EFECTIVIDAD de La Terapia en Disfonias Funcionales

Interventions for treating functional dysphonia in adults
(Review)
Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 1
http://www.thecochranelibrary.com
Interventions for treating functional dysphonia in adults (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Analysis 1.1. Comparison 1 Any intervention vs. no intervention, Outcome 1 Primary (subjective) outcomes. . . . 22
Analysis 1.2. Comparison 1 Any intervention vs. no intervention, Outcome 2 Secondary (objective) outcomes. . . 23
Analysis 2.1. Comparison 2 Combined direct and indirect voice therapy vs. TFL-assisted treatment, Outcome 1 Vocal
Performance Questionnaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Interventions for treating functional dysphonia in adults (Review) i

[Intervention Review]
Jani H Ruotsalainen1 , Jaana Sellman2 , Laura Lehto3 , Merja Jauhiainen4 , Jos H Verbeek5
1 Cochrane Occupational Health Field, Finnish Institute of Occupational Health, Kuopio, Finland. 2 Department of Speech Sciences,
University of Helsinki, Helsinki, Finland. 3 Laboratory of Acoustics and Audio Signal Processing, Helsinki University of Technology,
HUT, Finland. 4 Knowledge Transfer Team, Finnish Institute of Occupational Health, Helsinki, Finland. 5 Finnish Institute of Occu-
pational Health, Center of Expertise for Good Practices and Competence, Team of Knowledge Transfer in Occupational Health and
Safety, Cochrane Occupational Health Field, Kuopio, Finland
Contact address: Jani H Ruotsalainen, Cochrane Occupational Health Field, Finnish Institute of Occupational Health, Neulaniementie
4, Kuopio, 70701, Finland. jani.ruotsalainen@ttl.fi.
Editorial group: Cochrane Ear, Nose and Throat Disorders Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 21 May 2007.
Citation: Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults.
Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD006373. DOI: 10.1002/14651858.CD006373.pub2.
ABSTRACT
Background
Poor voice quality due to functional dysphonia can lead to a reduced quality of life. In occupations where voice use is substantial it can
lead to a loss of employment.
Objectives
To evaluate the effectiveness of interventions to treat functional dysphonia in adults.
Search methods
We searched MEDLINE (PubMed, 1950 to 2006), EMBASE (1974 to 2006), CENTRAL (The Cochrane Library, Issue 2 2006),
CINAHL (1983 to 2006), PsychINFO (1967 to 2006), Science Citation Index (1986 to 2006) and the Occupational Health databases
OSH-ROM (to 2006). The date of the last search was 5th April 2006.
Selection criteria
Randomised controlled trials (RCTs) of interventions evaluating the effectiveness of treatments targeted at adults with functional
dysphonia. For work-directed interventions interrupted time series and prospective cohort studies were also eligible.
Data collection and analysis
Two authors independently extracted data and assessed trial quality. Meta-analysis was performed where appropriate.
Main results
We identified six randomised controlled trials including a total of 163 participants in intervention groups and 141 controls. One trial
was high quality. Interventions were grouped into 1) Direct voice therapy 2) Indirect voice therapy 3) Combination of direct and
indirect voice therapy and 4) Other treatments: pharmacological treatment and vocal hygiene instructions given by phoniatrist.
No studies were found evaluating direct voice therapy on its own. One study did not show indirect voice therapy on its own to be
effective when compared to no intervention. There is evidence from three studies for the effectiveness of a combination of direct and
Interventions for treating functional dysphonia in adults (Review) 1
indirect voice therapy on self-reported vocal functioning (SMD -1.07; 95% CI -1.94 to -0.19), on observer-rated vocal functioning
(WMD -13.00; 95% CI -17.92 to -8.08) and on instrumental assessment of vocal functioning (WMD -1.20; 95% CI -2.37 to -
0.03) when compared to no intervention. The results of one study also show that the remedial effect remains significant for at least
14 weeks on self-reported vocal functioning (SMD -0.51; 95% CI -0.87 to -0.14) and on observer-rated vocal functioning (Buffalo
Voice Profile) (WMD -0.80; 95% CI -1.14 to -0.46). There is also limited evidence from one study that the number of symptoms may
remain lower for a year. The combined therapy with biofeedback was not shown to be more effective than combined therapy alone in
one study nor was pharmacological treatment found to be more effective than vocal hygiene instructions given by phoniatrist in one
study. Publication bias may have influenced the results.
Authors’ conclusions
Evidence is available for the effectiveness of comprehensive voice therapy comprising both direct and indirect therapy elements. Effects
are similar in patients and in teachers and student teachers screened for voice problems. Larger and methodologically better studies are
needed with outcome measures that match treatment aims.
PLAIN LANGUAGE SUMMARY
Functional dysphonia is characterised by an abnormal quality of voice in the absence of an identifiable lesion. People in occupations
where voice use is central, like teachers, are more at risk of developing functional dysphonia. The causes of voice disorders are still
being debated. There is also no consensus on the best method of evaluating voice, although many consider auditory voice quality
assessment as a gold standard measure. Because functional dysphonia is a non-organic voice disorder there is no indication for surgical
or medical interventions, and it is treated with behavioural (i.e. voice) therapy. Voice therapy usually consists of a combination of direct
and indirect treatment techniques. Direct techniques focus on the underlying physiological changes needed to improve an individual’s
technique in using the vocal system whereas indirect techniques concentrate on contributory and maintenance aspects of the voice
disorder (such as lack of knowledge).
We conducted a systematic search of the literature on treating functional dysphonia in adults. We then appraised the quality of the
studies found and combined their results.
A combination of direct and indirect voice therapy is effective in improving vocal functioning when compared to no intervention. The
achieved results may still be apparent after a year.
Most of the studies are small and of low methodological quality and further research is warranted.
BACKGROUND
voice in the absence of an identifiable lesion. Some clinicians label
Voice disorders are generally characterised by abnormalities in them as idiopathic, indicating that there is no known cause, while
pitch, loudness and/or quality of the voice that can limit the effec- others view them as resulting from the individual’s improper use
tiveness of oral communication (Ramig 1998). Recent definitions of his or her voice (Titze 1994). The improper use of voice (also
of a disordered voice stress the ability of the voice to fulfil the known as vocal misuse) refers to functional voicing behaviours
speaker’s social and occupational requirements (Aronson 1985; (e.g. excessive shouting or loud talking) and/or functional misuse
Sataloff 2000; Stemple 1995). Due to the difficulties of classifying of vocal components (respiration, phonation, resonance, pitch,
voice disorders in a systematic way, there is no universally accepted loudness and rate) that can contribute to the development of la-
classification system for voice problems (Oates 2004). Tradition- ryngeal pathologies (Stemple 1995). When the classification into
ally, two major classes of voice disorder have been identified: or- functional versus organic emphasises the aetiology of the problem
ganic and functional (Fawcus 1986; Oates 2004; Titze 1994). (vocal strain or excessive muscular tension), minor tissue changes
Functional disorders are characterised by an abnormal quality of such as vocal-fold thickening and vocal nodules are often con-
sidered functional (Boone 1987) or behavioural (Fawcus 1986). or laryngeal performance are considered as secondary outcomes,
Therefore, in a strict sense dichotomous classification is undeni- along with measures of sickness absence and return to work.
ably problematic and overly simplistic. In this review we define
When it comes to the treatment of functional dysphonia, most ex-
functional dysphonia as an impaired voice sound and/or reduced
perts agree that surgical or medical interventions are not indicated
vocal capacity (Roy 2003; Seifert 2005) with a possible concomi-
(Carding 1999). Voice therapy is considered effective for the treat-
tant diagnosis of minor pathologies of vocal fold cover (nodules,
ment of voice disorders caused by vocal misuse (Stemple 1995).
polyps, oedema) that are direct results of either vocal misuse or
Colton 2006 states that: “In general, the goal of voice therapy is
result from trauma caused to vocal fold tissues by phonatory be-
to restore the best voice possible, a voice that will be functional for
haviour.
purposes of employment and general communication”. There are
The prevalence of voice disorders in the general adult popula- numerous different therapy techniques available for the treatment
tion has been suggested to be between 3% and 9% in the USA of patients with dysphonia (Carding 1999; Carding 2000). These
and at about 4% in Australia (Verdolini 2001). In the UK up to techniques fall into two main categories:
40,000 patients with dysphonia are referred to voice therapy every
1) Indirect treatment techniques that concentrate on psychosocial
year (Wilson 1995). Professional voice users such as teachers and
aspects such as patient education (Aronson 1985), auditory train-
singers are at significantly higher risk of developing a voice dis-
ing (Boone 1983; Fawcus 1986) and vocal hygiene programmes
order compared to the general population (Russell 1998; Smith
(Wilson 1987);
1997). It has been estimated that at least in developed countries,
a well functioning voice is an essential tool for a third of the en- 2) Direct treatment techniques that concentrate on mechanical
tire adult working population (Vilkman 2004). In Poland, occu- or physical aspects such as the yawn-sigh method (Boone 1993),
pational voice problems ranked highest among all occupational establishing optimal pitch (Boone 1983) and laryngeal manipula-
diseases in 2004 (Szeszenia-D. 2005). In a group of 1262 voice tion (Roy 1993).
patients, the prevalence of vocal pathologies that could be con-
Studies of the effectiveness of interventions for preventing the
sidered as functional dysphonia (no visible pathology) or as being
onset or relapse of a voice disorder have also been conducted,
direct results of traumatising phonatory behaviour (vocal nodules,
and since such measures are taken in the absence of a diag-
oedema, polyps) was 57.6% (Herrington-Hall 1988).
nosed voice disorder they have been dealt with in a separate re-
The voice is a multidimensional function that, like physical view (Ruotsalainen 2007). In this review we proposed to establish
strength, cannot be measured with any one single scale or test whether interventions aimed at treating adult patients diagnosed
(Hirano 1989; Hartl 2005). Measures of voice have therefore been with functional (non-organic) dysphonia are effective when com-
developed to cover widely different perspectives including, for ex- pared to no intervention or to alternative interventions.
ample: aerodynamic, visual and auditory perceptual, physiological
and acoustic measurements (Carding 2000). To increase compa-
rability of the results of individual studies, it has been suggested OBJECTIVES
that all studies of vocal treatment effectiveness should perform an
extensive battery of tests (Dejonckere 2001). On the other hand, 1) To assess the effectiveness of interventions for treating func-
in order to ensure that the results are clinically relevant it has been tional (non-organic) dysphonia compared to no intervention or
suggested that the outcome measures should be matched to treat- an alternative intervention.
ment goals and to efficacy criteria (Carding 2000). For some time
2) To categorise interventions aimed at treating patients diagnosed
now, the patient’s own views regarding judgements of the ben-
with functional (non-organic) dysphonia.
efits of treatment have been acknowledged as also being impor-
tant (Carding 2000; Enderby 1995). A number of patient self-re-
port questionnaires, such as the Voice Handicap Index (Jacobson
1999), the Voice-Related Quality of Life (Hogikyan 1999), the METHODS
Vocal Performance Questionnaire (Carding 1992) and the Voice
Activity and Participation Profile (Ma 2001) have been developed
to measure the subjective impact of voice problems. Criteria for considering studies for this review
In this review we chose self-reported measures of voice handicap,
voice symptoms and voice-related quality of life as primary indi-
cators of treatment effectiveness. This is because of the variation Types of studies
between individuals as to how a particular voice disturbance can All randomised controlled studies or cluster-randomised trials
be perceived to affect their communication or ability to fulfil so- evaluating the effectiveness of treatments targeted at individuals
cial and occupational requirements. All other measures of vocal with functional dysphonia. For environmental or work-related

