

3 cases with incomplete glottic closure, (two with vocal fold paralysis and one with sulcus vocalis), and comments on other 29 cases. Therapy provided once per week, 30-minute session, with variable number of sessions. Pre and post auditory, laryngeal, MPT measures and dB via VISIPITCH. Improvements present after VR. Technique should be used with caution and contraindications are presented.

JAPAN and USA

5.   HYDRATION THERAPY

1994

Katherine Verdolini-Marston, Mary Sandage, Ingo R. Titze. Effect of hydration treatments on laryngeal nodules and polyps and related voice measures, In Journal of Voice, Volume 8, Issue 1, 1994, Pages 30-47

6 adults female with dysphonia from vocal fold nodules or polyps, enrolled in a placebo-controlled approach using 5 consecutive days of hydration treatment and 5 days of placebo control. Hydration consisted of  eight or more glasses of water per day, one teaspoon of a mucolytic agent three times a day, and 2 hours daily exposure to a high humidity environment. Placebo consisted of eight or more sets of 20 bilateral forefinger flexions per day, one teaspoon of  an "herbal medication" three times per day at 6-hour intervals, and 2 hour daily exposure to a dry environment room. Auditory

perceptual and laryngeal appearance improvements were present after hydration, possibly due to reduction in the viscosity of vocal fold tissue.

 

USA

4.  6. RESONANT VOICE THERAPY  (RVT) versus CONFIDENTIAL VOICE THERAPY (CVT): two studies were included in this group, one that compares resonant voice with confidential voice therapy and another with an adapted LMRVT.

1995

Katherine Verdolini-Marston, Mary Katherine Burke, Arthur Lessac, Leslie Glaze, Elizabeth Caldwell. Preliminary study of two methods of treatment for laryngeal nodules, In Journal of Voice, Volume 9, Issue 1, 1995, Pages 74-85

13 women with vocal fold nodules were placed in 3 treatment groups: confidential voice therapy, resonant voice therapy and no treatment for 2 weeks. Both treatment groups improved. Results were related to adherence to methods and not to type of treatment itself. The authors recommended studying compliance in the voice area.

USA

2007

Sheng Hwa Chen, Tzu-Yu Hsiao, Li-Chun Hsiao, Yu-Mei Chung, Shu-Chiung Chiang. Outcome of Resonant Voice Therapy for Female Teachers With Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements, In Journal of Voice, Volume 21, Issue 4, 2007, Pages 415–425

24 female teachers with frequent dysphonia were given group therapy using an adapted LMRVT (stretching, breathing maneuvers and voice exercises), 8 sessions, 90-minute per session, once a week. Auditory perceptual judgment, videostroboscopic examination, acoustic measurements, aerodynamic measurements, and functional measurements were taken pre and post-VR. Many parameters improved in all dimensions of assessment. Therapy proved to be effective for this population.

TAIWAN

5.    7. LEE SILVERMAN VOICE TREATMENT  (LSVT®) versus RESPIRATORY EFFORT TREATMENT  (RET): two studies compared these two approaches in this series of articles.

1995

Marshall E. Smith, Lorraine Olson Ramig, Christopher Dromey, Kathe S. Perez, Ráz Samandari. Intensive voice treatment in Parkinson Disease: Laryngostroboscopic findings, In Journal of Voice, Volume 9, Issue 4, 1995, Pages 453-459

22 patients, randomized controlled study, with 13 patients receiving intensive therapy aimed at increasing vocal and respiratory effort (VR), and 9 patients received only respiratory effort therapy (R), with16 sessions in 4 weeks of therapy. The VR therapy group showed improvements larynx and voice. Intensive therapy focusing on phonatory effort improves adduction of the vocal folds with no risk.

USA

2001

Christina A. Baumgartner, Shimon Sapir, Lorraine O. Ramig. Voice Quality Changes Following Phonatory-Respiratory Effort Treatment (LSVT®) Versus Respiratory Effort Treatment for Individuals with Parkinson Disease. In Journal of Voice, Volume 15, Issue 1, 2001, Pages 105–114

18 individuals with idiopathic Parkinson’s Disease, placed in 2 groups, 11 patients received LSVT® and 7 received RET, using same regimen of intensive treatment. Results observed only at the LSVT® group.

USA

6.      8. THERAPY MODEL FOR PSYCHOGENIC VOICE DISORDER: COMBINED BEHAVIORAL AND COGNITIVE THERAPY

1998

Karin Andersson, Lucyna Schalén, Etiology and treatment of psychogenic voice disorder: Results of a follow-up study of thirty patients, In Journal of Voice, Volume 12, Issue 1, 1998, Pages 96-106

 

30 patients with psychogenic voice disorder (PVD) as a result of stress and 10 patients with phonoasthenia (vocal fatigue). VR consisted of traditional vocal exercises (respiration, phonation, relaxation, deep diaphragmatic breathing, and Accent Method), communicative exercises, and interactive therapeutic discourses.  Interpersonal conflicts related to family and work appeared as precipitating factors. PVD is interpreted as a specific disorder of verbal emotional expression. The  therapy model in which vocal exercises are performed, together with training of communicative skills, seems rewarding. Relapses were not reported in 88% of the patients during the follow up period of 1.9-8.4 years after  VR.

SWEDEN

7.      9. VOCAL WARM-UP PROTOCOL

1999

Thomas R. Blaylock. Effects of systematized vocal warm-up on voices with disorders of various etiologies, In Journal of Voice, Volume 13, Issue 1, 1999, Pages 43-50

4 subjects with voice disorders enrolled in a systematized vocal warm-up system, developed for a 15-minute session. Protocol uses a sequence of vocal exercises that covers the spectrum of the vocal range according to the given limits through the singing of specific vowels and consonants, with daily practice and weekly monitoring in the studio. Perceptual auditory analysis, self-ratings and spectrographic analysis indicated significant overall vocal quality and intensity improvements maintained over time.

USA

8.      10. INDIRECT and DIRECT VOCAL REHABILITATION: four studies

1999

Paul N. Carding, Irmgarde A. Horsley, Gerard J. Docherty. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia, In Journal of Voice, Volume 13, Issue 1, 1999, Pages 72-104

45 patients with nonorganic dysphonia, assigned in rotation to 1 of 3 groups; group 1 – control group, no treatment; group 2 – indirect therapy and group 3 -  indirect and direct therapy. Several qualitative and quantitative measures pre and post-VR showed significant difference between the 3 groups. Group 1 showed no significant change to almost all patients. Group 2 showed significant change in voice quality in almost 50% of individuals. Group 3 showed significant changes in voice quality in almost all patients.  Appendix offers a well-organized list of indirect and direct vocal techniques.

UNITED KINGDOM

1999

Adam M. Klein, Marcus Lehmann, Edie R. Hapner, Michael M. Johns III. Spontaneous Resolution of Hemorrhagic Polyps of the True Vocal Fold, In Journal of Voice, Volume 23, Issue 1, 2009, Pages 132–135

 

29 subjects with hemorrhagic vocal fold polyps: 16 subjects had conservative therapy while waiting for surgery, consisting of counseling on smoking cessation, vocal hygiene, and 9 subjects received voice therapy and were satisfied with their vocal outcome, showing also reduced vocal symptoms.

USA

2006

Susanna Simberg, Eeva Sala, Jyrki Tuomainen, Jaana Sellman, Anna-Maija Rönnemaa. The Effectiveness of Group Therapy for Students With Mild Voice Disorders: A Controlled Clinical Trial, In Journal of Voice, Volume 20, Issue 1, 2006, Pages 97–109

20 future teachers with mild dysphonia  and vocal fold nodules, edema or erythema and 20 controls with 3 homogenous groups of treatment, 7 sessions, once a week, 90 minute each. Two groups, one with therapy and the other with no intervention were assigned to indirect (voice ergonomics)  and direct voice therapy (resonance tube, accent method and bilabial fricative voice exercises). Laryngeal, auditory analysis, self-reported symptoms,  one year follow up on symptoms revealed group therapy to be effective for teacher students improving auditory-perceptual and voice symptoms. No laryngeal changes were observed.

FINLAND

2012

Thomas Law, Kathy Y.-S. Lee, Fiona N.-Y. Ho, Alexander C. Vlantis, Andrew C. van Hasselt, Michael C.-F. Tong. The Effectiveness of Group Voice Therapy: A Group Climate Perspective, In Journal of Voice, Volume 26, Issue 2, 2012, Pages e41-e48

12 teachers with hyperfunctional dysphonia received group therapy for eight 90-minute sessions with indirect (vocal hygiene and relaxation) and direct approaches (Lessac-Madsen Resonant Voice Therapy – LMRVT). Group therapy as a service delivery model possesses many advantages, offers good results and is important to the treatment success.

CHINA

9.      11. BEHAVIORAL VOICE THERAPY PROTOCOL

2001

Eva B. Holmberg, Robert E. Hillman, Britta Hammarberg, Maria Södersten, Patricia Doyle. Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules, In Journal of Voice, Volume 15, Issue 3, 2001, Pages 395–412

11 female patients with vocal fold nodules submitted to a behaviorally based voice therapy protocol with five basic behaviorally-based approaches: vocal hygiene, respiration, direct facilitation, relaxation, and carryover. Auditory-perceptual and laryngeal evaluations showed improvement in vocal function and absorption or reduction of lesions in the majority of patients.

SWEDEN

10.   12. COMBINED TREATMENT APPROACH - VOCAL FUNCTION EXERCISES (VFE) AND BODY ALIGNEMENT, BREATHING AND VOCAL HYGIENE

2006

Patricia Gillivan-Murphy, Michael J. Drinnan, Tadhg P. O'Dwyer, Hayder Ridha, Paul Carding. The Effectiveness of a Voice Treatment Approach for Teachers With Self-Reported Voice Problems, In Journal of Voice, Volume 20, Issue 3, 2006, Pages 423–431

20 teachers with dysphonia, placed in 2 groups, one with a combined approach including VFE, physical alignment and breathing plus voice hygiene and no-treatment control. Treatment group received 5 to 6 sessions, once a week, 50 to 60-minute duration. Physiological voice treatment and voice care education significantly improved the voice symptoms. There is a need of voice care knowledge for this high-risk population.

IRELAND AND UNITED KINGDOM

11.   13. TWANG THERAPY

2007

Lori E. Lombard, Kimberly M. Steinhauer. A Novel Treatment for Hypophonic Voice: Twang Therapy, In Journal of Voice, Volume 21, Issue 3, 2007, Pages 294–299

Pilot study with 6 subjects, treated with 2 to 8 sessions, 30-minute duration, starting with imitation of twang quality. Four outcome measures (auditory, self-assessment, physiologic and acoustic parameters) showed improved at least in 3 of the 4 measures. Manipulation of filter subsystem can be complementary to traditional VT focused on the sound source.

USA

12.   14. COMBINED TREATMENT: EXPIRATORY MUSCLE TRAINING and TRADITIONAL VOICE THERAPY

2007

Judith M. Wingate, William S. Brown, Rahul Shrivastav, Paul Davenport, Christine M. Sapienza. Treatment Outcomes for Professional Voice Users, In Journal of Voice, Volume 21, Issue 4, 2007, Pages 433–449

18 professional voice users, half with dysphonia (throat pain or vocal fatigue)  and half with vocal fold lesion. Cross over treatment for dysphonia group and lesion group, using expiratory muscle treating (5 weeks of training, five days per week, 25 breaths a day,5 sets of 5 repetitions) with a device – cylindrical mouthpiece and a one-way spring-loaded valve) followed by 6 sessions of 45 minutes, twice a week, 3 weeks of traditional voice therapy (vocal hygiene, abdominal breathing and facilitating techniques) or reverse order of treatment order. Repeated measures of auditory perceptual, laryngeal, self-assessment, acoustic and aerodynamic parameters showed no significant difference between groups, and no difference for treatment order. The combined treatment produced positive results and seemed more effective than either isolated approach.

USA

13.   15. ORAL RESONANCE PROGRAM

2007

Lisa Carew, Georgia Dacakis, Jennifer Oates. The Effectiveness of Oral Resonance Therapy on the Perception of Femininity of Voice in Male-to-Female Transsexuals, In Journal of Voice, Volume 21, Issue 5, 2007, Pages 591–603

10 transsexuals, male to female, were treated by the specific Oral Resonance Program. Positive acoustic impact with a higher fundamental frequency and formants was found after VR. Oral resonance is effective in increasing femininity of voice.

AUSTRALIA

14.   16. SPEECH PATHOLOGY INTERVENTION PROGRAM FOR CHRONIC COUGH  (SpeICh-C)

2008

Anne E. Vertigan, Deborah G. Theodoros, Alison L. Winkworth, Peter G. Gibson. A Comparison of Two Approaches to the Treatment of Chronic Cough: Perceptual, Acoustic, and Electroglottographic Outcomes, In Journal of Voice, Volume 22, Issue 5, 2008, Pages 581–589

82 participants with chronic cough, comparison of results of two types of treatment, the  direct approach Speech Pathology Intervention Program For Chronic Cough  (SpeICh-C) and  a placebo program, Healthy Lifestyle Education intervention program  (HLE) control group received 30 minute sessions. Perceptual auditory, acoustic and EGG analysis revealed  significant improvement in perceptual analysis and some acoustic improvements  with the behavioral treatment in the cough and dysphonia. Dysphonia in chronic cough can be due to the cough itself or a consequence of muscle tension or laryngeal irritation.

