European Journal of Disorders of Communication, 27, 137-158 (1992) 0 The College of Speech and Language Therapists, London

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An evaluation study of voice therapy in non-organic dysphonia Paul N. Carding Department of Speech Therapy, Ear, Nose and Throat Department, Freeman Hospital, Newcastle upon Tyne, U K

lrmgarde A. Horsley Department of Speech, University of Newcastle upon Tyne, UK

ABSTRACTS Thirty patients diagnosed as suffering from non-organic dysphonia were assigned to one of three treatment groups: direct therapy, indirect and no treatment for a period of 8 weeks. Therapeutic outcome was evaluated by independent judges, patient self-evaluation, electrolaryngograph ratings and measures of fundamental frequency. The direct treatment group showed the most significant improvement in the return to normal voice functioning followed by the indirect treatment group. One patient in the control group showed improvement without any intervention. This study provides evidence in support of the effectiveness of both direct and indirect therapy in the treatment of non-organic dysphonia and raises questions concerning individual patient responses to these approaches. Trente patients diagnostique's comme souffrant de dysphonie non-organique ont tte re'partis en trois groupes de traitement pendant une pe'riode de huit semaines: therapie directe, the'rapie indirecte et absence de soins. L'effet du traitement a e'te tvaluk par des juges skpare's, par l'auto-kvaluation des patients, par des examens par klectrolaryngographe et par des mesures de fre'quence fondamentale. C'est au sein du groupe soumis a la therapie directe que se sont re'vtle's les progres les plus significatijs vers un retour au fonctionnement normal de la voix, suivi par le groupe de thkrapie indirecte. I1 n'y a eu qu'un patient du groupe de contrble (absence de soins) chez qui s'est re'vklke une amklioration. Les rtsultats de cette e'tude renforcent l'hypothese de l'efficacitt des thkrapies directe et indirecte dans le traitement de la dysphonie non-organique, et remettent en question les attitudes individuelles des patients face a ces styles de traitement. Dreissig Patienten mit einer nicht-organischen Dysphonie sind wahrend 8 Wochen in drei Behandlungsgruppen aufgeteilt worden: direkte Therapie, indirekte Therapie, keine Therapie. Die therapeutischen Ergebnisse sind von unparteiischen Horern bewertet worden, durch Selbstbewertung und durch elektrolaryngographische Analysen und Messungen der Grundfrequenz. Die signifikanteste Verbesserung in Richtung der normalen Stimme zeigte die Gruppe mit direkter Therapie, gefolgt von der Gruppe mit indirekter Therapie. Ein Patient in der Gruppe ohne Therapie hatte eine Verbesserung gezeigt. Diese Studie beweist die Wirksamkeit sowohl der direkten als auch der indirekten Therapie in der Behandlung der nicht-organischen Dysphonie, und erhebt Fragen beziiglich Reaktionen einzelner Patienten auf diese therapeutischen Einsatze.

Key words: efficacy, dysphonia, treatment, ENT.

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INTRODUCTION

A considerable number of treatment strategies for the dysphonic patient have been reported in the literature. These therapeutic approaches may conveniently be divided into two broad categories: indirect and direct therapy. Indirect therapy represents all patient management strategies involved in the patient’s understanding of factors involved in the voice disorder and methods aimed at assisting the management of these, but not involving direct work on voice production. Direct therapy involves specific concentration on vocal rehabilitation exercises which are aimed to promote appropriate and efficient voice production. Direct therapy would also naturally include elements of the indirect approach. Just how these two broad categories of approaches are utilised by the individual therapist is a matter of that clinician’s judgement. Mathieson (1989) states that voice therapy is demonstrably effective for a large number of individuals with voice pathology and whilst clinical experience might support this claim, there is little experimental evidence to corroborate it. There are, however, several single-case studies (MacIntyre, 1981; Horsley, 1982; Ranford, 1982; Butcher & Elias, 1983) which serve as examples of evaluation of specific treatment techniques for an individual patient. As Howard (1986) points out, such single-case designs are valuable in furthering investigations into whether a particular treatment technique is equally effective with other patients with problems of a similar type. However, few replications of these studies have been reported. Hillman, Delassus Gress, Hargrave, Walsh and Bunting (1990) provide the most recent literature survey of efficacy of treatment of voice disorders. They conclude that, not only were there very few studies to evaluate, but that most of the results were of limited usefulness due to basic shortcomings in the research designs. Their conclusions mirror those made by Reid (1980) a decade ago, when he pointed out that there was little research evidence to substantiate claims that proposed voice therapy rationales and techniques caused specific changes in vocal function and therefore improved results in terms of auditory evaluation. Both authors acknowledge that the study of treatment effects relies upon well-defined terms of reference and accepted measurement techniques. The fact that these fundamental research tools are not well developed in the field of voice therapy no doubt accounts for the relative absence of such studies. There are some studies that rely upon retrospective analysis of trends in voice-disordered patients. Such a review of 109 ‘functional dysphonia’ patients by Bridger and Epstein (1983) concluded that only 56% of patients participating in a programme of voice therapy were ultimately considered to be ‘cured’. Another study by Koufman and Blalock (1982) reported a 100% success with 15 ‘habitually hoarse’ patients and only 56% success with similar numbers of ‘voice abusers’. These studies do not describe either their assessment criteria or information about the therapy techniques involved. Although the results of these kinds of studies tend to support the effectiveness of voice therapy in the treatment of dysphonia, they do not provide substantial evidence of the efficacy of intervention because of the absence of baseline assessments and control comparisons. Prospective studies are few. Drudge and Phillips (1976) attempted to provide a model form of voice therapy for the dysphonic patient but the emphasis

