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ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 4  |  Page : 242-245

Comparison of group therapy versus individual therapy for hyperfunctional voice disorders among teachers


Department of ENT, PGIMER, Chandigarh, India

Date of Web Publication15-Mar-2019

Correspondence Address:
Dr. Md Noorain Alam
Department of ENT, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_27_18

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  Abstract 


Introduction: In general, voice therapy is given on one-to-one basis where each individual is provided therapy by the clinician individually. On the other hand, in group therapy, the treatment is provided to a group of individuals with a similar disorder. Need of the Study: There was a need to conduct this study as there are very few studies on finding the efficacy of group therapy for hyperfunctional voice disorder among teachers especially in India. Aim: The primary aim of the study was to find out the efficacy of group voice therapy in hyperfunctional voice disorders among teachers. The secondary aim was to compare the outcome of group therapy and individual therapy in hyperfunctional voice disorder among teachers. Methodology: Totally 16 individuals in the age range between 25 and 45 years who were teachers by profession with hyperfunctional voice disorder were enrolled in the study. Two age and gender-matched groups were constituted. Group A consisted of eight (6 males and 2 females) individuals with a mean age of 35.6 years. Group B was comprised of eight (6 males and 2 females) with a mean age of 34 years. Group A was enrolled into group therapy while Group B was enrolled into individual voice therapy. The participants underwent a clinical voice evaluation including auditory-perceptual and quality of life assessment using Grade, Roughness, Breathiness, Asthenia, Strain scale, Dr. Speech software and Voice Handicap Inventory. Voice therapy protocol included 12 sessions once a week. It consisted of 15 min. of indirect and the rest 45 min. of Lessac-Madsen Resonant voice Therapy. Posttherapy measures were taken for both the groups. Results and Discussion: Results showed significant improvement post voice therapy in acoustic analysis measures, i.e. jitter and shimmer in both the groups. In perceptual measures, there was a significant improvement in Grade, Roughness, and Strain measures in both the groups while in quality of life measures there was significant improvement post-therapy in both the groups. When compared between groups A and B there was no significant difference in all the measures in both pre- and post-therapy assessments. Our study has recruited the control group and found there was no significant difference between the individual versus group voice therapy. Conclusion: Group voice therapy is as effective in the treatment of hyperfunctional voice disorders as individual therapy. There is a need to get data on a larger population to generalize the findings.

Keywords: Hyperfunctional voice, Grade, Roughness, Breathiness, Asthenia, Strain scale, group cohesion, resonant voice therapy


How to cite this article:
Alam MN, Munjal SK, Panda NK. Comparison of group therapy versus individual therapy for hyperfunctional voice disorders among teachers. Indian J Otol 2018;24:242-5

How to cite this URL:
Alam MN, Munjal SK, Panda NK. Comparison of group therapy versus individual therapy for hyperfunctional voice disorders among teachers. Indian J Otol [serial online] 2018 [cited 2019 Apr 23];24:242-5. Available from: http://www.indianjotol.org/text.asp?2018/24/4/242/254228




  Introduction Top


Hyperfunctional voice disorders are conditions of abuse and or misuse of the vocal mechanism due to excessive and or imbalanced muscular forces. This excessive muscular force may lead to vocal fold lesions such as nodules, contact ulcers, hemorrhages or polyps. Hyperfunctional voice disorders are more common in occupational voice users. When the prevalence of voice disorders are compared among different professions, it is more prevalent in teachers.[1] Among different professionals taking therapy for voice disorders from Speech Pathologists, teachers constitute about 16%–18%[2],[3] of this population. The prevalence of voice problems among teachers reported being between 20% and 75%.[2],[4] This high prevalence of voice disorders among teachers may be attributed to vocal abuse and misuse as well as poor acoustic environments of the classroom.

In general, voice therapy is given on one-to-one basis where each participant is provided therapy by the clinician individually. On the other hand, in group therapy, the treatment is provided to a group of individuals with a similar disorder. In a group therapy setting, group members may provide psychological support to each other. A discussion with other persons with the similar problem may alleviate the negative feelings. Group therapy is also a cost and time effective mode of treatment.

Need of the study

There was a need to conduct this study as there are very few studies on finding the efficacy of group therapy for hyperfunctional voice disorder among teachers especially in India.

Aim

The primary aim of the study was to find out the efficacy of group voice therapy in hyperfunctional voice disorders among teachers. The secondary aim was to compare the outcome of group therapy and individual therapy in hyperfunctional voice disorder among teachers.


  Methodology Top


Totally 16 participants in the age range between 25 and 45 years who were a teacher by profession with hyperfunctional voice disorder were enrolled in the study. Two age and gender-matched groups were constituted. Group A consisted of eight (6 males and 2 females) participants with a mean age of 35.6 years. Group B comprised of eight (6 males and 2 females) with a mean age of 34 years. All participants were nonsmokers. All participants underwent laryngeal examination by ENT specialist using videostroboscope and then by a speech-language pathologist using perceptual assessment.

