Van Stan et al. (2015)

September 10, 2020

SECONDARY REVIEW CRITIQUE

KEY:

C = clinician

f = female

m = male

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

SR = Systematic Review

Source: Van Stan, J., Roy, N., Awan, S., Stemple, J., & Hillman, R. E. (2015). A taxonomy of voice therapy. American Journal of Speech-Language Pathology, 24, 101-125. https://pubs.asha.org/doi/pdf/10.1044/2015_AJSLP-14-0030

Reviewer(s):  pmh

Date:  September 10, 2020

Overall Assigned Grade: No grade is assigned to this article because it was not concerned with directly with intervention. Rather, it provides guidance in identifying a classification system for voice therapy.

Level of Evidence:  D (Traditional Review)

Take Away:  Although the purpose of this article was to initiate the development of a taxonomy of voice therapy treatment procedures, readers can use this article as a source for treatments of prosodic targets. 

What type of secondary review?  Narrative 

1.  Were the results valid? Yes 

• Was the review based on a clinically sound clinical question? Yes 

• Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)? Yes

• The authors of the secondary research did not describe the search strategy.  

• Did the sources involve only English language publications? Yes 

•  Did the sources include unpublished studies? No

• Was the time frame for the publication of the sources sufficient? No 

• Did the authors of the secondary research identify the level of evidence of the sources? No 

• Did the authors of the secondary research describe procedures used to evaluate the validity of each of the sources? Not Applicable (NA )

• Was there evidence that a specific, predetermined strategy was used to evaluate the sources? NA

•  Did the authors of the secondary research or review teams rate the sources independently? NA 

• Were interrater reliability data provided? No

• Were assessments of sources sufficiently reliable? NA, reliability data were not provided.

• Was the information provided sufficient for the reader to undertake a replication? Yes

• Did the sources that were evaluated involve a sufficient number of participants? NA 

• Were there a sufficient number of sources? Yes _ 

2.  Description of outcome measures:

DIRECT INTERVENTIONS 

•  Outcome  #1: Improved pitch modification

INDIRECT INTERVENTIONS (These are treatments that included prosodic treatment techniques used in the described programs for treating voice disordders.)

•  Confidental Voice Therapy: soft loudness

•  Resonant Voice Therapy: pitch variability, loudness variability, rate variability  

•  Voice Function Exercises: soft loudness, sustained duration, pitch direction, pitch variation (includes glides or chants)

•  Lee Silverman Voice Therapy: increased loudness, sustained duration, pitch variation (includes glides or chants)

•  Manual Circumlaryngeal Therapy: prolonged duration, pitch variation

•  Laryngeal Manual Therapy: pitch level, pitch variation (includes glides or chants)

•  Accent Method: rhythm, sustained duration, loudness, pitch, intonation, 

3.  Description of results:   NA, this article did not involve treatment. It is included in the Clinical Prosody Blog because it lists sources that are concerned with voice therapy, including some that target prosodic element or use prosody to treatment certain aspects of voice.

4.  Were maintenance data reported? NA 

5.  Were generalization data reported?


Lu et al. (2013)

September 7, 2019

 

EBP THERAPY ANALYSIS for

Single Case Designs

 NOTE: 

  • The summary of the intervention procedure can be viewed by scrolling about 80% of the way down on this page.

Key:

C =  Clinician

EBP =  evidence-based practice

f =  female

GGS = glottal gap size

LSVT =  Lee Silverman Voice Treatment

m = male

NA  = not applicable

P =  Patient or Participant

Pmh =  Patricia Hargrove, blog developer

SLP =  speech–language pathologist

SPI =  soft phonation index

 

SOURCE:  Lu, F-L. Presley, S., & Lammers, B. (2013). Efficacy of intensive phonatory-respiratory treatment (LSVT) for presbyphonia: Two case reports. Journal of Voice, 27 (6), 786.e11 – 786.e23.

 

REVIEWER(S):  pmh

 

DATE: September 1, 2019

 

ASSIGNED OVERALL GRADE:  The highest possible grade, based on the design of the investigation (Single Case Design) is C+. This grade represents the design quality of the investigation and is not meant to be a judgment about the quality of the intervention.

