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Voice-Specialized Speech-Language Pathologist’s
Criteria for Discharge from Voice Therapy
Amanda I. Gillespie and Jackie Gartner-Schmidt,Pittsburgh, Pennsylvania
Summary: Objective. No standard protocol exists to determine when a patient is ready and able to be discharged
from voice therapy. The aim of the present study was to determine what factors speech-language pathologists (SLPs)
deem most important when discharging a patient from voice therapy. A second aim was to determine if responses dif-
fered based on years of voice experience.
Methods. Step 1: Seven voice-specialized SLPs generated a list of items thought to be relevant to voice therapy dis-
charge. Step 2: Fifty voice-specialized SLPs rated each item on the list in terms of importance in determining discharge
from voice therapy.
Results. Step 1: Four themes emerged—outcome measures, laryngeal appearance, SLP perceptions, and patient factors—as
important items when determining discharge from voice therapy. Step 2: The top five most important criteria for dis-
charge readiness were that the patient had to be able to (1) independently use a better voice (transfer), (2) function
with his or her new voice production in activities of daily living (transfer), (3) differentiate between good and bad voice,
(4) take responsibility for voice, and (5) sound better from baseline. Novice and experienced clinicians agreed between
94% and 97% concerning what was deemed “very important.”
Conclusions. SLPs agree that a patient’s ability to use voice techniques in conversation and real-life situations outside
of the therapy room are the most important determinants for voice therapy discharge.
Key Words: Voice therapy–Discharge–Patient satisfaction–Survey–Attrition.
INTRODUCTION
Voice therapy is the standard-of-care for many of the nearly 30%of
people in the United States who have experienced voice disorders.1
Despite voice therapy being a first-line treatment, no standard
protocol exists to determine when a patient is ready and able
to be discharged from voice therapy. Five “dismissal criteria”
were recommended by Boone in 1974.2These criteria were
(1) improved laryngeal appearance; (2) patient sounded better;
(3) patient felt that his or her voice was better; (4) patient ex-
perienced no change in voice; and (5) patient self-discharged
without clinician’s permission. However, there remains a paucity
of formalized discharge standards in research on voice therapy.2
The present study, a survey of voice-specialized speech-
language pathologists (SLPs) regarding voice therapy discharge,
represents the first step in the development of such an evidence-
based protocol.
Attrition rates for voice therapy are estimated upwards of
65%,3,4 with at least one study reporting voice problem relapse
rates at nearly 70%.3One reason for such high relapse rates may
be patients being inappropriately discharged from voice therapy.
A review of the existing voice therapy literature reveals a lack
of consistency in number of sessions completed, and little to no
information on why patients are discharged from treatment. For
example, studies on voice therapy for benign vocal fold lesions
vary widely in the number of treatment sessions required to treat
the disorder. In some, patients were discharged after as few as
three sessions,5,6 in others, as many as 24 voice therapy sessions.7
According to previous studies, reasons for voice therapy dis-
charge fall into one of three categories: (1) all of the prescribed
sessions in a specific voice therapy program were complete8–12;
(2) the SLP thought that the patient had met his or her therapy
goals without offering any quantitative substantiation13–16; and
(3) no reason for discharge was provided in the study.17–22
The available literature on published voice therapy programs
offers little information on how the number of prescribed
sessions was originally determined, or guidance for the treat-
ing SLP as to when a patient may be ready for discharge. One
possible explanation for why discharge criteria are lacking
may be that “success” in voice therapy is not easily objectively
defined. In other areas of speech-language pathology, measur-
able outcomes, such as intelligibility at certain ages, speech
sound acquisition, are available to determine when treatment
success has been achieved.23–24 Improvement from voice therapy
is often determined by a combination of outcomes including
the SLP’s perception of change, the patient’s perception of
change, improvement in laryngeal appearance, and acoustic
and aerodynamic outcomes. A lack of guidance on what deter-
mines voice therapy discharge may cause patients to remain in
ineffective treatments or be discharged before treatment gains
are met. Recent results from a systematic review of voice
therapy corroborated that there are differences in the number
of voice therapy sessions completed and the length of each
voice therapy session or number of sessions per week. Specif-
ically, results from 96 publications on voice therapy showed that,
on average, voice therapy lasted 9.25 weeks, which was allo-
cated over 10.87 sessions, lasting mostly 30 minutes (36.35%)
or 60 minutes (27.27%) and occurred once (34.55%) or twice
(28.18%) a week.25 Desjardins et al reviewed 10 voice therapy
studies that provided information on duration of session and re-
ported that the mean duration of therapy was 40.75 minutes
Accepted for publication May 25, 2017.
