Voice therapy for dysphonia — still more art than science?

Abstract

ABSTRACT It is estimated that between 16,000–55,000 patients undergo voice therapy for dysphonia in speech and language therapy clinics annually in the UK. Although well‐founded in tradition, the remedial techniques have not been subject to scientific scrutiny. No evaluation of voice therapy efficacy can be possible until established practice has been defined. The aim of this study was, therefore, to assess prevailing treatment strategies for common causes of dysphonia. A questionnaire outlining five typical dysphonia case histories — vocal cord nodules, chronic laryngitis, glottic chink, functional dysphonia and Reinke's oedema — was circulated to 237 UK speech and language therapy managers for completion by the area voice specialist. Respondents were asked to select from 10 offered therapeutic strategies, and to indicate counselling and group therapy approaches. A working definition of consensus was agreed at the outset: >75% = acceptance; <25% = rejection. One hundred and sixty‐three completed responses (69%) were obtained from therapists with a median of 12 years' experience. Most use two to six treatment sessions (up to 30% favoured more than six sessions). Group therapy was rejected as sole management for each condition, but accepted in combination with individual therapy by 60% for vocal nodules. A minority approved its use in combination for Reinke's oedema, chronic laryngitis and glottic chink. Counselling was accepted for all conditions (76–89%). Non‐directive counselling was almost always the most popular option (used significantly more in glottic chink and Reinke's oedema than in chronic laryngitis p<0.0002 and functional dysophonia, p=0.02). A choice of 50 treatment strategies (10 for each of five conditions) was offered. Twelve (24%) were accepted by consensus and nine (18%) were rejected. The remaining 29 strategies fell into a grey area being nether accepted nor rejected. The survey had a high response rate by experienced therapists and is a valid representation of UK practice. Therapists are agreed on the duration of treatment, the inadvisability of group therapy as a sole strategy and of the importance of counselling. The principal conclusion of the study is, however, that the level of agreement in voice treatment strategies is low. Those items which were more general, such as voice hygiene, lifestyle application, relaxation and breath support, being the most widely agreed upon. Of the more ‘voice specific’ measures only one achieved consensus at the 75% level, i.e. reduction of hard glottic attack in vocal nodules. The variation in clinical practice among speech and language therapists reflects the lack of scientific basis for treatment selection. The results do, however, highlight the more commonly used strategies which should be given priority in the design of studies on the efficacy of voice therapy for dysphonia.