AUSTRALIA

15.   17. LARYNGEAL MANUAL THERAPY versus THORACO-ABDOMINAL VOCALIZATION

2010

Kristiane M. Van Lierde, Marc De Bodt, Evelien Dhaeseleer, Floris Wuyts, Sofie Claeys. The Treatment of Muscle Tension Dysphonia: A Comparison of Two Treatment Techniques by Means of an Objective Multiparameter Approach, In Journal of Voice, Volume 24, Issue 3, 2010, Pages 294–301

10 subjects  with muscle tension dysphonia enrolled in two approaches: first approach used vocalization with abdominal breath support and after completion, the manual circumlaryngeal therapy (MCT), one session each with 45 minutes  duration. Acoustic measures by the dysphonia severity index (DSI), pre and post-each treatment assessment, showed no significant differences with abdominal breath support approach. MCT proved to be an effective treatment technique for patients with elevated laryngeal position, increased laryngeal muscle tension, and MTD.

.

BELGIUM

16.   18. COORDINATION THERAPY  (CTh) versus CONVENTIONAL VOICE THERAPY

2010

L. Demmink-Geertman, P.H. Dejonckere. Differential Effects of Voice Therapies on Neurovegetative Symptoms and Complaints, In Journal of Voice, Volume 24, Issue 5, 2010, Pages 585–591

34 female patients with nonorganic dysphonia received 15 sessions of holistic coordination therapy  (CTh). 34 matched controls received conventional voice therapy. After VR, there was in general a highly significant reduction in the number of autonomic symptoms and complaints. Symptoms and complaints of other nature (validity control) were not influenced. Patients who received CTh demonstrated a higher reduction of neurovegetative symptoms/complaints related to voice and speech.

THE NETHERLANDS

17.   19. VOCAL FUNCTION EXERCISES  (VFE) and SYMPTOMATIC VOICE THERAPY

2013

Marylou Pausewang Gelfer, Bethany Ramsey Van Dong. A Preliminary Study on the Use of Vocal Function Exercises to Improve Voice in Male-to-Female Transgender Clients, In Journal of Voice, Volume 27, Issue 3, 2013, Pages 321-334

9 subjects (3 male to female transsexuals, 3 men and 3 women) enrolled in 6-week therapy program of 12 sessions, twice per week. Auditory-perceptual and acoustic analysis pre and post-VR with symptomatic voice therapy concurrently to VFE were obtained. The addition of the VFE to a symptomatic voice therapy protocol did not produce a positive effect of the displacement of the speaking fundamental frequency when compared to other studies that did not use VFE.

USA

18.   20. COUNSELING OF PARENTS versus BERNESE BRIEF DYNAMIC INTERVENTION versus TRADITIONAL VOICE THERAPY

2013

Jürg Kollbrunner, Eberhard Seifert. Functional Hoarseness in Children: Short-Term Play Therapy With Family Dynamic Counseling as Therapy of Choice, In Journal of Voice, Volume 27, Issue 5, 2013, Pages 579-588

3 groups of intervention for children with non-organic dysphonia: 24 received counseling of parents (2 meetings), 20 received Brief Dynamic Intervention on the lines of the BBDI (3 to 5 sessions with the child plus two to four sessions with the parents), and 20 received traditional voice therapy. Significant improvement in voice quality was obtained in the 3 groups according to the parents’ perception. BBDI seems to explore more deeply the problem and has the potential possibility of most enduring effect on children with dysphonia. A diagnostic tool is presented in the article.

SWITZERLAND

19.   21. HYGIENIC versus SYMPTOMATIC versus PHYSIOLOGICAL VOICE THERAPY

2013

Özgül Akin Şenkal, Müzeyyen Çiyiltepe. Effects of Voice Therapy in School-Age Children, In Journal of Voice, Volume 27, Issue 6, 2013, Pages 787.e19-787.e25

99 subjects, aged 7-15 years, with several voice disorders in the subject pool:  vocal nodules, polyps, edema, muscle tension dysphonia,  mutational falsetto, laryngopharyngeal reflux  and vocal fold paralysis. Therapy ranged from 1 to 112 sessions, once or twice per week, for 30-minute sessions. 3 groups: hygienic, symptomatic, or physiological voice therapy. Vocal fold nodules were the most common diagnosis.  Symptomatic voice therapy was the most successful method of therapy for school-age children. Physiological approaches seem to be harder to implement with young patients.

TURKEY

20.   22. STRUCTURED PROTOCOL FOR VOICE REHABILITATION AFTER RADIOTHERAPY

2014

Lisa Tuomi, Eva Björkner, Caterina Finizia. Voice Outcome in Patients Treated for Laryngeal Cancer: Efficacy of Voice Rehabilitation, In Journal of Voice, Volume 28, Issue 1, 2014, Pages 62-68

20 patients with laryngeal cancer after radiotherapy, were enrolled into two treatment groups. One group (N=10) received 10 sessions of VR, 30-minute each, once a week.  The second group (N=10) received vocal hygiene advice. VR was given according to a specific protocol.  Auditory-perceptual, acoustic and  self-perceived function (hoarseness, vocal fatigue and vocal loudness) were obtained after  one and 6 months following completion of radiotherapy.  Jitter and shimmer improved for both groups, but harmonics-to-noise-ratio and maximum phonation time improved only for the VR group. The self-assessment questions  improved for both groups while hoarseness showed no change. Trends with greater improvement in perturbation and self-assessment measures are noted in the study group. Results suggest positive effects of VR in both voice quality and self-perceived function. Authors recommended a larger randomized study.

SWEDEN

21.   23. STRETCH-AND-FLOW VOICE THERAPY   (SnF)

2015

Christopher R. Watts, Shelby S. Diviney, Amy Hamilton, Laura Toles, Lesley Childs, Ted Mau. The Effect of Stretch-and-Flow Voice Therapy on Measures of Vocal Function and Handicap, In Journal of Voice, Volume 29, Issue 2, 2015, Pages p191–199

8 participants with primary muscle tension dysphonia or phonotraumatic lesions were given stretch-and-flow therapy given once a week, for six weeks. Aerodynamic measures, acoustic measures and self-assessment pre-and post-VR showed large effect size on s/z ratio and VHI, and moderate size for maximum phonation time  (MPT) and Cepstral Peak Prominence  (CPP). Good appendixes are present on vocal hygiene guidelines and home tracking exercises form.

USA

22.   24. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) versus LARYNGEAL MANIPULATION THERAPY (LMT)

2015

Kelly Cristina A. Silverio, Alcione G. Brasolotto, Larissa T. D. Siqueira, Christiano G. Carneiro, Ana P. Fukushiro, Rinaldo R. J. Guirro. Effect of Application of Transcutaneous Electrical Nerve Stimulation and Laryngeal Manual Therapy in Dysphonic Women: Clinical Trial, In Journal of Voice, Volume 29, Issue 2, 2015, Pages p200–208

Control trial study of 20 women with bilateral vocal fold nodules; 2 groups of treatment, one with TENS application, another with Laryngeal Manipulation Therapy, 12 sessions, twice a week, 20 minutes each. Improvement observed with both approaches in some parameters of discomfort. Acoustic analysis showed no differences after both treatments. Vocal quality was not improved, with exception of strain, after TENS. TENS appeared to be a treatment method intended to be used as a complement to voice therapy.

BRAZIL

23.   25. VOCAL FUNCTION EXERCISES  (VFE): two studies

2015

Mami Kaneko, Shigeru Hirano, Ichiro Tateya, Yo Kishimoto, Nao Hiwatashi, Masako Fujiu-Kurachi, Juichi Ito. Multidimensional Analysis on the Effect of Vocal Function Exercises on Aged Vocal Fold Atrophy, In Journal of Voice, Volume 29, Issue 5, 2015, Pages p638–644

16 patients above age 65 years, with presbyphonia submitted to VFE treatment, 8 sessions, once per week, with use of home exercises twice a day, and 6 patients served as historical group control. Perceptual auditory, laryngeal analysis and self-assessment showed improvement in subjective, objective, and patient self-evaluation following VFE. Vocal fold bowing due to age does not improve but muscle function is more effective after VRE.

JAPAN

2017

Narges Jafari, Abolfazl Salehi, Farzad Izadi, Saeed T. Moghadam, Abbas Ebadi, Payman Dabirmoghadam, Maryam Faham, Mehdi Shahbazi. Vocal Function Exercises for Muscle Tension Dysphonia: Auditory-Perceptual Evaluation and Self-Assessment Rating, In Journal of Voice, Volume 31, Issue 4, 2017, Pages 506.e25 - 506.e31

15 subjects with muscle tension dysphonia received 6 weeks of treatment with VFE, once a week. Auditory perceptual and self-assessment analysis revealed improvements for both dimensions.

IRAN

24.   26. VOCAL FUNCTION EXERCISES (VFE) versus AMPLIFICATION

2015

Letícia Caldas Teixeira, Mara Behlau. Comparison Between Vocal Function Exercises and Voice Amplification, In Journal of Voice, Volume 29, Issue 6, 2015, Pages p718–726

Randomized clinical trial with 162 teachers with behavioral dysphonia, , two intervention groups (VFE and VA) and a control group. Treatment groups received 6 weeks of treatment, once a week session. Auditory-perceptual, acoustic laryngeal, self-ratings analysis  found VFE yielded the best outcomes  with reduced severity of dysphonia, self-perceived impact and improved laryngeal results. VA improved self-perceived dysphonia. Lack of treatment (control group) worsened their dysphonia.

BRAZIL

25.   27. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION  (TENS) versus LIP AND TONGUE TRILLS

2016

Juscelina Kubitscheck de Oliveira Santos, Kelly Cristina Alves Silvério, Neide Fátima Cordeiro Diniz Oliveira, Ana Cristina Côrtes Gama. Evaluation of Electrostimulation Effect in Women With Vocal Nodules. In Journal of Voice, Volume 30, Issue 6, 2016, Pages p769.e1–769.e7

60 adult women with vocal fold nodules were placed into three groups: TENS, TENS plus tongue trill, or a control group with some participants from both intervention groups but with the TENS device off.; Laryngeal configuration, auditory-perceptual and acoustic analyses, and self-assessment of phonation effort after TENS were reported.;; TENS applied alone or combined with tongue trills aided in glottal closure and in improved comfort during phonation. TENS plus trills helped to reduce roughness and yielded better vocal quality.

BRAZIL

26.   28. VOCAL FUNCTION EXERCISES  (VFE) versus COMPREHENSIVE VOICE REHABILITATION PROGRAM

2016

Vanessa Pedrosa, Antônio Pontes, Paulo Pontes, Mara Behlau, Stella Maria Peccin. The Effectiveness of the Comprehensive Voice Rehabilitation Program Compared With the Vocal Function Exercises Method in Behavioral Dysphonia: A Randomized Clinical Trial, In Journal of Voice, Volume 30, Issue 3, 2016, p377.e11–377.e19

Randomized clinical trial, double blind, with 80 voice professionals with behavioral dysphonia were treated in two groups: VFE and CVRP; subjects received the same number of sessions, once per week during six weeks.  3 assessments (pre, immediate post-VR and one month after completion of the intervention) of self-assessment, auditory-perceptual, and laryngeal examination were obtained at each assessment point. Both interventions produced good results. Effect size was larger for some parameters for the CVRP.

BRAZIL

27.   29. ACUPUNCTURE

2016

Edwin M.L. Yiu, Karen M.K. Chan, Elaine Kwong, Nicole Y.K. Li, Estella P.M. Ma, Fred W. Tse, Zhixiu Lin, Katherine Verdolini Abbott, Raymond Tsang. Is Acupuncture Efficacious for Treating Phonotraumatic Vocal Pathologies? A Randomized Control Trial, In Journal of Voice, Volume 30, Issue 5, 2016, Pages p611–620

123 patients with benign vocal fold lesions; 3 groups, genuine acupuncture, sham and no-treatment participated in 6 weeks of treatment, two 20-minute sessions per week. Acoustic analysis via vocal range profile and perceive quality of life improved in both acupuncture and sham groups but reduction in size of lesion was observed only in the genuine acupuncture group.

CHINA, CANADA and UNITED STATES

28.   30. COMBINED PROGRAM USING VOCAL FUNCTION EXERCISES (VFE) AND RESONANT    VOICE THERAPY (RVT) and BREATHING and RELAXATION TECHNIQUES

2016

Pan Zhuge, Huihua You, Hanqing Wang, Yulan Zhang, Huanle Du. An Analysis of the Effects of Voice Therapy on Patients With Early Vocal Fold Polyps, In Journal of Voice, Volume 30, Issue 6, 2016, Pages p698–704

88 patients with vocal fold polyps and control group of 30 healthy subject with self-assessment, acoustic measures through dysphonia severity index (DSI) and laryngeal image pre and post a combined program using  relaxation training, breathing exercises, vocal function exercises,  resonant improvement exercises, carryover exercises, prevention of misuse and abuse of the voice, and  popularization of health knowledge related to voice use. 22 patients abandoned the treatment. Dysphonia group showed 30% reabsorption of the lesions and 50% reduction in size. Voice therapy may be an treatment option for certain cases.

TAIWAN

29.   31. VOICE TRAINING METHOD

2017

Fa-Ya Liang, Xiao-Ming Huang, Liang Chen, Yu-Zhang Huang, Xue-Yuan Zhang, Jin-Hui Su, Ya-Jing Wang, Jin-Shan Yang, Yi-Qing Zheng, Xiang-Sheng Mei, Zhong Guan. Voice Therapy Effect on Mutational Falsetto Patients: A Vocal Aerodynamic Study. In Journal of Voice, Volume 31, Issue 1, 2017, Pages 114.e1–114.e5

26 patients with mutational falsetto and 20 controls participated in 4 weeks of VR program with five components: abdominal breathing, breath control, rapid breathing exercise, relaxation and reciting poetry vocal exercise. Assessment through VHI-10, fundamental frequency and aerodynamic parameters. VT is an effective for treating mutational falsetto. Older patients had less effective results.