 

TAKE AWAY: Single case studies were used to explore the efficacy of Lee Silverman Voice Treatment (LSVT) for improving voice quality of 2 patients with vocal fold atrophy and bowing that accompanied with aging (i.e., presbyphonia). The investigation revealed significant and/or marked improvement in almost all of the laryngeal configuration, glottal gap, phonatory function, acoustic correlates of vocal fold adduction/voicing qualities, and perceptual aspects of voice quality outcomes.

 

  1. What was the focus of the research? Clinical

 

 

  1. What type of evidence was identified?

What type of single subject design was used?  Case Studies:  Description with Pre and Post Test Results (Prospective, Nonrandomized)

  • What was the level of support associated with the type of evidence? Level = C+       

                                                                                                           

 

  1. Was treatment concealed?
  • from participants?No
  • from clinicians? No
  • from data analyzers? Unclear

 

 

  1. Were the participants (Ps) adequately described? Yes

–  How many Ps were involved in the study?  2

–  What P characteristics/variables were controlled or described?

CONTROLLED CHARACTERISTIC:

  • diagnosis: Presbylaryngis      

DESCRIBED CHARACTERISTICS:

  • age:

∞  Subject 1: 62 years

∞  Subject 2: 88 years

  • gender:

∞  Subject 1:  f

∞  Subject 2: m                          

  • profession

∞  Subject 1: retired office worker

∞  Subject 2: retired professor of vocal studies               

  • medical history:

∞  Subject 1:

  • asthma (for 6 years)
  • allergies (airborne; since young adulthood)
  • sinus (year round; since young adulthood)
  • suspected gastroesophageal reflux

∞  Subject 2:

  • suspected gastroesophageal reflux

                                                 

–  Were the communication problems adequately described? Yes

–  List the disorder type:  Presbylaryngis

–  List other aspects of communication that were described:

  •      Subject 1:

          ∞ In long conversations, her voice quality became weak and breathy.

∞  On the telephone, listeners had moderate difficulty hearing her.

  • Subject 2:

          ∞ in conversation

  • weak and breathy voice
  • trouble being heard

∞  Voice problems started about 5 years prior to the investigation. Voice quality has slowly declined.

                                                                                                                       

  1. Was membership in treatment maintained throughout the study?Yes

                

 

  • If there was more than one participant, did at least 80% of the participants remain in the study? Yes
  • Were any data removed from the study?No

 

 

  1. Did the design include appropriate controls? No, it was a case study.

                                                                       ,

  • Were baseline/preintervention data collected on all behaviors?Yes
  • Did probes/intervention data include untrained stimuli?Yes
  • Did probes/intervention data include trained stimuli?Yes
  • Was the data collection continuous? Yes, for some of the outcomes.
  • Were different treatment counterbalanced or randomized?NA

 

 

  1. Were the outcome measures appropriate and meaningful? Yes

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health before and after intervention
  • OUTCOME #2:Severity of vocal fold atrophy and bowing before and after intervention
  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS) before and after intervention
  • OUTCOME #4: Vibratory pattern of the vocal folds before and after intervention

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)
  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)
  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #9: Maximum phonation time (before and after intervention and during 16 treatment sessions)
  • OUTCOME #10: Highest pitch (before and after intervention)
  • OUTCOME #11:Lowest pitch (before and after intervention)
  • OUTCOME #12: Pitch range (before and after intervention)

 

ACOUSTIC MEASUREMENTS

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention
  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention
  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention
  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention
  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention
  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention
  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention
  • OUTCOME #20:Voice breaks:  Number  of voice breaks pre and post intervention
  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention
  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #23: Description of voice quality before and after treatment
  • OUTCOME #24:Rating on GRBAS scale (0= normal; 3 = extremely deviant)

 

–  Outcomes that are subjective:

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health
  • OUTCOME #2:Severity of vocal fold atrophy and bowing
  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS)
  • OUTCOME #4: Vibratory pattern of the vocal folds

