The Effects of Yoga Breathing Before Motor Speech Practice in Acquired Apraxia of Speech: An n-of-1 Trial.

A previous study discovered that two speakers with moderate apraxia of speech increased their sequential motion rates after unilateral forced-nostril breathing (UFNB) practiced as an adjunct to speech-language therapy in an AB repeated-measures design. The current study sought to: (1) delineate possible UFNB plus practice effects from practice effects alone in motor speech skills; (2) examine the relationships between UFNB integrity, participant-reported stress levels, and motor speech performance; and (3) sample a participant-led UFNB training schedule to contribute to the literature's growing understanding of UFNB dosage. A single-subject (n-of-1 trial), ABAB reversal design was used across four motor speech behaviors. A 60-year-old female with chronic, severe apraxia of speech participated. The researchers developed a breathing app to assess UFNB practice integrity and administer the Simple Aphasia Stress Scale after each UFNB session. The participant improved from overall severe to moderate apraxia of speech on the Apraxia Battery for Adults. Visual inspection of graphs confirmed robust motor speech practice effects for all variables. Articulatory-kinematic variables demonstrated sensitivity to the UFNB-plus-practice condition and correlated to stress scale scores but not UFNB integrity scores. The participant achieved 20-minute UFNB sessions 4 times per week. Removal of UFNB during A2 (UFNB withdrawal) and after a 10-day break during B2 (UFNB full dosage) revealed UFNB practice effects on stress scale scores. UFNB with motor speech practice may benefit articulatory-kinematic skills compared to motor speech practice alone. Regular, cumulative UFNB practice appeared to lower self-perceived stress levels. These findings, along with prior work, provide a foundation to further explore yoga breathing and its use with speakers who have apraxia of speech.

A Comparison of Voice Therapy Attendance Rates Between In-Person and Telepractice.

PURPOSE: This study sought to investigate whether a significant difference exists in attendance, cancellations, and no-shows between in-person therapy and telepractice. The authors hypothesized that telepractice no-show and cancellation rates would be less than in-person no-show and cancellation rates. METHOD: This retrospective study manually reviewed and analyzed attendance, no-show, and cancellation data over a 3-month span of in-person-only visits (September 2019-November 2019) and a 3-month span of telepractice visits (September 2020-November 2020) conducted at the Emory Voice Center, a tertiary care practice in urban Atlanta, Georgia. Additionally, data were collected for each patient's full course of therapy outside of the 3-month windows and analyzed for attendance, no-show, and cancellation patterns. RESULTS: Data from 521 patients were available for review from the selected time frame. In 2019 (in-person), 157 patients met inclusion criteria, and in 2020 (telepractice), 176 patients were included. Therapy initiation, therapy attendance, and no-show rates had significant increases in the telepractice year, and cancellations made greater than 24 hr before the appointments had a significant decrease in the telepractice year. Furthermore, the overall course of therapy showed significantly fewer missed appointments and more attended appointments in the telepractice year. CONCLUSIONS: Patients participating in voice therapy via telepractice are more likely to initiate treatment and attend treatment and less likely to cancel sessions compared with patients receiving treatment in person. These data combined with extant data on telepractice treatment efficacy indicate that telepractice should be considered standard of care and offered to all patients seeking treatment, as it removes many reported barriers to treatment.

Enhancing Adherence to Voice Therapy via Social Cognitive Strategies.

Treatment adherence is a challenge in behavioral voice therapy. Patients commonly encounter difficulties with practicing and implementing target voice techniques outside of the clinic. Several mobile support strategies have been shown to improve adherence. These strategies are driven by social cognitive theory, which provides a theoretical but practical framework for understanding adherence behavior and solving adherence problems. Key features of the theory include (1) its model of triadic asymmetrical reciprocal causation, (2) the concept of human agency, and (3) the constructs of self-efficacy and goal commitment. The purpose of this article is to (1) explain voice therapy adherence within the framework of social cognitive theory, (2) illustrate three broad categories of adherence problems, and (3) provide examples of strategies to address each. With this exemplified knowledge, the clinician can diagnose factors that underlie patients' adherence problems and develop individualized solutions. Given the significant role adherence plays in behavioral interventions, this information holds substantial clinical relevance.

