Original Paper Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
Published online: April 1, 2014
Reliability and Validity of the Italian Version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) F. Mozzanica a D. Ginocchio b E. Borghi a C. Bachmann a A. Schindler a a
Department of Clinical Sciences ‘L. Sacco’, University of Milan, and b Department of Audiology, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
Key Words Dysphonia · CAPE-V · Voice disorders · Perceptual voice evaluation
Abstract Objectives: To evaluate the reliability and validity of the Italian version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Patients and Methods: Eighty dysphonic patients and 120 asymptomatic subjects were enrolled. The voice signal of each participant was recorded, listened to and rated by 3 licensed speech-language pathologists using the GRBAS scale and the Italian version of the CAPE-V. The intra- and interrater reliability of the CAPE-V was assessed as well as the degree of association between the CAPE-V and GRBAS judgments. The CAPE-V values were also compared between the patients with dysphonia and the asymptomatic subjects. Results: The intra- and interrater reliability appeared to be good for all the parameters except for the strain parameter. The attributes ‘consistent’ and ‘intermittent’ demonstrated optimal intra- and interrater reliability. The difference between pathological and control groups was significant for six perceptual parameters. The highest average correlation between GRBAS and CAPE-V judgments was found between overall severity and grade while the lowest was found between the two strain scales. CAPE-V profiles differed significantly between different
© 2014 S. Karger AG, Basel 1021–7762/14/0655–0257$39.50/0 E-Mail [email protected] www.karger.com/fpl
pathological groups. Conclusion: The Italian version of CAPE-V appears to be a reliable and valid tool for the perceptual analysis of the voice signal. © 2014 S. Karger AG, Basel
Introduction
In the assessment of a voice disorder no single value or instrumental measure can conclusively quantify or characterize the disease. In fact, the evaluation of voice remains a multifactorial process involving several approaches (e.g. perceptual evaluation, acoustic and physiologic measures, self-assessment of voice handicap) in order to offer different perspectives on describing the vocal function. In 2001, Dejonckere et al. [1] proposed a basic protocol for a functional assessment of voice pathology including five different approaches: perception, videostroboscopy, acoustics, aerodynamic analysis and subjective rating by the patient. Even if perceptual voice evaluation is fundamental in the assessment of voice quality, it appears to be a controversial subject probably because of the many psychophysical scaling issues that influence the tasks [2] and the difficulties in obtaining good reliability [3]. Several scaling methods are available in the international literature [4–9]. Nowadays, the auditory perceptual protocol in greatest use worldwide is the Francesco Mozzanica Ospedale ‘L. Sacco’ Via G.B. Grassi 74 IT–20157 Milan (Italy) E-Mail francesco.mozzanica @ gmail.com
GRBAS scale [4]. The GRBAS scale contains five welldefined parameters: G (overall grade of hoarseness), R (roughness), B (breathiness), A (asthenicity) and S (strained quality); each parameter is rated on a four-point equal-appearing interval scale from 0 (no problem) to 3 (severe problem). Reliability, clinical relevance and correlation with acoustic measures have been studied by several authors [10, 11]. In particular, De Bodt et al. [10] reported that the test-retest reliability of the grade parameter ranged from fair to good; Bhuta et al. [11] demonstrated a significant correlation between the noiserelated parameters of the Multi-Dimensional Voice Program (noise-to-harmonic ratio, voice turbulence index and soft phonation index) and the components of the GRBAS scale. Even if the GRBAS scale appears to have high reliability and clinical validity, it frequently provides insufficient information on the quality of a patient’s voice. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) has been introduced recently. It was developed after a 2002 consensus conference convened by the American Speech-Language Hearing Association’s Special Interest Division No. 3 for Voice and Voice Disorders. Like the GRBAS scale, the CAPE-V includes ratings of overall severity (‘grade’), roughness, breathiness and strain; additional parameters of the CAPE-V are pitch and loudness. The CAPE-V also includes two unlabeled scales; the clinician may use them to rate additional prominent attributes required to describe a given voice. Furthermore, the CAPE-V uses a visual analog scale labeled with visual markers for ‘mild’, ‘moderate’ and ‘severe’ under each line, instead of a four-point equal-appearing interval scale [12, 13]. Moreover, the CAPE-V prescribes specific tasks (vowel prolongations, specific sentences designed to elicit various laryngeal behaviors and running speech). The rater judges whether the voice attribute is consistent (C) or intermittent (I) for each of the six parameters; a judgment of I indicates that the attribute occurred inconsistently within or across tasks; a judgment of C indicates that the attribute was continuously present throughout the tasks. The CAPE-V seems to provide more detailed information on the characteristics of the examined voice, allowing for better communication among clinicians. To the best of our knowledge, only a few studies [2, 14–19] attempted to analyze the characteristics of the CAPE-V. Karnell et al. [14] reported high correspondence between CAPE-V and GRBAS scores and good intra- and interrater reliability on the CAPE-V. Kelchner et al. [15], who examined CAPE-V reliability for disordered pediatric voices, found excellent agreement within and across 3 raters from the same set258
Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
ting. Finally, Zraick et al. [2] examined the validity of the CAPE-V by comparing the judgments made by 21 raters of normal and disordered voices using the CAPE-V and the GRBAS scales and by comparing the raters’ judgments of overall severity to a priori consensus judgments of severity. They reported slightly improved rater reliability using the CAPE-V and evidence for satisfactory construct validity of this scale. Finally, Nemr et al. [19] reported a strong correlation in the intrajudge consensus analysis, both for the GRBAS scale as well as CAPE-V; a high degree of correlation between the general GRBAS and CAPE-V grades was found. In addition, the authors indicated that the GRBAS was the fastest and the CAPE-V the most sensitive, especially for detecting small changes in voice. The latter element is probably related to the use of a visual analog scale in the CAPE-V [9, 14, 19]. The CAPE-V has been used in different outcome studies; however, it is a recent tool and little information is available concerning the possible impact of social and cultural aspects on the perceptual judgment of the voice [19]. Replication studies on validity and reliability in different cultural settings are therefore useful to assess the applicability of the measures in a broad range of clinical settings. An Italian version of the CAPE-V has been provided [20], but a validation study of this version of the assessment has not been published. The aims of this study were (1) to evaluate the reliability and clinical validity of the Italian CAPE-V; (2) to analyze the correlations between the CAPE-V and GRBAS scores in a large cohort of dysphonic and nondysphonic patients, and (3) to compare CAPE-V scores in dysphonic patients with different underlying pathologies. Reliability and validity must be determined before applying the CAPE-V in the Italian context. In addition, even if previous research has shown that raters of different linguistic and cultural background do not show significant differences when rating the same voice [21], it is not known whether a change of the voice samples from English to Italian impacts the reliability and validity of the CAPE-V. Finally, there are clinical implications in knowing whether the CAPE-V can discriminate among dysphonias resulting from differing underlying conditions. The aim of this study is to culturally adapt the CAPEV to Italian and to evaluate its internal consistency, reliability and validity. The importance of a study using Italian speakers and raters lies in the fact that social and cultural aspects impact on the perceptual judgment of the voice [19]. Besides, a reliable and valid Italian version of the CAPE-V will allow the accomplishment of cross-cultural and cross-country studies. Mozzanica/Ginocchio/Borghi/Bachmann/ Schindler
Materials and Methods Participants Eighty dysphonic patients, 30 males and 50 females, were enrolled in a quasi-experimental study. The mean age was 50.1 ± 16.4 years (range 23–76). Six different etiological diagnoses were associated with dysphonia, including vocal fold polyp (6 patients), nodules (12 patients), Reinke’s edema (14 patients), unilateral vocal fold paralysis (UVFP, 20 patients), vocal fold scar (18 patients), and muscle tension dysphonia (10 patients). One hundred and twenty asymptomatic control subjects, 48 males and 72 females, all nonprofessional voice users with no history of voice disorders, were included to establish normative data. The mean age was 40.9 ± 14.5 years (range 16–72). Voice Measurements To obtain samples for auditory perceptual evaluation, the six groups of dysphonic patients and the 120 asymptomatic subjects were asked to complete the three tasks prescribed in the CAPE-V (vowel prolongations, reading sentences aloud, and conversation). The voice signal was recorded and directly stored in the host computer using the Computerized Speech Lab Model 4500 (Kay Elemetrics, Lincoln Park, N.J., USA). All voices were recorded with a microphone positioned approximately 10 cm from the mouth with an off-axis positioning (45–90° from the mouth axis) to reduce airflow effects. All recordings were made in a quiet room (ambient noise 0.80) for the remaining parameters (strain, pitch and loudness). The results for interrater reliability are reported in table 3. For the dysphonic participants, the correlations reached a value of 0.90 or greater for the first three parameters (overall severity, roughness, breathiness); correlations for the control group were somewhat lower. The interrater reliability appeared to be good (>0.80) for the parameters of pitch and loudness, while the reliability coefficient was 0.76 for the strain parameter. Results for the intra- and interrater reliability of attributes C and I are reported in table 4. Both agreement scores and k values were strong for intra- and interrater reliability analysis. Reliability of the paper and pencil scores was calculated to be greater than 95% for 60 randomly selected CAPE-V ratings.
Validity Analysis For all the raters the differences in CAPE-V values between the dysphonic and control groups were significant by t test for all six parameters (table 1). Kruskal-Wallis analysis for the parameters overall severity, roughness, breathiness, strain, and loudness from the CAPE-V revealed a significant main effect for group (p = 0.01, p = 0.049, p = 0.048, p = 0.041, and p = 0.001, respectively). Figure 1 shows CAPE-V scores obtained from patients with dysphonia from different causes. Post hoc MannWhitney comparisons demonstrated that patients with vocal polyps had significantly lower scores for St and L as compared to patients with UVFP, vocal fold scar, and muscle tension dysphonia. Patients with UVFP, on the other hand, had significantly higher scores for S, whereas patients with vocal fold scar had significantly higher scores for B as compared to all other subgroups of dysphonic patients.
