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Year : 2015  |  Volume : 21  |  Issue : 2  |  Page : 149-153

Efficacy of voice therapy in teachers: Using perceptual assessment protocol

1 Shabda Brahma Speech and Hearing Clinic, Ahmedabad, Gujarat, India
2 Department of ENT, M.P. Shah Government Medical College, Jamnagar, Gujarat, India
3 Department of ENT, Civil Hospital, B.J. Medical College, Ahmedabad, Gujarat, India

Date of Web Publication20-Apr-2015

Correspondence Address:
Rupali Mathur
Shabda Brahma Speech and Hearing Clinic, TF/3, Aakar Complex, Sardar Patel Stadium Road, Near Golden Triangle, Navrangpura, Ahmedabad, Gujarat - 380 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.155334

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Introduction: Teachers are professional voice users, and thus, they have more chances of having voice disorders. Risk factors due to occupation have been comprehensively examined; however, very little research has been done on the need of therapy and efficacy of voice therapy in teachers. Objectives: To assess the efficacy of voice therapy in teachers using qualitative assessment protocol and to recognize factors those are more sensitive to voice therapy. Methods: This study included two groups within the age range of 25-50 years. Group 1 included 10 participants having dysphonia who attended therapy and group 2 included five participants having dysphonia who could not attend therapy due to some reasons. Participants in both groups were teachers. Further, a perceptual assessment protocol was administered twice with the interval of 3 months. Results and Discussion: Voice therapy improved voice quality in group 1 who attended therapy compared to group 2. There was a significant difference seen in perceptual measures in group 1 pre- and post-therapy. Conclusion: Voice therapy lead to improvement in voice quality which is indicating that teachers should be sensitize for vocal hygiene and voice therapy, and further research is needed in this area.

Keywords: Phonation, Speech therapy, Voice therapy

How to cite this article:
Mathur R, Vishwakarma C, Sinha V, Vishwakarma R, Pandey A, Thakur P. Efficacy of voice therapy in teachers: Using perceptual assessment protocol. Indian J Otol 2015;21:149-53

How to cite this URL:
Mathur R, Vishwakarma C, Sinha V, Vishwakarma R, Pandey A, Thakur P. Efficacy of voice therapy in teachers: Using perceptual assessment protocol. Indian J Otol [serial online] 2015 [cited 2020 Sep 24];21:149-53. Available from: http://www.indianjotol.org/text.asp?2015/21/2/149/155334

  Introduction Top

Professionals who use their voice at work have more chances of having voice problems, which can directly affect their quality of life such as social, emotional and physical aspects of everyday situation. [1],[2] Teachers are found to be at increased risk for voice disorders. [3],[4],[5],[6] Many studies have focused on the teaching population and found that the prevalence of vocal dysfunction was more in teachers (ranging from 11% to 81.0%) compared with others (ranging from 1.0% to 36.1%). [4],[7],[8],[9],[10],[11] Higher occurrence of voice disorders in teachers could be due to their aggravated and long term voice use, speaking in a noisy environment and inefficient phonation techniques. Teachers are more susceptible to aphonia, edema, polyps, and nodules than nonvocal professionals.

In comparison to the extensive literature describing the vocal risk factors and consequences of these voice disorders, very few studies have investigated the treatment-seeking behavior of the teachers and voice therapy in teachers. Most of the voice disorders can be resolved by voice therapy. Voice therapy includes various strategies aimed at changing vocal behaviors in order to minimize or resolve the voice disorder. Evidence on the effectiveness of treatment program has become central nowadays. Many problems to adequately control the effectiveness of voice therapy are derived from the methodology used in assessment and diagnosis of the vocal disorder. Voice can be assessed in either objective or subjective manner. Traditionally, the voice has been measured subjectively through the clinical experience of the professional, making interinstitutional comparisons nearly impossible. However, relying on a single indicator is not recommended in voice problems, especially given contradictory results in the scientific literature about this parameter. However, there exist certain methodological problems in rigorously assessing effectiveness. Many studies lack reliability, validity, and sensitivity due to the research designs used or to inadequate indicators of therapeutic change.

In addition, there is a lack of research examining the effectiveness of voice therapy in teachers. [12] In Indian scenario, there are very few studies done to find the effectiveness of voice therapy in teachers.

Aims of the study

The purpose of this study was to find out

  • Effectiveness of voice therapy in teachers using a qualitative assessment protocol
  • Parameters, those are most sensitive to voice therapy.

  Methods Top


Fifteen professional voice users (9 male and 6 female), those are teachers having dysphonia within the age range of 25-50 years participated in the study.

  • Inclusion criteria: Any changes in voice or lesion at larynx
  • Exclusion criteria: Normal voice quality.