treatment interventions, it is much more difficult to randomise 1) Direct voice therapy meaning that the therapy is applied directly
when the intervention is applied at the group level. For this type of to the voice production apparatus;
intervention we also considered for inclusion prospective cohort 2) Indirect voice therapy meaning therapy that is applied to other
studies (otherwise known as controlled clinical trials, controlled mental or bodily structures or functions that influence voice pro-
before-after studies or quasi-experimental studies). duction;
3) Combination of direct and indirect voice therapy;
4) Other treatments.
Types of participants We compared interventions with no intervention and, when pos-
sible, with alternative interventions.
We included studies in which the participants were adults (16 or
over) who had been diagnosed as having functional / non-organic
dysphonia, which means that they are experiencing one of the Types of outcome measures
following two symptoms:
1) an impaired voice sound;
2) reduced vocal capacity.
Primary outcomes
The voice changes throughout life. In childhood the morphology
of vocal fold tissues keeps changing and during puberty the larynx As primary outcomes we included patient-reported measures of
grows (Titze 1994). The three connective tissue layers of the lamina voice handicap, voice symptoms or voice-related quality of life.
propria, despite being apparent already during puberty, continue There are four validated instruments for these measurements that
to become more differentiated until the age of 16 or 17 (Colton can be used with functional dysphonia patients: Voice-Related
2006). In advanced age some age-related changes (e.g. ossification, Quality of Life (Hogikyan 1999), Voice Activity and Participation
atrophy, dystrophy and oedema) affect phonation (Jasper 2000). Profile (Ma 2001), Voice Symptom Scale (Deary 2003) and the
However, it is the physiological rather than the chronological age Voice Handicap Index (Jacobson 1999).
that has a strong impact on how well the larynx functions in phona-
tion (Titze 1994). In this study we consider patients older than 16
Secondary outcomes
years as adults. For practical reasons, we also included studies in
which a minority of participants (less than 50%) may have been As secondary outcomes we included all other measurement tech-
diagnosed with minor tissue changes of vocal fold cover (nodules, niques for establishing the state of vocal or laryngeal performance
polyps, oedema) that are regarded as a result of vocal misuse. including:
We excluded studies in which any of the participants had been 1. Instrumental measurements:
diagnosed as having any of the following: • Aerodynamic measurements
• a voice disorder associated with local nervous system • Acoustic/electroglottographic measurements (e.g.
involvement (e.g. spasmodic dysphonia, essential laryngeal phonetogram, perturbation measures)
tremor, vocal fold paralysis); • Laryngeal image analysis (e.g. stroboscopic rating)
• neurological disorders (e.g. Parkinson’s, Alzheimer’s, ALS, 2. Observer ratings:
Tourette’s, essential tremor, paralysis); • Perceptual acoustic analysis (e.g. GRBAS)
• organic disease or trauma (e.g. keratosis, contact ulcers,
papillomas, laryngeal granulomas and inhalation, thermal etc. 3. Combined measures:
traumas); • Multidimensional measure (e.g. Dysphonia Severity Index)
• the paediatric (e.g. with congenital anomalies) or the
We were also going to include studies measuring sickness absence
geriatric voice;
or return to work but no studies were found using these outcomes.
• carcinoma or other tumours;
• gastro-oesophageal reflux disease.
We also excluded studies in which participants had been diagnosed Search methods for identification of studies
with a hearing impairment which may affect auditory discrimina-
tion.
Electronic searches
We searched the literature for evaluation studies of interventions
Types of interventions for functional voice disorders without restrictions on language
We included studies with any intervention aiming to treat pa- or publication. Systematic search strategies were developed to-
tients diagnosed with functional (non-organic) dysphonia. We cat- gether with the Cochrane ENT Trials Search Co-ordinator and
egorised interventions as: the Cochrane Occupational Health Field Information Specialist.

We searched MEDLINE (PubMed, 1950 to March 2006), EM- it impossible for the patients to be unaware of whether or not they
BASE (embase.com, 1974 to March 2006), CENTRAL (The are receiving active treatment. We nonetheless assessed whether
Cochrane Library, Issue 2, 2006), CINAHL (OVID, 1983 to allocation was concealed for those assessing the outcome, when it
March 2006), PsychINFO (webSPIRS, 1967 to February 2006), came to secondary observer-rated outcomes. Two authors (JR and
Science Citation Index (ISI Web of Science, Thomson, 1986 to JS) independently assessed trial quality using the quality criteria
March 2006) and the Occupational Health databases OSH-ROM mentioned in the Cochrane Handbook for the Systematic Review
(webSPIRS, to February 2006). The search string for randomised of Interventions. This consisted of an appraisal of the studies in
controlled trials is based on Robinson 2002 and the string for terms of their randomisation, allocation concealment and blinding
non-randomised studies on Verbeek 2005. Since the opportuni- procedures as well as attrition suffered. See Table 1 for a listing
ties for naming and classifying voice disorders and their various of the judgements that we made in terms of these four criteria.
treatments are so abundant, the searches were developed with the Studies were rated as high quality if they were found adequate in
aim of maximum sensitivity at the expense of specificity. The date terms of all four quality criteria (or three in cases where blinding
of the last search was 5th April 2006. was not an issue). For the appraisal of cohort studies, we were
Search strategies for CENTRAL, MEDLINE and EMBASE are going to use a validated instrument (Slim 2003). No cohort studies
shown in Appendix 1, Appendix 2 and Appendix 3. were however included in this review. Disagreements were settled
through discussion.
Searching other resources