Italian Version of CAPE-V
Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
261
34.2 35.2
42.8 27.9
13.2
24.8
26.4 27.1
37.5
37.6
45.6
46.6
49.1 23.9 26.1
12
8.8 ReinkeٿV edema
39.4
48.5 32.3 36.8 26.6 29.8
14.9
29.2
32.4 28.6 27.7
24.2 6.3
5.2
19.5 19.9 16.8
Polyp
53.1
63.6
S R B St P L
UVFP
1RGXOHV
Scar
MTD
Fig. 1. CAPE-V scores in patients with dysphonia of different origin. The mean scores for each subscale of CAPE-V have been reported. MTD = Muscle tension dysphonia; S = overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness.
Table 2. Intrarater reliability analysis of the CAPE-V using ICC analysis in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
0.93 (0.89–0.96) 0.92 (0.86–0.96) 0.90 (0.85–0.93) 0.90 (0.82–0.93) 0.89 (0.81–0.94) 0.78 (0.72–0.86)
0.91 (0.86–0.92) 0.91 (0.85–0.94) 0.90 (0.86–0.92) 0.88 (0.79–0.94) 0.86 (0.80–0.90) 0.82 (0.75–0.87)
0.92 (0.86–0.96) 0.92 (0.85–0.96) 0.90 (0.85–0.93) 0.89 (0.79–0.94) 0.88 (0.80–0.94) 0.80 (0.72–0.87)
S = Overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness. Ranges are reported in parentheses.
Table 3. Interrater reliability analysis of the CAPE-V using ICC
analysis in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
0.94 (0.87–0.96) 0.65 (0.52–0.74) 0.70 (0.62–0.78) 0.86 (0.78–0.91) 0.89 (0.82–0.93) 0.82 (0.73–0.91)
0.91 (0.82–0.94) 0.90 (0.78–0.94) 0.91 (0.82–0.94) 0.65 (0.54–0.72) 0.70 (0.59–0.82) 0.87 (0.78–0.93)
0.92 (0.82–0.96) 0.91 (0.72–0.96) 0.90 (0.81–0.94) 0.76 (0.62–0.83) 0.83 (0.71–0.89) 0.82 (0.74–0.90)
S = Overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness. Ranges are reported in parentheses.
Table 4. Results on the intra- and interrater reliability of attributes C and I of the CAPE-V in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
% agreement
κ value
% agreement
κ value
% agreement
κ value
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
1 1 1 1 1 0.97
1 1 0.97 1 1 0.97
1 1 1 1 1 0.95
1 1 0.97 1 1 0.94
0.97 0.97 0.92 0.89 0.94 1
0.94 0.86 0.89 0.81 0.78 0.92
0.97 0.97 0.91 0.88 0.94 1
0.94 0.83 0.88 0.77 0.73 0.91
0.98 0.98 0.96 0.95 0.97 0.98
0.97 0.93 0.96 0.91 0.89 0.98
0.98 0.98 0.96 0.95 0.97 0.98
0.97 0.93 0.96 0.90 0.88 0.98
IntraR = Intrarater reliability; InterR = interrater reliability; S = overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness.
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Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
Mozzanica/Ginocchio/Borghi/Bachmann/ Schindler
Table 5. Correlations between comparable CAPE-V and GRBAS
scales CAPE-V
GRBAS
Correlation
Overall severity Roughness Breathiness Strain
Grade Roughness Breathiness Strain
0.92* 0.84* 0.87* 0.79*
* p < 0.05.
Table 5 reports correlations between four CAPE-V and GRBAS scales (overall severity/grade, roughness, breathiness and strain). The highest average correlation was found between overall severity and grade (0.92), while the lowest was found between the two strain scales (0.79).