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was not on proving the effectiveness of the intervention so much as describing the learning process involved in shaping the changed behaviour pattern. They reported successful treatment of all three patients and recommended larger, replicative studies with comparative data and control groups. Another study by Andrews, Warner and Stewart (1986) compared EMG biofeedback and relaxation techniques with five matched pairs of patients diagnosed as having ‘hyperfunctional dysphonia’. They reported no significant difference in treatment effects. The problem of evaluating the efficacy of therapy in speech and language disorders is not restricted to dysphonia. Schoonen (1991), considering the internal validity of efficacy studies of language therapy for aphasic patients, concluded that ‘stronger research designs with better control of treatments and larger random samples, divided randomly into a control and an experimental group, are necessary’ if ambiguous outcomes are to be avoided. This is echoed in the advice given by Hillman et al. (1990) on designing evaluation studies in dysphonia. He recommends the employment of clearly defined treatment aims, well-documented treatment procedures and a study design which enables either closely matched control groups or non-treatment baseline conditions from which treatment effects can be compared. The present study attempted to incorporate this advice when examining some currently advocated therapeutic techniques with a group of patients diagnosed as having a nonorganic dysphonia. Because of the lack of agreed terminology, it was necessary to adopt a working definition of non-organic dysphonia (see Method) which allowed several exclusions and inclusions for the purpose of this study. There were three groups of patients: one group received a combination of approaches which fell mainly under the heading of direct therapy; another group received a combination of indirect therapy approaches; the third group was assessed initially and then reassessed 8 weeks later but did not receive any intervening treatment. This latter group served as a control group, albeit temporarily (for a maximum of 8 weeks). The study was carried out under ordinary clinical conditions in order to reflect general current clinical practice. The patients in the temporary control group might be considered as patients on a waiting list. It was hypothesised that the direct therapy group would show more improvement than the indirect therapy group and that both these groups would show more improvement than the no-treatment control group. METHOD Subjects

The study sample consisted of 30 dysphonic patients who were referred to the Speech and Language Therapy Clinic by the staff otolaryngologists of a large regional hospital. All patients were diagnosed as suffering from non-organic dysphonia. For the purpose of this study, non-organic dysphonia refers to disordered voice when under one of the following conditions:

1. Direct and/or indirect laryngoscopy revealed no apparent significant organic impairment in terms of laryngeal structure or function (diagnosed by a laryngologist) .

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2. Direct and/or indirect laryngoscopy revealed minor laryngeal pathology which was attributed to excessive voice use and abuse (Van Thal, 1961) and where no surgical intervention was deemed appropriate. Thus, minor laryngeal pathologies, such as minor oedema, tissue irritation and dysphonia plica ventricularis, were included. 3. Fibreoptic nasoendoscopy revealed laryngeal ‘movement’ pathology, i .e. where the disordered voice was caused by inappropriate laryngeal coordination or activity. Table 1: Composition of patient groups.

Age (years)

Degree of severity

Patient

sex

Treatment group 1* E.T. P.W. G.G. B.R. L.L. L.M. C.B. J.G. J.O. C.C.

Female Female Female Female Female Female Female Male Male Female

59 33 22 36 25 51 23 68 41 28

Severe Severe Moderate Moderate Severe Moderate Moderate Moderate Moderate Severe

Treatment group 2t I.W. D.S. J.H. V.S. R.R. I.T. A.L. P.T. A.F. I.B.

Female Female Male Female Female Female Female Female Female Male

47 58 67 50 37 76 18 48 27 71

Moderate Moderate Severe Severe Severe Severe Severe Moderate Moderate Severe

Treatment group 3$ G.L. A.M. D.M. M.M. L.R. P.W. I.C. J.I. S.B. D.A.

Male Female Female Female Male Female Female Male Female Female

56 39 40 75 69 33 20 28 65 18

Severe Moderate Moderate Moderate Moderate Severe Moderate Severe Severe Severe

* Mean age = 38.8 years (range 22-68 years); mean onset time of dysphonia = 17 weeks (range 5-42 weeks). t Mean age = 50.1 years (range 18-76 years); mean onset time of dysphonia = 24 weeks (range 6-52 weeks). $ Mean age = 44.3 years (range 18-75 years); mean onset time of dysphonia = 29 weeks (range 5-52 weeks).

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Once their diagnosis had been confirmed, patients had to fulfil several other criteria in order to be included in the study. These include the following: 1. All patients presented with a perceptible dysphonia. 2. All patients presented within 12 months of the onset of their dysphonia. Patients were excluded from the study if they reported any of the following: 1. Excessive cigarette or alcohol consumption. 2. A history of any psychosomatic conditions or a positive psychiatric history. 3. Professional use of voice (i.e. singers, actors). These patients were treated immediatelv. Exposure to previous speech and language therapy; no apparent motivation to change (i.e. expression of no interest in participating) ; inability to attend regular sessions (i.e. unable to arrange time off from work); severe hearing loss. Of the total of 30 patients who participated in the study 7 were male and 23 were female.

