Perceptions of Voice Therapy From Patients Diagnosed With Primary Muscle Tension Dysphonia and Benign Mid-Membranous Vocal Fold Lesions *,†Aaron Ziegler, *Christina Dastolfo, *Rita Hersan, *,‡Clark A. Rosen, and *,‡Jackie Gartner-Schmidt, *yzPittsburgh, Pennsylvania

Summary: Objectives. Studies have established the role of behavioral therapy in treating voice problems. However, studies have also identified patient adherence as a limitation in voice therapy effectiveness. Accordingly, an understanding of patient preferences may help to improve adherence and increase voice therapy success. The primary aim of this study was to understand patient-perceived facilitators and barriers influencing voice therapy effectiveness in a group of treatment-seeking individuals with voice disorders. A secondary aim was to examine the relationship between selfreported improvement from voice therapy and the Voice Handicap Index-10 (VHI-10). Study Design. Retrospective, observational study design. Methods. One hundred ten patients enrolled in voice therapy at the University of Pittsburgh Voice Center completed a self-administered Patient Perception of Voice Therapy questionnaire on discharge. Data from 45 individuals who met study criteria were analyzed. Results. Patient-reported improvement from voice therapy was correlated with changes in VHI-10 scores. A majority of patients identified specific voice therapy exercises and transfer of techniques to conversation as the most useful aspects of treatment. Few patients rated vocal hygiene education as most useful. Generalizing new vocal behaviors was also identified as a barrier to voice therapy success for many patients. Conclusions. In this study, patients valued direct voice therapy in which they worked on altering vocal behaviors more than indirect voice therapy that aimed to educate patients about their voice. Study findings suggest the importance of direct voice therapy and the need to incorporate carryover activities early on in the therapy process for greater treatment satisfaction and success. Key Words: Voice therapy–Patient preferences–Therapy effectiveness.

INTRODUCTION Numerous studies have established the effectiveness of voice therapy for the treatment of voice disorders.1–8 Some studies have focused on indirect versus direct voice therapy,9–13 yet others have investigated specific treatment techniques (eg, manual circumlaryngeal reposturing, resonant voice).14–18 Those studies have been valuable in demonstrating voice therapy effectiveness; however, voice therapy effectiveness outcomes have lacked the patient’s direct perspective of voice therapy. To date, only one study has investigated patients’ perceptions of voice therapy.19 Due to the paucity of research on this topic, patients’ perception of therapeutic facilitators and barriers to ultimate success in voice therapy are less understood. In addition, because various types of indirect and direct voice therapy approaches are available, information about patient preferences concerning differing component parts of voice therapy is essential.13 Finally, given the limited adherence to voice therapy recommendations,19–21 understanding patients’ perceptions of voice therapy is critical.

Accepted for publication February 17, 2014. From the *University of Pittsburgh Voice Center, Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; yDepartment of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania; and the zDepartment of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania. Address correspondence and reprint requests to Jackie Gartner-Schmidt, University of Pittsburgh Voice Center, University of Pittsburgh Medical Center Mercy, 1400 Locust Street, Suite 11-500, Building B, Pittsburgh, PA 15219. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-11 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.02.007

Surprisingly, 38% of patients who were referred for voice therapy did not attend the initial session according to the literature, and 47% have been recorded as not returning after the initial speech-language pathology (SLP) evaluation.21 Overall, voice therapy dropout rates have ranged from 44% to 65%.20,22 Considering these high dropout rates, investigating patient perceptions of voice therapy and barriers to success is critical in retaining and rehabilitating patients. Initial efforts to understand the reasons for reduced adherence to recommendations should include qualitative feedback from a treatment-seeking population. Information regarding patients’ perception about therapy would appropriately shape future studies investigating causes and solutions for high dropout rates. van Leer and Connor19 authored the only study dedicated solely to exploring patient perceptions concerning low adherence rates in voice therapy. The authors interviewed 15 patients enrolled in voice therapy about their perceptions regarding adherence to therapy guidelines. Qualitative analysis revealed three main themes gathered from either person-to-person or telephone interviews about voice therapy: (1) voice therapy is hard, (2) make it happen, and (3) the clinician-patient match matters.19 Although this study generated valuable data, one potential confounding variable was the lack of control for disorder type (eg, nodules, hyperfunction, sulcus, chronic cough, presbyphonia, granuloma, unilateral vocal fold paralysis were included). Patients with disorders that may be more resistant to behavioral change (eg, unilateral vocal fold paralysis, scarring/sulcus)23,24 may negatively bias perceptions of voice therapy because of physiological limitations of the laryngeal mechanism.

