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BACKGROUND Laryngeal dystonia (LD), or spasmodic dysphonia (SD), is a neurological disorder characterized by focal dystonia or involuntary spasms of the laryngeal muscles and associated voice symptoms. It is typically treated with injection of botulinum toxin (BoNT) that weakens the affected muscles. AIMS The primary purpose of this qualitative study was to explore participants' experience of living with LD and BoNT treatment. The secondary purpose was to examine those experiences as a function of participants' scores on the Communicative Participation Item Bank (CPIB). Results will enhance our understanding of restrictions in communicative participation, assist in planning intervention targeting these restrictions and aid in clinical interpretation of CPIB scores. METHODS & PROCEDURES Semi-structured interviews using a phenomenological tradition and focusing on BoNT treatment and communicative participation were conducted with 26 people with LD who are on established BoNT treatment regimens. Interviews were recorded, transcribed, coded and analysed inductively. Participants were categorized by CPIB scores into groups ranging from none to extensive participation restrictions. Both self- and expert ratings of voice were obtained. OUTCOMES & RESULTS Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. These differences were organized into the following topics: BoNT and voice; attitudes toward participation; coping strategies; and advice. For all participants except those in the least restricted and most restricted groups, expert ratings of voice did not relate to CPIB scores. CONCLUSIONS & IMPLICATIONS Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. Participants reported coping with these restrictions in many ways; some of these strategies were more successful than others. Those with restricted participation recommended more support for daily life and the emotional toll of LD, as well as support for family members. This support might be offered by speech-language pathologists. WHAT THIS PAPER ADDS What is already known on the subject Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. What this study adds to the existing knowledge Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. What are the potential or actual clinical implications of this work? SLP services that take a participation-focused approach to intervention and use multi-factorial approaches to help clients maximize their life participation in the context of LD are well within the SLP scope of practice. SLPs can help clients find and use their optimal voices within the constraints of the dystonia and BoNT effects.

Purpose This study (a) examined the effect of different levels of background noise on speech intelligibility and perceived listening effort in speakers with impaired and intact speech following treatment for head and neck cancer (HNC) and (b) determined the relative contribution of speech intelligibility, speaker group, and background noise to a measure of perceived listening effort. Method Ten speakers diagnosed with nasal, oral, or oropharyngeal HNC provided audio recordings of six sentences from the Sentence Intelligibility Test. All speakers were 100% intelligible in quiet: Five speakers with HNC exhibited mild speech imprecisions (speech impairment group), and five speakers with HNC demonstrated intact speech (HNC control group). Speech recordings were presented to 30 inexperienced listeners, who transcribed the sentences and rated perceived listening effort in quiet and two levels (+7 and +5 dB SNR) of background noise. Results Significant Group × Noise interactions were found for speech intelligibility and perceived listening effort. While no differences in speech intelligibility were found between the speaker groups in quiet, the results showed that, as the signal-to-noise ratio decreased, speakers with intact speech (HNC control) performed significantly better (greater intelligibility, less perceived listening effort) than those with speech imprecisions in the two noise conditions. Perceived listening effort was also shown to be associated with decreased speech intelligibility, imprecise speech, and increased background noise. Conclusions Speakers with HNC who are 100% intelligible in quiet but who exhibit some degree of imprecise speech are particularly vulnerable to the effects of increased background noise in comparison to those with intact speech. Results have implications for speech evaluations, counseling, and rehabilitation.

PurposeThe reliability of auditory-perceptual judgments between listeners is a long-standing problem in the assessment of voice disorders. The purpose of this study was to determine whether a relatively novel experimental scaling method, called visual sort and rate (VSR), yielded stronger reliability than the more frequently used method of visual analog scales (VAS) for ratings of overall severity (OS) and breathiness (BR) in speakers with voicedisorders.MethodFifty speech samples were selected from a database of speakers with voice disorders. Twenty-two inexperienced listeners provided ratings of OS or BR in four rating blocks: VSR-OS, VSR-BR, VAS-OS, and VSR-BR. For the VAS task, listeners rated each speaker for BR or OS using a vertically oriented 100-mm VAS. For the VSR task, stimuli were distributed into sets of samples with a range of speaker severities in each set. Listeners sorted and ranked samples for OS or BR within each set, and final ratings were captured on a vertically oriented 100-mm VAS. Interrater variability, defined as the mean of the squared differences between a listener's ratings and group mean ratings, and intrarater reliability (Pearsonr) were compared across rating tasks for OS and BR using pairedttests.ResultsResults showed that listeners had significantly less interrater variability (better reliability) when using VSR methods compared to VAS for judgments of both OS and BR. Intrarater reliability was high across rating tasks and dimensions; however, ratings of BR were significantly more consistent within individual listeners when using VAS than when using VSR.ConclusionsVSR is an experimental method that decreases variability of auditory-perceptual judgments between inexperienced listeners when rating speakers with a range of dysphonic severities and disorders. Future research should determine whether a clinically viable tool may be developed based on VSR principles and whether such benefits extend to experienced listeners.

OBJECTIVE: To determine how communicative participation is affected in patients with oral and oropharyngeal head and neck cancers (HNC) pre-treatment, and whether communication function predicts HNC-specific quality of life (QOL) before treatment, beyond known demographic, medical, psychosocial, and swallowing predictors. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Eighty-seven patients with primary oral (40.2%) or oropharyngeal (59.8%) HNC were recruited prior to treatment. T stage, tumor site, and p16 status were extracted from medical records. Demographic and patient-reported measures were obtained. Communicative participation was measured using the Communicative Participation Item Bank (CPIB) General short form. A hierarchical regression analysis included demographic, medical, psychosocial, and functional measures of swallowing and communication as predictors; the University of Washington Quality of Life (UW-QOL v4) composite score was the predicted variable. RESULTS: Median baseline CPIB scores were 71.0 (SD = 11.83); patients with oral cancers reported worse scores. A final sequential hierarchical regression model that included all variables explained 71% of variance in QOL scores. Tumor site, T stage, and p16 status accounted for 28% of variance (P < 0.001). Perceived depression predicted an additional 28% of the variance (P < 0.001). Swallowing and communicative participation together predicted an additional 12% of variance (P = 0.005). Tumor site, perceived depression, swallowing, and communication measures were unique predictors in the final model. Finally, communicative participation uniquely predicted QOL, above and beyond other predictors. CONCLUSION: Pre-treatment communication predicted QOL, and was negatively impacted in some oral and oropharyngeal HNC patients.

Purpose This study is a secondary analysis of existing data. The goal of the study was to construct an acoustic model of perceived overall severity of dysphonia in adductory laryngeal dystonia (AdLD). We predicted that acoustic measures (a) related to voice and pitch breaks and (b) related to vocal effort would form the primary elements of a model corresponding to auditory-perceptual ratings of overall severity of dysphonia. Method Twenty inexperienced listeners evaluated the overall severity of dysphonia of speech stimuli from 19 individuals with AdLD. Acoustic features related to primary signs of AdLD (hyperadduction resulting in pitch and voice breaks) and to a potential secondary symptom of AdLD (vocal effort, measures of relative fundamental frequency) were computed from the speech stimuli. Multiple linear regression analysis was applied to construct an acoustic model of the overall severity of dysphonia. Results The acoustic model included an acoustic feature related to pitch and voice breaks and three acoustic measures derived from relative fundamental frequency; it explained 84.9% of the variance in the auditory-perceptual ratings of overall severity of dysphonia in the speech samples. Conclusions Auditory-perceptual ratings of overall severity of dysphonia in AdLD were related to acoustic features of primary signs (pitch and voice breaks, hyperadduction associated with laryngeal spasms) and were also related to acoustic features of vocal effort. This suggests that compensatory vocal effort may be a secondary symptom in AdLD. Future work to generalize this acoustic model to a larger, independent data set is necessary before clinical translation is warranted.