Discussion
Perceptual voice evaluation plays a key role in the assessment of voice quality and nowadays the most commonly used auditory perceptual protocol is the GRBAS scale. The CAPE-V, an alternative to GRBAS, is an auditory perceptual assessment protocol developed in the USA in 2002 and increasingly used in both clinical practice and voice research [19, 22, 23]. Even if the reliability and validity of the CAPE-V has been the object of previous investigation [2, 14, 15], there is still a paucity of information on the clinical validity and reliability of this tool, and only limited data exist on its application in different cultures and different languages [19]. Intra- and interrater reliability, as well as the validity of the Italian CAPE-V, have been studied for the first time in patients with dysphonia associated with various etiologies and in a control group of Italianspeaking people. Reliability and validity of the Italian CAPE-V appeared to be good, suggesting useful application of the protocol for both clinical practice and voice research. The CAPE-V demonstrated high intra- and interrater reliability. Stronger results were found for intrarater, as compared to interrater reliability. In particular, in this latter analysis the parameters of strain, loudness and pitch scored less than 0.90, while the best result was found for overall severity of dysphonia. These observations are consistent with existing literature on the GRBAS scale [9, 24] and CAPE-V analysis [2, 14–16]. In particular, the rater reliability of CAPE-V was evaluated in a study by KelchItalian Version of CAPE-V
ner et al. [15]. The authors found that the interrater reliability was strongest for perceptual ratings of breathiness, roughness, pitch and overall severity. Reliability was lower for ratings of loudness and strain, while intrarater reliability, on all but the parameter of strain, was moderate to strong. Solomon et al. [16] found the highest reliability for the parameter of overall severity, and the worst result for vocal strain. These findings are in agreement with those of the present study. It is possible that the lower correlation for the perception of strain found in this study depended on the particular voice disorders included in the present study. This study had only a limited set of voice disorders likely to have a high degree of strain. Perhaps the inclusion of severely strained voices, such as in spasmodic dysphonia, would have increased the total range of strain, resulting in higher average correlation values. The reliability results reported here appear higher than those of other studies. This probably depends on various factors such as differences in number of stimuli, characteristics of dysphonic voice, number of judges, experimental procedures and training, and presentation of voice samples. Previous research has shown that reliability of perceptual assessment decreases in cases of severe roughness and breathiness [25]; besides, CAPE-V ratings obtained in clinical settings with live voices have been compared to those obtained in laboratory settings, presented over headphones and accompanied by an auditory reference for moderate severity [16]. In the present study, the lower reliability of the parameters of loudness and pitch was probably related to the reduced experience of the raters in the evaluation of these parameters compared to the parameters already present in the GRBAS scale. As far as the degree of association between the GRBAS and the CAPE-V scores is concerned, the results reported here appear quite similar to previous studies and this further supports the construct validity of the CAPE-V [2, 14, 19]. It is possible that the slight differences in the correlation level between CAPE-V and GRBAS reported in previous studies were related to many factors, such as rating systems, number of raters, and type of statistical analysis. Further studies, including pathological voices of different etiologies and a larger number of raters exploring the effect of the raters’ experience and education, are needed to further validate the CAPE-V because previous research on perceptual voice assessment indicates that all of these parameters play a significant role in its reliability [24, 26–29]. Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
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Persons with no history of voice disorders were rated using the CAPE-V, with scores near 0 by all the raters. As expected, patients were rated with higher scores. Furthermore, it seems that patients with different diseases score differently on the CAPE-V analysis. Statistically significant differences for CAPE-V scores were found for the first time among patients with different pathological origins, as shown in figure 1. In particular, patients with UVFP presented a higher severity of dysphonia whereas patients with scarred vocal folds had a higher degree of breathiness. These data confirm clinical impressions and are in line with previous research on the GRBAS scale [25]. This finding is important as it suggests that the CAPE-V and GRBAS scales may contribute to separating different clinical entities, thus supporting clinicians in the diagnostic process. A major difference between the CAPE-V and the GRBAS scale is the introduction of pitch and loudness parameters in the former. In the present study, patients with polyps showed significantly lower scores on loudness compared to other pathological groups. In addition, patients with muscle tension dysphonia, vocal fold scar, and UVFP presented higher loudness scores compared to patients with nodules, Reinke’s edema, and polyps. Even
though not all these differences reached statistical significance, they support the introduction of the loudness parameter. No differences between different pathologies were found for the pitch parameter. This finding should be considered with care and does not necessarily mean that pitch is a useless parameter in voice evaluation. In fact, it is likely that in the present study the absence of differences in the pitch parameter is related to the type of voice pathologies included in the study. Different results might be found with other pathologies, such as mutational falsetto, psychogenic dysphonia, or transgender voice. This study has some limitations. First, each voice was rated by only 3 speech-language pathologists, and it is possible that the high reliability scores were partially related to the similar clinical and scientific education of the raters. Also, although there is some evidence for different CAPE-V profiles for different types of voice disorder, the study does not allow the identification of disorder-specific profiles because of the relatively small number of patients enrolled in the study. The results for the participants with dysphonia must therefore be regarded as preliminary evidence for the ability of CAPE-V to discriminate dysphonias associated with different underlying causes.