CHINA

30.   32. SKMVT®

2017

Yoon Se Lee, Dam Hee Lee, Go-Eun Jeong, Ji Won Kim, Jong-Lyel Roh, Seung-Ho Choi, Sang Yoon Kim, Soon Yuhl Nam. Treatment Efficacy of Voice Therapy for Vocal Fold Polyps and Factors Predictive of Its Efficacy, In Journal of Voice Volume 31, Issue 1, 2017, Pages 120.e9–120.e13

92 patients with vocal fold polyps submitted to VT; 42% improved with the Korean SKMVTT® with laughter, vocal hygiene, and breathing exercises. Patients with small sessile polyps and female patients showed the most effective response to voice therapy.

KOREA

31.   33. FUNCTIONAL VOICE PROGRAM  (FVP)

2017

Ewelina Sielska-Badurek, Ewa Osuch-Wójcikiewicz, Maria Sobol, Ewa Kazanecka, Kazimierz Niemczyk. Singers' Vocal Function Knowledge Levels, Sensorimotor Self-awareness of Vocal Tract, and Impact of Functional Voice Rehabilitation on the Vocal Function Knowledge and Self-awareness of Vocal Tract. In Journal of Voice Volume 31, Issue 1, 2017, Pages 122.e17–122.e24

40 dysphonic classical singers, 20 received the Functional Voice Program and 20 received no treatment for voice disorder. Therapy program included improving posture, reducing tension, and improving breathing patterns and conscious appoggio with the techniques listed at the introduction of this section. Therapy subjects received10–15 individual sessions, 30–40 minutes each, 1 week intervals.  Self-assessment, auditory, laryngeal and acoustic evaluation pre and post-VR revealed that singers have limited information and  misconceptions about the physiology of the vocal mechanism and  minimal sensorimotor self-awareness of their vocal tract. Functional rehabilitation can improve this situation.

POLAND

32.   34. COMBINED FUNCTIONAL VOICE THERAPY  (FSVT)

2017

Ewelina Sielska-Badurek, Ewa Osuch-Wójcikiewicz, Maria Sobol, Ewa Kazanecka, Anna Rzepakowska, Kazimierz Niemczyk. Combined Functional Voice Therapy in Singers With Muscle Tension Dysphonia in Singing, In Journal of Voice, Volume 31, Issue 4, 2017, Pages 509.e23 - 509.e31

40 singers with muscle tension dysphonia received functional singing voice therapy, 10–15 individual sessions, 30–40 minutes each, once per week with 20 singers treated and 20 controls. Laryngeal imaging, palpation of the vocal tract structures, perceptual speaking and singing voice assessment, acoustic analysis and self-assessment protocol were obtained. Improvement in palpation of the vocal tract structures, auditory-perceptual analysis, phonetograms and singing range for treated group. 

POLAND

33.   35. PLANNED VOCAL REHABILITATION FOR UNILATERAL VOCAL FOLD PARALYISIS and VOCAL HYGIENE

2017

Ya-Chuan Kao, Shen-Hwa Chen, Yu-Tsai Wang, Pen-Yuan Chu, Ching-Ting Tan, Wan-Zu Diana Chang. Efficacy of Voice Therapy for Patients With Early Unilateral Adductor Vocal Fold Paralysis, In Journal of Voice, Volume 31, Issue 5, 2017, Pages 567 - 575

19 participants, 2 groups, 16 sessions one group with planned VR and one group with vocal hygiene, up to 16 sessions with at least 7 sessions provided. Voice therapy protocol was effective on laryngeal physiology, voice quality, voice stability, voice efficiency, and communication function.

TAIWAN

34.   36. KINESIO® TAPING METHOD  (KT)

2017

Chiara Mezzedimi, Walter Livi, Maria C. Spinosi. Kinesio Taping in Dysphonic Patients, In Journal of Voice, Volume 31, Issue 5, 2017, Pages 589 - 593

Randomized controlled study with 30 patients with muscle tension dysphonia, placed in 2 groups and  received 10 sessions, once a week intervention. Both groups received traditional VR, including vocal hygiene recommendation. Half of participants complemented the treatment with KT “Y” form over the anterior region of the neck. Both groups showed better acoustic and self-assessment evaluations. The group with KT presented better self-assessment results. KT approach seems to be useful as complementary option.

ITALY

35.   37. SEMI-OCCLUDED VOCAL TRACT EXERCISES  (SOVTE): two studies

2017

Daniela de Vasconcelos, Adriana de Oliveira Camargo Gomes, Cláudia Marina Tavares de Araújo. Treatment for Vocal Polyps: Lips and Tongue Trill, In Journal of Voice, Volume 31, Issue 2, 2017, Pages 252.e27–252.e36

10 patients with vocal fold polyps, two groups, participated in treatment with lip and tongue trills with a control group, 10 sessions from 30 to 45-minute, once per week. Laryngeal, auditory, and acoustic assessment pre and post-VR found 60% of treatment group participants improved and 80% avoided surgery.

BRAZIL

2017

Marco Guzman, Rodrigo Jara, Christian Olavarria, Paloma Caceres, Geordette Escuti, Fernanda Medina, Laura Medina, Sofia Madrid, Daniel Muñoz, Anne-Maria Laukkanen. Efficacy of Water Resistance Therapy in Subjects Diagnosed With Behavioral Dysphonia: A Randomized Controlled Trial, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 385.e1–385.e10

randomized control trial with 20 participants with behavioral dysphonia, 8 sessions of VT, water resistance therapy versus tube phonation in the air.; Self-assessment, auditory, electroglottographic, acoustic, aerodynamic and laryngeal measures showed voice improvement and no difference on results with both tubes. Tubes decrease phonatory effort.

CHILE and FINLAND

36.   38. BEHAVIORAL VOICE INTERVENTION PROTOCOL FOR PREMATURE CHILDREN

2017

Victoria Reynolds, Suzanne Meldrum, Karen Simmer, Shyan Vijayasekaran, Noel French. A Randomized, Controlled Trial of Behavioral Voice Therapy for Dysphonia Related to Prematurity of Birth, In Journal of Voice Volume 31, Issue 2, 2017, Pages 247.e9–247.e17

Randomized controlled trial, 27 preterm children with dysphonia, pilot study of 3 groups:  immediate intervention, delayed-intervention and waiting list control group. Six participants did not complete the trial. behavioral voice therapy protocol, 8 sessions, once per week. Auditory-perceptual, acoustic and pediatric self-assessment protocol. Dysphonia in the majority of premature children is persistent. Some spontaneous recovery may occur. Therapy  decreased supraglottic constriction, improved breath support, and increased regularity of vocal fold vibration.  When both groups of intervention were  pooled together, results showed a good response to therapy.

AUSTRALIA

39. PROEL METHOD

2017

Lucchini E, Ricci Maccarini A, Bissoni E, Borragan M, Agudo M, González MJ, Romizi V, Schindler A, Behlau M, Murry T, Borragan A. Voice Improvement in Patients with Functional Dysphonia Treated with the Proprioceptive-Elastic (PROEL) Method, In Journal of Voice 2017, volume 31, 2017 /epub-ahead of print/

Clinical study with 52 patients with functional dysphonia, 3 groups (with no chink, with chink and with chink and nodules), 15 sessions, twice a week, 45 to 60 minute each. Multidimensional analysis, with perceptual, laryngeal, acoustic and self-assessment data. Patients from 3 groups improved.

ITALY, BRAZIL, USA and SPAIN

 

GROUP 4 ARTICLES: EFFECTS OF VOICE REHABILITATION AND RELATED FACTORS

This group consists of 47 articles, from 1989 to 2017, with various focus directly or indirectly related to the process of VR, on effects and on interfering factors that may enhance or compromise the quality of results.  The USA contributed with 22 publications, The Netherlands with 5, Australia, Brazil and Italy with 3, Belgium, Spain and United Kingdom with 2 each, Israel and Sweden with one article each and a joint effort between The Netherlands and Belgium, between Germany and Sweden, and between Sweden and USA produced also one article each.

Isolated contributions on specific aspects were present. For example, vocal rest (complete or partial) and pre-surgery VR are related to better surgical results (KOUFMAN and BLAYLOCK, 1989), and reducing prolonged dysphonia after a surgical intervention. Koufman and Blaylock (1989) provides a good basis to propose a short period of VR pre-surgery. NIENKERKE-SPRINGER et al (2005) concluded that family therapy can help on reducing dysphonia in children, and can improve the communication between family members, including conflict management in the pediatric dysphonia population.

Interactional aspects, such as clinicians’ and clients’ behavior and personality of clinicians are studied in three articles from the same group. Instability in behaviors of graduate student clinicians was demonstrated in different aspects on a regular VR session (SCHMIDT, ANDREWS, 1993). The impact of the clinician-patient personalities (ANDREWS, SCHMIDT, 1995), measured by Myers-Briggs Type Indicator (MBTI), revealed that the thinking-feeling, judgement-perception and sensing-intuition preferences are related to many behaviors demonstrated in therapy sessions. Therapeutic dynamics is elegantly explored in these two articles. The third contribution is related to the reliability and the focus of attention of evaluations of voice therapy sessions. It offers some useful information on how clinical skills are acquired, and how to enhance students’ abilities to apply proper behaviors needed for delivering good treatment sessions (ANDREWS, SCHMIDT 1999).

The patients’ personality, (McGRORY et al, 1997) found patients with functional dysphonia are heterogeneous and can present with normal emotional profiles, as well as many forms of maladjustment and poor levels of adaptive functioning. Forms include somatic complaints, diffuse anxiety and dysphoria. In addition to conversion, other mechanisms need to be considered in the functional dysphonic. There are clinical implications on the outcome of VR.

Voice plasticity proved to be a good prognostic factor for outcome in VR and can be used to decide on the management of a patient with dysphonia. The index of voice plasticity differs among diagnostic categories. Voice plasticity is defined as the degree of improvement in deviant voice quality that can be achieved immediately, or quasi-immediately, by changing basic voicing conditions, posture, articulation or resonance, breathing mechanics, laryngeal position, or auditory feedback (DEJONCKERE, LEBACQ, 2001).

Aspects of attendance, completion, adherence, dropout, discharge, long-term results, timing of therapy and similar aspects of VT were present in 9 articles. On attendance, JOHN et al (2005) developed a benchmark study analyzing results from seven different clinics in the UK and concluded that most patients had good vocal results. This was associated with completion of the treatment program. Many differences were exposed. Many treatment contacts, duration of treatment and reasons to discharge have been identified. VT completion and dropout rates were well documented by HAPNER et al (2009) and revealed a 65% dropout rate. This was not correlated to demographics, quality-of-life impact, diagnosis and severity of dysphonia. Other factors such as readiness for change, referral from an otolaryngologist, insurance coverage and time consumed for attending sessions may be involved but were not explored in this article. Also on attendance to VR, SMITH et al (2010) study showed an overall success rate for outcomes of 53%, but they did not identify a single characteristic, or set of characteristics, capable to predict therapy attendance and outcome. The identification of patient profiles may assist clinicians and the office personal to have a better interaction with patients. Patients with complex problems, other health issues, occupational aspect, a higher perceived severity of the problem may have a higher risk of dropout. Van LEER and CONNOR (2010) advanced the comprehension of the patient’s perspective when submitted to VT. They identified three main themes related to the adherence of sessions and recommendations: voice therapy is hard (for example: starting from scratch, learning techniques, thoughts and feelings that do not help), the need to make it happen (motivation and supportive people are crucial), and the match matters (technique and feedback are useful and the reassurance the therapist is on the patient’s side).  One interesting article by MORSOMME et al (2010) explored long-term results and showed that speech therapy plays an important role in long-term treatment of patients with dysfunctional dysphonias, as measured 6 or more months after termination of therapy, by the sole point of view of the patient. Moreover, vocal handicap seems not to be directly related to the patient's perception of vocal quality or efficacy of treatment. On patients’ opinions on the therapeutic process, ZIEGLER et al (2014) used a self-administered Patient Perception of Voice Therapy questionnaire on discharge. They concluded that patients valued direct voice therapy (altering vocal behaviors through exercises and carryover activities) more than indirect voice therapy (education and counseling) that aimed to educate patients about their voice. On timing of referral to VR, a large retrospective study with 171 patients with unilateral vocal fold paralysis (MATTIOLI et al, 2015) concluded that early VR intervention benefit both results and recovery of movement.  BUSTO-CRESPO et al (2016) concluded that VT is effective long-term in patients with UVFP whether administered early or late. VT improves quality of life and its benefits are sustained for at least one year after completion of the program. Early referral for VT (less than one year after diagnosis) produces greater benefit. Regarding timing of VT, any sort of pre-operative vocal rehabilitation seems to benefit patient’s perception on positive outcome of treatment (TANG, THIBEAULT 2017).

Two more articles can be included in this subgroup related to attendance in VT. The first one is on searching for VR and the use of coping strategies (ZANBON et al 2014) while the second one is an interesting historical prospective study on the consequences of non-adherence to VT (RINSKY-HALIVNI et al, 2017). ZAMBON et al (2014) concluded that teachers with vocal complaints who sought voice therapy use more coping strategies, with a higher tendency to use more problem-focused coping strategies. There was a positive correlation between the perception of limitation and restriction of participating in vocal activities and the number of coping strategies used. Therefore, exploring coping can help VR positive outcomes, particularly when dysfunctional strategies have been used by patients. Finally, RINSKY-HALIVNI et al (2017) analyzed a large group of classroom teachers in a 5-year interval and proved that declining work capability was associated with non-adherence to VT recommendation. Further, voice rest and microphone use were not sufficient to preserve working capabilities. VR is a strong predictor for maintaining fitness and should be instituted as soon as possible, particularly in classroom teachers.