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #13: Description of voice quality before and after treatment
  • OUTCOME #14:Rating on GRBAS scale (0= normal; 3 = extremely deviant) before and after intervention

                                                                                       

–  Outcomes that are objective:

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)
  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)
  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #9: Maximum phonation time (before and after intervention and during 16 treatment sessions)
  • OUTCOME #10: Highest pitch (before and after intervention)
  • OUTCOME #11:Lowest pitch (before and after intervention)
  • OUTCOME #12: Pitch range (before and after intervention)

 

ACOUSTIC MEASUREMENTS

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention
  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention
  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention
  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention
  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention
  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention
  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention
  • OUTCOME #20:Voice breaks:  Number of voice breaks pre and post intervention
  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention
  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

 

– RELIABILITY DATA: No reliability data were provided.

 

 

  1. Results:

–  Did the target behaviors improve when treated?  Yes, for the most part

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health (description of changes from pre to post intervention)

–  Subjects 1 and:  color of vocal folds improved

 

  • OUTCOME #2:Severity of vocal fold atrophy and bowing (description of changes from pre to post intervention)

–  Subjects 1 and 2 :  concavity of edges of the vocal folds was reduced following intervention

 

  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS) (description of changes from pre to post intervention)

–  Subjects 1 and 2:  size of GGS reduced from small /moderate to minute anterior slit or complete or near complete closure; normalized GGS significantly smaller post treatment

 

  • OUTCOME #4: Vibratory pattern of the vocal folds (description of changes from pre to post intervention)

–  Subjects 1 and 2: improved from moderate deviance to normal/near normal

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #9: Maximum phonation time (MPT, before and after intervention and during 16 treatment sessions)

–  Subject 1:  significant increase from pre to post intervention with steady improvement over the course of therapy

–  Subject 2:  significant increase over the course of treatment but the pre intervention was abnormally long and; therefore, there was no significant difference from pre to post intervention

 

  • OUTCOME #10: Highest pitch (before and after intervention)

–  Subjects 1 and 2:  significantly higher

 

  • OUTCOME #11:Lowest pitch (before and after intervention)

–  Subject 1:  significantly higher

–  Subject 2:  no significant difference

 

  • OUTCOME #12: Pitch range (before and after intervention)

–  Subjects 1 and 2: significantly wider

 

ACOUSTIC MEASUREMENTS  (these differences were only described; no inferential statistical analysis

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention

–  Subject 1: improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #20:Voice breaks:  Number  of voice breaks pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention

–  Subjects 1 and :  lowered after treatment

 

  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

–  Subject 1 and:  lowered after treatment

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #23: Description of voice quality before and after treatment

– Subject 1:

∞  preintervention described as hoarse, weak, shortened phrasing

∞  postintervention describes as normal with trace of breathiness

– Subject 2:

∞  preintervention described as hoarse, breathy, weak, slightly shaky

 

  • OUTCOME #24: Rating on GRBAS scale (0= normal; 3 = extremely deviant) before and after intervention

 

Subject 1

Pre                            Post

–  Grade =                               2                                1

–  Roughness =                     1                                 0

–  Breathiness =                    2                                1

–  Asthenia =                          2                                0

–  Strain =                               0                                0

 

Subject 2

Pre                            Post

–  Grade =                               2                                1

–  Roughness =                     2                                1

–  Breathiness =                    2                                1

–  Asthenia =                          2                                0

–  Strain =                               0                                0

 

 

  1. Description of baseline:

 

9a  Were baseline data provided?  Variable, the following outcomes were measured during each treatment session:

                       

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3  (marked improvement)

 

  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3 (moderate improvement)

 

  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3  (moderate improvement)

 

  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3 (marked improvement)

 

  • OUTCOME #9: Maximum phonation time (MPT, before and after intervention and during 16 treatment sessions)

–  Subject 1:  significant increase from pre to post intervention with steady improvement over the course of therapy (marked improvement)

–  Subject 2:  significant increase over the course of treatment but the pre intervention was abnormally long and; therefore, there was no significant difference from pre to post intervention  (limited improvement)

 

–  Was baseline low (or high, as appropriate) and stable?  Generally the baselines were low and stable.

