Patient Related Outcome Measures Dovepress

open access to scientific and medical research

Open Access Full Text Article Review

Functional dysphonia: strategies to improve patient

outcomes
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

This article was published in the following Dove Press journal:

Patient Related Outcome Measures
1 December 2015
Number of times this article has been viewed

Mara Behlau Abstract: Functional dysphonia (FD) refers to a voice problem in the absence of a physical
Glaucya Madazio condition. It is a multifaceted voice disorder. There is no consensus with regard to its definition
Gisele Oliveira and inclusion criteria for diagnosis. FD has many predisposing and precipitating factors, which
may include genetic susceptibility, psychological traits, and the vocal behavior itself. The assess-
Voice Department, Centro de Estudos
For personal use only.

da Voz – CEV, São Paulo, Brazil ment of voice disorders should be multidimensional. In addition to the clinical examination,
auditory-perceptual, acoustic, and self-assessment analyses are very important. Self-assessment
was introduced in the field of voice 25 years ago and has produced a major impact in the clinical
and scientific scenario. The choice of treatment for FD is vocal rehabilitation by means of direct
therapy; however, compliance has been an issue, except for cases of functional aphonia or when
an intensive training is administered. Nevertheless, there are currently no controlled studies that
have explored the different options of treatment regimens for these patients. Strategies to improve
patient outcome involve proper multidisciplinary diagnosis in order to exclude neurological and
psychiatric disorders, careful voice documentation with quantitative measurement and qualita-
tive description of the vocal deviation for comparison after treatment, acoustic evaluation to
gather data on the mechanism involved in voice production, self-assessment questionnaires
to map the impact of the voice problem on the basis of the patient’s perspective, referral to
psychological evaluation in cases of suspected clinical anxiety and/or depression, identification
of dysfunctional coping strategies, self-regulation data to assist patients with their vocal load,
and direct and intensive vocal rehabilitation to reduce psychological resistance and to reassure
patient’s recovery. An international multicentric effort, involving a large population of voice-
disordered patients with no physical pathology, could produce enough data for achieving a
consensus regarding this complex problem.
Keywords: voice, dysphonia, evaluation, patient-related outcomes, quality of life, voice
handicap

Multidisciplinary diagnosis
The human voice is a complex phenomenon. An individual’s vocal quality depends on
anatomofunctional features, psychological traits, and social and professional aspects.
Voice disorders, also called dysphonias, occur in 3%–9% of the population.1 Dysphonia
is any deviation that may restrain the natural voice production2 and that impacts the
quality of life. The American Academy of Otolaryngology – Head and Neck Surgery
Correspondence: Mara Behlau Foundation published a clinical guideline about “hoarseness”. In the guideline, dyspho-
Voice Department, Centro de Estudos
da Voz – CEV, Rua Machado Bittencourt
nia is characterized as any “deviation in the vocal quality, pitch, loudness, and vocal
361, São Paulo 04044-001, Brazil effort that affect communication or produces a negative impact on the voice-related
Tel +55 11 5575 1710
Fax +55 11 5575 1710
quality of life”. In other words, it is an individual’s reduction of the self-perceived
Email [email protected] physical, emotional, social, or economic status due to a voice problem.1

submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6 243–253 243
Dovepress © 2015 Behlau et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0)
http://dx.doi.org/10.2147/PROM.S68631
License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on
how to request permission may be found at: http://www.dovepress.com/permissions.php
Powered by TCPDF (www.tcpdf.org)
 Behlau et al Dovepress

Dysphonia can be etiologically and traditionally classi- and psychological traits.5,12,13 A deviated vocal behavior
fied into two main broad categories: organic and functional with inadequate muscle activity can produce benign mass
types.2 Organic dysphonias are the consequences of aspects lesions, such as vocal nodules and polyps. These cases are
nonrelated to the use of voice, such as gastroesophageal sometimes called organofunctional or behaviorally based
reflux, vocal fold paralysis, and systemic diseases, eg, dysphonias with benign mass lesions.14
Parkinson’s and amyotrophic lateral sclerosis. Functional In order to suggest strategies to improve the outcomes
dysphonias (FDs) are the results of phonotraumatic events for the FD patient, we need to understand certain aspects of
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

(abusive behaviors or voice misuse), poor vocal technique, its diagnosis and treatment.
and/or muscle imbalance, with or without psychoemotional
involvement. Voice documentation with
FD is sometimes referred to as behavioral dyspho- multidimensional descriptions
nias, since the deviated vocal gesture is at the core of this The assessment of a patient with a voice problem is multidi-
disturbance. The label “functional voice disorders” has been mensional and will usually include the following procedures:
at the center of scientific debates since the 1960s.3 Since then, 1) visual laryngeal examination (via nasal or oral endoscopy,
there has been no consensus regarding its usage and concept. to visualize the vocal folds and detect lesions and/or problems
Particularly in the last 2 decades, American authors either with muscle activity); 2) auditory-perceptual analysis of
avoid using the term FD or replace it with muscle tension voice quality (to identify the degree and type of deviation);
dysphonia (MTD).4–6 When MTD is used as a synonym of FD, 3) acoustic/aerodynamic measures (to quantify different
For personal use only.

it can be differentiated into two types6: primary and secondary aspects related to the fundamental frequency, noise param-
MTD. Primary MTD is a voice disorder in which excessive eters, and maximum phonation time); and 4) self-assessment
atypical or abnormal laryngeal movements are observed tools (to identify the perception of the patient with regard to
during phonation in the absence of any of the following: the impact of the voice disorder on his/her life). Additionally,
organic pathology, and psychogenic or neurologic etiology. the identification of behavioral aspects related to the use of
Secondary MTD is a voice disorder in which excessive com- voice must be assessed for a thorough diagnosis. These aspects
pensatory atypical or abnormal laryngeal movements are seen need to be carefully considered, ideally by collaboration
during phonation in the presence of organic vocal pathology, between the physician and the speech–language pathologist/
psychogenic, or neurologic problem, originated as a response voice specialist to properly deal with clinical requirements.
to the primary etiology. In addition to MTD, the other com- A combined evaluation by these two professionals is the best
mon terms used to refer to FD are as follows: psychogenic option for improving diagnostic precision and patient’s adher-
dysphonias, hyper-, and hypo-FDs, with differentiations ence to treatment, as well as to reduce health costs.15
according to the authors.7 Particularly for MTD cases, the The clinical evaluation of voice that includes multiple
situation is so complex, that three etiological subgroups can procedures is a common practice in the field; however, during
be recognized:8 1) psychological and/or personality factors, the last few decades, instruments that measure the patient’s
2) vocal misuse and abuse, and 3) compensation for the experience of living with a voice problem hold a special place
underlying disease. in the armamentarium of assessment.16–21
FD can manifest itself with different voice qualities. The multidimensional voice evaluation can be grouped
There is not a single vocal pattern, which characterizes these into two main categories: clinician-centered perspective and
patients’ voice disorder. Weak voice, strained sound, hoarse patient-centered perspective.
or breathy vocal qualities, and whispering phonation, as
well as lack of vocal efficacy, vocal fatigue, and kinesthetic Clinician-centered perspective
symptoms (effort during speech) can be seen. In cases of total This perspective usually includes laryngeal examination,
loss of voice, vegetative sounds (coughing, throat clearing, auditory-perceptual analysis, and some acoustic/aerodynamic
and laughing) are frequently preserved.9 For some authors, measurements.
MTD should be regarded more as a speech problem than a
voice disorder.4,10 Laryngeal examination
Vocal behavior is at the center of FD; however, the Laryngeal analysis is the focus of the medical examination
ethiopathogenesis is complex and can involve anatomofunc- in the presence of a voice symptom. Laryngeal structures,
tional predispositions, such as small glottic proportions11 particularly the vocal folds, are assessed during breathing