References from articles were also carefully reviewed. Authors of Measures of treatment effect
studies and other experts in the field were contacted for advice on
further studies. The results of each trial were plotted as means and standard devi-
ations (SD) for continuous outcomes. Standardised mean differ-
ences (SMD) were used for pooling outcome data from different
instruments deemed similar enough for comparison.
Data collection and analysis
Dealing with missing data

Selection of studies
After employing the search strategies outlined above, two authors Where necessary, we sought missing statistics data (means and
(JR and JS) undertook study selection. Both authors indepen- standard deviations) from authors. Since all studies had outcomes
dently assessed whether the studies thus found met the inclu- using continuous data, we were unable to conduct an intention-
sion criteria. A third author (LL) resolved any disagreements. We to-treat analysis. We could not utilise standard approaches such
sought to obtain further information from the authors when a as last observation carried forward or imputing baseline outcomes
paper was found to contain insufficient information for reaching since we did not have access to raw patient data. Therefore all
a decision on eligibility. results were based on available case analysis.
The authors intend to perform a new search for trials every two
years and to update the review accordingly.
Assessment of heterogeneity
We tested for statistical heterogeneity by means of the I2 in the
Data extraction and management
meta-analysis graphs. The I2 statistic describes the percentage of
Two authors (JR and JS) independently extracted data from each total variation across trials that is attributable to heterogeneity
of the included trials regarding the country where the study was rather than chance. I2 values of 25%, 50% and 75% correspond to
conducted, the type of study design used, characteristics of the low, moderate and high between-trial heterogeneity. When studies
study participants (as per study inclusion criteria) and types of were statistically heterogeneous, a random-effects model was used;
interventions and outcomes. Results data (means and standard otherwise a fixed-effect model was used. All estimates included a
deviations) were also extracted for the purpose of meta-analysis. 95% confidence interval (95% CI).
Where possible, we sought missing data from authors. A third
author (LL) resolved any disagreements.
Assessment of reporting biases

Assessment of risk of bias in included studies We were planning to assess publication bias by means of a funnel
For this review, it was clear that allocation concealment could not plot but the low number of included studies made it impossible
be an issue since the nature of treatments for voice disorders renders to make valid conclusions in this regard.

Data synthesis and the later one in English. We felt that there was no reason to
For interventions directed at individuals, we used only randomised favour the latter just because of language. We also found out from
controlled trials to draw conclusions. For work- or environment- the author himself that two studies (Carding 1992 and Carding
directed interventions that are applied at the group level we were 1999) actually used the same participants. We included the later
going to include also prospective cohort studies but none were one where more participants were added to the sample used in the
identified that met our inclusion criteria. previous study. Thus, our final sample consisted of six studies (see
The decision to pool quantitatively was based first on clinical ho- ’Characteristics of included studies’ table).
mogeneity. Clinically homogeneous studies were defined as those Additional information regarding study details and/or statistical
with similar populations, interventions and outcomes measured data was sought from six authors and was received from four. One
at the same follow-up point. We pooled studies with sufficient of the authors provided statistical data that had not been published
data, judged to be clinically homogeneous, with RevMan 4.2.5 in his article.
software. The scoring of a scale was reversed for the purposes of Study designs
pooling if a high score denoted a good outcome (e.g. Voice-Re- All six of the included studies were randomised controlled trials
lated Quality of Life) instead of more pronounced dysphonia. of person-directed interventions.
A rating system, based on the Levels of Evidence, was used to Country and time period
summarise the strength of scientific evidence of the effects of the All of the included studies were conducted in Europe: three in
treatment. The rating system is based on both the quality and the the United Kingdom, one in Ireland, one in Denmark and one in
outcome of the studies (van Tulder 2003): Finland. One of the included studies was conducted in 1999 and
I. Strong evidence - consistent evidence in multiple high quality five in 2001 or later.
randomised controlled trials Type of settings and participants
II. Moderate evidence - consistent findings in multiple low quality All of the interventions were carried out in clinical settings. In
randomised controlled trials and/or controlled clinical trials and/ four of the studies the participants were consecutive patients in a
or one high quality randomised controlled trial speech and language therapy clinic. In Gillivan-Murphy 2005 the
III. Limited evidence - one low quality randomised controlled trial participants were teachers with self-reported symptoms who were
or controlled clinical trial recruited and in Simberg 2006 they were student teachers who
IV. Conflicting evidence - inconsistent findings in multiple ran- were screened for inclusion.
domised controlled trials and/or controlled clinical trials Sample sizes
V. No evidence - no randomised controlled trials or controlled The total number of participants in the various intervention
clinical trials. groups was 163, and in the control groups 141. The number of
The outcome of the studies were considered ’consistent’ if at least participants in the smallest study groups was less than 20 in three
75% of the trials reported statistically significant results in the same studies, between 20 and 60 in two studies, and more than 60 in
direction. There were not enough studies to conduct a sensitivity one study (MacKenzie 2001). This one study was the only one
analysis to find out if quality level leads to changes. that had conducted a priori power calculations to ensure that ex-
perimental groups were large enough (i.e. there would be sufficient
statistical power) to detect significant differences.
Interventions
We found the following types of interventions:
RESULTS
1. Direct voice therapy
No studies were found that evaluated the effectiveness of direct
Description of studies therapy alone. Direct techniques focus on the underlying physi-
ological changes needed to improve an individual’s technique in
See: Characteristics of included studies; Characteristics of excluded
using the vocal system. Direct voice therapy usually consists of an
studies.
individually tailored combination of some of the following tech-
Study selection
niques: specific laryngeal relaxation, yawn-sigh method, chewing
From the initial set of 5937 references identified by the systematic
technique, altering tongue position, diaphragmatic breathing, co-
searches, a set of 48 potentially eligible studies were identified.
ordination of breathing with phonation, establishing and main-
These were then scrutinised further with regard to our inclusion
taining appropriate laryngeal tone, pitch variation and control, re-
and exclusion criteria. Altogether 40 studies were excluded (see
duction of vocal loudness, elimination of glottal attack, establish-
’Characteristics of excluded studies’ table) leaving a total of eight
ing optimal pitch, voice ’placing’, developing optimal resonance
studies. However, we noticed that two studies (Beranova 2003 and
and maintenance and generalisation of optimal phonatory con-
Pedersen 2004) actually reported results of the same study so we
trol.
excluded the one published later. The first was published in Czech