Effect of an iOS App on Voice Therapy Adherence and Motivation.

Purpose Patients commonly report difficulties adhering to voice therapy. An iOS app was developed in our lab that assists practice via reminder notifications, instructional recordings, and cepstral peak prominence analysis results. The purpose of this study was to assess the effect of such homework support modality on adherence behavior and associated motivation in a comparison of app support and written homework instructions and to assess the usability and utility of the app. Method Thirty-four individuals exhibiting adducted hyperfunction were randomized to receive either written homework instructions or the app when practicing resonant voice exercises for 3 weeks. All patients digitally audio-recorded all home practice, provided self-reported estimates of generalization, and completed weekly motivation scales. Results App support significantly increased practice frequency but did not affect self-reported generalization or motivation. Practice was significantly predicted by System Usability Scale scores. Utility of reminders and instructions were good, but cepstral peak prominence feedback was considered useful to only a subset of participants. Conclusion Interactive mobile therapy support can significantly increase practice of resonant voice homework without influencing motivation.

Toward a Consensus Description of Vocal Effort, Vocal Load, Vocal Loading, and Vocal Fatigue.

Purpose The purpose of this document is threefold: (a) review the uses of the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" (as found in the literature) in order to track the occurrence and the related evolution of research; (b) present a "linguistically modeled" definition of the same from the review of literature on the terms; and (c) propose conceptualized definitions of the concepts. Method A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scientific Electronic Library Online. Four terms ("vocal fatigue," "vocal effort," "vocal load," and "vocal loading"), as well as possible variants, were included in the search, and their usages were compiled into conceptual definitions. Finally, a focus group of eight experts in the field (current authors) worked together to make conceptual connections and proposed consensus definitions. Results The occurrence and frequency of "vocal load," "vocal loading," "vocal effort," and "vocal fatigue" in the literature are presented, and summary definitions are developed. The results indicate that these terms appear to be often interchanged with blurred distinctions. Therefore, the focus group proposes the use of two new terms, "vocal demand" and "vocal demand response," in place of the terms "vocal load" and "vocal loading." We also propose standardized definitions for all four concepts. Conclusion Through a comprehensive literature search, the terms "vocal fatigue," "vocal effort," "vocal load," and "vocal loading" were explored, new terms were proposed, and standardized definitions were presented. Future work should refine these proposed definitions as research continues to address vocal health concerns.

Feasibility of the Fake Phone Call: An iOS App for Covert, Public Practice of Voice Technique for Generalization Training.

OBJECTIVES: Generalization is a challenging phase in voice therapy, involving the implementation of a targeted voice technique in all spoken communication. Among other barriers to generalization, self-consciousness keeps patients from practicing and recalibrating their voice technique when they can be overheard (eg, at work). We developed an iOS application that covertly assists users in producing their target voice while they appear to be engaged in a cellular phone call. METHODS: To examine the feasibility of this Fake Phone Call, 11 adults in the generalization stage of voice therapy received a simulated call four times daily for 1 week. Usability, utility, and preliminary efficacy of the application were assessed via triangulated measures including self-report scales, a semistructured interview, and perceptual voice quality assessment of each completed phone call. RESULTS: Results indicated good feasibility, usability, and utility of the Fake Phone Call in eliciting target voice practice in public without bystander detection of the call's simulated nature. Preliminary efficacy data suggested a positive effect on vocal self-evaluation skill. CONCLUSION: The Fake Phone Call and comparable mobile strategies hold potential to facilitate covert public practice and generalization of a speaking-voice technique.

Patient, Parent, and Speech-Language Pathologists' Perceptions of Pediatric Voice Therapy Through Interviews.