On the type of delivery of treatment, intensive or regular regimen, WENCKE et al (2014) showed superior results for attendance, satisfaction and reduced handicap with the intensive regimen. This contrasted findings by FU et al (2015) who obtained similar results in the treatment of women with vocal fold nodules using intensive or regular regimen of VR.

Different parameters and methods of documentation of treatment and for reporting positive results due to VR were explored in several studies. One retrospective study searched for changes in several phonation time measures and concluded that these once popular measures did not differ from the normal voice population and were not sensible to identify improvements in VR (TREOLE, TRUDEAU, 1997). Aerodynamic and acoustic spectral measures pre-and post-VR with a behavioral approach (HOLMBERG et al, 2003) revealed than aerodynamic measures reflected the presence of vocal pathology better than acoustics spectral measures. Large individual session-to-session variation was found for all measures which contributed to nonsignificant differences between baseline and therapy data. Voice range profile was tested pre-and post-RV on different types of dysphonia (SPEYER et al 2003). The main effect was to gain a larger area on low frequency and low intensity. Not all patients showed significant changes and there was not a clear difference among the types of diagnosis. One very interesting study explored the correlation between auditory-perceptual, acoustic and laryngeal data (SPEYER, WIENEKE, DEJONCKERE, 2004) and proved the need for a multidimensional assessment to properly evaluate outcome results of VR due to the low correlation among the three methods of assessment. Four studies explored the reliability of acoustic measures to identify voice changes after medical, surgical or behavioral interventions. Long time average spectra (LTAS) (TANER et al 2005) may be one acoustic marker sensitive to reduction in the dysphonia severity after VT.  Speaking fundamental frequency (SFF) (ROY et al 2005) does not present a consistent directional pattern after therapy for patients with functional dysphonia, however voice improvement was frequently accompanied by a frequency shift. Nonlinear dynamic analysis, specifically, the use of phase space reconstructions and the correlation dimension, was not able to accurately track and quantify voice change after primary muscle tension dysphonia treatment (AWAN et al, 2010). On the other hand, a new combined measure, the Cepstral Spectral Index of Dysphonia –(CSID) proved to have a robust relationship with the clinical auditory perceptual analysis of voice deviation and can be used as an objective measure of treatment outcome (PETERSON et al, 2013).

Opposite to the trend to identify a single measure that could correlate with dysphonia and express the result of rehabilitation, 4 articles using combined parameters can be mentioned. SCHINDLER et al (2008) used a multidimensional protocol pre-and post-VR in patients with unilateral vocal fold paralysis and showed that a combination of parameters, such as improved glottal closure in some patients. Improvement in vocal quality (by auditory-perceptual and acoustic analysis) and self-assessment protocol measures the disadvantage due to a voice problem as a good strategy to understand the rehabilitation results (). The second article (RODRÍGUEZ-PARRA et al, 2009) used a specific multidimensional multiparametric protocol, named the Teatino’s, to improve the clinical assessment of patients after VR. This protocol was capable of measurement of the most relevant aspects sensible to change after VR. These include some auditory-perceptual aspects, aerodynamic, acoustic and laryngeal parameters, as well as vocal well-being, self-assessment, vocal hygiene and anxiety measures to identify changes after VR.  The third article used a combined objective acoustic index, Dysphonia Severity Index  (DSI) and the Voice Handicap Index  (VHI), a subjective patient self-assessment of the impact of a voice problem (to verify the intrasubject effect of treatment with voice therapy and phonosurgery. The conclusion was that both indexes have good clinical applicability (HAKKESTEEGT et al, 2010). Finally, the forth article used a multipametric protocol of evaluation to study the effectiveness in group therapy for teachers with dysphonia (CANTARELLA et al, 2017). The authors concluded that improvements were shown in perceptual, acoustic, aerodynamic, and self-evaluated parameters in some patients with dysphonia. Using only the perspective of self-assessment, van LEER and van MERSBERGEN (2017) tested the adapted Physical Exertion Scale  (Borg CR10) to measure the perception of vocal effort pre and post-VR. They concluded that this scale captures the severity of perceived effort during phonation and can be used in association with the Voice Handicap Index –(VHI).

Technology to help effectiveness, adherence of exercises, and controlling vocal parameters was presented in eight articles. The use of variable technological helpers usually show that voice becomes more concrete for the patients, making the process of rehabilitation faster and easier. For example, the use of flexible nasolaryngoscopic biofeedback while conducting voice exercises helped patients with paradoxical vocal fold to control their breathing and phonation (ALTMAN et al, 2000). Use of laryngeal and velopharyngeal feedback helped patients who did not respond to traditional voice therapy (Van LIERDE et al 2004). Finally, the use of  feedback with transnasal flexible laryngoscopy was capable of reducing the time duration for completing VR (RATTENBURY et al, 2004). Use of videogames, the technology that could replicate engagement and motivation for children with voice problems,  has potential to enhance VR outcomes (KING et al 2012). The use of video recording of both adult patients and clinicians doing exercises for home practice increased adherence, generalization and self-management of the problem (van LEER and CONNOR, 2012),although it did not have any positive impact in children. It sometimes helped the patient to remember to do the exercises (van LEER and van MERSBERGEN, 2017). Telepractice used to deliver intensive voice therapy to patients with vocal fold nodules has shown results similar to those from a separate study on face-to-face modality of treatment (FU et al 2014). Finally, a commercial portable voice accumulator, the VoxLog biofeedback, was used for loudness control in patients with Parkinson’s Disease (GUSTAFSSON et al, 2016), and proved to be a useful strategy to maintain a good level of vocal intensity during speech.

Positive effects beyond improvement in voice parameters as a possible consequence of VR were identified in six studies. The first study with elderly patients showed that vocal improvement and quality of life can significantly improve after VR (BERG et al 2008). The second study showed a reduction in neurovegetative symptoms whether related or not to voice after vocal rehabilitation (DEMMINK-GEERTMAN and DEJONCKERE, 2008). The third article showed a reduction in negative psychosocial impact in patients with benign voice disorder after VR (BOUWERS and DIKKERS, 2009). The fourth demonstrated that speech intelligibility improves after voice treatment in patients with Parkinson’s Disease (CANNITO et al, 2012). The fifth study showed that symptoms of anxiety and depression reduce after VR in patients with variable laryngeal disorders (MARTINEZ e CASSOL, 2015). Finally, a sixth study used a Vocal Screening Protocol to analyze risk factors (organizational, environmental and personal) and concluded that group therapy can reduce personal risk factors in patients with behavioral dysphonia (SILVA et al, 2017).

 

Figure 4. GROUP 4. EFFECTS OF VOICE REHABILITATION AND RELATED FACTORS

 

YEAR

REFERENCE

COMMENTS

COUNTRY OF AUTHOR(S)

1989

James A. Koufman, P. David Blalock. Is voice rest never indicated?, In Journal of Voice, Volume 3, Issue 1, 1989, Pages 87-91

Retrospective review of 127 surgical cases showed that vocal rest after surgery and VR pre-surgery are preventive measures of prolonged dysphonia after surgery.

USA

1993

Charles P. Schmidt, Moya L. Andrews. Consistency in clinicians' and clients' behavior in voice therapy: An exploratory study, In Journal of Voice, Volume 7, Issue 4, 1993, Pages 354-358

Consistency in graduate students clinicians behavior in sessions of VR proved to be instable in many aspects, particularly for the pace of therapy.

USA

1995

Moya L. Andrews, Charles P. Schmidt. Congruence in personality between clinician and client: Relationship to ratings of voice treatment, In Journal of Voice, Volume 9, Issue 3, 1995, Pages 261-269

Partnership at VR sessions are studied under the frame of the MBTI instrument revealing the impact of some personality preferences on the interactions. Personality issues are pertinent to the therapeutic process.

USA

1997

Jay J. McGrory, Stephen M. Tasko, Diane M. Bless, Dennis Heisey, Charles N. Ford. Psychological correlates of functional dysphonia: an investigation using the Minnesota multiphasic personality inventory, In Journal of Voice, Volume 11, Issue 4, 1997, Pages 443-451

Abnormal psychological factors are related to functional dysphonia, with a wide range of presentation, suggesting an elevated degree of maladjustment. 2 different groups of patients emerge one with more somatic complaints (hypochondriasis) and another with more diffuse anxiety (psychasthenia).

USA

1997

Kathleen Treole, Michael D. Trudeau. Changes in sustained production tasks among women with bilateral vocal nodules before and after voice therapy, In Journal of Voice, Volume 11, Issue 4, 1997, Pages 462-469

MPT in 5 different sustained notes vowels, s/z ratio did not differ pre-and post-VR in 13 women with vocal fold nodules.

USA

1999

Moya L. Andrews, Charles P. Schmidt. Reliability of student evaluations of voice therapy implications for theory and training, In Journal of Voice, Volume 13, Issue 2, 1999, Pages 227-233

This study explored the reliability and the focus of attention during evaluation of voice therapy sessions and offer some implications on how to train students to become effective clinicians.

USA

2000

Ken W. Altman, Natasha Mirza, Cesar Ruiz, Robert T. Sataloff. Paradoxical vocal fold motion: Presentation and treatment options, In Journal of Voice, Volume 14, Issue 1, 2000, Pages 99-103

Retrospective study of10 patients with paradoxical vocal fold motion, eight patients were females. 6 patients required an acute airway intervention at presentation, 3 patients eventually underwent tracheotomy for respiratory decompensation, 5 patients were treated with botulinum toxin, and 2 patients were treated with flexible nasolaryngoscopic biofeedback while conducting voice exercises. Procedures of Botulinum toxin and biofeedback suggest they are viable treatment options.

USA

2001

P.H Dejonckere, J Lebacq. Plasticity of Voice Quality: A Prognostic Factor for Outcome of Voice Therapy? In Journal of Voice, Volume 15, Issue 2, 2001, Pages 251–256

Voice plasticity (immediate or quasi-immediate changes in vocal quality) after applying several maneuvers is a good prognostic factor for outcome of VR.

THE NETHERLANDS and BELGIUM

2003

Eva B. Holmberg, Patricia Doyle, Joseph S. Perkell, Britta Hammarberg, Robert E. Hillman. Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy, In journal of Voice, Volume 17, Issue 3, 2003, Pages 269–282

10 patients with vocal nodules, aerodynamic (transglottal air pressure and glottal waveform) and acoustic (SPL, f0, and spectrum slope) measures pre-and post-VR with a behavioral approach.  Aerodynamic measures reflected the presence of vocal pathology better than acoustics spectral measures. Large individual session-to-session variation was found for all measures which contributed to nonsignificant differences between baseline and therapy data.

SWEDEN and USA

2003

Renée Speyer, George H Wieneke, Ida van Wijck-Warnaar, Philippe H Dejonckere. Effects of voice therapy on the voice range profiles of dysphonic patients, In Journal of Voice, volume 17, Issue 4, 2003, Pages 544-556

 

62 subjects with several types of dysphonia: voice range profile (VRP) were obtained pre-and post-VR and after 3 months. VRP shape varied. Some patients did not present changes in the area after VR. Most subjects gained enlargement access to low frequency and low intensity. VR included voice hygiene, exercise training, and integration of the newly obtained vocal behavior in spontaneous voicing and speaking.

THE NETHERLANDS

2004

Kristiane M Van Lierde, Sofie Claeys, Marc De Bodt, Paul Van Cauwenberge. Outcome of laryngeal and velopharyngeal biofeedback treatment in children and young adults: A pilot study, In Journal of Voice, Volume 18, Issue 1, 2004, Pages 97–106

Pilot study: laryngeal and velopharyngeal feedback can be useful in treating patients, especially when not responding to traditional voice or velopharyngeal therapy.

BELGIUM

2004

R. Speyer, G.H. Wieneke, P.H. Dejonckere. Documentation of progress in voice therapy: perceptual, acoustic, and laryngostroboscopic findings pretherapy and posttherapy, In Journal of Voice, Volume 18, Issue 3, 2004, Pages 325–340

 

62 dysphonic subjects were evaluated for effect of VR by auditory-perceptual, acoustic and laryngeal analysis. The effects of VR vary greatly among individuals. A significant improvement was found in 40% to 50% of the patients. Laryngeal findings do not always parallel auditory and acoustic results. Correlation between the three methods of assessment are low, therefore, a multidimensional evaluation of the voice is necessary to give a complete picture of the therapy outcome.

 

THE NETHERLANDS

2004

Helen J. Rattenbury, Paul N. Carding, Paul Finn. Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial, In Journal of Voice, Volume 18, Issue 4, 2004, Pages 522–533

50 patients with muscle tension dysphonia were divided in two groups; one with traditional voice therapy and the second with transnasal flexible laryngoscopy biofeedback during exercises. The average time to conclude VT was shorter with the use of the flexible scope. Excellent appendixes are provided with lists of indirect vocal techniques and prognostic probes.

UNITED KINGDOM

2005

Anke Nienkerke-Springer, Anita McAllister, Johan Sundberg. Effects of Family Therapy on Children's Voices, In Journal of Voice, Volume 19, Issue 1, 2005, Pages 103–113

Children's dysphonia can be related to family conditions. Family therapy can contribute to a less deviant voice and better communication between family members.

GERMAN and SWEDEN

2005

Alexandra John, Pamela Enderby, Anthony Hughes. Comparing Outcomes of Voice Therapy: A Benchmarking Study Using the Therapy Outcome Measure, In Journal of Voice, Volume 19, Issue 1, 2005, Pages 114–123

Comparison of outcome results in 7 different clinics showed difference in the treatment outcomes and reason for discharge across the services, even if patients shared similar symptomatology and diagnosis.