2. Indirect voice therapy group. Two studies (Beranova 2003 and Rattenbury 2004) com-
One study (Carding 1999) looked at indirect voice therapy alone. pared two active interventions with one another.
Indirect techniques concentrate on the contributory and mainte- Acceptability of treatment
nance aspects of the voice disorder (such as lack of knowledge). As to drop-outs prior to randomisation or participants declining
This usually consists of an individually tailored combination of participation we found information on this topic in three of the
some of the following: patient education, reassurance, general re- six included studies. In Rattenbury 2004 four out of 24 subjects
laxation, counselling, auditory training, elimination of abuse/mis- (17%) withdrew before randomisation. No information is given as
use, voice diary, vocal hygiene program, avoidance of irritants, en- to reasons why or about their personal characteristics. In Carding
vironmental awareness and voice conservation advice. 1999 one patient declined to enter the study and was subsequently
3. Combination of direct and indirect voice therapy treated outside of the project. In Beranova 2003 there is a discrep-
Five studies (Carding 1999; Gillivan-Murphy 2005; MacKenzie ancy in figures so that according to the text 18 patients were ran-
2001; Rattenbury 2004 and Simberg 2006) examined the effec- domised but in the table of patient characteristics there are only
tiveness of a combination of direct and indirect voice therapy. 16 patients in the two groups. It is impossible to say if two pa-
One study (Rattenbury 2004) looked at the added effect of patients were excluded or if it is a typing mistake. In general it seems
tient feedback using trans-nasal flexible laryngoscopy (TFL). TFL that participation in treatment trials appears to be acceptable for
is a tool that is widely used for diagnosis but can also be used to functional dysphonia patients. We do not think this has had an
give a patient direct feedback on how treatment is affecting the effect on our results in relation to external validity.
behaviour of his or her vocal cords. Follow up
4. Other treatments Four studies (Beranova 2003; Carding 1999; Gillivan-Murphy
One study (Beranova 2003) compared the effectiveness of phar- 2005 and Rattenbury 2004) conducted only before and immedi-
macological treatment with vocal hygiene instructions given by ately after intervention measurements. In fact, Carding 1999 ap-
phoniatrist. Pharmacological treatment consisted of treatment as parently had done measurements immediately after the interven-
deemed appropriate for allergy, infection, reflux or environmental tion but he only reported four-week follow-up scores and so these
irritants (e.g. dust or noise). were entered as immediately after intervention data. Two stud-
ies (MacKenzie 2001 and Simberg 2006) followed up the long-
Outcomes measured term effectiveness of the interventions employed. The length of
1. Primary outcomes: self-report measures follow up differed from 14 weeks (MacKenzie 2001) to one year
Three studies (Carding 1999; MacKenzie 2001 and Rattenbury (Simberg 2006) although in the latter case only information from
2004) used the Vocal Performance Questionnaire (Carding 1992). one symptom questionnaire was available instead of data from all
Two studies (Beranova 2003 and Gillivan-Murphy 2005) mea- the measurements.
sured Voice-Related Quality of Life (Hogikyan 1999). One study Excluded studies
(Gillivan-Murphy 2005) used the Voice Symptom Severity scale Reasons for excluding the 40 studies were the following (see table
(Deary 2003). One study used a questionnaire concerning the of ’Characteristics of excluded studies’):
prevalence of seven vocal symptoms (Simberg 2006). See Table 2 (a) No control group (Amir 2005; Andersson 1998; Birkent 2004;
for a description of the scales used, their minimum and maximum Broaddus-L. 2000; Fex 1994; Holbrook 1974; Jonsdottir 2001;
values and what they mean. Jonsdottir 2002; Kotby 1993; Laukkanen 2005; Lehto 2003;
2.1. Secondary outcomes: observer-rated measures Lehto 2005; McCabe 2002; Milbrath 2003; Motel 2003; Prosek
Two studies (Rattenbury 2004 and Simberg 2006) measured voice 1978; Roy 1993 and Roy 1997)
quality with the GRBAS scale (Hirano 1989) whilst Carding 1999 (b) Controlled study but no work-directed intervention (Andrews
used his own overall severity rating scale. One study (MacKenzie 1986; Garcia Real 2002; Mendoza-Lara 1990; Popovici 1993;
2001) used the Buffalo Voice Profile (Wilson 1987). Three studies Sliwinska-K. 2002; Zhao 2005)
(Beranova 2003; Carding 1999 and MacKenzie 2001) performed (c) No intervention (John 2005 and Sellars 2002)
laryngeal examinations. One study measured vocal fry and pitch (d) Majority of participants had been diagnosed with a clearly
(Simberg 2006). organic voice disorder (Bassiouny 1998; Yiu 2005 and Zhao 2005)
2.2. Secondary outcomes: instrumental measures (e) Participants were self-diagnosed and it is unclear if they had
Three studies (Carding 1999; MacKenzie 2001 and Rattenbury functional or organic voice disorders (Roy 2001; Roy 2002 and
2004) performed acoustic analyses. Two studies (Beranova 2003 Roy 2003)
and Carding 1999) measured fundamental frequency and/or in- (f ) Participants had no diagnosed voice problems (Bovo 2006;
tensity. Chan 1994; Duffy 2004; Timmermans 2004a; Timmermans
Type of control group 2004b and Timmermans 2005). These studies were considered for
Four studies (Carding 1999; Gillivan-Murphy 2005; MacKenzie inclusion in the prevention of voice disorders review (Ruotsalainen
2001 and Simberg 2006) employed a no intervention control 2007).

(g) Duplicate publication (Pedersen 2004) different in terms of either rate of attrition (30% in the therapy
(h) Article is part of an ongoing study with more participants group, 39% in the no treatment group) or characteristics of pa-
added later (Carding 1992). tients who dropped out (sociodemographic variables or baseline
voice or psychological variables)”. In the Simberg 2006 study there
was differential attrition from study groups. There were no drop-
Risk of bias in included studies outs from the treatment group and only one exclusion because of
the need for immediate medical treatment, whereas nine subjects
in the control group did not attend the second laryngeal examina-
Allocation tion (three months post onset) and four subjects did not return the
questionnaire one year post onset (altogether 39% of the initial
The method of randomisation was adequate in two studies sample). MacKenzie 2001 was the only study to have conducted
that employed computer generated random numbers (MacKenzie a priori power calculations to ensure that even with attrition there
2001 and Rattenbury 2004). In one study, allocation was by rota- would be adequate statistical power to detect significant differ-
tion which was considered inadequate (Carding 1999). In another ences.
study, after contacting the authors, it appeared that participants
had assigned themselves into groups by drawing lots from a hat
(Simberg 2006) which was also considered inadequate. We did
Effects of interventions
not get information on the randomisation procedure of the other
two studies which were therefore listed as unclear (see Table 1). All the results are baseline versus immediately after intervention
When it comes to the treatment of functional dysphonia the con- unless stated otherwise.
cealment of allocation into intervention and control groups is not 1. Direct voice therapy versus no intervention
an issue for participants as they cannot help but notice if they are No studies were found that evaluated the effectiveness of direct
receiving treatment or not. However, Rattenbury 2004 did not therapy separately.
report if the randomisation procedure was concealed from the re- 2. Indirect voice therapy versus no intervention
searchers. 2.1 Primary outcome: Self-report measures of vocal functioning
All studies reported some descriptive data comparing the study Carding 1999 did not find a difference in effectiveness between
groups after allocation thus portraying the acceptability of the ran- indirect voice therapy on its own and no intervention (mean dif-
domisation procedure. MacKenzie 2001 reported that the groups ference -0.38; 95% CI -0.94 to 0.18) when measured with the
were comparable for mean age, gender, laryngeal features and sub- Vocal Performance Questionnaire.
jective and objective voice variables. Simberg 2006 reported base- 3. Combination of direct and indirect voice therapy versus no
line comparability only for mean age, whilst the remaining four intervention
studies (Beranova 2003, Carding 1999, Gillivan-Murphy 2005 3.1 Primary outcome: Self-report measures of vocal functioning
and Rattenbury 2004) reported also that some of the following A combination of direct and indirect voice therapy is effective in
items were comparable at baseline: age range, male to female ratio, improving vocal functioning (SMD -1.07; 95% CI -1.94 to -0.19)
laryngeal diagnosis, average duration of problems, mean onset of when compared to no intervention and when measured with the
problems and years of teaching. Vocal Performance Questionnaire (VPQ) and the Voice-Related
Quality of Life scale (Carding 1999; Gillivan-Murphy 2005 and
MacKenzie 2001). When we transformed the effect size back to
Blinding a score on the VPQ this yielded a mean difference of -11.3. This
When the blinding of those assessing the outcome was an issue, i.e. covers 25% of the range of the VPQ scale. There was consider-
with secondary or observer-rated outcomes, the voice samples were able heterogeneity in this meta-analysis of direct and indirect in-
assessed in each case by an independent panel of judges that were terventions combined. Possible reasons for the heterogeneity are
unaware of treatment allocation and participant identity. Studies publication bias and differences in responsiveness to change of the
that used observer-rated outcomes (i.e. where blinding was an scales used and in methodological quality of studies. It cannot be
issue) were Carding 1999; MacKenzie 2001; Rattenbury 2004 and due to differences in sample (e.g. vocal loading) because Carding
Simberg 2006. 1999 used consecutive patients and Gillivan-Murphy 2005 used
volunteer teachers and their results were nonetheless quite similar.
The difference between MacKenzie 2001 and the other two stud-
Incomplete outcome data ies is probably due to higher methodological quality which has led
The loss of participants was low throughout, with only two of to more realistic results.
the studies (MacKenzie 2001; Simberg 2006) suffering a loss ex- 3.1.2 Long-term follow up of self-reported vocal functioning
ceeding 20% of the initial sample. MacKenzie 2001 states that: The results of MacKenzie 2001 show that the intervention group’s
“The voice therapy and no treatment groups were not significantly vocal performance remained better than the control group’s at 14