244 submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Functional dysphonia patient outcomes

and phonation. Laryngoscopy is the minimal examination assessment of vocal quality, objective in nature, or at least,
required for voice diagnosis.1 Videolaryngostroboscopy semiobjective since there is a lot of human interaction.
(VLS) is a well-established procedure that analyzes the vocal Humans are involved in the process of developing the
folds’ vibration and has become the routine examination software, selecting the algorithm, recording, storing, and
method for voice problems.22 VLS is critical to evaluate a analyzing the signal.
dysphonic patient and its use increases diagnostic accuracy It is important to highlight that the acoustic analysis is
in 68.3% of cases of hoarseness.23 In case of FD, special only a part of the voice evaluation process. Its efficiency
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

attention is given to the glottal closure, vocal fold vibra- depends essentially on the clinician’s ability to integrate
tion, mucosal wave, and supraglottic activity. Even though, the findings of perceptual, acoustic, and laryngeal imaging
VLS is a useful tool for voice evaluation, it should not be analyses. Among the suitability of the acoustic analysis,
the sole method used for diagnostic purposes, since there is the main aspects are to facilitate the comprehension of
no relationship between the clinical course and changes in voice production, generate normative data, produce vocal
stroboscopic data.24 Recent technical advances, such as high- documentation, monitor treatment outcome, follow-up the
speed cameras, are more sensitive and offer more detailed voice development, and early detection of voice problems.
information about phonatory function. However, they are The acoustic analysis represents the objective portion of
expensive and there are many methodological challenges to the voice evaluation process. Due to its objective nature,
overcome (such as excessive data and time-consuming analy- it allows the transformation of an abstract construct into a
sis) before proposing it as a clinical tool for the evaluation concrete reality.
For personal use only.

of patients with voice problems.23 An external examination Acoustic analysis gained popularity in the 1990s due to
(palpation) of laryngeal extrinsic muscles, neck, mandible the development of inexpensive computer-based programs
and observation of facial gestures during speech can add that allowed the average clinician to obtain data previously
important information particularly for the cases of FD due to limited to university and hospital voice laboratories. The use
MTD,4,10 even if there is reduced information on the validity of these measures in isolation is controversial.30 However,
of these assessments.10 some important information about the sound composition
and production can be collected and compared to the percep-
Auditory-perceptual analysis tual data. Since voice has harmonic and noise components,
Voice is a fundamentally perceptual phenomenon, thus per- parameters are related to each of these aspects. Fundamental
ceptual evaluation is a strong candidate for the gold standard frequency measurements, at least their extraction, are shown
assessment of patients with voice disorders. 25 Although to be robust parameters. The same is not true for perturba-
widely used for diagnosis, treatment outcome, follow-ups, tion analysis, such as jitter and shimmer.31 Noise parameters
and dismissal, reliability problems were pointed out since are considered clinically important, because the noisier the
early studies were performed.26–28 This reliability issue is voice, the more distant it is from the normal vocal quality.
even considered as a noncontrolled effect of the human Nonetheless, the reliability of noise measurements is related
auditory processing nature.29 Some variables, such as type to many factors such as the overall deviation of vocal
of stimuli, presentation context, personal and professional quality.32 The problem with this traditional acoustic analysis
experiences, and cultural influences,26,27,29 have been repeat- is that the quantification of the voice sample is based on the
edly highlighted as interfering factors. These aspects can assumption that the signal is nearly periodic. However, this
be minimized by standardizing the assessment protocol is not often the case for dysphonic voices, and quantifica-
and training of listeners, but it does not solve the problem tion of these signals can be meaningless.32 A new approach
for FD cases since patients usually show instability in their has been recently described, the Cepstral Spectral Index of
voices and mixed components of roughness, breathiness, and Dysphonia,33 which is a multivariate estimate of dysphonia
strain. The overall degree of vocal deviation, which reflects severity. This measure seems to be a potentially robust tool for
the total amount of abnormality, has been used to reduce the voice disorder identification; yet, its validity as an outcome
reliability problem.14 measure has been limited to few studies.34
An alternative approach to dealing with dysphonic signals
Acoustic/aerodynamic measurements is to use nonlinear dynamical systems analysis35 but there are
Acoustic analysis aims to measure different parameters of the only few contributions in order to draw conclusions about its
voice signal. It is considered as a noninvasive quantitative use for clinical purposes.36

Patient Related Outcome Measures 2015:6 submit your manuscript | www.dovepress.com

245
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Behlau et al Dovepress

Patient-centered perspective – self- Furthermore, specific scores of vocal activity limitation

assessment questionnaires and participation restrictions can be obtained by using one
Voice-disordered quality of life is a disease-specific construct instrument.19 Recently, cross-cultural differences of health,
aimed to evaluate the impact of a voice problem in ­activity illness, and disability perception have also been documented
limitations and participation restrictions for a specific patient. in the area of voice.75,76
The voice-disordered quality of life instruments were intro- Self-assessment instruments have achieved rapid interna-
duced in the late 1990s16–18 and have been used for clinical tional popularity, which was not seen before with any other
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

diagnosis, to quantify the impact of a voice problem, to assessment approach,21 regardless of some methodological
help adherence, to contribute in therapeutic management, problems identified in their development process.42,77 Some
to evaluate the patient’s response to different treatments, reasons behind this popularity are, the global spread of the
and to screen large populations. These instruments not concept of health and disease by the World Health Oraganiza-
only showed good psychometric properties16–20,37–72 but also tion,78 the excellent cost–benefit ratio of using questionnaires
improved clinical care. with no need of fancy equipment, the reduction of time for
Self-assessment instruments reveal new information completing an objective self-evaluation (up to 5 minutes), its
about the impact of dysphonia related to the quality of life utility for voice diagnosis, with the possibility of quantifying
that could not have been obtained by traditional approaches. and qualifying the impact of a voice disorder in a person’s
Additionally, because there is a low correlation between the life; and the insights produced by simply answering a list
patient’s perspective and the clinician’s analysis,73,74 this type of questions. A typical clinical observation from patients is
For personal use only.

of investigation should be mandatory. that they say they were not aware of how much their voice
These instruments were initially developed mostly in problem caused them losses and negative implications until
English and were subsequently validated in several other they answered the instrument.
languages in different countries (Table 1). The validated No self-assessment instrument for voice disorders was
instruments showed comparable psychometric properties specifically developed for the evaluation of a particular diag-
to their original versions. The worldwide spread of these nostic category, including FD, except for the Voice Outcome
instruments made us understand that there is a common Survey designed for patients with vocal fold paralysis.79
universal trait for patients with voice problems. Physical Nevertheless, these instruments are crucial because they
(organic), functional (activity and participation), and emo- reveal the subjective perception of negative impacts imposed
tional (socio-emotional) aspects are shared by all instruments. by a voice problem. This information is unique and cannot