All the participants were first assessed using assessment protocol for baseline measurements, further they were called for voice therapy. Of the 15 participants, only 10 (6 male and 4 female) came for voice therapy while 5 (3 male and 2 female) could not attend voice therapy due to some reasons. After the termination of voice therapy, again posttherapy measurements were done to compare the performance. Further assessment of another group of participants was also done after 3 months who could not attend therapy.

Study design is explained in [Figure 1]:
Figure 1: Study design

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Following parameters were measured:

  • Case history: A detailed case history was taken including various parameters such as vocal well-being, self-voice assessment, muscular tension, vocal extension, vocal hygiene, anxiety and stress, amount of vocal use, and information about - family history risk, hormonal factors, oral contraceptives, smoking habit
  • Aerodynamic: It included - Maximum phonation time and s/z ratio
  • Perceptual: Using consensus auditory-perceptual evaluation of voice (CAPE-V). For perceptual assessment, first the speech was recorded using a digital tape recorder than this recorded speech was rated by 3 experienced speech language pathologists using CAPE-V. Speech sample included phonation of/a/,/i/,/u/,/s/,/z/, narration and reading.


Voice therapy basically consisted of five phases beginning with the recommendation for vocal hygiene and finished with generalization. The exercises used were commonly applied in clinical practice. Details of phases are as followed:

  • General information and counseling (vocal hygiene)
  • Relaxation
  • Breathing
  • Production and placement
  • Carry over.

Decision about termination of therapy will be taken based on following things:

  • Return of previous or normal voice
  • Improvement in quality of voice but not like before followed by no improvement noticed for continuous 3 weeks
  • No improvement noticed for continuous 3 weeks.

Statistical analysis

Appropriate statistical analysis using SPSS software was carried out. [13]

  Results Top

Case history

As per the case history, most of the participants in groups 1 and 2 had vocal nodule and vocal congestion, which are mainly due to vocal abuse and misuse, as teachers has to speak continuously and many times the shouts and speak loudly. Few of them had vocal fold paralysis and bowing of vocal folds. Details obtained from the both groups revealed following information in [Table 1] and [Table 2].
Table 1: Case history details of group A

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Table 2: Case history details of group B

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Aerodynamic measures

To represent aerodynamic measures, maximum phonation duration (MPD) and s/z ratio were obtained.

Maximum phonation duration

Maximum phonation duration values of group 1 participants are demonstrated in [Graph 1]. Further data were analyzed for group 1 participants, Mann-Whitney U-test was performed to compare the difference between pre- and post-therapy MPD. Results showed significant difference (U = 0, P < 0.05) between pre- and postvoice therapy. MPD had increased posttherapy, which is a good indicator.

Data of group 2 participants are demonstrated in [Graph 2]. MPD values of group 2 participants were compared for two conditions values using Mann-Whitney U-test. Result was not significant (U = 11.5, P < 0.05) between two conditions. MPD was almost same.

s/z ratio

Data obtained for group 1 participants are demonstrated in [Graph 3] further Mann-Whitney U-test was performed to compare the difference between pre- and post-therapy values of s/z ratio. Results showed significant difference (U = 0, P < 0.05) between two groups. The s/z ratio had reduced in almost all the participants and has come near value of 1, which shows good functioning of vocal folds.

Group 2 participants' s/z ratio details over a period is demonstrated in [Graph 4]. Mann-Whitney U-test was performed to compare the difference between pre- and posttherapy values of s/z ratio in group 2 participants. There was no significant difference (U = 12, P < 0.05) between two conditions. s/z ratio was almost similar in both conditions as they had not attended voice therapy.


It was done using CAPE-V, and overall severity is demonstrated in [Graph 5] and [Graph 6]. For group 1, averaged CAPE-V scores from the ratings of 3 SLPs were compared using Mann-Whitney U-test for pre- and postvoice therapy. Results demonstrated a significant difference (U = 0, P < 0.05).

Mann-Whitney U-test was performed for pre and post 3 months without therapy for averaged CAPE-V scores from the ratings of three SLPs which is demonstrated in Graph 4. Results were not significant (U = 11, P > 0.05). Overall voice quality severity was almost same in both conditions as they had not attended any intervention.

  Discussion Top

Present study evaluated the effectiveness of voice therapy in teachers with voice disorders. In initial interview and case history, most of the participants showed hyperfunctional dysphonia. It has been shown that this kind of functional dysphonia is most common among the patients whose jobs involve considerable vocal effort. [14.15] Vocal nodules were detected in 20%, and vocal congestion was seen in 53.3% of the total participants which are signs of trauma to vocal folds due to excessive use.

