Evaluation Akzentmethode

Main Report W Hauptreferat W Rapport principal

Folia Phoniatr Logop 1998;50:146–164

Efficacy of the Accent Method ofVoice Therapy

Samia Bassiouny

Faculty of Medicine, Ain ShamsUniversity, Cairo, Egypt

Dr. Samia BassiounyFaculty of MedicineAin Shams UniversityCairo (Egypt)Fax +20 2 260 5805

ABCFax + 41 61 306 12 34E-Mail [email protected]

© 1998 S. Karger AG, Basel1021–7762/98/0503–0146$15.00/0

This article is also accessible online at:http://BioMedNet.com/karger

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Key WordsEfficacy W Accent method W Voice therapy W Voice hygiene advice W

Voice disorders

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AbstractThere is an increasing need for studies of efficacy ofbehavior readjustment therapy procedures in humancommunicative disorders. Legal, social, scientific andprofessional considerations point up the need for morecareful documentation of the effects of treatment tech-niques used by phoniatricians and speech-languagepathologists. This study is conducted in order to evalu-ate the efficacy of the accent method of voice therapy(AM). The AM is one of the holistic approaches forbehavior readjustment voice therapy. It tackles collec-tively and simultaneously the various parameters ofvoice such as pitch, loudness and timbre. The results ofintervention utilizing the AM in this clinical trial areassessed in a relatively controlled setup. Patients withvoice problems resulting from various etiologic vocalpathologies are distributed randomly into two groups.Group 1 (G1) is given the full aspect of the AM, that is,voice hygiene advice plus the accent exercises to cor-rect the faulty vocal technique (habit). Group 2 (G2)

receives only voice hygiene advice. The AM is admin-istered in individual sessions 20 min each, twice aweek, while the voice hygiene advice counseling is giv-en once a week. The assessment of the vocal pathologyis done following a diagnostic protocol utilizing subjec-tive as well as quasi-objective measures of evaluation.The initial assessment presents the baseline (pretest)data for both groups. The follow-up evaluations aredone at mid intervention (mid-test), that is, 10 sessionsfor G1 and 5 sessions for G2, and at the termination ofintervention/therapy (post-test). The difference in im-provement between G1 and G2 at the end of the obser-vation was generally significant in favor of G1. Therewere significant improvements in G1 in certain itemsspecific for the various etiologic categories. The im-provement from pretest to mid-test to post-test valuesfollowed a linear tendency. The significance of theresults is discussed and the conclusions are outlinedand criticized.

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Die Wirksamkeit der Akzentmethode in der StimmtherapieDie Arbeit der Phoniater und Logopäden erfordertvermehrte Untersuchungen betreffend der Wirksam-keit angewendeter Behandlungstechniken. Diese Stu-die prüft die Wirksamkeit der Akzentmethode in derfunktionellen Stimmrehabilitation. Die Akzentmetho-de befasst sich mit verschiedenen Stimmelementenwie Tonhöhe, Lautheit und Timbre. Die Daten derTherapieresultate wurden in kontrollierten Gruppen

erhoben. Bezüglich der Versuchsanordnung wurdenzwei randomisierte Gruppen gebildet, nämlich G1 dievoll mit Akzentmethode behandelt wurde, und einerKontrollgruppe G2, die nur stimmhygienische Bera-tung erhielt. Die G1-Patienten erhielten zweimal20 min Therapie pro Woche, während die G2-Gruppeeinmal wöchentlich Stimmhygieneberatung erhielt. Ineinem Protokoll wurden objektive und halbobjekte Be-

Efficacy of the Accent Method of VoiceTherapy

Folia Phoniatr Logop 1998;50:146–164 147

funde eingetragen, wobei der Eingangsstatus für beideGruppen identisch gehalten wurde. Der erste Thera-piebefund wurde bei der G1-Gruppe nach 10, bei derG2-Gruppe nach 5 Sitzungen erhoben, ebenso beiBeendigung der Therapie. Der Vergleich zwischen G1

und G2 ergab statistisch signifikante Unerschiede zu-gunsten von G1. Dieser Erfolg konnte für verschiedeneAtiologien nachgewiesen werden. Die Resultate derBefunde werden diskutiert.

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Efficacité de la méthode de l’accent en thérapie vocaleL’étude de l’efficacité des mesures thérapeutiques uti-lisées pour la réadaptation des troubles de la communi-cation rencontre un intérêt croissant. Des considéra-tions légales, sociales, scientifiques et professionnellesincitent à une documentation plus précise des effetsdes traitements utilisés par les phoniatres et les logopé-distes. Cette étude évalue l’efficacité de la méthode del’accent (MA) en thérapie vocale. La MA est uneapproche holistique intéressant les différents paramè-tres de la voix (hauteur, intensité et timbre). Des

patients présentant des problèmes vocaux d’étiologiesdiverses furent divisés en deux groupes randomisés,l’un et l’autre recevant des conseils d’hygiène vocale,mais un seul étant traité par la MA. Les évaluations sefirent à 3 stades du traitement. Le groupe ayant bénéfi-cié de la MA montra des améliorations significativespour certains aspects spécifiques de diverses variétésétiologiques. Les résultats sont soumis à une étude cri-tique.

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Introduction

Need for Efficacy StudiesThere is an increasing need for efficacy

studies of behavior readjustment therapy pro-cedures in human communicative disorders.The clinician needs a proof that the proce-dures adopted in daily practice are clinicallyeffective. Clinicians and researchers needguidelines for improvement and modificationof existing therapy procedures. Auditors andfunding agencies also need a proof that thetime and money spent in clinical settings isworth the effort and spending, and that theprocess is cost-effective. As a general princi-ple, professional services rendered anywhereshould not be based upon subjective evalua-tions, but rather justifiable on objectivegrounds. Any health authority in a clinicalsetup will not continue to support clinicalbudget services whose effects are questionableor are based upon subjective evaluations. Ob-jective documentation of the effectiveness oftreatment is an essential goal in managing allpatients.