                                                       

–  Was the percentage of nonoverlapping data (PND) provided?  No

 

 

  1. What is the clinical significance(List outcome number with data with the appropriate Evidence Based Practice, EBP, measure.) NA, magnitude of effect was not provided.

 

  1. Was information about treatment fidelity adequate?Not Provided

 

 

  1. Were maintenance data reported? No. However,when direct treatment was terminated, Ps were expected to complete daily practice routines to ensure maintenance. Maintenance, however, was not targeted as an outcome in this investigation.

 

 

  1. Were generalization data reported?Yes.Since improved loudness is considered the focus of LSVT, any outcome not targeting loudness/intensity can be considered generalization.

 

 

  1. Brief description of the design:

 

  • Two adults who had been diagnosed with presbyphonia (age related vocal fold atrophy and bowing) were Ps in this investigation (design: nonrandomized, prospective case study.)

 

  • Each of the Ps received 4 weeks of LSVT from SLPs who also were certified by LSVT.

 

  • For all the outcomes, the investigators administered pre and post intervention measures of laryngeal configuration, glottal gap, phonatory function, acoustic correlated of vocal fold adduction/voicing qualities, and perceptual aspects of voice quality.

 

  • For several of the outcomes, the investigators also administered probes during each of the 16 treatment sessions.

 

  • The data were analyzed using inferential statistics (ANOVA, t-tests) and descriptively.

 

 

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  C

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the efficacy of LSVT for Ps with presbyphonia.

 

POPULATION:  Presbyphonia; Adult

 

MODALITY TARGETED:  production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED :  loudness, pitch, duration

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: voice quality, laryngeal structure

 

DOSAGE:  4 one-hour sessions for 4 weeks (16 sessions)

 

ADMINISTRATOR:  SLP certified foe LSVT

 

MAJOR COMPONENTS:

 

  • Session structure

–  first 30 minutes

∞  maximize phonation time and pitch range; practice functional speech using short meaningful sentences using “shot loud” intensity.

–  second 30 minutes

∞  used increased loudness/intensity by increasing respiratory and phonatory effort in a variety of tasks:

  • reading aloud
  • questions
  •  word generation
  • conversation

 

  • Ps were assigned daily homework and when direct treatment was terminated, Ps were expected to complete daily practice routines to insure maintenance. Maintenance, however, was not targeted as an outcome in this investigation.

_________________________________________________________________


Block (2017)

May 21, 2018

 CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

(also known as Expert Opinion)

NOTE:  A brief summary of recommended interventions recommended by the author can be found by scrolling about ½  of the way down this page.

KEY
C =  clinician

fo=  fundamental frequency

NA = not applicable

P =  patient or participant

pmh =  Patricia Hargrove, blog developer

SLP = speech-language pathologist

Source:  Block, C. (2017.)   Making a case for transmasculine voice and communication training. Perspectives of the ASHA Special Interest Groups: Sig 3 (Part 1), 33-41.

Reviewer(s):  pmh

Date:  May 16, 201

Overall Assigned Grade: because there are no supporting data, the highest grade will be F.  This grade reflects the level of data provided in this article. It does not reflect a judgment on the value of the recommendations provided by the author.

Level of Evidence:  F = Expert Opinion, no supporting evidence for the effectiveness of the intervention although the author may provide secondary evidence supporting components of the intervention.

Take Away:  This article provides recommendations for treating voice and communication problems associated with transmasculine voices. The author highlights aspects of communication that may be a challenge to speakers and provides recommendations for treatment. In addition, the author a clear rationale for speech-language pathologists (SLPs) to provide services to speakers with transmasculine voices.

 

  1. Was there a review of the literature supporting components of the intervention?No, for many of the recommendation some existing references were briefly summarized but not critiqued.