From the University of Pittsburgh Voice Center, University of Pittsburgh School of Med-
icine, Department of Otolaryngology, Pittsburgh, Pennsylvania.
Address correspondence and reprint requests to Amanda I. Gillespie, University of
Pittsburgh Voice Center, University of Pittsburgh Medical Center Mercy, 1400 Locust St,
Suite 11-500, Building B, Pittsburgh PA, 15219. Email: gillespieai@upmc.edu
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2017.05.022
ARTICLE IN PRESS
(range 10-60 minutes).26 This temporal variability found in voice
therapy research may also contribute to the lack of formal cri-
teria for voice therapy discharge.25 Similarly, because the “active
ingredient” of voice therapy has yet to be established and may
evade ultimate detection because of the multidimensionality of
voice therapy,27 there is a need for discharge criteria that are in-
dependent from the number and duration of voice therapy
sessions, as well as “active ingredient.” Such discharge criteria
would allow for individualized treatment planning.
Discharge tool development in other fields
The field of physical therapy has created therapy discharge tools
using a version of the Delphi technique, which relies on expert
intuition and judgment in decision making.28–30 This technique
calls for an expert team developing a list of items they deemed
important in determining when to discharge a patient from therapy
followed by questionnaires administered to a larger group of
experts, and then expert panel discussion until clinical consen-
sus on the most salient items are agreed upon.
The goal of the present study was to determine the criteria
deemed most salient by voice-specialized SLPs in determining
voice therapy discharge criteria. Specifically, the study fol-
lowed the Delphi guidelines and first used a clinical panel to
develop pertinent items regarding voice therapy discharge
(Step 1), followed by the administration of these items through
a questionnaire to a group of clinical SLPs specialized in voice
(Step 2). The study also aimed to determine if discharge deci-
sion making differed between novice (<5 years of clinical practice)
and experienced (>10 years clinical practice) SLPs. We hypoth-
esized that factors related to transfer to conversational speech
would be ranked high and that there would be a discrepancy
between novice and experienced SLPs. This study is the first step
in development of a voice therapy discharge tool for use across
clinical and research domains.
METHODS
All study procedures were approved by the University of Pitts-
burgh Internal Review Board (PRO16090544).
Step 1: Clinical consensus group
This step was conducted to generate content for a survey to be
distributed to voice-specialized SLPs regarding voice therapy
discharge.
Participants
Seven voice-specialized SLPs at the University of Pittsburgh Voice
Center were recruited. All were female and ranged in age from
27 to 59 years. They had clinical voice experience ranging from
3 to 35 years.
Procedures
The SLPs were first asked to independently generate items that
they thought were important and what they most often consid-
ered when discharging a patient from voice therapy. The SLPs
were also asked to consider outcome measures commonly used
in the voice literature. A master list of items was generated from
the individual SLP lists. Any overlapping responses were
combined into one, and responses that strayed from the discharge
theme were discarded.
Results
The master list emerged with five distinct themes: (1) laryn-
geal factors, (2) acoustic factors, (3) aerodynamic factors,
(4) patient factors, and (5) SLP factors. The final list of items
was organized by theme and redistributed to the clinical con-
sensus group for agreement.
The final consensus group met again and further condensed
the items to four themes: (1) outcome measures, (2) laryngeal
appearance, (3) SLP perception, and (4) patient factors. From
this final list of items, a survey was developed for distribution
among voice-specialized SLPs for Step 2. (Appendix A).
Step 2: Survey administration to
voice-specialized SLPs
A total of 120 surveys were distributed to SLPs at two national
conferences, the Fall Voice Conference in Scottsdale, Arizona,
October 13–15, 2016, and an invited short course on voice therapy
at the American Speech-Language Hearing Association (ASHA)
annual convention, Philadelphia, Pennsylvania, November 17–20,
2016. At the Fall Voice Conference, surveys were placed on the
conference check-in desk, and at ASHA surveys were placed on
the short-course attendees’ chairs before the course initiation.
