The Effectiveness of the Comprehensive Voice

Rehabilitation Program Compared With the Vocal

Function Exercises Method in Behavioral Dysphonia:
A Randomized Clinical Trial
*,†Vanessa Pedrosa, *Ant^
onio Pontes, *,†Paulo Pontes, *,†Mara Behlau, and *Stella Maria Peccin, *yS~ao Paulo,
Brazil

Summary: Objective. To evaluate the effectiveness of the Comprehensive Voice Rehabilitation Program (CVRP)
compared with Vocal Function Exercises (VFEs) to treat functional dysphonia.
Study Design. This is a randomized blinded clinical trial.
Methods. Eighty voice professionals presented with voice complaints for more than 6 months with a functional dysphonia
diagnosis. Subjects were randomized into two voice treatment groups: CVRP and VFE. The rehabilitation program con-
sisted of six voice treatment sessions and three assessment sessions performed before, immediately after, and 1 month after
treatment. The outcome measures were self-assessment protocols (Voice-Related Quality of Life [V-RQOL] and Voice
Handicap Index [VHI]), perceptual evaluation of vocal quality, and a visual examination of the larynx, both blinded.
Results. The randomization process produced comparable groups in terms of age, gender, signs, and symptoms. Both
groups had positive outcome measures. The CVRP effect size was 1.09 for the V-RQOL, 1.17 for the VHI, 0.79 for vocal
perceptual evaluation, and 1.01 for larynx visual examination. The VFE effect size was 0.86 for the V-RQOL, 0.62 for
the VHI, 0.48 for the vocal perceptual evaluation, and 0.51 for larynx visual examination. Only 10% of the patients were
lost over the study.
Conclusions. Both treatment programs were effective. The probability of a patient improving because of the CVRP
treatment was similar to that of the VFE treatment.
Key Words: Randomized clinical trial–Voice treatment–Voice quality–Vocal quality–Voice–Speech therapy–Voice
disorders.

INTRODUCTION When the vocal disorder is directly related to the vocal

The dissemination of evidence-based practice is encouraging behavior and results in incorrect voice use and negative habits,
scientific research to achieve better results in rehabilitation treat- it can be classified as behavioral.10,11 Therefore, behavioral
ment. Until now, only few studies have evaluated the effects of dysphonia is a multifactorial problem and may involve vocal
speech rehabilitation and clinical trials with assessed quality.1,2 technique issues, intense vocal use, or misuse.12–15 Its
The main limitations of these studies are related to the occurrence is very common among voice professionals such
methodology such as the absence of sample size calculation, as teachers. The prevalence of chronic voice disorder in this
allocation and randomization, lack of clarity, and inappropriate group varies between 11.6% and 16%.16
assessment of the outcomes and statistical analysis.1,3,4 Modern vocal rehabilitation includes three major approaches:
Despite these deficiencies, the literature indicates that vocal vocal hygiene, a symptomatic approach, and a physiological
rehabilitation is the best treatment for behavioral dysphonia. approach.5,17 Vocal hygiene is a component of a broader
Several intervention methods have been tested; the main prob- program or may also be used as a single approach. However, it
lems facing these studies have been small sample sizes and the results in better outcomes when it is applied as part of a larger
lack of randomization. However, the results from most of these treatment program.18–22 A recent study has found that two
interventions have been essentially positive.5,6 vocal hygiene orientation sessions could improve teachers’
Dysphonia can be defined as an oral communication disor- quality of life.23 The symptomatic approach, also referred to
der, where the voice is unable to fulfill its basic role of transmit- as traditional rehabilitation, has produced little evidence as to
ting verbal and emotional messages.7,8 The main symptoms of its effectiveness.5,11 Finally, the physiological approach
dysphonia are hoarseness, aphonia, pain, vocal fatigue, voice (holistic orientation) has been extensively studied. This
failures, poor vocal projection, and difficulty while speaking holistic technique was designed and proposed in parallel with
at a high intensity.9 the development of the laryngeal modern examination through
nasoendoscopy and telendoscopy. These techniques facilitate
Accepted for publication March 23, 2015. the analyses of physiological changes of voice production.
From the *Departamento de Medicina, Universidade Federal de S~ao Paulo UNIFESP,
S~ao Paulo, Brazil; and the yDepartamento de Medicina, Centro de Estudos da Voz, S~ao
The Vocal Function Exercises (VFEs) program is the holistic
Paulo, Brazil. physiologic method most tested for behavioral dysphonia treat-
Address correspondence and reprint requests to Vanessa Pedrosa, Rua Machado Bitten-
court 361, S~ao Paulo 04044-001, Brazil. E-mail: [email protected]
ment. It works all three vocal subsystems together: breath,
Journal of Voice, Vol. 30, No. 3, pp. 377.e11-377.e19 phonation, and resonance.18–20,24–29
0892-1997/$36.00
Ó 2016 The Voice Foundation
A 2014 literature review of behavioral or functional
http://dx.doi.org/10.1016/j.jvoice.2015.03.013 dysphonia treatment initially yielded 623 studies in four
377.e12 Journal of Voice, Vol. 30, No. 3, 2016