Bleile [1] reported that the need for infor-mation on treatment outcome was listed asthe highest health care priority by a recentAmerican Speech-Language and Hearing As-sociation task force [2]. The fact that theAmerican Speech-Language and Hearing As-sociation and the National Institute on Deaf-ness and Other Communication Disorders ofthe National Institutes of Health sponsoredresearch conference on models for the evalua-tion of treatment efficacy during the 1992annual ASHA convention is an explicit recog-nition of the need to improve and developresearch methods that provide sufficient da-ta to guide the selection of treatment ap-proaches.

Types of Efficacy StudiesHegde [3] stated that the distinction be-

tween improvement in client behaviors andeffectiveness of treatment techniques high-lights the importance of controlled clinicalresearch. Client improvement while receivingtreatment does not necessarily suggest that thetreatment was indeed effective. Improvement

148 Folia Phoniatr Logop 1998;50:146–164 Bassiouny

is a necessary but not a sufficient conditionfor establishing effectiveness of treatmenttechniques. In uncontrolled studies on treat-ment/therapy, there is no assurance thatclients would not have produced those im-proved behaviors in the absence of treatment.In other words, what are considered ‘normaldevelopmental changes’, ‘spontaneous recov-ery’, ‘potential influence of formal or informaltreatment programs’ initiated by sources oth-er than the clinician are not ruled out. ‘Clientimprovement’ is noted when follow-up of thepatient reveals changes in behaviors undertreatment. ‘Treatment effectiveness’ is docu-mented only when the influence of other po-tential treatment variables is ruled out. Thisgoal is attained when controlled documentedresearch is conducted. Such documentedchanges also demonstrate clinician’s accoun-tability.

Law [4] reported that treatment evaluationrefers to several levels of accountability: effec-tiveness, efficiency, effects and efficacy. ‘Ef-fectiveness’ refers to whether a treatment canbe shown to work or not insofar as it alters thecourse of a disorder. ‘Efficiency’ looks at therelative values of different treatments but alsorefers to broader concepts relating to clinicalpractice, including economic analysis. ‘Ef-fects’ refers to changes in behaviors and isequivalent to outcomes. ‘Efficacy’ refers toevaluation carried out under more rigorouslycontrolled laboratory conditions. Efficacy,however, is interpreted differently by differ-ent authors.

There are several models to test efficacy oftherapeutic agents and procedures [3, 5].Some of the models are not feasible, and insome instances, even unethical, to apply tobehavioral studies. Withholding the therapyfor a period of time under the experiment, anethical question in itself, may not reverse thegains in a reasonable period of time to allowobjective judgment regarding the relationship

between the initial gains and the therapy pro-cedure. In such clinical trials other modelsmay be applied. Patients may be distributedrandomly into several groups. The tested ther-apy procedure will be withheld from onegroup, while administered to another group.For additional control a third group may begiven a therapy procedure that is not address-ing the target as the tested procedure, forexample an articulation drill in case of a voicedisorder. In that latter group the active thera-py procedure may be considered as a pla-cebo.

The two basic approaches to documenteffectiveness of treatment programs are thebetween-groups strategy and the within-sub-ject strategy. The former strategy, which isvariously known as group design study, or sta-tistical research design, is based on the con-cept of group comparisons. One group is theexperimental group, which receives treat-ment; the other is the control group, which isuntreated. The basic assumption in this ap-proach is that patients who are treated willchange while those who are not treated re-main unchanged. The within-subject strategy,also known as single-subject strategy, is basedon the fact that each subject serves as his orher own control. The clients receive treatmentin one condition and do not receive treatmentin another condition. The same behaviors ofthe patient under treatment versus no treat-ment are compared to determine the efficacyof treatment. Another characteristic of thisstrategy is that the patient’s behaviors aremeasured continuously. Treatment effects arenot determined on the basis of pretest andpost-test measures, but are assessed in eachexperimental session so that a continuous pic-ture of change over time is obtained. Hegde[3] reported several single-subject designs todetermine treatment effectiveness, e.g. theABA, the ABAB and the multiple baselinedesign which are the most commonly used



models. In the ABA, in the first A phase theinitial baselines are established. In the Bphase, the therapy is applied and new data arecollected. The final A phase represents thedata when the therapy is withdrawn. TheABAB design has two versions: The first is the‘ABAB withdrawal’ where the initial A and Bare similar to the ABA design. The second A isthe withdrawal of therapy. The final B repre-sents data after reapplication of therapy. Thesecond version is the ‘ABAB reversal’ which issimilar to the first version but in the second Aefforts are made to reverse the therapeuticgains achieved in the first B. The final B is toreapply the therapy to correct the deficit andreach the therapeutic target behavior again.

The Accent Method of Voice TherapyThe management of voice disorders may

follow one of four lines, one of them is behav-ior readjustment measures [6]. In voice thera-py behavior readjustment comprises two ele-ments [7]. These are voice hygiene advice andcorrection of a faulty vocal technique. Theaccent method (AM) of voice therapy is one ofthe holistic approaches for behavior modifica-tion of the voice [6]. It was introduced bySvend Smith in the thirties of this century [8].It has been applied for the treatment of voicedisorders for decades in various parts of theworld.