2 Building on the importance of this preliminary research, investigating patient perceptions of voice therapy in a group of patients with voice disorders thought to be the most responsive to voice therapy is needed. Furthermore, correlating traditionally accepted measures of treatment effectiveness in voice therapy (eg, symptom severity scale measures) with patients’ perception of improvement from voice therapy should be explored. In general, symptom severity scale instruments were developed as methods to quantify level of handicap in patients’ daily lives and were not designed to assess patients’ perception of voice therapy or usefulness of its component parts. Although not explicitly addressed in the voice science literature, there have been examples of authors who have used short, nonpsychometrically validated, quasitreatment-satisfaction questionnaires in their studies, reflecting perhaps an instinctive need for a measure of patients’ perception of voice therapy.19,25–27 Barkmeier-Kraemer and colleagues25 used an 8-question survey to examine patient’s perception of therapy effectiveness and exercise usefulness in vocal tremor patients via a LikertScale questionnaire. Similarly, Roy and colleagues12,26,28 used a 4-question survey to examine patients’ satisfaction of treatment regarding effectiveness and patients’ perception of his or her adherence to recommendations. More recently, Nanjundeswaran and colleagues27 investigated the utility of two voice therapy programs in the prevention of voice problems in student teachers and the researchers measured satisfaction using a short 3-question survey. Perhaps these ideas require further investigation to develop a formal instrument intended to qualify and quantify voice therapy effectiveness from the patients’ perspective. This article represents a preliminary study to capture patientperceived factors influencing voice therapy effectiveness in a group of treatment-seeking individuals with voice disorders traditionally thought to be amenable to voice therapy. Specifically, the Patient Perceptions of Voice Therapy form (PPVT form) was designed to gain a better understanding of patients’ benefit from voice therapy and identify facilitators and barriers to voice therapy usefulness. A secondary aim of this study was to examine correlations between self-reported improvement from voice therapy and a traditionally accepted symptom severity scale measure.

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and was based on the extant literature. Final items were based on clinical consensus. The questionnaire consisted of a prepared list of open- and closed-ended questions. Furthermore, an attempt was made to balance dual statements by stating questions positively and negatively. Questions that addressed the same construct (ie, voice therapy effectiveness) were also asked in a number of different ways (eg, binary, multiple choice, and visual analog scale [VAS]). A VAS is a means of quantifying subjective information by asking participants to mark their response on a line between two marked end points, which represent the possible extremes.29 In this study, participants rated their benefit from voice therapy via multiple methods, including a VAS (Appendix A). The questions were arranged in a logical order with simple initial questions that introduce the topic of the study and difficult questions occurring late in the sequence. In addition, general questions appeared early in the questionnaire and specific questions appeared late in the questionnaire. Moreover, response options used in more than one question were randomly ordered. The last question on the PPVT form focused on whether patients could function with their voice after the completion of therapy. Voice function is the ultimate goal of any behavioral, medical, or surgical treatment. Finally, the PPVT form was designed to be quick and easy to administer and complete.

MATERIALS AND METHODS All procedures in this study were approved by the University of Pittsburgh Institutional Review Board (IRB #12020693). The study used a retrospective observational design.

Participants Patients in this study were 18 years or older, had a diagnosis of primary muscle tension dysphonia (MTD-1) or benign vocal fold lesions (Lesion), and received voice therapy as a firstline treatment. Diagnosis of MTD-1 required dysphonia with normal morphology and movement of the vocal folds.30 All patients with benign vocal fold lesions were included in the Lesion group; this included bilateral and unilateral lesions. Lesions were considered benign if they were mid-membranous with grossly normal overlying epithelium. All diagnoses were determined based on voice-specialized SLP and laryngologist evaluation. Data were collected over the course of 2 years; all patients with the previously mentioned diagnoses who participated in voice therapy and completed the PPVT form were included. Patient data were excluded if they had vocal fold surgery or had missing data. In addition, the University of Pittsburgh Voice Center database was queried to identify patients who had a complete set of pre- and post-therapy Voice Handicap Index-10 (VHI-10) scores. The VHI-10 represents a validated and shortened version of the VHI.31 An initial pool of 110 patients was identified as having completed the PPVT form. However, only 45 patients satisfied the aforementioned criteria and their data were analyzed (Figure 1).