databases (Embase, Lilacs, PubMed, and Web of Science). throughout Greater S~ao Paulo were contacted. Paper advertise-
After reviewing the database, we identified 15 clinical trials, ments and radio calls were also used to gather volunteers. Those
five case-control studies, and five case studies that were relevant interested answered a questionnaire to confirm that they met the
to our research. Among these studies, 15 tested the effect of initial inclusion criteria. They also included signs and symptoms
VFE alone or in combination with other therapeutic tech- in e-mail responses, a method of data collection which has pre-
niques.18–20,24–35 VFE efficacy is already proven. Therefore, viously been used in other studies.16,38,39 The initial inclusion
we consider it to be the best design method. criteria were age between 18 and 50 years, professional voice
The VFE studies highlighted positive results in different user, and vocal complaint with a minimum of four signs and
outcome measures, such as vocal quality,26–28,30,34 dysphonia symptoms for more than 6 months. The final inclusion
symptoms,18,20,26,30 maximum phonation time,20,25,28,29,35 criterion was determined by the otorhinolaryngological (ENT)
acoustic parameters,24,25,27,31–34 and improvement of glottal examination confirming a behavioral dysphonia diagnosis
closure.24,25 In addition, one study used a self-assessment pro- with referral for vocal rehabilitation.
tocol, the Voice Handicap Index (VHI),18 and two other studies Subjects with acute or organic dysphonia and singing profes-
used the Voice-Related Quality of Life (V-RQOL).26,30 The sionals were excluded. Figure 1 represents the flowchart for
three articles highlighted a consistent improvement in quality study participants.
of life regarding vocal aspects26,30 as well as patients’ To ensure the CONSORT criteria,40 patients were random-
perception of a reduction in vocal disadvantage.18 ized into two groups of treatment using computer software.
Only two studies investigated indirect laryngeal image. Their Participants were submitted to three assessments and six
results indicated improvement in glottal closure as shown by the vocal rehabilitation sessions. The assessments included (1)
aerodynamic measures of phonation volume and maximum ENT evaluation, (2) self-assessment evaluation, and (3)
phonation time.24,25 No research has yet included previsual auditory-perceptual evaluation (APE).
and postvisual data of laryngeal examination.
The search of the literature also failed to find references that (1) The ENT evaluation consisted of history of the patient, na-
establish the duration of rehabilitation treatment for behavioral sofibrolaryngoscopy, telelaryngoscopy, and stroboscopy
dysphonia. According to estimates done among Brazilian pro- evaluation. For patients with an overactive gag reflex,
fessionals, vocal rehabilitation usually happen once or twice a only the flexible endoscope and stroboscopy were used
week in 40–45 minutes sessions during a period of 4–6 months, (40% of the examinations). Topical anesthetics (lidocaine
accounting for more than 10 sessions.36 In the international 4%) were applied. Digital images were stored on a hard
clinical practice, the number of sessions varies between six disk. Laryngoscope Machida (Machida Inc.) LYC30
and ten, but the length of session is not specified.11 700, Machida ENT-30PIII camera ASAP Popcam (Ma-
The small amount of evidence in the literature, the poorly chida Inc.), scanner Endodigi, 12:10:07 software Version
defined duration of treatment, the few holistic therapeutic pro- (Endodigi Inc.), WelchAllyn reference light source 501
grams properly described for behavioral dysphonia, and the (WelchAllyn Inc.), strobe Estrobolight Ecleris (Ecleris
Brazilian traditional symptomatic therapy with holistic focus Inc.), scanning equipment for Apple iMac with a processor
led us to design an exercise program called the Comprehensive Core 2Duo were used for larynx examination (Apple Inc.).
Voice Rehabilitation Program (CVRP).37 The program origi- Patients were asked to sustain the vowels /e/ and /i/ at their
nated from a research carried out by the Larynx Institute in habitual frequency and intensity. The same technique was
S~ao Paulo (INLAR) and Centre for the Study of Voice (CEV) used for immediate and 1 month after treatment assess-
in the 1990s. CVRP has been the basis of the voice clinical ments. The laryngologic examination was performed to
care of CEV, voice specialists, and UNIFESP. Therefore, it confirm the behavioral diagnosis of dysphonia and to
needs to be compared with a well-accepted program so that manage the vocal rehabilitation.
we can analyze differences between both. (2) Self-assessment evaluation consisted of the vocal
If the CVRP shows advantages or equivalence to the VFE impact analysis using the questionnaires from the
method, it could be considered as another treatment option VHI41 and V-RQOL Index.42,43
for behavioral dysphonia. (3) The perceptual auditory analysis was performed with the
recorded sustained /ae/ vowel. For the voice recording,
the microphone position was 5 cm from the mouth, at a
Objective 45 angle. The speech samples were recorded directly
To evaluate the effectiveness of the CVRP compared with VFEs into the computer (HP Pavilion ZV6000 (Hewlett Pack-
to treat functional dysphonia. ard Inc.), Athlon 64 AMD, microphone headset Genius
HS-04SU (Genius Inc.)). For the perceptual evaluation,
MATERIALS AND METHODS samples were played via a professional headset Sony
Samples and evaluations MDR-7502 model (Sony Inc.).
Participants in this study were invited to take part in the research All participants freely signed the consent form. The Ethical
through announcements at their workplaces. Companies and in- Committee of the institution approved this study, under the
stitutions employing professional voice users such as schools, number CEP 0715/10, and it was registered in the Clinical Tri-
television or radio stations, telemarketing centers, and law firms als database under the number 2010/15 166-3.
Vanessa Pedrosa, et al Voice Rehabilitation Randomized Clinical Trial 377.e13