The AM targets holistically the improve-ment of the respiratory, phonatory, articulato-ry, and gesticulatory aspects of verbal com-munication in an integrated manner. The AMmay be considered holistic also from the vocalpoint of view as it collectively and simulta-neously tackles the various parameters of thevoice such as pitch, loudness and timbre. TheAM rests technically on three major princi-ples: (1) optimal abdominodiaphragmaticbreath support; (2) rhythmic play of accen-tuated relaxed vowels with progressive carry-over to connected speech, and (3) dynamic

rhythmic body and arm movements. Thetherapeutic procedure consists of: (1) respira-tory exercises; (2) phonatory exercises, and (3)articulatory exercises, by which the beneficialnew vocal habits are transferred to connectedspeech.

In the domain of voice disorders the AM istherapeutically indicated as (a) a mainstreamline of therapy, or (b) a complementary one[7]. The main applications in the former caseare: (1) Nonorganic (functional) habitualvoice disorders in adults and children; (2)nonorganic psychogenic voice disorders; (3)selected types of minimal associated patho-logical lesions such as vocal nodules and con-tact granuloma, and (4) selected types of or-ganic voice disorders such as motor disordersof the vocal folds (paralytic dysphonia), anddysplasia. The main application of the AM asa complementary line of treatment is in as-sociation with pharmacotherapy or phono-surgery.

The efficacy of the AM has been reportedin several studies [9–11]. Kotby et al. [12] in1991 indicated the efficacy of the AM in themanagement of all nonorganic voice disor-ders, selected cases of minimal associatedpathological lesions such as vocal nodules andcontact granuloma as well as selected cases oforganic voice disorders such as paralytic dys-phonia and dysplasia. Additional controlledclinical trials are, however, still needed to testthe efficacy of the AM.

This study is conducted in order to evalu-ate the efficacy of the AM utilizing a morecontrolled experimental model. The study isbased on the concept of group comparisons.The efficacy of the accent exercises is testedby assessment of the effect of voice hygieneadvice alone against the effect of both voicehygiene advice and the accent exercises forthe correction of the faulty vocal technique(habit). By separating the two elements ofbehavior readjustment therapy, one may be


Table 1. Etiologic categories

Nonorganic (functional) dysphoniaHyperfunctional 14Phonasthenia 8

MAP lesionsNodules 10Reinke edema 2

Vocal fold immobility (paralysis)Ideopathic 3Post-thyroidectomy 5

Total 42

MAP = Minimal associated pathological.

able to demonstrate the efficacy of each, espe-cially the latter. Such a study may be used asan approach to efficacy research in behaviorreadjustment therapy in human communica-tive disorders.

Material and Method

The material of this study comprised 42 patientswho presented with a variety of vocal pathologies (ta-ble 1). They were randomly categorized into twogroups. Group 1 (G1) comprised 21 patients (8 malesand 13 females) with age ranging from 20 to 54 years(mean = 37). This group received voice hygiene adviceplus the accent exercises of voice therapy. Group 2(G2) comprised 21 patients (10 males and 11 females)with age ranging from 20 to 60 years (mean = 40). Thisgroup was given voice hygiene advice only preparatoryto active voice therapy later on.

In G1 the AM is administered in individual ses-sions 20 min each, 2 times per week with a follow-upevaluation after 10 and 20 sessions of therapy. The ses-sion includes both voice hygiene advice and the exer-cises aiming at correction of the faulty vocal technique(habit). In G2, the same type of vocal hygiene advicewas given in a single weekly session, with a follow-upsystem similar to the patients of G1, that is, an assess-ment at mid-therapy (after 5 sessions) and at the termi-nation of therapy (after 10 sessions). The values of theinitial assessment are taken as pretherapy or ‘pretest’data. The full battery of voice assessment is applied on

the 2 follow-up occasions producing values for ‘mid-test’ and ‘post-test’, respectively. The diagnostic proce-dure followed a protocol of voice assessment devel-oped and applied at the Unit of Phoniatrics, AinShams University Hospitals [6]. The protocol, whichutilizes both subjective and objective measures, high-lights the following items:

Elementary Diagnostic Procedures(1) Patient’s interview, including: (a) the patient’s

own grading of severity of voice dysfunction on a 5-point scale (4 = very good to 0 = very bad) recordedinitially and at every session, and (b) searching for pos-sible predisposing factors.

(2) Auditory perceptual assessment (APA) as as-sessed by a group of expert judges following a modifiedGRBAS scale [13, 14], with 4 grades from 0 (normal)to 3 (severe dysphonia). The following vocal character-istics are included in this evaluation [GSLBI = overallgrade (G), strained (S), leaky (L), breathy (B), andirregular (I)].

(3) Preliminary visual assessment of glottic pathol-ogy by indirect mirror laryngoscope.

Clinical Diagnostic Aids(1) Laryngo-video-stroboscopy using a Kay Ele-

metrics rhinolaryngeal stroboscope model 9100, at-tached to either the rigid oral telescope or flexible naso-fibroscope [15]. This was used for augmentation anddocumentation of the visual assessment of the vocalorgan [16]. At video-stroboscopy the following param-eters were observed: the glottic wave and amplitude ofvocal fold vibration; symmetry of the wave; phase clo-sure of the glottis; presence, shape, and size of a phona-tory gap, and details of morphological changes such asearly nodules and edema [17].

(2) High fidelity voice recording, in a soundproofbooth, using a Sony digital audiotape deck systemDTC-60ES connected to Sony stereo amplifier F101k.

Additional Instrumental Measures(1) Aerodynamic measures using Nagashima Sys-

tem (Ps-77H): These include vital capacity (VC), maxi-mum phonation time (MPT), phonatory quotient(PQ), mean flow rate (MFR), sound pressure level(SPL) range as the difference between the loudest andsoftest phonations, frequency (Fo) range as the differ-ence between the highest and lowest Fo, subglotticpressure (Psub), glottal efficiency (GE) and glottalresistance (GR) [18, 19].