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8 Moerman M, Martens JP, Crevier-Buchman L, de Haan E, Grand S, Tessier C, Woisard V, Dejonckere P: The INFVo perceptual rating scale for substitution voicing: development and reliability. Eur Arch Otorhinolaryngol 2006;263:435–439. 9 Kempster GB, Gerratt BR, Verdolini Abbott K, Barkmeier-Kraemer J, Hillman RE: Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol. Am J Speech Lang Pathol 2009;18:124–132. 10 De Bodt MS, Wuyts FL, Van de Heyning PH, Croux C: Test-retest study of GRBAS scale: influence of experience and professional background on perceptual rating of voice quality. J Voice 1997;11:74–80. 11 Bhuta T, Patrick L, Garnett JD: Perceptual evaluation of voice quality and its correlation with acoustic measurements. J Voice 2004;18: 299–304. 12 Wuyts FL, De Bodt MS, Van de Heyning PH: Is the reliability of a visual analog scale higher than an ordinal scale? An experiment with the GRBAS scale for the perceptual evaluation of dysphonia. J Voice 1999;13:508–517. 13 Yu P, Revis J, Wuyts FL, Zanaret M, Giovanni A: Correlation of instrumental voice evaluation with perceptual voice analysis using a
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Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Published online: April 1, 2014
Reliability and Validity of the Italian Version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) F. Mozzanica a D. Ginocchio b E. Borghi a C. Bachmann a A. Schindler a a
Department of Clinical Sciences ‘L. Sacco’, University of Milan, and b Department of Audiology, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
Key Words Dysphonia · CAPE-V · Voice disorders · Perceptual voice evaluation
Abstract Objectives: To evaluate the reliability and validity of the Italian version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Patients and Methods: Eighty dysphonic patients and 120 asymptomatic subjects were enrolled. The voice signal of each participant was recorded, listened to and rated by 3 licensed speech-language pathologists using the GRBAS scale and the Italian version of the CAPE-V. The intra- and interrater reliability of the CAPE-V was assessed as well as the degree of association between the CAPE-V and GRBAS judgments. The CAPE-V values were also compared between the patients with dysphonia and the asymptomatic subjects. Results: The intra- and interrater reliability appeared to be good for all the parameters except for the strain parameter. The attributes ‘consistent’ and ‘intermittent’ demonstrated optimal intra- and interrater reliability. The difference between pathological and control groups was significant for six perceptual parameters. The highest average correlation between GRBAS and CAPE-V judgments was found between overall severity and grade while the lowest was found between the two strain scales. CAPE-V profiles differed significantly between different
© 2014 S. Karger AG, Basel 1021–7762/14/0655–0257$39.50/0 E-Mail [email protected] www.karger.com/fpl
pathological groups. Conclusion: The Italian version of CAPE-V appears to be a reliable and valid tool for the perceptual analysis of the voice signal. © 2014 S. Karger AG, Basel
Introduction
In the assessment of a voice disorder no single value or instrumental measure can conclusively quantify or characterize the disease. In fact, the evaluation of voice remains a multifactorial process involving several approaches (e.g. perceptual evaluation, acoustic and physiologic measures, self-assessment of voice handicap) in order to offer different perspectives on describing the vocal function. In 2001, Dejonckere et al. [1] proposed a basic protocol for a functional assessment of voice pathology including five different approaches: perception, videostroboscopy, acoustics, aerodynamic analysis and subjective rating by the patient. Even if perceptual voice evaluation is fundamental in the assessment of voice quality, it appears to be a controversial subject probably because of the many psychophysical scaling issues that influence the tasks [2] and the difficulties in obtaining good reliability [3]. Several scaling methods are available in the international literature [4–9]. Nowadays, the auditory perceptual protocol in greatest use worldwide is the Francesco Mozzanica Ospedale ‘L. Sacco’ Via G.B. Grassi 74 IT–20157 Milan (Italy) E-Mail francesco.mozzanica @ gmail.com
GRBAS scale [4]. The GRBAS scale contains five welldefined parameters: G (overall grade of hoarseness), R (roughness), B (breathiness), A (asthenicity) and S (strained quality); each parameter is rated on a four-point equal-appearing interval scale from 0 (no problem) to 3 (severe problem). Reliability, clinical relevance and correlation with acoustic measures have been studied by several authors [10, 11]. In particular, De Bodt et al. [10] reported that the test-retest reliability of the grade parameter ranged from fair to good; Bhuta et al. [11] demonstrated a significant correlation between the noiserelated parameters of the Multi-Dimensional Voice Program (noise-to-harmonic ratio, voice turbulence index and soft phonation index) and the components of the GRBAS scale. Even if the GRBAS scale appears to have high reliability and clinical validity, it frequently provides insufficient information on the quality of a patient’s voice. