Standard Deviation Of Fundamental Frequency Research Articles

Acoustic characteristics of voice in examinees with moderately-severe hearing loss

<p>Introduction.Voice is the result of vocal cord vibrations and resonance effects of the vocal tract, therefore, the instrumental monitoring of the vibrations themselves is one of the essential aspects of objective instrumental assessment of voice. Inadequate height and volume, as well as increased nasality, represent the basic characteristics of voice in hearing-impaired persons. The aim of the study was to perform a detailed analysis of the acoustic structure of vowel /a/ in the hearing-impaired persons and in those with normal hearing and voice. Methods. The sample comprised 40 participants, aged 17 to 20 years (18.50 ±1.13), both sexes (50% males), divided into two groups. The first group consisted of 20 participants with moderately-severe hearing loss (56-70 dB), while the second group included 20 normal-hearing participants. Members of both groups were equal to each other in sex and age (± 3 months). The research was conducted in secondary schools, the Faculty of Medicine in Foča, as well as in Special School with a Student's Dormitory "Bubanj" in Niš during May 2018. Results. A statistically significant difference between hearing-impaired and normal-hearing speakers was found in 11 out of 14 tested acoustic parameters of vowel /a/: Standard Deviation of Fundamental Frequency (STD), Absolute Jitter (Jitta), Percentage of Jitter (Jitt), Relative Average Perturbation (RAP), Fundamental Frequency Variation (vFo), Shimmer (Shdb), Percentage of Shimmer (Shim), Amplitude Perturbation Quotient (APQ), Noise-to-Harmonic Ratio (NHR), Soft Phonation Index (SPI) and Frequency Tremor Intensity Index (FTRI) whereby the hearing-impaired participants showed higher values of the above-mentioned parameters. Conclusion: The obtained results show pathological changes in the voice of hearing-impaired persons, as well as the need for voice rehabilitation.</p>

Vocal Fold Vibration in Older Adults With and Without Age-Related Dysphonia

The purpose of this study was to identify the extent to which 7 measures of glottal area timing and regularity differ between older adults with and without age-related dysphonia (ARD). Laryngeal high-speed videoendoscopy was completed at 4,000 frames per second for 42 adults aged 70 years and older (ARD: 9 female, 5 male; control group: 15 female, 13 male). Relative glottal gap, open quotient, speed index, maximum area declination rate, harmonics-to-noise ratio, harmonic richness factor, and standard deviation of fundamental frequency were measured from a 0.5-s segment of the glottal area waveform. Eta squared (η2) was computed to estimate group effect. Small effect sizes (η2 = .18-.35) were present for relative glottal gap, open quotient, maximum area declination rate, harmonic richness factor, and standard deviation of fundamental frequency. Speed index and glottal harmonics-to-noise ratio did not explain group membership (η2 = .001 and .05, respectively). These findings provide evidence that vocal fold vibration in ARD is different than in normal aging, whereas the overlap in values for every measure is consistent with the concept that normal aging and ARD exist as a continuum of health and disease.

Acoustic analysis of Parkinsonian speech in the early stage after subthalamic nucleus deep brain stimulation

Objective To investigate the early efficacy of deep brain stimulation (DBS) of subthalamic nucleus (STN) in the treatment of dysarthria in patients with Parkinson's disease (PD). Methods From May 2017 to November 2017, 10 PD patients treated with STN-DBS at Neurosurgery Department affiliated to Nanjing Medical University and 10 healthy volunteers (healthy control group) were recruited retrospectively. Ten PD patients without anti-Parkinson disease medication were recorded in a relatively quiet room at the states of 1 month after operation with stimulation-off, 1 month after operation with stimulation-on, and 3 months after stimulation-on. The speech signal was analyzed by Praat software and 3 fundamental frequency parameters were extracted which were the mean fundamental frequency, the range and standard deviation of fundamental frequency. The speech signals from the healthy control subjects were collected and analyzed at the same time. Results The speech fundamental frequency range (PD group: 15.5±4.8 St, control group: 22.5±5.6 St, t=-2.962, P=0. 008) and the standard deviation of fundamental frequency (PD group: 2.4±0.7 St, control group: 3.7±0.8 St, t=-4.017, P=0. 001) in PD group with stimulation-off 1 month post operation were significantly lower than those in healthy control group. There was no significant difference in any parameter of fundamental frequency of the PD patients between the state of 1 month after stimulation-on and the state of 1 month after operation (all P > 0.05). At 3 months after stimulation-on, the fundamental frequency range (19.23.8 St, P=0.017) and the fundamental frequency standard deviation (3.20.8 St, P=0.001) of the speech were significantly higher than those at 1 month after operation with stimulation-off, and those was not significant statistical different compared with controls (all P > 0.05). Conclusion Early stage of STN-DBS treatment could improve the phonological tone of PD patients and relieve the stiffness of laryngeal muscles and vocal cord. Key words: Parkinson disease; Dysarthria; Deep brain stimulation; Subthalamic nucleus; Acoustic analysis