PATIENT SELECTION CRITERIA

Figure 1: Study design.

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Treatment Groups

The subjects were allocated in rotation to one of three possible treatment groups (T1 , T2 and T3). All patients agreed to enter the study for a minimum period of 8 weeks. Patients in T1 attended their assessment appointments and received no treatment until 8 weeks had elapsed. Patients in T2 attended for assessments and received a combination of indirect treatments as deemed most suitable for each individual patient. Patients in T3 received direct treatment which was tailored to their individual symptoms as well as any necessary indirect approaches. The distribution of patients across treatment groups is shown in Table 1. All patients were informed of the nature of the study and could decline participation if they so wished. Only one patient, in fact, declined to enter into the study and he was subsequently offered treatment outside of the project. Study Design

The study design is represented in Figure 1. Equipment

Patients’ voices were recorded in a sound-proof room using a stereo tape deck (Phillips FC150) and lapel microphone (Sony ECM 144). Each recording consisted of [i] and [a] vowel utterances at mid, low and high pitch levels, rote speech (counting 1 to 10, days of the week) and a read speech sample (Fairbanks, 1960). Electrolaryngograph (Laryngograph) traces were taken from each patient using the principles and techniques of application suggested by Abberton, Fourcin and Howard (1989). A reasonable Lx trace was obtainable from all patients. A representative sample of a typical [i] vowel utterance (at midpitch) was recorded and analysed. Mean speaking fundamental frequency (mean SFo) was also measured from the reading of the ‘Rainbow Passage’. A histogram and mean frequency value were calculated using the extended Laryngograph software (Abberton et al., 1989). First-order Dx means were used and it is recognised that this may involve contamination of the signal with some high frequency ‘noise’. Assessments

Each patient was fully assessed prior to treatment using a battery of subjective and objective assessment techniques as listed below. Voice severity rating scale The Buffalo I11 Voice Profile (Wilson, 1987) was used to evaluate the patient’s voice quality perceptually. This profile requires the clinician to rate (1 = normal to 5 = very severe) 10 aspects of voice quality including laryngeal tone (‘breathiness’, ‘harshness’ etc.), pitch and various aspects of oral and nasal resonance. A more detailed description of the profile’s administration is found in the original Wilson text. A random selection of 20 tapes was played to a panel of three speech and language therapists who had experience of voice disorders. Their judgement ratings correlated significantly with the

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first author’s own judgements (Kendall’s Coefficient of Concordance, W = 0.759 and P < 0.01). As a result of this degree of agreement, all of the other tape samples were evaluated by the first author alone. Patient questionnaire of vocal performance A questionnaire was designed using a rating scale answer format. This enabled the patients to consider aspects of their own vocal performance (see Appendix). The range of possible total scores was 12 (normal voice functioning as perceived by the patient) to 60 (severely limited voice functioning). A total severity score was calculated for each patient. The questionnaire was administered formally with no discussion of possible answers allowed. A trial reliability study was analysed from a small sample of ten respondents. These dysphonic subjects completed the questionnaire on several occasions. Erratically answered questions were rejected or altered until a high level of answer response reliability could be expected (calculated at 0.95 Crombach’s a). Indirectldirect laryngoscopy The laryngologist’s comments following laryngoscopy were recorded in the appropriate clinical notes. Access to medical notes was always available as was discussion with the appropriate laryngologist if this seemed necessary. Electrolaryngography A clear Lx signal for each patient was printed out and stored in the record notes. A random sample of 20 Lx traces was scored by the same panel of speech and language therapists who made the perceptual judgements. The judgements were based upon expected visual norms as described by Reed (1982) and were rated on a scale of &5 with 0 representing normal and 5 representing a very abnormal Lx trace. These ratings were correlated with the author’s own scores (Kendall’s Coefficient of Concordance W = 0.83, P < 0.001). Subsequently all other Lx traces were rated by the first author alone. Fundamental frequency analysis The mean speaking fundamental frequency results were compared to expected normal mean SFo ranges (Saxman & Burk, 1967; Horii, 1975). Abnormal mean SFo scores were noted. Treatment Success

The criteria set for success of therapy is listed below:

1. The voice should sound within the normal quality range. 2. Objective measures should reveal no abnormal characteristics. 3. The patient should report normal voice usage. 4. There should be an absence of vocal strain, tension or unwanted variability. All therapeutic interventions were recorded in detail in the clinical notes. The same therapist (the first author) was involved in all patient contact and treatment. It was ensured that patients from T2 and T3 groups were given the same amount of patient-therapist contact time. Each individual from these groups agreed to attend for a course of eight therapy sessions. Patients from

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Treatment techniques.