UNITED KINGDOM

2005

Kristine Tanner, Nelson Roy, Andrea Ash, Eugene H. Buder. Spectral Moments of the Long-term Average Spectrum: Sensitive Indices of Voice Change After Therapy? In Journal of Voice, Volume 19, Issue 2, 2005, Pages 211–222

Two out of four features of the LTAS were sensitive to perceived voice improvement after voice therapy. This measure can be a marker to prove VR positive outcomes.

USA

2005

Nelson Roy, Heru Hendarto. Revisiting the Pitch Controversy: Changes in Speaking Fundamental Frequency (SFF) After Management of Functional Dysphonia, In Journal of Voice, Volume 19, Issue 4, 2005, Pages 582–591

SFF usually suffers some change after therapy in functional disorders patients, however without a directional defined trend.

USA

2008

Eric E. Berg, Edie Hapner, Adam Klein, Michael M. Johns III. Voice Therapy Improves Quality of Life in Age-Related Dysphonia: A Case-Control Study, In Journal of Voice, Volume 22, Issue 1, 2008, Pages 70–74

54 elderly patients with presbyphonia. 19 cases completed a VR program and 6 did not attend treatment but came for later evaluation. Patients who completed the program and who were adherent to exercises showed greater improvement not only on vocal parameters but also on quality of life scores.

 

 

USA

2008

Antonio Schindler, Alessandro Bottero, Pasquale Capaccio, Daniela Ginocchio, Fulvio Adorni, Francesco Ottaviani. Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis, In Journal of Voice, Volume 22, Issue 1, 2008, Pages 113–118

40 patients with unilateral vocal fold paralysis submitted to 12  sessions of VR. Multidimensional assessment protocol: MPT increased significantly, auditory-perceptual assessment was better for  five out of six parameters. Many acoustic improvements and reduced perceived disadvantage was observed after VR. Voice quality and quality of life after voice therapy is often reached and reasonable goal in patients with UVFP.  VR   techniques  varied according to the  degree of glottal incompetence and  compensatory behavior. Exercises were directed to: optimal breathing, abdominal support,  improvement of intrinsic muscle strength and agility; humming and resonant voice. When improvement on glottal competence was perceived,  sustained vowels and glides from the lowest to the highest note and vice versa were practiced. In few cases hard glottal attacks, pushing and half-swallow boom were used.

ITALY

2008

 

L. Demmink-Geertman and P.H. Dejonckere. Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia, In Journal of Voice, Volume 22, Volume 22, 2008, Issue 3, Pages 315–325

184 with nonorganic dysphonia and 126 normal controls. All patients answered a questionnaire of neurovegetative autonomic symptoms and complaints. 101 received functional voice therapy with pre and post-VR data analysis. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), but remained significantly higher when compared with controls.

THE NETHERLANDS

2009

Frans Bouwers, Frederik G. Dikkers. A Retrospective Study Concerning the Psychosocial Impact of Voice Disorders: Voice Handicap Index Change in Patients With Benign Voice Disorders After Treatment (Measured With the Dutch Version of the VHI), In Journal of Voice, Volume 23, Issue 2, 2009, Pages 218–224

 

68 patients and 68 controls, Voice Handicap Index (VHI) used pre and post-treatment proved a reduction on psychosocial negative impact due to the presence of the voice problem.

THE NETHERLANDS

2009

M.J. Rodríguez-Parra, J.A. Adrián, J.C. Casado. Voice Therapy Used to Test a Basic Protocol for Multidimensional Assessment of Dysphonia, In Journal of Voice, Volume 23, Issue 3, 2009, Pages 304–318

21 patients with dysphonia, pre and post-treatment; TEATINOS protocol (a multidimensional approach with subjective, qualitative, and objective voice assessments). The most sensitive indicators of progress after VT are: maximum phonation time of the vowel/a/, maximum expiratory time of the consonant /s/ and maximum phonation time of connected speech, jitter, vocal well-being, self-assessment,  vocal hygiene and anxiety, and perceptual, laryngoscopic, and spectrographic measures. These changes maintain or may improve after 4 months following termination of treatment.

SPAIN

2009

Edie Hapner, Carissa Portone-Maira, Michael M. Johns III. A Study of Voice Therapy Dropout, In Journal of Voice, Volume 23, Issue 3, 2009, Pages 337–340

A dropout rate of 65% was identified in two large voice centers, similar to reports from mental health and other behavior change fields. Demographics, diagnosis, quality of life, and severity of voice problem did not correlate with completion or dropout from VR.

USA

2010

 

D. Morsomme, M. Faurichon de la Bardonnie, I. Verduyckt, J. Jamart, M. Remacle. Subjective evaluation of the long-term efficacy of speech therapy on dysfunctional dysphonia, In Journal of Voice, Volume 24, Issue 2, 2010, Pages 178–182

29 patients with dysfunctional dysphonia; long-term results for 4 subjective measures, solely from the patient’s point of view obtained 6 or more months after termination of program. VR plays an important role in long-term treatment of dysfunctional dysphonias.

BELGIUM

2010

Marieke M. Hakkesteegt, Michael P. Brocaar, Marjan H. Wieringa. The Applicability of the Dysphonia Severity Index and the Voice Handicap Index in Evaluating Effects of Voice Therapy and Phonosurgery, In Journal of Voice, Volume 24, Issue 2, 2010, Pages 199–205

171 patients placed into 3 groups (voice therapy, phonosurgery and no intervention) were evaluated pre and post-treatment. The objective Dysphonia Severity Index (DSI) and subjective Voice Handicap Index (VHI) are applicable to determine the intrasubject result of evaluation.

THE NETHERLANDS

2010

Shaheen N. Awan, Nelson Roy, Jack J. Jiang. Nonlinear Dynamic Analysis of Disordered Voice: The Relationship Between the Correlation Dimension (D2) and Pre-/Post-Treatment Change in Perceived Dysphonia Severity, In Journal of Voice, Volume 24, Issue 3, 2010, Pages 285–293

88 patients with muscle tension dysphonia. Nonlinear dynamic analysis was not able to track and quantify voice change after successful therapy. The correlation dimension (D2) is not a good treatment-outcome measure, and does not correlate well with perceptual auditory analysis, particularly when the degree of severity of dysphonia is large.

USA

2010

Eva van Leer, Nadine P. Connor. Patient Perceptions of Voice Therapy Adherence. In Journal of Voice, Volume 24, Issue 4, 2010, Pages 458–469

Transcriptions of interviews regarding voice therapy revealed three common content themes: voice therapy is hard (starting from scratch, learning techniques, thoughts and feelings that do not help), make it happen (motivation and supportive people), and the match matters (technique and feedback are useful, the therapist is on my side).

USA

2010

Bonnie E. Smith, Gail B. Kempster, H. Steven Sims. Patient Factors Related to Voice Therapy Attendance and Outcomes, In Journal of Voice, Volume 24, Issue 6, 2010, Pages 694–701

No single characteristic or set of characteristics could be identified to predict dropout and outcome of VR, however patients with more complex diagnoses, more perceived vocal severity, occupational issues and more health issues, may be at greater risk for failing to attend voice therapy sessions.

USA

 

2012

Michael P. Cannito, Debra M. Suiter, Doriann Beverly, Lesya Chorna, Teresa Wolf, Ronald M. Pfeiffer. Sentence Intelligibility Before and After Voice Treatment in Speakers With Idiopathic Parkinson’s Disease, In Journal of Voice, Volume 26, Issue 2, 2012, Pages 214-219

 

8 subjects with Parkinson’s Disease enrolled in LSVT approach showed better speech intelligibility after rehabilitation, from the perceptual auditory and acoustic analysis from multiple daily assessments before and after treatment.

USA

2012

Eva van Leer, Nadine P. Connor. Use of Portable Digital Media Players Increases Patient Motivation and Practice in Voice Therapy, In Journal of Voice, Volume 26, Issue 4, 2012, Pages 447-453

Adult patient motivation and behavior can be improved with video recordings of exercises. Moreover, it can aid to generalization and patient self-management of the voice disorder.

USA

2012

Suzanne N. King, Larry Davis, Jeffrey J. Lehman, Bari Hoffman Ruddy. A Model for Treating Voice Disorders in School-Age Children within a Video Gaming Environment, In Journal of Voice, Volume 26, Issue 5, 2012, Pages 656-663

Testing of video gaming technology, Opera Slinger , was produced and tested on a 9 year-old child with dysphonia for home therapeutic applications. Good results were found on engagement and motivation.

USA

2013

 

 

Elizabeth Peterson, Nelson Roy, Shaheen N. Awan, Ray M. Merril, Russell Banks, Kristine Tanner.

Toward Validation of the Cepstral Spectral Index of Dysphonia (CSID) as an Objective Treatment Outcomes Measure,

In Journal of Voice, Volume 27, Issue 4, 2013, Pages 401-10

The validity of the CSID as an objective treatment outcomes measure of dysphonia severity was confirmed through a robust relationship between listener perception and CSID analysis of combined sustained vowels and connected speech sample across diverse diagnoses and severity of voice deviation levels.

USA

2014

Fabiana Zambon, Felipe Moreti, Mara Behlau. Coping Strategies in Teachers With Vocal Complaint, In Journal of Voice, Volume 28, Issue 3, 2014, Pages 341-348

Seeking VR is related to a higher use of coping strategies, particularly ones that are problem-focused. Therefore, coping is an important related factor to be analyzed.

BRAZIL

2014

Rachel J. Wenke, Penny Stabler, Chloe Walton, Leah Coman, Melissa Lawrie, John O'Neill, Deborah Theodoros, Elizabeth Cardell. Is More Intensive Better? Client and Service Provider Outcomes for Intensive Versus Standard Therapy Schedules for Functional Voice Disorders, In Journal of Voice, Volume 28, Issue 5, 2014, Pages 652.e31–652.e43

16 patients, two groups, 8 hours of treatment, intensive therapy 8 sessions a week, for 2 weeks compared to standard group receiving 1-hour treatment per week, for 8 weeks. Vocal hygiene orientation and an individualized program (resonance voice exercises and Voicecraft techniques), plus homework. Both groups improved but greater attendance, high satisfaction and statistically significant improvements on the VHI ratings were observed with the intensive group.

AUSTRALIA

2014

Sherry Fu, Deborah G. Theodoros and Elizabeth C. Ward. Delivery of Intensive Voice Therapy for Vocal Fold Nodules Via Telepractice: A Pilot Feasibility and Efficacy Study, In Journal of Voice, Volume 29, Issue 6, 2014, Pages 696–706

10 women with bilateral vocal fold nodules enrolled in Intensive Voice Therapy via telepractice. Telepractice has the potential to produce similar results to those obtained in face-to-face treatment.

AUSTRALIA

2014

Aaron Ziegler, Christina Dastolfo, Rita Hersan, Clark A. Rosen, Jackie Gartner-Schmidt. Perceptions of Voice Therapy From Patients Diagnosed With Primary Muscle Tension Dysphonia and Benign Mid-Membranous Vocal Fold Lesions, In Journal of Voice, Volume 28, Issue 6, 2014, Pages p742–752

Patients see positive impacts after the administration of VT and see more value on direct vocal therapy, with use of vocal exercises and carryover to speech, compared to indirect approaches based on education.

USA

2015

Sherry Fu, Deborah G. Theodoros, Elizabeth C. Ward. Intensive Versus Traditional Voice Therapy for Vocal Nodules: Perceptual, Physiological, Acoustic and Aerodynamic Changes, In Journal of Voice, Volume 29, Issue 2, 2015, Pages p260.e31–260.e44

53 females with vocal fold nodules, intensive (eight sessions within a 2-week period) or traditional regimen of delivery of VR (eight sessions, one per week), indirect and direct therapy treatment strategies, Lessac-Madsen Resonant Voice Therapy  (LMRVT) and Vocal Function Exercises  (VFEP). Similar results in both groups, comparing perceptual, physiological, and acoustic outcomes.

 

AUSTRALIA

2015

F. Mattioli, M. Menichetti, G. Bergamini, G. Molteni, M.P. Alberici, M.P. Luppi, F. Nizzoli, L. Presutti. Results of Early Versus Intermediate or Delayed Voice Therapy in Patients With Unilateral Vocal Fold Paralysis: Our Experience in 171 Patients, In Journal of Voice, Volume 29, Issue 4, 2015, Pages p455–458F.

171 patients with unilateral vocal fold paralysis, 11-year retrospective study, early versus intermediate and delayed VR. All patients submitted to rehabilitation with forcible exercises supplemented by manipulations and maneuvers. Results indicated that intervention after 8 weeks tend to show worse prognosis for both improvement on vocal quality and recovery of vocal fold movement.

 

ITALY

2015

Chenia Caldeira Martinez, Mauriceia Cassol. Measurement of Voice Quality, Anxiety and Depression Symptoms After Speech Therapy, In Journal of Voice, Volume 29, Issue 4, 2015, Pages p446–449

Voice quality improves in adult patients with variable laryngeal disorders after VR. Symptoms of anxiety and depression reduced but Hawthorne effect needs to be considered.

BRAZIL

2016

Joakim Gustafsson, Sten Ternström, Maria Södersten, Ellika Schalling. Motor-Learning-Based Adjustment of Ambulatory Feedback on Vocal Loudness for Patients With Parkinson's Disease, In Journal of Voice, Volume 30, Issue 4, 2016, Pages p407–415

The use of a portable voice accumulator for biofeedback on vocal loudness for individuals with Parkinson’s disease help to achieve a better learning outcome and as a consequence, improved results of VR.