  

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? Yes

  

  1. Was the intervention based on clinically sound clinical procedures? Yes

 

  1. Did the author provide a rationale for components of the intervention? Yes

 

  1. Description of outcome measures: 

–  Are outcome measures suggested? No, but they can be derived from the article.

–  Potential outcome measures,

  • Outcome #1: Lower average fundamental frequency (fo) of speech
  • Outcome #2: Gender appropriate intonation range
  • Outcome #3: Appropriate loudness level
  • Outcome #4: Gender appropriate resonance
  • Outcome #5: Reduction in hyperfunctional vocal patterns
  • Outcome #6: Remediate problems following phonosurgery
  • Outcome #7: Language that contains more masculine gender markers

 

  1. Was generalization addressed? No

  

  1. Was maintenance addressed? No

  

SUMMARY OF INTERVENTION

PURPOSE:  The author recommended that the role of the speech-language pathologist (SLP) should be to translate research about gender and communication to an individualized treatment plan appropriate to the specific client. The focus was on the transmasculine voice

POPULATION:  Transmasculine speakers; Adults

MODALITY TARGETED:Production

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch, intonation, loudness, singing

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:resonance, language, nonverbal communication (body language)

ADMINISTRATOR:  SLP

MAJOR COMPONENTS

  • Prior to working on transmasculine related targets, the SLP should insure that the client is free from dysphonia or that issues related to dysphonia have been addressed adequately. Irrespective of the cause of the dysphonia, the SLP should employ appropriate rehabilitative techniques.

 

  • The author provided recommendations for treating selected aspects of communication. For each aspect of communication that the author addressed, the information is summarized by listing

–  the aspect of communication,

–  anticipated problems, and

–  recommendation(s) for treatment.

 

ASPECT OF COMMUNICATION:  Pitch—lower frequencies

ANTICIPATED PROBLEMS:  Some individuals do not achieve targeted lower pitch levels following testosterone therapy. This may be due to limited success with the hormone, failure to use the new pitch range that is available to the speaker, or electing not to receive testosterone treatment.

RECOMMENDATIONS FOR TREATMENT:  Behavioral pitch training including

–  a guide when to intervene

–  useful techniques such as a chant-to-speak exercise and audio and visual feedback

 

ASPECT OF COMMUNICATION:  Intonation—limited range

ANTICIPATED PROBLEMS: Speakers may compensate for the tendency to use higher pitches when speaking “expressively” (p. 34) by limiting intonation range. This can result in sounding unfriendly.

RECOMMENDATIONS FOR TREATMENT:  Behavioral intonation training including

–  limiting the use of higher pitches

–  increased use of falling intonation contours

–  modifying the production of stress using

  • producing longer vowels
  • producing louder vowels
  • increasing the slope of falling intonation patterns
  • reducing blending between words (i.e., more staccato)

 

 

ASPECT OF COMMUNICATION: Loudness

ANTICIPATED PROBLEMS: It can be difficult to modulate loudness separately from pitch particularly because if the speaker elects to receive testosterone treatment as it usually increases vocal fold mass.

RECOMMENDATIONS FOR TREATMENT: Behavioral loudness and breath control training including focusing on diaphragmatic breathing

 

 

ASPECT OF COMMUNICATION:  Resonance

ANTICIPATED PROBLEMS: Some speakers sound younger or more feminine than desired despite a fothat is within normal limits for a male. It is suggested that this is due to a small upper airway.

RECOMMENDATION(S) FOR TREATMENT:  Recommendations included focusing on

–  lowering the jaw

–  lowering the base of the tongue

 

 

ASPECT OF COMMUNICATION:  Dysphonia

ANTICIPATED PROBLEMS: If the speaker attempts to change his voice without SLP guidance, he is at risk for adapting hyperfunctional vocal patterns.