Indirect treatment techniques

1. Vocal rest programme (Prater & Swift, 1984) 2. Patient education (Aronson, 1985) Explanation of the problem (Olsen, 1972) 3. Reassurance (Greene & Mathieson, 1989) 4. Counselling (Aronson, 1985; Brumfit, 1986) Non-directive counselling (Rogers, 1981) 5. Elimination of abuse-misuse (Boone, 1982; Johnson, 1985) 6. Voice abuse diary (data frequency collection) (Prater & Swift, 1984) 7. Vocal hygiene programme (Wilson, 1987) 8. A 10 step outline for voice abuse (Wilson, 1987) 9. Avoidance of laryngeal irritants (Greene & Mathieson, 1989) 10. Environmental awareness (Prater & Swift, 1984) 1 1 . Voice conservation advice (Green & Mathieson, 1989) 12. Hierarchy analysis (Boone, 1983, adapted from Wople, 1973) Direct treatment techniques 1. Auditory training (Fawcus, 1986)

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

15.

Ear training (Boone, 1983) Specific relaxation (Jacobsen 1934; Martin, 1987) Yawn-sigh method (Boone, 1982) Chewing technique (Froeschels, 1952) Altering tongue position (Fisher, 1975; Boone, 1983) Diaphragmatic breathing (Greene, 1980; Martin, 1987) Coordination of breathing with phonation (Martin, 1987) Establishing and maintaining appropriate laryngeal tone Pitch variation and control Reduction of vocal loudness (Prater & Swift, 1984) Elimination of hard glottal attack (Moncur & Brackett, 1974; Voice Monitor, 1977; Martin, 1987) Establishing optimal pitch (Cooper, 1973, Boone, 1983) Voice ‘placing’ (Perkins, 1981; Boone, 1983) Developing optimum resonance (Zaliouk, 1963; Fawcus, 1986) Maintenance and generalisation of optimal phonatory control

group T1 were seen for initial, post and review sessions only as they were acting as a control group. The range of indirect and direct therapy techniques utilised is listed in Table 2. The particular choice of treatments, specific emphasis and duration at any stage of therapy were adapted to meet individual needs.

RESULTS

The results are presented first for the Buffalo Voice Profile scores, secondly for self-perception questionnaire scores and finally for the Laryngograph and fundamental frequency analysis measurements. Statistical analyses for each assessment technique are presented separately.

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Buffalo Voice Profile (Perceptual Rating)

The results for all treatment groups at pre-treatment, post-treatment and review stages are presented in Table 3. The final column for each group represents the measure of difference between the pre- and review scores (prereview). Figure 2 represents the difference scores (pre-review) for each group. Figure 3 shows the mean improvements. Table 3: Buffalo Voice Profile (rating scores at all stages of assessment). *

Treatment 1

Treatment 2

Treatment 3

Patient Pre- Post- Review Diff

Patient Pre- Post- Review Diff

Patient Pre- Post- Review Diff

E.T. P.W. G.G. B.R. L.L. L.M. C.B. J.G. J.O. C.C.

I.W. D.S. J.H. V.S. R.R. I.T. A.L. P.T. A.F. I.B.

40 34 30 32 41 33 26 24 32 34

42 27 30 36 39 34 30 25 38 11

40 33 23 32 41 33 30 24 38 10

x

33 31 30 Mean difference = 2.1

0 1 7 0 0 0 -4 0 -6 24

26 29 37 36 40 43 41 25 38 47

16 18 37 11 21 12 39 16 35 46

15 16 36 10 12 11 38 16 36 47

x

36 25 23 Mean difference = 12.5

11 13 1 26 28 32 3 9 2 0

G.L. A.M. D.M. M.M. L.R. P.W. I.C. J.I. S.B. D.A.

33 30 31 23 32 39 32 48 34 37

x

23 13 13 13 11 20 15 44 10 20

34 18 Mean difference

10 11 11 12 11 11 10 44 10 17

23 19 20 11 21 28 22 4 24 20 -

15 19.2

=

The ‘Diff’ column represents the difference between the pre-assessment and the review scores. * Score range 43-10. 35

1

30

25

20 15

10

5

0 -5 T2

T3

-10

Figure 2: Buffalo Voice Profile: difference scores (pre-assessment to review).

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40

.

---. ----___---_

0 '

Pre

Post

Review

Figure 3: Mean group improvements (pre-assessment to review). & T1; -C---I--T3.

T2;

The comparison between the three sets of results was analysed by the Kruskal-Wallis one-way analysis of variance. Non-parametric statistical analysis was used to avoid the assumptions concerning normality and homogeneity of variance. There was no statistically significant difference between the three groups at the pre-treatment stage. However, there was a statistically significant difference between the groups at both the post-treatment and the review stage (Kruskal-Wallis, H = 6.14 (after correction for ties), P < 0.05). As can be seen from Figures 2 and 3, the largest difference is between T1 and T3. Self-perception Questionnaire of Voice Severity

The results for all treatment groups at pre-treatment, post-treatment and review stages are represented in Table 4. Figure 4 represents the difference scores (pre-review) for each group showing all individual improvements. Figure 5 shows the mean improvements (mean pre-review). The comparison between the three sets of results was analysed by KruskalWallis one-way analysis of variance. There was no statistical difference between the three groups at the pre-treatment stage. However, there was a statistically significant difference between the groups at the review stage (Kruskal-Wallis: H = 7.42 (after correction for ties), P < 0.05). Figures 4 and 5 indicate that the largest difference is between T1 and T3.