Table 1 Main self-assessment questionnaires for investigating the impact of FD, original country of development, and validation in
other countries
Name of instrument and mains aspects Original country Validation in other countries
Voice Handicap Index (VHI) – 30-item questionnaire: total, USA16 Germany,37 Taiwan,38 Portugal,39 France,40 Poland,41
functional, organic, and emotional domains UK,42 Germany,43 the Netherlands,44 Israel,45 Scotland,46
Spain,47 People’s Republic of China,48 Turkey,49
Sweden,50 Brazil,51 Italy,52 Greece,53 Saudi Arabia,54
Norway,55 Japan,56 Iran,57 Croatia,58 and Latvia59
Voice Handicap Index 10 (VHI-10) reduced version – 10-item USA60 People’s Republic of China,61 Israel,62 Brazil,63 Spain,47
questionnaire: total score and Italy64
Voice-Related Quality of Life (V-RQOL) – 10-item USA17 Germany,65 Brazil,66 and India67
questionnaire: total score, physical functioning domain, and
social–emotional domain
Vocal Performance Questionnaire (VPQ) – 12-item UK18 Brazil68
questionnaire: total score
Voice Activity and Participation Profile (VAPP) – 28-item People’s Republic of Finland,69 Brazil,70 and Italy71
questionnaire, five aspects: total score and scores on self- China (Hong Kong)19
perceived severity of voice problem, effect on job, effect on
daily communication, effect on social communication, and effect
on emotion. Two extra-scores for activity and participation
Voice Symptom Scale (VoiSS) – 30-item questionnaire: total, UK20 Brazil72
impairment, emotional, and physical domains
Abbreviation: FD, functional dysphonia.

246 submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Functional dysphonia patient outcomes

be obtained by either laryngeal examination or perceptual and they know they will be assessed (Hawthorne effect).83
and acoustic analysis. Therefore, clinicians must wisely use both clinician- and
There are some differences among these instruments with patient-oriented information for diagnosis and evaluation
regard to their conceptual development. Some of them are of treatment outcome.
more focused on the perceived handicap (Voice Handicap
Index),16 some on the quality of life (Voice-Related Qual- Psychological considerations: coping
ity of Life),17 some on the loss of vocal endurance (Voice and self-regulation strategies
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

Performance Questionnaire),18 others on activity limitation Emotional issues can be clearly seen in some but not all cases.
and participation restriction (Voice Activity and Participation Psychogenic factors seem to be more relevant in cases of total
Profile),19 and finally the other ones on combining disability voice loss, functional aphonia, than in cases of variable voice
and vocal symptoms (Voice Symptoms Scale).20 deviations.84 Using the personality traits construct, Roy et al5
Studies on specific populations with voice problems need compared patients among four diagnostic categories: FD,
to be performed, particularly including professional voice vocal fold nodules (both of them being behavioral-based
users with functional voice problems, both artistic (singers cases), spasmodic dysphonia, and vocal fold paralysis (both
and actors) and nonartistic (teachers, call center operators, of them being organic types). The findings made clear that
and sales persons). The question with the artistic profes- the behavioral-based dysphonias have specific psychological
sional voice users is even more complex because some vocal traits. Individuals with FD were characterized as introverted,
deviations may be part of their signature voice. In this case, stress reactive, alienated, and unhappy. Patients with vocal
For personal use only.

it can be difficult to differentiate between a stylistic choice nodules are socially dominant, stress-reactive, aggressive,
and a behavioral problem. There have been some attempts and impulsive. Finally, the organic-based cases and subjects
to develop specific tools for this population, but currently no without voice disorders did not present any consistent per-
extensive data was derived.80,81 Professional voice users face sonality features.
different demands regarding voice quality and endurance to Patients with common voice disorders, including FD
long periods of usage. It is plausible to consider that they may cases, assessed by the Hospital Anxiety and Depression
have a different sensibility to voice changes and also diverse Scale presented higher psychological distress. Stress and
ways of coping with the problem. A slight vocal problem depression were more common in patients with MTD. In
that would do no harm to a nonprofessional voice user can particular, females12 with FD usually present multiple psycho-
severely impair the career of an elite vocal professional. social problems.86 It is not sufficient to look only at the vocal
Therefore, a similar degree of dysphonia for a nonprofes- behavior; the other associated factors such as predisposition,
sional voice user may be perceived differently.81 precipitant, and maintenance factors must also be taken into
Finally, it is important to mention that voice is a cul- consideration.86 Predisposition factors are genetic susceptibil-
tural construct and vocal expression has been the mirror of ity, constitution of the individual, occupational susceptibility,
cultural differences throughout mankind. There is a known prolonged stress, laryngeal inflammatory processes, history of
relationship between voice, linguistic code, and cultural sexual and/or physical abuse, and perfectionism. Precipitant
behavior,21 but unfortunately this has not yet been explored factors are life events, vocal load, upper airway infections,
by voice clinicians. The exploration of cross-cultural differ- and laryngeal inflammatory processes. Finally, the potential
ences began only recently in the voice area, both regarding maintenance factors are probably prolonged stress and general
self-assessment of the voice problem76 and the manifestation fatigue.84,85 The popular conception is that voice loss is a result
of specific disorders.82 When cultural modifications lead to of unexpressed emotion and has no scientific evidence.85
qualitative changes in the voice, a voice disorder must be The specific role of psychogenic traits in the development of
considered.21 This subject deserves proper attention to better different categories of voice disorders as well as the interaction
suit specific aspects, particularly if we consider a globalized between predisposed and causal factors for FD is not completely
world with people living in different areas of the globe. understood. However, these factors have to be considered since
It is possible that self-assessment instruments capture a FD is commonly associated with reduced treatment attendance
different aspect of the vocal function that cannot be derived that leads to variable treatment outcomes.87
from auditory-perceptual or acoustic analysis and laryn- Two recent topics have appeared in the voice literature,
geal examination. It is also reasonable to say that some the concepts of coping and self-regulation, which are already
changes are seen because patients want to please clinicians acknowledged by psychologists dealing with behaviors.

