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Main Report W Hauptreferat W Rapport principal

Main Report W Hauptreferat W Rapport principal Folia Phoniatr Logop 1998;50:146–164 Samia Bassiouny Faculty of Medicine,
Main Report W Hauptreferat W Rapport principal Folia Phoniatr Logop 1998;50:146–164 Samia Bassiouny Faculty of Medicine,

Folia Phoniatr Logop 1998;50:146–164

Samia Bassiouny
Samia Bassiouny

Faculty of Medicine, Ain Shams University, Cairo, Egypt

Efficacy of the Accent Method of Voice Therapy

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Key Words

Efficacy W Accent method W Voice therapy W Voice hygiene advice W Voice disorders

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Abstract

There is an increasing need for studies of efficacy of behavior readjustment therapy procedures in human communicative disorders. Legal, social, scientific and professional considerations point up the need for more careful documentation of the effects of treatment tech- niques used by phoniatricians and speech-language pathologists. This study is conducted in order to evalu- ate the efficacy of the accent method of voice therapy (AM). The AM is one of the holistic approaches for behavior readjustment voice therapy. It tackles collec- tively and simultaneously the various parameters of voice such as pitch, loudness and timbre. The results of intervention utilizing the AM in this clinical trial are assessed in a relatively controlled setup. Patients with voice problems resulting from various etiologic vocal pathologies are distributed randomly into two groups. Group 1 (G1) is given the full aspect of the AM, that is, voice hygiene advice plus the accent exercises to cor- rect the faulty vocal technique (habit). Group 2 (G2)

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receives only voice hygiene advice. The AM is admin- istered in individual sessions 20 min each, twice a week, while the voice hygiene advice counseling is giv- en once a week. The assessment of the vocal pathology is done following a diagnostic protocol utilizing subjec- tive as well as quasi-objective measures of evaluation. The initial assessment presents the baseline (pretest) data for both groups. The follow-up evaluations are done at mid intervention (mid-test), that is, 10 sessions for G1 and 5 sessions for G2, and at the termination of intervention/therapy (post-test). The difference in im- provement between G1 and G2 at the end of the obser- vation was generally significant in favor of G1. There were significant improvements in G1 in certain items specific for the various etiologic categories. The im- provement from pretest to mid-test to post-test values followed a linear tendency. The significance of the results is discussed and the conclusions are outlined and criticized.

Die Wirksamkeit der Akzentmethode in der Stimmtherapie

Die Arbeit der Phoniater und Logopäden erfordert vermehrte Untersuchungen betreffend der Wirksam- keit angewendeter Behandlungstechniken. Diese Stu- die prüft die Wirksamkeit der Akzentmethode in der funktionellen Stimmrehabilitation. Die Akzentmetho- de befasst sich mit verschiedenen Stimmelementen wie Tonhöhe, Lautheit und Timbre. Die Daten der Therapieresultate wurden in kontrollierten Gruppen

erhoben. Bezüglich der Versuchsanordnung wurden zwei randomisierte Gruppen gebildet, nämlich G1 die voll mit Akzentmethode behandelt wurde, und einer Kontrollgruppe G2, die nur stimmhygienische Bera- tung erhielt. Die G1-Patienten erhielten zweimal 20 min Therapie pro Woche, während die G2-Gruppe einmal wöchentlich Stimmhygieneberatung erhielt. In einem Protokoll wurden objektive und halbobjekte Be-

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funde eingetragen, wobei der Eingangsstatus für beide Gruppen identisch gehalten wurde. Der erste Thera- piebefund wurde bei der G1-Gruppe nach 10, bei der G2-Gruppe nach 5 Sitzungen erhoben, ebenso bei Beendigung der Therapie. Der Vergleich zwischen G1

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und G2 ergab statistisch signifikante Unerschiede zu- gunsten von G1. Dieser Erfolg konnte für verschiedene Atiologien nachgewiesen werden. Die Resultate der Befunde werden diskutiert.

Efficacité de la méthode de l’accent en thérapie vocale

L’étude de l’efficacité des mesures thérapeutiques uti- lisées pour la réadaptation des troubles de la communi- cation rencontre un intérêt croissant. Des considéra- tions légales, sociales, scientifiques et professionnelles incitent à une documentation plus précise des effets des traitements utilisés par les phoniatres et les logopé- distes. Cette étude évalue l’efficacité de la méthode de l’accent (MA) en thérapie vocale. La MA est une approche holistique intéressant les différents paramè- tres de la voix (hauteur, intensité et timbre). Des

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patients présentant des problèmes vocaux d’étiologies diverses furent divisés en deux groupes randomisés, l’un et l’autre recevant des conseils d’hygiène vocale, mais un seul étant traité par la MA. Les évaluations se firent à 3 stades du traitement. Le groupe ayant bénéfi- cié de la MA montra des améliorations significatives pour certains aspects spécifiques de diverses variétés étiologiques. Les résultats sont soumis à une étude cri- tique.

Introduction

Need for Efficacy Studies

There is an increasing need for efficacy studies of behavior readjustment therapy pro- cedures in human communicative disorders. The clinician needs a proof that the proce- dures adopted in daily practice are clinically effective. Clinicians and researchers need guidelines for improvement and modification of existing therapy procedures. Auditors and funding agencies also need a proof that the time and money spent in clinical settings is worth the effort and spending, and that the process is cost-effective. As a general princi- ple, professional services rendered anywhere should not be based upon subjective evalua- tions, but rather justifiable on objective grounds. Any health authority in a clinical setup will not continue to support clinical budget services whose effects are questionable or are based upon subjective evaluations. Ob- jective documentation of the effectiveness of treatment is an essential goal in managing all patients.

Bleile [1] reported that the need for infor- mation on treatment outcome was listed as the highest health care priority by a recent American Speech-Language and Hearing As- sociation task force [2]. The fact that the American Speech-Language and Hearing As- sociation and the National Institute on Deaf- ness and Other Communication Disorders of the National Institutes of Health sponsored research conference on models for the evalua- tion of treatment efficacy during the 1992 annual ASHA convention is an explicit recog- nition of the need to improve and develop research methods that provide sufficient da- ta to guide the selection of treatment ap- proaches.

