Creating a Mastery Experience During the Voice Evaluation

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  • Creating a Mastery Experience Dthe Voice Evaluation

    Heather Shaw Bonilha and Amy Elizabeth Dawson, Charles

    Summary: Objectives. Adherence to treatment is a commorders. Improving their self-efficacy through a mastery experieideal mastery experience gives early and quick evidence that thfor a broad range of patients. This study sought to test whether

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    Charleston, SC 29425. E-mail:

    Cognitive structures, such as self-efficacy, afully reformed by a personal mastery experiean effective accomplishment or productive be

    Journal of Voice, Vol. 26, No. 5, pp. 665.e1-665.e70892-1997/$36.00 2012 The Voice Foundationdoi:10.1016/j.jvoice.2011.09.004self-efficacy is that they have a better prognosis. The socialcognitive theory proposes and has accrued evidence for foursources of self-efficacy: mastery experience, vicarious experi-ence, verbal persuasion, and emotional-physiological state.6,10

    Voice Conference; September 2011; Marseille, France.From the Department of Health Science and Research, Medical University of South

    Carolina, Charleston, South Carolina.Address correspondence and reprint requests to Heather Shaw Bonilha, Department of

    Health Science and Research, Medical University of South Carolina, 77 President Street,found that 47% of patients who were seen for a voicetion adhered to the recommendation of a speech-ge pathologist (SLP) for voice therapy. In a follow-upHapner et al found that 65% of patients dropped out ofherapy. Patient demographics, quality-of-life impact, se-of dysphonia (consensus auditory perceptual evaluationce), and diagnosis (hyperfunctional vs hypofunctional)ot predictive of patient dropout. It is possible that thisadherence is related to the inherent difficulty in makingbehavior changes.transtheoretical model (TTM) describes health behavioras a process that progresses in a series of stages.3 Tond maintain a health behavior change, one must progressh all stages successfully. The TTM has been studied and

    they could be aware of a possible change but are unwillpursue it. It is also thought that general indecision maya role in the precontemplation stage. That is, a patient maware that a behavior change is possible, but he or she iweighing the pros and cons of making that change.68 Thetemplation stage occurs when a patient is in fact starting tosider making a behavior change, but he or she has yet to athe thought. The preparation stage is characterized by a patresolve to pursue change. The action and maintenance sare regarded as the period when a person takes steps to mhis or her behavior and prevent relapse or recycling intoous stages.6,7

    Important to the TTM is the concept of self-efficacy ordividuals confidence in his or her ability to accomplish aSelf-efficacy is necessary to achieve and maintain behchange, and, fortunately, it is changeable within an indiviA commonly observed characteristic in patients with h

    ted for publication September 15, 2011.s of this study were presented at the 39th Symposium of The Voice Foundation:e Professional Voice; June 2010; Philadelphia, Pennsylvania, and the Pan Europeanapy.1,2 In 2006, Portone et al in a retrospective review of 294 changed or that a change would be beneficial. Congruently,produce sufficient change in acoustic analysis measuresa potentially useful mastery experience.Study Design. Prospective, repeated measures, pre- anMethods. Twenty-four consecutive patients with varyinstudy. Acoustic analysis was completed before and afteranalysis parameters evaluated include fundamental frequbulence index. Data pre- and posttreatment were analyzeResults. Results demonstrated a significant change fromsitioning from being outside to within normal limits, in 75itive change in one or more of the three acoustic measuresConclusion. Pairing a trial therapy with acoustic analysFuture research is needed to determine if this mastery expement outcomes.Key Words: VoiceEvaluationMastery experienceSel

    INTRODUCTIONA common difficulty experienced by clinicians is engagingtheir patients in treatment. Most treatment typically involveshealth behavior changes. This is especially true for patientswho require voice treatment. For successful health behaviorchanges, a patient must have sufficient self-efficacy andmotiva-tion to engage in and continue voice therapy. It is documentedthat many patients with voice disorders do not adhere to ther-uring

    ton, South Carolina

    on challenge when working with patients with voice dis-nce has the potential to improve treatment adherence. Ane patient will be successful with the treatment and worksa brief stimulability trial of forward focused voice couldrovide visibly improved objective results and, thus, be

    sttreatment.gnoses referred for a voice evaluation participated in thisrt stimulability trial of forward focused voice. Acoustic, jitter, shimmer, noise-to-harmonic ratio, and voice tur-r change and compared with normative values.- to posttrial, as indicated by the objective measure tran-f patients (P 0.000). When less rigid criterion of a pos-terest is used, improvement was noted in 96% of patients.ring a voice evaluation is a possible mastery experience.ce improves self-efficacy, treatment adherence, and treat-

    cacyAcoustic analysis.