Patient Related Outcome Measures 2015:6 submit your manuscript | www.dovepress.com

247
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Behlau et al Dovepress

Coping strategies In accordance with the previous Brazilian study,101 the teach-
Coping is defined as the manner with which an individual ers also tended to use more problem-focused strategies.103
deals with a stressful situation. Once the individual faces An important aspect that needs to be considered when
a certain event that exceeds his/her adaptation resources, studying coping is the role of culture. Within a specific cul-
cognitive and behavioral efforts are used to manage either ture, certain types of coping strategies will be more or less
external or internal demands.88–93 effective in fostering emotional well-being and in address-
Generally, coping strategies can be categorized as prob- ing problems that cause stress.104 The information about the
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

lem-focused and emotional-focused.88 Some individuals will role of culture on coping strategies can also be taken into
act directly into the stressful event using cognitive strategies consideration when designing interventions, especially for
to modify the situation, while others will use emotional strate- culturally diverse populations. The literature about the topic
gies to alleviate its psychological consequences. The function does not have multicentric studies that include samples from
of coping is to promote the adaptation of the individual to different countries; however, there are studies that compare
the unsettling situation. The sense of how much control the ethnic groups within a certain society.105,106 These studies have
individual perceives to have over the situation will in a way distinct designs and utilize diverse assessment instruments;
define the coping to be used.89–91,94–96 Consequently, when hence the findings obtained are manifold. For this reason, the
a health problem is associated with controllable aspects, results many times cannot be compared. In the field of voice,
patients tend to engage practical solutions directed to the there are no studies that compare the influence of culture on
problem itself. On the other hand, when the illness is not coping with voice problem. Consequently, further research
For personal use only.

curable and related factors cannot be controlled, people tend should include a multicultural population in order to investi-
to utilize strategies to manage emotions.97,98 gate the effect of culture on coping with voice problems.
When the mediating role of coping is taken into consider-
ation,89–91 it becomes easier to understand the diversity of the Self-regulation strategies
treatment outcome of a voice problem and the importance of Self-regulation, as well as coping strategies, may have been
addressing adequately this issue during both the evaluation underestimated in patients with FD. Perceived control is a
and intervention processes, since the expected result is the central construct in psychology. Present perceived control
effective adaptation of the individual to the situation. Speech– (PPC), opposed to control in the past, is the perception of
language pathologists should help patients identify the strat- having some kind of control over some current aspect of the
egies they are using to cope with their voice disorder and event.107 It is especially important when there are stressful
to assist them toward changing maladaptive strategies.99,100 life situations, such as a voice disorder limiting the abil-
During the evaluation session, the clinician should make use ity to communicate socially or at work. PPC is important
of a specific coping self-assessment tool to guide them in in adjustment to stress and to help the clinician facilitate
identifying and listing the nonadequate strategies. Over the patient’s control over his/her voice. Present control is related
course of therapy, the patient should also be encouraged to to lower perceived distress, which also benefits the patient’s
use problem-adequate strategies.101 improvement during vocal rehabilitation.
The first researchers who investigated coping strategies On a large study exploring the relation among distress,
with dysphonia looked at individuals with spasmodic dys- stress, vocal handicap and perceived control, 108 authors
phonia and with MTD using the Voice Disability Coping concluded that vocal handicap was more related to distress
Questionnaire.102 The results showed that individuals with among those individuals with low perceived control. The
spasmodic dysphonia used more emotion-focused strategies. severity of distress and vocal handicap were positively cor-
The same questionnaire was used to investigate a Brazilian related, and the relation between them was moderated by
population with and without vocal complaints; overall, indi- perceived control. The authors used PPC subscale, with eight
viduals with vocal complaints use several different strategies items (from a total of 17 sentences scale). These were the
to cope with their voice problem, especially problem-focused items most strongly associated with outcomes, adapted to be
strategies.101 Teachers with and without vocal complaint that used in the context of a voice problem.108 The authors rein-
sought (FD cases) or did not seek professional help were force the fact that the present control reflects the perceived
also studied.103 The interesting conclusion was that teachers ability to control one’s reaction to a stressful event and it is
who had a voice disorder and looked for help used more not the same as coping. Data from the general population on
coping strategies when compared to the other two groups. stressful events have shown that the avoidant coping could

248 submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Functional dysphonia patient outcomes

be related to more distress,107 but this was not investigated in different therapeutic programs for the treatment of behav-
dysphonic patients. If PPC is related to outcomes, it is still a ioral voice problem (FD was referred to as a behavioral
question to be determined. problem and not as MTD). The treatment options were the
Vocal Function Exercises and the Comprehensive Program
Voice rehabilitation for Voice Rehabilitation. In addition to these two therapeutic
Vocal rehabilitation consists of direct and indirect approaches methods, the authors administered a vocal hygiene session.
to ameliorate voice problems. Vocal rehabilitation is the They concluded that both options offer good results, with
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

primary management choice for FD treatment. An indirect positive outcomes in the laryngeal visual examination,
approach includes education about voice and communication, perceptual and acoustical analysis as well as in the self-
vocal health information, as well as counseling regarding assessment scales.14 Although indirect and direct combined
stress management and relaxation. On the other hand, direct intervention approaches seem to be more efficient,113,114 the
therapy consists of specific exercises to control and coordi- method chosen to deliver voice therapy should be based on
nate the different aspects of the voice production, based on the clinician’s or patient’s preferences or even on the need
the large information obtained from the multidimensional to include global communications aspects, particularly for
evaluation.109 A method of rehabilitation described since professional voice users.14
the 1990s is the perilaryngeal manipulation.110 There are A visual examination of the larynx can be used as a direct
several different approaches of laryngeal manipulation4,10,111 feedback tool during vocal rehabilitation, regardless of the
and evidence of its positive results, regardless of the type of fact that stroboscopic findings do not always correspond
For personal use only.

manipulation used, particularly for MTD cases.10 with voice improvement.24 It allows patients to realize what
The challenge for the speech–language pathologist is to the mechanics of voice is and how the treatment affected the
obtain the most accurate diagnosis and to select an effec- laryngeal configuration and activity.115
tive program of treatment for a specific patient with FD. Vocal rehabilitation in FD is effective;116 however, tradi-
Even if we admit that FD patients may present with related tional voice therapy can be unsuccessful for some patients,
psychodynamic issues, when FD is used as a synonym of often associated with poor compliance or lack of adherence
MTD, muscle activity is the main feature that should be to sessions and treatment.117–119 This fact may lead clinicians
addressed clinically.4,10 Before starting treatment, the first to frustration.120 An alternative approach is to offer intensive
session is usually performed to confirm the diagnosis. programs, particularly in cases of recalcitrant dysphonias,
During this session, diagnostic probes or muscular palpation with previous treatment failures.117 The intensive regimen
are tried out.9 The probes may include manual palpation of is based on motor learning theory, neurobiology, exercise
the extrinsic muscles of the larynx, nonspeech tasks, visual physiology, and psychotherapy. This approach also permits
and audio instrumental feedback, inhalatory phonation, customization in order to fulfill the patient’s demands and to
lip trills, task-specific sentences to distinguish MTD from assist in the transferring of acquired skills into spontaneous
spasmodic dysphonia, and perceptual and compensatory speech.121 Not only from a clinician’s perception, but also
behavior assessments. from a patient’s perspective, intensive treatment achieves
Vocal rehabilitation is typically administered worldwide a high level of satisfaction with vocal therapy and reduced
once or twice a week, in sessions of 30 minutes–45 minutes, voice handicap after treatment.87 In addition, it has been
delivered by a single clinician.18,21 This format enhances considered as one of the best ways to improve client adher-
progressive learning, favors patient–clinician rapport and ence and treatment outcomes.87,117,119 The results achieved
seems to be ideal for sustained behavioral changes. Cognitive by intensive therapy in 1 day may correspond to a 2-week
behavioral therapy also appears to be an additional effective regular regimen.117 There are no controlled studies compar-
approach in the treatment of FD, by reducing associated ing regular vs intensive approaches for FD and, of course,
distress.112 However, in cases of FD due to MTD, usually overdoses of exercises and training should be taken into
associated with complete aphonia or whispered phonation, consideration.122
voice is restored in few sessions of intensive laryngeal Patients are usually asked to perform exercises out of the
manipulation treatment.4 therapy session considering that functional cortical reorgani-
The ultimate goal of vocal rehabilitation is to restore zation depends on specific training.123 Daily practice allows
normal voice. There are few randomized clinical trials that voice stabilization and promotes continued improvement
investigated patients with FD. One study compared two in vocal quality, acoustic measures, self-assessment, and