weeks’ follow up (SMD -0.51; 95% CI -0.87 to -0.14). According workers. There were two studies that screened teachers or teacher
to the results of Simberg 2006 the intervention group’s number of students for vocal problems (Gillivan-Murphy 2005 and Simberg
voice-related symptoms also remained lower for a year. 2006). The severity of problems in these studies was about 25%
3.2 Secondary outcome: Observer-rated measurement of vocal of the maximum attainable unfavourable score. This was slightly
quality lower than the patient studies (Carding 1999 and MacKenzie
Buffalo Voice Profile 2001) with 58% and 33% respectively. The outcomes were com-
A combination intervention has no initial effect on voice qual- parable between patient and teacher studies. Both teacher studies
ity (WMD -0.20; 95% CI -0.51 to 0.11) when compared to no had a positive outcome.
intervention and when measured with the Buffalo Voice Profile Publication bias
immediately following the intervention (MacKenzie 2001). How- We included studies that compared any intervention with no in-
ever, after 14 weeks of follow-up the same measurement becomes tervention control because we felt that these would yield similar
significant meaning that the voice quality of patients in the inter- results. The number of studies is too low for drawing any valid
vention group had improved (WMD -0.80; 95% CI -1.14 to - conclusions from a funnel plot.
0.46).
GRBAS - Grade
The results of Simberg 2006 show the combination of direct and
indirect voice therapy as being effective in improving vocal func- DISCUSSION
tioning (WMD -13.00; 95% CI -17.92 to -8.08) when compared
to no intervention and when measured with GRBAS overall Grade. The meta-analyses in this review show that there is moderate ev-
3.3 Secondary outcome: Instrumental measurement of vocal qual- idence for the effectiveness of a combination of direct and indi-
ity rect voice therapy on vocal functioning when compared to no in-
Pitch perturbation (jitter) tervention. There is also moderate evidence from one study that
MacKenzie 2001 shows that a combination of direct and indirect the remedial effect of a combination of direct and indirect voice
voice therapy is not effective in improving vocal functioning when therapy as measured with patient-reported vocal performance or
compared to no intervention and when measured with pitch per- with observer-rated perceptual assessment (Buffalo Voice Profile)
turbation immediately following intervention (WMD 0.00; 95% remains significant for at least 14 weeks. There is limited evidence
CI -0.53 to 0.53) or after 14 weeks of follow up (WMD 0.50; from another study that the number of symptoms may remain
95% CI -0.04 to 1.04). lower for a year.
Amplitude perturbation (shimmer) Carding 2000 states that direct and indirect modes of intervention
According to the results of MacKenzie 2001 a combination of di- are not mutually exclusive as some indirect treatment is usually
rect and indirect voice therapy is effective in improving vocal func- also incorporated in direct treatment. He writes that indirect ap-
tioning when compared to no intervention and when measured proaches are based on the assumption that inappropriate phona-
with amplitude perturbation immediately following intervention tory behaviour is a symptom of excessive demands on the voice,
(WMD -1.20; 95% CI -2.37 to -0.03) but not at 14 weeks of abusive behaviours, personal anxiety and tension levels and a lack
follow up (mean difference -0.40; 95% CI -1.61 to 0.81). of knowledge regarding healthy voice production. Direct voice
4. Combination of direct and indirect voice therapy versus com- therapy is based on the assumption that the patient with func-
bination therapy with biofeedback tional dysphonia has adopted an incorrect and potentially damag-
According to the results of Rattenbury 2004, TFL-assisted treating mode of voice production. Direct techniques aim to identify
ment is not more effective than just a combination of direct and the inappropriate pattern of phonation and to enable the patient
indirect treatment approaches (WMD -2.40; 95% CI -0.76 to to correct her phonatory function.
5.56) when measured with the Vocal Performance Questionnaire.
This categorisation of interventions into direct and indirect modes
The patient contact treatment time for the TFL-treatment was on
is only one way to describe the contents of voice therapy. There
average two thirds (two hours) less than the time needed for the
are also many other ways to divide voice therapy approaches.
traditional approach.
For example, Stemple 2000 has divided voice therapy into symp-
5. Other treatments
tomatic, psychogenic, hygienic, eclectic and physiological ap-
Beranova 2003 reported that there were no significant differences
proaches. Boone 2005 has categorised voice therapies into cog-
between pharmacological treatment and vocal hygiene instruc-
nitive, gestalt-holistic, resonant therapy, vocal function exercise,
tions given by phoniatrist but since she did not report standard
visualisation and symptomatic therapy approaches. It is important
deviations this could not be verified statistically.
to remember that all categorisations of the various ways in which
Subgroup analyses
the voice can be treated are somewhat arbitrary and that therapists
Because interventions might work differently with groups with
will in any case use a combination of methods to meet the indi-
heavy vocal load we looked separately at studies that included only
vidual needs of each patient (Boone 2005).

The methodological quality of included studies was mostly poor. There are no previous reports of systematic reviews or meta-analy-
Most randomised controlled trials were small and in all but two of ses available in the literature that are concerned with voice therapy
the included randomised controlled trials (MacKenzie 2001 and or interventions for treating functional dysphonia. Previous nar-
Rattenbury 2004) the method of randomisation was not reported rative literature reviews or overviews (Carding 2000; Oates 2004
or not valid. It was also difficult to get a good impression of the and Ramig 1998) have identified altogether a total of 87 articles,
concealment of allocation from researchers. We assumed that out- published between 1960 and 2001, that have evaluated the effec-
comes that were measured by questionnaire were reported blind to tiveness of voice therapy. According to Oates 2004, 12 of the 87
the researchers but we could not be certain about this assumption. published studies can be categorised as randomised controlled tri-
The reporting of some studies was of low quality as well which is als. Half of these have investigated treatment methods for patients
reflected in having to contact the authors for further information. with Parkinson’s disease whilst the remainder have evaluated the
According to our classification of the studies, only one of the six accent method in patients with various aetiologies, vocal function
studies (MacKenzie 2001) was high quality in terms of randomi- exercises in subjects with normal voice and in teachers. Only two
sation, allocation concealment, blinding and dealing with attri- of the studies included in these previous reviews (Carding 1999;
tion. The results of this high quality study are consistent with the MacKenzie 2001) have studied the effectiveness of voice therapy
overall conclusions of this systematic review. We did not find any for functional dysphonia. Both studies were included in this re-
studies of work-directed/environmental interventions that satis- view. It is also important to note that the definition of functional
fied our inclusion criteria. dysphonia is not synonymous across studies. Functional dyspho-
nia, psychogenic dysphonia, mechanical dysphonia, muscle ten-
To make sure we did not overlook any relevant evidence we also
sion dysphonia, functional voice disorder, hyperfunctional voice,
present an overview of published controlled non-randomised trials
hyperfunctional dysphonia and non-organic dysphonia have all
of person-directed voice treatment interventions (see Table 3). Two
been used to describe dysphonia in the absence of organic pathol-
studies (Popovici 1993 and Sliwinska-K. 2002) had results that
ogy. The latest addition to this abundance of terminology is Ver-
are in line with the conclusions of the randomised trials meaning
dolini’s concept of phonotrauma. It adds greatly to the difficulty of
that voice therapy is effective in both teachers and in patients. One
comparing and combining studies when they are seemingly deal-
study (Garcia Real 2002) found a therapeutic benefit for hydration
ing with different issues.
with or without voice training and another study (Mendoza-Lara
1990) found that EMG biofeedback training was effective. One
study (Andrews 1986), did not find any significant differences
between EMG biofeedback training and progressive relaxation. AUTHORS’ CONCLUSIONS
No trials were found with results clearly refuting the effectiveness
of voice therapy or with results showing harmful effects. Implications for practice
Since most of the studies were small and reported positive out- A combination of direct and indirect voice therapy should be con-
comes it is conceivable that there may have been publication bias sidered as a primary or best available intervention method for
involved. Language bias was corrected for by not having language functional dysphonia at the moment. The diagnosis ’functional
restrictions in the systematic search strategy and by translating ar- dysphonia’ does not, however, in itself reveal what aspects of vo-
ticles written in languages that the authors were not proficient in. cal or speech production (pitch, loudness, intonation, phonation,
Only two of the six non-randomised controlled trials initially con- tempo, breathing, resonance or overall tension) needs to be mod-
sidered for inclusion had been published in English, another two ified. The therapist must choose the aims and the specific tech-
were published in Spanish, one in Polish and one in Romanian. niques of voice therapy accordingly. Screening and subsequently
treating teachers and student teachers is a feasible approach and
Clinical relevance
yields positive results. Before widespread implementation can be
Even though the result of the meta-analysis was significant and it recommended better quality studies are needed.
covered 25% of the range of the Vocal Performance Questionnaire
after transformation, we cannot be sure how this is related to the Implications for research
clinical relevance of the changes achieved in the studies. There
Given the high volume of dysphonia treatment, more research
is no generally accepted change in the two self-report measures
evaluating the effects of treatment is needed. Our review contains
used (Vocal Performance Questionnaire and Voice-Related Qual-
one high quality study (MacKenzie 2001) only which indicates a
ity of Life) that would be regarded as clinically relevant. Studies
need for more high quality studies. These future studies should
are needed to determine what is the relation between a change
include randomisation of participants to intervention and con-
score on the questionnaires and an important amount of change
trol groups and have sufficient statistical power to detect a mean
in outcome as rated by patients (cf. Stratford 2005).
change of ten points on the Vocal Performance Questionnaire.
Comparison with other reviews Having access to only small numbers of participants can be over-