Acoustic and Perceptual Analyses of Adductor Spasmodic Dysphonia in Mandarin-speaking Chinese

The objective of this study was to examine the perceptual structure and acoustic characteristics of speech of patients with adductor spasmodic dysphonia (ADSD) in Mandarin. Case-Control Study MATERIALS AND METHODS: For the estimation of dysphonia level, perceptual and acoustic analysis were used for patients with ADSD (N = 20) and the control group (N = 20) that are Mandarin-Chinese speakers. For both subgroups, a sustained vowel and connected speech samples were obtained. The difference of perceptual and acoustic parameters between the two subgroups was assessed and analyzed. For acoustic assessment, the percentage of phonatory breaks (PBs) of connected reading and the percentage of aperiodic segments and frequency shifts (FS) of vowel and reading in patients with ADSD were significantly worse than controls, the mean harmonics-to-noise ratio and the fundamental frequency standard deviation of vowel as well. For perceptual evaluation, the rating of speech and vowel in patients with ADSD are significantly higher than controls. The percentage of aberrant acoustic events (PB, frequency shift, and aperiodic segment) and the fundamental frequency standard deviation and mean harmonics-to-noise ratio were significantly correlated with the perceptual rating in the vowel and reading productions. The perceptual and acoustic parameters of connected vowel and reading in patients with ADSD are worse than those in normal controls, and could validly and reliably estimate dysphonia of ADSD in Mandarin-speaking Chinese.

The Acoustic Characteristics of the Voice in Cochlear-Implanted Children: A Longitudinal Study

The purpose of this study was to characterize changes in the voice and vowel articulation of prelingually deaf children after cochlear implantation. In this study, the patient group included 30 prelingually deaf children who underwent unilateral cochlear implantation at 4-6 years of age. The control group included normally hearing children of the same age. All deaf children had follow-ups before cochlear implantation and at 1, 3, 6, 12, and 24 months after implantation. The acoustic parameters, aerodynamic parameters, and vowel formants were measured in the patient group and compared with those of the control group. All acoustic parameters, aerodynamic parameters, and vowel formants differed significantly between normally hearing children and prelingually deaf children. For prelingually deaf children, all of the above parameters gradually decreased after cochlear implantation. Furthermore, the acoustic parameters Jitter and Shimmer were significantly reduced as early as 6 months, whereas the fundamental frequency, the standard deviation of fundamental frequency, estimated subglottal pressure, aF1, iF2, and uF2 were significantly altered 12 months after implantation. However, statistically significant differences in these parameters were not observed between 12 and 24 months after cochlear implantation. After cochlear implantation, prelingually deaf children established auditory feedback and improved voice control and vowel production.

A case study of vocal features associated with galvanic skin response to stressors in a clinical interaction

ObjectiveWe investigated vocal characteristics associated with physiologically determined stressful episodes by means of post-hoc acoustic analyses of speech recorded in a clinical setting. Our research addressed the understudied question of which vocal features may serve as cues naturally occurring stress and is the first to explore this issue in a pitch accent language. MethodsThe vocal profile of a single female patient interacting with a physician was analyzed with standard speech analysis software for acoustic indicators of stress-related arousal determined by galvanic skin response measurements. ResultsVocal jitter, representing an aspect of voice quality perceived as hoarseness, appeared to increase during and immediately after skin conductance response intervals. Skin conductance levels during the response intervals were negatively correlated with acoustic features used to approximate the perception of voice unsteadiness (slope and standard deviation of fundamental frequency). ConclusionAn acoustic analysis of vocal properties of speech uttered during independently detected skin conductance response intervals revealed individual patterns for some acoustic features linked to stress in earlier studies. Practice implicationsNon-invasive methods of arousal detection in physician-patient communication based on acoustic analyses of vocal profiles may, in combination with other analyses, help identify stressful events and thus improve the process of medical information gathering and decision-making.