    used as a behavior change assessment technique for a number ofhealth concerns. Researchers have determined the TTM to beeffective and useful for physical activity exercise, alcohol con-sumption, and smoking cessation.4,5

    There are five stages of change described in the TTM. Pre-contemplation, the first stage, occurs when a patient is not yetconsidering behavioral therapy. This can be attributed to thepatient being unaware that a problem behavior needs to be

  • and the Lee Silverman voice treatment.

    Journal of Voice, Vol. 26, No. 5, 2012665.e2for a mastery experience to be successful in improving patientsconfidence in therapy, it must be easily interpretable by patientsas presenting an improvement and prove advantageous for mostpatients.For patients with voice disorders, the first opportunity at pro-

    viding amastery experience is in the initial evaluation with stim-ulability trials. A patients presence or absence of stimulabilityfor therapy must be assessed to determine an appropriate treat-ment plan. The stimulability trial can also be used to determinewhether or not a patient believes that a certain treatment has thepotential to relieve their symptoms. This time point generally re-lates to the precontemplation or contemplation stages of theTTM, making it an ideal time to increase a patients self-efficacy. Patients may be in the precontemplation stage at thevoice evaluation because, although they have been referred toan SLP, theymay not yet know the extent towhich their behaviorneeds changing or that a change would even be beneficial. Pa-tients are in the process of learning about their behavior andits negative impacts on the voice and weighing the pros andcons to modifying the behavior. Once they are knowledgeableabout their condition and the health behavior changes suggestedby the SLP, they maymove onto the contemplation stage. This iswhen the patients are not yet resolved to engage in therapy or putin the effort required to modify their behavior, and/or, they arenot yet convinced that the therapy the SLP has to offer will, infact, prove beneficial. The patients are actively acquiring infor-mation about their condition at this point, acknowledging thatthey have a problem, and investigating their treatment options.Patients may present to the voice evaluation in either the precon-templation or the contemplation stage. When patients move tothe contemplation stage, they are actively seeking evidence sup-porting the efficacy of voice therapy; therefore, patients in thisstage are prone to benefit from cognitive methodologies usedto increase motivation.8 The use of the treatment stimulabilitytechnique proposed in this article may be helpful in movingpatients from the precontemplation and contemplation stagesto the preparation, action, and maintenance stages and inpreventing reversion into the previous stages.Before evaluating the outcome of a mastery experience for

    improving a patients self-efficacy, adherence to therapy, orvoice quality, we needed to develop a viable mastery experiencerelevant to most patients. The first step was to identify a voicetherapy approach to use for the stimulability trial that wouldbenefit and not harm the largest number of patients whilequickly providing notable voice improvement. Based on typicalpractice patterns and the authors clinical biases, a forwardfocused (resonant) voice approach was chosen for this study.This approach was chosen based on the concept that bothpatients with hyperfunctional and hypofunctional voice disor-ders benefit from forward focused voice therapy. Althoughforward focused voice is predominately touted for its position-ing of the vocal folds during phonation to minimize forcefulcontact and presumably allow tissue healing, it is also usefulfor persons with hypofunctional voice disorders for the samereason.11 Because forward focused voice does not require thesame level of vocal fold contact as nonforward focused phona-

    tion to be produced, it works with the anatomy of patients withThe second step in formulating the mastery experiencewas toidentify the appropriatemeasure of success that would be readilyadopted by the patient. We chose acoustic analysis for this pur-pose because it is both a biofeedback and a measurement tech-nique that provides a clear means for the patients tounderstand that they are improving. Because of the objective na-ture, visual display, and ability to replay the phonation, acousticanalysis seemed to provide the most opportunity for relaying in-formation on the change from the prestimulability to poststimul-ability trial. Anecdotally, information from acoustic analysis,both the visual image of the red and green diagram from multi-dimensional voice program (MDVP) and the numerical results,seems to be a measure that naturally resonates with patients.