Questionnaire development A group of seven voice-specialized SLPs from the University of Pittsburgh Voice Center developed the Patient Perceptions of Voice Therapy form (from here on out called PPVT form) (Appendix A) to better understand patients’ perception of voice therapy as well as the facilitators and barriers of voice therapy usefulness for the improvement of clinical services. The PPVT form content was selected to reflect current clinical thinking

Procedures Patients received individualized voice therapy based on their habitual speaking voice patterns and symptomatic complaints. In general, a combination of Resonant Voice Therapy, Flow Phonation, and Manual Circumlaryngeal Reposturing were used.14,32–36 Patients completed the PPVT form on termination of voice therapy. The voice therapy end point was determined on an individual basis by consensus between the

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FIGURE 1. Flowchart of study sample. SLP and patient. Patients were discharged from therapy if (a) individual treatment goals were successfully met or (b) patients failed to respond to therapy. In the latter situation, patients were referred back to the laryngologist for consideration of surgical, medical, or psychosocial interventions. The SLP working with the patient presented the individual with the PPVT form on a clipboard during the last 5–10 minutes of the final voice therapy session. The SLP briefly explained the purpose of the form and gave general instructions, reiterating the instructions printed on the form. To decrease the potential for social desirability bias, the PPVT form was self-administered without any identifying information in a quiet private room and the patient was given as much time as needed to complete the form. Emphasis was given to the patient to complete the form about therapy and not the therapist. The completed PPVT form was independently placed in a drop box at the exit of the Voice Center by the patient without further contact with the SLP. Analysis of daily focus of voice production Responses from the open-ended question ‘‘What aspect of voice therapy do you use (focus on) on a regular basis?’’ were examined descriptively. The process of ‘‘triangulation’’ was used similar to van Leer and Connor19; that is, multiple methods (open-ended vs closed-ended questions) were examined for the extent to which answers converged around the same behavioral phenomenon.37 Techniques to establish construct validity utilize this idea of convergence; an instrument is deemed valid if constructs that are theoretically related demonstrate conver-

gence when analyzed.38 Theoretically, participants’ daily focus should be one of the aspects of voice therapy that were most helpful. Thematic content analysis of the open-ended participant statements was qualitatively compared with some of the previous themes elicited from participants in closed-ended questions (eg, What was the most helpful aspect of voice therapy?). Participants in the study offered 75 statements in response to the question; some participants offered more than one statement, leading to a greater number of statements (75) than participants (45). First, three of the authors (A.Z., C.D., J.G.-S.) reviewed each statement and generated categories that represented the meaning of each statement. The categories included patients’ written verbiage related to transfer to conversation, specific voice exercises, resonance, airflow, relaxation, lifestyle changes, volume/loudness, and unable to code/too general. Then, the authors coded each of the statements into one of the previously mentioned categories on the basis of group consensus. Disagreements among the authors in statement coding were resolved by discussing the justification for coding a statement until finally reaching group consensus. Once the group of authors came to agreement, another rater, who was also a voice-specialized SLP, independently coded the responses using the predetermined categories to determine interrater agreement. The group and independent rater demonstrated 87% (65/75) agreement on response coding. Statistical analysis Analyses of the data used a combination of descriptive analyses as well as nonparametric and parametric statistical tests. The latter were done to examine differences between diagnostic groups. An alpha level of .05 was used. RESULTS Analysis of baseline comparability Participant characteristics are displayed in Table 1. Overall, patients were 38 women and seven men (N ¼ 45) aged 18–67 years (M ¼ 37.09 years, standard deviation [SD] ¼ 13.24). Average participant age for the MTD-1 (n ¼ 18) and Lesion (n ¼ 27) groups was 44.78 years (SD ¼ 11.86) and 31.96 years (SD ¼ 11.68), respectively. Post hoc analyses using an independent samples t test revealed the MTD-1 group was significantly older than the Lesion group (t[43] ¼ 3.584, P < 0.001). Age distribution for the groups is consistent with literature stating that MTD-1 is more typical in older women and lesions are more typical in younger women.39 Mean initial VHI-10 scores were 24.06 (SD ¼ 10.26) and 16.67 (SD ¼ 9.36) for MTD-1

TABLE 1. Summary of Participant Characteristics by Group Group MTD-1 (n ¼ 18) Lesion (n ¼ 27) Overall (N ¼ 45)

Age

VHI-10 (Initial)

CAPE-V

Tx Sessions

44.78 (11.86) 31.96 (11.68) 37.09 (13.24)

24.06 (10.26) 16.67 (9.36) 19.62 (10.29)

50.39 (28.04) 35.22 (21.94) 41.29 (25.39)

4.39 (1.42) 4.15 (1.23) 4.24 (1.30)

Abbreviations: CAPE-V, Consensus Auditory-Perceptual Evaluation of Voice; Tx, therapy.