Types of Efficacy Studies

Hegde [3] stated that the distinction be- tween improvement in client behaviors and effectiveness of treatment techniques high- lights the importance of controlled clinical research. Client improvement while receiving treatment does not necessarily suggest that the treatment was indeed effective. Improvement

Efficacy of the Accent Method of Voice Therapy

Folia Phoniatr Logop 1998;50:146–164

147

is a necessary but not a sufficient condition for establishing effectiveness of treatment techniques. In uncontrolled studies on treat- ment/therapy, there is no assurance that clients would not have produced those im- proved behaviors in the absence of treatment. In other words, what are considered ‘normal developmental changes’, ‘spontaneous recov- ery’, ‘potential influence of formal or informal treatment programs’ initiated by sources oth- er than the clinician are not ruled out. ‘Client improvement’ is noted when follow-up of the patient reveals changes in behaviors under treatment. ‘Treatment effectiveness’ is docu- mented only when the influence of other po- tential treatment variables is ruled out. This goal is attained when controlled documented research is conducted. Such documented changes also demonstrate clinician’s accoun- tability. Law [4] reported that treatment evaluation refers to several levels of accountability: effec- tiveness, efficiency, effects and efficacy. ‘Ef- fectiveness’ refers to whether a treatment can be shown to work or not insofar as it alters the course of a disorder. ‘Efficiency’ looks at the relative values of different treatments but also refers to broader concepts relating to clinical practice, including economic analysis. ‘Ef- fects’ refers to changes in behaviors and is equivalent to outcomes. ‘Efficacy’ refers to evaluation carried out under more rigorously controlled laboratory conditions. Efficacy, however, is interpreted differently by differ- ent authors. There are several models to test efficacy of therapeutic agents and procedures [3, 5]. Some of the models are not feasible, and in some instances, even unethical, to apply to behavioral studies. Withholding the therapy for a period of time under the experiment, an ethical question in itself, may not reverse the gains in a reasonable period of time to allow objective judgment regarding the relationship

between the initial gains and the therapy pro- cedure. In such clinical trials other models may be applied. Patients may be distributed randomly into several groups. The tested ther- apy procedure will be withheld from one group, while administered to another group. For additional control a third group may be given a therapy procedure that is not address- ing the target as the tested procedure, for example an articulation drill in case of a voice disorder. In that latter group the active thera- py procedure may be considered as a pla- cebo. The two basic approaches to document effectiveness of treatment programs are the between-groups strategy and the within-sub- ject strategy. The former strategy, which is variously known as group design study, or sta- tistical research design, is based on the con- cept of group comparisons. One group is the experimental group, which receives treat- ment; the other is the control group, which is untreated. The basic assumption in this ap- proach is that patients who are treated will change while those who are not treated re- main unchanged. The within-subject strategy, also known as single-subject strategy, is based on the fact that each subject serves as his or her own control. The clients receive treatment in one condition and do not receive treatment in another condition. The same behaviors of the patient under treatment versus no treat- ment are compared to determine the efficacy of treatment. Another characteristic of this strategy is that the patient’s behaviors are measured continuously. Treatment effects are not determined on the basis of pretest and post-test measures, but are assessed in each experimental session so that a continuous pic- ture of change over time is obtained. Hegde [3] reported several single-subject designs to determine treatment effectiveness, e.g. the ABA, the ABAB and the multiple baseline design which are the most commonly used

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models. In the ABA, in the first A phase the initial baselines are established. In the B phase, the therapy is applied and new data are collected. The final A phase represents the data when the therapy is withdrawn. The ABAB design has two versions: The first is the ‘ABAB withdrawal’ where the initial A and B are similar to the ABA design. The second A is the withdrawal of therapy. The final B repre- sents data after reapplication of therapy. The second version is the ‘ABAB reversal’ which is similar to the first version but in the second A efforts are made to reverse the therapeutic gains achieved in the first B. The final B is to reapply the therapy to correct the deficit and reach the therapeutic target behavior again.

The Accent Method of Voice Therapy

The management of voice disorders may follow one of four lines, one of them is behav- ior readjustment measures [6]. In voice thera- py behavior readjustment comprises two ele- ments [7]. These are voice hygiene advice and correction of a faulty vocal technique. The accent method (AM) of voice therapy is one of the holistic approaches for behavior modifica- tion of the voice [6]. It was introduced by Svend Smith in the thirties of this century [8]. It has been applied for the treatment of voice disorders for decades in various parts of the world. The AM targets holistically the improve- ment of the respiratory, phonatory, articulato- ry, and gesticulatory aspects of verbal com- munication in an integrated manner. The AM may be considered holistic also from the vocal point of view as it collectively and simulta- neously tackles the various parameters of the voice such as pitch, loudness and timbre. The AM rests technically on three major princi- ples: (1) optimal abdominodiaphragmatic breath support; (2) rhythmic play of accen- tuated relaxed vowels with progressive carry- over to connected speech, and (3) dynamic

rhythmic body and arm movements. The therapeutic procedure consists of: (1) respira- tory exercises; (2) phonatory exercises, and (3) articulatory exercises, by which the beneficial new vocal habits are transferred to connected speech. In the domain of voice disorders the AM is therapeutically indicated as (a) a mainstream line of therapy, or (b) a complementary one [7]. The main applications in the former case are: (1) Nonorganic (functional) habitual voice disorders in adults and children; (2) nonorganic psychogenic voice disorders; (3) selected types of minimal associated patho- logical lesions such as vocal nodules and con- tact granuloma, and (4) selected types of or- ganic voice disorders such as motor disorders of the vocal folds (paralytic dysphonia), and dysplasia. The main application of the AM as a complementary line of treatment is in as- sociation with pharmacotherapy or phono- surgery. The efficacy of the AM has been reported in several studies [9–11]. Kotby et al. [12] in 1991 indicated the efficacy of the AM in the management of all nonorganic voice disor- ders, selected cases of minimal associated pathological lesions such as vocal nodules and contact granuloma as well as selected cases of organic voice disorders such as paralytic dys- phonia and dysplasia. Additional controlled clinical trials are, however, still needed to test the efficacy of the AM. This study is conducted in order to evalu- ate the efficacy of the AM utilizing a more controlled experimental model. The study is based on the concept of group comparisons. The efficacy of the accent exercises is tested by assessment of the effect of voice hygiene advice alone against the effect of both voice hygiene advice and the accent exercises for the correction of the faulty vocal technique (habit). By separating the two elements of behavior readjustment therapy, one may be