Purpose: This study examined the discriminative ability of acoustic indices of vocal hyperfunction combining smoothed cepstral peak prominence (CPPS) and relative fundamental frequency (RFF). Method: Demographic, CPPS, and RFF parameters were entered into logistic regression models trained on two 1:1 case–control groups: individuals with and without nonphonotraumatic vocal hyperfunction (NPVH; n = 360) and phonotraumatic vocal hyperfunction (PVH; n = 240). Equations from the final models were used to predict group membership in two independent test sets ( n = 100 each). Results: Both CPPS and RFF parameters significantly improved model fits for NPVH and PVH after accounting for demographics. CPPS explained unique variance beyond RFF in both models. RFF explained unique variance beyond CPPS in the PVH model. Final models included CPPS and RFF offset parameters for both NPVH and PVH; RFF onset parameters were significant only in the PVH model. Area under the receiver operating characteristic curve analysis for the independent test sets revealed acceptable classification for NPVH (72%) and good classification for PVH (86%). Conclusions: A combination of CPPS and RFF parameters showed better discriminative ability than either measure alone for PVH. Clinical cutoff scores for acoustic indices of vocal hyperfunction are proposed for assessment and screening purposes.

Patient-reported outcomes (PROs) are essential in patient-centered, evidence-based practice in speech-language pathology. PROs respect individuals who live with communication disorders as key stakeholders providing a critically unique perspective on consequences of communication disorders, and whether interventions bring about meaningful changes. Some PROs focus on specific communication symptoms such as voice or language symptom severity, while others focus on broader constructs such as quality of life. Many PROs target specific diagnostic groups. This article presents the Communicative Participation Item Bank (CPIB), a PRO that measures communicative participation restrictions. The CPIB was based on the concept of participation, or engagement in life situations, as defined in the World Health Organization's International Classification of Functioning, Disability, and Health. It was designed to be relevant for adults across different communication disorders to facilitate clinical and research activities that may involve either comparing or aggregating data across communication disorders. The CPIB follows current PRO development protocols including systematic guidance from stakeholders through cognitive interviews, and the measurement methods of Item Response Theory that allow precise and adaptive assessment. This article reviews use of the CPIB across different diagnostic groups, and identifies needs for future efforts to expand the relevance of the CPIB further.

OBJECTIVE The primary aim of this study was to examine the effect of the videolaryngostroboscopic auditory signal on videolaryngostroboscopy (VLS) ratings and interpretation in normophonic and dysphonic speakers. STUDY DESIGN Prospective repeated measures design METHOD: Eight speech-language pathologists evaluated rigid VLS exams obtained from 12 dysphonic speakers with vocal fold pathology and 4 normophonic speakers with normal VLS exams. VLS exams were evaluated with the auditory signal present and absent with a washout period between rating sessions. VLS measures were obtained using the Voice-vibratory Assessment of Laryngeal Imaging (VALI) and a 100mm visual analog scale (VAS). The effects of the auditory signal and its interaction with voice quality severity on 9 VLS ratings, diagnostic billing codes, and treatment recommendations were examined. RESULTS There was no effect of auditory information on VLS measures or overall severity of laryngeal function evaluated using the VAS (ps > 0.05). There was a main effect of auditory information and a significant interaction with voice quality severity for only one VLS measure (non-vibrating portion-left) evaluated using the VALI (P = 0.05). Post-hoc analysis for this rating showed significant increases (t-test adjusted P < 0.05) when voice quality severity was moderate-severe (M = 4.8%; SD = 1.65%) and auditory information was present. Agreement in individual clinician's selection of diagnostic codes (73%) and treatment recommendations (65.6%) when auditory cues were present and absent was moderate to high. CONCLUSION The presence of the videolaryngostroboscopic auditory signal had a minimal effect on VLS ratings, treatment recommendations, or diagnostic billing codes.

Purpose Perceived listening effort is a perceptual dimension used to identify the amount of work necessary to understand disordered speech. The purpose of this study was to investigate the utility of perceived listening effort to provide unique information about disordered speech. The relationships between perceived listening effort and two current outcome measures (speech acceptability, intelligibility) were examined for listeners rating electrolaryngeal speech, along with their reliability and intra-rater agreement. Methods Ten healthy male speakers read low-context sentences using an electrolarynx. Twenty-five inexperienced listeners orthographically transcribed and rated the stimuli for perceived listening effort and speech acceptability using a visual analog scale. Strict reliability and agreement criteria were set. Results Perceived listening effort was moderately to strongly correlated with intelligibility (r = −0.76) and acceptability (r = −0.80), each of which contributed uniquely to ratings of perceived listening effort. However, only 17 listeners met stringent reliability and agreement criteria. Conclusions Ratings of perceived listening effort may provide unique information about the communicative success of individuals with communication disorders. There is great variability, however, among inexperienced listeners’ perceptual ratings of electrolaryngeal speech. Future research should investigate variables that may affect perceived listening effort specifically and auditory-perceptual ratings in general.

Objective The purpose of this study was to examine the unique contribution of psychosocial factors, including perceived social support, depression, and resilience to communicative participation, among adult survivors of head and neck cancer (HNC). Study Design Cross-sectional. Setting University-based laboratory and speech clinic. Subjects and Methods Adult survivors of HNC who were at least 2 years posttreatment for HNC completed patient-reported outcome measures, including those related to communicative participation and psychosocial function. Multiple linear regression analysis was conducted to predict communicative participation. Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis were entered first as a block of variables (block 1), and psychosocial factors were entered second (block 2). Results Eighty-eight adults who were on average 12.2 years post-HNC diagnosis participated. The final regression model predicted 58.2% of the variance in communicative participation (full model R2 = 0.58, P < .001). Self-rated speech severity, cognitive function, laryngectomy status, and time since diagnosis together significantly predicted 46.1% of the variance in block 1. Perceived social support, depression, resilience, and interactions significantly and uniquely predicted 12.1% of the additional variance in block 2. Conclusion For clinicians, psychosocial factors such as perceived depression warrant consideration when counseling patients with HNC about communication outcomes and when designing future studies related to rehabilitation.