Surveys were completed anonymously. A 5-point (0–4) Likert
scale was used for each survey statement.31 Completed surveys
were returned to the study team, and data were entered by a re-
search assistant with no knowledge of the survey participants
or goals of the study.
Participants
Fifty complete surveys were returned to the investigators. To main-
tain the anonymity of survey takers, age and gender were not
queried. All participants self-identified as voice clinicians with
some percentage of their current practice dedicated to treat-
ment of patients with voice disorders.
To assess if novice clinicians (those with less than 5 years’
experience treating patients with voice disorders) differed from
experienced clinicians (10+years in voice practice) in their opin-
ions on the salient factors that drive voice therapy discharge,
survey responses between these two groups were compared.
Results
The following data describe the survey responses from all the
SLPs:
1. Clinical demographics
(i) Years in practice as a voice-specialized SLP: 19 (38%)
responders had less than 5 years in clinical practice;
eight (16%) had 6-10 years; 12 (24%) had 11-20 years;
and 10 (20%) reported being in clinical practice
for >21 years.
(ii) Percent of practice dedicated to voice therapy:
13 (26%) responders spent less than 25% of their prac-
tice dedicated to voice therapy; six (12%) responders
spent 26%-50% of practice time in voice therapy;
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2Journal of Voice, Vol. ■■, No. ■■, 2017
10 (20%) spent 51%-75%; and 21 (42%) spent over
76% of their practice dedicated to voice therapy.
(iii) Average number of voice therapy sessions conducted
per patient: 13 (26%) responders treated patients in
≤4 sessions; 29 (58%) responders treated in 5-8 ses-
sions; seven (14%) responders used 9-12 sessions;
and only one responder typically used ≥13 ses-
sions of voice therapy.
2. Laryngeal factors
A near-even distribution occurred between responders on
the importance of having a patient’s larynx look “normal”
in determining when to discharge a patient from voice
therapy. Fifteen percent of SLPs thought that it was very
important; 21% thought it was moderately important; 23%
thought it was mildly to moderately important; 19%
thought it was mildly important; and 21% of SLPs did
not think it was important at all. However, a greater dif-
ference was observed on the importance of improved
laryngeal appearance from baseline. Twenty-seven percent
thought it was very important; 29% thought it was
moderately important; 24% thought it was mildly to mod-
erately important; 12% thought it was mildly important;
and 8% did not think it was important at all (Figure 1).
3. Measurements from patient-based voice outcomes
Thirty-five percent of SLPs thought that patient-based voice
outcomes (eg, voice handicap index-10, voice related quality
of life) improving from baseline was a very important dis-
charge criteria; 31% thought it was moderately important;
23% thought it was mildly to moderately important; 6%
thought it was mildly important; and 4% of SLPs did not
think it was important at all (Figure 2).
4. Measurements from acoustic or aerodynamic outcomes
A more evenly distributed response from SLPs as to what
they consider important concerning improvements in acous-
tics or aerodynamic measurements from baseline was evident
as compared with the voice outcomes discussed previously.
Twelve percent though it was very important; 27% thought
it was moderately important; 20% thought it was mildly to
moderately important, 18% thought it was mildly impor-
tant; and 22% thought it was not important at all (Figure 3).
0%
5%
10%
15%
20%
25%
30%
01234
Not at all important Mildly important Mil d to moderately
important
Moderately
important
Very important
Percentage of SLPs
Laryngeal appearance improved from baseline Larynx Normal
FIGURE 1. Importance of laryngeal factors in determining discharge readiness.
0%
5%
10%
15%
20%
25%
30%
35%
40%
01234
Not at all important Mildly important Mild to moderately
important
Moderately
important
Very important
FIGURE 2. Importance of improvements in patient-based voice outcomes in determining discharge readiness.
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Amanda I. Gillespie and Jackie Gartner-Schmidt Voice Therapy Discharge Criteria 3
5. Patient perception factors
The majority of the eight patient-factors were deemed either
very important or moderately important in determining when
to discharge a patient from voice therapy (Figure 4).
