Reliability of perceptions of voice quality: evidence from a problem asthma clinic population.

INTRODUCTION: Methods of perceptual voice evaluation have yet to achieve satisfactory consistency; complete acceptance of a recognised clinical protocol is still some way off. MATERIALS AND METHODS: Three speech and language therapists rated the voices of 43 patients attending the problem asthma clinic of a teaching hospital, according to the grade-roughness-breathiness-asthenicity-strain (GRBAS) scale and other perceptual categories. RESULTS AND ANALYSIS: Use of the GRBAS scale achieved only a 64.7 per cent inter-rater reliability and a 69.6 per cent intra-rater reliability for the grade component. One rater achieved a higher degree of consistency. Improved concordance on the GRBAS scale was observed for subjects with laryngeal abnormalities. Raters failed to reach any useful level of agreement in the other categories employed, except for perceived gender. DISCUSSION: These results should sound a note of caution regarding routine adoption of the GRBAS scale for characterising voice quality for clinical purposes. The importance of training and the use of perceptual anchors for reliable perceptual rating need to be further investigated.

Perceived vocal morbidity in a problem asthma clinic.

AIMS: Asthma treatment has the potential to affect patients' voices. We undertook detailed characterisation of voice morbidity in patients attending a problem asthma clinic, and we determined how patients' perceptions related to objective assessment by an experienced observer. METHODS: Forty-three patients took part in the study. Subjects completed the self-administered voice symptom score (VoiSS) questionnaire and underwent digital voice recording. These voice recordings were scored using the grade-roughness-breathiness-asthenicity-strain system (GRBAS). Laryngoscopy was also performed. RESULTS: The median VoiSS was 26 (range three to 83). VoiSS were significantly lower in the 17 patients with normal laryngeal structure and function (range four to 46; median 22), compared with the 26 patients with functional or structural laryngeal abnormality (range three to 83; median 33) (95 per cent confidence intervals for difference 0.0-21.0; p = 0.044). The overall grade score for the GRBAS scale did not differ between these two groups, and only 13 patients had a GRBAS score of one or more, recognised as indicating a voice problem. There were positive correlations between related GRBAS score and voice symptom score subscales. Although voice symptom scores were significantly more abnormal in patients with structural and functional abnormalities, this score performed only moderately well as a predictive tool (sensitivity 54 per cent; specificity 71 per cent). Nevertheless, the voice symptom score performed as well as the more labour-intensive GRBAS score (sensitivity 57 per cent; specificity 60 per cent). Patients' inhaled corticosteroid dose (median dose 1000 microg beclomethasone dipropionate or equivalent) had a statistically significant relationship with their overall grade score for the GRBAS scale (r = 0.56; p < 0.001), but not with their VoiSS. Only one patient had evidence of laryngeal candidiasis, and only two had any evidence of abnormality suggesting steroid-induced myopathy. CONCLUSIONS: Vocal morbidity is common in patients with asthma, and should not be immediately attributed to steroid-related candidiasis. The VoiSS merits further, prospective validation as a screening tool for ENT and/or speech and language therapy referral in patients with asthma.

Time and incidence of ovulation and conception rates after incorporating estradiol cypionate into a timed artificial insemination protocol.

Two experiments were conducted to determine the effect of estradiol cypionate (ECP), when incorporated into a conventional GnRH-PGF(2alpha)-GnRH timed artificial insemination protocol (Ovsynch), on systemic estradiol (E(2)), time and incidence of ovulation, luteal development, and conception rate in Holstein cows. Our objective was to determine if administration of 0.25 mg of ECP at the time of the second GnRH injection would effectively synchronize ovulation and increase conception rate. In Experiment 1, lactating Holstein cows (n = 23; 58.7 +/- 1.2 d in milk) were synchronized with PGF(2alpha) (at d -10). Ten days later, Ovsynch was initiated with the administration of 100 mug of GnRH (d 0) followed by PGF(2alpha) on d 7. On d 9, cows were assigned randomly to be treated with either GnRH + 0.25 mg of ECP (OVS-ECP; n = 11) or GnRH and 1 mL of cottonseed oil (OVS-C; n = 12). Ovarian activity was monitored by ultrasonography on d 0, 7, and 9. To determine the time of ovulation, ultrasound examinations were conducted at 12 and 20 h posttreatment and then at least every 3 h until either 36 h posttreatment or ovulation was observed. Blood samples were collected on d 0, 7, 9, and 16 for progesterone analysis. Blood samples also were collected at the time of treatment (d 9, 0 h) and at 6, 12, 20, and 28 h for E(2) analysis. Incidence of ovulation did not differ between treatments. Mean ovulation time relative to the second GnRH administration was similar between treatments. Serum progesterone concentration did not differ between treatments at any time. Serum E(2) concentration was not different at the time of treatment (0 h); however, mean E(2) concentration was greater for the OVS-ECP group at 6 and 12 h after treatment compared with OVS-C. In Experiment 2, lactating dairy cows (n = 333) in 3 commercial herds were randomly assigned to OVS-ECP (n = 169) or OVS-C (n = 164). Cows were inseminated 22 to 24 h posttreatment. Conception rates did not differ between treatments. Estradiol cypionate treatment was successful in increasing serum E(2) when administered at the time of the second dose of GnRH in the Ovsynch protocol. Conception rates, however, were not affected by treatment.