Importance The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure assessing the association between communication disorders and participation in daily communication. To our knowledge, no prior research has examined whether CPIB scores change after treatment of unilateral vocal fold immobility (UVFI). Objective To compare CPIB scores before and after treatment of UVFI and with patient-defined target treatment outcomes and other common clinical outcomes after UVFI intervention. Design, setting, and participants This single-group case series recruited a convenience sample of community-dwelling patients aged 18 years or older from an urban academic medical center who had a diagnosis of UVFI and planned to receive intervention for UVFI. The study was conducted from March 2014 to March 2019. Exposures Intervention for UVFI according to clinicians' recommendations. The treatment type was not controlled for this study. Main outcomes and measures Patients' self-reported communicative participation was assessed by obtaining CPIB scores before and after treatment of UVFI, with scores calibrated to the standardized T scale. Pearson correlations between the CPIB general short form and computerized adaptive format, the Voice Handicap Index-10 (VHI-10), and self-rated and clinician-rated voice severity were also evaluated. Results The sample included 25 participants, of whom 17 (68%) were male, 8 (32%) were female, and the mean (SD) age was 54.9 (17.0) years. Significant changes after treatment were observed in all quantitative outcomes including the primary outcome of the CPIB; the mean T score before treatment was 40.95 (95% CI, 37.49-44.41) and after treatment was 53.23 (95% CI, 48.41-58.04) (mean difference, -13.04 [95% CI, -7.30 to -18.79]; Cohen d, 0.96). The Pearson correlation between the CPIB general short form and computerized adaptive testing scores at pretreatment was r = 0.93 and at posttreatment, r = 0.95. Computerized adaptive testing showed efficiency advantages, with typically 5 to 6 items required for administration compared with 10 items for the short form. The correlation between the CPIB and VHI-10 was moderate before treatment (r = -0.70) and strong after treatment (r = -0.91). Moderate correlations were observed between the CPIB and clinician-rated voice quality before (r = -0.52) and after (r = -0.46) treatment and between CPIB and self-rated voice quality before (r = -0.56) and after (r = -0.62) treatment. Conclusions and relevance The results of this case series suggest that the CPIB is relevant for clinical use to assess changes in communicative participation among patients with UVFI before and after they receive treatment.

Summary Objectives The purposes of this study were to (1) determine and compare the diagnostic accuracy of a single acoustic measure, smoothed cepstral peak prominence (CPPS), to predict voice disorder status from connected speech samples using two software systems: Analysis of Dysphonia in Speech and Voice ( ADSV ) and Praat ; and (2) to determine the relationship between measures of CPPS generated from these programs. Study Design This is a retrospective cross-sectional study. Methods Measures of CPPS were obtained from connected speech recordings of 100 subjects with voice disorders and 70 nondysphonic subjects without vocal complaints using commercially available ADSV and freely downloadable Praat software programs. Logistic regression and receiver operating characteristic (ROC) analyses were used to evaluate and compare the diagnostic accuracy of CPPS measures. Relationships between CPPS measures from the programs were determined. Results Results showed acceptable overall accuracy rates (75% accuracy, ADSV ; 82% accuracy, Praat ) and area under the ROC curves (area under the curve [AUC] = 0.81, ADSV ; AUC = 0.91, Praat ) for predicting voice disorder status, with slight differences in sensitivity and specificity. CPPS measures derived from Praat were uniquely predictive of disorder status above and beyond CPPS measures from ADSV ( χ 2 (1) = 40.71, P r = 0.88, P Conclusions A single acoustic measure of CPPS was highly predictive of voice disorder status using either program. Clinicians may consider using CPPS to complement clinical voice evaluation and screening protocols.

Purpose The purpose of this study was to examine the effect of severity of adductor spasmodic dysphonia (ADSD) and information about it on unfamiliar listeners' attitudes about speakers' personal characteristics, perceived vocal effort, and listener comfort on the basis of ratings of speech recordings. Method Fifteen women with ADSD and 5 controls provided speech samples. Forty-five unfamiliar listeners were randomized into 3 groups. Listeners in Group 1 received no information, listeners in Group 2 were told that some speakers had voice disorders or had no voice concerns, and listeners in Group 3 were provided diagnostic labels for each speaker and information about ADSD. Listeners then rated speech samples for attitudes, perceived vocal effort, and listener comfort. Results Speakers with ADSD were judged significantly worse than controls for attitudes related to “social desirability” and “intellect.” There was no effect of severity on “personality” attributes. However, provision of a diagnostic label resulted in significantly more favorable personality ratings than when no label was provided. Perceived vocal effort and comfort became significantly more negative as ADSD severity increased. Finally, most listener ratings were unaffected by provision of additional information about ADSD. Conclusions Listeners' perceptions about speakers with ADSD are difficult to change. Directions for counseling and public education need future study.

Purpose The purpose of this study was to determine the influence of symptom severity and disclosure of adductor spasmodic dysphonia (ADSD) on the perceptions of human resource personnel members (HRPs) during a simulated phone interview. Method One female speaker with ADSD was recorded reading an interview script at two time points: (a) pre-BOTOX injection (severe), and (b) post-BOTOX injection (mild). Thirty-two HRPs evaluated the recording in one of the two conditions via a qualitative structured interview. HRPs gave their recommendations regarding when and how to disclose ADSD. Results In the mild condition, no HRP perceived that the applicant had a voice disorder. Disclosure was not recommended as often, as an impairment was not initially noticed. However, 15/16 HRPs commented on the applicant's voice in the severe condition, with most suspecting she was a smoker or had lung/throat cancer. Disclosure in the severe condition was recommended more often, as it clarified symptoms that were noted at the outset. Conclusions Symptom severity in ADSD influences employer perceptions during the phone interview process. Incorrect assumptions may be made about applicants with severe symptoms, and apparentness of symptoms influences whether or not disclosure is recommended. Results have implications for counseling individuals with ADSD who are navigating the job interview process.

Head and neck cancer (HNC) affects structures related to speech and voice, such as the tongue, floor of the mouth, nasal cavity, palate, mandible, and larynx, among others. As a result, one of the most significant difficulties experienced by HNC patients relates to changes in verbal communication. These difficulties may lead to problems in returning to work, developing and maintaining relationships, or participating in a variety of activities, which may lead to social isolation. All of these types of communication difficulties may result in a negative impact on a person’s quality of life. In this chapter, I describe challenges in everyday communication situations, or communicative participation, that may occur as a result of HNC. Next, a novel patient-reported outcome measure, the Communicative Participation Item Bank (CPIB), is introduced. A framework is proposed that accounts for multiple factors that may relate to communicative participation. These factors not only include speech and voice severity but also include those related to a person’s environment, such as social support, or those related to the person, such as individual coping mechanisms. Therefore, these factors as well as related issues need consideration in the hope of directing future research and implementing new clinical practice patterns in this patient population.

Purpose: Survivors of head and neck cancer have reported difficulties with memory, attention, verbal fluency, and processing speed sometimes persisting years after treatment. Self-perceived cognitive function is an important predictor of communication outcomes in this population. This study explores the lived experience of cognitive changes in survivors of non-nasopharyngeal head and neck cancer and how these changes affect communication in their daily lives.Materials and methods: In the phenomenological tradition, five adult survivors of non-nasopharyngeal head and neck cancer participated in individual semi-structured interviews. The interviews were audio-recorded, transcribed, coded, and summarized into themes.Results: Two major themes emerged: (1) I would have told you about being forgetful, but I forgot; and (2) It's such a journey that much of it is uncharted. Participants described problems with memory, focus/attention, and task initiation along with slowed processing and language difficulties. These difficulties affected communication at work, socially, and at home. Participants expressed feeling unprepared for the possibility of cognitive changes, not knowing why they were happening or what to do about them.Conclusions: Results of this study have implications for counseling and treatment of individuals with head and neck cancer, as well as advocating for these patients to receive appropriate information and intervention.Implications for rehabilitationSurvivors of non-nasopharyngeal head and neck cancer described experiencing problems with memory and focus/attention along with slowed processing and language difficulties.Study participants generally felt both unprepared for the cognitive changes they experienced and, in many ways, unsupported by healthcare providers and others.Rehabilitation professionals should be aware that cognitive changes following medical treatment for head and neck cancer may affect a patient's ability to learn and follow complex treatment regimens.Rehabilitation professionals can advise and advocate for these patients to receive the appropriate referrals for assessment and treatment of their cognitive symptoms.