SWEDEN

2016

Olivia Busto-Crespo, María Uzcanga-Lacabe, Ana Abad-Marco, Iosune Berasategui, Lola García, Enrique Maraví, Sergio Aguilera-Albesa, Alejandro Fernández-Montero, Secundino Fernández-González. Longitudinal Voice Outcomes After Voice Therapy in Unilateral Vocal Fold Paralysis, In Journal of Voice, Volume 30, Issue 6, 2016, Pages p767.e9–767.e15

70 patients with unilateral vocal fold paralysis, 2 groups according to time to initiation of treatment, less or more than one year after diagnosis.  A multidimensional diagnostic therapeutic assessment was used; 15 sessions of 30-minute duration, twice a week. Therapy was administered in 3 progressive stages: body posture, resonant voice and humming, and optimization to speech and training with auditory masking. Improvement in both groups, more evident in the early referral group. Long-term results were sustained for at least one year following program termination.

SPAIN

2017

Maia N. Braden, Eva van Leer. Effect of MP4 Therapy Videos on Adherence to Voice Therapy Home Practice in Children With Dysphonia, In Journal of Voice, Volume 31, Issue 1, 2017, Pages 114.e17–114.e23

Study tested the impact of video models of therapy tasks in the home practice of children with dysphonia and concluded that there is no influence of the recorded exercises in the frequency of training, contrary with results in adults. Children did not need videos to recall practice, but they were helpful as reminders for doing the exercises.

USA

2017

Lilah Rinsky-Halivni, Miriam Klebanov, Yehuda Lerman, Ora Paltiel. Adherence to Voice Therapy Recommendations Is Associated With Preserved Employment Fitness Among Teachers With Work-Related Dysphonia, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 386.e19–386.e26

Adherence to VT recommendations can preserve employment and vocal fitness in teachers; VR can retain vocal capabilities.

ISRAEL

2017

Eva van Leer, Miriam van Mersbergen. Using the Borg CR10 Physical Exertion Scale to Measure Patient-perceived Vocal Effort Pre and Post Treatment, In Journal of Voice, Volume 31, Issue 3, 2017, Pages 389.e19–389.e25

The authors tested the Borg CR10, widely used in other disciplines, adapted for patients with voice problems. Borg CR10 was found to have utility to measure perceived effort during phonation in patients with hyperfunctional dysphonia.

USA

2017

Wégina J. N.o da Silva, Leonardo W. Lopes, Anny E. R. de Macedo, Denise B. da Costa, Anna Alice F. de Almeida. Reduction of Risk Factors in Patients with Behavioral Dysphonia After Vocal Group Therapy, In Journal of Voice, Volume 31, Issue 1, 2017, Pages 123.e15–123.e19

26 patients with behavioral dysphonia, answered the Vocal Screening Protocol to analyze risk factors (organizational, environmental and personal), pre and post-group therapy, 8 sessions, eclectic program (education, breathing, voice exercises, non-verbal communication and expressiveness). Study concluded that group therapy can reduce personal risk factors,

BRAZIL

2017

Sharon S. Tang, Susan L. Thibeault. Timing of Voice Therapy: A Primary Investigation of Voice Outcomes for Surgical Benign Vocal Fold Lesion Patients, In Journal of Voice, Volume 31, Issue 1, 2017, Pages 129.e1–129.e7

31 patients, placed in 3 intervention groups: 10 patients received one session pre-op counselling, 11 patients received several sessions pre-op and post-op VR, and 8 patients received only post-op VR. Acoustic and self-assessment evaluations: no acoustic differences among groups. VHI scores were significantly more reduced in groups with some sort of pre-op intervention. Patients with pre-op VR have more reduced perceived handicap and adequate patients’ expectations.

USA

2017

 

Giovanna Cantarella, Sara Torretta, Silvia Ferruta, Annaclara Ciabatta, Claudia Manfredi, Lorenzo Pignataro, Philippe Dejonckere.

Multidimensional Assessment of the Effectiveness of Group Voice Therapy, In Journal of Voice, Volume 31, Issue 6, 2017, Pages 714–721

34 patients with functional dysphonia and minor lesions participated in group therapy, 7 sessions of one hour, once a week.  Assessment pre and post-VR with a multiparametric protocol: auditory-perceptual analysis, Evaluation Vocale Assistée (EVA) system aerodynamic and acoustic data, and self-assessment of the voice impact. Improvements were found in perceptual, acoustic, aerodynamic, and self-evaluated parameters in some patients with dysphonia. Group therapy can be used and can reduce costs, waiting list and enhance motivation. VR included hygiene principles, relaxation exercises, abdominal breathing training, resonance voice exercises, digital manipulation of the thyroid cartilage, neck muscle massage, articulation exercises, and semi-occluded vocal tract exercises.

 

ITALY

 

 

CONCLUSION

Journal of Voice has included 144 articles dealing mainly with voice rehabilitation during the first 30 years of publications. Graph 1 shows the evolution of distribution through the years. It is clear that the last decade has received the highest number of publications (90 articles), with the highest concentration, 26 contributions, in 2017.

 

The largest number of Speech-Language Pathologists in the world is in the United States, followed by Brazil. This mirrors the highest number of publications in vocal rehabilitation (Graph 2), Clinicians and scholars from 29 countries have selected the Journal of Voice as the scientific platform to disseminate their ideas, research and clinical observations. There has been a clear advance in methodological aspects.  Fifteen publications were credited to authors from more than one country, with the United States co-author in 6 publications. Multicentric and multicountry contributions have the potential to increase in the years to come. A combination of factors could explain the exceptional recent growth of number of publications and international authorship. The international interest of the speech-language pathologist working in the voice area is a factor as well as scientific studies showing the value of services provided by voice specialists.

Acknowledgment: The authors would like to acknowledge the help of the team of assistants at the CEV who helped in searching the whole Journal of Voice collection, organizing the original list of selected articles. 

REFERENCES

Altman KW, Mirza N, Ruiz C, Sataloff RT. Paradoxical vocal fold motion: Presentation and treatment options. J.Voice 2000;14;99-103.

Andersson K, Schalén L. Etiology and treatment of psychogenic voice disorder: Results of a follow-up study of thirty patients. J.Voice 1998;12; 96-106.

Andrews ML. Intervention with young voice users: A clinical perspective. J.Voice1993;7; 160-164.

Andrews ML, Schmidt CP. Congruence in personality between clinician and client: Relationship to ratings of voice treatment. J.Voice 1995; 9; 261-269.

Andrews ML. The singing/acting child: a speech-language pathologist's perspective. J.Voice 1997;11;130-134.

Andrews ML, Schmidt CP. Reliability of student evaluations of voice therapy implications for theory and training. J.Voice 1999;13; 227-233.

Arboleda W, Frederick AL. Considerations for maintenance of postural alignment for voice production. J.Voice. 2008;22(1):90-9.

Arnoux-Sindt, B. A propos de la technique reeducative de granulomes larynges. Le Cahiers d'ORL 1991; 26:13–15.

Aronson AE. Clinical voice disorders, 3rd edition. New York: Thieme Stratton, 1990.

Aronson AE. Importance of the psychosocial interview in the diagnosis and treatment of “functional” voice disorders. J.Voice 1990;4;287-289.

Awan SN, Roy N, Jiang JJ. Nonlinear Dynamic Analysis of Disordered Voice: The Relationship Between the Correlation Dimension (D2) and Pre-/Post-Treatment Change in Perceived Dysphonia Severity. J.Voice 2010;24;285–293.

 

Baumgartner CA, Sapir S, Ramig LO. Voice Quality Changes Following Phonatory-Respiratory Effort Treatment (LSVT®) Versus Respiratory Effort Treatment for Individuals with Parkinson Disease. J.Voice 2001;15;105–114.

 

Barillari MR, Volpe U, Mirra G, Giugliano F, Barillari U. Surgery or Rehabilitation: A Randomized Clinical Trial Comparing the Treatment of Vocal Fold Polyps via Phonosurgery and Traditional Voice Therapy with “Voice Therapy Expulsion” Training. J.Voice 2017;31;379.e13–379.e20.

 

Behlau M, Oliveira G, Pontes P. Vocal Fold Self-Disruption After Phonotrauma On A Lead Actor: A Case Presentation. J.Voice 2009;23;726-32.

 

Behlau M, Moreti F, Pecoraro G. [Customized vocal conditioning for singing professional voice users – case report]. Rev CEFAC. 2014;16(5):1713-22. English, Portuguese.

 

Behlau M, Murry T. International and intercultural aspects of voice and voice disorders (2012) In: Battle D. (ed) Communication Disorders in multicultural and international populations. 4ed. Pp 174-207.

 

Behlau M, Pontes P, Vieira VP, Yamasaki R and Madazio G. Presentation of the Comprehensive Vocal Rehabilitation Program for the treatment of behavioral dysphonia. Codas. 2013; 25: 492–496.

Benninger MS, Jacobson B. Vocal nodules, microwebs, and surgery. J.Voice 1995;9;326-331.

Berg EE, Hapner E, Klein A, Johns III MM. Voice Therapy Improves Quality of Life in Age-Related Dysphonia: A Case-Control Study. J.Voice 2008;22;70–74.

Blaylock TR. Effects of systematized vocal warm-up on voices with disorders of various etiologies. J.Voice 1999;13;43-50.

Bodt MD, Patteeuw T, Versele A. Temporal Variables in Voice Therapy. J.Voice 2015; 29;611–617.

Boone DR (1971) The Voice and Voice Therapy. 1 ed. Prentice-Hall Inc., Englewood Cliffs, NJ.

Boone DR, Respiratory training in voice therapy. J.Voice 1988;2; 20-25.

Boone DR, McFarlane SC, Von Berg SL & Zraick, RI (2010). The voice and voice therapy. Boston, MA: Allyn & Bacon.

Borragán A., Lucchini E., Agudo M. et al. Il Metodo Propriocettivo Elastico (PROEL) nella terapia vocale. Acta Phon Lat. 2008; 30:18–50

Bouwers F, Dikkers FG. A Retrospective Study Concerning the Psychosocial Impact of Voice Disorders: Voice Handicap Index Change in Patients With Benign Voice Disorders After Treatment (Measured With the Dutch Version of the VHI). J.Voice 2009;23;218–224

Braden MN, Van Leer E. Effect of MP4 Therapy Videos on Adherence to Voice Therapy Home Practice in Children with Dysphonia. J.Voice 2017;31;114.e17–114.e23.

Brodnitz FS. Folia Phoniatr (Basel). 1972; 24:77-8. In memoriam Emil Froeschels.

Busto-Crespo O, Uzcanga-Lacabe M, Abad-Marco A, Berasategui I, García L, Maraví E, Aguilera-Albesa S, Fernández-Montero A, Fernández-González S. Longitudinal Voice Outcomes After Voice Therapy in Unilateral Vocal Fold Paralysis. J.Voice 2016;30;767.e9–767.e15.

Caccini, G. Le nuove musiche (Florence, 1601). Facsimile reprint (Florence, 1983). Caccini, G. L'Euridice (Florence, 1600).

Cannito MP, Suiter DM, Beverly D, Chorna L, Wolf T, Pfeiffer RM. Sentence Intelligibility Before and After Voice Treatment in Speakers with Idiopathic Parkinson’s Disease. J.Voice 2012;26;214-219.

Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. J.Voice 1999;13;72-104.

Carew L, Dacakis G, Oates J. The Effectiveness of Oral Resonance Therapy on the Perception of Femininity of Voice in Male-to-Female Transsexuals. J.Voice 2007; 21;591–603.

Casper, J. (2000). Confidential voice. In J. C. Stemple (Ed.), Voice therapy: Clinical studies (pp. 128–139). San Diego, CA: Singular.

Chen X, Wan P, Yu Y, Li M, Xu Y, Huang P, Huang P. Types and Timing of Therapy for Vocal Fold Paresis/Paralysis After Thyroidectomy: A Systematic Review and Meta-Analysis. J.Voice 2014; 28;799–808

Chen SW, Hsiao T, Hsiao L, Chung Y, Chiang S. Outcome of Resonant Voice Therapy for Female Teachers with Voice Disorders: Perceptual, Physiological, Acoustic, Aerodynamic, and Functional Measurements. J.Voice 2007;21;415–425.

Colton RH, Casper JK (1996). Understanding Voice Problems: a physiological perspective for diagnosis and treatment. Williams and Wilkins, Baltimore.

Cooper M. (1973). Modern techniques of vocal rehabilitation. Springfield, IL: Charles C. Thomas.

D'Antoni ML, Lynn Harvey P, Fried MP, Alternative medicine: Does it play a role in the management of voice disorders?. J.Voice 1995;9; 308-311.

Dejonckere PH, Lebacq J. Plasticity of Voice Quality: A Prognostic Factor for Outcome of Voice Therapy?.J.Voice 2001;15;251–256.

Demmink-Geertman L, Dejonckere PH. Differential Effects of Voice Therapies on Neurovegetative Symptoms and Complaints. J.Voice 2010;24;585–591.

Demmink-Geertman L, Dejonckere PH. Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia. J.Voice 2008;22;315–325.

Demmink-Geertman L and Duits-Schouten S (2006) The Coordination Therapy According to Elfriede Öcker. 2 ed. Harcourt Publishers, Amsterdam. (in Dutch).

Desjardins M, Halstead L, Cooke M, Bonilha MS. A Systematic Review of Voice Therapy: What “Effectiveness” Really Implies. J.Voice 2017;31; 392.e13–392.e32.