(2) Acoustic analysis [20, 21] using the Kay CSLsystem (Kay Elemetrics): This included measurementsof average pitch, frequency and amplitude perturba-

0



Table 2. Patient’s own gradingof severity for the threeevaluations in G1 and G2

Patient’s owngrading of severity

Pretest

G1 G2

Mid-test

G1 G2

Post-test

G1 G2

Very bad 76% 71% 48% 67% 0% 52%1 Bad 10% 14% 27% 18% 5% 20%2 Moderate 10% 15% 10% 15% 5% 18%3 Good 4% 0% 5% 0% 42% 10%4 Very good 0% 0% 10% 0% 48% 0%

tion (jitter and shimmer, respectively) as well as har-monic-to-noise (H/N) ratio.

(3) Inverse filtering measures, by recording oral air-flow with a circumferentially vented pneumotacho-graph mask coupled to differential pressure transducer(Glottal Enterprises System, type MA-1) [22, 23]. Dig-ital inverse filtering was completed using the CSpeechversion 3.1 to yield the glottal airflow waveform. Thefollowing parameters are measured: (a) flow ampli-tude-based parameters: the peak flow and the mini-mum flow in milliliters per second; (b) time-basedparameters: open quotient (OQ), speed quotient (SQ),closing quotient (CQ) and speed index (SI).

Statistical comparison of the data between pretestsand mid-tests as well as between pre- and post-tests ineach group and subgroup was done using paired t test.Comparison between the progress of G1 and G2 acrossthe pre- and post-tests was done using t test. The sameprocedure was used to compare the amount of progressfrom pre- to mid-test and then from mid- to post-test inG1. The etiologic subgroups that have been dealt withstatistically (because they are of a reasonable number)were only four, namely: hyperfunctional dysphonia,phonasthenia, nodules, and vocal fold immobility (pa-ralysis). The category of Reinke edema was too small towarrant separate treatment.

Results

All patients presented with dysphonia withthe exception of 4 phonasthenia cases whocomplained only of phonasthenic symptomsin the throat. The grade and type of dysphoniavaried, but most patients had strained leakyvoice. The patients’ own subjective evalua-

tion of the impact of the vocal problem (quali-ty of voice) over a 5-point scale revealed thatin G1 76% gave a label of very bad while 71%of G2 gave the same label at the start of inter-vention. The development of the patients’evaluation of their own voices at the termina-tion of intervention is shown in table 2. Noneof the patients of G1 remained in the very badcategory while in G2 52% were still consid-ering their voice as very bad. In G1 90% of thepatients reached the good/very good categorywhile in G2 only 10% reached that level.

APA as evaluated by neutral judges in adouble-blind manner showed that the differ-ence in improvement of items G, S and Lbetween pretest and post-test indicates thatG1 has improved with a high degree of signifi-cance as compared to G2. The difference inimprovement in item B and I was not signifi-cant (table 3, fig. 1). The etiologic subgroupsof G1 showed specific tendencies in the im-provement in the different items of voicequality/character. In the vocal fold immobili-ty (paralysis) subgroup item B showed a high-ly significant improvement (table 4).

Nodule size and the paralytic phonatorygap showed improvement to a variable degreein both G1 and G2 (tables 5, 6, fig. 2, 3). Thedifference between the improvement in nod-ule size and the paralytic gap between pretestand post-test in both groups was highly signif-icant in favor of G1 (table 7).

G

G

Right base Right base


Table 3. Mean (BSD) difference in improvementbetween pretest and post-test of the APA in G1 andG2

APA Mean difference B SD

G1 G2

t

1.67B0.79 0.14B0.67 –4.62**S 1.21B0.97 –0.07B0.71 –3.38**L 1.05B0.99 –0.07B0.71 –2.90**B 0.36B0.76 0.14B0.65 –0.67I 0.45B0.79 0.07B0.43 –1.34

** p ! 0.01, highly significant. Fig. 1. Histogram representation of the mean dif-ference in the improvement of the APA between pre-tests and post-tests in both groups of voice therapy(G1, i) and voice hygiene advice (G2, W).

Table 4. Mean values (BSD)for the three evaluations of theAPA in the immobility group(n = 4) who received voice therapy(G1)

APA Pretest Mid-test t Post-test t

2.1B0.63 0.9B1.03 6.1** 0.3B0.50 23.7**S 0 0 – 0 –L 0 0 – 0 –B 2.1B0.63 0.9B1.03 6.1** 0.3B0.50 23.7**I 0 0 – 0 –

** p ! 0.01, highly significant.

Table 5. Mean values (BSD) in improvement be-tween pretest, and post-test for the pre- and post-testevaluations of nodules and phonatory (paralytic) gapsin G1 (n = 21)

Examination Pretest Post-test t

2.04B0.74 0 8.68**Right rise 0.64B0.60 0 3.36**Left base 2.22B0.47 0.24B0.54 3.87**Left rise 0.68B0.57 0.04B0.09 3.36**Gap 1.08B0.69 0.1B0.08 4.47**


Table 6. Mean values (BSD) in improvement be-tween pretest and post-test for the pre- and post-testevaluations of the nodules and the phonatory (paralyt-ic) gaps in G2 (n = 21)

Examination Pretest Post-test t

1.12B0.47 1.37B1.38 2.08Right rise 0.18B0.06 0.12B0.09 3.66**Left base 1.06B0.82 1.57B1.41 3.66**Left rise 0.37B0.18 0.20B0.16 2.76**Gap 0.76B0.21 0.54B0.28 3.2*

* p ! 0.05, significant; ** p ! 0.01, highly sig-nificant.