Summary Objective/Hypothesis To determine whether the presence and accuracy of a laryngeal medical diagnosis affects novice listeners' judgments of dysphonia. Study Design Prospective, within subjects, modified factorial experimental design. Methods Twenty-six speakers with dysphonia and four normophonic speakers provided speech recordings. Forty novice clinicians evaluated speech samples for roughness and breathiness using 100-mm visual analog scales in two conditions. First, speech samples were presented without diagnostic information. In the second condition, 50% of the speech samples were presented with the accurate laryngeal medical diagnosis, while the other 50% of samples were presented with an inaccurate (alternative) diagnosis. Results Results showed that judgments of dysphonia were affected by the presence of both accurate and inaccurate diagnoses. As expected, when compared to no known diagnosis, judgments of roughness significantly increased in severity when an accurate diagnostic label of vocal fold lesions was presented. Likewise, in comparison to no known diagnosis, judgments of breathiness trended toward an increase in severity when an accurate diagnostic label of vocal fold paralysis/paresis was presented. Interestingly, increases in perceived severity of dysphonia were also observed with the presentation of inaccurate diagnoses, with the overall effect of inaccurate diagnostic information being greater than accurate diagnoses. Specifically, increases in perceived roughness and breathiness were observed when inaccurate diagnoses included benign vocal fold lesion(s) and vocal fold paralysis/paresis. In contrast, inaccurate diagnostic labels indicating “clear larynx” or diagnoses other than benign vocal fold lesion(s) or paralysis/paresis resulted in decreased perceived roughness and breathiness severity. The magnitude of the differences in perceived severity between conditions was overall reduced for breathiness compared to roughness. Conclusions Sources of bias such as knowledge and accuracy of medical diagnoses should be considered when novice clinicians use auditory-perceptual measures to evaluate dysphonia and measure treatment outcomes.

Background The purpose of this study was to examine relationships between communicative participation and postlaryngectomy speech outcomes, including listener-rated speech intelligibility and acceptability, and patient-rated speech acceptability and voice handicap. Methods Thirty-six laryngectomized individuals completed the Communicative Participation Item Bank (CPIB) short form and the Voice Handicap Index-10 (VHI-10). They provided recordings from the Sentence Intelligibility Test (SIT) and a reading passage, and rated their own speech acceptability. Forty-eight inexperienced listeners transcribed the SIT sentences to derive intelligibility scores. Eighteen additional listeners judged the speech acceptability using the rating scales. Results Listeners judged tracheoesophageal speakers as significantly more intelligible and acceptable than electrolaryngeal speakers (p < .05). Speech acceptability was significantly more acceptable to speakers than listeners (p < .05). Weak, nonsignificant relationships were found between communicative participation and listener-rated outcomes. Stronger, significant relationships were found between communicative participation and self-rated speech acceptability and voice handicap (p < .05). Conclusion Patient-reported communication outcomes are complementary to listener-rated outcomes. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Individuals with adductor spasmodic dysphonia (ADSD) have reported that unfamiliar communication partners appear to judge them as sneaky, nervous or not intelligent, apparently based on the quality of their speech; however, there is minimal research into the actual everyday perspective of listening to ADSD speech. The purpose of this study was to investigate the impressions of listeners hearing ADSD speech for the first time using a mixed-methods design. Everyday listeners were interviewed following sessions in which they made ratings of ADSD speech. A semi-structured interview approach was used and data were analyzed using thematic content analysis. Three major themes emerged: (1) everyday listeners make judgments about speakers with ADSD; (2) ADSD speech does not sound normal to everyday listeners; and (3) rating overall severity is difficult for everyday listeners. Participants described ADSD speech similarly to existing literature; however, some listeners inaccurately extrapolated speaker attributes based solely on speech samples. Listeners may draw erroneous conclusions about individuals with ADSD and these biases may affect the communicative success of these individuals. Results have implications for counseling individuals with ADSD, as well as the need for education and awareness about ADSD.

Purpose The acoustic measure relative fundamental frequency (RFF) was investigated as a potential objective measure to track variations in vocal effort within and across individuals. Method Twelve speakers with healthy voices created purposeful modulations in their vocal effort during speech tasks. RFF and an aerodynamic measure of vocal effort, the ratio of sound pressure level to subglottal pressure level, were estimated from the aerodynamic and acoustic signals. Twelve listeners also judged the speech samples for vocal effort using the visual sort and rate method. Results Relationships between RFF and both the aerodynamic and perceptual measures of vocal effort were weak across speakers ( R 2 = .06–.26). Within speakers, relationships were variable but much stronger on average ( R 2 = .45–.56). Conclusions RFF showed stronger relationships between both the aerodynamic and perceptual measures of vocal effort when examined within individuals versus across individuals. Future work is necessary to establish these relationships in individuals with voice disorders across the therapeutic process.

Background Beyond the severity of voice, speech and language impairments, one potential predictor of communication success across adult populations with communication disorders may be perceived social support: the expectation that others will provide support if needed. Despite the preponderance of intervention approaches that assume a positive relationship between perceived social support and patient-reported communication success, the evidence base for these relationships is limited. Aims The aim of this systematic review is to explore relationships between measures of perceived social support and patient-reported communication outcomes in adult populations with communication disorders. Methods & procedures The PRISMA guidelines were followed in the conduct and reporting of this review. Electronic databases including PubMed, PsychINFO and CINAHL were systematically searched up to 19 May 2017. Additional data were obtained for two studies. All the included studies were appraised using the Critical Appraisal Skills Program (CASP) tools. Given the heterogeneous nature of the studies, data synthesis was narrative for the quantitative studies. A meta-ethnographic approach was used to synthesize qualitative data. Outcomes & results Eight quantitative and four qualitative studies met eligibility criteria. All quantitative studies met eight of eight quality criteria. For the qualitative studies, one study met nine of nine quality criteria; the remaining three studies met three, seven and eight quality criteria. Of the eight included quantitative studies, six independent data sets were used. Results revealed no significant relationships between perceived social support and communication outcomes in three studies (two aphasia with one data set, one Parkinson's disease), while perceived social support was a weak, but significant predictor in two studies (one multiple sclerosis, one head and neck cancer). Three additional studies (two aphasia with one data set; one Parkinson's disease) found that relationships were initially weak, but strengthened over time to become moderate. Results from qualitative studies (one head and neck cancer, two aphasia, one multiple sclerosis) revealed that perceived social support acted as a facilitator, and absent or misguided support acted as a barrier to communication outcomes. Skilful, responsive family members were able to facilitate better quality of communicative interactions, whereas lack of social support, or negative attitudes and behaviours of other people, were barriers. Conclusions & implications While perceived social support may affect communication outcomes in adults with communication disorders, current measures may not adequately capture these constructs. Results have implications for future research and interventions for speech and language therapists.

Summary Objective To determine the effect of presence and location of severity labels for different types of visual analog scales (VAS) on overall severity (OS) ratings in dysphonic speech. Study Design Experimental, between group comparisons. Methods Dysphonic and normal voice samples from male and female speakers were presented to inexperienced listeners for judgments of OS. To rate samples, listeners used an undifferentiated 100-mm VAS labeled at the extremes, a VAS with nonlinearly distributed labels as in the “beta” version of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), or a VAS with symmetrically distributed labels as in the “official” version of the CAPE-V. Results Overall, mean OS ratings did not differ significantly across scale types, although ratings using the nonlinearly marked VAS were generally lower than those from other scales. This effect was significant for female speakers whose samples tended toward moderate OS. The ratings distribution, when compiled into 10-mm bins, differed significantly by scale type, with users of the nonlinearly marked scales skewing their ratings toward normal. Conclusions The presence and placement of labels on VAS did not significantly affect OS ratings overall, but values were significantly lower when rating female voices with the nonlinearly labeled VAS. Results indicate that professionals should specify the scale type used for rating OS and use scales consistently when comparing voices.