VOICE THERAPY IN NON-ORGANIC DYSPHONIA Table 4:

147

Self-perception questionnaire (rating scores at all stages of assessment).

Treatment 1

Treatment 2

Treatment 3

Patient Pre- Post- Review Diff

Patient Pre- Post- Review Diff

Patient Pre- Post- Review Diff

E.T. P.W. G.G. B.R. L.L. L.M. C.B. J.G. J.O. C.C.

48 45 33 37 38 35 34 37 38 52

44 35 34 34 44 38 36 37 39 14

23 43 33 38 38 39 37 36 38 14

I.W. D.S. J.H. V.S. R.R. I.T. A.L. P.T. A.F. I.B.

25 2 0 -1

0 -4 -3 1

0 38

32 28 50 37 54 45 36 51 31 50

26 19 51 16 21 21 37 41 44 48

18 12 49 17 14 I6 38 24 41 49

14 16 1

20 40 29 -2 27 -10 1

G.L. 41 A.M. 34 D.M. 59 M.M. 40 L.R. 40 P.W. 29 52 I.C. 54 J.I. S . B . 30 D . A . 38

17 14 15

14 15 16 25 52 16 19

~

x

39 35 Mean difference

x

41 32 Mean difference

33 = 5.4

27 = 13.6

16

12 14 13 12 16

23 54 15 16 ~~

x

41 20 19 Mean difference = 22.6

The ‘Diff’ column represents the difference between the pre-assessment and the review scores. Score range 60-12.

45 40 35 30 25 20 15 10 5

0 -5 -10 T1

T2

T3

Figure 4: Self-perceptionquestionnaire: difference scores (pre-assessment to review).

25 22 45 27 28 13 29 0 15

22

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Post

Pre

Review

Self-perceptionquestionnaire: mean improvemenfs (pre-assessment to review). & T1; -0- T2; ---I--T3.

Table 5: Latyngograph ratings (rating scores at all stages of assessment).

Treatment 1

Treatment 2

Patient Pre- Post- Review Diff

Patient Pre- Post- Review Diff

~

E.T. P.W. G.G. B.R. L.L. L.M. C.B. J.G. J.O. C.C.

5 3 4 4 5 1 4 1 5 5

5 4 2 4 5 3 4 2 3 0

5

4 2 5 5 2 4 1 3 0

3.5 3.2 3.1 Mean difference = 0.60

.t

~~

0 -1 2 -1 0 -1 0 0 2

5

Treatment 3

I.W. D.S. J.H. V.S. R.R. I.T. A.L. P.T. A.F. I.B.

~

4 4 5 5 3 5 5 5 5 5

3 2 1 0

1 1 5 2 5 5

1 1

5 0 0 0 5 0 5 5

4.6 2.5 2.2 Mean difference = 2.4

f

Patient Pre- Post- Review Diff ~

3 3 0 5 3 5 0 5 0 0

~~

G.L. A.M. D.M. M.M.

L.R. P.W. I.C. J.I. S.B. D.A.

2 5 3 5 3 5 3 5 5 3

0 0 1 0 0 1 0 4 1 0

0 0 0 1 0 0 0 5 0 0

x

3.9 0.7 0.6 Mean difference = 3.3

The ‘Diff’ column represents the difference between the pre-assessment and the review scores. Score range CL5.

2 5 3 4 3 5 3 0 5 3

VOICE THERAPY IN NON-ORGANIC DYSPHONIA

(4

149 - 50%

-0

Time (20.1 ms)

- 50%

Time (20.1 rns)

- 50% - 50%

-0

Time (20.1 ms)

- 50% - 50%

-0

Time (20.1 rns)

- 50%

Figure 6: Examples of Lx traces pre- and post-treatment: (a) 64-year-old male pre-treatment; (b) 64-year-old male post-treatment; (c) 22-year-old female pre-treatment; (d) 22-year-old female post-treatment.

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Table 6 : Mean speaking fundamental frequency. Pre-treatment (in Hz)

Post-treatment (in Hz)

Review (in Hz)

Treatment group 1 E.T. (F) 59 P.W. (F) 33 G.G. (F) 22 B.R. (F) 36 L.L. (F) 25 L.M. (F) 51 C.B. (F) 23 68 J.G. (M) J.O. (M) 41 C.C. (F) 28

292* 253* 156* 553* 238 147* 307* 72* 87 284*

323* 258* 148* 603* 220 225 277* 87 137 230

330* 263* 160* 468* 191 177 347* 1I 8 91 208

Treatment group 2 I.W. (F) 47 D.S. (F) 58 J.H. (M) 67 V.S. (F) 50 R.R. (F) 37 I.T. (F) 76 18 A.L. (F) P.T. (F) 48 A.F. (F) 27 I.B. (M) 71

267 237 212" 413* 576* 399* 232 175 291 * 174*

162 225 124 246 261 * 228 304* 196 278* 182%

240 220 261 * 218 244 228 317* 192 284* 191*

Treatment group 3 G.L. (M) 56 A.M. (F) 39 D.M. (F) 40 M.M. (F) 75 L.R. (M) 69 P.W. (F) 33 I.C. (F) 20 28 J.I. (M) S.B. (F) 65 D.A. (F) 18

364* 210 351* 242 56* 324* 331* 331* 273* 303*

244* 207 254 228 89 217 235 364* 218 118

156 212 232 238 97 210 220 298* 235 120

Patient (Sex)

Age (years)

~~

* Denotes the mean SFo is outside the normal range (Baken, 1987).

