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SUMMARY Objectives To investigate the noninferiority of intensive voice therapy and compare its effects with weekly voice therapy on multidimensional outcomes of voice and well-being, satisfaction, and attendance in people with muscle tension dysphonia (MTD). The study further aimed to explore clinician's perceptions of barriers and enablers to implementation of intensive therapy. Study Design Noninferiority randomised controlled trial with nested focus group. Methods Twenty adults with MTD were randomised to receive either weekly voice therapy (1 hour per week for 8 weeks) or intensive voice therapy (1 hour, 4 days per week for 2 weeks). Participants were assessed by a blinded assessor twice before treatment, once post treatment and once at 4 weeks follow up on the primary outcome measure VHI and a range of secondary auditory-perceptual, acoustic, and patient (i.e., VoiSS, satisfaction) and clinician reported outcome measures (i.e., AusTOMs, attendance rates). Five Speech Language Pathologists also participated in a focus group to explore barriers and enablers to implementing intensive therapy, with questions and analyses guided by the Theoretical Domains Framework. Results While noninferiority for the primary outcome measure VHI was not confirmed, secondary outcome measures revealed comparable within group clinically important improvements for VoiSS and the AusTOMs, as well as selected acoustic and auditory-perceptual measures for both groups. A trend of more improvements being maintained in the intensive group was identified. Comparably high satisfaction and attendance was also found between groups. Clinicians reported more enablers than barriers to providing intensive therapy which included beliefs that it led to greater progression and consolidation of patient learning, was supported by the local context and was associated with positive emotions. Barriers related to difficulties with booking and scheduling and the belief that intensive therapy was not for all patients. Conclusions While the current study was likely underpowered to establish non-inferiority of intensive therapy, secondary outcomes suggested that intensive therapy may produce comparable benefits to voice, wellbeing, satisfaction and attendance compared to weekly therapy and may be a viable therapy option for individuals with MTD. When implementing intensive therapy, clinicians should consider patient's preferences and availability, as well as systems which allow for flexible booking and therapy provision for patients. Clear recommendations for future research including the use of a larger sample and telehealth are also provided.

Objective To examine the effect of traditional voice therapy and cognitive therapy on the voice and client-wellbeing outcomes in adults with functional voice disorders (FVD). Methods A systematic review of English articles was conducted using Medline (Ovid), Embase (Elsevier), CINAHL (Ebsco), The Cochrane Central Register of Controlled Trials (CENTRAL), PsychInfo (Ebsco) and Speechbite from inception to current date. Additional studies were identified through bibliographies and authors were contacted when further information was required from an article. All study designs were included with pretest/posttest outcome measures related to voice. Independent extraction of studies was completed by three authors using predefined data fields and quality assessment tools. Results Outcomes of 23 studies (2 RCTs and 21 cohort or case studies) are summarised using a narrative style due to heterogeneity of interventions and outcome scales used. Overall research quality of included studies was low, with many cohort and case studies lacking controls, blinding and robust outcome measures. Conclusions There are some benefits to pairing cognitive behavioural therapy (CBT) with traditional voice therapy for FVD including improved voice quality, psychosocial wellbeing and prevention of relapse. It is feasible to train speech-language pathologists (SLPs) in CBT-enhanced voice therapy. Further high-quality research is needed, however, to guide the clinical implementation of CBT for the management of FVD.

Aim To review the evidence for behavioural interventions to reduce drooling in children with neurodisability. Method A detailed search in eight databases sought studies that: (1) included participants aged 0 to 18 years with neurodisability and drooling; (2) provided behavioural interventions targeting drooling or a drooling-related behaviour; and (3) used experimental designs. Two reviewers extracted data from full-text papers independently. Results were tabulated for comparison. The Risk of Bias assessment in N-of-1 Trials scale for single case experimental designs (SCEDs) and the Cochrane risk of bias assessment tool for randomized controlled trials (RCTs) were applied. Results Of an initial yield of 763, seven SCEDs and one RCT were included. Behavioural interventions included the use of reinforcement, prompting, self-management, instruction, extinction, overcorrection, and fading. Each assessed body functions or structures' outcomes (drooling frequency and severity); three included activity outcomes (mouth drying, head control, eye contact, and vocalizations) and none assessed participation or quality of life. While each study reported positive effects of intervention, risk of bias was high. Interpretation Low-level evidence suggests behavioural interventions may be useful for treatment of drooling in children with neurodisability. Well-designed intervention studies are urgently needed to determine effectiveness. What this paper adds Behavioural interventions used to treat drooling included reinforcement, prompting, self-management, extinction, overcorrection, instruction, and fading. Interventions targeted body structures and function-level outcomes and activity-level outcomes. Low-level evidence supports the use of behavioural intervention to treat drooling.

Unilateral vocal fold paralysis (UVFP) typically results in marked changes in voice quality and performance and has a significant impact on quality of life. Treatment approaches generally aim to restore glottal closure for phonation and improve vocal function. There are a wide range of voice outcome measures that are available to measure the treatment effect. Careful selection of voice outcome measures is required to ensure that they are adequate for purpose and are psychometrically sound to detect the treatment effect. This article aims to critically evaluate the literature for voice outcome measures that are used for patients with UVFP.Systematic review.Nine databases were searched for UVFP treatment studies published since 2003 (n = 2,484 articles). These articles and their references were screened using inclusion/exclusion criteria, including population characteristics, treatment, voice outcomes, and study findings. Data from the included articles was extracted and appraised with respect to multidimensionality, timing, selection rationale, validity, reliability, and responsiveness to change of the voice outcome measures.A total of 29 studies met the inclusion criteria for the systematic review. These studies showed considerable variability in the rationale, selection, and application of voice outcome measures for reporting the treatment effect for patients with UVFP.There is currently a significant disparity in the selection and use of voice outcome measures for patients with UVFP. A set of principles around selection rationale, validity, reliability, and responsiveness to change is proposed to enhance the judicious selection of voice outcome measures for this patient group. Laryngoscope, 129:187-197, 2019.