Patient Related Outcome Measures 2015:6 submit your manuscript | www.dovepress.com

249
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Behlau et al Dovepress

other outcome measures.109 Conventional voice therapy and decision-making level, including evaluation and treatment.
laryngeal manipulation have shown a moderate treatment The main tools for comprehending and measuring the conse-
effect. Nonetheless, a customized approach to the patient’s quences of health disorders are self-rating questionnaires that
limitations and the lack of control groups in many studies reflect a direct patient-reporting method. If this is carried out
restrict the quality of evidence.109 with well-constructed instruments, it can become a robust plat-
There is an increasing understanding of the need to form to implement and sustain public health strategies.125
employ high-quality outcome measures in clinical research. Strategies to improve the FD patient outcome involve
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

For FD cases, the difficulty is even greater and starts with a a series of procedures, including (Figure 1) the following:
basic problem, such as, terminology. Other problems include 1) proper diagnosis to exclude neurological and psychiatric
the need of a multidimensional approach for diagnosis, the disorders that can have similar physical presentation and
lack of a single characteristic vocal quality related to this can require the use of vocal probes for differential diagno-
disorder, comprehension of differential diagnosis, and the sis; 2) careful recording of the voice signal with quantita-
influence of psychological aspects. The last problem would tive measurement and qualitative description of the vocal
require a tailored approach to the patient’s treatment. deviation for comparison after treatment; 3) acoustic evalu-
ation including both extraction of selected parameters and
Strategies for improving patient description of the spectrographic trace, to gather data on the
outcome mechanism involved in voice production; 4) self-assessment
Health-related quality of life is a broad concept that refers questionnaires to map the impact of the voice problem and
For personal use only.

to patient-perceived impact of the disease and treatment on to comprehend the dimensions involved; 5) referral to a
physical, psychological, and social function (World Health psychological evaluation in cases of suspected anxiety
Organization).78 The individual’s well-being is the core of and/or depression; 6) identification of coping strategies to
this concept. Patient-related outcomes were initially defined face dysfunctional approaches; 7) self-regulation data to
as subjective health indicators that allow disability and illness assist the patient regarding vocal load; and finally 8) direct
to be assessed, based on the patient, caregiver, or physician and intensive vocal rehabilitation to reduce psychological
self-reports.124 Patients’ opinion should be considered at any resistance and to reassure patients recovery.

Diagnosis

Differential Recording of
diagnosis voice signal

Self-
Laryngeal Perceptual Acoustic
assessment
imaging analysis analysis
questionnaires

Referrals

Identification Self-
Voice
of coping regulation
rehabilitation
strategies data

Figure 1 Flowchart with strategies to improve FD patient outcome.

Abbreviation: FD, functional dysphonia.

250 submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Functional dysphonia patient outcomes

Disclosure 23. Paul BC, Chen S, Sridharan S, Fang Y, Amin MR, Branski RC.
­D iagnostic accuracy of history, laryngoscopy, and stroboscopy.
The authors report no conflicts of interest in this work. ­Laryngoscope. 2013;123(1):215–219.
24. Halawa WE, Muñoz IV, Perez SS. Effectiveness of laryngostrobos-
copy for monitoring the evolution of functional dysphonia after reha-
References bilitator treatment. Indian J Otolaryngol Head Neck Surg. 2013;65(4):
1. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarse- 322–326.
ness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3):S1–S31. 25. Oates J. Auditory-perceptual evaluation of disordered vocal quality –
2. Behlau M, Pontes P. Avaliação e Tratamento das Disfonias [Assess- pros, cons and future directions. Folia Phoniatr Logop. 2009;61(1):
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

ment and Treatment of Dysphonias]. São Paulo: Lovise; 1995:17–37. 49–56.

Portuguese. 26. Kreiman J, Gerratt B, Ito M. When and why listeners disagree in voice
3. Perelló J. Disfonies fonctionnelles. Folia Phoniatr. 1962;14:150–205. quality assessment tasks. J Am Stat Assoc. 2007;122(4):2354–2364.
4. Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy 27. Roy N. Optimal dose-response relationships in voice therapy. Int J
for functional dysphonia: an evaluation of short- and long-term treat- Speech Lang Pathol. 2012;14(5):419–423.
ment outcomes. J Voice. 1997;11:321–331. 28. Hillman RE. SIGnatures: The Quest for Voice Assessment Guidelines:
5. Roy N, Bless DM, Heisey D. Personality and voice disorders: Special Interest Group 3, Voice and Voice Disorders. Rockville, MD:
a multitrait-multidisorder analysis. J Voice. 2000;14(4):521–548. The ASHA Leader; 2013:54–55.
6. Verdolini K, Rosen C, Branski R. Classification Manual for Voice 29. Patel S, Shrivastav R. Perception of dysphonic vocal quality: some
Disorders – I. Special Interest Division 3, Voice and Voice Disorders. thoughts and research update. Perspect Voice Voice Disord. 2007;17:
Rockville: ASHA; 2006:249–256. 3–7.
7. Butcher P, Elias A, Cavali L. Understanding and Treating Psycho- 30. Brockmann-Bauser M, Drinnan MJ. Routine acoustic voice analysis:
genic Voice Disorder: A Cognitive Behavioral Therapy Framework. time to think again. Curr Opin Otolaryngol Head Neck Surg. 2011;19:
­Chichester: Wiley; 2007. 165–170.
8. Van Houtte E, Van Lierde K, Claeys S. Pathophysiology and treatment 31. Rabinov CR, Kreiman J, Gerratt BR, Bielamowicz S. Comparing
of muscle tension dysphonia: a review of the current knowledge. J Voice. reliability of perceptual ratings of roughness and acoustic measures of
For personal use only.

2011;25(2):202–207. jitter. J Speech Hear Res. 1995;38:26–32.