come by organising a multi-centre study. As participants, persons ACKNOWLEDGEMENTS
with a high vocal load should particularly be included. The inter-
ventions should involve both direct and indirect techniques but
according to a well designed protocol. The comparison should still Mari Qvarnström and Anita Länsivuori From Kuopio University
be a no intervention, observation only control group, or if this Hospital provided valuable insight into the everyday practice of
is deemed unacceptable a minimal intervention only. Assuming voice assessment and therapy. Felix de Jong and Eeva Sala gave
that the interventions are aiming at improving vocal performance, their advice when we were in the beginning stages with the proto-
outcome should be measured with a validated questionnaire such col. Maria Hirvonen assisted with statistical calculations. Carolyn
as the Voice Handicap Index (Jacobson 1999) and be blind for Doree from the Cochrane ENT Group provided advice regard-
researchers and care-providers. To be able to better judge the out- ing our search strategies. Patricia Gillivan-Murphy, Nelson Roy,
come, research is needed to determine a clinically relevant change Paul Carding and Susanna Simberg provided us further informa-
on these questionnaires. Even though trans-nasal flexible laryn- tion about their studies. Finally, an especially warm thank you to
goscopy (TFL) assisted treatment was not more effective than a Katarina Kulhankova, Ligia Grindenau and Consol Serra for your
combination of direct and indirect voice therapy, it might be more help in translating articles from Czech, Romanian and Spanish to
efficient. This should be studied in an economic evaluation. English.
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Chipponi J. Methodological index for non-randomized ∗
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Beranova 2003
Methods Randomised controlled trial
Participants 16 consecutive patients with dysphonia persisting for more than two weeks
Interventions 1) Indirect treatment (9)

2) Pharmacotherapy (7)
Outcomes 1) Voice-Related Quality of Life

2) Videostroboscopy; Phonetogram
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear D - Not used
Carding 1999
Participants 45 patients diagnosed with non-organic dysphonia
Interventions 1) Indirect treatment (15)

2) Direct and indirect treatment (15)
3) No intervention (15)
Outcomes 1) Vocal Performance Questionnaire

2) Auditory voice quality ratings; Laryngoscopy; Laryngography; Fundamental Frequency analysis; Acous-
tic analysis
Notes
Risk of bias

Gillivan-Murphy 2005
Participants 20 teachers with self-reported voice/throat symptoms
Interventions 1) Direct and indirect treatment (10)

Outcomes 1) Voice-Related Quality of Life; Voice symptom scale

2) Voice care knowledge VAS
Notes
Risk of bias
MacKenzie 2001
Participants 133 outpatients with persistent hoarseness for at least two months


2) Laryngeal rating; Buffalo Voice Profile; amplitude and pitch perturbation
Notes
Risk of bias
Allocation concealment? Yes A - Adequate
Rattenbury 2004
Participants 50 consecutive patients with muscle tension dysphonia (MTD)

2) TFL-assisted voice therapy (24)

Rattenbury 2004 (Continued)

2) GRBAS; amplitude and pitch perturbation
Notes
Risk of bias
Allocation concealment? Unclear B - Unclear
Simberg 2006
Participants 40 teacher students screened as having a voice disorder: reporting two or more voice symptoms weekly or
more and/or observed deviant voice quality
Interventions 1) Direct and indirect group treatment (20)

Outcomes 2) GRBAS; vocal fry and pitch
Notes
Risk of bias
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Amir 2005 ALLOCATION:

Not randomised.
Andersson 1998 ALLOCATION:

Not randomised.
Andrews 1986 ALLOCATION:

Not randomised.

(Continued)
Bassiouny 1998 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients with vocal fold immobility (paralysis).
Birkent 2004 ALLOCATION:

Not randomised.
Bovo 2006 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients without any voice problems.
Broaddus-L. 2000 ALLOCATION:

Not randomised.
Carding 1992 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients are in part the same individuals as in Carding 1999
Carding 1998 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients are in part the same individuals as in Carding 1999
Chan 1994 ALLOCATION:

Not randomised.
Duffy 2004 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients without any voice problems.
Fex 1994 ALLOCATION:

Not randomised.
Garcia Real 2002 ALLOCATION:

Not randomised.
Holbrook 1974 ALLOCATION:

Not randomised.
John 2005 ALLOCATION:

Not randomised.
Jonsdottir 2001 ALLOCATION:

Not randomised.

(Continued)
Jonsdottir 2002 ALLOCATION:

Not randomised.
Kotby 1993 ALLOCATION:

Not randomised.
Laukkanen 2005 ALLOCATION:

Not randomised.
Lehto 2003 ALLOCATION:

Not randomised.
Lehto 2005 ALLOCATION:

Not randomised.
McCabe 2002 ALLOCATION:

Not randomised.
Mendoza-Lara 1990 ALLOCATION:

Not randomised.
Milbrath 2003 ALLOCATION:

Not randomised.
Motel 2003 ALLOCATION:

Not randomised.
Pedersen 2004 ALLOCATION:

Randomised.
PARTICIPANTS:
Included patients are the same individuals as in Beranova 2003. The two articles are identical apart from
language
Popovici 1993 ALLOCATION:

Not randomised.
Prosek 1978 ALLOCATION:

Not randomised.
Roy 1993 ALLOCATION:

Not randomised.

Not randomised.

Randomised.
PARTICIPANTS:
Included patients without a diagnosis of functional dysphonia

(Continued)

Randomised.
PARTICIPANTS:

Randomised.
PARTICIPANTS:
Sellars 2002 ALLOCATION:

Not randomised.
Sliwinska-K. 2002 ALLOCATION:

Not randomised.
Timmermans 2004a ALLOCATION:

Not randomised.
Timmermans 2004b ALLOCATION:

Not randomised.
Timmermans 2005 ALLOCATION:

Not randomised.
Yiu 2005 ALLOCATION:

Randomised.
PARTICIPANTS:
The majority of included patients had organic dysphonia.
Zhao 2005 ALLOCATION:

Not randomised.

DATA AND ANALYSES
Comparison 1. Any intervention vs. no intervention
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Primary (subjective) outcomes 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Indirect voice therapy vs. 1 30 Std. Mean Difference (IV, Random, 95% CI) -0.46 [-1.19, 0.27]
no intervention (VPQ) (After
intervention)
1.2 Combined direct and 3 182 Std. Mean Difference (IV, Random, 95% CI) -1.07 [-1.94, -0.19]
indirect voice therapy vs.
no intervention (VPQ and
V-RQOL) (After intervention)
1.3 Combined direct and 1 118 Std. Mean Difference (IV, Random, 95% CI) -0.51 [-0.87, -0.14]
indirect voice therapy vs. no
intervention (VPQ) (Follow
up: 14 weeks)
2 Secondary (objective) outcomes 2 Mean Difference (IV, Fixed, 95% CI) Totals not selected
2.1 Combined direct and 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
intervention (Buffalo Voice
Profile) (After intervention)
intervention (Buffalo Voice
Profile) (Follow up: 14 weeks)
intervention (GRBAS - Grade)
(After intervention)
2.4 Combined direct 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
and indirect voice therapy
vs. no intervention (Pitch
Perturbation) (After
intervention)
2.5 Combined direct 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
and indirect voice therapy
vs. no intervention (Pitch
Perturbation) (Follow up: 14
weeks)
no intervention (Amplitude
Perturbation) (After
intervention)
no intervention (Amplitude
Perturbation) (Follow up: 14
weeks)
Comparison 2. Combined direct and indirect voice therapy vs. TFL-assisted treatment
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Vocal Performance 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
Questionnaire
Analysis 1.1. Comparison 1 Any intervention vs. no intervention, Outcome 1 Primary (subjective)
outcomes.
Review: Interventions for treating functional dysphonia in adults
Comparison: 1 Any intervention vs. no intervention
Outcome: 1 Primary (subjective) outcomes
Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Indirect voice therapy vs. no intervention (VPQ) (After intervention)

