Evaluation Akzentmethode

Main Report W Hauptreferat W Rapport principal
Folia Phoniatr Logop 1998;50:146164

Efficacy of the Accent Method of
Voice Therapy
Samia Bassiouny
Faculty of Medicine, Ain Shams
University, Cairo, Egypt
Dr. Samia Bassiouny
Faculty of Medicine
Ain Shams University
Cairo (Egypt)
Fax +20 2 260 5805
ABC
Fax +41 61 306 12 34
E-Mail karger@karger. ch
www.karger. com
1998 S. Karger AG, Basel
10217762/98/05030146$15.00/0
This article is also accessible online at:
http://BioMedNet.com/karger
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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)
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.
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Die Wirksamkeit der Akzentmethode in der Stimmtherapie
Die Arbeit der Phoniater und Logopden erfordert
vermehrte Untersuchungen betreffend der Wirksam-
keit angewendeter Behandlungstechniken. Diese Stu-
die prft die Wirksamkeit der Akzentmethode in der
funktionellen Stimmrehabilitation. Die Akzentmetho-
de befasst sich mit verschiedenen Stimmelementen
wie Tonhhe, Lautheit und Timbre. Die Daten der
Therapieresultate wurden in kontrollierten Gruppen
erhoben. Bezglich der Versuchsanordnung wurden
zwei randomisierte Gruppen gebildet, nmlich 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, whrend die G2-Gruppe
einmal wchentlich Stimmhygieneberatung erhielt. In
einem Protokoll wurden objektive und halbobjekte Be-
Efficacy of the Accent Method of Voice
Therapy
Folia Phoniatr Logop 1998;50:146164 147
funde eingetragen, wobei der Eingangsstatus fr 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
und G2 ergab statistisch signifikante Unerschiede zu-
gunsten von G1. Dieser Erfolg konnte fr verschiedene
Atiologien nachgewiesen werden. Die Resultate der
Befunde werden diskutiert.
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Efficacit de la mthode de laccent en thrapie vocale
Ltude de lefficacit des mesures thrapeutiques uti-
lises pour la radaptation des troubles de la communi-
cation rencontre un intrt croissant. Des considra-
tions lgales, sociales, scientifiques et professionnelles
incitent une documentation plus prcise des effets
des traitements utiliss par les phoniatres et les logop-
distes. Cette tude value lefficacit de la mthode de
laccent (MA) en thrapie vocale. La MA est une
approche holistique intressant les diffrents param-
tres de la voix (hauteur, intensit et timbre). Des
patients prsentant des problmes vocaux dtiologies
diverses furent diviss en deux groupes randomiss,
lun et lautre recevant des conseils dhygine vocale,
mais un seul tant trait par la MA. Les valuations se
firent 3 stades du traitement. Le groupe ayant bnfi-
ci de la MA montra des amliorations significatives
pour certains aspects spcifiques de diverses varits
tiologiques. Les rsultats sont soumis une tude cri-
tique.
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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
148 Folia Phoniatr Logop 1998;50:146164 Bassiouny
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 clinicians 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 patients 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
Therapy
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 [911]. 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
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) Patients interview, including: (a) the patients
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-
0
Therapy
Table 2. Patients own grading
of severity for the three
evaluations in G1 and G2
Patients own
grading of severity
Pretest
G1 G2
Mid-test
G1 G2
Post-test
G1 G2
Very bad 76% 71% 48% 67% 0% 52%
1 Bad 10% 14% 27% 18% 5% 20%
2 Moderate 10% 15% 10% 15% 5% 18%
3 Good 4% 0% 5% 0% 42% 10%
4 Very good 0% 0% 10% 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).
G
G
Right base Right base
Table 3. Mean (BSD) difference in improvement
between pretest and post-test of the APA in G1 and
G2
APA Mean difference B SD
G1 G2
t
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
(G1)
APA Pretest Mid-test t Post-test t
2.1B0.63 0.9B1.03 6.1** 0.3B0.50 23.7**
S 0 0 0
L 0 0 0
B 2.1B0.63 0.9B1.03 6.1** 0.3B0.50 23.7**
I 0 0 0
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)
Examination Pretest Post-test t
2.04B0.74 0 8.68**
Right rise 0.64B0.60 0 3.36**
Left base 2.22B0.47 0.24B0.54 3.87**
Left rise 0.68B0.57 0.04B0.09 3.36**
Gap 1.08B0.69 0.1B0.08 4.47**
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
1.12B0.47 1.37B1.38 2.08
Right rise 0.18B0.06 0.12B0.09 3.66**
Left base 1.06B0.82 1.57B1.41 3.66**
Left rise 0.37B0.18 0.20B0.16 2.76**
Gap 0.76B0.21 0.54B0.28 3.2*
* p ! 0.05, significant; ** p ! 0.01, highly sig-
nificant.
Right base
Therapy
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.