RECOMMENDATIONS FOR TREATMENT:  Vocal rehabilitation training

 

ASPECT OF COMMUNICATION:  Maladaptive response to phonosurgery

ANTICIPATED PROBLEMS: Speakers may experience problems following phonsurgery

RECOMMENDATIONS FOR TREATMENT: Vocal rehabilitation training

 

 

ASPECT OF COMMUNICATION:  Language production

ANTICIPATED PROBLEMS: Speakers may maintain their use of feminine language patterns

RECOMMENDATIONS FOR TREATMENT:  The SLP may target language behaviors such as

–  vocabulary selection

–  using fewer words to convey a meaning

 

 

ASPECT OF COMMUNICATION:  Nonverbal communication

ANTICIPATED PROBLEMS: Speakers may maintain their use of feminine body language  patterns

RECOMMENDATION(S) FOR TREATMENT:  The SLP may target nonverbal communication behaviors such as

–  taking up more space

–  increasing the rigidity of hand and body movement

 

 


Adler (2015)

May 8, 2018

                                                                                                            

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

(also known as Expert Opinion)

 

KEY

C =  clinician

NA = not applicable

P =  patient or participant

pmh =  Patricia Hargrove, blog developer

SLP = speech-language pathologist

WPATH =  World Professional Association for Transgender Health

 

SOURCE:  Adler, R. (2015.)  Voice and communication for the transgender/transsexual client: Presenting the WPATH Standing Committee on Voice and Communication.  Perspectives on Voice and Voice Disorders, 25. 32-36.

 

REVIEWER(S): pmh

 

DATE:  May 8, 2018

 

 

Overall Assigned Grade (because there are no supporting data, the highest grade will be F):  F  This grade should be interpreted as a evaluation of the Level of Evidence provided in the paper and not as a judgment about the quality of the paper or the information contained in the paper.

 

Level of Evidence:  F = Expert Opinion, no supporting evidence for the effectiveness of the recommendations although the author may provide secondary evidence supporting the interventions.

 

Take Away:  This introduction to the World Professional Association for Transgender Health (WPATH)  provides a brief rationale and history of WPATH as well as an explanation of how and why voice and communication issues were included in WPATH guidelines. In addition, the author provides a brief tutorial regarding transgender/transsexual terminology and professional resources. By accessing the WPATH webpage (referenced by the author), one can review the current “Standards of Care for the Health of Transgender, Transsexual, and Gender Nonconforming People” which includes recommendations for Speech-Language Pathologists (SLPs). This is good starting point for planning to initiate practice including people who are transgender/transsexual.

 

 

 

  1. Was there a review of the literature supporting components of the intervention?No

 

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? Not Applicable (NA)

 

 

  1. Were the recommendations based on clinically sound clinical procedures? NA

 

 

  1. Did the author provide a rationale for the recommendations? Yes

 

 

  1. Description of recommendations:

 

  • Speech-language pathologists (SLPs) working with transgender/transsexual clients should educate themselves regarding the needs of this population. A starting point can be the information in this article and the most current “Standards of Care for the Health of Transgender, Transsexual, and Gender Nonconforming People” on the WPATH website.

 

  • SLPs’ role should include communication skills such as articulation, language, prosody as well a voice.

 

  • SLPs should remember that evidence-based practice involves

– research evidence,

– clinician’s expertise, and

– client’s needs.

 

  1. Are outcome measures suggested? NA

 

 

  1. Was generalization addressed? NA

 

 

  1. Was maintenance addressed? NA

 

 

 


Hancock et al. (2017)

December 12, 2017

 

 

EBP THERAPY ANALYSIS

Treatment Groups

 

Note: Scroll about two-thirds of the way down the page to read the summary of the procedures.

 Key:

C = Clinician

CPP = cepstral peak prominence

EBP = evidence-based practice

F0 = fundamental frequency

Hz = Hertz

JITT = jitter

MaxF0 = Maximum fundamental frequency

MF0 = minimum fundamental frequency

Min-max F0 = change in fundamental frequency

NA = not applicable

NHR = noise-to-harmonic levels

P = Patient or Participant

PFR = Phonation frequency range

pmh = Patricia Hargrove, blog developer

SHIM = shimmer

ST = semitones

SLP = speech–language pathologist

Trans men = individuals who had been assigned as female sex at birth but who identified as male

WNL = within normal limits

 

 

SOURCE: Hancock, A. B., Childs, K. D., & Irwig, M. (2017.) Trans male voice in the first year of testosterone treatment: Make no assumptions. Journal of Speech, Language, and Hearing Research, 60, 2472-2482.