Purpose: Voice therapy is heavily reliant on patient adherence for success, and patient perceptions are an important piece of understanding adherence. Patient perceptions of voice therapy have not been studied in the pediatric population. The purpose of this study was to examine patient, parent, and speech-language pathologists' experiences and perceptions of voice therapy and how they reflect barriers to and facilitators of adherence to therapy. Method: Participants took part in semistructured interviews, which were transcribed, and content analysis was completed using established qualitative methods of content analysis to identify themes and subthemes related to voice therapy adherence. Participants: Thirty-four voice therapy patients (of ages 4-18) and their parents and 5 pediatric speech-language pathologists were included in the study. Results: Seven primary themes with multiple subthemes were identified. The primary themes identified were as follows: (a) voice therapy is fun, (b) voice therapy is easy, (c) voice therapy is worthwhile, (d) the clinician-patient match matters, (e) support systems are helpful, (f) fitting it in, and (g) changing behavior is hard. Conclusions: Adherence to voice therapy in pediatric populations is complex and depends on multiple intrinsic and extrinsic factors. Identification of themes related to adherence in voice therapy should serve to assist clinicians in planning therapy and in developing treatment programs.

An iOS-based Cepstral Peak Prominence Application: Feasibility for Patient Practice of Resonant Voice.

OBJECTIVES/HYPOTHESIS: Patients participating in voice therapy often express difficulty replicating therapy targets during their independent home practice. To assist patients, an iOS-based app was developed that calculates and displays cepstral peak prominence (CPP) values for patient self-monitoring of voice quality. The purpose of this study was to investigate the usability (ie ease of use) and utility (ie helpfulness) of this app in patient practice of resonant voice, and its effect on self-efficacy for practice. DESIGN: This study used mixed methods including repeated measures, survey, and semi-structured interview. METHODS/RESULTS: A total of 14 individuals undergoing voice therapy for a variety of voice disorders produced sustained phonation and connected speech tasks in three sequential conditions: habitual voice quality, resonant voice quality achieved without clinician assistance, and resonant voice quality achieved in interaction with the CPP app. For both tasks, CPP values were significantly and progressively higher in subsequent conditions, indicating utility of mobile CPP to differentiate habitual voice quality from resonant voice production. The participants found the app easy to use as indicated by high System Usability Scale ratings, and rated self-efficacy for practice with the app significantly higher than for unassisted practice. The interviews suggested that the participants found numeric CPP feedback helpful in self-evaluating voice quality, and thought it was "fun" to use the app. CONCLUSION: CPP information provided on a mobile app has potential to assist and motivate patients in the achievement of resonant voice production.

Effect of MP4 Therapy Videos on Adherence to Voice Therapy Home Practice in Children With Dysphonia.

OBJECTIVES/HYPOTHESIS: Voice disorders in children are often treated with behavioral voice therapy, which requires home practice of exercises. Previous studies with adults demonstrated increased practice frequency when patients were given videos of a clinician and patient performing therapy tasks. The purpose of this study was to determine whether videos of practice exercises would increase adherence to therapy in children. STUDY DESIGN: The study used a randomized double crossover research design. METHODS: Twenty-eight patients, aged 6-18, referred for voice therapy were included in the study. Two conditions were alternated on a weekly basis: standard-of-care therapy and standard-of-care therapy with video models added. Participants recorded practice frequency and participated in semi-structured interviews, which were analyzed for themes. RESULTS: Participants practiced an average of 1.79 times per day without videos and 1.72 with videos (P = 0.743), indicating no significant difference between conditions. There was also no age group effect (P = 0.314). Qualitative analysis of interview responses established the following themes: (1) I knew how to do my exercises, (2) I didn't like seeing/hearing myself, (3) Videos helped me remember to practice, (4) I didn't like the video player itself, (5) The videos didn't make a difference with practice, and (6) Practicing was no fun. CONCLUSIONS: Video models of therapy tasks do not appear to influence adherence to home practice frequency in children with voice disorders, in contrast to findings in adults. Videos were found useful by several participants as reminders to practice.

Using the Borg CR10 Physical Exertion Scale to Measure Patient-perceived Vocal Effort Pre and Post Treatment.