Examining the cognitive demands of analogy instructions compared to explicit instructions

Purpose: In many learning domains, instructions are presented explicitly despite high cognitive demands associated with their processing. This study examined cognitive demands imposed on working memory by different types of instruction to speak with maximum pitch variation: visual analogy, verbal analogy and explicit verbal instruction.Method: Forty participants were asked to memorise a set of 16 visual and verbal stimuli while reading aloud a Cantonese paragraph with maximum pitch variation. Instructions about how to achieve maximum pitch variation were presented via visual analogy, verbal analogy, explicit rules or no instruction. Pitch variation was assessed off-line, using standard deviation of fundamental frequency. Immediately after reading, participants recalled as many stimuli as possible.Result: Analogy instructions resulted in significantly increased pitch variation compared to explicit instructions or no instructions. Explicit instructions resulted in poorest recall of stimuli. Visual analogy instructions resulted in significantly poorer recall of visual stimuli than verbal stimuli.Conclusion: The findings suggest that non-propositional instructions presented via analogy may be less cognitively demanding than instructions that are presented explicitly. Processing analogy instructions that are presented as a visual representation is likely to load primarily visuospatial components of working memory rather than phonological components. The findings are discussed with reference to speech therapy and human cognition.

Examining correlations between phonetic parameters: Implications for forensic speaker comparison

The research presented in this paper builds upon a previous pilot study (Gold and Hughes 2012). This paper explores the correlation structure of speech parameters from a sociolinguistically homogeneous set of male speakers of Southern Standard British English using a series of segmental, suprasegmental and linguistic parameters. Data was extracted from a subset of speakers from the Dynamic Variability in Speech (DyViS) database (Nolan et al., 2009) and consist of: midpoint F1, F2 & F3 values for /a ɔ u/, midpoint F1, F2 & F3 values hesitation markers UM and UH, dynamic F1, F2 & F3 values for PRICE /aɪ/, long-term formant distributions (LTFD) F1-F4, mean and standard deviation of fundamental frequency (F0), mean articulation rate (AR), voice onset time (VOT) for word-initial /t/ and /k/, and click rate (ingressive velaric stops). The results of the study present a complex correlation structure between linguistic-phonetic variables, and not all correlations are predicted by phonetic theory. The results of the correlations are discussed in relation to implications that exist when combining parameters for forensic speaker comparison casework; specifically, the caution that needs to be yielded by experts in casework to avoid over- or under-estimating the strength of evidence.

Acoustic analysis of voice in children with cochlear implants

Introduction. The focus of this study was the analysis of objective acoustic characteristics of voice in children with cochlear implants. The objective of this study was to compare acoustic parameters of voice in children with cochlear implants and normal hearing children of the same age, and to determine differences, if there were any. Material and Methods. There were 60 children (aged from 6 to 13) included in this prospective study. They were divided into 2 groups: children with cochlear implants (30) and normal hearing children with normal speech development (30). The most stable voice sample was analyzed using a software program Dr Speech: Vocal Assessment. Objective acoustic analysis of voice included 13 acoustic parameters. Results. Standard deviation of fundamental frequency was significantly (p=0.000) higher in children with cochlear implants, as well as the values of harmonic to noise ratio (p=0.003) and signal to noise ratio (p=0.000) parameters. Values of jitter %, shimmer %, normalized noise energy, fundamental frequency tremor and amplitude tremor showed no significant differences between the two groups. However, the values of parameters that refer to voice frequency (habitual fundamental frequency, mean fundamental frequency, min fundamental frequency and max fundamental frequency) and the mean value of voice intensity (p=0.004), were significantly higher in the boys and the girls with cochlear implants than in the normal hearing children. Conclusion. Gender non-related parameters of hoarseness did not show significant differences between the children with cochlear implants and the normal hearing children; the results of cochlear implantation and voice and speech education were therefore positive. However, the children with cochlear implants of both gender showed significantly higher values of voice intensity, voice pitch and insufficient control of voice pitch variation.