Right base



Fig. 2. Video printouts for afemale case with bilateral vocalfold nodules before therapy (a) andafter therapy (b). Notice disappear-ance of the nodules after voice ther-apy.

Table 7. Mean difference (BSD) in improvementbetween pretest and post-test for nodules size and thephonatory gap of the immobility patients in G1 andG2

Mean difference B SD

G1 G2

t

2.04B0.74 0.27B0.40 –6.62**Right rise 0.64B0.60 0.07B0.06 –2.99**Left base 0.98B0.80 0.33B0.29 –2.40**Left rise 0.64B0.60 0.13B0.15 –2.57**Gap 0.97B0.69 0.22B0.22 –3.30**


Patients in G2, receiving counseling re-garding voice hygiene advice only, showed nochange of any significance in the stroboscopicassessment from pretest to mid-test to post-test observations. Patients in G1, who re-ceived voice hygiene advice plus accent exer-cises, showed highly significant change in allvideo-stroboscopic ratings from the pretestthrough the mid-test to the post-test assess-ments, indicating improvement or normaliza-tion (tables 8–11). Significant improvement(with normalization reached in some cases)was noticed in the mid-test assessment re-garding the phase closure and the pattern ofthe phonatory gap only (tables 10, 11).

a

b


Fig. 3. Video printouts for amale case with right vocal fold im-mobility before therapy (a) and af-ter therapy (b) at rest and duringphonation. Notice marked reduc-tion of the phonatory gap aftervoice therapy.

The difference in improvement of aerody-namic measures between pre- and post-testevaluation of both groups was highly signifi-cant in favor of G1 in the following parame-ters: SPL range, Psub, GE and GR (table 12).On the other hand, G1, when followed acrossthe three assessment occasions, showed a sig-

nificant improvement in the post-test valuesas compared to the pretest measures, whilethere was no significant improvement be-tween the pretest and mid-test. The post-testvalues as compared to the pretest valuesshowed a significant decrease in the PQ and ahighly significant improvement in the SPL

a

b

Right

Symmetrical

Normal

0

VC, ml



Table 8. Percent change in amplitude and mucosalwave for the three videostroboscopic evaluations ofG1

Amplitude andwave

Pretest Mid-test Post-test

0 Normal 10% 15% 67%**1 Small 67% 62% 15%2 Great 5% 5% 0%*3 Absent 18% 18% 18%

Left0 Normal 29% 38% 86%**1 Small 66% 57% 14%**2 Great 5% 5% 0%*3 Absent 0% 0% 0%

* p ! 0.05, significant; ** p ! 0.01, highly signifi-cant.

Table 9. Percent change in symmetry for the threevideostroboscopic evaluations in G1

Symmetry Pretest Mid-test Post-test

10% 19% 71%**Asymmetrical 90% 81% 29%**


Table 10. Percent change in phase closure for thethree videostroboscopic evaluations in G1

Phase closure Pretest Mid-test Post-test

0% 24%* 67%**Open 67% 48% 24%**Closed 33% 28% 9%*Inconsistent 0% 0% 0%


Table 11. Percent change in phonatory gap for thethree videostroboscopic evaluations in G1

Phonatory gap Pretest Mid-test Post-test

Normal 0 38%* 76%**1 Anterior 0 0% 0%2 Posterior 5% 5% 10%3 Longitudinal 52% 18%* 5%**4 Fusiform 19% 18% 9%5 Hourglass 24% 24% 0%


Table 12. Mean difference(BSD) in improvement betweenpretest and post-test of theaerodynamics in G1 and G2


G1 G2

t

–164.33B711.18 –0.17B413.60 0.63MPT, ms –3.15B5.01 –2.18B4.08 0.47PQ 68.8B267.8 47.8B100.3 –0.34MFR, ml/s 46.67B62.52 31.86B75.25 –0.47Fo range, Hz –16.76B43.62 7.90B54.11 –1.63SPL range, dB –6.14B8.02 1.24B6.54 –3.27**Psub, mm H2O 29.48B21.01 –4.14B9.32 –4.62**GE –0.0029B0.0012 –0.0005B0.013 –6.28**GR 0.070B0.217 –0.084B0.12 2.87**


VC, ml

VC, ml


Table 13. Mean values (BSD) for the three evaluations of the aerodynamics in G1 (n = 21)

Aerodynamics Pretest Mid-test t Post-test t

2,150B1,050 2,130B1,040 –0.73 2,310B1,155 –0.73MPT, s 10.8B8.9 12.6B9.9 –1.95 14.0B11.8 –1.99PQ 285B192 231B164 2.70 237B179 2.8*MFR, ml/s 199B99 165B57 1.71 153B51 2.36Fo range, Hz 19B32 23B20 –0.52 37B24 –1.8SPL range, dB 8B7 11B6 –2.2 14B7 –3.51**Psub, mm H2O 106B25 91B16 3.55 77B13 4.44**GE 0.0043B0.019 0.0056B0.0021 –4.5 0.0072B0.002 –11.07**GR 0.62B0.29 0.61B0.22 –0.44 0.55B0.18 1.4

* p ! 0.05, significant; ** p ! 0.01, highly significant.