Electrolaryngograph and Fundamental Frequency Analysis 1 . The Lx rating results are presented in Table 5. Two examples of before

and after treatment Lx traces are shown in Figure 6. 2. The mean fundamental frequency measures are presented in Table 6. The Laryngograph and pitch analysis data both suggest similar trends to those shown by the Buffalo Voice Profile and the self-perception questionnaire. Correlation of Buffalo Ill and Questionnaire Results

The Kendall Test of Correlation was applied to the review scores of both the Wilson Profile and the self-perception questionnaire. The correlation was S = 272, P > 0.01. This confirmed that the scores of both assessments were highly correlated and that both assessment techniques appeared to be measuring the same trend of change across all subjects.

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DISCUSSION

The results of this study provide evidence that voice therapy is effective in the treatment of non-organic dysphonia. Patients who were assigned to direct voice therapy intervention (T3) showed the greatest degree of improvement from their pretreatment state. Nine out of ten of these patients displayed normal voice functioning following treatment. This may be compared to the no-treatment patient group (Tl) where nine out of ten showed no improvement. Group T2 showed an interesting intermediate pattern of response as six patients improved and four remained dysphonic. These findings are discussed below. lndividualised Treatments: Typical Therapy Programmes

Each treatment programme was of necessity different in order to meet the needs of each individual client. The particular choice of techniques, their order and the length of time spent at each stage were dependent on the nature of the patient’s dysphonia and the patient’s response to any particular treatment strategy. Examples of individual therapy programmes for the two treatment groups are as follows. T2 indirect treatment I.W. received a typical programme of indirect therapy. The first two sessions concentrated on providing information about the nature of her particular voice problem. This included an explanation of normal vocal function and how her current voice production differed from this. Explanation was aided by diagrams, use of a model larynx and information sheets. Care was taken to incorporate advice on conservation of her existing voice at all relevant times. As I.W.’s understanding of her problem increased it became possible to provide a session devoted to more specific reassurance and counselling. I.W. was able to discuss many of the demands in her life and how they might be contributing to her voice problem. This principle of treatment followed through the whole therapeutic programme. Therapy then proceeded to develop her awareness of her vocal abuses and misuses in her working and domestic environment. The rest of the treatment programme concentrated on providing I.W. with a method to monitor the abuses/misuses which she was able to identify. This was mainly achieved by asking her to keep a vocal diary which required detailed entries at regular intervals throughout the day. This procedure was successful in emphasising the demands she was constantly placing on her own voice, and consequently she was able to eliminate many aspects of persistent abuse. I.W.’s programme is summarised in Table 7.

T3 direct treatment D.M. was involved in a direct therapy programme. Treatment began with the therapist fully explaining the nature of her problems and how her voice deviated from healthy phonation. As with I.W.’s programme, environmental irritants and obvious vocal abuse factors (i.e. coughing, shouting etc.) were discussed and appropriate management and advice was given. This was followed by an auditory training programme which enabled further explanation of D.M.’s specific vocal problems. Auditory training also provided identification of aspects of her phonatory behaviour which required modification by

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Table 7 : Example treatment programmes. I.W.’s indirect therapy

D.M.’s direct therapy

Session (average = 45 min) 1 . Patient education (Aronson, 1985) and explanation (Olsen, 1972) 2. Voice conservation (Greene & Mathieson, 1989)

Session (average = 45 min) 1. Patient education (Aronson, 1985)

3. Reassurance (Greene & Mathieson, 1989) Counselling (Brumfit, 1986) 4. Elimination of vocal abuse (Boone, 1982;

5. Environmental awareness (Greene & Mathieson, 1989) 6. Vocal hygiene programme (Wilson, 1987) 7. Vocal diary (Prater & Swift, 1984) 8.

2. Elimination of vocal abuse (Boone, 1982; Wilson, 1987) Environmental awareness (Greene & Mathieson, 1989) 3 . Reassurance (Greene & Mathieson, 1989) Auditory training (Boone, 1982; Fawcus, 1986) 4. Specific relaxation (Martin, 1987) Breathing for voice (Martin, 1987; Greene & Mathieson, 1989) 5. Appropriate laryngeal tone Hard glottal attack (Boone, 1982) 6. Pitch and volume variation 7. Optimal resonance (Perkins, 1981; Fawcus, 1986) 8. Maintenance/generalisation