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) has been introduced recently. It was developed after a 2002 consensus conference convened by the American Speech-Language Hearing Association’s Special Interest Division No. 3 for Voice and Voice Disorders. Like the GRBAS scale, the CAPE-V includes ratings of overall severity (‘grade’), roughness, breathiness and strain; additional parameters of the CAPE-V are pitch and loudness. The CAPE-V also includes two unlabeled scales; the clinician may use them to rate additional prominent attributes required to describe a given voice. Furthermore, the CAPE-V uses a visual analog scale labeled with visual markers for ‘mild’, ‘moderate’ and ‘severe’ under each line, instead of a four-point equal-appearing interval scale [12, 13]. Moreover, the CAPE-V prescribes specific tasks (vowel prolongations, specific sentences designed to elicit various laryngeal behaviors and running speech). The rater judges whether the voice attribute is consistent (C) or intermittent (I) for each of the six parameters; a judgment of I indicates that the attribute occurred inconsistently within or across tasks; a judgment of C indicates that the attribute was continuously present throughout the tasks. The CAPE-V seems to provide more detailed information on the characteristics of the examined voice, allowing for better communication among clinicians. To the best of our knowledge, only a few studies [2, 14–19] attempted to analyze the characteristics of the CAPE-V. Karnell et al. [14] reported high correspondence between CAPE-V and GRBAS scores and good intra- and interrater reliability on the CAPE-V. Kelchner et al. [15], who examined CAPE-V reliability for disordered pediatric voices, found excellent agreement within and across 3 raters from the same set258
Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
ting. Finally, Zraick et al. [2] examined the validity of the CAPE-V by comparing the judgments made by 21 raters of normal and disordered voices using the CAPE-V and the GRBAS scales and by comparing the raters’ judgments of overall severity to a priori consensus judgments of severity. They reported slightly improved rater reliability using the CAPE-V and evidence for satisfactory construct validity of this scale. Finally, Nemr et al. [19] reported a strong correlation in the intrajudge consensus analysis, both for the GRBAS scale as well as CAPE-V; a high degree of correlation between the general GRBAS and CAPE-V grades was found. In addition, the authors indicated that the GRBAS was the fastest and the CAPE-V the most sensitive, especially for detecting small changes in voice. The latter element is probably related to the use of a visual analog scale in the CAPE-V [9, 14, 19]. The CAPE-V has been used in different outcome studies; however, it is a recent tool and little information is available concerning the possible impact of social and cultural aspects on the perceptual judgment of the voice [19]. Replication studies on validity and reliability in different cultural settings are therefore useful to assess the applicability of the measures in a broad range of clinical settings. An Italian version of the CAPE-V has been provided [20], but a validation study of this version of the assessment has not been published. The aims of this study were (1) to evaluate the reliability and clinical validity of the Italian CAPE-V; (2) to analyze the correlations between the CAPE-V and GRBAS scores in a large cohort of dysphonic and nondysphonic patients, and (3) to compare CAPE-V scores in dysphonic patients with different underlying pathologies. Reliability and validity must be determined before applying the CAPE-V in the Italian context. In addition, even if previous research has shown that raters of different linguistic and cultural background do not show significant differences when rating the same voice [21], it is not known whether a change of the voice samples from English to Italian impacts the reliability and validity of the CAPE-V. Finally, there are clinical implications in knowing whether the CAPE-V can discriminate among dysphonias resulting from differing underlying conditions. The aim of this study is to culturally adapt the CAPEV to Italian and to evaluate its internal consistency, reliability and validity. The importance of a study using Italian speakers and raters lies in the fact that social and cultural aspects impact on the perceptual judgment of the voice [19]. Besides, a reliable and valid Italian version of the CAPE-V will allow the accomplishment of cross-cultural and cross-country studies. Mozzanica/Ginocchio/Borghi/Bachmann/ Schindler
Materials and Methods Participants Eighty dysphonic patients, 30 males and 50 females, were enrolled in a quasi-experimental study. The mean age was 50.1 ± 16.4 years (range 23–76). Six different etiological diagnoses were associated with dysphonia, including vocal fold polyp (6 patients), nodules (12 patients), Reinke’s edema (14 patients), unilateral vocal fold paralysis (UVFP, 20 patients), vocal fold scar (18 patients), and muscle tension dysphonia (10 patients). One hundred and twenty asymptomatic control subjects, 48 males and 72 females, all nonprofessional voice users with no history of voice disorders, were included to establish normative data. The mean age was 40.9 ± 14.5 years (range 16–72). Voice Measurements To obtain samples for auditory perceptual evaluation, the six groups of dysphonic patients and the 120 asymptomatic subjects were asked to complete the three tasks prescribed in the CAPE-V (vowel prolongations, reading sentences aloud, and conversation). The voice signal was recorded and directly stored in the host computer using the Computerized Speech Lab Model 4500 (Kay Elemetrics, Lincoln Park, N.J., USA). All voices were recorded with a microphone positioned approximately 10 cm from the mouth with an off-axis positioning (45–90° from the mouth axis) to reduce airflow effects. All recordings were made in a quiet room (ambient noise 0.80) for the remaining parameters (strain, pitch and loudness). The results for interrater reliability are reported in table 3. For the dysphonic participants, the correlations reached a value of 0.90 or greater for the first three parameters (overall severity, roughness, breathiness); correlations for the control group were somewhat lower. The interrater reliability appeared to be good (>0.80) for the parameters of pitch and loudness, while the reliability coefficient was 0.76 for the strain parameter. Results for the intra- and interrater reliability of attributes C and I are reported in table 4. Both agreement scores and k values were strong for intra- and interrater reliability analysis. Reliability of the paper and pencil scores was calculated to be greater than 95% for 60 randomly selected CAPE-V ratings.