 

REVIEWER(S): pmh

 

DATE: December 11, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: C (The highest possible grade based on the design of the investigation was C+, Prospective, Single Group with Pre and Post Testing.)

 

TAKE AWAY: The investigators explored the changes in fundamental frequency, pitch range, voice quality, and perceptions of effectiveness of hormone therapy administered to transgender males. Although there was individual variation, overall participants tended to produce lower pitch levels indicating a deepening of their voices.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing

                                                                                                          

  • What was the level of support associated with the type of evidence?

Level = _ C+___

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No
  • from clinicians? No
  • from analyzers? No

                                                                    

 

  1. Were the groups adequately described? Yes, if one includes the baseline data a descriptors

 

           How many Ps were involved in the study?

  • total # of Ps: 7
  • # of groups: 1
  • List names of groups and the # of participants (Ps) in each group:

     – Trans men (individuals who had been assigned as female sex at birth but who identified as male.)

 

– CONTROLLED CHARACTERISTICS

  • gender: trans men
  • previous and current voice therapy: None
  • smokers/nonsmokers: 6 nonsmokers; 1 smoked 1 -7 cigarettes a day
  • medications: none of the Ps had used testosterone

 

– DESCRIBED CHARACTERISTICS

  • age: 18 to 39 years
  • ethnic/racial background: Black (2), Racially mixed (3), White (2)
  • professional singer?: none

 

–   Were the groups similar before intervention began? NA, there was only one group.

                                                         

– Were the communication problems adequately described? Yes

 

  • other: baseline data describes jitter (JITT), shimmer (SHIM), noise-to-harmonic levels (NHR), cepstral peak prominence (CPP), fundamental frequency (F0), minimum fundamental frequency (MF0), change in fundamental frequency (Min-max F0), Phonation frequency range (PFR), Habitual pitch level. Only some of these measures were atypical for some of the participants (Ps.)

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

– Did each of the groups maintain at least 80% of their original members? Yes

                                                               

– Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? NA. there was only one group.

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

– OUTCOMES

 

  • OUTCOME #1: Percentage Jitter (JITT)
  • OUTCOME #2: Percentage Shimmer (SHIM)
  • OUTCOME #3: Noise-to-harmonic ration (NHR)
  • OUTCOME #4: Minimum fundamental frequency (MF0)
  • OUTCOME #5: Cepstral peak prominence (CPP)
  • OUTCOME #6: Maximum fundamental frequency (MaxF0)
  • OUTCOME #7: Change in fundamental frequency from minimum to maximum pitch (Min-Max F0)
  • OUTCOME #8: Phonation frequency range (PFR) in Hertz (Hz) and semitones (ST)
  • OUTCOME #9: Habitual pitch level
  • OUTCOME #10: Self –perception of “maleness” of voice
  • OUTCOME #11: Self-perception that P’s voice reflects true self
  • OUTCOME #12: Self-perception of error required to produce voice they way P wants it to sound.

 

– The following outcome measures were subjective:

 

  • OUTCOME #10: Self –perception of “maleness” of voice
  • OUTCOME #11: Self-perception that P’s voice reflects true self
  • OUTCOME #12: Self-perception of error required to produce voice they way P wants it to sound.

 

The following outcome measures were objective:

 

  • OUTCOME #1: Percentage Jitter (JITT)
  • OUTCOME #2: Percentage Shimmer (SHIM)
  • OUTCOME #3: Noise-to-harmonic ration (NHR)
  • OUTCOME #4: Minimum fundamental frequency (MF0)
  • OUTCOME #5: Cepstral peak prominence (CPP)
  • OUTCOME #6: Maximum fundamental frequency (MaxF0)
  • OUTCOME #7: Change in fundamental frequency from minimum to maximum pitch (Min-Max F0)
  • OUTCOME #8: Phonation frequency range (PFR) in Hertz (Hz) and semitones (ST)
  • OUTCOME #9: Habitual pitch level