Purpose of review Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options. Recent findings There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP. Summary Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP.

Summary: Objectives. Dysphonia due to unilateral vocal fold paralysis (UVFP) can be characterized by hoarseness and weakness, resulting in a significant impact on patients’ activity and participation. Voice therapy provided by a speech-language pathologist is designed to maximize vocal function and improve quality of life. The purpose of this paper is to systematically review literature surrounding the effectiveness of speech-language pathology intervention for the management of UVFP in adults. Study Design. This is a systematic review. Methods. Electronic databases were searched using a range of key terms including dysphonia, vocal fold paralysis, and speech-language pathology. Eligible articles were extracted and reviewed by the authors for risk of bias, methodology, treatment efficacy, and clinical outcomes. Results. Of the 3311 articles identified, 12 met the inclusion criteria: seven case series and five comparative studies. All 12 studies subjectively reported positive effects following the implementation of voice therapy for UVFP; however, the heterogeneity of participant characteristics, voice therapy, and voice outcome resulted in a low level of evidence. Conclusions. There is presently a lack of methodological rigor and clinical efficacy in the speech-language pathology management of dysphonia arising from UVFP in adults. Reasons for this reduced efficacy can be attributed to the following: (1) no standardized speech-language pathology intervention; (2) no consistency of assessment battery; (3) the variable etiology and clinical presentation of UVFP; and (4) inconsistent timing, frequency, and intensity of treatment. Further research is required to develop the evidence for the management of UVFP incorporating controlled treatment protocols and more rigorous clinical methodology. Key Words: Unilateral vocal fold paralysis–Voice therapy–Speech pathology.

Evaluating the evidence of treatment efficacy allows clinicians to select the delivery of the intervention that is most likely to improve the patient outcomes for a given clinical condition. Collation and critical appraisal of this evidence highlights areas of strength but also areas of research weakness. This paper provides a collation and summary appraisal of the evidence of treatment efficacy for voice therapy for a number of voice disorders that are routinely treated by speech pathologists/therapists. Table 1 lists a hierarchy that is commonly used and is highly applicable to behavioural interventions (www.joannabriggs. edu.au). It is interesting to note that this hierarchy also includes level IV evidence which acknowledges opinion of respected authorities, clinical experience and reports of expert committees. Strictly speaking, this is not evidence at all. The summary of evidence in the following sections of this paper will refer to the hierarchical level detailed in Table 1. However, Robey1 argues that evaluation of treatment effectiveness must also be considered within a broader organising structure for conducting clinical-outcome research activities. His five-phase model (Table 2) describes a logically ordered sequence from initial ‘proof of concept’ via various stages of ‘treatment efficacy’ and then ‘treatment effectiveness’ through to complete adaptation into clinical practice. Treatment efficacy research (Phase 1–3) examines clinical outcomes in an environment that ‘minimizes all sources of extraneous or confounding variation’ and ‘indexes the maximum potential of a treatment protocol for bringing about change’ (pg 402). In contrast, treatment effectiveness research examines the benefit of an intervention ‘provided in a typical fashion by typical practitioners to typical patients in typical clinical settings’ (pg 402). Therefore, the ultimate goal is evidence of treatment effectiveness but effectiveness can only be tested when efficacy has been firmly established. However, as Pring2 highlights, these essential phases of building an evidence base can often be overlooked in the ‘rush’ to publish large group trials and make claims about clinical effectiveness. The five levels are summarised in Table 2. This paper addresses the literature and evidence base for speech/voice therapy intervention for five types of voice disorders which commonly utilise voice therapy intervention as a primary strategy. These are functional voice disorders, vocal nodules, organic voice disorders, unilateral vocal fold paralysis (UVFP) and Parkinson’s disease voice disorder. This evidence will be categorised according to Robey’s five-phase model. The study descriptions and levels consistent with the Joanna Briggs terminology listed in Table 1 will also be documented. Each section also includes a summary table of all recent relevant voice treatment efficacy published studies.

Summary Background Functional dysphonias are commonly associated with reduced treatment attendance leading to variable treatment outcomes. Preliminary research has proposed that intensive treatment may improve client adherence and outcomes; however, further research into the application of intensive models in functional dysphonia in comparison with standard intensity models is warranted. Aims The present study evaluated the impact of intensive and standard treatments on functional, well-being, and service outcome measures in clients with functional dysphonia. Methods Participants with a functional dysphonia were randomly allocated to one of two treatment groups: (1) intensive treatment (n = 7) or (2) standard treatment (n = 9). Participants completed the voice handicap index (VHI) and the Australian therapy outcome measures voice assessment (conducted by a blinded assessor) before and after treatment and 4 weeks after treatment. Satisfaction questionnaires were completed after treatment and data pertaining to attendance and duration of intervention were collected throughout treatment. In addition to a vocal hygiene education session, all participants received a total of 8 hours of treatment; intensive treatment consisted of four 1-hour treatment sessions per week over 2 weeks, whereas the standard group received one 1-hour treatment session per week over 8 weeks. Results High satisfaction and statistically significant improvements on the VHI ratings were found after treatment in the intensive group. Significantly greater attendance rates were found in the intensive group. Intensive treatment is a potentially viable service delivery option for functional dysphonia and warrants further larger scale investigation.