Efficacy of intensive voice therapy for patients with vocal fold nodules

The primary aetiologic factor for vocal fold nodules has been proposed to be cumulative perpendicular impact stress between the vocal folds over time, which increases with voice use (Titze, 1994). Many people with vocal fold nodules work in high vocal demand occupations, therefore, it is essential that they recover vocal function so that their ability to perform their jobs is not compromised (Karkos & McCormick, 2009). A number of studies have reported positive improvements in vocal fold nodules following various types of behavioural voice therapy, and as such, voice therapy is recommended as a first-line treatment (Blood, 1994; Holmberg, Hillman, Hammarberg, Sodersten, & Doyle 2001; Holmberg et al, 2003; Hogikyan, Appel, Guinn, & Haxer, 1999; Hufnagle & Hufnagle, 1984; Lancer, Syder, Jones, & Le Boutillier, 1988; Lockhart, Paton, & Pearson, 1997; Murry & Woodson, 1992; Verdolini-Marston, Burke, Lessac, Glaze, & Caldwell, 1995). The majority of the intervention studies for patients with vocal fold nodules have examined treatment outcomes following traditional voice therapy models, typically delivered once a week over a period of multiple weeks. To date, no studies have systematically examined the impact of using an intensive, massed practice therapy approach. In that the rehabilitation process for vocal fold nodules requires the learning, maintenance and transfer of new behaviours, it is possible that a more condensed voice therapy protocol may yield equal or even greater benefit. Therefore, the primary aim of this thesis was to explore the efficacy of intensive voice therapy (eight sessions within 3 weeks) as compared with traditional voice therapy (one session per week for 8 weeks). Both the short and long term effects of the different treatments on perceptual, acoustic, and physiological outcomes were examined. Although it has been established that voice therapy is often effective, in many caseloads, rates of therapy completion are poor and this creates a challenge for clinicians (Portone-Maira, Wise, Johns, & Hapner, 2011). Traditional, face-to-face (FTF) voice therapy has shown dropout rates as high as 65% (Hapner, Portone-Maira, & Johns, 2009). Various factors contributing to nonattendance include travel time, inflexible work conditions, and inability to access due to physical barriers. Non-attendance not only affects treatment success, but also results in unnecessary extensions to treatment, and repeated examinations without sufficient behavioural change to effect improvement. Ultimately, there may be a loss of revenue or even employment if patients are unable to meet the vocal requirements of their occupations (Portone, et al., 2008; Portone-Maira et al., 2011). Consequently, there is a need to explore ways to help maximise attendance and ultimately enhance outcomes for people with vocal fold nodules. To this end, the secondary aim of this thesis