                                         

 

  1. Were reliability measures provided?

                                                                                                            

  • Interobserver for analyzers? No
  • Intraobserver for analyzers?
  • Treatment fidelity for clinicians? No _x__     Unclear ____
  • If yes, describe

 

  1. What were the results?

 

∞ What level of significance was required to claim significance? NA. For the most part, the results were presented descriptively; that is, inferential statistics were not used. However, there were some correlational statistics but they will not be described here. To signify significant change, the investigators noted if the 12 month results 2 standard deviations from the 2 baseline data points.

 

PRE AND POST TREATMENT ANALYSES

 

 

  • OUTCOME #1: Percentage Jitter (JITT3

– At 12 months, variable results: some Ps JITT increased above threshold and for others threshold decreased.

 

  • OUTCOME #2: Percentage Shimmer (SHIM)

3 additional Ps produced SHIM beyond threshold at 12 months

 

  • OUTCOME #3: Noise-to-harmonic ration (NHR)

2 Ps were above threshold at baseline; all Ps were below threshold at 12 months.

 

  • OUTCOME #4: Minimum fundamental frequency (MF0)

Ps’ MF0s were closer to the predicted mean for mean (123 Hz) at the 12 month data collection.

– All Ps’ MF0s were significantly lower than the baseline.

 

  • OUTCOME #5: Cepstral peak prominence (CPP)

– CPP was within normal limits (WNL) for all Ps at baseline and at 12 months.

 

  • OUTCOME #6: Maximum fundamental frequency (MaxF0)

– For 5 of 7 Ps, the change from baseline to 12 months was significantly lower.

 

  • OUTCOME #7: Change in fundamental frequency from minimum to maximum pitch (Min-Max F0)

At 12 months, this measures was WNL.

 

  • OUTCOME #8: Phonation frequency range (PFR) in Hertz (Hz) and semitones (ST)

– For all Ps, the lowest and highest notes decreased from baseline to 12 months but there was variability in the individual Ps’ amount of decrease.

 

  • OUTCOME #9: Habitual pitch level

– One P produced a significant decrease in habitual pitch and one P produced a significant increase.

 

  • OUTCOME #10: Self –perception of “maleness” of voice

Self-perception of male gender of all Ps’ voices increased.

 

  • OUTCOME #11: Self-perception that P’s voice reflects true self

Self-perception that Ps’ voices reflected their true selves increased.

 

  • OUTCOME #12: Self-perception of effort required to produce voice they way P wants it to sound.

3 of the Ps never reported experiencing effort in producing their voices in the way they wanted at baseline or at 12 months.

– 4 of the Ps reported experiencing decreased effort in producing their voices in the way they wanted from baseline to12 months.

 

 

 

∞ What was the statistical test used to determine significance? Place xxx after any statistical test that was used to determine significance.

 

  • Spearman Rho
  • To signify significant change, the investigators noted if the 12 month data was 2 standard deviations from the 2 baseline data points.

 

Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceNA

 

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.
  • Ps were assessed at baseline (prior to hormone treatment) and 3 months, 6 months, 9 months, and 12 months into the hormone treatment.
  • The baseline consisted of 2 sessions. All other testing periods involved only one session.
  • Following baseline, Ps, who were treated by the same endocrinologist, initiated hormone treatment (serum testosterone and estradiol.)
  • Ps enrolled in neither voice therapy or voice lessons during the intervention.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To measure the changes associated with the hormone therapy with transgender males.

 

POPULATION: Transgender Males; Adults

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch (level and range)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: voice quality

 

OTHER TARGETS: self- perception of effectiveness

 

DOSAGE: Ps were monitored every 2 weeks. All Ps started at 50 mg and the physician increased dose levels at needed based on clinical data and testosterone levels.

 

ADMINISTRATOR: endocrinologist

 

MAJOR COMPONENTS:

 

  • Under the direction of the same endocrinologist, all Ps were administered either testosterone enanthate or cypionate.

 

 

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