Faculty Bibliography

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (i.e., ingredients) actively improve specific patient functions (i.e., targets). However, the RTSS does not provide methodology for standardly identifying specific, unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (i.e., different words describing the same treatment) or meaningfully different (e.g., different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this manuscript is to describe the challenges encountered during the project and the methodology developed to address those challenges. Since the methodology was based on the RTSS's broadly applicable framework, it can be used across all of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc.) or impairment domain (language, cognition, ambulation, upper extremity training, etc.). The resulting standard, operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

Objectives (1) To determine the short-term effectiveness of oral steroids in women with benign vocal fold lesions and (2) to determine the effectiveness of adjuvant oral steroids in women undergoing voice therapy for benign vocal fold lesions. Study Design Randomized, double-blind, placebo-controlled clinical trial. Setting Tertiary voice care center. Subjects and Methods Thirty-six patients undergoing voice therapy for the treatment of phonotraumatic vocal fold lesions randomly received either a 4-day course of oral steroids or a placebo prior to initiating voice therapy. Voice Handicap Index-10 (VHI-10) scores, video and audioperceptual analyses, acoustic and aerodynamic analyses at baseline, and patient perception of improvement after a short course of steroids or a placebo and at the conclusion of voice therapy were collected. Results Thirty patients completed the study, of whom 27 (only female) were analyzed. The primary outcome measure, VHI-10, did not improve after the 4-day course of steroids or placebo. Secondary measures similarly showed no improvement with steroids relative to placebo. Voice therapy demonstrated a positive effect on both VHI-10 and patient-perceived improvement of voice in all subjects. Conclusion A short course of oral steroids did not benefit women with phonotraumatic vocal fold lesions. In addition, steroids had little beneficial effect when used adjunctively with voice therapy in this patient cohort.

OBJECTIVES: To introduce the conceptual, theoretical, and practical foundations of a novel approach to voice therapy, called conversation training therapy (CTT), which focuses exclusively on voice awareness and efficient voice production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. CTT is grounded in motor learning theory, focused on training target voice goals in spontaneous, conversational speech in the first session and throughout. CTT was developed by a consensus panel of expert clinical voice-specialized speech-language pathologists (SLPs) and patients with voice problems. STUDY DESIGN: This is a prospective, clinical consensus design. METHODS: A preliminary CTT approach to voice therapy was developed by the first and last authors (J.G-S. and A.I.G.) and incorporated six interchangeable tenets: clear speech, auditory/kinesthetic awareness, rapport building, negative practice, basic training gestures, and prosody. Five expert voice-specialized clinical SLPs (consensus group) were then presented CTT and a discussion ensued. Later, an informal interview by a neutral third party person occurred for further recommendations for CTT. RESULTS: The CTT approach was modified to reflect all the consensus groups' recommendations, which included the need for more detail and rationale in the program, troubleshooting suggestions, and the concern for potential challenges for novice clinicians. CONCLUSIONS: CTT is a new therapy approach based on motor learning theory, which exclusively uses patient-driven conversational narrative as the sole therapeutic stimuli. CTT is conceptually innovative because it represents an approach to voice therapy developed without the use of a traditional therapeutic hierarchy. It is also developed using input from patients with voice disorders and expert clinical providers.

OBJECTIVES/HYPOTHESIS: Glottic insufficiency (GI) can be either grossly obvious or subtle in its presentation. Subtle GI is demonstrated by various Laryngovideostroboscopic (LVS) clues, including complete but "short" phase closure of the true vocal folds (VFs) during the glottic cycle. We used the frame by frame analysis (FBFA) technique to evaluate its effectiveness in objectively contributing to the diagnosis of subtle GI in patients with atrophic and/or paretic VFs. This article intends to formally present the methods and intentions of the FBFA technique and report our findings using FBFA on subjects with clinically diagnosed GI and normal volunteers. STUDY DESIGN: Retrospective review and demonstration of technique. METHODS: Forty-four subjects with a prior clinical diagnosis of true VF atrophy (25/44) and/or paresis (19/44) and five normal volunteers were identified. Using the FBFA technique, each subject's average percentage of closed frames per glottic cycle was recorded. RESULTS: Subjects with atrophy spent 32.4% of the frames of the glottic cycle in the closed phase, subjects with paresis spent 35.7% of the frames closed, and normal subjects spent 50.2% of the frames closed. CONCLUSIONS: FBFA appears to be a simple objective method for the novice or experienced LVS interpreter, by which one can suspect subtle GI. Because of the inherent physical properties by which LVS gives an "illusionary" representation of the glottic cycle, the FBFA technique remains a theoretical tool. Future studies using high-speed digital imaging are needed to validate this useful technique.

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has been primarily described in the neurology and psychiatry literature. The symptoms of this syndrome typically are a range of obsessive compulsive disorders and neuromuscular tics. The otolaryngologist occasionally becomes involved with these children when it is deemed that chronic tonsil infections are the source. We report here on a child diagnosed with PANDAS who presented with severe ventricular hyperfunction and adductor spasmodic dysphonia. She was treated with botulinum toxin, which resulted in a significant improvement in subjective voice as well as reduced jitter and shimmer on objective voice measurements.

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.