9. Hancock R. Management of functional aphonia and related severe mus- 32. Titze IR. Workshop on Acoustic Voice Analysis: Summary Statement.
cle tension disorders: a practical approach with historical underpinnings. National Center for Voice and Speech; Iowa City;1995.
Perspect Voice Voice Disord. 2014;24(2):55–63. 33. Awan SN, Roy N, Zhang D. Validation of the cepstral spectral index of
10. Mathieson L. The evidence for laryngeal manual therapies in the treat- dysphonia (CSID) as a screening tool for voice disorders: development
ment of muscle tension dysphonia. Curr Opin Otolaryngol Head Neck of clinical cutoff scores. J Voice. 2010;24(3):285–293.
Surg. 2011;19(3):171–176. 34. Peterson EA, Roy N, Awan SN, Merrill RM, Banks R, Tanner K. Toward
11. Pontes P, Behlau M, Kyrillos L. Glottic configurations and glottic validation of the cepstral spectral index of dysphonia (CSID) as an
proportion: an attempt to understand the posterior glottic chink. Rev objective treatment outcomes measure. J Voice. 2013;27(4):401–410.
Otol Rhinol Laryngol. 1994;115:261–266. 35. Herzel D, Berry H, Titze IR, Saleh M. Analysis of vocal disorders
12. Dietrich M, Verdolini Abbott K, Gartner-Schmidt J, Rosen CA. The with methods from nonlinear dynamics. J Speech Hear Res. 1994;37:
frequency of perceived stress, anxiety, and depression in patients with 1008–1019.
common pathologies affecting voice. J Voice. 2008;22(4):472–488. 36. Awan SN, Roy N, Jiang JJ. Nonlinear dynamic analysis of disordered
13. Siupsinskiene N, Razbadauskas A, Dubosas L. Psychological distress in voice: the relationship between the correlation dimension (D2) and
patients with benign voice disorders. Folia Phoniatr Logop. 2011;63(6): pre-/post-treatment change in perceived dysphonia severity. J Voice.
281–288. 2010;24(3):285–293.
14. Pedrosa V, Pontes A, Pontes P, Behlau M, Peccin SM. The effectiveness 37. Nawka T, Wiesmann U, Gonnermann U. Validierung des voice handicap
of the comprehensive voice rehabilitation program compared with the index (VHI) in der deutschen Fassung. HNO. 2003;51:921–930.
vocal function exercises method in behavioral dysphonia: a randomized 38. Hsiung MW, Lu P, Kang BH, Wang HW. Measurement and validation
clinical trial. J Voice. 2015. Epub ahead of print. of the voice handicap index in voice-disordered patients in Taiwan.
15. Litts JK, Gartner-Schmidt JL, Clary MS, Gillespie AI. Impact of laryn- J Laryngol Otol. 2003;117(6):478–481.
gologist and speech pathologist coassessment on outcomes and billing 39. Guimarães I, Abberton E. An investigation of the voice handicap index
revenue. Laryngoscope. 2015;125(9):2139–2142. with speakers of Portuguese: preliminary data. J Voice. 2004;18(1):
16. Jacobson BH, Johson A, Grywalsky C, et al. The voice handicap index 71–82.
(VHI): development and validation. Am J Speech Lang Pathol. 1997;6: 40. Woisard V, Bodin S, Puech M. The voice handicap index: impact of
66–70. the translation in French on the validation. Rev Laryngol Otol Rhinol
17. Hogikyan ND, Sethuraman G. Validation of an instrument to measure (Bord). 2004;125(5):307–312.
voice- related quality of life (V-RQOL). J Voice. 1999;13:557–569. 41. Pruszewicz A, Obrebowski A, Wiskirska-Woznica B, Wojnowski W.
18. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness Complex voice assessment-polish version of the voice handicap index
of voice therapy in the treatment of 45 patients with non-organic (VHI). Otolaryngol Pol. 2004;58(3):547–549.
dysphonia. J Voice. 1999;13(1):72–104. 42. Franic DM, Bramlett RE, Bothe AC. Psychometric evaluation of
19. Ma EP, Yiu EM. Voice activity and participation profile: assessing the disease specific quality of life instruments in voice disorders. J Voice.
impact of voice disorders on daily activities. J Speech Lang Hear Res. 2005;19(2):300–315.
2001;44(3):511–524. 43. Günther S, Rasch T, Klotz M, Hoppe U, Eysholdt U, Rosanowski F.
20. Deary IJ, Wilson JA, Carding PN, MacKenzie K. VoiSS: a patient-­derived Bestimmung der subjektiven Beeinträchtigung durch Dysphonien. Ein
voice symptom scale. J Psychosom Res. 2003;54(5):483–489. Methodenvergleich. HNO. 2005;53:895–904.
21. Behlau M, Murry T. International and intercultural aspects of voice 44. Hakkesteegt MM, Wieringa MH, Gerritsma EJ, Feenstra L.
and voice disorders. In: Battle DE, editor. Communication Disorders ­Reproducibility of the Dutch version of the voice handicap index. Folia
in Multicultural and International Populations. 4th ed. St Louis, MO: Phoniatr Logop. 2006;58(2):132–138.
Elsevier; 2012:174–207. 45. Amir O, Ashkenazi O, Leibovitzh T, Michael O, Tavor Y, Wolf M. Apply-
22. Mehta DD, Hillman RE. Current role of stroboscopy in laryngeal ­imaging. ing the voice handicap index (VHI) to dysphonic and nondysphonic
Curr Opin Otolaryngol Head Neck Surg. 2012;20(6):429–436. Hebrew speakers. J Voice. 2006;20(2):318–324.

Patient Related Outcome Measures 2015:6 submit your manuscript | www.dovepress.com

251
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Behlau et al Dovepress

46. Webb AL, Carding PN, Deary IJ, MacKenzie K, Steen IN, Wilson JA. 68. Paulinelli BR, Gama ACC, Behlau M. Validation of the vocal perfor-
Optimizing outcome assessment of voice interventions, I: reliability and mance questionnaire in Brazil. Rev Soc Bras Fonoaudiol. 2012;17(1):
validity of three self-reported scales. J Laryngol Otol. 2007;121(8): 85–91.
763–767. 69. Sukanen O, Sihvo M, Rorarius E, Lehtihalmes M, Autio V, Kleemola L.
47. Núñez-Batalla F, Corte-Santos P, Señaris-González B, Llorente- Voice activity and participation profile (VAPP) in assessing the effects
Pendás JL, Górriz-Gil C, Suárez-Nieto C. Adaptation and validation of voice disorders on patients’ quality of life: validity and reliability of
to the Spanish of the voice handicap index (VHI-30) and its shortened the Finnish version of VAPP. Logoped Phoniatr Vocol. 2007;32:3–8.
version (VHI-10). Acta Otorrinolaringol Esp. 2007;58(9):386–392. 70. Ricarte A, Oliveira G, Behlau M. Validation of the voice activity and
48. Xu W, Li HY, Hu R, et al. Analysis of reliability and validity of the participation profile protocol in Brazil. Codas. 2013;25(3):242–249.
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