FIGURE 1. Flowchart.

Randomization process of quality of life improvement for individuals treated with

An online database was developed to catalog all data and as- CVRP to be higher than for individuals treated with VFE. To
sessments. A professional specialized in information technol- have an estimation of the difference needed to ensure a positive
ogy who did not have any contact with the researchers treatment result, we used the minimum limit of 15.5 points be-
organized the process of randomization. The participants’ tween pretreatment and posttreatment (26) on the V-RQOL
forms were included in the program, and a randomization questionnaire. To consider the superiority of any approach,
icon was inserted on each of them. The SLP responsible for we defined a minimum difference of seven points on the total
delivering the treatment received the result of this automatic score of V-RQOL between treatment groups (FVE and
randomization. Once allocated in one of the two groups, no CRVP). Considering a ¼ 0.05 type 1 error and type 2 error
modification was possible. The program did not allow random- b ¼ 20% within power of the test of 80%, 47 patients would
ization to predict in advance in which group the patient would be required in each group for the research to detect a difference
be assigned, and the patient received a number out of sequence, of seven points in the averages between the pretreatment and
ensuring allocation concealment. posttreatment groups.

Sample size calculation Treatment

The calculation of the sample size for randomized clinical trials Two speech-language pathologists’ graduate students were
was done with superiority test.44 The test verified the hypothesis selected and trained to administer both therapeutic programs.
377.e14 Journal of Voice, Vol. 30, No. 3, 2016

Both SLPs felt confident in administering both treatment Therapeutic criteria

modalities. To collect the data, some criteria were established for treatment
Patients received weekly support materials consisting of adherence.
handouts related to vocal hygiene, guidelines with the exercises
for the week, graphic chart to record the frequency of exercises (1) All patients were submitted to a six-session program; in
at home, and a CD with audio recording of the exercises. A tun- case of any canceled appointment, a replacement ses-
ing fork was used to present the musical notes proposed by the sion was offered. In case of three consecutive absences,
VFE program. the participant was excluded from the final sample.
Both programs consisted of six sessions of 40 minutes dura- (2) Adherence of treatment was considered when the patient
tion, once a week, delivered by the same therapist. reported to have done at least 50% of the required exer-
cises at home.
Treatment program (3) Participants with acute upper respiratory infections,
Vocal orientation was administered for both groups. Question allergies, or respiratory problems stopped performing
on vocal hygiene and well-being were created, as well as the exercises and resumed the regimen after recovery.
questions identifying vocal behaviors and habits that could
be harmful. Alternatives were discussed with and suggested
to participants. Outcomes evaluated and results analysis
The CVRP treatment involves perception, awareness and Three outcomes were evaluated: (1) evaluation of the laryngeal
changing negative vocal habits, body-voice association tech- pattern (LP); (2) self-assessment evaluation via VHI and
niques, glottal competence, and resonance exercises. These V-RQOL; and (3) APE.
treatment modalities were associated with articulatory exer-
cises, breathing control, and vocal projection after the initial (1) Evaluation of LP. an ENT, senior professor, with
sessions. The program focuses on five characteristics: body- >30 years of experience in laryngeal evaluation and