Carding 1999 15 29.1 (14.9) 15 35.2 (10.6) 100.0 % -0.46 [ -1.19, 0.27 ]
Subtotal (95% CI) 15 15 100.0 % -0.46 [ -1.19, 0.27 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.24 (P = 0.22)
2 Combined direct and indirect voice therapy vs. no intervention (VPQ and V-RQOL) (After intervention)
Carding 1999 15 17.4 (10.5) 15 35.2 (10.6) 25.6 % -1.64 [ -2.48, -0.80 ]
Gillivan-Murphy 2005 9 -88.3 (6.3) 11 -64.3 (21.6) 20.3 % -1.38 [ -2.38, -0.38 ]
MacKenzie 2001 67 22.4 (5.8) 65 25.4 (8.1) 54.1 % -0.42 [ -0.77, -0.08 ]
Subtotal (95% CI) 91 91 100.0 % -1.07 [ -1.94, -0.19 ]

Heterogeneity: Tau2 = 0.45; Chi2 = 8.98, df = 2 (P = 0.01); I2 =78%
3 Combined direct and indirect voice therapy vs. no intervention (VPQ) (Follow up: 14 weeks)
MacKenzie 2001 61 21.6 (6.3) 57 25.4 (8.5) 100.0 % -0.51 [ -0.87, -0.14 ]
-4 -2 0 2 4
Favours intervention Favours control
(Continued . . . )

(. . .Continued)
Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Subtotal (95% CI) 61 57 100.0 % -0.51 [ -0.87, -0.14 ]
Heterogeneity: not applicable
-4 -2 0 2 4
Analysis 1.2. Comparison 1 Any intervention vs. no intervention, Outcome 2 Secondary (objective)
outcomes.
Comparison: 1 Any intervention vs. no intervention
Outcome: 2 Secondary (objective) outcomes
Mean Mean
Study or subgroup intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Combined direct and indirect voice therapy vs. no intervention (Buffalo Voice Profile) (After intervention)
MacKenzie 2001 74 2.3 (0.93) 69 2.5 (0.93) -0.20 [ -0.51, 0.11 ]
2 Combined direct and indirect voice therapy vs. no intervention (Buffalo Voice Profile) (Follow up: 14 weeks)
MacKenzie 2001 70 2.2 (1) 63 3 (1) -0.80 [ -1.14, -0.46 ]
3 Combined direct and indirect voice therapy vs. no intervention (GRBAS - Grade) (After intervention)
Simberg 2006 20 15 (6) 18 28 (9) -13.00 [ -17.92, -8.08 ]
4 Combined direct and indirect voice therapy vs. no intervention (Pitch Perturbation) (After intervention)
MacKenzie 2001 67 2.8 (1.5) 57 2.8 (1.5) 0.0 [ -0.53, 0.53 ]
5 Combined direct and indirect voice therapy vs. no intervention (Pitch Perturbation) (Follow up: 14 weeks)
MacKenzie 2001 65 2.7 (1.5) 54 2.2 (1.5) 0.50 [ -0.04, 1.04 ]
6 Combined direct and indirect voice therapy vs. no intervention (Amplitude Perturbation) (After intervention)
MacKenzie 2001 67 4.5 (2.6) 57 5.7 (3.8) -1.20 [ -2.37, -0.03 ]
7 Combined direct and indirect voice therapy vs. no intervention (Amplitude Perturbation) (Follow up: 14 weeks)
MacKenzie 2001 65 4.1 (3) 54 4.5 (3.6) -0.40 [ -1.61, 0.81 ]
-4 -2 0 2 4

Analysis 2.1. Comparison 2 Combined direct and indirect voice therapy vs. TFL-assisted treatment,
Outcome 1 Vocal Performance Questionnaire.
Comparison: 2 Combined direct and indirect voice therapy vs. TFL-assisted treatment
Outcome: 1 Vocal Performance Questionnaire
Mean Mean
Study or subgroup TFL-assisted Traditional Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Rattenbury 2004 24 20.1 (6.5) 25 17.7 (4.6) 2.40 [ -0.76, 5.56 ]
-10 -5 0 5 10
Favours TFL-assisted Favours traditional
ADDITIONAL TABLES
Table 1. Assessment of study quality
Study ID Randomisation Allocation con- Blinding Attrition Attr. differential? Score

method cealed
Beranova 2003 Method not re- Unclear N/A Possibly two pa- Yes 0/3
ported tients (11%) ex-
cluded or lost to
follow up from en-
tire sample
Carding 1999 Allocation in ro- Inadequate Adequate None No 2/4

tation
Gillivan- Method not re- Unclear N/A Four patients Yes 0/3
Murphy 2005 ported (20%)
withdrew after ran-
domisation
MacKenzie 2001 Computer gen- Adequate Adequate 30 patients (30%) No 4/4

erated random from the interven-
numbers tion group and 41
(39%) from the
control group
Rattenbury Computer gen- Unclear Adequate None No 3/4

2004 erated random
numbers

Table 1. Assessment of study quality (Continued)
Simberg 2006 Drawing lots Inadequate Adequate None from the Yes 1/4
from a hat intervention group
and 13 (39%) from
the control group
Table 2. Description of rating scales used
Instrument Type Scoring range Number of items Scaling method
Vocal Per- Self-report 12 (best) - 60 (worst) 12 5-point Likert scale

formance Questionnaire
(Carding 1992)
Voice-Related Quality of Self-report 0 (worst) - 100 (best) 10 5-point Likert scale

Life (Hogikyan 1999)
Voice Symptom Severity Self-report 0 (best) - 150 (worst) 30 5-point Likert scale
Scale (Deary 2003)
Questionnaire about vo- Self-report 7 (worst) - 42 (best) 7 6-point Likert scale

cal symptoms (Simberg
2006)
GRBAS (Hirano 1989), Observer-rated 0 (best) - 100 (worst) 5 100 mm VAS

GRBAS =
Grade, Rough, Breathy,
Asthenic, Strain
Overall severity scale Observer-rated 1 (best) - 7 (worst) 1 7-point Likert scale

(Carding 1999)
Buffalo Voice Profile Observer-rated 0 (best) - 5 (worst) 1 5-point Likert scale

(Wilson 1987)
Table 3. Controlled (Non-randomised) Trials
Study ID Methods Participants Interventions Outcomes Results
Andrews 1986 Controlled trial 10 female subjects 1) EMG biofeedback Laryngeal Both inter-
matched based on training (5) muscle tension, con- ventions effective; no
age and dysphonia 2) Progressive relax- trol of vocal fold vi- significant difference
severity ation training (5) bration, auditory between groups
evaluation, personal-
ity measures, self-rat-
ing of voice, laryn-
goscopy

Table 3. Controlled (Non-randomised) Trials (Continued)
Garcia Real 2002 Controlled trial 75 professional voice 1) Hydration treat- Laryngoscopy, maxi- Both inter-
users with a mini- ment (27) mum phonation ventions effective; no
mum of four hours 2) Hydration and di- time, speaking time significant difference
of daily voice use rect treatment (25) and fundamental fre- between groups
and who had had in 3) No intervention quency
the past symptoms or (23)
signs of vocal dam-
age due to voice use
for a minimum of six
months
Mendoza-Lara Controlled trial 14 dysphonic teach- 1) Traditional treat- Auditory voice qual- Both interven-
1990 ers and 14 teachers ment (7) ity ratings (inten- tions effective; signif-
without voice prob- 2) EMG biofeedback sity, tone, dyspho- icant differences be-
lems training (7) nia, timbre, rough- tween treatment and
3) No intervention ness, breathiness) control; no signifi-
(14) cant difference be-
tween treatments
Popovici 1993 Controlled trial 39 patients suffering 1) Classical therapy Symptom scale (vo- Combination of clas-
from psychosomatic and relaxation (24) cal, laryngeal, neu- sical therapy with re-
or conversive voice 2) Classical therapy rotic), capacity to laxation is effective
problems (15) relax self-evaluation
scale
Sliwinska-K. 2002 Controlled trial 83 female teachers 1) Logopedic treat- Symptom question- Logopedic voice
with chronic dyspho- ment (47) naire, phoniatric ex- therapy is effective
nia 2) No intervention amination,
(36) videostroboscopy
APPENDICES
Appendix 1. Search strategy for CENTRAL