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and Lesion groups, respectively, and 19.62 (SD ¼ 10.88) for the entire group of patients. A score on the VHI-10 of more than 11 suggests that a patient has a voice handicap40; therefore, the average respondent in both MTD-1 and Lesion groups had a recognized voice handicap at the onset of therapy. The MTD1 group started therapy with a significantly higher mean VHI10 score than the Lesion group (t[43] ¼ 2.497, P ¼ 0.016). Mean Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)41 overall severity rating was 41.29 (SD ¼ 25.40) for the entire group of patients. Overall, patients attended a mean of 4.24 (SD ¼ 1.30) therapy sessions. No differences between diagnostic groups were found for CAPE-V overall severity ratings and number of therapy sessions attended (P ¼ 0.071 [Due to a violation in the assumption of normality in the Lesions group (P ¼ 0.012), the CAPE-V overall severity ratings of the MTD-1 and Lesions groups were reanalyzed by performing a nonparametric Mann-Whitney test, which revealed that the two medians did not differ significantly. The results of the Mann-Whitney test were reported.] and P ¼ 0.549). Administration of PPVT form The mean difference in time for the administration of the PPVT form and the post-therapy VHI-10 instrument was 4.23 weeks (SD ¼ 3.26). Voice therapy satisfaction Help, harm, and ability. All patients (N ¼ 45) reported that voice therapy helped them. The majority of patients (n ¼ 43; 95.6%) reported that they could do what they wanted/needed to do with their voice after the completion of voice therapy. Change in VHI-10. Means and SDs for pre-post treatment change (absolute and percent) in VHI-10 scores are presented in Table 2. Overall, patients registered a mean improvement (more negative values suggest greater improvement due to a lower VHI-10 value denoting less handicap) in voice handicap

via VHI-10 scores of 8.80 (10.18) or 28.35% (SD ¼ 69.69). For patients with MTD-1, mean improvement in VHI-10 scores was 10.67 (12.25) or 30.90% (SD ¼ 78.36). For patients with lesions, mean improvement in VHI-10 scores was 7.56 (8.56) or 26.65% (SD ¼ 67.52). Post hoc analysis using a paired samples t test revealed a significant difference on prepost treatment change in VHI-10 scores for the total patient sample, t(44) ¼ 5.798, P < 0.001, and an independent samples t test failed to reveal significant differences on mean pre-post treatment change in VHI-10 scores (absolute and percent) between the two diagnostic groups (P ¼ 0.321 and P ¼ 0.847, respectively). Self-reported improvement (VAS and percent better). Means and SDs for self-reported improvement (VAS and percent better) are presented in Table 2. Patients reported, on average, 79.27 mm (SD ¼ 17.42) and 74.02% (SD ¼ 21.44) improvement from voice therapy. On average, patients with MTD-1 reported 77.89 mm (SD ¼ 21.78) and 77.78% (SD ¼ 22.24) of improvement and patients with lesions reported 80.19 mm (SD ¼ 14.19) and 71.52% (SD ¼ 20.93) of improvement from voice therapy. Post hoc analyses using an independent samples t test revealed no significant differences on mean self-reported improvement (VAS scale and percent better) values between groups (P ¼ 0.670 and P ¼ 0.343, respectively). Correlation between VHI-10 percent change and selfreported improvement (VAS). An examination of a scatterplot (Figure 2) suggested the presence of linearity for VHI-10 pre-post percent change scores and self-reported improvement values using a VAS. A Spearman rank order correlation coefficient (ie, Spearman rho) was performed to determine the correlation between VHI-10 pre-post percent change scores and self-reported improvement values. The Spearman rho revealed a statistically significant negative relationship between VHI-10 pre-post percent change scores and self-reported improvement values (rs [45] ¼ 0.338, P ¼ 0.023).