Table 14. Mean values (BSD) for the three evaluations of the aerodynamics in the hyperfunctional groupwho received voice therapy (G1, n = 7)


1,995B1,154 1,875B1,112 –0.57 2,180B1,215 –0.57MPT, s 12.3B9.0 12.0B10.6 0.29 14.6B14.7 –0.99PQ 214B159 217B165 –0.19 209B165 0.13MFR, ml/s 145B43 146B44 –0.11 123B30 2.43Fo range, Hz 11B16 19B24 –0.85 32B22 –2.96*SPL range, dB 5B6 9B4 –1.06 11B5 –1.86Psub, mm H2O 101B15 90B12 3.41** 77B6 5.32**GE 0.0056B0.0018 0.0063B0.0027 –1.04 0.0086B0.027 –6.61**GR 0.79B41 0.68B0.29 1.36 0.66B0.18 1.16


range, Psub and GE (table 13). G2 showed ahighly significant increase in the GR in thepost-test evaluation (t = –3.32, p ! 0.01). Theetiologic subgroups showed variable results.The hyperfunctional subgroup showed signifi-cant/highly significant improvement in thefrequency range, Psub and GE (table 14).Phonasthenia showed significant/highly sig-

nificant improvement in MPT, frequencyrange, Psub and GE (table 15). The nodulesgroup showed significant and highly signifi-cant variation in MPT, MFR, SPL range,Psub and GE (table 16). The immobilitygroup showed significant/highly significantimprovement in MPT, PQ, MFR, Psub andGE (table 17).

VC, ml

VC, ml



Table 15. Mean values (BSD) for the three evaluations of the aerodynamics in the phonasthenia group whoreceived voice therapy (G1, n = 4)


3,165B960 3,300B558 –1.79 3,565B817 –1.79MPT, s 14.7B13.1 17.17B15.61 –3.0* 18.75B17.25 –3.0*PQ 75B2.38 75B2.16 –0.7 76B2.22 –0.0MFR, ml/s 217B54.87 199B39.21 3.0* 188B33.21 2.44Fo range, Hz 233B88.53 247B108.36 –1.4 241B105.47 –5.6**SPL range, dB 8B4 10B6 –1.2 13B6 –2.6Psub, mm H2O 126B28.75 100B18.14 7.3** 85B20.42 9.6**GE 0.0030B0.0011 0.0041B0.0013 –7.6** 0.0052B0.0016 –6.6**GR 0.60B0.15 0.51B0.11 B2.8* 0.46B0.15 2.5


Table 16. Mean values (BSD) for the three evaluations of the aerodynamics in the nodules group whoreceived voice therapy (G1, n = 5)


2,015B645 1,915B795 –1.5 2,220B635 –1.5MPT, s 7.6B5.6 11.6B6.0 –6.1** 11.4B7.1 –3.1**PQ 314B96 172B21 4.17** 246B110 2.2MFR, ml/s 175B33 150B11 1.99 150B6 2.7*Fo range, Hz 24B13 20B23 0.29 35B28 –0.62SPL range, dB 8B10 13B10 –6.45** 18B9 4.8**Psub, mm H2O 100B27 82B16 3.31** 74B15 5.8**GE 0.0043B0.0015 0.0059B0.0097 –3.82** 0.0068B0.0016 –7.3**GR 0.58B0.18 0.56B0.15 –0.33 0.49B0.12 2.2


The difference in improvement betweenG1 and G2 in shimmer was significant whileit was highly significant in H/N ratio (ta-ble 18, fig. 4). The acoustic analysis in G1showed a significant decrease in jitter valuesand highly significant increase in H/N ratiobetween the pretest and post-test measuresonly (table 19). The etiologic subgroups of

phonasthenia, nodules, and vocal fold immo-bility showed an additional highly significantimprovement in shimmer values between pre-test and post-test measures. The etiologic sub-groups showed variable tendencies of im-provement between the pretest and the mid-test (table 20–22).

VC, ml

Average pitch, Hz

Average pitch, Hz


Table 17. Mean values (BSD) for the three evaluations of the aerodynamic measures in the immobility groupwho received voice therapy (G1, n = 4)


1,268B463 1,339B290 0.6 1,168B729 0.6MPT, s 5.3B4.35 7.4B4.16 3.1** 8.9B4.69 –2.9*PQ 385B354 277B266 1.8 229B302 3.54*MFR, ml/s 322B166.41 198B104.11 4.7** 184B94.47 4.9**Fo range, Hz 39B73 37B18 0.03 48B35 –0.2SPL range, dB 10B10 11B2 0.19 13B5 –0.3Psub, mm H2O 107B36.09 94B20.89 2.42 71B15.46 2.7*GE 0.0031B0.0023 0.0052B0.0027 –2.9* 0.0070B0.0032 –4.6**GR 0.36B0.10 0.54B0.21 –1.6 0.46B21 –0.8


Table 18. Mean difference (BSD) in improvement between pretestand post-test of the acoustic analysis of G1 and G2


G1 G2

t

3.28B11.75 6.57B28.63 0.33Jitter 0.985B1.089 0.333B0.700 –1.59Shimmer 1.019B1.657 –0.058B0.478 –1.95*H/N –4.181B3.477 –0.133B2.988 2.79**

* p ! 0.05, significant; ** p ! 0.01, highly significant. Fig. 4. Histogram representa-tion of the H/N mean values for thevoice therapy group (G1) and thevoice hygiene advice group (G2) inthe three evaluations.