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
G1 G2
t
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**
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 811). 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).
a
b
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.
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
a
b
Right
Symmetrical
Normal
0
VC, ml
Therapy
Table 8. Percent change in amplitude and mucosal
wave for the three videostroboscopic evaluations of
G1
Amplitude and
wave
Pretest Mid-test Post-test
0 Normal 10% 15% 67%**
1 Small 67% 62% 15%
2 Great 5% 5% 0%*
3 Absent 18% 18% 18%
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 9. Percent change in symmetry for the three
videostroboscopic evaluations in G1
Symmetry Pretest Mid-test Post-test
10% 19% 71%**
Asymmetrical 90% 81% 29%**
Table 10. Percent change in phase closure for the
three videostroboscopic evaluations in G1
Phase closure Pretest Mid-test Post-test
0% 24%* 67%**
Open 67% 48% 24%**
Closed 33% 28% 9%*
Inconsistent 0% 0% 0%
cant.
Table 11. Percent change in phonatory gap for the
three videostroboscopic evaluations in G1
Phonatory gap Pretest Mid-test Post-test
Normal 0 38%* 76%**
1 Anterior 0 0% 0%
2 Posterior 5% 5% 10%
3 Longitudinal 52% 18%* 5%**
4 Fusiform 19% 18% 9%
5 Hourglass 24% 24% 0%
cant.
Table 12. Mean difference
(BSD) in improvement between
pretest and post-test of the
aerodynamics in G1 and G2
G1 G2
t
164.33B711.18 0.17B413.60 0.63
MPT, ms 3.15B5.01 2.18B4.08 0.47
PQ 68.8B267.8 47.8B100.3 0.34
MFR, ml/s 46.67B62.52 31.86B75.25 0.47
F
o
range, Hz 16.76B43.62 7.90B54.11 1.63
SPL range, dB 6.14B8.02 1.24B6.54 3.27**
Psub, mm H
2
O 29.48B21.01 4.14B9.32 4.62**
GE 0.0029B0.0012 0.0005B0.013 6.28**
GR 0.070B0.217 0.084B0.12 2.87**
VC, ml
VC, ml
Table 13. Mean values (BSD) for the three evaluations of the aerodynamics in G1 (n = 21)
Aerodynamics Pretest Mid-test t Post-test t
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)
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
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).
VC, ml
VC, ml
Therapy
Table 15. Mean values (BSD) for the three evaluations of the aerodynamics in the phonasthenia group who
received voice therapy (G1, n = 4)
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
Table 16. Mean values (BSD) for the three evaluations of the aerodynamics in the nodules group who
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
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 2022).
VC, ml
Average pitch, Hz
Average pitch, Hz
Table 17. Mean values (BSD) for the three evaluations of the aerodynamic measures in the immobility group
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
Table 18. Mean difference (BSD) in improvement between pretest
and post-test of the acoustic analysis of G1 and G2
G1 G2
t
3.28B11.75 6.57B28.63 0.33
Jitter 0.985B1.089 0.333B0.700 1.59
Shimmer 1.019B1.657 0.058B0.478 1.95*
H/N 4.181B3.477 0.133B2.988 2.79**
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
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**
Average pitch, Hz
Average pitch, Hz
Average pitch, Hz
Therapy
Table 20. Mean values (BSD) for the three evaluations of the acoustic analysis in the phonasthenia group
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**
Table 21. Mean values (BSD) for the three evaluations of the acoustic analysis in the nodules group who
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**
Table 22. Mean values (BSD) for the three evaluations of the acoustic analysis in the immobility group who
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**
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 2427).
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
Peak flow, ml/s
Peak flow, ml/s
Peak flow, ml/s
Table 23. Mean difference
(BSD) in improvement between
pretest and post-test of the inverse
filtering of G1 and G2
G1 G2
t
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
Inverse filtering
parameters
Pretest Mid-test t Post-test t
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**
Table 25. Mean values (BSD) for the three evaluations of the inverse filtering in the phonasthenia group who
Inverse filtering
parameters
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
Peak flow, ml/s
Peakflow, ml/s
Therapy
Table 26. Mean values (BSD) for the three evaluations of the inverse filtering in the nodules group who
Inverse filtering
parameters
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
Table 27. Mean values (BSD) for the three evaluations of the inverse filtering in the immobility group who
Inverse filtering
parameters
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**
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. 57).
Discussion
The efficacy of the AM is tested in this
study in a controlled setup that eliminates
extraneous independent variables. The thera-
L
L
L
L
Fig. 5. A representation of the trend of improve-
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).
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 clients 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-
5 6
7
Therapy
significant values while certain of those items
became significant (in one or the opposite
direction) when computed for the particular
subgroups separately (tables 2427).
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
patients response to the clinicians 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
1417). 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 2022). 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. 57). This may indicate that
the beneficial effects of the accent exercises
and the patients 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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