OBJECTIVES: Reduction of vocal effort is a therapeutic goal in resonant voice therapy and in the treatment of a variety of voice disorders. The Borg CR10 is a perceived effort scale that is widely accepted across a wide variety of disciplines. The purpose of the present study was to examine (1) the utility of an anchored, adapted Borg CR10 in observing treatment-related vocal effort reduction and (2) the convergent validity of the Borg CR10 in its relation to Voice Handicap Index (VHI) item 14. STUDY DESIGN: This is a pretest-posttest experimental design. METHODS: A total of 36 individuals with phonotraumatic hyperfunctional voice disorders completed item 14 of the VHI and the Borg CR10 at the start and completion of four sessions of resonant voice therapy treatment. RESULTS: Scores from the Borg CR10 significantly differentiated pre- from post-therapy perceived effort levels. Convergent validity was demonstrated through significant associations with scores from item 14 of the VHI. CONCLUSION: The anchored Borg CR10 is an easy to use clinical tool to capture treatment-related vocal effort reduction. Whereas VHI item 14 indicates how frequently increased perceived effort is experienced, the Borg CR10 captures the severity of perceived effort used. Thus, the two measures complement each other.

Predicting and influencing voice therapy adherence using social-cognitive factors and mobile video.

PURPOSE: Patient adherence to voice therapy is an established challenge. The purpose of this study was (a) to examine whether adherence to treatment could be predicted from three social-cognitive factors measured at treatment onset: self-efficacy, goal commitment, and the therapeutic alliance, and (b) to test whether the provision of clinician, self-, and peer model mobile treatment videos on MP4 players would influence the same triad of social cognitive factors and the adherence behavior of patients. METHOD: Forty adults with adducted hyperfunction with and without benign lesions were prospectively randomized to either 4 sessions of voice therapy enhanced by MP4 support or without MP4 support. Adherence between sessions was assessed through self-report. Social cognitive factors and voice outcomes were assessed at the beginning and end of therapy. Utility of MP4 support was assessed via interviews. RESULTS: Self-efficacy and the therapeutic alliance predicted a significant amount of adherence variance. MP4 support significantly increased generalization, self-efficacy for generalization, and the therapeutic alliance. An interaction effect demonstrated that MP4 support was particularly effective for patients who started therapy with poor self-efficacy for generalization. CONCLUSION: Adherence may be predicted and influenced via social-cognitive means. Mobile technology can extend therapy to extraclinical settings.

Factors associated with singers' perceptions of choral singing well-being.

OBJECTIVES: Choral singing is a popular vocational pastime across cultures. The potential health benefits associated with choral singing, including positive effect on well-being, are a topic of interest in health research. However, anecdotal reports from voice professionals suggest that the unique demands of choral singing may enforce unhealthy singing habits. This study explores suboptimal vocal behaviors that are sometimes associated with choral singing, which include singing outside comfortable pitch range, singing too loudly, and singing too softly for blend. METHOD: The relationships between suboptimal choral singing habits, vocal warm-ups (WUs), vocal fatigue, and singing-related well-being were assessed via a 14-item Likert-based response format questionnaire. Participants consisted of 196 attendees of the international World Choir Games. The final study group consisted of 53 male and 143 female international amateur singers aged 10-70. RESULTS: Results indicated a positive correlation between vocal fatigue and suboptimal singing behaviors (r = 0.34, P < 0.0001). Participants who did not engage in suboptimal singing behavior experienced increased singing-related well-being (r = -0.32, P < 0.0001, N = 141). Vocal WUs were not related to vocal fatigue or singing well-being. Substantially, more participants from this demographic preferred choir over solo singing (X²[1, N = 196] = 22.93, P < 0.0001). CONCLUSION: Suboptimal choral singing behaviors may result in vocal fatigue and reduction of choral singing well-being and should therefore be considered when examining the effect of choral singing on singing-related well-being and health. Future research will compare the amateurs' perceptions of choral singing with perceptions from professional singers and will look at determinants of choral singing well-being.

Use of portable digital media players increases patient motivation and practice in voice therapy.