voice integration, glottal source, resonance, coordination of treatment, evaluated all laryngeal images and was
subsystems, and communicative attitude. Body posture was blinded to the patient’s identifying information and to
corrected during the exercises and interactions with the thera- the order of previous patient assessments. Each partic-
pist. Particular attention was given to the involvement of cer- ipant’s samples were presented sequentially, in a
vical and shoulder girdle musculature, using visual, auditory, random order. For the larynx, visual perceptual evalu-
and kinesthetic feedback. The program’s glottal-source feature ation of three different aspects was considered: vocal
consisted of using several techniques to improve glottic folds closure, glottal closure, presence and size of
closure, to reduce supraglottic interference and to increase lesion, and degree of supraglottic constriction.45 A vi-
vocal efficiency. Mucosal wave exercises such as lips and sual analog scale of 100 points for each of these three
tongue drills were used to increase vibration amplitude. The aspects was used, considering 0 as normal and 100 as
therapeutic regimen to improve vocal resonance consisted of extremely abnormal. For example, a complete glottic
semioccluded vocal tract exercises, mainly nasal sounds. The closure was marked 0 and the total lack of glottic
perception and control of resonance was enhanced with kines- closure 100. The absence of lesion was documented
thetic cues to facilitate speech transference. Breathing control with a zero, whereas the presence of a large lesion im-
was achieved by using pneumophonic exercises, such as chant- pairing closure and with significant impact on the
ing sequences. The main goal was to facilitate the executions mucosal wave was documented with a 100. Finally,
of the exercise. the lack of supraglottic involvement was marked as
The program VFE strictly followed the proposal of Stemple zero and the total anteroposterior and medial supraglot-
et al,24 in which the larynx muscles are treated like any other tic closure as 100. The otorhinolaryngologist who per-
muscle in the body. With this method, the exercises should be formed the laryngeal evaluation did not examine the
practiced twice a day.24 The vowel must be produced using patients and considered only the laryngeal image in
the maximum prolongation and must vary in vocal frequency, making his assessment. No identification regarding pa-
resonance, and projection. The method proposes four exercises: tient demographic data, type, and/or stage of treatment
warm-up, vocal folds shortening, vocal folds gentle length- was given to the ENT evaluating the LPs. The images
ening, and vocal folds adduction. were grouped according to each participant, in a
In both programs, the individuals were instructed to do the random order. The judge could review the images until
exercises twice a day at home during the 6 weeks of the treat- he was sure of his evaluation.
ment period. After these six sessions, they were instructed to (2) Self-assessment evaluation: Questionnaire score VHI
continue doing the exercises and to follow the instructions of and Questionnaire V-RQOL Index in the three moments
vocal hygiene for 1 month. All patients were instructed not to (VHI1, VHI2, VHI3 and V-RQOL1, V-RQOL2, V-
perform the exercises mechanically but rather to focus on the RQOL3). The difference among the total score averages
control of the requested adjustment and to actively seek the of the questionnaire, V-RQOL Index, between pretreat-
physiological gesture associated with the ideal vocal ment and immediate posttreatment assessment was also
production. calculated.
Vanessa Pedrosa, et al Voice Rehabilitation Randomized Clinical Trial 377.e15