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Table 1. Etiologic categories

Nonorganic (functional) dysphonia Hyperfunctional

14

Phonasthenia

8

MAP lesions

Nodules

10

Reinke edema

2

Vocal fold immobility (paralysis) Ideopathic

3

Post-thyroidectomy

5

Total

42

MAP = Minimal associated pathological.

able to demonstrate the efficacy of each, espe- cially the latter. Such a study may be used as an approach to efficacy research in behavior readjustment therapy in human communica- tive disorders.

Material and Method

The material of this study comprised 42 patients who presented with a variety of vocal pathologies (ta- ble 1). They were randomly categorized into two groups. Group 1 (G1) comprised 21 patients (8 males and 13 females) with age ranging from 20 to 54 years (mean = 37). This group received voice hygiene advice plus the accent exercises of voice therapy. Group 2 (G2) comprised 21 patients (10 males and 11 females) with age ranging from 20 to 60 years (mean = 40). This group was given voice hygiene advice only preparatory to active voice therapy later on. In G1 the AM is administered in individual ses- sions 20 min each, 2 times per week with a follow-up evaluation after 10 and 20 sessions of therapy. The ses- sion includes both voice hygiene advice and the exer- cises aiming at correction of the faulty vocal technique (habit). In G2, the same type of vocal hygiene advice was given in a single weekly session, with a follow-up system similar to the patients of G1, that is, an assess- ment at mid-therapy (after 5 sessions) and at the termi- nation of therapy (after 10 sessions). The values of the initial assessment are taken as pretherapy or ‘pretest’ data. The full battery of voice assessment is applied on

the 2 follow-up occasions producing values for ‘mid-

test’ and ‘post-test’, respectively. The diagnostic proce- dure followed a protocol of voice assessment devel- oped and applied at the Unit of Phoniatrics, Ain Shams University Hospitals [6]. The protocol, which utilizes both subjective and objective measures, high- lights the following items:

Elementary Diagnostic Procedures

(1) Patient’s interview, including: (a) the patient’s own grading of severity of voice dysfunction on a 5- point scale (4 = very good to 0 = very bad) recorded

initially and at every session, and (b) searching for pos-

sible predisposing factors.

(2) Auditory perceptual assessment (APA) as as-

sessed by a group of expert judges following a modified

GRBAS scale [13, 14], with 4 grades from 0 (normal) to 3 (severe dysphonia). The following vocal character- istics are included in this evaluation [GSLBI = overall grade (G), strained (S), leaky (L), breathy (B), and irregular (I)]. (3) Preliminary visual assessment of glottic pathol- ogy by indirect mirror laryngoscope.

Clinical Diagnostic Aids

(1) Laryngo-video-stroboscopy using a Kay Ele- metrics rhinolaryngeal stroboscope model 9100, at- tached to either the rigid oral telescope or flexible naso- fibroscope [15]. This was used for augmentation and documentation of the visual assessment of the vocal organ [16]. At video-stroboscopy the following param- eters were observed: the glottic wave and amplitude of vocal fold vibration; symmetry of the wave; phase clo- sure of the glottis; presence, shape, and size of a phona- tory gap, and details of morphological changes such as early nodules and edema [17]. (2) High fidelity voice recording, in a soundproof booth, using a Sony digital audiotape deck system DTC-60ES connected to Sony stereo amplifier F101k.

Additional Instrumental Measures

(1) Aerodynamic measures using Nagashima Sys- tem (Ps-77H): These include vital capacity (VC), maxi- mum phonation time (MPT), phonatory quotient (PQ), mean flow rate (MFR), sound pressure level (SPL) range as the difference between the loudest and softest phonations, frequency (F o ) range as the differ- ence between the highest and lowest F o , subglottic pressure (Psub), glottal efficiency (GE) and glottal resistance (GR) [18, 19]. (2) Acoustic analysis [20, 21] using the Kay CSL system (Kay Elemetrics): This included measurements of average pitch, frequency and amplitude perturba-

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Table 2. Patient’s own grading of severity for the three evaluations in G1 and G2

Patient’s own

Pretest

Mid-test

Post-test

grading of severity

G1

G2

G1

G2

G1

G2

  • 0 48%

Very bad

76%

71%

67%

0%

52%

  • 1 27%

Bad

10%

14%

18%

5%

20%

  • 2 10%

Moderate

10%

15%

15%

5%

18%

  • 3 5%

Good

4%

0%

0%

42%

10%

  • 4 10%

Very good

0%

0%

0%

48%

0%

tion (jitter and shimmer, respectively) as well as har- monic-to-noise (H/N) ratio. (3) Inverse filtering measures, by recording oral air- flow with a circumferentially vented pneumotacho- graph mask coupled to differential pressure transducer (Glottal Enterprises System, type MA-1) [22, 23]. Dig- ital inverse filtering was completed using the CSpeech version 3.1 to yield the glottal airflow waveform. The following parameters are measured: (a) flow ampli- tude-based parameters: the peak flow and the mini- mum flow in milliliters per second; (b) time-based parameters: open quotient (OQ), speed quotient (SQ), closing quotient (CQ) and speed index (SI). Statistical comparison of the data between pretests and mid-tests as well as between pre- and post-tests in each group and subgroup was done using paired t test. Comparison between the progress of G1 and G2 across the pre- and post-tests was done using t test. The same procedure was used to compare the amount of progress from pre- to mid-test and then from mid- to post-test in G1. The etiologic subgroups that have been dealt with statistically (because they are of a reasonable number) were only four, namely: hyperfunctional dysphonia, phonasthenia, nodules, and vocal fold immobility (pa- ralysis). The category of Reinke edema was too small to warrant separate treatment.

