Voice EBP
Extravaganza 2010

 Common caseload (inpts > outpatients)
 Unknown:
 When to provide therapy and for how long
 What therapy to provide
 Contraindications
 Role of surgery in recovery
 Prognosis and pattern of recovery

For patients with unilateral vocal cord paralysis, does voice therapy improve voice outcomes?

 Search words:
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Unilateral vocal fold/cord paralysis/paresis
RLN palsy
Voice therapy
Voice disorders
Hemiplegia
 Databases:
 Medline / PubMed
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Web of science
Cochrane
Scopus

 Critically appraised 16 articles
 Each article appraised by 2 people
 Developed specific Q’s to assist our broad clinical
Q
 Mix of retrospective and experimental time series studies
 No control groups
 Level of evidence: III to IV
 Range of participants per study: 3 - 91

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Hoarseness (53%), dysphagia (34%), difficulty breathing (12.8%).
Kelchner
 low intensity, low pitch, rough, breathy, reduced phonation time, vocal fatigue, little resonance, loud whisper, intermittent voicing, rapid rate, excessive glottal leak, intermittent flutter
Heuer
 Increased mean values of GRBAS (Overall severity, roughness, breathiness, asthenia, strain) D’Alatri
 Sudden onset hoarseness
 Overall, no pattern of symptoms described
Tsunoda

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Mostly eclectic approaches where many techniques were used in combination
In all of these studies, these techniques were shown to improve the voice on a range of measures.
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D’Alatri et al used specific techniques targeting specific symptoms e.g. glottic competence and hyperfunction
Smith Accent Method was also effective in 3 reported participants
(Khidr, 2003)
Yawning Breath Pattern (breath support, lower larynx) with biofeedback was effective in a larger group of patients (Xu, 1991)
Head turn was not effective (Paseman, 2004)

 Many studies didn’t consider spontaneous recovery and timing of intervention often not specified
 Voice therapy improved voice outcomes.
 Eclectic approach equally effective < 3 months or 3 mths
- 21 years post-onset (Cantarella et al, 2010)
 Effective 1-13 years post-onset (Khidr, 2003).
 Voice therapy may be more effective closer to onset, but this is unclear in the literature

 Cantarella = 10-40 sessions
 Khidr = 16 sessions
 Heuer = 3-7 sessions (less for non-surgical)
 D’Alatri = 8-35 (mean = 24) sessions
 Schindler = 6-20 (mean 12.6) sessions
 Xu = 10 weekly sessions
 Overall: > 10 sessions.
 Frequency = weekly or twice-weekly

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Kelchner = paramedian or lateral
Impact of position not discussed in relation to voice outcomes a: median b: paramedian c: intermediate d: fully abducted
Ishimoto S et al. Chest 2002;121:1911-1915

 Most studies use multidimensional outcome measures
 videostroboscopy, acoustic measures, perceptual evaluation, aerodynamic measures and patient-reported quality of life (i.e. VHI).
 No reported blinding for rating
 Intra or inter-rater reliability for perceptual evaluation often not reported
 Acoustic measures used h/e type of acoustic signal not specified to ensure reliability

 Surgery > voice therapy for sig dysphonia
 Surgery = voice therapy for less severe dysphonia
(Kelchner et al , 1999)
 Pre-op voice therapy may help patients achieve adequate voicing without surgery
(Heuer, 1997)
 Many studies reported voice outcomes from surgery alone → no CAP

 Timing of Rx – early is better than later to prevent hyperfunction
 Rx techniques – gentle vocal adduction while preventing hyperfunction
 Position of cord – therapy more beneficial for those with smaller glottic gaps
 Length of therapy – re-evaluate if no improvement after approx. 4 sessions
 Outcomes – use a range but all using perceptual ratings

 Patient choice was not documented in most studies
 The only reference to patient choice was in Heuer and
Khidr, where patients elected to have voice therapy vs surgery
 As a group we all consider client choice and other factors e.g. compliance, fatigue, cognition

 Yes voice therapy is effective for UVFP to some degree
 Therapy approaches appear to be
eclectic in nature
 We are still unsure how effective specific therapy approaches are
 We are also unsure of when it’s best to intervene with therapy and the nature of spontaneous recovery

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Increased confidence discussing literature evidence with clients and referrers
Voice therapy for those clients with mild dysphonia / small glottic gap
Clients with severe dysphonia / large glottic gap may benefit more from ENT for surgical intervention
Continue current voice therapy techniques and re-refer to
ENT if no improvement
Continue collecting voice outcomes to evaluate success of therapy

Judy Rough
Katrina Blyth
Sam Warhurst
Danielle Stone
Katherine Kelly
Asta Fung
Beth Atkins
Sharon Moore
Margaret Jacobs
Therese Dodds
Helen Brake
Academic link: Cate Madill