(3) Three independent speech-language pathologists, voice Of these 80 individuals, eight dropped out from treatment
specialists with extensive clinical experience (>8 years) during the therapeutic process after being randomized, three
performed the APE. They did not participate in any other were from the CVRP group, and five from the VFE. The rea-
part of the research process. Therefore, they were blinded sons for withdrawal were lack of time (n ¼ 4) or complete
to the findings. The voices were presented via headphone, loss of contact (n ¼ 2) when the patient failed to answer
without any identification included in the recording. Each scheduling calls and did not respond to e-mails. In two other
patient’s samples were presented sequentially, in a cases, the patient scheduled the sessions and did not attend
random order. A visual analog scale of 100 points in the any of them.
degree of dysphonia parameter was used, considering Among the 72 patients who completed the treatment, eight
0 to be with no vocal deviation and 100 to be the patients reported consistently doing <50% of their assigned
maximum deviation. Three speech therapists specialized home exercises. After the six-session period, 27 (37.5%) pa-
in voice therapy performed this evaluation. Each speech tients reported completely stopping or only sporadically
therapist, randomly and blindly, listened to the voices. continuing to do the exercises.
Each of the three vocal aspects received a score between Intention to treat was calculated for all patients, including the
0 and 100. Then, the average of these three aspects was eight dropout patients.
computed (APE1, APE2, and APE3). No significant difference was found between men and
women in both groups in chi-square test P ¼ 0.143 (Table 1).
No significant difference was found for signs and symptoms
RESULTS quantity between the CVRP and VFE (P ¼ 0.55; Table 2).
The study lasted 1 year and 3 months. A total of 306 volunteers Intrasubject agreement was tested with 30% of cases repeti-
who had made contact via e-mail or phone were registered and tion. The judge with highest values was kept as the single eval-
they received the list of vocal signs and symptoms.38,39 From uator 91.6% in the pretherapy samples, kappa 0.771; 87.5%
these 306 volunteers, 212 (69.28%) answered the list and immediate posttreatment, kappa 0.813; and 91.6% after 1-
were professional voice users. From these 212, 159 (51.96%) month posttreatment, kappa of 0.840.
had four or more signs and symptoms and were between the For the LP variable, there was a reduction in the two posttreat-
ages of 18 and 50 years. The 159 individuals were referred ment scores, for both treatment groups (Table 3). According to
for an initial assessment and 99 (32.35%) were evaluated. the mean, the CVRP groups showed greater improvements
Among them, 19 were excluded for not having a behavioral than the VFE group.
dysphonia diagnosis. Eighty patients (26.14%) were included The average of the results of the questionnaire also showed a
in this research, and the sample was randomized. reduction of VHI2 and VHI3, for both groups, when compared
Of the 80 enrolled patients, 56 were women with an average with VHI1. However, the greatest reduction occurred in VFE
age of 35.1 years and standard deviation of 10.1 years. There group with a difference of 3.63 points. The mean scores of
were 24 men with an average age of 35.9 years and standard de- the questionnaire V-RQOL demonstrate that there was an in-
viation of 8.7 years. The average age in the CVRP group was crease in quality of life at the immediate posttreatment assess-
34.5 years with a standard deviation of 9.03. In the VFE group, ment (V-RQOL2) and 1 month after the treatment discharge.
the average age was 36.05 years and the standard deviation of Descriptive means of perceptual evaluation showed reduced
10.37. Both groups were statistically similar (P ¼ 0.143), scores in CVRP groups for PAE2 and PAE3. In EFV, reduction
Table 1. occurred just between PAE1 and PAE2.