Chinese version of voice handicap index (VHI). Zhonghua Er Bi Yan 71. Fava G, Paolillo NP, Oliveira G, Behlau M. Cross-cultural adaptation,
Hou Tou Jing Wai Ke Za Zhi. 2008;43(9):670–675. validation, and cutoff point of the Italian version of the voice activity
49. Kiliç MA, Okur E, Yildirim I, et al. Reliability and validity of the and participation profile: Profilo di Attività e Partecipazione Vocale.
Turkish version of the voice handicap index. Kulak Burun Bogaz Ihtis J Voice. 2015;29(1):.e11–.e19.
Derg. 2008;18(3):139–147. 72. Moreti F, Zambon F, Oliveira G, Behlau M. Cross-cultural adapta-
50. Ohlsson AC, Dotevall H. Voice handicap index in Swedish. Logoped tion, validation, and cutoff values of the Brazilian version of the voice
Phoniatr Vocol. 2009;34(2):60–66. symptom scale-VoiSS. J Voice. 2014;28(4):458–468.
51. Behlau M, Alves Dos Santos LM, Oliveira G. Cross-cultural adaptation 73. Karnell MP, Melton SD, Childes JM, Coleman TC, Dailey SA,
and validation of the voice handicap index into Brazilian Portuguese. ­Hoffman HT. Reliability of clinician-based (GRBAS and CAPE-V) and
J Voice. 2011;25(3):354–359. ­patient-based (V-RQOL and IPVI) documentation of voice disorders.
52. Schindler A, Ottaviani F, Mozzanica F, et al. Cross-cultural adaptation J Voice. 2007;21:576–590.
and validation of the voice handicap index into Italian. J Voice. 2010; 74. Ugulino AC, Oliveira G, Behlau M. Perceived dysphonia by the clini-
24(6):708–714. cian’s and patient’s viewpoint. J Soc Bras Fonoaudiol. 2012;24(2):
53. Helidoni ME, Murry T, Moschandreas J, Lionis C, Printza A, Velegrakis GA. 113–118.
Cross-cultural adaptation and validation of the voice handicap index 75. Krischke S, Weigelt S, Hoppe U, et al. Quality of life in dysphonic
into Greek. J Voice. 2010;24(2):221–227. patients. J Voice. 2005;19(1):132–137.
For personal use only.

54. Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T. Validation 76. Konnai RM, Jayaram M, Scherer RC. Development and validation
and cultural modification of Arabic voice handicap index. Eur Arch of a voice disorder outcome profile for an Indian population. J Voice.
Otorhinolaryngol. 2010;267(11):1743–1751. 2010;24(2):206–220.
55. Karlsen T, Grieg AR, Heimdal JH, Aarstad HJ. Cross-cultural adap- 77. Branski RC, Cukier-Blaj S, Pusic A, et al. Measuring quality of life
tion and translation of the voice handicap index into Norwegian. Folia in dysphonic patients: a systematic review of content development in
Phoniatr Logop. 2012;64(5):234–240. patient-reported outcomes measures. J Voice. 2010;24:193–198.
56. Taguchi A, Mise K, Nishikubo K, Hyodo M, Shiromoto O. Japanese 78. World Health Organization. International Classification of Func-
version of voice handicap index for subjective evaluation of voice tioning, Disability, and Health. Geneva, Switzerland: World Health
disorder. J Voice. 2012;26(5):.e15–.e19. Organization; 2001.
57. Moradi N, Pourshahbaz A, Soltani M, Javadipour S, Hashemi H, 79. Gliklich RE, Glovsky RM, Montgomery WW. Validation of a voice
Soltaninejad N. Cross-cultural equivalence and evaluation of psycho- outcome survey for unilateral vocal cord paralysis. Otolaryngol Head
metric properties of voice handicap index into Persian. J Voice. 2013; Neck Surg. 1999;120:153–158.
27(2):.e15–.e258. 80. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and valida-
58. Bonetti A, Bonetti L. Cross-cultural adaptation and validation of the tion of the singing voice handicap index. Ann Otol Rhinol Laryngol.
voice handicap index into croatian. J Voice. 2013;27(1):.e7–.e130. 2007;116(6):402–406.
59. Trinite B, Sokolovs J. Adaptation and validation of the voice handicap 81. Murry T, Zschommler A, Prokop J. Voice handicap in singers. J Voice.
index in Latvian. J Voice. 2014;28(4):452–457. 2009;23:376–379.
60. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and 82. Nguyen DD, Kenny DT, Tran ND, Livesey JR. Muscle tension dys-
validation of the voice handicap index-10. Laryngoscope. 2004;114(9): phonia in Vietnamese female teachers. J Voice. 2009;23(2):195–208.
1549–1556. 83. Leonard KL. Is patient satisfaction sensitive to changes in the quality
61. Lam PK, Chan KM, Ho WK, Kwong E, Yiu EM, Wei WI. Cross-cultural of care? An exploitation of the Hawthorne effect. J Health Econ. 2007;
adaptation and validation of the Chinese voice handicap index-10. 27(2):444–459.
Laryngoscope. 2006;116(7):1192–1198. 84. Freidl W, Friedrich G, Egger J, Fitzek T. Psychogenic aspects of func-
62. Amir O, Tavor Y, Leibovitzh T, et al. Evaluating the validity of the voice tional dysphonia. Folia Phoniatr. 1993;45(1):10–13.
handicap index-10 (VHI-10) among Hebrew speakers. Otolaryngol 85. Deary V, Miller T. Reconsidering the role of psychosocial factors in
Head Neck Surg. 2006;135(4):603–607. functional dysphonia. Curr Opin Otolaryngol Head Neck Surg. 2011;
63. Costa T, Oliveira G, Behlau M. Validation of the voice handicap 19(3):150–154.
index: 10 (VHI-10) to the Brazilian Portuguese. Codas. 2013;25(5): 86. Kiese-Himmel C. Clinical-psychological components in the consider-
482–485. ation of functional dysphonia-a review. Laryngorhinootologie. 2015;
64. Forti S, Amico M, Zambarbieri A, et al. Validation of the Italian voice 94(3):156–162.
handicap index-10. J Voice. 2014;28(2):.e17–.e263. 87. Wenke RJ, Stabler P, Walton C, et al. Is more intensive better?
65. Schwanfelder C, Eysholdt U, Rosanowski F, Graessel E. Voice- Client and service provider outcomes for intensive versus standard
related quality of life: structure, validity and factors of the German therapy schedules for functional voice disorders. J Voice. 2014;28(5):
questionnaire. Folia Phoniatr Logop. 2008;60:241–248. .e31–.e652.
66. Gasparini G, Behlau M. Quality of life: validation of the Brazilian 88. Folkman S. Stress, Appraisal and Coping. New York, NY: Springer
version of the voice-related quality of life (V-RQOL) measure. J Voice. Publishing Company; 1984.
2009;23:76–81. 89. Folkman S. Personal control and stress and coping processes: a theoreti-
67. Deshpande MS, Kakade AC, Chaukar DA, et al. Validation and assess- cal analysis. J Pers Soc Psychol. 1984;46:839–852.
ment of voice-related quality of life in Indian patients undergoing total 90. Folkman S, Lazarus RS. If it changes it must be a process: study of
laryngectomy and primary tracheoesophageal puncture. Head Neck. emotion and coping during three stages of a college examination.
2009;31(1):37–44. J Pers Soc Psychol. 1985;48:150–170.