6. SLP perception factors
The top three items considered to be the most important
from an SLP perspective were that patients (i) could dif-
ferentiate between producing good and bad voice; (ii)
sounded better from baseline; and (iii) took responsibility
for their voice production (Figure 5).
Taken together, the SLPs’ survey responses show that the
top five criteria for discharging patients from voice therapy
were that the patient had to be able to (1) independently use a
better voice, (2) function with their new voice production in
activities of daily living, (3) differentiate between good and
bad voice, (4) take responsibility for voice, and (5) sound
better from baseline, to be discharged from voice therapy.
Much of these discharge criteria represent the patient’s ability
to be in control of his or her voice production outside of the
voice therapy room (eg, transfer to conversational speech and
to sound better after therapy than before going to therapy
(Figure 6).
Response to voice therapy discharge survey by years of
experience
Survey results between voice-specialized novice and experi-
enced SLPs showed a similar response in what each deemed
important criteria in discharging a patient from voice therapy.
0%
5%
10%
15%
20%
25%
30%
01234
Not at all important Mildly important Mil d to moderately
important
Moderately important Very important
FIGURE 3. Importance of improvements in acoustics or aerodynamics in determining discharge readiness.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Percentage of SLPs
0 = Not at all important 1 = Mildly important 2 = Mild to moderately important
3 = Moderately important 4 = Very important
FIGURE 4. Patient perception factors in determining discharge readiness.
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4Journal of Voice, Vol. ■■, No. ■■, 2017
Novice and experienced clinicians agreed between 94% and 97%
concerning what was deemed “very important” (Figure 7).
DISCUSSION
This study reports the criteria deemed most important by voice-
specialized SLPs in determining patient discharge from voice
therapy. Overall, across experience levels, over 85% of the SLPs
surveyed think that a patient’s ability to transfer voice techniques
to conversational speech (ie, do what he or she needs to do with
his or her voice outside of the therapy room) is the most im-
portant factor in determining that a patient is ready for discharge
from treatment. These results are in concordance with data on
0%
10%
20%
30%
40%
50%
60%
70%
0 = Not at all
important
1 = Mildly
important
2 = Mild to
moderately
important
3 = Moderately
important
4 = Very important
Percentage of SLPs
Differenitates between good and bad voice Sounds better than baseline
Takes responsibility for voice production
FIGURE 5. Top three SLP perception factors in determining discharge readiness.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Differentiates
between good & bad
voice
Takes responsibility
for voice
Independently uses
better voice
Can function with
voice
Sounds better from
baseline
Percentage of SLPs
0 = Not at all important 1 = Mildly important 2 = Mild to moderately important
3 = Moderately important 4 = Very important
FIGURE 6. Top five criteria for discharging patients from voice therapy by degree of importance.
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Amanda I. Gillespie and Jackie Gartner-Schmidt Voice Therapy Discharge Criteria 5
patients’ perception of voice therapy discharge, which revealed
that transfer to conversation was the most challenging and the
most beneficial aspect of voice therapy.14
The two other factors reported to be most important in de-
termining discharge from voice therapy were (1) the patient’s
ability to discriminate between good and bad voice produc-
tions, and (2) the patient’s ability to sound better because of
treatment. These factors are also deemed important across seven
published therapy programs (Lee Silverman Voice Therapy, Vocal
Function Exercises, Resonant Voice Therapy, Laryngeal Manual
Therapy, Manual Circumlaryngeal Therapy) according to the voice
therapy taxonomy.3,10,11,16,32,33 In addition, sounding better from
baseline corroborates Boone’s endorsement of this discharge cri-
terion as being important.2Likewise, results support the therapy
discharge definition developed by Portone-Maira et al, which state
that patients are ready for discharge when (1) therapy is com-
plete; (2) voice quality has improved, per patient report; and
(3) patient progress had plateaued.34 Lastly, overall, 92% of SLPs
deemed the patient taking responsibility for his or her voice pro-
duction as either very important (58%) or moderately important
(34%) in determining a patient’s readiness for discharge from
voice therapy.
It is interesting to note the lack of agreement among SLPs
surveyed on the importance of improvement in acoustic and aero-
dynamic outcomes following treatment as a metric of discharge
readiness. Acoustic and aerodynamic measurements are com-
monly used to document treatment change in the voice
literature.35–42 Results of the current investigation, however, in-
dicate that voice-specialized SLPs do not agree on the value of
such measurements in determining that a patient is ready and
able to be discharged from voice therapy. Patient-ability measures
were deemed more relevant to discharge planning by the SLPs
surveyed.