Results

All patients presented with dysphonia with the exception of 4 phonasthenia cases who complained only of phonasthenic symptoms in the throat. The grade and type of dysphonia varied, but most patients had strained leaky voice. The patients’ own subjective evalua-

tion of the impact of the vocal problem (quali- ty of voice) over a 5-point scale revealed that in G1 76% gave a label of very bad while 71% of G2 gave the same label at the start of inter- vention. The development of the patients’ evaluation of their own voices at the termina- tion of intervention is shown in table 2. None of the patients of G1 remained in the very bad category while in G2 52% were still consid- ering their voice as very bad. In G1 90% of the patients reached the good/very good category while in G2 only 10% reached that level. APA as evaluated by neutral judges in a double-blind manner showed that the differ- ence in improvement of items G, S and L between pretest and post-test indicates that G1 has improved with a high degree of signifi- cance as compared to G2. The difference in improvement in item B and I was not signifi- cant (table 3, fig. 1). The etiologic subgroups of G1 showed specific tendencies in the im- provement in the different items of voice quality/character. In the vocal fold immobili- ty (paralysis) subgroup item B showed a high- ly significant improvement (table 4). Nodule size and the paralytic phonatory gap showed improvement to a variable degree in both G1 and G2 (tables 5, 6, fig. 2, 3). The difference between the improvement in nod- ule size and the paralytic gap between pretest and post-test in both groups was highly signif- icant in favor of G1 (table 7).

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Table 3. Mean (BSD) difference in improvement between pretest and post-test of the APA in G1
Table 3. Mean (BSD) difference in improvement
between pretest and post-test of the APA in G1 and
G2
APA
Mean difference B SD
t
G1
G2
G
1.67B0.79
0.14B0.67
–4.62**
S
1.21B0.97
–0.07B0.71
–3.38**
L
1.05B0.99
–0.07B0.71
–2.90**
B
0.36B0.76
0.14B0.65
–0.67
I
0.45B0.79
0.07B0.43
–1.34
** p ! 0.01, highly significant.
Fig. 1. Histogram representation of the mean dif-
ference in the improvement of the APA between pre-
tests and post-tests in both groups of voice therapy
(G1, i) and voice hygiene advice (G2, W).
Table 4. Mean values (BSD)
for the three evaluations of the
APA in the immobility group
(n = 4) who received voice therapy
APA
Pretest
Mid-test
t
Post-test
t
G
2.1B0.63
0.9B1.03
6.1**
0.3B0.50
23.7**
S
0
0
–0
(G1)
L
0
0
–0
B
2.1B0.63
0.9B1.03
6.1**
0.3B0.50
23.7**
I
0
0
–0

** p ! 0.01, highly significant.

Table 5. Mean values (BSD) in improvement be- tween pretest, and post-test for the pre- and post-test evaluations of nodules and phonatory (paralytic) gaps in G1 (n = 21)

Table 6. Mean values (BSD) in improvement be- tween pretest and post-test for the pre- and post-test evaluations of the nodules and the phonatory (paralyt- ic) gaps in G2 (n = 21)

Examination

Pretest

Post-test

t

 

Examination

Pretest

Post-test

t

Right base

2.04B0.74

0

8.68**

Right base

1.12B0.47

1.37B1.38

2.08

Right rise

0.64B0.60

0

3.36**

Right rise

0.18B0.06

0.12B0.09

3.66**

Left base

2.22B0.47

0.24B0.54

3.87**

Left base

1.06B0.82

1.57B1.41

3.66**

Left rise

0.68B0.57

0.04B0.09

3.36**

Left rise

0.37B0.18

0.20B0.16

2.76**

Gap

1.08B0.69

0.1B0.08

4.47**

Gap

0.76B0.21

0.54B0.28

3.2*

 

* p

!

0.05, significant; ** p !

0.01, highly sig-

 

** p ! 0.01, highly significant.

 

nificant.

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Bassiouny

Fig. 2. Video printouts for a female case with bilateral vocal fold nodules before therapy (a) and after therapy (b). Notice disappear- ance of the nodules after voice ther- apy.

Fig. 2. Video printouts for a female case with bilateral vocal fold nodules before therapy (

a

Fig. 2. Video printouts for a female case with bilateral vocal fold nodules before therapy (

b

Table 7. Mean difference (BSD) in improvement between pretest and post-test for nodules size and the phonatory gap of the immobility patients in G1 and

G2

 

Mean difference B SD

t

G1

G2

Right base

2.04B0.74

0.27B0.40

–6.62**

Right rise

0.64B0.60

0.07B0.06

–2.99**

Left base

0.98B0.80

0.33B0.29

–2.40**

Left rise

0.64B0.60

0.13B0.15

–2.57**

Gap

0.97B0.69

0.22B0.22

–3.30**

** p ! 0.01, highly significant.

Patients in G2, receiving counseling re- garding voice hygiene advice only, showed no change of any significance in the stroboscopic

assessment from pretest to mid-test to post- test observations. Patients in G1, who re-

ceived voice hygiene advice plus accent exer-

cises, showed highly significant change in all video-stroboscopic ratings from the pretest through the mid-test to the post-test assess- ments, indicating improvement or normaliza- tion (tables 8–11). Significant improvement

(with normalization reached in some cases)

was noticed in the mid-test assessment re-

garding the phase closure and the pattern of the phonatory gap only (tables 10, 11).

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153

Fig. 3. Video printouts for a male case with right vocal fold im- mobility before therapy (a) and af- ter therapy (b) at rest and during phonation. Notice marked reduc- tion of the phonatory gap after voice therapy.