Many studies showed that vocal training can contribute to improved voice quality and voice endurance in people whose jobs involve considerable vocal load. [12],[16],[17],[18],[19] The present study also revealed similar results with the highest ratio of subjective improvement after the voice therapy. MPD refers to increase in respiratory and phonatory capacity which means less air leakage from vocal folds. Bassiouny [20] also demonstrated that the voice therapy leads to improvement in MPD. In the present study, there was a significant increment in MPD in participants who attended voice therapy. Similar findings have been also obtained by other studies. [12]

There was a reduction in overall severity of voice quality on CAPE-V scale which indicates that voice therapy has a positive impact. Similar results have been demonstrated by MacKenzie et al. [21] that is, voice therapy is effective in improving voice quality as assessed by self-rated and observer-rated methods. Results obtained in the present study are also in resonance with Simberg et al. [22] study, which showed pre- to post-treatment data of perceptual evaluation of voice and patient's self-reported vocal symptoms, indicate significant changes in the treatment group compared with the group who did not attend therapy.

  Conclusion Top

Results of the present study indicate that voice therapy has a positive impact on voice quality of teachers. It is needed that professional voice users that is, teachers should attend voice therapy and vocal hygiene to conserve their voice as they have to speak for longer duration. Voice therapy enhances their long good quality voice. Further, there is a need to conduct many awareness programs for teachers in schools to improve their vocal habits.

  References Top

Colton RH, Casper JK. Understanding Voice Problems: A Physiological Perspective for the Diagnosis and Treatment. Philadelphia: Lippincott Williams and Wilkins; 1996.  Back to cited text no. 1
Van Lierde KM, Claeys S, Dhaeseleer E, Deley S, Derde K, Herregods I, et al. The vocal quality in female student teachers during the 3 years of study. J Voice 2010;24:599-605.  Back to cited text no. 2
De Jong FI, Kooijman PG, Thomas G, Huinck WJ, Graamans K, Schutte HK. Epidemiology of voice problems in Dutch teachers. Folia Phoniatr Logop 2006;58:186-98.  Back to cited text no. 3
Fritzell B. Voice disorders and occupations. Logoped Phoniatr Vocol 1996;21:7-12.  Back to cited text no. 4
Sliwinska-Kowalska M, Niebudek-Bogusz E, Fiszer M, Los-Spychalska T, Kotylo P, Sznurowska-Przygocka B, et al. The prevalence and risk factors for occupational voice disorders in teachers. Folia Phoniatr Logop 2006;58:85-101.  Back to cited text no. 5
Smith E, Lemke J, Taylor M, Kirchner HL, Hoffman H. Frequency of voice problems among teachers and other occupations. J Voice 1998;12:480-8.  Back to cited text no. 6
Gotaas C, Starr CD. Vocal fatigue among teachers. Folia Phoniatr (Basel) 1993;45:120-9.  Back to cited text no. 7
Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res 2004;47:281-93.  Back to cited text no. 8
Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice 1998;12:467-79.  Back to cited text no. 9
Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of teachers' voice problems. J Voice 1997;11:81-7.  Back to cited text no. 10
Smith E, Kirchner HL, Taylor M, Hoffman H, Lemke JH. Voice problems among teachers: Differences by gender and teaching characteristics. J Voice 1998;12:328-34.  Back to cited text no. 11
Niebudek-Bogusz E, Sznurowska Przygocka B, Fiszer M, Kotylo P, Sinkiewicz A, Modrzewska M, et al. The effectiveness of voice therapy or teachers with dysphonia. Folia Phoniatr Logop 008;60:134-41.  Back to cited text no. 12
SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.   Back to cited text no. 13
Koufman JA. Evaluation of laryngeal biomechanics by fiberoptic laryngoscopy. In: Rubin JS, Sataloff RT, Korovin GS, editors. Diagnosis and Treatment of Voice Disorders. 2nd ed. New York: Thomson Delmar Learning; 2003. p. 171-82.  Back to cited text no. 14
Kooijman PG, de Jong FI, Oudes MJ, Huinck W, van Acht H, Graamans K. Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints. Folia Phoniatr Logop 2005;57:134-47.  Back to cited text no. 15
Cantarella G, Viglione S, Forti S, Pignataro L. Voice therapy for laryngeal hemiplegia: The role of timing of initiation of therapy. J Rehabil Med 2010;42:442-6.  Back to cited text no. 16
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Rattenbury HJ, Carding PN, Finn P. Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: A randomized controlled trial. J Voice 2004;18:522-33.  Back to cited text no. 19
Bassiouny S. Efficacy of the accent method of voice therapy. Folia Phoniatr Logop 1998;50:146-64.  Back to cited text no. 20
MacKenzie K, Millar A, Wilson JA, Sellars C, Deary IJ. Is voice therapy an effective treatment for dysphonia? A randomised controlled trial. BMJ 2001;323:658-61.  Back to cited text no. 21
Simberg S, Sala E, Tuomainen J, Sellman J, Rönnemaa AM. The effectiveness of group therapy for students with mild voice disorders: A controlled clinical trial. J Voice 2006;20:97-109.  Back to cited text no. 22


  [Figure 1]

  [Table 1], [Table 2]

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