TABLE 2. Means and SDs as well as Frequencies and Percentages for Voice Therapy Effectiveness Data Did Voice Therapy Help Group

Voice Does What I VHI-10 Change Want/Need (Absolute)

VHI-10 Change (%)

Better, VAS (in mm)

Better (in %)

Therapy Caused Changes

Mean (SD)

Mean (SD)

Mean (SD)

n (%)

Harm

% Yes % No

n (% Yes)

Mean (SD)

MTD-1 (n ¼ 18)

100

100

17 (94.4)

10.67 (12.25) 30.90 (78.36) 77.89 (21.77) 77.78 (22.24)

Lesion (n ¼ 27)

100

100

26 (96.3)

7.56 (8.56)

26.65 (67.52) 80.19 (14.18) 71.52 (20.93)

A, 3 (11.1) B, 9 (33.3) C, 15 (55.6)

Overall (N ¼ 45)

100

100

43 (95.6)

8.80 (10.18) 28.35 (71.21) 79.27 (17.42) 74.02 (21.44)

A, 4 (8.9) B, 11 (24.4) C, 30 (66.7)

A, 1 (5.6) B, 2 (11.1) C, 15 (83.3)

Notes: A, voice therapy probably irrelevant to voice change; B, voice therapy may have caused voice changes; C, voice therapy definitely caused voice changes.

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FIGURE 2. Scatterplot of VHI-10 change scores versus self-reported improvement. Cause of voice changes. Overall, 66.7% of patients (n ¼ 30) reported that voice therapy definitely caused voice changes (Table 2). When grouped by diagnosis, 83.3% of patients (n ¼ 15) with MTD-1 and 55.6% of patients with lesions (n ¼ 15) reported that voice therapy definitely caused voice changes. In contrast, only 8.9% of patients (n ¼ 4) reported that voice therapy was probably irrelevant to voice changes. Facilitators and barriers of voice therapy effectiveness. Frequencies and percentages for self-reported valuable and challenging aspects of voice therapy are presented in Table 3. A two-way chi-square with exact test evaluated differences in most useful, second most useful, and hardest aspects of voice therapy between the two diagnostic groups among the expected responses. There was not a significant difference in the expected responses between MTD-1 and Lesion groups on most useful, second most useful, and hardest aspects of voice therapy, c2 (4, n ¼ 45) ¼ 5.294, P < 0.218; c2 (4,

n ¼ 45) ¼ 1.978, P < 0.791; c2 (3, n ¼ 45) ¼ 0.209, P < 1.000, respectively. Hence, there is no real evidence that the percentages of most useful, second most useful, and hardest aspects of therapy varies by diagnosis. Overall, 75.6% of patients (n ¼ 34) reported that specific voice therapy exercises were the most useful aspect of voice therapy and 40.0% of patients (n ¼ 18) reported that carryover of normal voice to ‘‘real’’ life conversation was the second most useful aspect of voice therapy. Next, 64.4% of patients (n ¼ 29) reported transfer of voice therapy techniques to normal speech as the hardest aspect of voice therapy. The same pattern of responses is evident when considering specific diagnoses (Figures 3 and 4). Treatment adherence: self-reported practice patterns. Frequency and percentages of self-reported practice patterns are presented in Table 3. A two-way chi-square with exact test evaluated differences in the extent to which patients practiced voice exercises between the two diagnostic groups among

TABLE 3. Group Percentages and Frequencies for Facilitators and Barriers of Voice Therapy Effectiveness Practice

Practice Frequency

Most Useful Aspect

Second Most Useful Aspect

Hardest Aspect

% Yes (n)

% (n)

% (n)

% (n)

% (n)

MTD-1 (n ¼ 18)

100 (18)

A, 44.4 (8) B, 44.4 (8) C, 5.6 (1) D, 5.6 (1)

A, 0.0 (0) B, 5.6 (1) C, 5.6 (1) D, 72.2 (13) E, 16.6 (3)

A, 27.8 (5) B, 16.7 (3) C, 5.5 (1) D, 22.2 (4) E, 27.8 (5)

A, 11.1 (2) B, 22.2 (4) C, 61.1 (11) D, 0.0 (0) E, 5.6 (1)

Lesion (n ¼ 27)

96.3 (26)

A, 40.7 (11) B, 37.0 (10) C, 11.1 (3) D, 11.1 (3)

A, 11.1 (3) B, 0.0 (0) C, 0.0 (0) D, 77.8 (21) E, 11.1 (3)

A, 18.5 (5) B, 14.8 (4) C, 3.7 (1) D, 14.8 (4) E, 48.1 (13)

A, 11.1 (3) B, 18.5 (5) C, 66.7 (18) D, 0.0 (0) E, 3.7 (1)

Overall (N ¼ 45)

97.8 (44)

A, 42.2 (19) B, 40.0 (18) C, 8.9 (4) D, 8.9 (4)

A, 6.7 (3) B, 2.2 (1) C, 2.2 (1) D, 75.6 (34) E, 13.3 (6)