When broken down by years of experience as a voice-
specialized SLP, novice and experienced clinicians agreed on
the top five criteria deemed “very important” for discharging pa-
tients from voice therapy. This agreement may indicate that novice
SLPs are learning from experienced clinicians and putting this
knowledge into their clinical practice.
LIMITATIONS
This study has several limitations. First, the survey develop-
ment occurred with SLPs at one clinical site. Items may have
differed if opinions from clinicians located in different geo-
graphical regions or with different patient populations or practice
patterns were queried for initial survey development. Second,
survey responses were gathered only from SLPs attending na-
tional conferences and cannot be assumed to represent the
opinions of all voice-specialized SLPs. Furthermore, it is unknown
how information learned at these meetings may have influ-
enced SLP responses. In an attempt to overcome this limitation,
surveys were also emailed to members of the ASHA Special In-
terest Group on Voice Disorders. This email query did not generate
any new responders.
FUTURE DIRECTIONS
The data collected from the current study will be used toward
the generation of a discharge tool to help guide clinicians and
researchers in determining the most appropriate time for voice
therapy discharge. Future studies should also query patients who
FIGURE 7. Comparison between novice and experienced SLPs in degree of importance of top criteria for discharge.
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6Journal of Voice, Vol. ■■, No. ■■, 2017
have completed voice therapy on what they believe to be the most
important aspect in determining treatment discharge.
CONCLUSION
Across experience levels, voice-specialized SPLs think that patient
factors, specifically around a patient’s ability to use voice tech-
niques in conversation and real-life situations outside of the
therapy room, are the most important determinants for voice
therapy discharge.
Acknowledgments
The authors would like to acknowledge Tina Harrison and Ali
Lewandowski, MA, for their assistance with this study.
APPENDIX A
Free-text, open-ended responses to SLP survey.
•Discharge is usually patient based. If they “own” their voice
and they can understand how to modify their own voice
so it is functional for how they use their voice in their live,
they are ready for discharge.
•For singer—show close to baseline function prior to
injury/disorder
•How patient is feeling about their voice and indepen-
dence with therapy tasks; Pt is able to participate in their
daily activities/work/social; Pt is able to carry over tasks
over longer periods (about 2 weeks).
•Pt priority/commitment
•Financial/insurance factors (unfortunately, patient’s travel
schedule, not necessarily discharging in general but might
not be able to ever see me again)
•I work in a county facility and the patient population that
I serve is very financially challenged. Attendance and ad-
herence is a huge challenge.
•Patient motivation to continue voice therapy. Patient is able
to function in daily lives and their original complaint has
resolved or improved significantly.
•If a patient is noncompliant or has plateaued with pro-
gress in direct therapy, consideration of early discharge
may be warranted pending discussion with patient and con-
sideration of any other option. If discharged for surgical/
medical management, we would likely to see them back
postoperatively/post-treatment for reassessment and pos-
sible further rehabilitative post-op/tx voice therapy.
•They “become their own therapist.”
•I discharge if there is a plateau with therapy benefit and
make sure patient understands maintenance protocol. If the
patient requires help from other fields (ie, PT), I invite them
back for reassessment.
•This is a sticky question because many patients often
suspend therapy mid-therapy due to other reasons (insur-
ance, time, kids, etc) so it is rare that a patient actually is
formally discharged. But I do think we d/c pts before they
totally get it or even 80%. This seems to be a cultural shift
in our field to do therapy in as few sessions as possible,
which is a shame. Voice changes in behavioral changes
and like other forms of behavioral change—weight loss,
habit reduction—quick almost never works, and leads to
relapse that can be worse. Behavior modification takes time
and expertise that we relinquish too quickly.
•Other reasons for discharge include: 1. intervening medical
event. 2. no shows/no calls. 3. high frequency of cancellations
•Compliance—discharge if not compliant. Continuing to
improve—discharge if pt is not making progress toward
goals.
