An Update on Voice Research in the United States There has been a boom in the amount of really great research pertaining to voice and voice disorders. The areas of research are diverse, which only strengthens our knowledge and helps us take better care of patients,” states Alison Behrman of New York University. Behrman’s sentiment is echoed by many ... Features
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Features  |   May 01, 2006
An Update on Voice Research in the United States
Author Notes
  • Ryan Branski, is assistant attending speech and swallowing scientist at Memorial Sloan-Kettering Cancer Center and assistant professor of speech-language pathology and otorhinolaryngology at Weill Medical College of Cornell University in New York. Contact him at branskir@mskcc.org.
    Ryan Branski, is assistant attending speech and swallowing scientist at Memorial Sloan-Kettering Cancer Center and assistant professor of speech-language pathology and otorhinolaryngology at Weill Medical College of Cornell University in New York. Contact him at branskir@mskcc.org.×
  • Mahalakshmi Sivasankar, is an assistant professor in the Department of Speech, Language and Hearing Sciences at Purdue University, where she directs the Laryngeal Research Laboratory. Contact her at msivasankar@purdue.edu.
    Mahalakshmi Sivasankar, is an assistant professor in the Department of Speech, Language and Hearing Sciences at Purdue University, where she directs the Laryngeal Research Laboratory. Contact her at msivasankar@purdue.edu.×
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Speech, Voice & Prosody / Features
Features   |   May 01, 2006
An Update on Voice Research in the United States
The ASHA Leader, May 2006, Vol. 11, 10-11. doi:10.1044/leader.FTR1.11062006.10
The ASHA Leader, May 2006, Vol. 11, 10-11. doi:10.1044/leader.FTR1.11062006.10
There has been a boom in the amount of really great research pertaining to voice and voice disorders. The areas of research are diverse, which only strengthens our knowledge and helps us take better care of patients,” states Alison Behrman of New York University. Behrman’s sentiment is echoed by many other scientists whom we asked to comment on recent developments in voice research in the United States.
This research renaissance can be attributed to a novel attitude among investigators to collaborate with experts in varied fields to increase our insight into laryngeal and voice science. Contemporary voice research in the U.S. is dynamic and incorporates techniques from engineering, chemistry, cellular and molecular biology, mathematics, neuroscience, and physics, to name just a few areas. Voice researchers are investigating everything from the genetic characteristics of vocal fold cells, to the role of collagen matrices as a means to replace injured vocal fold tissue, to the biological and mechanical properties of the tissue that facilitate vocal fold vibration.
This integration of various disciplines within the field of voice research has provided valuable insight into the nature of voice production as well as potential treatments for a myriad of voice disorders. For example, speech-language pathologists are currently engaged in a collaborative effort to determine the effectiveness of novel tissue engineering materials to reconstruct the vocal folds following injury and surgical manipulation. Work on mucosa harvested from the pig small intestine appears to hold promise as a tissue engineering tool for laryngeal reconstruction (Huber et al., 2003) although it is in the early stages of investigation.
Researchers are also investigating approaches to reduce the detrimental effects of vocal fold scarring associated with phonosurgery. For example, certain naturally occurring chemicals, called “growth factors,” have been shown to reduce scarring when applied to injured vocal folds in an animal model. Growth factor therapy may provide future benefit in improving post-surgical functional voice outcomes (Hirano et al, 2004).
Translational Research
The application of basic science to clinical practice or “translational research” is also receiving tremendous attention in areas ranging from laryngeal hydration to vocal fold gene expression. Improved understanding of the cellular mechanisms underlying water and ion transport in the vocal folds has led researchers to question the efficacy of traditional hydration treatments such as steam inhalations and glycerin-based lubricants. Results from a recent study reveal that osmotic agents that are nebulized into the airway are more beneficial to phonation than traditional approaches such as aerosolizing water or using commercially available over-the-counter lubricants (Roy et al, 2003).
Similarly, new knowledge about the stages, timeline, and the role of exercise in wound healing has led investigators to rethink traditional beliefs and recommendations about the importance of voice rest. Emerging evidence suggests that certain types of voice treatment exercises may be beneficial in the context of acute vocal fold injury. This finding contradicts the historic practice of prescribing a course of voice rest or limited voice use for patients with vocal fold inflammation or lesions (Verdolini et al, 2005).
Such research findings are significantly altering the face of clinical practice. “Advances made in the lab are having a direct influence on how speech-language pathologists take care of patients with voice disorders. Now more than ever, clinicians need to read journals and attend scientific meetings to stay up to date on the current state of patient care,” states Katherine Verdolini of the University of Pittsburgh.
CAPE-V
In addition to innovative research collaboration at individual institutions, Special Interest Division 3, Voice and Voice Disorders provides a forum for open communication among researchers and clinicians interested in voice production and voice disorders (see story on page 16). Furthermore, Division 3 has initiated several research endeavors including the development of a perceptual voice rating instrument, the Consensus Auditory Perceptual Evaluation of Voice, commonly referred to as the CAPE-V. This scale was developed during a consensus meeting of SLPs, voice scientists, and experts in other perceptual fields (e.g., vision and hearing), held in 2002 at the University of Pittsburgh.