A, 22.2 (10) B, 15.6 (7) C, 4.4 (2) D, 17.8 (8) E, 40.0 (18)

A, 11.1 (5) B, 20.0 (9) C, 64.4 (29) D, 0.0 (0) E, 4.4 (2)

Group

Notes: Practice Frequency: A, everyday; B, every couple of days; C, every week; D, only when needed; Most Useful Aspect: A, lifestyle changes; B, information on structure and function; C, possible voice/emotion issues; D, specific voice therapy exercises; E, carryover to ‘‘real’’ life conversation; Second Most Useful Aspect: A, lifestyle changes; B, information on structure and function; C, possible voice/emotion issues; D, specific voice therapy exercises; E, carryover to ‘‘real’’ life conversation; Hardest Aspect: A, feeling sensations; B, practicing regularly; C, transferring learned behaviors to normal speech; D, understanding/rationale of voice therapy; E, lifestyle changes.

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FIGURE 3. Most useful aspect of voice therapy by diagnostic group. FIGURE 4. Most difficult aspect of voice therapy by diagnostic the expected responses. There was not a significant difference in the expected responses between MTD-1 and Lesion groups on practice patterns, c2 (3, n ¼ 45) ¼ 0.933, P < 0.808. Hence, there is no real evidence that the percentage of practice patterns varies by diagnosis. All but one patient (n ¼ 44, 97.8%) reported practicing. Overall, an equal number of patients practiced everyday (n ¼ 19, 42.2%) or every couple of days (n ¼ 18, 40.0%). Therefore, a majority of patients (n ¼ 37, 82.2%) practiced on a regular basis (ie, everyday or every couple of days). A similar practice pattern was demonstrated when the overall group was broken down by diagnosis. Daily focus of voice production. The open-ended responses from participants reinforced the aspects that were most helpful in therapy found on the other closed-ended questions (namely, specific voice therapy exercises and transfer to conversation). The categories coded most frequently, and for which there was unanimous agreement for coding categories, included patients focusing on airflow (n ¼ 18), transfer to conversation (n ¼ 13), resonance (n ¼ 12), and specific voice exercises (n ¼ 11). Therefore, statements from the open-ended question replicated the finding from closed-ended questions that direct voice therapy was more important than indirect voice therapy (only four responses were coded as lifestyle changes). Qualitatively, data from both open-ended and closed-ended questions converge around the same ideas (direct voice therapy techniques were most helpful). DISCUSSION The goal of this research study was to capture information regarding patients’ perception about voice therapy. Voice therapy

group.

effectiveness was documented through both a symptom severity scale and various measures on the PPVT form and results have clarified facilitators and barriers to success from the patients’ perspective. For example, useful therapy tasks included (1) specific voice therapy exercises and (2) transfer to conversational speech tasks; alternatively, the most difficult aspect of voice therapy was transfer to conversational speech. This information alone has therapeutic implications and requires attention to address patients’ needs, but it also highlights the importance of developing and validating a future treatment satisfaction instrument for voice therapy. Perhaps it is through patients’ feedback that SLPs can provide better voice therapy and, consequently, retain more patients. In addition, given a subject pool of 45 patients and seven different SLPs, these results offer generalizable findings that may offer a starting point to evaluate voice therapy based on patient feedback. Patient responses gravitated toward aspects of the therapeutic process aimed at action rather than information. Interestingly, the aforementioned aspects of voice therapy that participants found most helpful were direct voice therapy strategies (specific exercises, practice in conversational speech) and not indirect voice therapy strategies (vocal hygiene, emotion and voice, structure and function). This finding is supported by previous research that found direct voice therapy to be more effective than vocal hygiene alone.9,26,42,43 It also coincides with recent literature stating that SLPs spend more time in direct therapy compared with indirect therapy.13,42 The SLPs’ strategy to spend more time in direct therapy is supported by the motor learning literature, which states that repetitive practice (direct