Purpose To determine whether unfamiliar listeners' perceptions of speakers with adductor spasmodic dysphonia (ADSD) differ from control speakers on the parameters of relative age, confidence, tearfulness, and vocal effort and are related to speaker-rated vocal effort or voice-specific quality of life. Method Twenty speakers with ADSD (including 6 speakers with ADSD plus tremor) and 20 age- and sex-matched controls provided speech recordings, completed a voice-specific quality-of-life instrument (Voice Handicap Index; Jacobson et al., 1997), and rated their own vocal effort. Twenty listeners evaluated speech samples for relative age, confidence, tearfulness, and vocal effort using rating scales. Results Listeners judged speakers with ADSD as sounding significantly older, less confident, more tearful, and more effortful than control speakers ( p < .01). Increased vocal effort was strongly associated with decreased speaker confidence ( r s = .88–.89) and sounding more tearful ( r s = .83–.85). Self-rated speaker effort was moderately related ( r s = .45–.52) to listener impressions. Listeners' perceptions of confidence and tearfulness were also moderately associated with higher Voice Handicap Index scores ( r s = .65–.70). Conclusion Unfamiliar listeners judge speakers with ADSD more negatively than control speakers, with judgments extending beyond typical clinical measures. The results have implications for counseling and understanding the psychosocial effects of ADSD.

Objective: The purpose of this study was to determine how a new self-report outcome measure of communicative participation, the Communicative Participation Item Bank (CPIB), related to disease- and discipline-specific quality of life (QOL) outcomes in a head and neck cancer (HNC) population. Methods: One hundred ninety-five individuals treated for HNC completed the CPIB, the University of Washington Quality of Life questionnaire (UW-QOL), and the Voice Handicap Index–10 (VHI-10). Results: Results revealed moderate QOL scores across the UW-QOL (mean scores: global QOL = 66; physical subscale = 70; social-emotional subscale = 73) and VHI-10 (mean = 16). Correlations between the CPIB and the UW-QOL scores were statistically significant ( P < .001) but relatively weak ( r = .37–.38). As hypothesized, a stronger correlation was found between the CPIB and the VHI-10 ( r = −0.79; P < .001). Conclusion: Clinicians may consider adopting the CPIB to complement existing tools in assessing communication outcomes after HNC.

Purpose The aim of this study was to recommend protocols for instrumental assessment of voice production in the areas of laryngeal endoscopic imaging, acoustic analyses, and aerodynamic procedures, which will (a) improve the evidence for voice assessment measures, (b) enable valid comparisons of assessment results within and across clients and facilities, and (c) facilitate the evaluation of treatment efficacy. Method Existing evidence was combined with expert consensus in areas with a lack of evidence. In addition, a survey of clinicians and a peer review of an initial version of the protocol via VoiceServe and the American Speech-Language-Hearing Association's Special Interest Group 3 (Voice and Voice Disorders) Community were used to create the recommendations for the final protocols. Results The protocols include recommendations regarding technical specifications for data acquisition, voice and speech tasks, analysis methods, and reporting of results for instrumental evaluation of voice production in the areas of laryngeal endoscopic imaging, acoustics, and aerodynamics. Conclusion The recommended protocols for instrumental assessment of voice using laryngeal endoscopic imaging, acoustic, and aerodynamic methods will enable clinicians and researchers to collect a uniform set of valid and reliable measures that can be compared across assessments, clients, and facilities.

Purpose The purpose of this study was to examine how sentence intelligibility relates to self-reported communication in tracheoesophageal speakers when speech intelligibility is measured in quiet and noise. Method Twenty-four tracheoesophageal speakers who were at least 1 year postlaryngectomy provided audio recordings of 5 sentences from the Sentence Intelligibility Test. Speakers also completed self-reported measures of communication—the Voice Handicap Index-10 and the Communicative Participation Item Bank short form. Speech recordings were presented to 2 groups of inexperienced listeners who heard sentences in quiet or noise. Listeners transcribed the sentences to yield speech intelligibility scores. Results Very weak relationships were found between intelligibility in quiet and measures of voice handicap and communicative participation. Slightly stronger, but still weak and nonsignificant, relationships were observed between measures of intelligibility in noise and both self-reported measures. However, 12 speakers who were more than 65% intelligible in noise showed strong and statistically significant relationships with both self-reported measures ( R 2 = .76–.79). Conclusions Speech intelligibility in quiet is a weak predictor of self-reported communication measures in tracheoesophageal speakers. Speech intelligibility in noise may be a better metric of self-reported communicative function for speakers who demonstrate higher speech intelligibility in noise.

Purpose The purpose of this study was to examine the effects of an internally versus externally cued speech task on perceived understandability and naturalness in speakers with Parkinson's disease (PD) and cerebellar disease (CD). Method Sentences extracted from a covertly recorded conversation (internally cued) were compared to the same sentences read aloud (externally cued) by speakers with PD and a clinical comparison group of speakers with CD. Experienced listeners rated the speech samples using a visual analog scale for the perceptual dimensions of understandability and naturalness. Results Results suggest that experienced listeners rated the speech of participants with PD as significantly more natural and more understandable during the reading condition. Participants with CD were also rated as significantly more understandable during the reading condition, but ratings of naturalness did not differ between conversation and reading. Conclusions Speech tasks can have a pronounced impact on perceived speech patterns. For individuals with PD, both understandability and naturalness can improve during reading tasks versus conversational tasks. The speech benefits from reading may be attributed to several mechanisms, including possible improvement from an externally cued speech task. These findings have implications for speech task selection in evaluating individuals with dysarthria.

Purpose In this study, the authors aimed to determine the relationship between relative fundamental frequency (RFF) and listener perception of vocal effort in individuals with varying degrees of vocal hyperfunction. Method Thirty women diagnosed with voice disorders commonly associated with vocal hyperfunction and 10 healthy women provided speech samples that were used to obtain parameters of RFF. Twelve listeners judged the speech samples for overall severity and vocal effort (VE) using rating scales. Results Significant but relatively weak negative correlations were found between perceptual measures and offset RFF parameters. Although offset RFF was increased in healthy participants relative to speakers with voice disorders, no differences were seen in RFF as a function of severity of VE in individuals with voice disorders. Conclusions Although a statistically significant correlation between offset RFF and VE was found, examination of data as a function of both VE and health status indicated that RFF more accurately classifies the presence of a voice disorder than does severity of voice quality or VE. There is a need for further research to investigate the clinical utility of RFF measures for assessment of rehabilitation progress.

To determine how standard residency training and educational background affect otolaryngology resident auditory-perceptual judgments compared with inexperienced listeners. A secondary aim was to assess the impact of a brief training session on the reliability of judgments among otolaryngology residents.Mixed cross-sectional and cohort study.Twenty adult dysphonic and four normal speaker samples were selected from a database. Fifteen listeners at various stages of residency in otolaryngology judged all samples for breathiness and roughness using visual analog scales. Fifteen inexperienced listeners judged the same samples. Subsequently, 12 otolaryngology residents underwent a brief training session. During training, listeners were provided definitions of rating dimensions and accuracy feedback while rating 20 novel (training) stimuli. The feedback included averaged responses from experienced clinicians who had previously evaluated the same speech samples. The residents then completed posttraining evaluations.As a group, otolaryngology resident listeners had significantly better interrater agreement for judgments of roughness compared with inexperienced listeners (P0.05) and trended toward better interrater agreement for judgments of breathiness (P=0.058). Posttraining, no significant improvement in interrater agreement for judgments of roughness was observed; however, a significant improvement was found in interrater agreement of judgments of breathiness (P0.05).Compared with inexperienced (untrained) listeners, otolaryngology resident listeners had better interrater agreement overall for judgments of dysphonia. A short training module was associated with improved reliability in resident evaluation of breathiness. Results have implications for improving and standardizing resident evaluation of dysphonia.