Díaz Gómez M, Gonzalez Riancho Colongues A, and Borragán Torre A. (1999) In: Asociación CELF (Ed.) CELF: Cirugía Endolaríngea Fibroscópica y Rehabilitación Vocal. 

Elliot N, Sundberg J, Gramming P. Physiological aspects of a vocal exercise. J.Voice 1997;11;171-177.

Emami AJ, Morrison M, Rammage L, Bosch D. Treatment of laryngeal contact ulcers and granulomas: A 12-year retrospective analysis. J.Voice 1999;13;612-617.

Fex B, Fex S, Shiromoto O, Hirano M. Acoustic analysis of functional dysphonia: Before and after voice therapy (accent method). J.Voice 1994; 8;163-167.

Friedrich G, Kiesler K, Gugatschka M. Treatment of Functional Ventricular Fold Phonation by Temporary Suture Lateralization. J.Voice 2010;24;606–609

Froeschels E. (1952). Chewing method as therapy. Arch. Otolaryngol., 56:427-434.

Froeschels E. (1943). A contribution to the pathology and therapy of dysarthria due to certain cerebral lesions. Journal of Speech and Disorders, 8, 301-321.

Fu S, Theodoros DG, Ward EC. Intensive Versus Traditional Voice Therapy for Vocal Nodules: Perceptual, Physiological, Acoustic and Aerodynamic Changes. J.Voice 2015; 29;260.e31–260.e44.

Fu S, Theodoros DG, Ward EC. Delivery of Intensive Voice Therapy for Vocal Fold Nodules Via Telepractice: A Pilot Feasibility and Efficacy Study. J.Voice 2014;29;696–706.

Gartner-Schmidt J, Gherson S, Hapner ER, Muckala J,Roth D, Schneider S, Gillespie AI. The Development of Conversation Training Therapy: A Concept Paper. J.Voice 2016;30;563-573.

Gates GA, Coping with dysphonia. J.Voice 1992;6;22-26.

Gelfer MP, Van Dong BR. A Preliminary Study on the Use of Vocal Function Exercises to Improve Voice in Male-to-Female Transgender Clients. J.Voice 2013;27;321-334.

Gillespie AI, Helou LB, Ingle JW, Baldwin M, Rosen CA, The Role of Voice Therapy in the Treatment of Dyspnea and Dysphonia in a Patient with a Vagal Nerve Stimulation Device. J.Voice 2014; 28; 59-61.

Gillivan-Murphy P, Drinnan MJ, O'Dwyer TP, Ridha H, Carding P. The Effectiveness of a Voice Treatment Approach for Teachers with Self-Reported Voice Problems. J.Voice 2006;20;423–431.

Gilman M, Gilman SL. Electrotherapy and the Human Voice: A Literature Review of the Historical Origins and Contemporary Applications. J.Voice 2008;22; 219–231.

Goffi-Fynn JC, Carroll LM, Collaboration and Conquest: MTD as Viewed by Voice Teacher (Singing Voice Specialist) and Speech-Language Pathologist.J.Voice, 2013;27;391.e9-391.e14

Gökdoğan Ç, Gökdoğan O, Tutar H, Aydil U, Yılmaz M. Speech Range Profile (SRP) Findings Before and After Mutational Falsetto (Puberphonia). J.Voice 2016;30; 448–451.

Guirro RRJ, Bigaton DR, Silvério KCA, Berni KCS, Distéfano G, Santos FL, and Forti F Transcutaneous electrical nerve stimulation in dysphonic women. Pro Fono. 2008; 20:189–194.

Gustafsson J, Ternström S, Södersten M, Schalling E. Motor-Learning-Based Adjustment of Ambulatory Feedback on Vocal Loudness for Patients with Parkinson's Disease. J.Voice 2016;30;407–415.

Guzman M, Jara R, Olavarria C, Caceres P, Escuti G, Medina F, Medina L, Madrid S, Muñoz D, Laukkanen AM. Efficacy of Water Resistance Therapy in Subjects Diagnosed With Behavioral Dysphonia: A Randomized Controlled Trial. J.Voice 2017;31;385.e1–385.e10.

Guzman M, Castro C, Testart A, Muñoz D, Gerhard J. Laryngeal and Pharyngeal Activity During Semioccluded Vocal Tract Postures in Subjects Diagnosed with Hyperfunctional Dysphonia. J.Voice, 2013;27; 709-716.

Guzman M, Laukkanen AM, Krupa P, Horáček J,  Švec JG, Geneid A. Vocal Tract and Glottal Function During and After Vocal Exercising With Resonance Tube and Straw. J.Voice 2013;27;523.e19–523.e34.

Hapner E, Portone-Maira C, Johns III MM. A Study of Voice Therapy Dropout. J.Voice 2009;23; 337–340.

Hakkesteegt MM, Brocaar MP, Wieringa MH. The Applicability of the Dysphonia Severity Index and the Voice Handicap Index in Evaluating Effects of Voice Therapy and Phonosurgery. J.Voice 2010;24;199–205.

Heuer RJ, Behavioral therapy for spasmodic dysphonia. J.Voice 1992;6;352-354.

Heuer RJ, Sataloff RT, Emerich K, Rulnick R, Baroody M, Spiegel JR, Durson G, Butler J. Unilateral recurrent laryngeal nerve paralysis:The importance of “preoperative” voice therapy. J.Voice 1997;11; 88-94.

Hirani LMSP, Epstein R, Baken RJ, Wood G, Rubin JS. Laryngeal Manual Therapy: A Preliminary Study to Examine its Treatment Effects in the Management of Muscle Tension Dysphonia. J.Voice 2009; 23; 353–366.

Holmberg EB, Doyle P, Perkell JS, Hammarberg B,Hillman RE. Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy. J.Voice 2003;17;269–282.

Holmberg EB, Hillman RE, Hammarberg B, Södersten M, Doyle P. Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules. J.Voice 2001;15; 395–412.

Hoit JD. Influence of body position on breathing and its implications for the evaluation and treatment of speech and voice disorders. J.Voice 1995;9; 341-347.

Ishikawa K, Thibeault S. Voice Rest Versus Exercise: A Review of the Literature. J.Voice 2010;24; 379–387.

Iwarsson, J. Logopedisk röstbehandling. (2007) in: L. Hartelius, U. Nettelbladt, B. Hammarberg (eds.) Logopedi. 1 ed. Studentlitteratur, Lund, Sweden; 2007: 264–269 (In Swedish)

Jafari N, Salehi A, Izadi F, Moghadam ST, Ebadi A, Dabirmoghadam P,Faham M, Shahbazi M. Vocal Function Exercises for Muscle Tension Dysphonia: Auditory-Perceptual Evaluation and Self-Assessment Rating. J.Voice 2017; 31;506.e25 - 506.e31.

John A, Enderby P, Hughes A. Comparing Outcomes of Voice Therapy: A Benchmarking Study Using the Therapy Outcome Measure. J.Voice 2005;19; 114–123.

Kaneko M, Hirano S, Tateya I, Kishimoto Y, Hiwatashi N, Fujiu-Kurachi M, Ito J. Multidimensional Analysis on the Effect of Vocal Function Exercises on Aged Vocal Fold Atrophy. J.Voice 2015; 29;638–644.

Kase K, Wallis J, and Kase T. (2003) Clinical Therapeutic Applications of the Kinesio Taping Method. 2nd ed. Kinesio Taping Association, Albuquerque.

Kao Y, Chen S, Wang Y, Chu P, Tan C, Chang WD. Efficacy of Voice Therapy for Patients With Early Unilateral Adductor Vocal Fold Paralysis. J.Voice 2017;31;567 – 575.

Kelchner LN, Stemple JC, Gerdeman B, Lee Borgne W, Adam S. Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective. J.Voice 1999;13;592-601.

King SN, Davis L, Lehman JJ, Ruddy BH. A Model for Treating Voice Disorders in School-Age Children within a Video Gaming Environment. J.Voice 2012;26;656-663.

Klein AM, Lehmann M, Hapner ER, Johns III MM. Spontaneous Resolution of Hemorrhagic Polyps of the True Vocal Fold. J.Voice 2009;23;132–135.

Kollbrunner J, Seifert E. Functional Hoarseness in Children: Short-Term Play Therapy With Family Dynamic Counseling as Therapy of Choice. J.Voice 2013;27;579-588.

Kollbrunner, J. Funktionelle Dysphonien bei Kindern. (2006) Ein psycho- und familiendynamischer Therapieansatz. ISchulz-Kirchner, Idstein. (in German).

Kotby MN, El-Sady SR, Basiouny SE, Abou-Rass YA, Hegazi MA. Efficacy of the accent method of voice therapy. J.Voice 1991;5;316-320.

Koufman JA, Blalock PD. Is voice rest never indicated?. J.Voice, 1989; 3; 87-91.

Law T, Lee KYS, Ho FNH, Vlantis AC, Van Hasselt AC, Tong MCF. The Effectiveness of Group Voice Therapy: A Group Climate Perspective. J.Voice 2012;26;e41-e48.

Lessac A. (1967) Tire use and training of the human voice: a practical approach to speech and voice dynamics. New York: Drama Book Publishers.

Liang F, Huang X, Chen L, Huang Y, Zhang X, Su J, Wang Y, Yang J, Zheng Y, Mei X, Guan Z. Voice Therapy Effect on Mutational Falsetto Patients: A Vocal Aerodynamic Study. J. Voice 2017;31;114.e1–114.e5.

Lombard LE, Steinhauer KM. A Novel Treatment for Hypophonic Voice: Twang Therapy. J.Voice 2007;21;294–299.

Lu FL, Presley SL, Lammers B. Efficacy of Intensive Phonatory-Respiratory Treatment (LSVT) for Presbyphonia: Two Case Reports. J.Voice 2013;27;786.e11-786.e23.

Lucchini E, Ricci Maccarini A, Bissoni E, Borragan M, Agudo M, González MJ, Romizi V, Schindler A, Behlau M, Murry T, Borragan A. Voice Improvement in Patients with Functional Dysphonia Treated with the Proprioceptive-Elastic (PROEL) Method. J.Voice 2017;31; 2017 /epub-ahead of print/.

McGrory JJ, Tasko SM, Bless DM, Heisey D, Ford CN. Psychological correlates of functional dysphonia: an investigation using the Minnesota multiphasic personality inventory. J.Voice 1997; 11; 443-451.

 

Martin S and Darnley L. (1992) The Voice Sourcebook. Winslow Press, Oxon.

Martinez CC, Cassol M. Measurement of Voice Quality, Anxiety and Depression Symptoms After Speech Therapy. J.Voice 2015; 29;446–449.

 

Mattioli F, Menichetti M, Bergamini G, Molteni G, Alberici MP, Luppi MP, Nizzoli F, Presutti F. Results of Early Versus Intermediate or Delayed Voice Therapy in Patients with Unilateral Vocal Fold Paralysis: Our Experience in 171 Patients. J.Voice 2015;29;455–458.

Menezes MHM, Ubrig-Zancanella MT, Cunha MGB, Cordeiro GF, Nemr K, Tsuji DH. The Relationship Between Tongue Trill Performance Duration and Vocal Changes in Dysphonic Women. J.Voice 2011;25; e167–e175.

 

Mezzedimi C, Livi W, Spinosi MC. Kinesio Taping in Dysphonic Patients. J.Voice 2017;31;589 – 593.

Moreira TC, Gadenz CD, Capobianco DM, Figueiró LR, Ferigolo M, Vissoci JRN, Barros HMT, Cassol M, Pietrobon R. Factors Associated with Attrition in Randomized Controlled Trials of Vocal Rehabilitation: Systematic Review and Meta-Analysis. J.Voice, 2017;31; 259.e29–259.e40.

Morsomme D, faurichon de la Bardonnie M, Verduyckt I, Jamart J, Remacle M. Subjective evaluation of the long-term efficacy of speech therapy on dysfunctional dysphonia. J.Voice 2010; 24;178–18.

Murry T, Woodson GE. Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy. J.Voice 1995;9;460-465.

Murry T, Woodson GE. A comparison of three methods for the management of vocal fold nodules. J.Voice 1992;6;271-276.

Nienkerke-Springer A, McAllister A, Sundberg J. Effects of Family Therapy on Children's Voices. J.Voice 2005;19;103–113.

 

Ogawa M, Hosokawa K, Yoshida M, Iwahashi T, Hashimoto M, Inohara H. Immediate Effects of Humming on Computed Electroglottographic Parameters in Patients with Muscle Tension Dysphonia. J.Voice 2014;28;733–741.

 

Paes SM, Zambon F, Yamasaki R, Simberg S, Behlau M. Immediate Effects of the Finnish Resonance Tube Method on Behavioral Dysphonia. J.Voice 2013; 27; 717-722.

 

Patel RR, Pickering J, Stemple J, Donohue KD. A Case Report in Changes in Phonatory Physiology Following Voice Therapy: Application of High-Speed Imaging. J.Voice 2012; 26;734-741.

 

Pedrosa V, Pontes A, Pontes P, Behlau M, Peccin SM. The Effectiveness of the Comprehensive Voice Rehabilitation Program Compared With the Vocal Function Exercises Method in Behavioral Dysphonia: A Randomized Clinical Trial. J.Voice 2016;30;377.e11–377.e19

Peterson E, Roy N, Awan SN, Merril RN, Banks R, Toward KT. Validation of the Cepstral Spectral Index of Dysphonia (CSID) as an Objective Treatment Outcomes Measure. J.Voice 2013,27; 401-10.

Petrovic-Lazic M, Jovanovic N, Kulic M, Babac S, Jurisic V. Acoustic and Perceptual Characteristics of the Voice in Patients with Vocal Polyps After Surgery and Voice Therapy. J.Voice 2015;29;241–246.