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therapy) facilitates learning more than explanation of ‘‘how’’ the voice works (a component of indirect therapy).44,45 Patients in this study also reported thinking more about direct voice therapy techniques (eg, specific voice therapy exercises) as a daily focus as opposed to the indirect components of voice therapy. One may conclude that therapy could be improved by allocating more time to those activities that are most helpful to the patient (ie, direct voice therapy). Patient feedback from this study supports the use of direct voice therapy and provides valuable insight about what patients found useful about the therapy session. Patient responses also provided insight about challenging aspects of voice therapy. Transfer to conversational speech was a recurrent selection in both the second most useful aspect of voice therapy and the most difficult aspect of voice therapy. The study by van Leer and Connor19 corroborates this finding. Perhaps this sentiment may be communicative of patient needs, specifically, a need for more focus on transfer to conversation in voice therapy. Interestingly, these patient responses are consistent with speech literature stating that practicing specific speech sounds alone may not transfer to conversational speech.46 Considering the combined evidence between patients’ responses on the PPVT form and speech literature, increased focus on conversational speech tasks early in the therapeutic process instead of nonspeech sounds may be needed to increase voice therapy retention rates and overall improvement. Furthermore, attending to conversational speech tasks earlier in therapy may potentially engage patients in the therapeutic process by starting with relevant tasks, thereby reducing dropout rates.47 Traditional methods of voice therapy instruction typically do not begin by addressing the challenge that patients have expressed: conversational speech. Traditional therapies have taken a hierarchical approach to reach the goal of balanced phonation in conversation, starting with the least complex tasks (ie, phonemes) and ending with the most complex tasks (ie, conversation).48,49 Some theories in learning literature conflict with this hierarchical approach to instruction.50,51 The desirable difficulties concept and challenge-point framework describe learning advantages to increasing cognitive load or complexity during the learning process.50,51 Addressing complex tasks (ie, conversational speech) earlier in therapy may facilitate the motor learning process via increasing cognitive load. Data compiled from the PPVT form have provided valuable information about patients’ needs regarding voice therapy in this article, adding to preliminary efforts by van Leer and Connor. The PPVT form in this study was deliberately designed in an effort to provide valid information. Results comparing the multiple methods of data collection (open-ended and closedended questions) demonstrated convergence of the responses. Similarly, the VAS and multiple choice question formats, which were used within the PPVT form, have been validated in other voice measurements41,52 and in measurements across the medical profession53–56 to accurately quantify subjective information. Although, in its current format, the PPVT form is not a formal questionnaire, perhaps, more investigation is warranted to develop a formal voice therapy satisfaction questionnaire.

7 Future instruments focused on patients’ perception of voice therapy may provide an avenue to capture salient information that could potentially be used to design more efficient and effective voice therapy sessions. Patient satisfaction is a multifactorial construct, including general/global health care issues (insurance, cost) as well as treatment-specific issues (treatment preference, complexity of treatment).57 A long-term goal for this project would then include other voice therapy patient satisfaction measures as opposed to global measures of patient satisfaction.57 Evidence from this study demonstrated a potential gap in our ability to capture necessary treatment outcome data with traditional symptom severity scale measures. Although the current study corroborated voice therapy effectiveness between patient perceived improvement on selected measures within the PPVT form and decreased voice handicap from the VHI-10, the VHI10 data and VAS data did not correlate as expected. Participants reported 79.27% improvement after voice therapy using a VAS but only 28% improvement as measured via the pre-post therapy VHI-10 data. Similarly, patients reported 74.02% percent improvement when directly asked, ‘‘How much better did you get with voice therapy?’’ All the participants indicated that voice therapy helped them, but the high SD in percent change in voice handicap from the pre-post VHI-10 percent change scores (SD ¼ 69.7%) revealed that not all patients demonstrated improvement on the VHI-10. This is in contrast with 95.6% of participants reporting that they could do what they wanted/ needed to do with their voice after completing voice therapy. Dissociation between VHI-10 pre-post changes and patient perceived improvement via questions on the PPVT form that addressed the same construct (ie, voice therapy effectiveness) using differing formats of questions (eg, binary, multiple choice, and VAS) may have been confounded by the length of time between onset and discharge from therapy (PPVT form administration) and physician follow-up visits (VHI-10 administration). Regardless, this discrepancy in patient response highlights potential information not captured by traditional symptom severity scale measures. Symptom severity scale measures were never intended to measure patients’ direct perception of therapeutic outcome or if patients’ felt that voice therapy helped; however, a future instrument aimed at measuring patients’ perception of therapy results may be valuable to close this gap in understanding patient outcomes following voice therapy. Limitations All data for this study were gathered from a single institution. It is possible that SLPs from one institution form similar approaches toward therapy. Future studies should include multisite data collection including varied backgrounds of both the SLPs and participant population. Another limitation inherent in the study design is that only participants who completed therapy were given the PPVT form. Finally, although great care was taken to decrease the social desirability bias by instructing patients to fill out the form based on the therapy and not to ‘‘please’’ the therapist, the potential for biased responses is present.