Validity Analysis For all the raters the differences in CAPE-V values between the dysphonic and control groups were significant by t test for all six parameters (table 1). Kruskal-Wallis analysis for the parameters overall severity, roughness, breathiness, strain, and loudness from the CAPE-V revealed a significant main effect for group (p = 0.01, p = 0.049, p = 0.048, p = 0.041, and p = 0.001, respectively). Figure 1 shows CAPE-V scores obtained from patients with dysphonia from different causes. Post hoc MannWhitney comparisons demonstrated that patients with vocal polyps had significantly lower scores for St and L as compared to patients with UVFP, vocal fold scar, and muscle tension dysphonia. Patients with UVFP, on the other hand, had significantly higher scores for S, whereas patients with vocal fold scar had significantly higher scores for B as compared to all other subgroups of dysphonic patients.
Italian Version of CAPE-V
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34.2 35.2
42.8 27.9
13.2
24.8
26.4 27.1
37.5
37.6
45.6
46.6
49.1 23.9 26.1
12
8.8 ReinkeٿV edema
39.4
48.5 32.3 36.8 26.6 29.8
14.9
29.2
32.4 28.6 27.7
24.2 6.3
5.2
19.5 19.9 16.8
Polyp
53.1
63.6
S R B St P L
UVFP
1RGXOHV
Scar
MTD
Fig. 1. CAPE-V scores in patients with dysphonia of different origin. The mean scores for each subscale of CAPE-V have been reported. MTD = Muscle tension dysphonia; S = overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness.
Table 2. Intrarater reliability analysis of the CAPE-V using ICC analysis in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
0.93 (0.89–0.96) 0.92 (0.86–0.96) 0.90 (0.85–0.93) 0.90 (0.82–0.93) 0.89 (0.81–0.94) 0.78 (0.72–0.86)
0.91 (0.86–0.92) 0.91 (0.85–0.94) 0.90 (0.86–0.92) 0.88 (0.79–0.94) 0.86 (0.80–0.90) 0.82 (0.75–0.87)
0.92 (0.86–0.96) 0.92 (0.85–0.96) 0.90 (0.85–0.93) 0.89 (0.79–0.94) 0.88 (0.80–0.94) 0.80 (0.72–0.87)
S = Overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness. Ranges are reported in parentheses.
Table 3. Interrater reliability analysis of the CAPE-V using ICC
analysis in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
0.94 (0.87–0.96) 0.65 (0.52–0.74) 0.70 (0.62–0.78) 0.86 (0.78–0.91) 0.89 (0.82–0.93) 0.82 (0.73–0.91)
0.91 (0.82–0.94) 0.90 (0.78–0.94) 0.91 (0.82–0.94) 0.65 (0.54–0.72) 0.70 (0.59–0.82) 0.87 (0.78–0.93)
0.92 (0.82–0.96) 0.91 (0.72–0.96) 0.90 (0.81–0.94) 0.76 (0.62–0.83) 0.83 (0.71–0.89) 0.82 (0.74–0.90)
S = Overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness. Ranges are reported in parentheses.
Table 4. Results on the intra- and interrater reliability of attributes C and I of the CAPE-V in both the pathological and the control groups
S R B St P L
Control group (n = 120)
Pathological group (n = 80)
Total (n = 200)
% agreement
κ value
% agreement
κ value
% agreement
κ value
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
IntraR
InterR
1 1 1 1 1 0.97
1 1 0.97 1 1 0.97
1 1 1 1 1 0.95
1 1 0.97 1 1 0.94
0.97 0.97 0.92 0.89 0.94 1
0.94 0.86 0.89 0.81 0.78 0.92
0.97 0.97 0.91 0.88 0.94 1
0.94 0.83 0.88 0.77 0.73 0.91
0.98 0.98 0.96 0.95 0.97 0.98
0.97 0.93 0.96 0.91 0.89 0.98
0.98 0.98 0.96 0.95 0.97 0.98
0.97 0.93 0.96 0.90 0.88 0.98
IntraR = Intrarater reliability; InterR = interrater reliability; S = overall severity; R = roughness; B = breathiness; St = strain; P = pitch; L = loudness.
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Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
Mozzanica/Ginocchio/Borghi/Bachmann/ Schindler
Table 5. Correlations between comparable CAPE-V and GRBAS
scales CAPE-V
GRBAS
Correlation
Overall severity Roughness Breathiness Strain
Grade Roughness Breathiness Strain
0.92* 0.84* 0.87* 0.79*
* p < 0.05.
Table 5 reports correlations between four CAPE-V and GRBAS scales (overall severity/grade, roughness, breathiness and strain). The highest average correlation was found between overall severity and grade (0.92), while the lowest was found between the two strain scales (0.79).