The clinical voice evaluation included auditory-perceptual and quality of life assessment.

Perceptual assessment

Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale[5] was used. For each one, a value in the range 0–3 is considered, where 0 corresponds to healthy voice, 1 to light disease, 2 to moderate and 3 to severe. Despite some limitations, GRBAS is simple and fast and has a good correlation with some acoustic parameters.

Acoustic analysis

Dr. Speech software (Tiger Electronics, Neu-Anspach, Germany) was used to measure jitter and shimmer. Jitter is defined as the periodic variation from cycle to cycle and shimmer relates to the amplitude variation of the wave sound. The jitter is affected mainly by the lack of control of vibration of the vocal cords; the voices of patients with pathologies often have a higher percentage of jitter. The shimmer changes with the reduction of glottal resistance and mass lesions on the vocal cords and is correlated with the presence of noise emission and breathiness.

Quality of life assessment

It was carried out using Voice Handicap Index (VHI).[6] The VHI aims at the self-assessment of the severity of the vocal problems of patients with dysphonia. It consists of 30 questions with three subsections functional, physical, and emotional with ten questions each. The response has a 5 point Likert's scale where 0 denotes “never” and 4 denotes “always”. Total score varies from 0 to 120. Scoring is associated to level of disability or restriction associated with the voice.

Group A was enrolled in group voice therapy while the Group B was enrolled in individual voice therapy.

Group voice therapy

A voice therapy protocol consisting of 12 sessions, one per week, lasting 60 minutes was used. Therapy sessions consisted of both indirect and direct voice therapy. First 15 min were dedicated to indirect therapy consisting of vocal hygiene and relaxation exercises. Direct therapy was given in rest 45 mins. in the form of Lessac-Madsen Resonant voice Therapy (LMVRT).[7],[8] LMRVT uses perceptual measures to guide patient target behavior, which is a resonant voice. The resonant voice is characterized by vibratory sensations along the anterior alveolar ridge and a feeling of phonatory “ease.” If a patient is producing a resonant voice quality, he/she can feel the easy production as well as forward vibrations. After the vibration sensation is felt by the patient, therapy is targeted to produce simple phonemes and later conversational speech with correct resonance. Finally, the resonant voice is used to produce louder phonation and to produce voice according to patient's lifestyle.

During the voice therapy sessions, the purpose of each exercise was explained to the participants and the exercises were repeated during every session to ensure that the participants did them correctly and felt comfortable doing them. They were asked to perform the resonant voice therapy exercises practiced in the group therapy sessions at home two times each day for about 5-10 min per exercise session throughout the whole voice therapy period.

Individual voice therapy was similar to the group voice therapy. The only difference was that it was given on one-to-one basis.

After completion of 12 sessions all the tests, i.e., Videostroboscopic examination, Dr. Speech, GRBAS, and VHI scale were readministered on both the groups.


  Results Top


Videostroboscopic examination

Pre and post-therapy findings of videostroboscopic examination are summarized in [Table 1].
Table 1: Pre- and post-therapy findings of videostroboscopic examination

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Acoustic analysis by Dr. Speech

Mainly jitter and shimmer measurements were taken. As shown in [Table 2], in the pre-therapy measurement in the Group A, mean value of jitter was 0.655 (0.237) which decreased to 0.198 (0.16) in the posttherapy measure. In Group B, the value of jitter was 0.675 (0.211) in the pretherapy evaluation, while it was reduced to 0.180 (0.15) in the posttherapy measure. Similarly, the pretherapy measure of shimmer showed a value of 3.83 (0.678) and 3.71 (.887), respectively, which reduced to 2.53 (0.364) and 2.38 (0.394), respectively, on the posttherapy measure. When value of pre- and post-therapy of jitter and shimmer were compared on t-test there was a significant decrease of both jitter and shimmer in both the groups (P < 0.05). This showed significant improvement in acoustic parameters of voice in both the groups post therapy.
Table 2: Pre- and post-therapy findings of Acoustic analysis on Dr. Speech in Group A and Group B

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To find out the difference between groups A and B Mann-Whitney U test was applied. There was no significant difference between pre- and post-therapy measures in both A and B groups (P > 0.05).