Search strategy for CENTRAL
#1 dysphoni* (in Title, Abstract, Keywords) OR hoarseness (in Title, Abstract, Keywords) OR phonastheni* OR trachyphoni* OR
functional voice disorder* OR psychogenic voice disorder* OR ventricular phonation OR conversion voice disorder* OR functional
aphonia OR conversion aphonia OR conversion dysphonia OR phonation break OR functional falsetto OR mutational falsetto OR
puberphonia OR juvenile voice OR laryngeal myasthenia
#2 (voice OR vocal OR phonation) NEAR (problem* OR symptom* OR complaints OR hygiene OR disorder* OR disease* OR
disturbance* OR tremor* OR impair* OR handicap* OR tension* OR strain* OR abuse* OR fatigue* OR misuse* OR reduct*)
#3 #1 OR #2

Appendix 2. Search strategy for MEDLINE via PubMed
#1 dysphoni*[tw] OR hoarseness[mh] OR phonastheni*[tw] OR trachyphoni*[tw] OR functional voice disorder*[tw] OR psychogenic
voice disorder*[tw] OR ventricular phonation[tw] OR conversion voice disorder*[tw] OR functional aphonia[tw] OR conversion
aphonia[tw] OR conversion dysphonia[tw] OR phonation break[tw] OR functional falsetto[tw] OR mutational falsetto[tw] OR
puberphonia[tw] OR juvenile voice[tw] OR laryngeal myasthenia[tw]
#2 phonation[tw] NEAR (disease*[tw] OR disorder*)
#3 (voice[tw] OR vocal[tw] OR phonation[tw]) NEAR (problem*[tw] OR symptom*[tw] OR complaints[tw] OR hygiene[tw] OR
disturbance*[tw] OR tremor*[tw] OR impair*[tw] OR handicap*[tw] OR tension*[tw] OR strain*[tw] OR abuse*[tw] OR fatigue*[tw]
OR misuse*[tw] OR reduct*[tw])
#4 (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled trials[mh] OR random allocation[mh]
OR double-blind method[mh] OR single-blind method[mh] OR clinical trial[pt] OR clinical trials[mh] OR “clinical trial”[tw] OR
((singl*[tw] OR doubl*[tw] OR trebl*[tw] OR tripl*[tw]) AND (mask*[tw] OR blind*[tw])) OR “latin square”[tw] OR placebos[mh]
OR placebo*[tw] OR random*[tw] OR research design[mh:noexp] OR comparative study[mh] OR evaluation studies[mh] OR follow-
up studies[mh] OR prospective studies[mh] OR cross-over studies[mh] OR control*[tw] OR prospectiv*[tw] OR volunteer*[tw])
NOT (animal[mh] NOT human[mh])
#5 (effect*[tw] OR control*[tw] OR evaluation*[tw] OR protect*[tw]) NOT (animal[mh] NOT human[mh])
#6 (#1 OR #2 OR #3) AND (#4 OR #5)
Appendix 3. Search strategy for EMBASE

#1 dysphonia/exp OR hoarseness/exp OR phonastheni* OR trachyphoni* OR “functional voice disorder*” OR “psychogenic voice
disorder*” OR “ventricular phonation” OR “conversion voice disorder*” OR “functional aphonia” OR “conversion aphonia” OR
“conversion dysphonia” OR “phonation break” OR “functional falsetto” OR “mutational falsetto” OR puberphonia OR “juvenile
voice” OR “laryngeal myasthenia”
#2 phonation AND (disease* OR disorder*)
#3 (voice/exp OR vocal OR phonation) AND (problem* OR symptom* OR complaints OR hygiene/exp OR disturbance* OR tremor*
OR impair* OR handicap* OR tension* OR strain* OR abuse* OR fatigue* OR misuse* OR reduct*
#4 #1 OR #2 OR #3
#5 #4 AND [embase]/lim AND [article]/lim AND [human/]lim
#6 #5 AND [randomized controlled trial]/lim
#7 #5 AND [controlled clinical trial]/lim
#8 randomized controlled trial/exp OR clinical trial/exp OR double blind procedure/exp OR single blind procedure/exp OR (singl*
OR doubl* OR trebl* OR tripl*) AND (mask* OR blind*) OR placebo/exp OR placebo* OR random* OR comparative study/
exp OR “evaluation study” OR evaluation studies/exp OR follow up/exp OR prospective study/exp OR crossover procedure/exp OR
prospectiv* OR volunteer*
#9 #5 AND #8
#10 #6 OR #7 OR #9
WHAT’S NEW
Last assessed as up-to-date: 21 May 2007.
Date Event Description
25 October 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 1, 2007
Review first published: Issue 3, 2007
Date Event Description
22 May 2007 New citation required and conclusions have changed Substantive amendment
CONTRIBUTIONS OF AUTHORS
Jani Ruotsalainen conceptualised the review jointly with JV and took the lead in writing the protocol.
Jos Verbeek conceptualised the review jointly with JR and wrote the methods section of the protocol.
Merja Jauhiainen designed the systematic search strategies in collaboration with the Cochrane ENT Group’s Trials Search Co-ordinator.
Jaana Sellman and Laura Lehto wrote the second version of the protocol.
DECLARATIONS OF INTEREST
Jaana Sellman is one of the authors of one of the included articles (Simberg 2006).
SOURCES OF SUPPORT
Internal sources
• Ministry of Social Affairs and Health, Finland.
• Cochrane Occupational Health Field, Finland.
External sources
• Pension Fund Loyalis, Netherlands.
INDEX TERMS
Medical Subject Headings (MeSH)

Randomized Controlled Trials as Topic; Voice Disorders [rehabilitation; ∗ therapy]; Voice Quality; Voice Training

MeSH check words
Adult; Humans


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Interventions for treating functional dysphonia in adults

Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH

Interventions for treating functional dysphonia in adults (Review)

Interventions for treating functional dysphonia in adults (Review) i

Interventions for treating functional dysphonia in adults

Editorial group: Cochrane Ear, Nose and Throat Disorders Group.

PLAIN LANGUAGE SUMMARY

Interventions for treating functional dysphonia in adults

Interventions for treating functional dysphonia in adults (Review) 3

Interventions for treating functional dysphonia in adults (Review) 4

Searching other resources

Dealing with missing data

Assessment of reporting biases

Interventions for treating functional dysphonia in adults (Review) 5

Interventions for treating functional dysphonia in adults (Review) 6

Interventions for treating functional dysphonia in adults (Review) 7

Interventions for treating functional dysphonia in adults (Review) 8

Interventions for treating functional dysphonia in adults (Review) 9

Interventions for treating functional dysphonia in adults (Review) 10

Interventions for treating functional dysphonia in adults (Review) 13

Sataloff 2000 Vilkman 2004

Seifert 2005 Wilson 1987

Interventions for treating functional dysphonia in adults (Review) 14

Characteristics of included studies [ordered by study ID]

Methods Randomised controlled trial

Interventions 1) Indirect treatment (9)

Outcomes 1) Voice-Related Quality of Life

Item Authors’ judgement Description

Allocation concealment? Unclear D - Not used

Methods Randomised controlled trial

Participants 45 patients diagnosed with non-organic dysphonia

Interventions 1) Indirect treatment (15)

Outcomes 1) Vocal Performance Questionnaire

Item Authors’ judgement Description

Allocation concealment? Unclear D - Not used

Interventions for treating functional dysphonia in adults (Review) 15

Methods Randomised controlled trial

Participants 20 teachers with self-reported voice/throat symptoms

Interventions 1) Direct and indirect treatment (10)

Outcomes 1) Voice-Related Quality of Life; Voice symptom scale

Item Authors’ judgement Description

Allocation concealment? Unclear D - Not used

Methods Randomised controlled trial

Interventions 1) Direct and indirect treatment (70)

Outcomes 1) Vocal Performance Questionnaire

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Methods Randomised controlled trial

Participants 50 consecutive patients with muscle tension dysphonia (MTD)

Interventions 1) Direct and indirect treatment (26)

Interventions for treating functional dysphonia in adults (Review) 16

Outcomes 1) Vocal Performance Questionnaire

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Methods Randomised controlled trial

Interventions 1) Direct and indirect group treatment (20)

Outcomes 2) GRBAS; vocal fry and pitch

Item Authors’ judgement Description

Allocation concealment? Unclear D - Not used