Table 19. Mean values (BSD) for the three evaluations of the acoustic analysis in G1 (n = 21)

Acoustic analysis Pretest Mid-test t Post-test t

191B53 186B50 0.15 188B50 0.88Jitter 1.448B1.20 0.905B0.66 2.27 0.462B0.22 2.86*Shimmer 1.600B1.98 1.168B1.34 1.02 0.581B1.07 1.94H/N 7.429B3.43 9.158B3.93 –1.44 11.610B4.22 3.80**


Average pitch, Hz

Average pitch, Hz

Average pitch, Hz



Table 20. Mean values (BSD) for the three evaluations of the acoustic analysis in the phonasthenia groupwho received voice therapy (G1, n = 4)


128B7.55 138B9.91 –2.2 132B7.1 –1.0Jitter 0.500B0.115 0.525B0.150 –1.6 0.425B0.150 4.7**Shimmer 0.500B0.216 0.425B0.57 4.7** 0.250B0.173 4.1**H/N 8.90B3.735 10.18B4.168 –3.3** 10.80B4.205 –4.2**


Table 21. Mean values (BSD) for the three evaluations of the acoustic analysis in the nodules group whoreceived voice therapy (G1, n = 5)


225B8.4 205B28.2 2.2 221B7.5 1.2Jitter 2.000B0.73 1.101B0.46 10.5** 0.481B0.22 7.0**Shimmer 0.900B0.65 1.032B0.75 –2.1 0.280B0.13 3.4**H/N 7.10B3.70 10.50B5.7 –1.2 15.52B1.0 –8.1**


Table 22. Mean values (BSD) for the three evaluations of the acoustic analysis in the immobility group whoreceived voice therapy (G1, n = 4)


210B51.86 2.3B44.86 1.9 193B48.79 3.7**Jitter 2.375B1.997 1.450B1.179 2.6* 0.475B0.359 3.6**Shimmer 1.200B0.890 0.725B0.745 3.5** 0.425B0.525 3.7**H/N 5.775B2.649 8.500B2.726 –4.7** 11.350B3.740 –9.5**


There was no significant change in theinverse filtering measures in both G1 and G2between the pretest and mid-test nor betweenthe pretest and post-test values. There wasalso a nonsignificant difference in improve-ment between G1 and G2 (table 23). The etio-

logic subgroups, however, showed irregulartendencies in improvement (tables 24–27).The hyperfunctional group showed signifi-cant/highly significant improvement in SQ,CQ and SI in the post-test results, while thephonasthenia group showed highly significant

Peak flow, ml/s

Peak flow, ml/s

Peak flow, ml/s


Table 23. Mean difference(BSD) in improvement betweenpretest and post-test of the inversefiltering of G1 and G2


G1 G2

t

19.50B91.47 9.38B79.07 –0.26Minimum flow, ml/s 24.62B70.90 10.24B49.72 –0.52OQ 0.07B0.11 0.03B0.13 –0.98SQ 0.06B0.39 0.07B0.41 0.07CQ 0.035B0.092 –0.01B0.10 –1.13SI –0.018B0.16 –0.002B0.11 0.24

Table 24. Mean values (BSD) for the three evaluations of the inverse filtering in the hyperfunctional groupwho received voice therapy (G1, n = 7)

Inverse filteringparameters

Pretest Mid-test t Post-test t

246B61 258B59 –0.78 278B50 –2.53Minimum flow, ml/s 127B44 129B51 –0.21 132B38 –0.31OQ 0.82B0.13 0.82B0.17 0.12 0.84B0.08 –0.52SQ 1.52B0.63 1.23B0.52 2.34* 1.12B0.56 5.53**CQ 0.35B0.13 0.36B0.17 –1.21 0.39B0.10 –2.86*SI 0.19B0.17 0.14B0.18 2.81 0.08B0.19 5.99**


Table 25. Mean values (BSD) for the three evaluations of the inverse filtering in the phonasthenia group whoreceived voice therapy (G1, n = 4)



368B71.41 362B28.30 3.8** 355B80.61 4.3**Minimum flow, ml/s 152B100.61 138B11.31 2.7* 112B14.85 29.8**OQ 0.77B0.06 0.76B0.03 0.1 0.72B0.04 11.2**SQ 1.2B0.15 1.2B0.17 –0.1 1.20B0.06 0.0CQ 0.35B0.01 0.35B0.04 0.1 0.33B0.03 2.2SI 0.09B0.06 0.12B0.05 –1.0 0.09B0.03 0.2


Peak flow, ml/s

Peakflow, ml/s



Table 26. Mean values (BSD) for the three evaluations of the inverse filtering in the nodules group whoreceived voice therapy (G1, n = 5)



133B7 135B12 –0.71 144B15 –2.8*Minimum flow, ml/s 91B13 93B7 –0.12 91B10 –0.01OQ 0.94B0.01 0.93B0.03 0.21 0.81B0.09 3.7**SQ 1.4B0.62 1.6B0.70 –1.03 1.4B0.50 –0.8CQ 0.40B0.09 0.38B0.10 0.72 0.37B10.05 1.9SI 0.14B0.19 0.13B0.15 –0.63 0.14B0.12 –0.08


Table 27. Mean values (BSD) for the three evaluations of the inverse filtering in the immobility group whoreceived voice therapy (G1, n = 4)



370B152.22 272B72.3 2.4 244B43.05 2.9*Minimum flow, ml/s 185B137.97 124B81.1 2.1 101B21.52 2.2OQ 0.94B0.06 0.82B0.08 13.2** 0.76B0.05 21.3**SQ 1.31B0.55 1.37B0.48 0.9 1.53B0.71 –1.1CQ 0.43B0.11 0.41B0.09 2.1 0.28B0.06 4.4**SI 0.10B0.19 0.12B0.17 –1.8 0.31B0.13 –3.4**


improvement in peak flow, minimum flow,and OQ. The nodules group showed signifi-cant/highly significant improvement only inthe peak flow measures and the OQ. Theimmobility group showed significant/highlysignificant improvement in peak flow, OQand CQ and SI. Mid-test values showed sig-nificant/highly significant change in SQ of thehyperfunctional subgroup, peak flow andminimum flow of the phonasthenia subgroupand OQ of the immobility subgroup.