Speech and language therapy for dysarthria due to non-progressive brain damage.

BACKGROUND: Dysarthria is a common sequel of non-progressive brain damage (typically stroke and traumatic brain damage). Impairment-based therapy and a wide variety of compensatory management strategies are undertaken by speech and language therapists with this patient population. OBJECTIVES: To determine the efficacy of speech and language therapy interventions for adults with dysarthria following non-progressive brain damage. SEARCH STRATEGY: We searched the trials registers of the following Cochrane Groups: Stroke, Injuries, Movement Disorders and Infectious Diseases. We also searched the trials register of the Cochrane Rehabilitation and Related Therapies Field. The trials registers were last searched in September 2004. The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to September 2004), EMBASE (1980 to September 2004), CINAHL (1983 to September 2004), PsycINFO (1974 to October 2004), and Linguistics and Language Behavior Abstracts (1983 to December 2004) were searched electronically. We handsearched the International Journal of Language and Communication Disorders (1966 to 2005, Issue 1) and selected conference proceedings, and scanned the reference lists of relevant articles. We approached colleagues and speech and language therapy training institutions to identify other possible published and unpublished studies. SELECTION CRITERIA: Unconfounded randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: One author assessed trial quality. Two co-authors were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS: No trials of the required standard were identified. AUTHORS' CONCLUSIONS: There is no evidence of the quality required by this review to support or refute the effectiveness of speech and language therapy interventions for dysarthria following non-progressive brain damage. Despite the recent commencement of a RCT of optimised speech and language therapy for communication difficulties after stroke, there continues to be an urgent need for good quality research in this area.

Speech and language therapy for dysarthria due to non-progressive brain damage.

BACKGROUND: Dysarthria is a common sequel of non-progressive brain damage (typically stroke and traumatic brain damage). Impairment-based therapy and a wide variety of compensatory management strategies are undertaken by speech and language therapists with this patient population. OBJECTIVES: To determine the efficacy of speech and language therapy interventions for adults with dysarthria following non-progressive brain damage. SEARCH STRATEGY: This review has drawn on the search strategies developed for the following Cochrane Groups as a whole: Stroke, Injuries, Movement Disorders and Infectious Diseases. Relevant trials were identified in the Specialised Registers of Controlled Trials (see Review Group details for more information). We also searched the trials register of the Cochrane Rehabilitation and Related Therapies Field. The Trials Registers were last searched in December 2001. The Cochrane Controlled Trials Register (Cochrane Library 2002, Issue 1), MEDLINE (1966-December 2001), EMBASE (1980-December 2001), CINAHL (1983-December 2001), PsycINFO (1974-February 2002) and Linguistics and Language Behavior Abstracts (1983-October 2001) were searched electronically. We handsearched the International Journal of Language and Communication Disorders (1966-2002, Issue 1) and selected conference proceedings, and scanned the reference lists of relevant articles. Colleagues were approached to identify other possible published and unpublished studies. SELECTION CRITERIA: Unconfounded randomised controlled trials. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality. Two co-reviewers were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS: No trials of the required standard were identified. REVIEWER'S CONCLUSIONS: There is no evidence of the quality required by this review to support or refute the effectiveness of Speech and Language Therapy interventions for dysarthria following non-progressive brain damage. There is an urgent need for good quality research in this area.

Is voice therapy an effective treatment for dysphonia? A randomised controlled trial.

OBJECTIVES: To assess the overall efficacy of voice therapy for dysphonia. DESIGN: Single blind randomised controlled trial. SETTING: Outpatient clinic in a teaching hospital. PARTICIPANTS: 204 outpatients aged 17-87 with a primary symptom of persistent hoarseness for at least two months. INTERVENTIONS: After baseline assessments, patients were randomised to six weeks of either voice therapy or no treatment. Assessments were repeated at six weeks on the 145 (71%) patients who continued to this stage and at 12-14 weeks on the 133 (65%) patients who completed the study. The assessments at the three time points for the 70 patients who completed treatment and the 63 patients in the group given no treatment were compared. MAIN OUTCOME MEASURES: Ratings of laryngeal features, Buffalo voice profile, amplitude and pitch perturbation, voice profile questionnaire, hospital anxiety and depression scale, clinical interview schedule, SF-36. RESULTS: Voice therapy improved voice quality as assessed by rating by patients (P=0.001) and rating by observer (P<0.001). The treatment effects for these two outcomes were 4.1 (95% confidence interval 1.7 to 6.6) points and 0.82 (0.50 to 1.13) points. Amplitude perturbation showed improvement at six weeks (P=0.005) but not on completion of the study. Patients with dysphonia had appreciable psychological distress and lower quality of life than controls, but voice therapy had no significant impact on either of these variables. CONCLUSION: Voice therapy is effective in improving voice quality as assessed by self rated and observer rated methods.