Purpose To determine (a) the effect of fundamental frequency (f 0 ) on speech intelligibility, acceptability, and perceived gender in electrolaryngeal (EL) speakers, and (b) the effect of known gender on speech acceptability in EL speakers. Method A 2-part study was conducted. In Part 1, 34 healthy adults provided speech recordings using electrolarynges set at 75 Hz, 130 Hz, and 175 Hz, and 36 listeners transcribed the recordings. In Part 2, 22 speech samples were presented to 16 listeners. First, listeners identified the gender of each speaker and judged his or her speech acceptability using rating scales. Second, listeners judged the same samples for speech acceptability when gender information was provided. Results In Part 1, speakers were significantly more intelligible when using 75-Hz devices. In Part 2, the f 0 of the speech signal significantly impacted listeners' accuracy in perceiving the speaker’s gender: In gender-incongruent conditions (males using 175-Hz devices, females using 75-Hz devices), listeners were unable to identify female speakers. Speech acceptability judgments were directly related to intelligibility. Finally, listeners differentially penalized female speakers who used 75-Hz devices when gender information was known. Conclusion Low f 0 facilitated speech intelligibility. However, at low f 0 , listeners were unable to identify females as female, and females were differentially penalized for speech acceptability. Results may have implications for rehabilitation.

To investigate how ways of coping and traditional factors (age, sex, time postlaryngectomy, stage of disease, radiation, alaryngeal speech method) predict global quality of life, head and neck cancer-specific quality of life, and voice-related quality-of-life outcomes after total laryngectomy.Cross-sectional survey.University-based laboratory and speech clinic.Sixty-seven individuals who underwent total laryngectomy secondary to cancer were recruited from support groups and professional contacts. Individuals were at minimum 9 months postlaryngectomy. All outcomes were patient reported and included demographic data as well as a number of validated questionnaires: the Ways of Coping-Cancer Version (WOC-CV) scale, the Voice-Related Quality of Life (V-RQOL) scale, and the University of Washington Quality of Life (UW-QOL) composite and global QOL scores.Fifty-three individuals identified a stressful aspect of their laryngectomy. As a set, traditional variables (age, time postlaryngectomy, alaryngeal speech method) accounted for only 5% of global QOL scores but between 25% and 30% of the variance of composite UW-QOL and V-RQOL scores. Time postlaryngectomy was the strongest traditional predictor. Ways of coping accounted for 23% to 32% of all QOL scores. Avoidant coping strategies (both cognitive and behavioral escape) were among the strongest predictors of poorer QOL. When traditional variables were combined with ways of coping, they together accounted for 26% to 46% of the variance of QOL outcomes.Coping is important to consider when evaluating postlaryngectomy outcomes, above and beyond traditionally investigated factors.

Background: The term ‘speech usage’ refers to what people want or need to do with their speech to fulfil the communication demands in their life roles. Speech–language pathologists (SLPs) need to know about clients’ speech usage to plan appropriate interventions to meet their life participation goals. The Levels of Speech Usage is a categorical scale intended for client self-report of speech usage, but SLPs may want the option to use it as a proxy-report tool. The relationship between self-report and clinician ratings should be examined before the instrument is used in a proxy format. Aims: The primary purpose of this study was to compare client self-ratings with SLP ratings on the Levels of Speech Usage scale. The secondary purpose was to determine if the SLP ratings differed depending on whether or not the SLPs knew about the clients’ medical condition. Methods & Procedures: Self-ratings of adults with communication disorders on the Levels of Speech Usage scale were available from prior research. Vignettes about these individuals were created from existing data. Two sets of vignettes were created. One set contained information about demographic information, living situation, occupational status and hobbies or social activities. The second set was identical to the first with the addition of information about the clients’ medical conditions and communication disorders. Various communication disorders were represented including dysarthria, voice disorders, laryngectomy, and mild cognitive and language disorders. Sixty SLPs were randomly divided into two groups with each group rating one set of vignettes. The task was completed online. While this does not replicate typical in-person clinical interactions, it was a feasible method for this study. For data analysis, the client self-ratings were considered fixed points and the percentage of SLP ratings in agreement with the self-ratings was calculated. Outcomes & Results: The percentage of SLP ratings in exact agreement with client self-ratings was 44.9%. Agreement was lowest for the less-demanding speech usage categories and highest for the most demanding usage category. There was no significant difference between the two groups of SLPs based on knowledge of medical condition. Conclusions & Implications: SLPs often need to document the speech usage levels of clients. This study suggests the potential for SLPs to misjudge how clients see their own speech demands. Further research is needed to determine if similar results would be found in actual clinical interactions. Until then, SLPs should seek the input of their clients when using this instrument.

Objectives: Little is known about the function of the true vocal folds (TVFs) during cough. The objective of this study was to determine the reliability of measuring TVF movements during cough and to obtain preliminary normative data for these measures. Methods: Sequential glottal angles associated with TVF adduction and abduction across the phases of cough were analyzed from laryngeal videoendoscopy records of 38 young healthy individuals. Results: The intraobserver and interobserver reliability of 3 experienced measurers was high (intraclass correlation of at least 0.97) for measuring sequential and maximum glottal angles. The TVF abduction velocity during expulsion was significantly higher than the precompression adduction velocity (p = 0.002), but there were no significant differences in maximum angle. No statistically significant differences were seen in maximum TVF angle and velocity when they were compared between the sexes and between the levels of cough strength. True vocal fold closure following expulsion occurred in 42% of soft coughs and in 57% of moderate to hard coughs. Conclusions: The TVF abduction angles during cough can be reliably measured from laryngeal videoendoscopy in young healthy individuals. The TVF movements are faster for expulsion abduction than for precompression adduction, but the extents of abduction are similar. To validly determine the cough phase duration, simultaneous measures of airflow are needed.

Purpose To determine the effect of auditory anchors on judgments of overall severity (OS) and vocal effort (VE) in dysphonic speech when judgments are made by experienced and inexperienced listeners, and when self-rated by individuals with dysphonia (speaker–listeners). Method Twenty individuals with dysphonia and 4 normal controls provided speech recordings. Speaker–listeners judged their own speech samples for OS and VE without auditory anchors, and then in the presence of anchors, using 100-mm visual analog scales (VAS). Twenty inexperienced and 10 experienced listeners evaluated the same speech samples for OS and VE in similar rating conditions. Twenty inexperienced listeners also made judgments of the speech samples solely in anchored conditions. Results All listeners judged the speech samples as significantly less severe and effortful in the anchored conditions. No significant effects of anchors or experience were found for intrarater agreement within 7.14 mm on the VAS. Both inexperienced and experienced listeners were significantly less variable and showed improved interrater agreement in the anchored conditions. Anchors significantly improved agreement across groups of listeners, particularly between inexperienced and speaker–listeners. Conclusion Listeners systematically shift judgments of voice quality in response to auditory anchors. Anchors reduce interrater variability and may improve agreement across some types of listeners.