Fig. 3. Video printouts for a male case with right vocal fold im- mobility before therapy

a

Fig. 3. Video printouts for a male case with right vocal fold im- mobility before therapy

b

The difference in improvement of aerody- namic measures between pre- and post-test evaluation of both groups was highly signifi- cant in favor of G1 in the following parame- ters: SPL range, Psub, GE and GR (table 12). On the other hand, G1, when followed across the three assessment occasions, showed a sig-

nificant improvement in the post-test values as compared to the pretest measures, while there was no significant improvement be- tween the pretest and mid-test. The post-test values as compared to the pretest values showed a significant decrease in the PQ and a highly significant improvement in the SPL

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Bassiouny

Table 8. Percent change in amplitude and mucosal wave for the three videostroboscopic evaluations of

Table 10. Percent change in phase closure for the three videostroboscopic evaluations in G1

G1

 

Phase closure

Pretest

Mid-test

Post-test

   

Amplitude and

Pretest

Mid-test

Post-test

 
 
 

wave

 

Normal

0%

24%*

67%**

 

Open

67%

48%

24%**

 
 

Right

Closed

33%

28%

9%*

0

Normal

10%

15%

67%**

Inconsistent

0%

0%

0%

1

Small

67%

62%

15%

2

Great

5%

5%

0%*

* p ! 0.05, significant; ** p ! 0.01, highly signifi-

3

Absent

18%

18%

18%

cant.

 
 

Left

0

Normal

29%

38%

86%**

1

Small

66%

57%

14%**

2

Great

5%

5%

0%*

3

Absent

0%

0%

0%

* p ! 0.05, significant; ** p ! 0.01, highly signifi- cant.

Table 11. Percent change in phonatory gap for the three videostroboscopic evaluations in G1

Phonatory gap

Pretest

Mid-test

Post-test

Normal

  • 0 0

38%*

76%**

Anterior

  • 1 0

0%

0%

  • 2 5%

Posterior

5%

10%

  • 3 52%

Longitudinal

18%*

5%**

  • 4 19%

Fusiform

18%

9%

  • 5 24%

Hourglass

24%

0%

Table 9. Percent change in symmetry for the three videostroboscopic evaluations in G1

Table 8. Percent change in amplitude and mucosal wave for the three videostroboscopic evaluations of Table

Symmetry

Pretest

Mid-test

Post-test

Symmetrical

10%

19%

71%**

Asymmetrical

90%

81%

29%**

** p ! 0.01, highly significant.

 

Table 12. Mean difference (BSD) in improvement between pretest and post-test of the aerodynamics in G1 and G2

 

VC, ml MPT, ms PQ MFR, ml/s F o range, Hz SPL range, dB Psub, mm H 2 O GE GR

* p ! 0.05, significant; ** p ! 0.01, highly signifi- cant.

Mean difference B SD

t

G1

G2

–164.33B711.18

–3.15B5.01

68.8B267.8

46.67B62.52

–16.76B43.62

–6.14B8.02

29.48B21.01

–0.17B413.60

–2.18B4.08

47.8B100.3

31.86B75.25

7.90B54.11

1.24B6.54

–4.14B9.32

–0.0029B0.0012 –0.0005B0.013

0.070B0.217

–0.084B0.12

0.63

0.47

–0.34

–0.47

–1.63

–3.27**

–4.62**

–6.28**

2.87**

** p ! 0.01, highly significant.

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Table 13. Mean values (BSD) for the three evaluations of the aerodynamics in G1 (n = 21)

Aerodynamics

Pretest

Mid-test

t

Post-test

t

VC, ml

2,150B1,050

2,130B1,040

–0.73

2,310B1,155

–0.73

MPT, s

10.8B8.9

12.6B9.9

–1.95

14.0B11.8

–1.99

PQ

285B192

231B164

2.70

237B179

2.8*

MFR, ml/s

199B99

165B57

1.71

153B51

2.36

F o range, Hz

19B32

23B20

–0.52

37B24

–1.8

SPL range, dB

8B7

11B6

–2.2

14B7

–3.51**

Psub, mm H 2 O

106B25

91B16

3.55

77B13

4.44**

GE

0.0043B0.019

0.0056B0.0021

–4.5

0.0072B0.002

–11.07**

GR

0.62B0.29

0.61B0.22

–0.44

0.55B0.18

1.4

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 

Table 14. Mean values (BSD) for the three evaluations of the aerodynamics in the hyperfunctional group who received voice therapy (G1, n = 7)

Aerodynamics

Pretest

Mid-test

t

Post-test

t

VC, ml

1,995B1,154

1,875B1,112

–0.57

2,180B1,215

–0.57

MPT, s

12.3B9.0

12.0B10.6

0.29

14.6B14.7

–0.99

PQ

214B159

217B165

–0.19

209B165

0.13

MFR, ml/s

145B43

146B44

–0.11

123B30

2.43

F o range, Hz

11B16

19B24

–0.85

32B22

–2.96*

SPL range, dB

5B6

9B4

–1.06

11B5

–1.86

Psub, mm H 2 O

101B15

90B12

3.41**

77B6

5.32**

GE

0.0056B0.0018

0.0063B0.0027

–1.04

0.0086B0.027

–6.61**

GR

0.79B41

0.68B0.29

1.36

0.66B0.18

1.16

* p ! 0.05, significant; ** p ! 0.01, highly significant.

range, Psub and GE (table 13). G2 showed a highly significant increase in the GR in the post-test evaluation (t = –3.32, p ! 0.01). The etiologic subgroups showed variable results. The hyperfunctional subgroup showed signifi- cant/highly significant improvement in the frequency range, Psub and GE (table 14). Phonasthenia showed significant/highly sig-

nificant improvement in MPT, frequency range, Psub and GE (table 15). The nodules group showed significant and highly signifi- cant variation in MPT, MFR, SPL range, Psub and GE (table 16). The immobility group showed significant/highly significant improvement in MPT, PQ, MFR, Psub and GE (table 17).