Discussion
Perceptual voice evaluation plays a key role in the assessment of voice quality and nowadays the most commonly used auditory perceptual protocol is the GRBAS scale. The CAPE-V, an alternative to GRBAS, is an auditory perceptual assessment protocol developed in the USA in 2002 and increasingly used in both clinical practice and voice research [19, 22, 23]. Even if the reliability and validity of the CAPE-V has been the object of previous investigation [2, 14, 15], there is still a paucity of information on the clinical validity and reliability of this tool, and only limited data exist on its application in different cultures and different languages [19]. Intra- and interrater reliability, as well as the validity of the Italian CAPE-V, have been studied for the first time in patients with dysphonia associated with various etiologies and in a control group of Italianspeaking people. Reliability and validity of the Italian CAPE-V appeared to be good, suggesting useful application of the protocol for both clinical practice and voice research. The CAPE-V demonstrated high intra- and interrater reliability. Stronger results were found for intrarater, as compared to interrater reliability. In particular, in this latter analysis the parameters of strain, loudness and pitch scored less than 0.90, while the best result was found for overall severity of dysphonia. These observations are consistent with existing literature on the GRBAS scale [9, 24] and CAPE-V analysis [2, 14–16]. In particular, the rater reliability of CAPE-V was evaluated in a study by KelchItalian Version of CAPE-V
ner et al. [15]. The authors found that the interrater reliability was strongest for perceptual ratings of breathiness, roughness, pitch and overall severity. Reliability was lower for ratings of loudness and strain, while intrarater reliability, on all but the parameter of strain, was moderate to strong. Solomon et al. [16] found the highest reliability for the parameter of overall severity, and the worst result for vocal strain. These findings are in agreement with those of the present study. It is possible that the lower correlation for the perception of strain found in this study depended on the particular voice disorders included in the present study. This study had only a limited set of voice disorders likely to have a high degree of strain. Perhaps the inclusion of severely strained voices, such as in spasmodic dysphonia, would have increased the total range of strain, resulting in higher average correlation values. The reliability results reported here appear higher than those of other studies. This probably depends on various factors such as differences in number of stimuli, characteristics of dysphonic voice, number of judges, experimental procedures and training, and presentation of voice samples. Previous research has shown that reliability of perceptual assessment decreases in cases of severe roughness and breathiness [25]; besides, CAPE-V ratings obtained in clinical settings with live voices have been compared to those obtained in laboratory settings, presented over headphones and accompanied by an auditory reference for moderate severity [16]. In the present study, the lower reliability of the parameters of loudness and pitch was probably related to the reduced experience of the raters in the evaluation of these parameters compared to the parameters already present in the GRBAS scale. As far as the degree of association between the GRBAS and the CAPE-V scores is concerned, the results reported here appear quite similar to previous studies and this further supports the construct validity of the CAPE-V [2, 14, 19]. It is possible that the slight differences in the correlation level between CAPE-V and GRBAS reported in previous studies were related to many factors, such as rating systems, number of raters, and type of statistical analysis. Further studies, including pathological voices of different etiologies and a larger number of raters exploring the effect of the raters’ experience and education, are needed to further validate the CAPE-V because previous research on perceptual voice assessment indicates that all of these parameters play a significant role in its reliability [24, 26–29]. Folia Phoniatr Logop 2013;65:257–265 DOI: 10.1159/000356479
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Persons with no history of voice disorders were rated using the CAPE-V, with scores near 0 by all the raters. As expected, patients were rated with higher scores. Furthermore, it seems that patients with different diseases score differently on the CAPE-V analysis. Statistically significant differences for CAPE-V scores were found for the first time among patients with different pathological origins, as shown in figure 1. In particular, patients with UVFP presented a higher severity of dysphonia whereas patients with scarred vocal folds had a higher degree of breathiness. These data confirm clinical impressions and are in line with previous research on the GRBAS scale [25]. This finding is important as it suggests that the CAPE-V and GRBAS scales may contribute to separating different clinical entities, thus supporting clinicians in the diagnostic process. A major difference between the CAPE-V and the GRBAS scale is the introduction of pitch and loudness parameters in the former. In the present study, patients with polyps showed significantly lower scores on loudness compared to other pathological groups. In addition, patients with muscle tension dysphonia, vocal fold scar, and UVFP presented higher loudness scores compared to patients with nodules, Reinke’s edema, and polyps. Even
though not all these differences reached statistical significance, they support the introduction of the loudness parameter. No differences between different pathologies were found for the pitch parameter. This finding should be considered with care and does not necessarily mean that pitch is a useless parameter in voice evaluation. In fact, it is likely that in the present study the absence of differences in the pitch parameter is related to the type of voice pathologies included in the study. Different results might be found with other pathologies, such as mutational falsetto, psychogenic dysphonia, or transgender voice. This study has some limitations. First, each voice was rated by only 3 speech-language pathologists, and it is possible that the high reliability scores were partially related to the similar clinical and scientific education of the raters. Also, although there is some evidence for different CAPE-V profiles for different types of voice disorder, the study does not allow the identification of disorder-specific profiles because of the relatively small number of patients enrolled in the study. The results for the participants with dysphonia must therefore be regarded as preliminary evidence for the ability of CAPE-V to discriminate dysphonias associated with different underlying causes.
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