Voice EBPExtravaganza 2010

BackgroundCommon caseload (inpts > outpatients)Unknown:

When to provide therapy and for how longWhat therapy to provideContraindicationsRole of surgery in recoveryPrognosis and pattern of recovery

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

Search strategySearch words:

Unilateral vocal fold/cord paralysis/paresisRLN palsyVoice therapyVoice disordersHemiplegia

Databases:Medline / PubMedWeb of scienceCochraneScopus

ResultsCritically appraised 16 articlesEach article appraised by 2 peopleDeveloped specific Q’s to assist our broad

clinical QMix of retrospective and experimental

time series studiesNo control groupsLevel of evidence: III to IVRange of participants per study: 3 - 91

Trends of presenting S&SHoarseness (53%), dysphagia (34%), difficulty breathing

(12.8%). Kelchner

low intensity, low pitch, rough, breathy, reduced phonation time, vocal fatigue, little resonance, loud whisper, intermittent voicing, rapid rate, excessive glottal leak, intermittent flutter

Heuer

Increased mean values of GRBAS (Overall severity, roughness, breathiness, asthenia, strain) D’Alatri

Sudden onset hoarseness Tsunoda

Overall, no pattern of symptoms described

Rx techniquesMostly eclectic approaches where many

techniques were used in combinationIn all of these studies, these techniques were

shown to improve the voice on a range of measures.D’Alatri et al used specific techniques targeting specific

symptoms e.g. glottic competence and hyperfunctionSmith Accent Method was also effective in 3 reported

participants (Khidr, 2003)Yawning Breath Pattern (breath support, lower larynx)

with biofeedback was effective in a larger group of patients (Xu, 1991)

Head turn was not effective (Paseman, 2004)

Time frame for Rx?Many studies didn’t consider spontaneous

recovery and timing of intervention often not specified

Voice therapy improved voice outcomes. Eclectic approach equally effective < 3 months

or 3 mths - 21 years post-onset (Cantarella et al, 2010)

Effective 1-13 years post-onset (Khidr, 2003). Voice therapy may be more effective closer

to onset, but this is unclear in the literature

Length of Rx?Cantarella = 10-40 sessionsKhidr = 16 sessionsHeuer = 3-7 sessions (less for non-surgical)D’Alatri = 8-35 (mean = 24) sessionsSchindler = 6-20 (mean 12.6) sessionsXu = 10 weekly sessionsOverall: > 10 sessions. Frequency = weekly or twice-weekly

Position of paralysed VC? Kelchner = paramedian or lateral Impact of position not discussed in relation

to voice outcomes

a: medianb: paramedianc: intermediate d: fully abducted

Ishimoto S et al. Chest 2002;121:1911-1915

Reliability and validity of outcome measures?Most studies use multidimensional

outcome measuresvideostroboscopy, acoustic measures,

perceptual evaluation, aerodynamic measures and patient-reported quality of life (i.e. VHI).

No reported blinding for ratingIntra or inter-rater reliability for

perceptual evaluation often not reportedAcoustic measures used h/e type of

acoustic signal not specified to ensure reliability

Role of SxSurgery > voice therapy for sig dysphoniaSurgery = voice therapy for less severe

dysphonia (Kelchner et al , 1999)

Pre-op voice therapy may help patients achieve adequate voicing without surgery

(Heuer, 1997)

Many studies reported voice outcomes from surgery alone → no CAP

Evidence from clinical practiceTiming of Rx – early is better than later to

prevent hyperfunctionRx techniques – gentle vocal adduction

while preventing hyperfunction Position of cord – therapy more beneficial

for those with smaller glottic gapsLength of therapy – re-evaluate if no

improvement after approx. 4 sessionsOutcomes – use a range but all using

perceptual ratings

Clients valuesPatient choice was not documented in most

studiesThe only reference to patient choice was in

Heuer and Khidr, where patients elected to have voice therapy vs surgery

As a group we all consider client choice and other factors e.g. compliance, fatigue, cognition

Clinical bottom lineYes voice therapy is effective for UVFP

to some degreeTherapy approaches appear to be

eclectic in natureWe are still unsure how effective

specific therapy approaches areWe are also unsure of when it’s

best to intervene with therapy and the nature of spontaneous recovery

Clinical applicationIncreased confidence discussing

literature evidence with clients and referrers

Voice therapy for those clients with mild dysphonia / small glottic gap

Clients with severe dysphonia / large glottic gap may benefit more from ENT for surgical intervention

Continue current voice therapy techniques and re-refer to ENT if no improvement

Continue collecting voice outcomes to evaluate success of therapy

NSW EBP membersJudy Rough

Katrina BlythSam WarhurstDanielle StoneKatherine Kelly

Asta FungBeth Atkins

Sharon MooreMargaret JacobsTherese DoddsHelen Brake

Academic link: Cate Madill