Vocal Characteristics during Child Development: Perceptual-Auditory and Acoustic Data

Objective: To analyze perceptual-auditory and acoustic characteristics of children's voices of different age ranges. Patients and Methods: Ninety-three 3- to 10-year-old children grouped from 3 to 5, 6 to 7, and 8 to 10 years served as participants. The severity of vocal deviation and the parameters of roughness, breathiness, strain, and instability were assessed using a visual analog scale. We calculated the mean and standard deviation of fundamental frequency (F₀), jitter, shimmer, and glottal-to-noise excitation ratio for the sustained vowel, and the mean of F₀ variability for connected speech. Results: The most affected voices were in the age range 8-10 years, and only the phonation tension level was reduced as a result of aging. There were significant differences between children aged 3-5 years and the other age ranges for F₀ mean for sustained vowels and F₀ variability. Conclusion: Children aged 8-10 years had the highest severity of vocal deviation. There was a significant reduction of phonation tension and measure of F₀, jitter, and shimmer after the age of 5 years.

Analogy Instruction and Speech Performance Under Psychological Stress

To examine the efficacy of explicit and implicit forms of instruction for speech motor performance under conditions of psychological stress. In experiment 1, 20 participants were asked to deliver a formal presentation to validate the modified Trier Social Stress Test (TSST). In experiment 2, 40 participants were instructed explicitly by verbal explanation or implicitly by analogy to speak with minimum pitch variation and were subjected to psychological stress using the modified TSST. Acoustic correlates of pitch height (mean fundamental frequency) and pitch variation (standard deviation of fundamental frequency) significantly increased in experiment 1 when participants delivered a speech under modified TSST condition. In experiment 2, explicitly instructed participants were unable to maintain minimum pitch variation under psychological pressure caused by the modified TSST, whereas analogy-instructed participants maintained minimal pitch variation. The findings are consistent with existing evidence that analogy instructions may result in characteristics of implicit motor learning, such as greater stability of performance under pressure. Analogy instructions may therefore benefit speech motor performance and might provide a useful clinical tool for treatment of speech-disordered populations.

The use of analogy in speech motor performance

The acoustic correlates of pitch variation were examined in 40 participants who received analogy instructions or explicit instructions that required them to modulate their intonation during speech production. First, using focus group methodology, professional speech-language pathologists were asked to identify analogies that best described minimum pitch variation (monotone), moderate pitch variation (normal intonation), and maximum pitch variation (exaggerated intonation) in speech. The focus group established that an appropriate pitch variation metaphor may be related to imagery of “waves at sea”, with minimum pitch variation represented by a flat calm sea, moderate pitch variation represented by a moderate sea, and maximum pitch variation represented by a choppy sea. Forty adult participants without speech impairments were asked to read aloud a standard paragraph using their habitual pitch variation (control condition). They were then allocated randomly to an analogy or an explicit instruction group and were asked to read aloud different paragraphs with minimum, moderate, or maximum pitch variations. Results revealed that acoustic correlates of pitch variation (standard deviation of fundamental frequency, SDF0) were not different for the control condition, or moderate and maximum pitch variation conditions in the two groups. However, the analogy instruction was significantly more effective than the explicit instruction for inducing minimum pitch variation. Analysis of participants in each group who showed higher than normal pitch variation in the control condition (>.5 SD above the group SDF0) revealed that the analogy instruction was more effective than the explicit instruction in the minimum variation condition. It was concluded that analogy instructions may be a useful tool in speech rehabilitation.

Voice Quality After Treatment of Early Glottic Carcinoma

Increasing incidence of laryngeal carcinoma and advancement in diagnostics and therapy methods, have led to constant exploration in that field. Early glottic carcinoma can be treated successfully with several procedures: cordectomy through laryngofissure, laser cordectomy, and radiotherapy. Our objective was to assess the voice quality after these different modalities of treatment. Prospective controlled study with 69 patients, treated in a 1-year period for glottic Tis and T1a carcinoma at the tertiary medical centre. Nineteen of our patients were treated endoscopically with CO(2) laser (types III-IV cordectomy according to recommended European Laryngological Society classification of endoscopic cordectomies). Thirty-five patients underwent cordectomy through laryngofissure, 15 patients had radiotherapy. Multidimensional computer analysis of voice and speech was conducted 1, 6, and 12 months after the treatment. Three programs included 14 parameters, which were observed. While comparing the parameters between the groups, there were significant differences in the values of fundamental frequency (Hz), jitter (%), normalized noise energy (dB), standard deviation of fundamental frequency (Hz), percent silent time (%), and sound-pressure level in the different follow-up periods (P<0.05). In the long run, patients treated with radiotherapy show better voice quality in comparison with other two groups.

