Effective Treatments For Hyperfunctional Voice Disorders
By Abigail Shoemaker
Three treatments for hyperfunctional voice disorders are equally effective in producing successful outcomes, a pilot investigation has revealed.
Researchers from three different universities studied the physiological effects and functional outcomes of various treatment methods for 10 patients with hyperfunctional voice disorders and nodules.
Conducting the study were Mark Leddy, PhD, CCC-SLP, of the University of Wisconsin at Whitewater; Robin Samlan, MS, CCC-SLP, of the University of Wisconsin at Madison; and Bruce Poburka, PhD, CCC-SLP, of Mankato State University, Mankato, MN.
Three patients took part in confidential voice treatment, four received resonant voice therapy, and three used the accent method. "All 10 patients reported considerable or maximal gains," reported Dr. Leddy.
The researchers measured patient outcomes using a tool developed by members of the American Speech-Language-Hearing Association Special Interest Division 3 (ASHA SID 3), the Treatment Outcomes in Voice: Client Rating Questionnaire (SID 3 TOV), and the Functional Communication Measure of Voice Disorders (FCMVD) developed by ASHA.
Patients are asked eight of the nine questions on the SID3 TOV scale before treatment, including how bad they perceive their voice to be, how their voice interferes with communication, and whether their voice is distracting to others. After therapy the patients are asked the same eight questions and how much they feel their voice improved.
"All the techniques showed improvements in functional voice use based on the FCMVD," stated Samlan, who researched the accent method.
Patients who took part in confidential, or breathy, voice treatment reported success ratings of 5 or 6 on the SID 3 TOV. Clinicians reported a change of one level on the FCMVD. This facilitating technique features incomplete or light vocal fold closure that reduces transglottal pressure and discourages hard glottal attack.
The technique is particularly effective for nodules or laryngitis. It is not designed to be used as a permanent vocal style, emphasized Dr. Poburka. "The phonatory pattern allows patients to have a voice they can use while tissues heal, but there are limits to the extent they can use it."
After receiving confidential voice therapy, a patient may switch to resonant voice therapy, which uses humming to encourage vibration above the level of the larynx. Patients who received this therapy reported gains similar to the confidential method, but the gains were slightly higher for those with small or pre-nodule conditions. Through resonant voice therapy, Samlan said, a patient develops a fuller, louder sound without expending additional effort.
Stroboscopy images reveal the most dramatic changes in patients with nodules. Prior to treatment vocal folds with nodules have an hourglass closure at primary contact. With therapy the vocal folds close more completely, and contact forces are redistributed.
"The nodules are not taking all the force during the closure," Samlan noted.
Two patients who used the accent method started with a rating of 5 on the FCMVD. One patient did not increase a level, while the other patient progressed to 6 by the end of therapy.
The accent method incorporates rhythmic body movements, sound play, vocal hygiene and abdominal diaphragmatic accentuations to produce an optimal voice, Samlan explained. Treatment goals are to improve pulmonary support for phonation, restore symmetrical vocal fold vibration, and optimize respiratory-laryngeal timing.
This technique is particularly effective for actors, singers and people who are not inhibited by performing exercises many people think are unusual.
The accent method encourages change in vocal behavior through modeling instead of instruction alone. The technique traditionally is done in 20-minute sessions two times a week for about 10 weeks, but it may be successful in less time. Samlan sometimes uses 45-minute or one-hour sessions if patients cannot come to therapy two times a week.
Dr. Leddy cited a need for larger-scale efficacy studies of the three therapy techniques to determine which are the most effective in patient gains and cost.
"There is a clear need to look at the different techniques and outcomes and find out what types of changes we're making in people's health, voice and lives and how quickly we are doing it," said Samlan
Currently, the SID 3 TOV is a pilot version available only to ASHA SID 3 members. The FCMVD is available to all speech-language pathologists through ASHA.
Dr. Leddy cited the need for self-report and other outcomes measures to be made widely available to all speech-language pathologists.
The Voice Handicap Index (VHI), the Weekly Voice Diary and the Voice Lifestyle Questionnaire are among the self-report treatment outcome measures that can be used.
The VHI was developed by Barbara Jacobson, PhD, CCC-SLP, and her colleagues at Henry Ford Hospital, in Detroit, MI. The index (American Journal of Speech-Language Path-ology, in press) consists of three categories--emotional, functional and physical--with 10 questions in each.
"The questions related to function provide clinicians with insight about how effective their treatments are," Dr. Leddy explained. "Treatment efficacy should result in functional outcomes. If what we are doing is efficacious, changes in function should be reflected in these questions."
The Weekly Voice Diary was developed by researchers, speech-language pathologists and students at the National Center for Voice and Speech based at the University of Iowa in Iowa City. The Voice Lifestyle Questionnaire (Journal of Voice, in press) was developed by Elaine Smith, PhD, at the university.
For More Information
Mark Leddy, PhD, Department of Communicative Disorders, University of Wisconsin, Whitewater, WI 53190; (414) 472-5204, or firstname.lastname@example.org
Bruce Poburka, PhD, Mankato State University, Department of Communication Disorders, MSU 77, P.O. Box 8400, Mankato, MN 56002-8400; (507) 389-5843
Robin Samlan, University of Wisconsin Hospital and Clinics, Otolaryngology and Head and Neck Surgery, 600 Highland Ave., Madison, WI 53792-3236; (608) 263-0121