direct treatment. Specific work to change her phonatory patterns began with relaxation of the head/neck/shoulders area. The aim was to increase her awareness of muscle tension and how this affected her laryngeal muscular performance. Relaxed and ‘easy’ breathing for speech was also practised (D.M. typically used strained and clavicular breath support for speech). Throughout the rest of the therapy programme each session would frequently begin with these preparatory exercises. Once the neck musculature was relaxed and the breathing well coordinated, therapy moved on to making ‘easy’ phonation. Any attempts at phonation had to be with minimal effort and with a controlled expiratory airflow. This was achieved by progressing from prolonged voiceless sounds to their voiced counterparts (i.e. from a prolonged [s] to [z] or [f] to [v]). The juxtaposition of the voiceless/voiced sounds served to emphasise the relative ease of phonation compared to her original dysphonic voice. The model of relaxed phonation was then refined by eliminating any unnecessary hard attack. This ideal mode of phonation was constantly reinforced and compared to the original dysphonic voice. Once D.M. was able to produce this satisfactory phonation at will, the programme progressed to introducing the variables of pitch and volume while maintaining this newly established voice control. Work quickly developed into humming and chanting of phrases with constant modification of any aspects which encouraged any dysphonic sound. As D.M.’s voice improved, vocal exercises concentrated more upon the development of appropriate natural resonance using tactile feedback. At all stages of treatment D.M. was encouraged to generalise her knowledge from the vocal exercises into everyday voice usage. As the programme continued, she became increasingly aware of the deviancy of her voice production and began consciously to adapt and monitor her own phonatory behaviour. D.M.’s therapy programme is also summarised in Table 7.

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Group T I (No Treatment) Patient C.C. C.C. represents the only patient in this group who improved significantly. At her reassessment appointment her voice was scored within normal limits on all of the criteria. This situation was completely maintained in her review assessments. She explained that her voice had spontaneously recovered over a period of 7 or 8 days following her initial speech and language therapy and ENT appointment. Spontaneous recovery is not uncommon and has been reported before (Aronson, 1985). It is most likely to occur where there is a large anxiety component in the dysphonia. In such cases spontaneous recovery is likely to be rapid. C.C. was the only subject in all three treatment groups who reported this spontaneous effect.

Patient E.T. (Tl) E.T.’s review scores are of particular interest. It is apparent that E.T. perceived her voice to have improved considerably in her self-questionnaire ratings. This change is not supported by any of the other assessments. The scores on her Buffalo Voice Profile were rated as equally dysphonic at all assessment stages. There are several possible explanations for E.T.’s response and one possibility is her expectation that her voice would improve as a result of attending a voice clinic even though she only attended for assessment sessions. Another explanation is that she adapted to her own dysphonic state over time. Alternatively, it may be a strategy to avoid engaging in a therapy programme. Group T2 (Indirect Treatment)

Six out of ten of those patients receiving indirect therapy showed a return to normal voice functioning and four did not. There were several common identifiable factors in those patients who were successful. The first was their ability to offer information about their lifestyles and personal stresses and pressures. The second was that each of them accepted that these factors might have a negative influence on their vocal functioning. The third was that they responded positively during the discussion about management of these contributing factors. By contrast, those patients who did not show improvement found it difficult to identify sources of stress and therefore did not accept these as possible influences on vocal performance. As a result, they were not amenable to suggestions of management. Whether or not these factors were important in their vocal dysfunction is uncertain. However, it is clear that the reasons for differences in response would lie mainly with the individual patient’s conception of the difficulty and probably their habitual modes of dealing with problems. Not everyone has the ability or willingness to introspect and examine aspects of their lives and discuss them openly. This observation suggests that initial approaches with a patient might profitably examine this aspect. Those individuals who were unresponsive or seemed resistant would receive direct therapy approaches where the focus was more tangibly placed upon correction of inappropriate phonatory behaviour. This would not necessarily rule out the use of indirect

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work subsequently. Those patients in the study who did not respond to indirect therapy are currently receiving a course of direct vocal rehabilitation. Group T3 (Direct Treatment) Patient J.I. (T3) J.I. was the only patient in treatment group 3 who did not improve. All assessment scores indicated no change in his voice quality. Direct therapy management succeeded in enabling J. I. to produce reasonably gentle phonation on a wide variety of isolated tasks. These had been expanded, with limited success, into varying pitch, volume and extended phonation duration. Any attempts to generalise this more appropriate voicing manner were unsuccessful. J.I.’s conversational voice remained consistently dysphonic throughout the treatment period. It was noted by Butcher, Elias, Raven, Yeatman and Littlejohns (1987) that a small proportion of patients with non-organic dysphonia did not respond to speech and language therapy intervention. They suggested that deep-seated ‘psychogenic’ dysphonia requires a joint therapeutic approach involving a clinical psychologist. The employment of cognitive-behavioural therapy is often recommended (Elias, Raven, Littlejohns & Butcher, 1989). At present J.I. is engaged in such a treatment programme. Assessment and Evaluation Considerations

The evaluation of dysphonic change relied upon the Buffalo auditory ratings and the patient questionnaire scorings. Full assessment also included instrumental measurement, and these more objective results offered some confirmation of the perceptual and subjective ratings. The emphasis on auditory and perceptual ratings highlights the clinical value of trained listeners. Instrumental fundamental frequency analysis often confirmed auditory ratings but could not be used as a consistent measure of change because aberrant pitch levels were not always a feature in all presenting dysphonias. The Lx traces were able to indicate dysphonia by the absence of some normal features in the trace (for example a lack of a smooth and rapid closing phase or a lack of a uniform Lx trace over time). There are no absolute values to judge these parameters and only visual estimations of normality were possible. The interpretation of these traces was made on a five-point scale following the guidelines of Baken (1987). This gross rating was able to distinguish between very large changes in laryngeal function but was of limited value in more subtle changes. The need to develop further quantitative instrumental techniques to complement clinical judgement of vocal pathology is well recognised. There are several spectral and computer-assisted analyses which hold potential for application in this area. Their increased clinical use awaits further development. CONCLUSIONS