Vocal therapy with larynx compression after partial laryngectomy

The aim of the study was to establish the effects of the vocal therapy by manual compression of the larynx on dysphonia due to a partial laryngectomy and compare them with the effects of the standard vocal therapy. The prospective study included 66 patients submitted to any partial laryngectomy type. The patients were randomly classified into two groups: Group I (33) receiving the standard vocal therapy, and Group II (33) submitted to larynx compression vocal therapy. The 6-week vocal treatment was performed. The treatment effects were evaluated by subjective and objective voice analysis methods. The subjective and objective acoustic voice analysis revealed a significant influence (p < 0.05) of either of the two vocal therapy modes on initial dysphonia. The larynx compression vocal therapy had better effects on the acoustic parameters: habitual fundamental frequency, mean fundamental frequency, standard deviation of fundamental frequency, maximal fundamental frequency, harmonics-to-noise ratio, and signal-to-noise ratio.

Intonation and Speech Rate in Parkinson's Disease: General and Dynamic Aspects and Responsiveness to Levodopa Admission

The aim of our study was the analysis of fundamental frequency (F(0)) variability (fundamental frequency standard deviation [F(0)SD]) and net speech rate (NSR) in the course of reading in Parkinsonian patients' speech, with special emphasis on the changes of F(0)SD and NSR from the first to the last sentence of the task. We examined 138 patients with Parkinson's disease (PD) and 50 age-matched control persons using a standardized reading task with subsequent acoustical analysis of F(0)SD and NSR. A subgroup of 20 PD patients underwent a standardized levodopa challenge. F(0)SD in PD patients was significantly reduced compared with the control group when based on the measurement of the entire reading task. Furthermore, in the PD group, NSR and F(0)SD showed significant changes from the first to the last sentence of the reading task, but no correlation was seen between NSR and F(0)SD. Standardized levodopa administration had no effect on NSR and F(0)SD when related to the entire reading passage, but the aforementioned decline of F(0) variability in the course of reading seemed to be counterbalanced by levodopa administration. In this large series of PD patients, previous findings of reduced F(0)SD in PD were confirmed. Additionally, this is the first analysis to show an increasing reduction of F(0) variability in the course of reading mirroring abnormalities in the dynamical aspects of speech in PD. According to the results of the levodopa challenge, dopaminergic stimulation seems to ameliorate dynamic intonation changes over time, whereas overall intonation variability might be a PD symptom independent of dopaminergic control.

A Comparison of Two Approaches to the Treatment of Chronic Cough: Perceptual, Acoustic, and Electroglottographic Outcomes

Voice problems have been reported to occur in association with chronic cough (CC) and can interfere with quality of life. Voice symptoms can improve following behavioral intervention for CC that persists despite medical management; however, formal measures of voice changes have not been reported. The aim of this study was to measure the changes in perceptual, acoustic, and electroglottographic voice characteristics after a SPEech Pathology Intervention Program for CHronic Cough (SPEICH-C) compared to a Healthy Lifestyle Education intervention program (HLE control). Eighty-two participants with CC that was refractory to medical management were randomly allocated to receive either the SPEICH-C or an HLE control. Participants in the SPEICH-C group demonstrated a significant reduction in perceptual ratings of breathy, rough, strain, and glottal fry qualities (P<0.001) in comparison to the HLE control group. There was a significant improvement between pre- and postintervention maximum phonation time, jitter, and harmonic-to-noise ratio values in the SPEICH-C group; however, the magnitude of change was not significantly different between groups. There was no significant change in fundamental frequency, standard deviation of fundamental frequency, phonation range, or closed phase of vocal fold vibration after intervention for either group. These results demonstrated that SPEICH-C can improve perceptual aspects of voice quality suggesting that dysphonia may be a fundamental characteristic of CC.