In G1, when the difference in improve-ment between pretest and mid-test in all pa-

rameters of assessment was compared to thedifference in improvement between mid-testand post-test, no significant difference wasfound in all measures except for PQ, whichshowed greater improvement in the pretest tomid-test assessments (fig. 5–7).

Discussion

The efficacy of the AM is tested in thisstudy in a controlled setup that eliminatesextraneous independent variables. The thera-


▲

▲

▲

▲

Fig. 5. A representation of the trend of improve-ment of APA of patients’ voices across the three evalu-ations for the voice therapy group (G1).

Fig. 6. A representation for the trend of improve-ment of PQ and Psub across the three evaluations forthe voice therapy group (G1).

Fig. 7. A representation of the trend of improve-ment of jitter and H/N across the three evaluations forthe voice therapy group (G1).

py group G1 and the voice hygiene counsel-ing/advice group G2 were comparable in allparameters except that G1 only received theaccent exercises. In this event the accent exer-cises were given in a setup that may establisha cause-and-effect relation between the testedtechnique implemented by the clinician andthe changes in the client’s vocal behavior.Withholding the accent exercises did notcause any ethical embarrassment as the pa-tients in G2 were followed up and were beingprepared eventually to reveive the accent ex-ercises. This model of a clinical trial aiming atdemonstrating the efficacy of the AM is be-lieved to be most suited to a behavior read-justment therapy.

The general trend of the final resultsshowed a significant difference in improve-

ment of vocal function parameters in favor ofthe accent exercises group G1. There are,however, some specific patterns that are dis-cussed under each tested item. Moreover, thedifference in improvement between G1 andG2 in the collective patients’ material showeddifferent values in certain parameters whencompared to the improvement measured forthe various etiologic subgroups separately.The pathophysiologic mechanism in the var-ious etiologic subgroups, namely hyperfunc-tional dysphonia, phonasthenia, nodules, andvocal fold immobility (paralysis), does varyand may even be of opposing directions. Inparalysis the glottis shows a tendency to wastewhile in hyperfunctional dysphonia the glottisis tight. Accordingly, the results of improve-ment in the whole material showed some non-

5 6

7



significant values while certain of those itemsbecame significant (in one or the oppositedirection) when computed for the particularsubgroups separately (tables 24–27).

The difference in improvement betweenG1 and G2 in patients’ own assessment ofsubjective improvement of voice shows agreater value, in favor of G1, as compared tothe difference in improvement in other quasi-objective measures (table 2). This discrepancymay be due partially to a possibility that thepatient’s response to the clinician’s questionregarding improvement in vocal complaintmay fall under an unavoidable autosuggestioninfluence from the clinician.

The nonsignificance of the difference inimprovement in the collective patient materi-al of items B and I in APA assessment may bedue to the small number of patients present-ing with these vocal characteristics. On theother hand, the difference in improvement initem B was significant in the etiologic sub-group of vocal fold immobility as most pa-tients presented with a breathy (B) characterof voice (tables 3, 4).

There has been some improvement in nod-ule size and the paralytic gap in both G1 andG2. The difference in improvement, however,was highly significant in favor of G1 (table 7),indicating the efficacy of the accent exercisesin controlling these two morphological defi-cits in vocal pathology. This favorable effectof the accent exercises in G1 is confirmed bythe significant positive changes observed onlyin G1 in stroboscopic findings. The lattermay reflect more subtle changes in glottal be-havior.

The significant difference in improvementin favor of G1 in the aerodynamic analysiswas selective. The improvement in the etio-logic subgroups was detectable already in themid-test values, and most of the improveditems continued to improve in the post-testmeasures. Few new items showed improve-

ment only in the post-test measures (tables14–17). The improvement in the dynamicrange was more significant than the differencein frequency range, a point that may indicatethat the breakdown, and hence the gain inresponse to therapy, in dynamic range isgreater than the frequency range in the typesof vocal pathologies investigated in this study.The improvement in PQ, MPT, and MFR inthe vocal fold immobility group may reflectan improvement in glottic closure (table 17).The improvement of MFR in the group ofnodules may also reflect an improvement ofthe associated phonatory gap.

There was a nonconformity of improve-ment of all the three parameters of acousticanalysis in between the groups (G1 and G2).The etiologic subgroups showed an additionalinconsistency of the trend of improvementamong the computed parameters of acousticanalysis (tables 20–22). These findings mayindicate that the acoustic analysis used in thisstudy are not very sensitive or not highly spe-cific [24]. On the other hand the differentparameters of acoustic analysis like jitter andshimmer may correlate with different aspectsof the mechanism of breakdown in the vocalfunction of the etiologic groups investigatedin this study [25].

There was no significant improvement inthe collective patient material in G1 in theinverse filtering values (table 23). This may beexplained by the possibility that the nature ofthe pathophysiology of the different catego-ries may be in opposite directions, that is, acategory may show a tight glottis and anothermay show glottic waste. However, significantimprovements in certain items specific toeach etiologic subgroup were detected.

Comparison between the initial findings(pretest) and the measures in the mid-test andthe end results in post-test measures showedthat the improvement followed a more or lesslinear curve (fig. 5–7). This may indicate that


the beneficial effects of the accent exercisesand the patient’s gain continue smoothlythroughout the therapy period of 20 sessions.

Conclusion

The general outcome of this study supportsthe notion that behavior readjustment thera-peutic procedures are clinically effective in

the management of some human communica-tive disorders. The overall tendency in theresults of this clinical trial, with the providedcontrol measures, indicates a positive efficacyof the AM of voice therapy in the manage-ment of the vocal pathologies investigated inthis study. Further controlled studies of clini-cal trials using additional experimental mod-els are still needed to test the efficacy ofbehavior readjustment therapy.

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