•Insurance limitations, patient request
•Patient is nonadherent, despite education and motiva-
tional interviewing techniques
•If a patient is not making any progress after 3-4 sessions
of therapy, I may consider other options for them of dis-
charge from therapy. They should make some progress
within first few sessions.
•Lung function breath support holding sound; Pt ability to
improve has stabilized; Pt health complications have been
addressed; vocal abuse has been controlled; habitual pitch
is safe and functional; use voice to evaluate for silent as-
piration; all my voice Pt had a medical problem.
•I work in SNFs and PD, s/p trach and get very little time
to really address carry over upon patient d/c. Sometimes
patients are discharged because of insurance limits.
•I discharge people before they are done “cooking.” Once
they can independently utilize the therapy tools and monitor
their vocal production to continue further progress I dis-
charge; a future time period scheduled to capture outcomes,
verify expected progress and troubleshoot/resume brief
therapy if needed.
REFERENCES
1. Roy N, Merrill RM, Gray SD, et al. Voice disorders in the general population:
prevalence, risk factors, and occupational impact. Laryngoscope.
2005;115:1988–1995.
2. Boone DR. Dismissal criteria in voice therapy. J Speech Hear Disord.
1974;39:133–139.
3. Roy N, Bless DM, Heisey D, et al. Manual circumlaryngeal therapy for
functional dysphonia: an evaluation of short and long-term treatment
outcomes. J Voice. 1997;11:321–331.
4. Hapner E, Portone-Maira C, Johns MM 3rd. A study of voice therapy
dropout. J Voice. 2009;23:337–340.
5. Holmberg EB, Hillman RE, Hammarberg B, et al. Efficacy of a behaviorally
based voice therapy protocol for vocal nodules. J Voice. 2001;15:395–
412.
6. Gartner-Schmidt J, Gherson S, Hapner ER, et al. The development of
conversation training therapy: a concept paper. J Voice. 2016;30:563–573.
7. Rodriguez-Parra MJ, Adrian JA, Casado JC. Comparing voice-therapy and
vocal-hygiene treatments in dysphonia using a limited multidimensional
evaluation protocol. J Commun Disord. 2011;44:615–630.
8. Ziegler A, Verdolini Abbott K, Johns M, et al. Preliminary data on two voice
therapy interventions in the treatment of presbyphonia. Laryngoscope.
2014;124:1869–1876.
9. Verdolini Abbott K. Lessac-Madsen Resonant Voice Therapy. San Diego,
CA: Plural Publishing; 2008.
10. Ramig LO, Countryman S, Thompson LL, et al. Comparison of two forms
of intensive speech treatment for Parkinson disease. J Speech Hear Res.
1995;38:1232–1251.
11. Stemple JC, Lee L, D’Amico B, et al. Efficacy of vocal function exercises
as a method of improving voice production. J Voice. 1994;8:271–278.
12. Roy N, Gray S, Simon M, et al. An evaluation of the effects of two treatment
approaches for teachers with voice disorders: a prospective randomized
clinical trial. J Speech Lang Hear Res. 2001;44:286–296.
ARTICLE IN PRESS
Amanda I. Gillespie and Jackie Gartner-Schmidt Voice Therapy Discharge Criteria 7
13. Gartner-Schmidt JL, Roth DF, Zullo TG, et al. Quantifying component parts
of indirect and direct voice therapy related to different voice disorders.
J Voice. 2013;27:210–216.
14. Ziegler A, Dastolfo C, Hersan R, et al. Perceptions of voice therapy from
patients diagnosed with primary muscle tension dysphonia and benign
mid-membranous vocal fold lesions. J Voice. 2014;28:742–752.
15. Litts JK, Gartner-Schmidt JL, Clary MS, et al. Impact of laryngologist and
speech pathologist coassessment on outcomes and billing revenue.
Laryngoscope. 2015;125:2139–2142.
16. Mathieson L, Hirani SP, Epstein R, et al. Laryngeal manual therapy:
a preliminary study to examine its treatment effects in the management of
muscle tension dysphonia. J Voice. 2009;23:353–366.
17. Berg EE, Hapner E, Klein A, et al. Voice therapy improves quality of
life in age-related dysphonia: a case-control study. J Voice. 2008;22:70–
74.
18. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice
therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice.
1999;13:72–104.