OBJECTIVES/HYPOTHESES: There are many documented barriers to successful adherence to voice therapy. However, methods for facilitating adherence are not well understood. The purpose of this study was to determine if patient adherence and motivation for practice could be improved by providing patients with practice support between sessions using mobile treatment videos. METHODS: Thirteen voice therapy participants were provided with portable media players containing videos of voice exercises exemplified by their therapists and themselves. A randomized crossover design of two conditions was used: (1) standard of care voice therapy where participants were provided with written homework descriptions; and (2) video-enhanced voice therapy where participants received a portable digital media player with clinician and self-videos. The duration of each condition was 1 week. Self-report measures of practice frequency and aspects of motivation were obtained at the end of each session. RESULTS: Practice of voice exercises was significantly greater in the video-enhanced voice therapy condition than in the standard of care "written" condition (P<0.05). Three aspects of participant motivation for practice-overall commitment to practice, importance of practice, and confidence in the ability to practice were also significantly greater after video-enhanced condition than after standard of care condition. CONCLUSION: These results support the use of video examples and portable digital media players in voice therapy for individuals who are comfortable using such technology.

Patient perceptions of voice therapy adherence.

Patient perspectives of behavioral voice therapy, including perspectives of treatment adherence, have not been formally documented. Because treatment adherence is, to a large extent, determined by patient beliefs, assessment of patient perspectives is integral to the study of adherence. Fifteen patients who had undergone at least two sessions of direct voice therapy for a variety of voice disorders/complaints were interviewed about their perspectives on voice therapy, with a particular focus on adherence. Interviews were transcribed and analyzed for content according to qualitative methods. Three common content themes emerged from the transcripts: Voice Therapy is Hard, Make it Happen, and The Match Matters. Findings were compared with reports of patient experiences in other behavioral interventions, such as diet and exercise, and related to existing theoretical models of behavior change and therapeutic process. This study yields information toward the development of scales to measure adherence-related constructs and strategies to improve treatment adherence in voice therapy.

Transtheoretical model of health behavior change applied to voice therapy.

Studies of patient adherence to health behavior programs, such as physical exercise, smoking cessation, and diet, have resulted in the formulation and validation of the Transtheoretical Model (TTM) of behavior change. Although widely accepted as a guide for the development of health behavior interventions, this model has not been applied to vocal rehabilitation. Because resolution of vocal difficulties frequently depends on a patient's ability to make changes in vocal and health behaviors, the TTM may be a useful way to conceptualize voice behavior change processes, including the patient's readiness for change. The purpose of this paper is to apply the TTM to the voice therapy process to: (1) provide an organizing framework for understanding of behavior change in voice therapy, (2) explain how treatment adherence problems can arise, and (3) provide broad strategies to improve treatment adherence. Given the significant role of treatment adherence in treatment outcome, considering readiness for behavior change should be taken into account when planning treatment. Principles of health behavior change can aid speech pathologists in such understanding and estimating readiness for voice therapy.

Bolus location associated with videofluoroscopic and respirodeglutometric events.

The purpose of the present investigation was to determine the relation between specific events observed with simultaneous videofluoroscopy and respirodeglutometry. The order of occurrence was determined for each of 31 events (18 videofluoroscopic, 13 respirodeglutometric). Using 1 video frame (33.3 ms) as the maximum distance allowed between the average times of 2 events in the same cluster, 8 potential clusters were identified, 3 of which were statistically confirmed based on 90% confidence intervals on the mean time distances between events. Confirmed clusters included the time of (a) complete velar descent and the onset of the small noninspiratory flow (SNIF), (b) full separation of the base of the tongue from the pharyngeal wall and SNIF nadir, complete upper esophageal sphincter closure, and SNIF nadir, and (c) onset of epiglottic return and apnea offset. The onset of respiratory flow occurred within 13 ms after the onset of epiglottic return. Additionally, the percentage of swallows during which the bolus head or tail was located at each of 6 locations was determined for 20 of these events (10 videofluoroscopic, 10 respirodeglutometric). The 6 locations of interest included the oral cavity, base of tongue, valleculae, pyriform sinuses, upper esophageal sphincter, and the esophagus. Lastly, of the 72 swallows performed by these healthy, young adults, 65 (90.3%) were preceded by expiration, and all (100%) were followed by expiration.