The objectives of this study were to determine the effect of musical background on both pitch discrimination abilities and the reliability of judging voice quality in dysphonic speakers, and to determine the relationship between pitch discrimination abilities and the reliability of voice quality judgments. Twenty musicians and 20 nonmusicians performed pitch discrimination tests. They also made judgments of dysphonic vowels and speech samples for breathiness and roughness using 100-mm visual analog scales. Musicians demonstrated significantly smaller pitch discrimination thresholds than nonmusicians. For measures of intrarater agreement, musicians were significantly more consistent than nonmusicians for judgments of breathiness in both vowels and speech produced by dysphonic speakers. Musicians also showed significantly better interrater agreement for judgments of breathiness in vowels. Weak to moderate relationships were found between pitch discrimination abilities and agreement values for voice quality judgments. Results suggest that musical background may affect a listener's reliability in making judgments of dysphonia, particularly for judgments of breathiness. However, simple pitch discrimination skills of pure tones do not explain these differences. More complex stimuli should be used in future investigations to help determine the nature of underlying differences.

Purpose The purpose of this study was to conduct the initial psychometric analyses of the Communicative Participation Item Bank—a new self-report instrument designed to measure the extent to which communication disorders interfere with communicative participation. This item bank is intended for community-dwelling adults across a range of communication disorders. Method A set of 141 candidate items was administered to 208 adults with spasmodic dysphonia. Participants rated the extent to which their condition interfered with participation in various speaking communication situations. Questionnaires were administered online or in a paper version per participant preference. Participants also completed the Voice Handicap Index (B. H. Jacobson et al., 1997) and a demographic questionnaire. Rasch analyses were conducted using Winsteps software (J. M. Linacre, 1991). Results The results show that items functioned better when the 5-category response format was recoded to a 4-category format. After removing 8 items that did not fit the Rasch model, the remaining 133 items demonstrated strong evidence of sufficient unidimensionality, with the model accounting for 89.3% of variance. Item location values ranged from −2.73 to 2.20 logits. Conclusions Preliminary Rasch analyses of the Communicative Participation Item Bank show strong psychometric properties. Further testing in populations with other communication disorders is needed.

To revise and improve the instructions, candidate items and response format for a tool to measure communicative participation.Cognitive interviewing techniques, designed to study the process that respondents use to answer survey questions, were used to test a bank of candidate items for a measure of communicative participation. Twelve participants with spasmodic dysphonia (SD), a neurologic condition characterized by voice and speech changes, were asked to complete a sample questionnaire and then were interviewed regarding the clarity of instructions, candidate items and response format. Analysis of the interviews was conducted using qualitative techniques and resulted in a series of modifications to the measurement tool.Problems identified related to candidate items included inadequate context, double-barreled or ambiguous items, redundancy, unclear or generally confusing items, infrequent situations, and cultural sensitivity. Participants preferred response options that asked them to rate interference rather than other dimensions such as satisfaction. CONCLUSIONS; Subtle differences in items and response options make key differences in how participants interpret and make decisions about their responses. Rich contextual information is needed in order to respond to items that sample communicative participation. Participants preferred response options that capture the barriers that they experience when participating in everyday communication situations.

Objectives: We performed a prospective, exploratory study 1) to determine differences in judgments of overall severity (OS) and vocal effort (VE) in adductor spasmodic dysphonia (ADSD) when judgments are made by experienced listeners, naive listeners, and speakers with ADSD; 2) to determine differences in judgments of listener comfort (LC) in ADSD when judgments are made by experienced and naive listeners; and 3) to determine relationships between auditory-perceptual ratings of voice and speakers' voice handicap. Methods: Twenty speakers with ADSD provided speech recordings. They judged their own speech samples for OS and VE and completed the Voice Handicap Index (VHI). Twenty naive and 8 experienced listeners evaluated speech samples for OS, VE, and LC using rating scales. Results: No differences were found for judgments of OS, VE, or LC across the groups. However, the strategies used by the speakers seemed to differ from those used by the other listeners in making OS and VE judgments. The speakers' self-judged VE correlated moderately with voice handicap; experienced and naive listeners' judgments were only weakly related to VHI scores. Conclusions: Speakers with ADSD and listeners appear to use auditory-perceptual dimensions differently. Voice handicap is best predicted by patient-perceived VE, and not by clinician or naive listeners' judgments.

Purpose To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation. Method Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties. Results No instrument exclusively measured communicative participation. Twenty-six percent ( n = 34) of all items ( N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties. Conclusions No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

Summary Objective The Americans with Disabilities Act Amendments Act of 2008 (ADAAA) resulted in changes to the legal definition of disability and substantially affected how those with voice disorders may qualify for reasonable accommodations under the law. However, there has been little guidance and a lack of awareness about these changes within the voice literature. This article examines the Americans with Disabilities Act of 1990 (ADA), the changes made in 2008 (ADAAA), and how the law applies to individuals with voice disorders. Study Design This is a review article. Methods The ADA and ADAAA are summarized with a particular focus on individuals with voice disorders. Types of reasonable accommodations within the workplace are suggested, and online resources are provided which outline the disclosure and accommodation process. Practical examples are used to provide guidance for clinicians who may be involved in counseling this clinical population. Results/Conclusions Many individuals with voice disorders may not realize that their conditions can be classified as disabilities under the law, entitling them to workplace accommodations and time off to pursue medical treatment. However, disclosure laws such as the right to refrain from mentioning a disability during a job interview may not be protective of individuals with severe voice impairments, as symptoms are often difficult to conceal. Clinical implications and directions for future research are discussed.

The purpose of this study was to determine the validity of voice pleasantness and overall voice severity ratings of dysphonic and normal speakers using direct magnitude estimation (DME) and equal-appearing interval (EAI) auditory-perceptual scaling procedures. Twelve naive listeners perceptually evaluated voice pleasantness and severity from connected speech samples produced by 24 adult dysphonic speakers and 6 normal adult speakers. A statistical comparison of the two auditory-perceptual scales yielded a linear relationship representative of a metathetic continuum for voice pleasantness. A statistical relationship that is consistent with a prothetic continuum was revealed for ratings of voice severity. These data provide support for the use of either DME or EAI scales when making auditory-perceptual judgments of pleasantness, but only DME scales when judging overall voice severity for dysphonic speakers. These results suggest further psychophysical study of perceptual dimensions of voice and speech must be undertaken in order to avoid the inappropriate and invalid use of EAI scales used in the auditory-perceptual evaluation of the normal and dysphonic voice.

Summary Objectives “Speech usage” refers to what people want or need to do with their speech to meet communication demands in life roles. The purpose of this study was to contribute to validation of the Levels of Speech Usage scale by providing descriptive data from a sample of adults without communication disorders, comparing this scale to a published Occupational Voice Demands scale and examining predictors of speech usage levels. Study design This is a survey design. Methods Adults aged ≥25 years without reported communication disorders were recruited nationally to complete an online questionnaire. The questionnaire included the Levels of Speech Usage scale, questions about relevant occupational and nonoccupational activities (eg, socializing, hobbies, childcare, and so forth), and demographic information. Participants were also categorized according to Koufman and Isaacson occupational voice demands scale. Results A total of 276 participants completed the questionnaires. People who worked for pay tended to report higher levels of speech usage than those who do not work for pay. Regression analyses showed employment to be the major contributor to speech usage; however, considerable variance left unaccounted for suggests that determinants of speech usage and the relationship between speech usage, employment, and other life activities are not yet fully defined. Conclusions The Levels of Speech Usage may be a viable instrument to systematically rate speech usage because it captures both occupational and nonoccupational speech demands. These data from a sample of typical adults may provide a reference to help in interpreting the impact of communication disorders on speech usage patterns.