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Table 15. Mean values (BSD) for the three evaluations of the aerodynamics in the phonasthenia group who received voice therapy (G1, n = 4)

Aerodynamics

Pretest

Mid-test

t

Post-test

t

VC, ml

3,165B960

3,300B558

–1.79

3,565B817

–1.79

MPT, s

14.7B13.1

17.17B15.61

–3.0*

18.75B17.25

–3.0*

PQ

75B2.38

75B2.16

–0.7

76B2.22

–0.0

MFR, ml/s

217B54.87

199B39.21

3.0*

188B33.21

2.44

F o range, Hz

233B88.53

247B108.36

–1.4

241B105.47

–5.6**

SPL range, dB

8B4

10B6

–1.2

13B6

–2.6

Psub, mm H 2 O

126B28.75

100B18.14

7.3**

85B20.42

9.6**

GE

0.0030B0.0011

0.0041B0.0013

–7.6**

0.0052B0.0016

–6.6**

GR

0.60B0.15

0.51B0.11

B2.8*

0.46B0.15

2.5

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 

Table 16. Mean values (BSD) for the three evaluations of the aerodynamics in the nodules group who received voice therapy (G1, n = 5)

Aerodynamics

Pretest

Mid-test

t

Post-test

t

VC, ml

2,015B645

1,915B795

–1.5

2,220B635

–1.5

MPT, s

7.6B5.6

11.6B6.0

–6.1**

11.4B7.1

–3.1**

PQ

314B96

172B21

4.17**

246B110

2.2

MFR, ml/s

175B33

150B11

1.99

150B6

2.7*

F o range, Hz

24B13

20B23

0.29

35B28

–0.62

SPL range, dB

8B10

13B10

–6.45**

18B9

4.8**

Psub, mm H 2 O

100B27

82B16

3.31**

74B15

5.8**

GE

0.0043B0.0015

0.0059B0.0097

–3.82**

0.0068B0.0016

–7.3**

GR

0.58B0.18

0.56B0.15

–0.33

0.49B0.12

2.2

* p ! 0.05, significant; ** p ! 0.01, highly significant.

The difference in improvement between G1 and G2 in shimmer was significant while it was highly significant in H/N ratio (ta- ble 18, fig. 4). The acoustic analysis in G1 showed a significant decrease in jitter values and highly significant increase in H/N ratio between the pretest and post-test measures only (table 19). The etiologic subgroups of

phonasthenia, nodules, and vocal fold immo- bility showed an additional highly significant improvement in shimmer values between pre- test and post-test measures. The etiologic sub- groups showed variable tendencies of im- provement between the pretest and the mid- test (table 20–22).

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Table 17. Mean values (BSD) for the three evaluations of the aerodynamic measures in the immobility group who received voice therapy (G1, n = 4)

Table 17. Mean values ( B SD) for the three evaluations of the aerodynamic measures in

Aerodynamics

Pretest

Mid-test

t

Post-test

 

t

VC, ml

1,268B463

1,339B290

0.6

1,168B729

 

0.6

MPT, s

5.3B4.35

7.4B4.16

3.1**

 

8.9B4.69

 

–2.9*

PQ

385B354

277B266

1.8

229B302

 

3.54*

MFR, ml/s

322B166.41

198B104.11

4.7**

 

184B94.47

 

4.9**

F o range, Hz

39B73

37B18

0.03

48B35

 

–0.2

 

SPL range, dB

10B10

11B2

0.19

13B5

 

–0.3

Psub, mm H 2 O

107B36.09

94B20.89

2.42

71B15.46

 

2.7*

GE

0.0031B0.0023

0.0052B0.0027

–2.9*

0.0070B0.0032

 

–4.6**

GR

0.36B0.10

0.54B0.21

–1.6

0.46B21

 

–0.8

 

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 
 

Table 18. Mean difference (BSD) in improvement between pretest

   

and post-test of the acoustic analysis of G1 and G2

and post-test of the acoustic analysis of G1 and G2
     
and post-test of the acoustic analysis of G1 and G2
 
 
 

Mean difference B SD

t

Mean difference B SD t
     
     

G1

G2

 
G1 G2
         
Aerodynamics Pretest Mid-test t Post-test t VC, ml 1,268 B 463 1,339 B 290 0.6 1,168

Average pitch, Hz

3.28B11.75

6.57B28.63

0.33

Jitter

 

0.985B1.089

0.333B0.700

–1.59

1.019B1.657

–0.058B0.478

–1.95*

 
1.019 B 1.657 –0.058 B 0.478 –1.95*
               

Shimmer

 
Shimmer
 
Shimmer
 

H/N

–4.181B3.477

–0.133B2.988

2.79**

 

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 

Fig. 4. Histogram representa-

 

tion of the H/N mean values for the voice therapy group (G1) and the voice hygiene advice group (G2) in the three evaluations.

Table 19. Mean values (BSD) for the three evaluations of the acoustic analysis in G1 (n = 21)

 

Acoustic analysis

Pretest

Mid-test

t

Post-test

 

t

Average pitch, Hz

191B53

186B50

0.15

188B50

 

0.88

 

Jitter

1.448B1.20

0.905B0.66

2.27

0.462B0.22

2.86*

Shimmer

1.600B1.98

1.168B1.34

1.02

0.581B1.07

1.94

 

H/N

7.429B3.43

9.158B3.93

–1.44

11.610B4.22

3.80**

* p ! 0.05, significant; ** p ! 0.01, highly significant.