252 submit your manuscript | www.dovepress.com Patient Related Outcome Measures 2015:6
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Functional dysphonia patient outcomes

91. Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. 109. Bos-Clark M, Carding P. Effectiveness of voice therapy in functional
Dynamics of a stressful encounter: cognitive appraisal, coping, and dysphonia: where are we now? Curr Opin Otolaryngol Head Neck
encounter outcomes. J Pers Soc Psychol. 1986;50:992–1003. Surg. 2011;19:160–164.
92. Lazarus RS. Coping theory and research: past, present, and future. 110. Aronson AE. Clinical Voice Disorders: An Interdisciplinary Approach.
Psychosom Med. 1993;55:234–247. New York, NY: Thieme; 1980.
93. Lazarus RS. Fifty Years of the Research and Theory of RS Lazarus: An 111. Mathieson L, Hirani SP, Epstein R, Baken RJ, Wood G, Rubin JS.
Analysis of Historical and Perennial Issues. Mahwah, NJ: Lawrence Laryngeal manual therapy: a preliminary study to examine its treat-
Erlbaum Associates; 1998. ment effects in the management of muscle tension dysphonia. J Voice.
94. Holahan CJ, Moos RH. Personal and contextual determinants of coping 2009;3:353–366.
Patient Related Outcome Measures downloaded from https://www.dovepress.com/ by 186.108.86.78 on 05-Jul-2021

strategies. J Pers Soc Psychol. 1987;52:946–955. 112. Daniilidou P, Carding P, Wilson J, Drinnan M, Deary V. Cognitive
95. Carver CS, Scheier MF, Weintraub JK. Assessing coping ­strategies: behavioral therapy for functional dysphonia: a pilot study. Ann Otol
a theoretically based approach. J Pers Soc Psychol. 1989;56: Rhinol Laryngol. 2007;116(10):l7–l22.
267–283. 113. Niebudek-Bogusz E, Sznurowska-Przygocka B, Fiszer M, et al. The
96. David JP, Suls J. Coping efforts in daily life: role of big five traits and effectiveness of voice therapy for teachers with dysphonia. Folia
problem appraisals. J Pers. 1999;67:265–294. Phoniatr Logop. 2008;60:134–141.
97. Chesney MA, Chambers DB, Taylor JM, Johnson LM, Folkman S. 114. Morsomme D, de la Bardonnie MF, Verduyckt I, Jamart J, Remacle M.
Coping effectiveness training for men living with HIV: results Subjective evaluation of the long-term efficacy of speech therapy on
from a randomized clinical trial testing a group-based intervention. dysfunctional dysphonia. J Voice. 2010;24:178–182.
Psychosom Med. 2003;65:1038–1046. 115. Rattenbury HJ, Carding PN, Finn P. Evaluating the effectiveness and
98. Hagger MS, Orbell S. A meta-analytic review of the common-sense efficiency of voice therapy using transnasal flexible laryngoscopy:
model of illness representations. Psychol Health. 2003;18:141–184. a randomized controlled trial. J Voice. 2004;18:522–533.
99. Van Opstal MJMC. A systematic, holistic and integrative process 116. Ruotsalainen J, Sellman J, Lic P, Lehto L. Systematic review of the
of self-control for voicing with optimal coping effects in teachers. treatment of functional dysphonia and prevention of voice disorders.
2. A process of change – an expert’s opinion. Folia Phoniatr Logop. Otolaryngol Head Neck Surg. 2008;138:557–565.
2010;62:71–85. 117. Behlau M, Madazio G, Pacheco C, Gielow I. Intensive short-term
For personal use only.

100. Meulenbroek LF, de Jong FI. Trainee experience in relation to voice voice therapy: the Brazilian experience. Perspect Voice Voice Disord.
handicap, general coping and psychosomatic well-being in female 2014;24:98–103.
student teachers: a descriptive study. Folia Phoniatr Logop. 2010;62: 118. Portone C, Johns MM, Hapner ER. A review of patient adherence to
47–54. the recommendation for voice therapy. J Voice. 2008;22:192–196.
101. Oliveira G, Hirani SP, Epstein R, Yazigi L, Behlau M. Coping strate- 119. van Leer E, Connor NP. Patient perceptions of voice therapy adherence.
gies in voice disorders of a Brazilian population. J Voice. 2012;26(2): J Voice. 2010;24(4):458–469.
205–213. 120. Bogaardt H, Hakkesteegt M, Grolman W, Lindeboom R. ­Validation
102. Epstein R, Hirani SP, Stygall J, Newman SP. How do individuals of the voice handicap index using Rasch analysis. J Voice. 2007;21:
cope with voice disorders? introducing the voice disability coping 337–344.
questionnaire. J Voice. 2009;23:209–217. 121. Patel RR, Bless DM, Thibeault SL. Boot camp: a novel intensive
103. Zambon F, Moreti F, Behlau M. Coping strategies in teachers with approach to voice therapy. J Voice. 2011;25:562–569.
vocal complaint. J Voice. 2014;28(3):341–348. 122. Roy N, Barkmeier-Kraemer J, Eadie T, et al. Evidence-based clinical
104. Folkman S, Moskowitz JT. Coping: pitfalls and promise. Ann Rev voice assessment: a systematic review. Am J Speech Lang Pathol.
Psychol. 2004;55:745–774. 2013;22(2):212–226.
105. Anderson M, Elam G, Solarin I, Gerver S, Fenton K, Easterbrook P. 123. Hamzei F, Liepert J, Dettmers C, Weiller C, Rijntjes M. Two different
Coping with HIV: Caribbean people in the United Kingdom. Qual reorganization patterns after rehabilitative therapy: an exploratory
Health Res. 2009;19:1060–1075. study with FMRI and TMS. Neuroimage. 2006;31:710–720.
106. Côté J, Delmas P, Delpierre C, Sylvain H, Delon S, Rouleau G. Factors 124. Acquardo C, Berzon R, Dubois D, et al. Incorporating the patient’s
related to quality of life in treatment-adherence, successfully treated perspective into drug development and communication: an ad hoc task
HIV patients in France. Open Nurs J. 2009;3:10–17. force report of the patient-reported outcomes (PRO) Harmonization
107. Frazier P, Keenan N, Anders S, Perera S, Shallcross S, Hintz S. Group meeting at the Food and Drug Administration. 2001. Value
­Perceived past, present, and future control and adjustment to stressful Health. 2003;6:522–531.
life events. J Pers Soc Psychol. 2011;100(4):749–765. 125. Farnik M, Pierzchała W. Instrument development and evaluation for
108. Misono S, Meredith L, Peterson CB, Frazier PA. New perspective on patient-related outcomes assessments. Patient Relat Outcome Meas.
psychosocial distress in patients with dysphonia: the moderating role 2012;3:1–7.
of perceived control. J Voice. 2015. Epub ahead of print.

Patient Related Outcome Measures Dovepress

Publish your work in this journal
Patient Related Outcome Measures is an international, peer-reviewed, The manuscript management system is completely online and includes
open access journal focusing on treatment outcomes specifically a very quick and fair peer-review system. Visit http://www.dovepress.
relevant to patients. All aspects of patient care are addressed within com/testimonials.php to read real quotes from published authors.
the journal and practitioners from all disciplines are invited to submit
their work as well as healthcare researchers and patient support groups.
Submit your manuscript here: http://www.dovepress.com/patient-related-outcome-measures-journal

Patient Related Outcome Measures 2015:6 submit your manuscript | www.dovepress.com

253
Dovepress

Powered by TCPDF (www.tcpdf.org)