Perceptual analysis by Grade, Roughness, Breathiness, Asthenia, Strain scale

In [Table 3], in Group A, the pretherapy mean measures showed values 2.125 (0.354), 1.875 (0.641), 2.125 (0.535), 1.875 (0.463), and 1.625 (0.744) while posttherapy measures were 0.5 (0.534), 0.5 (0.535), 0.5 (0.463), and 0.625 (0.744), respectively. While in Group B, the pre-therapy mean measures of GRBAS showed values 2 (0), 1.75 (0.463), 2 (0.517), 1.75 (0.518), and 1.875 (0.835) while posttherapy measures were 0.5 (0.535), 0.375 (0.517), 0.5 (0.354), 0.375 (0.353), and 0.5 (0.535), respectively.
Table 3: Pre- and post-therapy findings of Grade, Roughness, Breathiness, Asthenia, Strain Scale in Group A and Group B

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When t-test was administered, it was found out that posttherapy there was a significant reduction in Grade (G), Roughness (R) and Strained (S) parameters measures in both the groups (P < 0.05). This shows significant improvement in grade, roughness, and strained measures in voice in both the groups post therapy.

To find out the difference between A and B groups test of Mann–Whitney test was applied. There was no significant difference between pre-therapy and post-therapy measures in both A and B groups (P > 0.05).

Quality of life analysis on Voice Handicap Index scale

Total score on VHI was measured and pre- and post-therapy measures were taken. As shown in [Table 4], in Group A, the pretherapy mean total score was 59.125 (8.44) while posttherapy, it was 32.375 (7.79). In Group B, the mean total score was 60.875 (7.79) which reduced to 29.125 (4.29) in post-therapy measure. The decrease in total score was significant (P < 0.05) in both A and B group on t-test. This shows significant improvement in quality of life associated with voice in both the groups posttherapy.
Table 4: Pre- and post-therapy findings of Voice Handicap Index in Group A and Group B

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To find out the difference between A and B Group test of Mann–Whitney test was applied. There was no significant difference between pre- and posttherapy measures in both A and B groups (P > 0.05).


  Discussion Top


In the present study, we compared the two forms of voice therapy, i.e. individual voice therapy and group voice therapy in teachers with a hyperfunctional voice disorder. Two age and gender-matched group each consisting of eight participants were taken. Group A (6 male and 2 female) was enrolled in group therapy while group B (age and gender-matched to group A) was enrolled in individual voice therapy. The pretherapy evaluation consisted of acoustic measures (jitter and shimmer on Dr. Speech software), perceptual measures (GRBAS scale), and quality of life measures (VHI scale). Therapy protocol consisted of one hourly session of 12 weeks. Therapy was both direct and indirect. Initial 15 minutes was devoted to indirect therapy and rest 45 min was dedicated for LMVRT.

Results showed that post-voice therapy all measures improved significantly in both A and B groups. When compared between Groups A and B, there was no significant difference in all the measures in both pre- and post-therapy assessments. Thus, we found both group therapy and individual therapy are equally beneficial for the hyperfunctional voice disorder.

In a study by Law et al., 2012,[9] a group voice therapy using LMRVT therapy technique in teachers with hyperfucntional voice disorder showed to have positive results 6 months postvoice therapy. However, there was no control group to compare with individual voice therapy. Our study has recruited the control group and found there was no significant difference between the two groups.

Group therapy brings emotional and social benefits for the patient. It enables experienced dialogue and sharing situations which lead to an exchange of experiences that helps overcoming difficulties. Group therapy improves self-confidence and independence to minimize difficulties.[10] The subject becomes active in its group rehabilitation process.


  Conclusion Top


Group voice therapy is as effective in the treatment of hyperfunctional voice disorders as individual therapy. There is a need to get data on a larger population to generalize the findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Williams N, Carding P. Occupational Voice Loss. Boca Raton: Taylor and Francis Group; 2005.  Back to cited text no. 1
    
2.
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. 2
    
3.
Yiu EM, Ho PS. Voice problems in Hong Kong: A preliminary report. Aust J Hum Commun Disord 1991;19:45-58.  Back to cited text no. 3
    
4.
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. 4
    
5.
Hirano M. Clinical Examination of Voice. Wien, New York: Springer; 1981.  Back to cited text no. 5
    
6.
Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Genninger MS. The voice handicap index: Development and validation. Am J Speech Lang Pathol 1997;6:66-70.  Back to cited text no. 6
    
7.
Verdolini K. Case study: Resonant voice therapy. In: Stemple J, editor. Voice Therapy: Clinical Studies. 2nd ed. San Diego, CA: Singular Publishing Group, Inc.; 2000. p. 46-62.  Back to cited text no. 7
    
8.
Verdolini K. Lessac-Madsen Resonant Voice Therapy: Clinician Manual. San Diego, CA: Plural Publishing, Inc.; 2008.  Back to cited text no. 8
    
9.
Law T, Lee KY, Ho FN, Vlantis AC, van Hasselt AC, Tong MC, et al. The effectiveness of group voice therapy: A group climate perspective. J Voice 2012;26:e41-8.  Back to cited text no. 9
    
10.
Souza AP, Crestani AH, Vieira CR, Machado FC, Pereira LL. Speech and Language Therapy and the Group: Clinical and collective health sources. Rev CEFAC 2011;13:140-51.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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