TABLE 1.
Participants Separated by Group, Sex, and Profession
CVRP VFE

Female Male Total Female Male Total

Profession n % n % n % n % n % n %
Lawyer 2 5.0 1 2.5 3 3.8 0 0.0 0 0.0 0 0.0
Actor 1 2.5 0 0.0 1 1.3 1 2.5 0 0.0 1 1.3
SLP 0 0.0 0 0.0 0 0.0 1 2.5 0 0.0 1 1.3
Journalist 6 15.0 5 12.5 11 13.8 3 7.5 5 12.5 8 10.0
Religious leader 1 2.5 1 2.5 2 2.5 0 0.0 3 7.5 3 3.8
Professor 15 37.5 2 5.0 17 21.3 16 40.0 6 15.0 22 27.5
Teleoperator 4 10.0 0 0.0 4 5.0 4 10.0 0 0.0 4 5.0
Seller 2 5.0 0 0.0 2 2.5 0 0.0 1 2.5 1 1.3
Total 31 77.5 9 22.5 40 50.0 25 62.5 15 37.5 40 50.0
Abbreviations: CVRP, Comprehensive Voice Rehabilitation Program; VFE, Vocal Function Exercise.
377.e16 Journal of Voice, Vol. 30, No. 3, 2016

ate after treatment and 1 month after treatment; before therapy

TABLE 2.
Vocal Signs and Symptoms and the Distribution
and 1 month after treatment. The progress was considered only
According to Therapeutic Group when a difference equal or greater than 10 points was presented
for all the four evaluated outcomes. This value cutoff of 10
CVRP VFE Total points was chosen by the statistical guidance after analyzing
Signs and
Symptoms n % n % n % the four outcomes with scales of 100 mm. Ten points or
10 mm represents a minimum value of difference in the evalu-
4 7 8.8 7 8.8 14 17.5
ators’ choice. When there was not such difference, the result
5 5 6.3 7 8.8 12 15.0
6 3 3.8 6 7.5 9 11.3 was considered without progress. The relative risk (RR), the
7 7 8.8 7 8.8 14 17.5 P with confidence interval, and the effect size (ES) were
8 6 7.5 2 2.5 8 10.0 calculated.
9 3 3.8 4 5.0 7 8.8 In Table 4, the values in bold show the RR when the CVRP
10 3 3.8 1 1.3 4 5.0 intervention was found to be better than the EFV. The values
11 4 5.0 3 3.8 7 8.8 of the confidence interval show when values fall between 1
12 1 1.3 1 1.3 2 2.5 and 1 with significance. The ES, in bold, shows that the highest
13 0 0.0 2 2.5 2 2.5 effect of each group was >0.8. From these tables, we conclude
14 1 1.3 0 0.0 1 1.3 that the RR was >1 for the CVRP group when accounting for
Total 40 50 40 50 80 100
most of the comparisons between assessments. The confidence
Average 7.3 7.0 7.3
interval exceeds 1, but this was significant only in VHI1. At
SD 2.5 2.6 4.7
least in one of the comparisons, the ES was larger for the eval-
Note: P ¼ 0.55.
Abbreviation: SD, standard deviation.
uations of the four variables. In other words, patients did not
show improvement in all assessments but, at least in one of
the analysis performed the positive impact of the vocal rehabil-
itation was evident.
Table 3 presents a significant interaction that was observed in
the time variable for the four outcomes (LP, VHI, V-RQOL, and
PAE). This led us to the conclusion that both groups (CVRP and DISCUSSION
VFE) improved in the two posttreatment assessments. No sta- This blinded randomized clinical trial involved a low risk of
tistical significance was found for the group analysis. There- bias according to Cochrane criteria46 because it requires a blind
fore, the four outcomes for both groups were similar in the outcome assessment and a homogeneous sample. In the present
three evaluations. study, 10% of the patients were lost during treatment, which is
an acceptable number in a therapeutic trial.
Categorical statistical analysis The results showed that the two treatment programs pro-
We performed a categorical analysis among the three assess- duced positive results without significant differences between
ments: before therapy and immediate after treatment; immedi- them. The descriptive analysis shows a positive effect for