This study provides evidence of the effectiveness of voice therapy in the treatment of non-organic dysphonic patients. The most significant degree of improvement was shown in the third group (incorporating direct and indirect treatments). Ninety per cent of this patient group showed successful return

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to normal voice functioning as compared to 60 per cent of the indirect treatment group. One patient in the control group receiving no treatment showed spontaneous improvement. The study attempted to fill some of the gaps in the research literature as identified by Hillman et al. (1990) by clearly defining treatment aims, closely documenting treatment procedures and employing a no-treatment control group. Furthermore, it demonstrated that it is possible to carry out the necessary evaluation studies within normal clinical practice. It also raises interesting questions concerning individual patient responses to these approaches. Although the study did provide strict patient selection criteria as previously described, it did not attempt to control for all potential variables. Patients varied in a number of ways, e.g. occupational voice demands, personal stress levels, personality, as well as age and sex. The fact that it is difficult to control such variables is not restricted to the study of dysphonic patients. These variables are present in the study of all human behaviour. In clinical research, it is probably not possible or even necessary to identify each and every possible relevant factor before commencing therapy. What is important is that the therapeutic process should involve the ongoing evaluation of factors that emerge during therapy and which have an influence on treatment progress. Effective intervention is likely to remain a product of the clinician’s ability to be flexible in adapting to the individual needs of the patient as they emerge, and to select compatible approaches in remediation. The effective clinician’s skill lies in having a range of therapy techniques available for selection and to know when and how to apply them. ACKNOWLEDGEMENTS The authors would like to acknowledge the comments and recommendations of Professor R. Lesser and Dr G. Docherty, Department of Speech, University of Newcastle upon Tyne, and also of Mr A. R. Welch, FRCS, The Voice Clinic, Freeman Hospital, Newcastle upon Tyne.

APPENDIX: A QUESTIONNAIRE OF VOCAL PERFORMANCE Date. ............................................ Name ........................................... 1. How do you think your voice sounds now (as compared to before your voice problems started)? (a) No different from usual voice. (b) Only slightly different from usual voice. (c) Quite different from usual voice. (d) Very different from usual voice. (e) Totally different from usual voice. 2. Does your voice give you any physical discomfort when you talk? (a) No discomfort. (b) Slight discomfort. (c) Moderate discomfort. (d) A lot of discomfort. (e) Severe discomfort. 3. Does your voice get worse as you talk? (a) Not at all - it stays the same. (b) Occasionally when I talk. (c) Often gets worse when I talk.

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(d) Often gets a let worse when I talk. (e) Always gets a lot worse when I talk. 4. Do you find it an effort to talk? (a) No effort at all. (b) Slight effort sometimes (i.e. at the end of the day or when talking loudly etc.) (c) Quite an effort sometimes. (d) An effort most of the time. (e) A constant effort to talk. 5 . How much are you using your voice at present? (a) As much as I usually would. (b) A little less than I usually would. (c) Somewhat less than usual. (d) A lot less than usual. (e) Hardly at all. 6. Does your voice problem stop you from doing anything that you would otherwise normally do? (a) Doesn’t stop me doing anything that involves me using my voice. (b) Stops me doing a few things that involve using my voice. (c) Stops me doing a lot of things that involve using my voice. (d) Stops me doing most things that involve using my voice. (e) I can hardly do anything that involves me using my voice. 7. In your opinion do you think that your voice is ever difficult to hear or understand? (a) Not at all. (b) A little difficult. (c) Quite difficult. (d) Very difficult. (e) Extremely difficult. 8. Do OTHER people (e.g. close family) ever comment that your voice is difficult to hear or understand? (a) No comments. (b) Occasional comments. (c) Quite often there are comments. (d) Frequent comments. (e) Very frequent comments. 9. Since your voice problem started has your voice . . .? (a) Improved a lot. (b) Improved a little. (c) Not improved at all. (d) Deteriorated a little. (e) Deteriorated a lot. 10. Since your voice problem started have OTHER people (e.g. close family) commented that your voice has improved? (a) Other people say that my voice has improved a lot. (b) Other people say that my voice has improved a little. (c) Other people say that my voice has not improved at all. (d) Other people say that my voice has got a little worse. (e) Other people say that my voice has got a lot worse. 11. Would you say that the sound of your voice was . . . (a) Normal. (b) Not quite normal. (c) Mildly abnormal. (d) Quite abnormal. (e) Very abnormal. 12. How much do you worry about your voice problem now? (a) Not at all. (b) Hardly at all. (c) Quite a lot.

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(d) A good deal. (e) Almost all of the time. This Appendix is not t o be reproduced without the authors’ permission.

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Received January 1992; revised version received February 1992.