8 CONCLUSION Patients’ perception of voice therapy documented in the current PPVT form has highlighted aspects of voice therapy that warrant further investigation including increased focus on direct voice therapy techniques and transfer to conversational speech. Patients’ responses to the degree of improvement gained from voice therapy via VAS and percent improvement questions demonstrated a seemingly more favorable response to voice therapy compared with the symptom severity scale measurement data. Further research should work toward validating a voice therapy treatment satisfaction instrument so that more data may be gathered to facilitate voice therapy retention and evaluate quality of care, specific to voice therapy. Acknowledgments The authors thank Dr. Celia Bassich, PhD for her contributions to the data analysis in this study. REFERENCES 1. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg. 2008;138:557–565. 2. Speyer R. Effects of voice therapy: a systematic review. J Voice. 2008;22: 565–580. 3. Pannbacker M. Voice treatment techniques: a review and recommendations for outcome studies. Am J Speech Lang Pathol. 1998;7:49–64. 4. Pannbacker M. Treatment of vocal nodules: options and outcomes. Am J Speech Lang Pathol. 1999;8:209–217. 5. Gillivan-Murphy P, Drinnan MJ, O’Dwyer TP, Ridha H, Carding P. The effectiveness of a voice treatment approach for teachers with selfreported voice problems. J Voice. 2006;20:423–431. 6. MacKenzie K, Millar A, Wilson JA, Sellars C, Deary IJ. Is voice therapy an effective treatment for dysphonia? A randomised controlled trial. BMJ. 2001;323:658–661. 7. Ziegler A, Gillespie AI, Abbott KV. Behavioral treatment of voice disorders in teachers. Folia Phoniatr Logop. 2010;62(1–2):9–23. 8. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41:S101–S116. 9. Rodriguez-Parra MJ, Adrian JA, Casado JC. Comparing voice-therapy and vocal-hygiene treatments in dysphonia using a limited multidimensional evaluation protocol. J Commun Disord. 2011;44:615–630. 10. Verdolini-Marston K, Sandage M, Titze IR. Effect of hydration treatments on laryngeal nodules and polyps and related voice measures. J Voice. 1994; 8:30–47. 11. Chan RW. Does the voice improve with vocal hygiene education? A study of some instrumental voice measures in a group of kindergarten teachers. J Voice. 1994;8:279–291. 12. Roy N, Weinrich B, Gray SD, et al. Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study. J Speech Lang Hear Res. 2002;45:625–638. 13. Gartner-Schmidt JL, Roth DF, Zullo TG, Rosen CA. Quantifying component parts of indirect and direct voice therapy related to different voice disorders. J Voice. 2013;27:210–216. 14. Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice. 1997;11:321–331. 15. Verdolini K, Druker DG, Palmer PM, Samawi H. Laryngeal adduction in resonant voice. J Voice. 1998;12:315–327. 16. Ramig LO. How effective is the Lee Silverman voice treatment? ASHA. 1997;39:34–35. 17. Behrman A, Rutledge J, Hembree A, Sheridan S. Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma. J Speech Lang Hear Res. 2008;51:350–366.

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9 52. Nemr K, Simoes-Zenari M, Cordeiro GF, et al. GRBAS and Cape-V scales: high reliability and consensus when applied at different times. J Voice. 2012;26:812.e17–812.e22. 53. Bengtsson M, Persson J, Sjolund K, Ohlsson B. Further validation of the visual analogue scale for irritable bowel syndrome after use in clinical practice. Gastroenterol Nurs. 2013;36:188–198. 54. Lewinson RT, Wiley JP, Worobets JT, Stefanyshyn DJ. Development and validation of a computerized visual analog scale for the measurement of pain in patients with patellofemoral pain syndrome. Clin J Sport Med. 2013;23:392–396. 55. Thomas-Gibson S, Saunders BP. Development and validation of a multiple-choice question paper in basic colonoscopy. Endoscopy. 2005; 37:821–826. 56. Meadows KA, Fromson B, Gillespie C, et al. Development, validation and application of computer-linked knowledge questionnaires in diabetes education. Diabet Med. 1988;5:61–67. 57. Weaver M, Patrick DL, Markson LE, Martin D, Frederic I, Berger M. Issues in the measurement of satisfaction with treatment. Am J Manag Care. 1997; 3:579–594.

10 APPENDIX A Voice therapy PPVT form

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Perceptions of voice therapy from patients diagnosed with primary muscle tension dysphonia and benign mid-membranous vocal fold lesions.

Studies have established the role of behavioral therapy in treating voice problems. However, studies have also identified patient adherence as a limit...
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