Purpose The purpose of this study was to calibrate the items for the Communicative Participation Item Bank (CPIB; Baylor, Yorkston, Eadie, Miller, & Amtmann, 2009; Yorkston et al., 2008) using item response theory (IRT). One overriding objective was to examine whether the IRT item parameters would be consistent across different diagnostic groups, thereby allowing creation of a disorder-generic instrument. The intended outcomes were the final item bank and a short form ready for clinical and research applications. Method Self-report data were collected from 701 individuals representing 4 diagnoses: multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis, and head and neck cancer. Participants completed the CPIB and additional self-report questionnaires. CPIB data were analyzed using the IRT graded response model. Results The initial set of 94 candidate CPIB items were reduced to an item bank of 46 items demonstrating unidimensionality, local independence, good item fit, and good measurement precision. Differential item functioning analyses detected no meaningful differences across diagnostic groups. A 10-item, disorder-generic short form was generated. Conclusions The CPIB provides speech-language pathologists with a unidimensional, self-report outcomes measurement instrument dedicated to the construct of communicative participation. This instrument may be useful to clinicians and researchers wanting to implement measures of communicative participation in their work.

Objectives: This study characterized the relationship between relative fundamental frequency (RFF) and listeners' perceptions of vocal effort and overall spasmodic dysphonia severity in the voices of 19 individuals with adductor spasmodic dysphonia. Methods: Twenty inexperienced listeners evaluated the vocal effort and overall severity of voices using visual analog scales. The squared correlation coefficients (R2) between average vocal effort and overall severity and RFF measures were calculated as a function of the number of acoustic instances used for the RFF estimate (from 1 to 9, of a total of 9 voiced-voiceless-voiced instances). Results: Increases in the number of acoustic instances used for the RFF average led to increases in the variance predicted by the RFF at the first cycle of voicing onset (onset RFF) in the perceptual measures; the use of 6 or more instances resulted in a stable estimate. The variance predicted by the onset RFF for vocal effort (R2 range, 0.06 to 0.43) was higher than that for overall severity (R2 range, 0.06 to 0.35). The offset RFF was not related to the perceptual measures, irrespective of the sample size. Conclusions: This study indicates that onset RFF measures are related to perceived vocal effort in patients with adductor spasmodic dysphonia. These results have implications for measuring outcomes in this population.

Purpose To determine what research evidence exists to support the use of voice measures in the clinical assessment of patients with voice disorders. Method The American Speech-Language-Hearing Association (ASHA) National Center for Evidence-Based Practice in Communication Disorders staff searched 29 databases for peer-reviewed English-language articles between January 1930 and April 2009 that included key words pertaining to objective and subjective voice measures, voice disorders, and diagnostic accuracy. The identified articles were systematically assessed by an ASHA-appointed committee employing a modification of the critical appraisal of diagnostic evidence rating system. Results One hundred articles met the search criteria. The majority of studies investigated acoustic measures (60%) and focused on how well a test method identified the presence or absence of a voice disorder (78%). Only 17 of the 100 articles were judged to contain adequate evidence for the measures studied to be formally considered for inclusion in clinical voice assessment. Conclusion Results provide evidence for selected acoustic, laryngeal imaging–based, auditory–perceptual, functional, and aerodynamic measures to be used as effective components in a clinical voice evaluation. However, there is clearly a pressing need for further high-quality research to produce sufficient evidence on which to recommend a comprehensive set of methods for a standard clinical voice evaluation.

Purpose To explore the similarities and differences in self-reported restrictions in communicative participation across different communication disorders in community-dwelling adults. Method Interviews were conducted with 44 adults representing 7 different medical conditions: spasmodic dysphonia, multiple sclerosis, stroke, stuttering, Parkinson’s disease, amyotrophic lateral sclerosis, and laryngectomy. This article represents a secondary analysis of qualitative data collected in cognitive interviews during development of the Communicative Participation Item Bank. The data were analyzed to identify themes in participants' experiences related to communicative participation. Results Participants described many situations in which they experienced interference in communicative participation. Two themes emerged from the data. The first theme was Interference is both “functional” and “emotional,” in which participants defined interference as limitations in accomplishing tasks and emotional consequences. The second theme was “It depends”—sources of interference, in which participants described many variables that contribute to interference in participation. Participants had limited control of some variables such as symptoms and environmental contexts, but personal decisions and priorities also influenced participation. Conclusions Despite different impairments and activity limitations, participants described similar communicative participation restrictions. These similarities may have theoretical and clinical implications in terms of how we assess, treat, and study the participation restrictions associated with communication disorders.

The purpose of this study was to determine whether: (a) inexperienced listeners can reliably judge listener effort and (b) whether listener effort provides unique information beyond speech intelligibility or acceptability in tracheoesophageal speech. Twenty inexperienced listeners made judgments of speech acceptability and amount of effort required to listen to 14 male tracheoesophageal speakers using a paired comparison paradigm. Intelligibility was controlled to limit the analysis to the relationship between ratings of listener effort and speech acceptability. Results showed that as a group, inexperienced listeners reliably rated both speech acceptability and listener effort. In addition, ratings of speech acceptability and listener effort were strongly correlated ( r > .99); however, there was evidence that some individual listeners assigned different ratings for each dimension for the same speech samples. Results have important implications for communication success for tracheoesophageal speakers. Learning outcomes: Readers will be able to describe: (a) the measurement of listener burden in speech and (b) the differences and relationships among listener effort, speech acceptability and speech intelligibility.

Summary Objective/Hypothesis To determine whether knowledge of medical diagnosis biases listeners with varied experience levels in their judgments of dysphonia. Study Design Prospective, mixed experimental and comparative design. Methods Twenty-six speakers with dysphonia and four normal controls provided speech recordings. Twenty novice and eight experienced clinicians evaluated speech samples for roughness and breathiness using 100-mm visual analog scales. In one condition, the speech samples were presented without diagnostic information; in the second condition, samples were presented in conjunction with the medical diagnosis. Results Regardless of experience level, listeners judged the samples as significantly more severe when the speakers' diagnoses were known. Specifically, novice listeners (NLs) significantly increased the severity of judgments for speakers who were mildly breathy or mildly or moderately rough when diagnostic information was known. In addition, listeners in both groups judged speakers with mass lesions to be significantly rougher when diagnosis was known; this bias was not observed for speakers with other diagnoses. NLs also trended toward increasing the severity of breathiness judgments for individuals with known vocal fold paralysis but not other diagnoses. Conclusions Sources of bias such as knowledge of medical diagnoses should be considered when listeners with varied experience levels use auditory-perceptual measures to evaluate dysphonia.

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) provides a conceptual framework for assessing and treating individuals with communication disorders. This article provides an explanation and application of the ICF to communication after total laryngectomy. To evaluate outcomes associated with total laryngectomy, common assessment tools used in speech-language pathology are described in relation to communication at the levels of Body Functions and Structures, and Activities and Participation. Assessments for Contextual Factors also are discussed. Post-laryngectomy outcomes, including those related to quality of life, also are described relative to the ICF framework. In particular, the role of Environmental and Personal Factors is summarized, and implications are presented for approaches to assessment and treatment of this clinical population. A concluding case example illustrates how all of these concepts can be applied by speech-language pathologists who provide post-laryngectomy rehabilitation.