19. Rattenbury HJ, Carding PN, Finn P. Evaluating the effectiveness and
efficiency of voice therapy using transnasal flexible laryngoscopy:
a randomized controlled trial. J Voice. 2004;18:522–533.
20. Schindler A, Mozzanica F, Ginocchio D, et al. Vocal improvement
after voice therapy in the treatment of benign vocal fold lesions. Acta
Otorhinolaryngol Ital. 2012;32:304–308.
21. van Leer E, Connor NP. Use of portable digital media players increases
patient motivation and practice in voice therapy. J Voice. 2012;26:447–
453.
22. Gillivan-Murphy P, Drinnan MJ, O’Dwyer TP, et al. The effectiveness of
a voice treatment approach for teachers with self-reported voice problems.
J Voice. 2006;20:423–431.
23. Weiss CE. Weiss Intelligibility Test. Tigard, Oregon: C.C. Publications; 1982.
24. Kilminster MGE. Articulation development in children aged three to nine
years. Aust J Hum Commun Disord. 1978;6:23–30.
25. De Bodt M, Patteeuw T, Versele A. Temporal variables in voice therapy.
J Voice. 2015;29:611–617.
26. Desjardins M, Halstead L, Cooke M, et al. A systematic review of voice
therapy: what “effectiveness” really implies. J Voice. 2017;31:392.
27. Roy N. Optimal dose-response relationships in voice therapy. Int J Speech
Lang Pathol. 2012;14:419–423.
28. Eubank BH, Mohtadi NG, Lafave MR, et al. Using the modified Delphi
method to establish clinical consensus for the diagnosis and treatment of
patients with rotator cuff pathology. BMC Med Res Methodol. 2016;16:
56.
29. Helmer O. Analysis of the Future: The Delphi Method. Santa Monica, CA:
The RAND Corporation; 1967.
30. Ellerton C, Davis A, Brooks D. Preliminary development and validation of
a paediatric cardiopulmonary physiotherapy discharge tool. Physiother Can.
2011;63:34–44.
31. Albaum G. The Likert scale revisited. J Mark Res Soc. 1997;39:331–348.
32. Van Stan JH, Roy N, Awan S, et al. A taxonomy of voice therapy. Am J
Speech Lang Pathol. 2015;24:101–125.
33. Verdolini K, Druker DG, Palmer PM, et al. Laryngeal adduction in resonant
voice. J Voice. 1998;12:315–327.
34. Portone-Maira C, Wise JC, Johns MM 3rd, et al. Differences in temporal
variables between voice therapy completers and dropouts. J Voice.
2011;25:62–66.
35. Awan SN, Roy N. Outcomes measurement in voice disorders: application
of an acoustic index of dysphonia severity. J Speech Lang Hear Res.
2009;52:482–499.
36. Carding PN, Steen IN, Webb A, et al. The reliability and sensitivity to change
of acoustic measures of voice quality. Clin Otolaryngol Allied Sci.
2004;29:538–544.
37. Chen SH, Hsiao TY, Hsiao LC, et al. Outcome of resonant voice therapy
for female teachers with voice disorders: perceptual, physiological, acoustic,
aerodynamic, and functional measurements. J Voice. 2007;21:415–
425.
38. Fex B, Fex S, Shiromoto O, et al. Acoustic analysis of functional dysphonia:
before and after voice therapy (Accent Method). J Voice. 1994;8:163–
167.
39. Fu S, Theodoros DG, Ward EC. Intensive versus traditional voice therapy
for vocal nodules: perceptual, physiological, acoustic and aerodynamic
changes. J Voice. 2015;29:260, e231-244.
40. Gillespie AI, Dastolfo C, Magid N, et al. Acoustic analysis of four common
voice diagnoses: moving toward disorder-specific assessment. J Voice.
2014;28:582–588.
41. Halawa WE, Rodriguez Fernandez Freire A, Munoz IV, et al. Assessment
of effectiveness of acoustic analysis of voice for monitoring the evolution
of vocal nodules after vocal treatment. Eur Arch Otorhinolaryngol.
2014;271:749–756.
42. Holmberg EB, Doyle P, Perkell JS, et al. Aerodynamic and acoustic voice
measurements of patients with vocal nodules: variation in baseline and
changes across voice therapy. J Voice. 2003;17:269–282.
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