Artificial Neural Network-based Classification to Screen for Dysphonia Using Psychoacoustic Scaling of Acoustic Voice Features

For diagnosis and classification of dysphonia, voice specialists can choose from an array of diagnostic tools like perceptual tests or acoustic voice analysis. These methods have in common that they require a high level of specialized training and experience, and therefore are mostly reserved to specialized centers. We aimed at developing an acoustic voice analysis system that could be used as a screening device to monitor, document, and diagnose voice problems that are also encountered by non-voice specialists, such as anesthesiologists, head and neck surgeons, and general surgeons before surgery of the thyroid gland and the upper thoracic aperture. An acoustical feature extraction paradigm that focused on jitter, shimmer, standard deviation of fundamental frequency, and the glottal-to-noise excitation ratio was used to reanalyse 120 voice samples previously analyzed by Schönweiler et al (A Novel Approach to Acoustical Voice Analysis Using Artificial Neural Networks. JARO. 2000:1;270-282). An improved artificial neural network (ANN) was used for classification. Building on this preliminary work, we modified the mathematical algorithm to further improve classification accuracy. Eighty percent of all voice samples could be classified correctly as either healthy or hoarse (sensitivity: 63.0%; specificity: 93.9%; area under the curve: 0.854). The adaptation of the ANN-voice analysis system for mobile use may facilitate its use and acceptance by non-voice specialists for the discovery and documentation of preexisting voice disorders, and may thereby lead to a timely initiation of further diagnosis and therapy by voice specialists.

Acoustic-perceptual correlates of voice quality in elderly men and women

Common perceptual characteristics of the elderly voice include hoarseness, breathiness, instability, and a change in the pitch of the voice. Although research is available concerning changes in the elderly voice, little research has been completed to examine the relationship between the perception of voice quality and acoustic measures. The purpose of this study was to examine the relationship between perceived breathiness and hoarseness and selected acoustic variables. The results of the study revealed significant age-related differences in fundamental frequency standard deviation, amplitude perturbation quotient, and noise-to-harmonic ratio. No significant difference in perceived hoarseness was found between the young and elderly speakers. However, the young women were perceived as significantly more breathy than the elderly women. Moderate correlations were found between the perceptions of hoarseness and breathiness and the acoustic measures. These findings are discussed relative to age-related laryngeal changes that may contribute to the perception of aging. Learning outcomes (1) To understand the perceptual attributes of the aging voice in men and women. (2) To understand the relation between the perception of voice quality and acoustic measures of voice production in the aging voice.

Acoustic Signal Typing for Evaluation of Voice Quality in Tracheoesophageal Speech

Because of the aperiodicity of many tracheoesophageal voices, acoustic analysis of the tracheoesophageal voice is less straightforward than that of the normal voice. This study presents the development and testing of an acoustic signal typing system based on visual inspection of a narrow-band spectrogram that can be used by researchers for classification of voice quality in tracheoesophageal speech. In addition to this classification system, a selection of acoustic measures [median fundamental frequency, standard deviation of fundamental frequency, jitter, percentage of voiced (%Voiced), harmonics-to-noise ratio (HNR), glottal-to-noise excitation (GNE) ratio, and band energy difference (BED)] was computed to provide more insight into the acoustic components of tracheoesophageal voice quality. For clinical relevance, relationships between the acoustic signal types and an overall judgment of the voice were investigated as well. Results showed that the four acoustic signal types form a good basis for performing more acoustic analyses and give a good impression of the overall quality of the voice.

The Relationship Between VHI Scores and Specific Acoustic Measures of Mildly Disordered Voice Production

This study was designed to examine the relationship between the Voice Handicap Index (VHI) and acoustic measures of voice samples common in clinical practice. Fifty participants, 38 women and 12 men, ranging in age from 19 to 80 years, with a mean age of 49 years, served as participants. Of these 50 participants, 17 participants could be included in the acoustic analysis of voice based on measures of error calculated with the TF32 software. All participants completed the VHI and provided voice samples including three trials of the sustained vowel /A/ at a comfortable loudness level as well as a connected speech sample consisting of the Zoo Passage. Acoustic measures were made with TF32 and Cool Edit software and included fundamental frequency, jitter %, shimmer %, signal-to-noise ratio, mean root-mean-square intensity, fundamental frequency standard deviation, aphonic periods, and breath groups. Results indicate that these measures were not predictive of overall VHI score, and no cohesive or predictable pattern was identified when comparing individual measures with overall VHI or with each subscale item. Likely contributions to this lack of correlation and subsequent clinical implications are discussed, as well as the direction for further research.