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Table 20. Mean values (BSD) for the three evaluations of the acoustic analysis in the phonasthenia group who received voice therapy (G1, n = 4)

Acoustic analysis

Pretest

Mid-test

t

Post-test

t

Average pitch, Hz

128B7.55

138B9.91

–2.2

132B7.1

–1.0

Jitter

0.500B0.115

0.525B0.150

–1.6

0.425B0.150

4.7**

Shimmer

0.500B0.216

0.425B0.57

4.7**

0.250B0.173

4.1**

H/N

8.90B3.735

10.18B4.168

–3.3**

10.80B4.205

–4.2**

** p ! 0.01, highly significant.

 

Table 21. Mean values (BSD) for the three evaluations of the acoustic analysis in the nodules group who received voice therapy (G1, n = 5)

Acoustic analysis

Pretest

Mid-test

t

Post-test

t

Average pitch, Hz

225B8.4

205B28.2

2.2

221B7.5

1.2

Jitter

2.000B0.73

1.101B0.46

10.5**

0.481B0.22

7.0**

Shimmer

0.900B0.65

1.032B0.75

–2.1

0.280B0.13

3.4**

H/N

7.10B3.70

10.50B5.7

–1.2

15.52B1.0

–8.1**

** p ! 0.01, highly significant.

 

Table 22. Mean values (BSD) for the three evaluations of the acoustic analysis in the immobility group who received voice therapy (G1, n = 4)

Acoustic analysis

Pretest

Mid-test

t

Post-test

t

Average pitch, Hz

210B51.86

2.3B44.86

1.9

193B48.79

3.7**

Jitter

2.375B1.997

1.450B1.179

2.6*

0.475B0.359

3.6**

Shimmer

1.200B0.890

0.725B0.745

3.5**

0.425B0.525

3.7**

H/N

5.775B2.649

8.500B2.726

–4.7**

11.350B3.740

–9.5**

* p ! 0.05, significant; ** p ! 0.01, highly significant.

There was no significant change in the inverse filtering measures in both G1 and G2 between the pretest and mid-test nor between the pretest and post-test values. There was also a nonsignificant difference in improve- ment between G1 and G2 (table 23). The etio-

logic subgroups, however, showed irregular tendencies in improvement (tables 24–27). The hyperfunctional group showed signifi- cant/highly significant improvement in SQ, CQ and SI in the post-test results, while the phonasthenia group showed highly significant

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Table 23. Mean difference (BSD) in improvement between pretest and post-test of the inverse filtering of G1 and G2

Mean difference B SD

t

G1

G2

 

Peak flow, ml/s

19.50B91.47

9.38B79.07

–0.26

Minimum flow, ml/s

24.62B70.90

10.24B49.72

–0.52

OQ

0.07B0.11

0.03B0.13

–0.98

SQ

0.06B0.39

0.07B0.41

0.07

CQ

0.035B0.092

–0.01B0.10

–1.13

SI

–0.018B0.16

–0.002B0.11

0.24

Table 24. Mean values (BSD) for the three evaluations of the inverse filtering in the hyperfunctional group who received voice therapy (G1, n = 7)

Inverse filtering

Pretest

Mid-test

t

Post-test

t

parameters

Peak flow, ml/s

246B61

258B59

–0.78

278B50

–2.53

Minimum flow, ml/s

127B44

129B51

–0.21

132B38

–0.31

OQ

0.82B0.13

0.82B0.17

0.12

0.84B0.08

–0.52

SQ

1.52B0.63

1.23B0.52

2.34*

1.12B0.56

5.53**

CQ

0.35B0.13

0.36B0.17

–1.21

0.39B0.10

–2.86*

SI

0.19B0.17

0.14B0.18

2.81

0.08B0.19

5.99**

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 

Table 25. Mean values (BSD) for the three evaluations of the inverse filtering in the phonasthenia group who received voice therapy (G1, n = 4)

Inverse filtering

Pretest

Mid-test

t

Post-test

t

parameters

Peak flow, ml/s

368B71.41

362B28.30

3.8**

355B80.61

4.3**

Minimum flow, ml/s

152B100.61

138B11.31

2.7*

112B14.85

29.8**

OQ

0.77B0.06

0.76B0.03

0.1

0.72B0.04

11.2**

SQ

1.2B0.15

1.2B0.17

–0.1

1.20B0.06

0.0

CQ

0.35B0.01

0.35B0.04

0.1

0.33B0.03

2.2

SI

0.09B0.06

0.12B0.05

–1.0

0.09B0.03

0.2

* p ! 0.05, significant; ** p ! 0.01, highly significant.

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Table 26. Mean values (BSD) for the three evaluations of the inverse filtering in the nodules group who received voice therapy (G1, n = 5)

Inverse filtering

Pretest

Mid-test

t

Post-test

t

parameters

Peak flow, ml/s

133B7

135B12

–0.71

144B15

–2.8*

Minimum flow, ml/s

91B13

93B7

–0.12

91B10

–0.01

OQ

0.94B0.01

0.93B0.03

0.21

0.81B0.09

3.7**

SQ

1.4B0.62

1.6B0.70

–1.03

1.4B0.50

–0.8

CQ

0.40B0.09

0.38B0.10

0.72

0.37B10.05

1.9

SI

0.14B0.19

0.13B0.15

–0.63

0.14B0.12

–0.08

* p ! 0.05, significant; ** p ! 0.01, highly significant.

 

Table 27. Mean values (BSD) for the three evaluations of the inverse filtering in the immobility group who received voice therapy (G1, n = 4)

Inverse filtering

Pretest

Mid-test

t

Post-test

t

parameters

Peakflow, ml/s

370B152.22

272B72.3

2.4

244B43.05

2.9*

Minimum flow, ml/s

185B137.97

124B81.1

2.1

101B21.52

2.2

OQ

0.94B0.06

0.82B0.08

13.2**

0.76B0.05

21.3**

SQ

1.31B0.55

1.37B0.48

0.9

1.53B0.71

–1.1

CQ

0.43B0.11

0.41B0.09

2.1

0.28B0.06

4.4**

SI

0.10B0.19

0.12B0.17

–1.8

0.31B0.13

–3.4**

* p ! 0.05, significant; ** p ! 0.01, highly significant.

improvement in peak flow, minimum flow, and OQ. The nodules group showed signifi- cant/highly significant improvement only in the peak flow measures and the OQ. The immobility group showed significant/highly significant improvement in peak flow, OQ and CQ and SI. Mid-test values showed sig- nificant/highly significant change in SQ of the hyperfunctional subgroup, peak flow and minimum flow of the phonasthenia subgroup and OQ of the immobility subgroup. In G1, when the difference in improve- ment between pretest and mid-test in all pa-

rameters of assessment was compared to the difference in improvement between mid-test and post-test, no significant difference was found in all measures except for PQ, which showed greater improvement in the pretest to mid-test assessments (fig. 5–7).

