The Effects of Respiratory Training on Voice

Study Overview
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Brief Summary
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Primary muscle tension dysphonia is a voice disorder that involves excessive and poorly coordinated muscle activity affecting multiple subsystems that are involved in speech production, in the absence of structural or neurologic abnormalities of the larynx. Primary muscle tension dysphonia (MTD) is one of the most common forms of voice disorders, accounting for at least 40% of patients seen in voice clinics. Perceptually the voice sounds hoarse and strained, with reduced loudness and pitch range, and people with MTD find speaking very effortful and fatiguing. The physiological abnormalities that characterize MTD are considered multifactorial, and include over-activity of muscles in and around the larynx, laryngeal constriction patterns, and abnormal speech breathing patterns. However, standard treatment approaches for MTD primarily address laryngeal function, including repositioning of laryngeal structures, reducing activity in the intrinsic and extrinsic laryngeal muscles, and altering vibratory patterns. Although voice improvement may follow these treatments, many people with MTD show recurrence of voice problems after only a few months, and some do not improve with treatment. These findings highlight the need for alternative treatments that address the respiratory contributions to MTD, which directly affect the phonatory system. The goal of this project is to compare the effects of two respiratory-based training conditions in people with MTD. A randomized group design will be implemented to determine the respiratory and acoustic effects of each condition. We will determine the effects of each condition immediately after and then 3 and 6 months after training completion to assess short- and long-term training effects. We propose that respiratory training will have a positive effect on related laryngeal behavior and voice. The proposed project has the potential to substantially advance the evidence-based treatment options for MTD, providing a vital step toward reducing the debilitating effects of this disorder.

Official Title
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The Effects of Respiratory-Based Treatment for Muscle Tension Dysphonia: A Randomized Controlled Trial

Conditions
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Muscle Tension Dysphonia

Intervention / Treatment
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* Behavioral: Breathing training without a device
* Behavioral: Breathing training with a device


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Ages 18 or older Self-report of general good health other than voice disorder Self-report of normal pulmonary function Non-smoker status for at least the last 5 years English as their primary language to avoid potential linguistically-based differences in acoustic measures of voice Adequate visual acuity (with or without corrective lenses) to read basic graphs and print, as determined with visual screening No evidence of current organic or neurologic laryngeal pathology, as assessed by nasolaryngoscopy examination and reviewed by a laryngologist No prior surgery to the vocal folds Do not report difficulty with swallowing Not currently receiving voice therapy or other voice treatment that cannot be discontinued Do not report a bilateral, severe to profound hearing loss Willingness to be recorded for data collection that is necessary for this study Have a confirming diagnosis of Muscle Tension Dysphonia from an otolaryngologist and speech-language pathologist Demonstrate quantified auditory-perceptual dysphonia and acoustic dysphonia (Cepstral/Spectral Index of Dysphonia) that exceed normative values for the participant's age and sex Based on the nasolaryngoscopy examination and assessment performed by the otolaryngologist, show one or more patterns of supraglottic activity that are consistent with adducted vocal fold hyperfunction Show no evidence of abnormal, incomplete vocal fold closure patterns as determined on the videostroboscopy assessment (patterns of posterior glottal gaps are normal and expected) Show no evidence of additional neurological voice disorders such as spasmodic dysphonia or vocal fold paralysis Show elevated hyolaryngeal position that exceeds normative expectations as determined through quantitative analysis of ultrasonographic laryngeal images measuring change from rest to phonation Demonstrate voice problems that have persisted for ≥2 months Demonstrate self-reported increase in speaking effort Show evidence of speech breathing abnormalities relative to accepted normative values Exclusion Criteria: Ages 17 or younger Self-report of major health problems Self-report of pulmonary disease such as asthma, chronic obstructive pulmonary disease, or emphysema Current smoker status or prior smoker status within the last 5 years English not the primary language Inadequate visual acuity (with corrective lenses if applicable) to read basic graphs and print as determined by failing a visual screening Evidence of current organic or neurologic laryngeal pathology, as assessed by nasolaryngoscopy examination and reviewed by a laryngologist Prior surgery to the vocal folds Currently receiving voice therapy or other voice treatment that cannot be discontinued Self-report of a bilateral, severe to profound hearing loss Not willing to be recorded for data collection that is necessary for this study No confirming diagnosis of Muscle Tension Dysphonia from an otolaryngologist and speech-language pathologist Do not demonstrate quantified auditory-perceptual dysphonia and acoustic dysphonia (Cepstral/Spectral Index of Dysphonia) that exceed normative values for the participant's age and sex Based on the nasolaryngoscopy examination and assessment performed by the otolaryngologist, do not show one or more patterns of supraglottic activity that are consistent with adducted vocal fold hyperfunction Show evidence of abnormal, incomplete vocal fold closure patterns as determined on the videostroboscopy assessment (patterns of posterior glottal gaps are normal and expected) Show evidence of additional neurological voice disorders such as spasmodic dysphonia or vocal fold paralysis Do not show elevated hyolaryngeal position that exceeds normative expectations as determined through quantitative analysis of ultrasonographic laryngeal images measuring change from rest to phonation Demonstrate voice problems that have persisted for less than 2 months Do not demonstrate self-reported increase in speaking effort Do not show evidence of speech breathing abnormalities relative to accepted normative values

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Participants will be randomly assigned to one of two conditions
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Breathing training with a device<br>Respiratory intervention delivered once a week for 6 weeks, after two initial baseline testing sessions. Participants will perform exhalation exercises through a breathing device. Homework activities will be assigned. Post-training testing sessions will also be conducted. | Behavioral: Breathing training with a device<br>* Breathing training with a mouth device<br>|
| Active Comparator: Breathing training without a device<br>Respiratory intervention delivered once a week for 6 weeks, after two initial baseline testing sessions. Participants will receive training on the use of breathing techniques without a device, but with visual feedback throughout training. Homework activities will be assigned. Post-training testing sessions will also be conducted. | Behavioral: Breathing training without a device<br>* Breathing training without a mouth device<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Lung Volume Initiation | Average level of lung volume at which speech breaths are initiated, expressed in percent vital capacity relative to resting expiratory level. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 
| Change in Lung Volume Termination | Average level of lung volume at which speech breaths are terminated, expressed in percent vital capacity relative to resting expiratory level. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 
| Change in Lung Volume Excursion | Average level of lung volume at which speech breaths are terminated, expressed in percent vital capacity. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 
| Change in Cepstral Peak Prominence | Average energy in first cepstral peak relative to overall cepstral energy, measured in cepstral decibels | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 
| Change in Cepstral/Spectral Index of Dysphonia | Average multivariate measure of spectral and cepstral voice features that reflects the amount of acoustic voice disorder severity. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Auditory-Perceptual Overall Severity of Voice Disorder | Listener-rated assessment of overall voice disorder severity on a 0-100 millimeter visual analog scale. The minimum value is 0 and the maximum value is 100 on this scale. Higher scores mean greater voice disorder severity. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 
| Change in Voice Handicap Index-10 | Participant self-ratings of the impact and disability of the voice disorder. The Voice Handicap Index-10 is a rating scale questionnaire with 10 questions, each scored on a scale of 0 (Never happens) to 4 (Always happens). Higher scores mean greater handicap and disability from the voice disorder. | Assessed during initial baseline testing and approximately 7 weeks later directly after training completion. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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voice disorder, treatment, respiratory, muscle tension dysphonia, training, voice