TABLE 3.
Descriptive Measures of All Variables, Presenting Three Assessments
CVRP VFE

Variable and Moment Average SD Minimum Maximum Average SD Minimum Maximum

LP1 81.42 38.53 15.00 190.0 75.63 40.32 5.0 175.00
LP2 57.25 34.10 5.00 155.0 60.13 36.61 10.0 160.00
LP3 44.17 27.68 0.00 110.0 51.75 36.82 5.0 155.00
VHI1 43.00 22.44 8.00 99.00 32.52 20.32 5.00 92.00
VHI2 25.40 20.90 1.00 99.00 23.93 19.09 1.00 92.00
VHI3 21.32 20.58 0.00 99.00 17.70 16.38 0.00 92.00
V-RQOL1 64.44 20.27 2.50 97.50 72.00 18.77 27.50 97.50
V-RQOL2 80.75 18.98 2.50 100.00 82.00 15.19 27.50 100.00
V-RQOL3 82.19 20.42 2.50 100.00 87.00 13.54 27.50 100.00
PAE1 48.63 13.62 23.00 90.00 46.88 14.55 17.00 75.00
PAE2 36.05 15.21 16.00 73.00 38.20 14.72 10.00 73.00
PAE3 33.33 11.94 13.00 63.00 40.52 18.29 8.00 89.00
Note: ANOVA Time LP: 0.001 group LP: 0.539, VHI: 0.001 group VHI: 0.268, Time V-RQOL: 0.001, group V-RQOL: 0.196, Time PAE: 0.001 group PAE: 0.258.
Abbreviations: SD, standard deviation; LP, laryngeal pattern; VHI, Voice Handicap index; V-RQOL, Voice-Related Quality of Life; PAE, perceptive auditory
evaluation.
Vanessa Pedrosa, et al Voice Rehabilitation Randomized Clinical Trial 377.e17

TABLE 4.
Positive Outcomes by Group, Relative Risk With Confidence Interval and Significance Level and Size Effect for the CVRP and
VFE, Comparing the Three Assessments*
Progress % Effect Size

