The primary etiologic factor for vocal fold nodules has been proposed to be cumulative perpendicular impact stress between the vocal folds over time, which increases with voice use (Titze, 1994). Many people with vocal fold nodules work in high vocal demand occupations, therefore, it is essential that they recover vocal function so that their ability to perform their jobs is not compromised (Karkos & McCormick, 2009). A number of studies have reported positive improvements in vocal fold nodules following various types of behavioural voice therapy, and as such, voice therapy is recommended as a first-line treatment (Blood, 1994; Holmberg, Hillman, Hammarberg, Sodersten, & Doyle 2001; Holmberg et al, 2003; Hogikyan, Appel, Guinn, & Haxer, 1999; Hufnagle & Hufnagle, 1984; Lancer, Syder, Jones, & Le Boutillier, 1988; Lockhart, Paton, & Pearson, 1997; Murry & Woodson, 1992; Verdolini-Marston, Burke, Lessac, Glaze, & Caldwell, 1995).
The majority of the intervention studies for patients with vocal fold nodules have examined treatment outcomes following traditional voice therapy models, typically delivered once a week over a period of multiple weeks. To date, no studies have systematically examined the impact of using an intensive, massed practice therapy approach. In that the rehabilitation process for vocal fold nodules requires the learning, maintenance and transfer of new behaviours, it is possible that a more condensed voice therapy protocol may yield equal or even greater benefit. Therefore, the primary aim of this thesis was to explore the efficacy of intensive voice therapy (eight sessions within 3 weeks) as compared with traditional voice therapy (one session per week for 8 weeks). Both the short and long term effects of the different treatments on perceptual, acoustic, and physiological outcomes were examined.
Although it has been established that voice therapy is often effective, in many caseloads, rates of therapy completion are poor and this creates a challenge for clinicians (Portone-Maira, Wise, Johns, & Hapner, 2011). Traditional, face-to-face (FTF) voice therapy has shown dropout rates as high as 65% (Hapner, Portone-Maira, & Johns, 2009). Various factors contributing to non-attendance include travel time, inflexible work conditions, and inability to access due to physical barriers. Non-attendance not only affects treatment success, but also results in unnecessary extensions to treatment, and repeated examinations without sufficient behavioural change to effect improvement. Ultimately there may be a loss of revenue or even employment if patients are unable to meet the vocal requirements of their occupations (Portone, et al., 2008; Portone-Maira et al., 2011). Consequently, there is a need to explore ways to help maximise attendance and ultimately enhance outcomes for people with vocal fold nodules. To this end, the secondary aim of this thesis was to examine the feasibility and outcomes of delivering intensive voice therapy via telepractice, as an alternative service delivery model for patients with vocal fold nodules.
To address aim one, 53 female patients (56% professional voice users) with bilateral vocal fold nodules were recruited. Participants were matched in pairs according to their age, occupation, and severity of dysphonia and assigned to either of two treatment groups: traditional therapy of eight sessions delivered once a week for 8 weeks (n = 29) or intensive therapy of eight sessions delivered over 3 weeks (n = 24). All participants underwent physiological, acoustic and perceptual voice assessments pre-treatment, then again immediately post, and 6 months post therapy. Three investigations were reported from this initial study including: the perceptual, vocal fold functions and lesion outcomes following intensive voice treatment compared to traditional voice therapy (Chapter 2); the acoustic and physiological changes observed in cohorts treated via either traditional or intensive voice treatment (Chapter 3); and the long-term effects of intensive voice treatment compared with traditional voice therapy (Chapter 4). To explore the secondary aim, 10 participants with vocal fold nodules were recruited and completed intensive voice therapy via telepractice. Perceptual, physiological, acoustic and aerodynamic assessments of vocal function, as well as the Voice Handicap Index and a telepractice satisfaction questionnaire were completed both before and after treatment. This data is reported as Chapter 5.
Analysis revealed significant improvements in vocal fold condition, voice quality and acoustic parameters following FTF delivery of intensive voice therapy. Short- and long-term results were comparable to a traditional voice therapy model. For those who completed intensive therapy via telepractice, patient perceptions were positive and significant improvements were found in perceptual, physiological, acoustic and aerodynamic parameters as well as patient perceptions of vocal function post treatment. Overall, the present thesis provides evidence which supports the implementation of intensive voice therapy via both conventional FTF and telepractice service delivery modalities. The series of investigations in this thesis demonstrate compelling evidence that intensive voice therapy can facilitate behavioural change for long-term maintenance. The outcomes of the current thesis provide valuable information for speech-language pathologists regarding evidence-based treatment for individuals with vocal fold nodules.