Discussion

The efficacy of the AM is tested in this study in a controlled setup that eliminates extraneous independent variables. The thera-

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5

     

6

 
 
5 6 Fig. 5. A representation of the trend of improve- ment of APA of patients’
 
 

Fig. 5. A representation of the trend of improve-

Fig. 5. A representation of the trend of improve-

ment of APA of patients’ voices across the three evalu-

ment of APA of patients’ voices across the three evalu-

ations for the voice therapy group (G1). Fig. 6. A representation for the trend of improve- ment of PQ and Psub across the three evaluations for the voice therapy group (G1). Fig. 7. A representation of the trend of improve- ment of jitter and H/N across the three evaluations for the voice therapy group (G1).

ations for the voice therapy group (G1). Fig. 6. A representation for the trend of improve-

7

py group G1 and the voice hygiene counsel- ing/advice group G2 were comparable in all parameters except that G1 only received the accent exercises. In this event the accent exer- cises were given in a setup that may establish a cause-and-effect relation between the tested technique implemented by the clinician and the changes in the client’s vocal behavior. Withholding the accent exercises did not cause any ethical embarrassment as the pa- tients in G2 were followed up and were being prepared eventually to reveive the accent ex- ercises. This model of a clinical trial aiming at demonstrating the efficacy of the AM is be- lieved to be most suited to a behavior read- justment therapy. The general trend of the final results showed a significant difference in improve-

ment of vocal function parameters in favor of the accent exercises group G1. There are, however, some specific patterns that are dis- cussed under each tested item. Moreover, the difference in improvement between G1 and G2 in the collective patients’ material showed different values in certain parameters when compared to the improvement measured for the various etiologic subgroups separately. The pathophysiologic mechanism in the var- ious etiologic subgroups, namely hyperfunc- tional dysphonia, phonasthenia, nodules, and vocal fold immobility (paralysis), does vary and may even be of opposing directions. In paralysis the glottis shows a tendency to waste while in hyperfunctional dysphonia the glottis is tight. Accordingly, the results of improve- ment in the whole material showed some non-

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significant values while certain of those items became significant (in one or the opposite direction) when computed for the particular subgroups separately (tables 24–27). The difference in improvement between G1 and G2 in patients’ own assessment of subjective improvement of voice shows a greater value, in favor of G1, as compared to the difference in improvement in other quasi- objective measures (table 2). This discrepancy may be due partially to a possibility that the patient’s response to the clinician’s question regarding improvement in vocal complaint may fall under an unavoidable autosuggestion influence from the clinician. The nonsignificance of the difference in improvement in the collective patient materi- al of items B and I in APA assessment may be due to the small number of patients present- ing with these vocal characteristics. On the other hand, the difference in improvement in item B was significant in the etiologic sub- group of vocal fold immobility as most pa- tients presented with a breathy (B) character of voice (tables 3, 4). There has been some improvement in nod- ule size and the paralytic gap in both G1 and G2. The difference in improvement, however, was highly significant in favor of G1 (table 7), indicating the efficacy of the accent exercises in controlling these two morphological defi- cits in vocal pathology. This favorable effect of the accent exercises in G1 is confirmed by the significant positive changes observed only in G1 in stroboscopic findings. The latter may reflect more subtle changes in glottal be- havior. The significant difference in improvement in favor of G1 in the aerodynamic analysis was selective. The improvement in the etio- logic subgroups was detectable already in the mid-test values, and most of the improved items continued to improve in the post-test measures. Few new items showed improve-

ment only in the post-test measures (tables 14–17). The improvement in the dynamic range was more significant than the difference in frequency range, a point that may indicate that the breakdown, and hence the gain in response to therapy, in dynamic range is greater than the frequency range in the types of vocal pathologies investigated in this study. The improvement in PQ, MPT, and MFR in the vocal fold immobility group may reflect an improvement in glottic closure (table 17). The improvement of MFR in the group of nodules may also reflect an improvement of the associated phonatory gap. There was a nonconformity of improve- ment of all the three parameters of acoustic analysis in between the groups (G1 and G2). The etiologic subgroups showed an additional inconsistency of the trend of improvement among the computed parameters of acoustic analysis (tables 20–22). These findings may indicate that the acoustic analysis used in this study are not very sensitive or not highly spe- cific [24]. On the other hand the different parameters of acoustic analysis like jitter and shimmer may correlate with different aspects of the mechanism of breakdown in the vocal function of the etiologic groups investigated in this study [25]. There was no significant improvement in the collective patient material in G1 in the inverse filtering values (table 23). This may be explained by the possibility that the nature of the pathophysiology of the different catego- ries may be in opposite directions, that is, a category may show a tight glottis and another may show glottic waste. However, significant improvements in certain items specific to each etiologic subgroup were detected. Comparison between the initial findings (pretest) and the measures in the mid-test and the end results in post-test measures showed that the improvement followed a more or less linear curve (fig. 5–7). This may indicate that

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the beneficial effects of the accent exercises and the patient’s gain continue smoothly throughout the therapy period of 20 sessions.

Conclusion

The general outcome of this study supports the notion that behavior readjustment thera- peutic procedures are clinically effective in

the management of some human communica- tive disorders. The overall tendency in the results of this clinical trial, with the provided control measures, indicates a positive efficacy of the AM of voice therapy in the manage- ment of the vocal pathologies investigated in this study. Further controlled studies of clini- cal trials using additional experimental mod- els are still needed to test the efficacy of behavior readjustment therapy.

OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

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