Pinho SMR, Tsuji DH, Sennes L, Menezes M. Paradoxical vocal fold movement: A case report. J.Voice 1997;11;368-372.

Pitts T, Bolser D, Rosenbek J, Troche M, Okun MS, & Sapienza C. Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. CHEST Journal 2009;135;1301–1308.

Pontes P, Behlau M. Treatment of sulcus vocalis: Auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. J.Voice 1993;7;365-376.

Pyne D, Shenker NG. Demystifying acupuncture. Reumathology (Oxford) 2008; 47:1132-6.

Ramig LO. Speech therapy for patients with Parkinson's disease. (1995) In: Koller W, Paulson G, eds. Therapy of Parkinson's disease. New York: Marcel Dekker, pp 539-50.

Ramos LA, Gama ACC. Effect of Performance Time of the Semi-Occluded Vocal Tract Exercises in Dysphonic Children. J.Voice, 2017; 31; 329–335.

 

Rattenbury HJ, Carding PN, Finn P. Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial. J.Voice 2004;18; 522–533.

 

Reynolds V, Meldrum S, Simmer K, Vijayasekaran S, French N. A Randomized, Controlled Trial of Behavioral Voice Therapy for Dysphonia Related to Prematurity of Birth. J.Voice 2017;31; 247.e9–247.e17.

 

Ribeiro V, Pedrosa V, Silverio K, Behlau M. Laryngeal Manual Therapies for Behavioral Dysphonia: A Systematic Review and Meta-analysis. J.Voice 2017;31,  2017 /epub - ahead of print.

 

Rinsky-Halivni L, Klebanov M, Lerman Y, Paltiel O. Adherence to Voice Therapy Recommendations Is Associated with Preserved Employment Fitness Among Teachers with Work-Related Dysphonia. J.Voice 2017;31;386.e19–386.e26.

 

Rodríguez-Parra MJ, Adrián JA, Casado JC. Voice Therapy Used to Test a Basic Protocol for Multidimensional Assessment of Dysphonia. J.Voice 2009;23;304–318.

 

Roy N, Hendarto H. Revisiting the Pitch Controversy: Changes in Speaking Fundamental Frequency (SFF) After Management of Functional Dysphonia. J.Voice 2005;19; 582–591

 

Roy N, Weinrich B, Gray SD, Tanner K, Toledo SW, Dove H, Corbin-Lewis K, Stemple JC. Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study.  J Speech Lang Hear Res. 2002;45(4):625-38.

 

Roy N, Gray SD, Simon M, Dove H, Corbin-Lewis K, Stemple JC. An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial.  J Speech Lang Hear Res. 2001;44:286-96.

 

Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes. J.Voice 1997;11;321-331.,

 

Roy N, Leeper HA. Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: Perceptual and acoustic measures. J.Voice 1993;7;242-249.

 

Santos JKO, Silvério KCA, Oliveira NFCD, Gama AAC. Evaluation of Electrostimulation Effect in Women with Vocal Nodules. J.Voice 2016;30;769.e1–769.e7.

 

Sataloff RT. Voice: a new specialty. J. Voice 1987a;1.

 

Sataloff RT. The professional voice: Part III. Common diagnoses and treatments. J Voice 1987b; 283-292.

 

Schindler A, Bottero A, Capaccio P, Ginocchio D, Adorni F, Ottaviani F. Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis. J.Voice 2008; 22;113–118.

 

Schmidt CP, Andrews ML. Consistency in clinicians' and clients' behavior in voice therapy: An exploratory study.  J.Voice 1993;7;354-358.

 

Se Lee Y, Hee Lee D, Jeong G, Kim JW, Roh J, Choi S, Kim SY, Nam SY. Treatment Efficacy of Voice Therapy for Vocal Fold Polyps and Factors Predictive of Its Efficacy. J.Voice 2017;31;120.e9–120.e13.

 

Şenkal OA, Çiyiltepe M. Effects of Voice Therapy in School-Age Children, J.Voice 2013;27;787.e19-787.e25.

 

Sielska-Badurek E, Osuch-Wójcikiewicz E, Sobol M, Kazanecka E, Niemczyk K. Singers' Vocal Function Knowledge Levels, Sensorimotor Self-awareness of Vocal Tract, and Impact of Functional Voice Rehabilitation on the Vocal Function Knowledge and Self-awareness of Vocal Tract. J.Voice 2017;31;122.e17–122.e24.

 

Sielska-Badurek E, Osuch-Wójcikiewicz E, Kazanecka MSE, Rzepakowska A, Niemczyk K. Combined Functional Voice Therapy in Singers With Muscle Tension Dysphonia in Singing. J.Voice 2017;31;509.e23 - 509.e31.

 

Sielska-Badurek E, Osuch-Wójcikeiwicz E, Sobol M, Kazanecka E, Niemczyk  K. Singers' vocal function knowledge levels, sensorimotor self-awareness of vocal tract, and impact of functional voice rehabilitation on the vocal function knowledge and sensorimotor self-awareness of vocal tract. J Voice. 2016; 31:122.e17-122.e24.

 

Silva WJN, Lopes LW, Macedo AER, Costa DB, Almeida AAF. Reduction of Risk Factors in Patients with Behavioral Dysphonia After Vocal Group Therapy. J.Voice 2017;31;123.e15–123.e19.

 

Silverio KCA, Brasolotto AG, Siqueira LTD, Carneiro CG, Fukushiro AP, Guirro RRJ. Effect of Application of Transcutaneous Electrical Nerve Stimulation and Laryngeal Manual Therapy in Dysphonic Women: Clinical Trial. J.Voice 2015;29;200 – 208.

 

Simberg S, Sala E, Tuomainen J, Sellman J, Rönnemaa A. The Effectiveness of Group Therapy for Students with Mild Voice Disorders: A Controlled Clinical Trial. J.Voice 2006;20; 97–109.

 

Smith ME, Ramig LO, Dromey C, Perez KS, Samandari R, Intensive voice treatment in parkinson disease: Laryngostroboscopic findings. J.Voice 1995;9;453-459.

 

Smith, S and Thyme, K. Statistic research on changes in speech due to pedagogic treatment (The Accent Method). Folia Phoniatr (Basel). 1976; 28: 98–103.

 

Smith BE, Kempster GB, Sims HS. Patient Factors Related to Voice Therapy Attendance and Outcomes. J.Voice 2010;24;694–701.

Speyer R, Wieneke GH, Dejonckere PH. Documentation of progress in voice therapy: perceptual, acoustic, and laryngostroboscopic findings pretherapy and posttherapy. J.Voice 2004;18; 325–340

Speyer R, Wieneke GH, Van Wijck-Warnaar I, Dejonckere PH. Effects of voice therapy on the voice range profiles of dysphonic patients. J.Voice 2003;17;544-556.

Stemple JC, Voice research: So What? A clearer view of voice production, 25 years of progress; the speaking voice. J.Voice, 1993;7;293-300.

Stemple JC (1984). Clinical voice pathology: Theory and management. Columbus, OH: Charles E. Merrill.

Stone RE, & Casteel R (1982). Restoration of voice in nonorganically based dysphonia. In M. Filter (Ed.), Phonatory voice disorders in children (pp. 132–165). Springfield, IL: C.C. Thomas.

Tang SS, Thibeault SL. Timing of Voice Therapy: A Primary Investigation of Voice Outcomes for Surgical Benign Vocal Fold Lesion Patients. J.Voice 2017;31;129.e1–129.e7.

Tanner K, Roy N, Ash A, Buder EH. Spectral Moments of the Long-term Average Spectrum: Sensitive Indices of Voice Change After Therapy? J.Voice 2005;19;211–222.

Teixeira LC, Behlau M. Comparison Between Vocal Function Exercises and Voice Amplification. J.Voice 2015;29;718–726.

Titze IR. (2006). Voice training and therapy with a semi-occluded vocal tract: Rationale and scientific underpinnings. Journal of Speech, Language, and Hearing Research, 49, 448–459.

Treole K, Trudeau MD. Changes in sustained production tasks among women with bilateral vocal nodules before and after voice therapy. J.Voice,1997,11,462-469.

Titze IR. Heat generation in the vocal folds and its possible effect on vocal endurance. In: Lawrence VL, ed. Transcripts of the tenth symposium: care of the professional voice. Part I: Instrumentation in voice research. New York: The Voice Foundation, 1981:52-65.

Tuomi L, Björkner E, Finizia C. Voice Outcome in Patients Treated for Laryngeal Cancer: Efficacy of Voice Rehabilitation, J.Voice 2014;28; 62-68.

Van Houtte E, Van Lierde K, Claeys S. Pathophysiology and Treatment of Muscle Tension Dysphonia: A Review of the Current Knowledge. J.Voice 2011; 25; 202–207.

Van Leer E, Van Mersbergen M. Using the Borg CR10 Physical Exertion Scale to Measure Patient-perceived Vocal Effort Pre and Post Treatment. J.Voice 2017;31;389.e19–389.e25.

Van Leer E, Connor NP. Use of Portable Digital Media Players Increases Patient Motivation and Practice in Voice Therapy. J.Voice 2012;26;447-453.

Van Leer E, Connor NP. Patient Perceptions of Voice Therapy Adherence. J.Voice 2010; 24;458–469

Van Lierde KM, Bodt MD, Dhaeseleer E, Wuyts F, Claeys S. The Treatment of Muscle Tension Dysphonia: A Comparison of Two Treatment Techniques by Means of an Objective Multiparameter Approach. J.Voice 2010;24;294–301.

Van Lierde KM, Claeys S, Bodt MD, Van Cauwenberge P. Outcome of laryngeal and velopharyngeal biofeedback treatment in children and young adults: A pilot study. J.Voice 2004;18;97–106

Vasconcelos D, Gomes AOC, Araújo CMT. Treatment for Vocal Polyps: Lips and Tongue Trill. J.Voice 2017;31;252.e27–252.e36.

Verdolini K. Lessac-Madsen Resonant Voice Therapy. (2005). Training manual and patient materials distributed at Summer Vocology Institute, Denver, CO.

Verdolini K. Resonant voice therapy. (2000) in: J.C. Stemple (Ed.) Voice Therapy: Clinical Case Studies. 2nd ed. Singular Publishing Group, San Diego, CA; pp 46–61.

Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E. Preliminary study of two methods of treatment for laryngeal nodules. J.Voice 1995;9;74-85.

Verdolini-Marston K, Sandage M, Titze IR. Effect of hydration treatments on laryngeal nodules and polyps and related voice measures. J.Voice 1994;8;30-47.

Vertigan AE, Theodoros DG, Winkworth AL, Gibson PG. A Comparison of Two Approaches to the Treatment of Chronic Cough: Perceptual, Acoustic, and Electroglottographic Outcomes. J.Voice 2008;22;581–589.

Vertigan AE,Theodoros DG, Gibson PG, and Winkworth AL. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax. 2006; 61: 1065–1069.

Vlot C, Ogawa M, Hosokawa K, Iwahashi T, Kato C, Inohara H. Investigation of the Immediate Effects of Humming on Vocal Fold Vibration Irregularity Using Electroglottography and High-speed Laryngoscopy in Patients with Organic Voice Disorders. J.Voice, 2017,31; 48–56.

Walton C, Conway E, Blackshaw H, Carding P. Unilateral Vocal Fold Paralysis: A Systematic Review of Speech-Language Pathology Management. J.Voice 2017;31; 509.e7 - 509.e22.

Watts CR, Diviney SS, Hamilton A, Toles L, Childs L, Mau T. The Effect of Stretch-and-Flow Voice Therapy on Measures of Vocal Function and Handicap. J.Voice 2015;29;191–199.

Wenke RJ, Stabler P, Walton C, Coman L, Lawrie M, O'Neill J, Theodoros D, Cardell E. Is More Intensive Better? Client and Service Provider Outcomes for Intensive Versus Standard Therapy Schedules for Functional Voice Disorders. J.Voice 2014;28;652.e31–652.e43.

Wingate JM, Brown WS, Shrivastav R, Davenport P, Sapienza CM. Treatment Outcomes for Professional Voice Users. J.Voice 2007;21;433–449.

Yamaguchi H, Yotsukura Y, Sata H, Watanabe Y, Hirose H, Kobayashi N, Bless DM. Pushing exercise program to correct glottal incompetence. J.Voice 1993;7; 250-256.

Yamasaki R, Murano EZ, Gebrim E, Montagnoli AHA, Behlau M, Tsuji DH. Vocal Tract Adjustments of Dysphonic and Non-Dysphonic Women Pre- and Post-Flexible Resonance Tube in Water Exercise: A Quantitative MRI Study. J.Voice, 2017;31;441-454.

Yiu EML, Chan KMK, Kwong E, Li NYK, Ma EPM, Tse FW, Lin Z, Abbott KV,Tsang R. Is Acupuncture Efficacious for Treating Phonotraumatic Vocal Pathologies? A Randomized Control Trial. J.Voice 2016;30;611–620.

Zambon F, Moreti F, Behlau M. Coping Strategies in Teachers with Vocal Complaint. J.Voice 2014;28;341-348.

Zhuge P, You H, Wang H, Zhang Y, Du H. An Analysis of the Effects of Voice Therapy on Patients With Early Vocal Fold Polyps. J.Voice 2016;30;698–704.

Ziegler A, Dastolfo C, Hersan R, Rosen CA, Gartner-Schmidt J. Perceptions of Voice Therapy From Patients Diagnosed With Primary Muscle Tension Dysphonia and Benign Mid-Membranous Vocal Fold Lesions. J.Voice 2014; 28;742–752.

www.counseling.org. consulted in December 20, 2017.

 

 

Advertisement