The CAPE-V is now undergoing field validity testing in a multicenter trial also sponsored by Division 3. In the fall of 2005, Division 3 published the Classification Manual for Voice Disorders - I, a 284-page text that provides comprehensive descriptions of more than 130 pathological conditions affecting the larynx and voice production. The purpose of the text is to promote consistent nomenclature among voice clinicians and researchers who describe voice disorders. Proceeds are directed to Division 3 to fund future endeavors.
Finally, Division 3 affiliates may participate in an e-mail listserv, sid3voice, aimed at promoting discussion among health care professionals, scientists, and professional voice users. This forum is open to everyone and covers clinical and scientific issues relating to the normal and disordered human voice.
Presenters also disseminate and discuss scientific, research, and clinical findings at national conferences and meetings, exchanging information on topics ranging from basic and applied voice research to clinical treatment studies.
The “basic science” and “voice and resonance” sessions at the ASHA annual convention provide an opportunity for sharing research and clinical findings. Both the Voice Foundation’s Care of the Professional Voice and the University of California-San Francisco’s Voice Conference include presentations in basic and clinical voice research, in addition to offering hands-on clinical experience through break-out workshops.
The Annual Conference of the Pacific Speech and Voice Foundation has also re-emerged as a popular meeting, bringing together professionals with diverse interests in the human voice, while addressing a central theme. In 2005 the meeting focused on the production and perception of emotional expression in the human voice. This year the meeting will be held in Reno, NV, and will be dedicated to occupational voice disorders.
Clinical Voice
The strong and innovative gains in basic voice science are echoed by novel and productive activity in clinical voice investigation. Among other areas, clinicians and voice scientists are collaborating on projects aimed at identifying voice users who may be at risk for developing laryngeal pathology, with the ultimate goal of reducing the prevalence of voice disorders.
Voice scientists, clinicians, and engineers have produced a new, wearable instrument that measures the amount of an individual’s voice use. This novel device is aptly called the “voice dosimeter.” These data, collected from many speakers, may help to establish occupational norms for safe amounts of voice use, similar to safety limits for noise exposure (Popolo, Svec, & Titze, 2005).
Such a device would be especially relevant to professional voice users who frequently report symptoms of a voice problem. Among these individuals, teachers have been identified as having increased risk for voice disorders (Roy et al., 2004). A recent study found that the incidence of voice disorders was higher in teachers of vocal music, drama, and performing arts. Interestingly, the study also found that chemistry teachers were at increased risk for developing voice disorders, likely from exposure to chemicals and pollutants at the workplace (Thibeault et al., 2004).
Voice literature also reports clinical case studies, randomized clinical trials, and single subject and group experimental designs that assess the effectiveness and efficacy of various voice treatments in occupational voice users. In teachers, a clinical trial investigated the efficacy of three interventions for voice disorders. Voice amplification appeared to be the most effective means to alleviate vocal complaints; however, resonant therapy was also an effective treatment modality (Roy et al., 2003).
Integrative Research
As professionals, SLPs want current information about advances in behavioral therapy and laryngeal surgery as well as neurology, physiology, pharmacology, and medicine. Research that integrates the fields of neurophysiology and laryngology has resulted in new strategies to manage laryngeal neuromuscular disorders without significantly altering quality of life. Preliminary clinical trials are investigating whether an indwelling neurostimulator can sufficiently reanimate vocal fold movement in patients with bilateral vocal fold paralysis, as an alternative to existing management techniques that could impair phonation (Zealear et al., 2003).
In the area of pharmacology, researchers are focusing on the interaction of pharmacological agents and voice. For example, a recent study reported that dysphonia was a potential, although transient, side effect of epidural corticosteroid injections (Bhat et al., 2005). Commonly used medications such as antihistamines are often recommended to reduce nasal congestion and sensitivity to environmental allergens. However, possible side effects could include the thickening of airway secretions and airway dehydration, which could prove detrimental to voice production. As the medical complexity of caseloads for SLPs in hospitals and long-term care facilities increases, clinicians need to recognize and understand drug classes, side effects, and possible drug interactions.
Changes in patient demographics, increased patient awareness, and reimbursement in the current climate of health care are some additional issues that have prompted voice research studies in the United States.
A quest for objective clinical outcome data has contributed to the increased availability of instrumental voice measures for evaluation and treatment. Consequently, there is ongoing interest in studies that examine the validity and reliability of these objective voice measures. For example, a recent study proposed a novel means to potentially improve the capacity for real time voice analysis utilizing non-linear dynamical theory (Zhang et al., 2005).
Both the quality and amount of voice-related research conducted in the United States are growing as institutions develop research programs that add to our knowledge of voice science, laryngology, and clinical management. We encourage all speech-language pathologists to learn more about these exciting research reports and apply the findings to improve services for patients with voice disorders.
References
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May 2006
Volume 11, Issue 6