Speech and language therapy for dysarthria due to non-progressive brain damage.

BACKGROUND: Dysarthria is a common sequel of non-progressive brain damage (typically stroke and traumatic brain damage). Impairment-based therapy and a wide variety of compensatory management strategies are undertaken by speech and language therapists with this patient population. OBJECTIVES: To determine the efficacy of speech and language therapy interventions for adults with dysarthria following non-progressive brain damage. SEARCH STRATEGY: This review has drawn on the search strategies developed for the following Cochrane Groups as a whole: Stroke, Injuries, and Infectious Diseases. Relevant trials were identified in the Specialised Registers of Controlled Trials (see Review Group Details for more information). We also searched the trials register of the Cochrane Rehabilitation and Related Therapies Field. The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and Linguistics and Language Behavior Abstracts were electronically searched. Hand-searching of The International Journal of Language and Communication Disorders and of reference lists from relevant articles and conference proceedings was also undertaken. Colleagues were approached to identify other possible published and unpublished studies. Date of most recent searches: May 2000. SELECTION CRITERIA: Unconfounded randomised controlled trials. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality. Two co-reviewers were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS: No trials of the required standard were identified. REVIEWER'S CONCLUSIONS: There is no evidence of the quality required by this review to support or refute the effectiveness of Speech and Language Therapy interventions for dysarthria following non-progressive brain damage. There is an urgent need for good quality research in this area.

Barriers to achieving evidence-based stroke rehabilitation.

OBJECTIVE: To determine the perceived barriers to evidence-based practice by health professionals working within the field of stroke rehabilitation. DESIGN: Focus groups were carried out to identify the perceived barriers; these were followed by a postal questionnaire that asked stroke rehabilitation professionals to rate their agreement with the perceived barriers. SUBJECTS: One hundred and five stroke rehabilitation professionals participated in the focus groups and were sent the postal questionnaire. Eighty-six responses were returned, from 27 physiotherapists, 26 occupational therapists, 22 nurses, 6 speech and language therapists, and 5 other professionals. MAIN OUTCOME MEASURES: Proportion of subjects rating their level of agreement with statements as 1 'agree', 2, 3, 4 or 5 'disagree'. Scores of 1 or 2 were classified as 'agreement', and scores of 4 or 5 were classified as 'disagreement': the percentages of subjects agreeing or disagreeing with each statement were calculated. RESULTS: Twenty barriers were identified, classified under the headings 'ability', 'opportunity' and 'implementation'. Seventy-nine (92%) of all respondents agreed that keeping up to date with research findings was important to them, but only 7 (8%) were happy with the time that they had to do this. Fifty-eight (67%) perceived a need for further training. Only 4 (5%) agreed that it was easy to transfer research findings into their daily practice. A number of significant differences were found between the perceived barriers of different disciplines.

Swallowing abnormalities after acute stroke: A case control study.

Dysphagia is a common and potentially fatal complication of acute stroke. However, the underlying pathophysiology, especially the relative importance of motor and sensory dysfunction, remains controversial. We conducted a case control study of 23 acute stroke patients (mean age = 72 yr) at a median of 6 days post-stroke and 15 healthy controls (mean age = 76 yr). We used novel methods to assess swallowing in detail, including a timed videoendoscopic swallow study and oral sensory threshold testing using electrical stimulation. Vocal cord mobility and voluntary pharyngeal motor activity were impaired in the stroke group compared with the controls (p = 0.01 and 0.03). There was a delay during swallowing in the time to onset of epliglottic tilt in the stroke group, particularly for semisolids (p = 0.02) and solids (p = 0.01), consistent with a delay in initiation of the swallow. Sensory thresholds were not increased in the stroke group compared with controls. We conclude that pharyngeal motor dysfunction and a delay in swallow initiation are common after acute stroke. Vocal cord mobility is reduced, and this may result in reduced airway protection. We found no evidence to support the hypothesis that oropharyngeal sensory dysfunction is common after acute stroke.

A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients.

Pulse oximetry has recently received attention in the dysphagia literature because of its possible contribution to the management of neurogenic dysphagia. The present study was devised to examine whether pulse oximetry could be exploited to determine episodes of aspiration in patients with known dysphagia of neurologic origin. To this end, pulse oximetry was undertaken in six patients undergoing videofluoroscopic study of swallow. Normal controls also underwent pulse oximetry during feeding. The results indicate that there is no clear-cut relationship between changes in arterial oxygenation and aspiration. However, some support is found for the association between altered arterial oxygenation and oral feeding in dysphagic individuals. Further research in both normals and compromised individuals is needed.