    PURPOSEThe purpose of this study was to evaluate whether objectiveacoustic analysis paired with a short stimulability trial of for-ward focused voice provides positive feedback to most patients.If acoustic analysis during a forward focused stimulability trialprovides early, quick, and positive feedback for most patients, itmay be a useful mastery experience to improve patient adher-ence to and benefit from voice therapy. The long-term planfor this line of research is to follow patients who are exposedto this mastery experience to determine if this approach doesimprove self-efficacy, treatment adherence, and behavioraltreatment outcomes.The specific research questions for the first step in this pro-

    cess were

    1. Do the acoustic analysis parameters of frequency and am-plitude perturbation, noise-to-harmonic ratio (NHR), andvoice turbulence index (VTI) differ before and after voicestimulability trials?

    2. Is the change of fundamental frequency (Fo), not thehypofunctional voice disorders to also improve their voicequality. Additionally, there is a relatively low possibility ofharming the vocal fold tissue during a supervised trial of for-ward focused therapy during the voice evaluation. As reportedby Boone and McFarlane,12 the approach is generally helpful topatients with voice disorders with the exception of those whosedisorder involves a hypernasality component. Forward focusedvoice has the advantage of providing a large amount of innatefeedback to the patient. Forward focused voice exercises pro-vide the feeling of vibration or sensation on the lips or in themouth, a decrease in laryngeal tension, and an immediatechange in voice quality. Forward focused voice exercises areubiquitous in the voice clinic and have been part of many voicetherapy approaches advocated by the leaders in the field.1315

    Other voice therapy approaches that may provide similarlyfast changes in vocal quality may also be appropriate for thispurpose depending on the individual patient characteristics.A noninclusive list of such therapies that may be explored forthis purpose are the Lessac-Madsen resonant voice therapy,vocal function exercises, the accent method, flow phonation,change in voice quality because of the treatment,

  • [RAP]), shimmer (Shim), NHR, and VTI using MDVP.


    tic analysis measures were achieved. The MDVP normativethresholds were used to group patients into categories: withinnormal limits or outside normal limits for analysis using theMcNemars test for matched pairs.


    Do the acoustic analysis parameters of frequencyand amplitude perturbation, NHR, and VTI differbefore and after a voice stimulability trial?Overall, the RAP and Shim measures were improved during thestimulability trial from the initial recordings (Figures 14). Theprestimulability habitual pitch average RAP measure of 1.38%was reduced to an average poststimulability measure of 0.68%.The average prestimulability habitual pitch Shim measure of3.9% was reduced to an average of 2.7% when measured post-stimulability trial. For NHR, the prestimulability habitual pitch

    Heather Shaw Bonilha and Amy Elizabeth Dawson Mastery Experience 665.e3alysisNemars test for matched pairs and paired t test were used toresponsible for the changes in acoustic analysis measuresbetween pre- and poststimulability trial recordings?


    ParticipantsTwenty-four consecutive patients referred for voice evaluationat the Medical College of Georgia (MCG) participated in thisstudy. The procedures used in this study were those commonlyused for the evaluation of patients with voice disorders. Thedata for this study were assessed in a retrospective chart reviewapproved by the institutional review board of the MCG. The pa-tients included in this study were not restricted by any criteria.The patients referred had diagnoses ranging from prenodules topresurgery for cysts to unilateral paralysis.

    Data collectionParticipants were recorded sustaining /a/ at habitual pitch andvolume, high pitch and habitual volume, and low pitch and ha-bitual volume with a headset microphone. Subjects were notguided in the selection of pitch for any of the tasks. Patientsthen underwent a stimulability trial that ranged from 3 to 5 min-utes. The trial duration depended on the patients ease of learn-ing the task. The stimulability trial began by asking the patientsto take a breath and hum; they were then asked to repeat this andfeel for any vibration or sensation on their lips or the front oftheir mouth. Patients who were instructed to specifically attendto their oral cavity were not advised to attend to their nasal cav-ity as we wished to simplify the task for the patient and haveonly one...


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