CVRP VFE Relative Risk Confidence Interval P CVRP VFE

LP1 85 42 1.61 1.17 2.23 0.003 1.01y 0.51
LP2 58 50 1.15y 0.764y 1.730y 0.502 0.49 0.44y
LP3 73 57.5 1.22y 0.889y 1.699y 0.211 1.25y 0.72
VHI1 70 37.5 1.86 1.19 2.92 0.006y 1.17y 0.62
VHI2 30 25 1.20y 0.58y 2.45y 0.617 0.52 0.50
VHI3 73 45 1.61 1.08 2.38 0.017 1.29y 0.82y
V-RQOL1 65 60 1.08y 0.770y 1.522y 0.644y 1.09y 0.86y
V-RQOL2 30 50 0.600 0.340 1.056 0.076 0.14 0.91y
V-RQOL3 70 68 1.037y 0.771y 1.393y 0.809 1.21y 0.45
PAE1 72.5 52.5 1.38y 0.972y 1.962y 0.071 0.79 0.48
PAE2 45 42.5 1.058y 0.643y 1.141y 0.821 0.19 0.13
PAE3 75 57.5 1.30y 0.946y 1.797y 0.14 0.84y 0.30
Abbreviations: LP, laryngeal pattern; VHI, Voice Handicap index; V-RQOL, Voice-Related Quality of Life; PAE, perceptive auditory evaluation.
* Comparison between assessment 1 and 2 (LP1, VHI1, V-RQOL1, and PAE1), assessment 2 and 3 (LP2, VHI2, V-RQOL2, and PAE2), and assessment 1 and 3 (LP3,
VHI3, V-RQOL3, and PAE3), respectively.
y
Statistical significance.

both groups. The analysis of dichotomous data reveals a small Only one previous study26 presented all the necessary data to
difference between the two groups, slightly favoring the CVRP, calculate the sample size (total score, mean score, mean differ-
but this difference was not statistically significant. ence, and standard deviation of the difference between before
A systematic search of the medical literature revealed that and after treatment in individuals treated with VFE); therefore,
this is the only randomized clinical trial involving multidi- V-RQOL variable is justified. The number of patients included
mensional assessment that considers CVRP and EFV thera- in the study was less than the proposed sample number (40 vs 47
peutic programs results for the treatment of behavioral in each group), for this reason, the power of the test to detect the
dysphonia. seven-point difference in the chosen variable (seven-point
This study does not have a nontreated group included. improvement difference in the V-RQOL score between the
Despite the existence of many studies reporting vocal progress CVRP group and the VFE group) was reduced to 73%. If there
of a placebo group who do not receive vocal therapy, the authors had been more patients in each group, the power of the test
believe that speech therapy has a positive impact on voice. Spe- would have been greater, and the results might have shown
cifically, positive vocal outcomes would not happen without greater statistical difference.
voice therapy. Therefore, the aim of the present study was to The expected therapeutic proposal, especially for the CVRP,
compare a new treatment with a treatment considered the involves clear stages related to the patient’s vocal quality and
gold standard in voice therapy. his/her understanding of the use of his/her voice. The patient
The CVRP, which was tested in this study, reflected the most must only start one stage once she/he has understood and
commonly used exercises used in Brazilian clinics. It has been completed the previous stage. For example, pneumophonic
well adapted culturally so it does not bear any specific cultural coordination should only be addressed once the patient has
markers. Exercises were also designed to be substituted when acquired more adequate vocal quality and resonance. However,
patients presented with difficulties to produce them, for because of technical limitations, this study did not take into ac-
example, tongue vibration. The premise of the CVRP is to un- count patients’ individual progress. Therefore, some patients
derstand the individual with a behavioral dysphonia in a broad presented incomplete improvement.
sense and to pursue a segmented learning approach during the This study proposed a treatment duration of 6 weeks, with the
therapeutic process. Treatment involves the identification, authors aware of possible restrictions in terms of measuring
awareness, and modification of negative speech habits and tech- outcomes. The 6 weeks of treatment probably did not lead to
niques to benefit voice-body association, glottal adjustment, full vocal recovery in many patients. Thus, we may conclude
resonance balance, and automation techniques. This treatment that treatment did offer individuals an understanding of good
is associated with the articulatory precision of the speech vocal practices, the ability to identify both healthy and
sounds. It affects pneumo-phono-articulatory coordination in unhealthy habits, and exercises to help control some high-
voice projection and patient’s attitude toward communication. pitched vocal changes.
The broad application of the CVRP required a clinical study Proof that the CVRP leads to positive results in the treatment
to prove its effectiveness. of behavioral dysphonia is good news for clinical practice. The
377.e18 Journal of Voice, Vol. 30, No. 3, 2016

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