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Group Voice Therapy Reduces Anxiety in Patients With Dysphonia
ARTICLE IN PRESS
Group Voice Therapy Reduces Anxiety in Patients With Dysphonia via Maiele Pedroza Trajano, †Larissa Nadjara Alves Almeida, †Sauana Alves Leite de Alencar, *,†Fla ~ ‡Joao Euclides Fernandes Braga, and §Anna Alice Almeida, *yzxJo~ao Pessoa, Brazil Summary: Objective. To evaluate the impact of group therapy in patients with dysphonia, as well as to verify the correlation between vocal symptoms and levels of anxiety. Methods. The study was composed of 52 patients subdivided into two groups, named the Experimental Group (EG) with 28 volunteers and the Control Group (CG) with 24 volunteers. Anxiety and voice protocols were used for data collection. The State-Trait Anxiety Inventory (STAI) was used to measure trait levels of anxiety that after collection were categorized according to the variation in scores value: low anxiety (20-40 points); average anxiety (40-60 points); high anxiety (60-80 points). In addition, the Voice Symptom Scale (VoiSS) was used for voice assessment. Inferential statistical analysis from the Student’s t test for paired and independent data, in order to compare the average scores of STAI trait levels and VoiSS domains of the pre- and postmoments, intra- and intergroups, EG and CG, respectively. For that purpose, the program Statistical Package for Social Sciences (SPSS) was used. Results. Half of the patients in the survey presented an average trait level of anxiety. Regarding the EG, there was a significant reduction of state anxiety when comparing the moments before and after group therapy. There was also a significant reduction in the values of the VoiSS-Total and VoiSS-Physical domains when compared to the pre- and postgroup therapy moments. It was verified the existence of a positive correlation between the levels of anxiety after group therapy and VoiSS-Total, VoiSS-Limitation, and VoiSS-Physical domains. As for the CG, there was an increase in anxiety levels as well as in all domains of the VoiSS scale when compared to the pre- and postmoments. Conclusions. Group voice therapy was effective for a significant reduction of vocal symptoms and anxiety − common conditions in patients with dysphonia. It was possible to perceive the positive correlation between anxiety levels and vocal symptoms. Key Words: Anxiety−Behavior−Dysphonia−Speech therapy−Voice−Group practices.
INTRODUCTION Anxiety presents itself as an emotional reaction experienced by individuals in certain moments of their lives, which when exacerbated can generate a mood, behavior, and even thought disorders, leading to a physiological repercussion.1 The combination of these factors subjects the individual to an anxious condition that can be characterized by a feeling of insecurity, catastrophic thinking, insomnia, tachycardia, pallor, muscle tension, tremors, among other symptoms.2 Accepted for publication March 12, 2019. Funding: This study is part of a research project funded by the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnol ogico - CNPq), under Process No. 482337/2013-3. Conflicts of interest: None. Authors’ contributions: All authors contributed significantly to the design and development of this study. F.M.P.T., L.N.A.A., and S.A.L.A. contributed to data collection, tabulation, and analysis; J.E.F.B. participated in data analysis and revision of the manuscript; A.A.F.A. (research project coordinator) was involved in study supervision, data and statistical analysis, and manuscript review. From the *Cognitive Neuroscience and Behavior at the Federal University of Paraíba (Universidade Federal da Paraíba − UFPB), Jo~ao Pessoa, Brazil; yDecision and Health Models, UFPB, Jo~ ao Pessoa, Brazil; zDepartment of Nursing and Collective Health, UFPB, Jo~ ao Pessoa, Brazil; and the xDepartment of Speech-Language Pathology, UFPB, Jo~ ao Pessoa, Brazil. Address correspondence and reprint requests to Anna Alice Almeida, Departamento de Fonoaudiologia, Centro de Ci^encias da Sa ude, Cidade Universitaria − Campus I, Bairro Castelo Branco, Jo~ao Pessoa, PB CEP: 58051-900, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.03.003
Anxiety may cause impairment in the life of sufferers, including changes in the communication process, for example, voice characteristics, as noted in by several studies.3−7 Voice changes or difficulties are known as dysphonia and are classified as organic or functional. Organic dysphonia is characterized by tissue changes in the vocal folds, whether of genetic or mechanical etiology. Functional dysphonia is related to the use of voice.8 Genetic and environmental factors contribute to the onset of voice problems, which become even greater when the individual makes professional use of the voice. Dysphonia may have a strong impact on the social and professional life of affected individuals. A study on voice professionals and nonprofessionals indicated that the greater the perception of dysphonia by the subjects was, the stronger the impact of dysphonia on their quality of life.9 Voice therapy for dysphonia is historically centered on individual treatments based on the curative model of health care, with a focus on the disease only in an attempt to find healing alternatives. However, this reality has changed over the years, and group therapies are more common today.10 Group therapy is considered valuable by health professionals because it provides the patient knowledge and experience while offering the ability to cope with disease and exchange experiences. The latter favors the formation of personal bonds and the patient's involvement in a relationship of subjectivity.10,11
ARTICLE IN PRESS 2 Group voice therapy has been gaining prominence as a therapeutic modality for treating dysphonia. Several studies have demonstrated the effectiveness of this method in treating dysphonia in different target populations.8,12,13 The objective of this study is to determine the anxiety levels and vocal symptoms before and after group voice therapy in patients with dysphonia and assess the relationship between anxiety and vocal symptoms. METHOD This quantitative and interventional field study evaluated the impact of a therapeutic modality in a population with dysphonia over time. The study was approved by the Human Research Ethics Committee of the Health Sciences Center of a public university under Protocol No. 383.061/ 2013. Patients with dysphonia who sought care in the Voice Laboratory of a higher education institution participated in the study. They were divided into two groups: Experimental Group (EG), who participated in group therapy care; and the Control Group (CG), who were waiting for care and during the data collection period did not participate in any type of voice treatment. The EG was constituted, initially, by 44 patients, with which 7 therapeutic groups were formed, with an average of 6 participants each. The meetings took place between March and December 2014. However, there were 14 dropouts during the process, remaining 30 individuals. Of these, 28 patients met the following eligibility criteria: having a laryngological report and diagnosis of dysphonia; receiving exclusively group care; presenting no more than two absences in the therapeutic process; performing no previously Speech Therapy before; responding to the research instruments of pre- and postgroup therapy; and not presenting comorbidity that could affect cognition or communication. The CG was constituted by 24 participants with dysphonia who were not submitted to any type of vocal intervention, and who were awaiting care. The obtained demographic data were gender, age, work activities, and laryngeal diagnosis. In addition, two questionnaires were used to assess the anxiety levels and voice characteristics. The State-Trait Anxiety Inventory (STAI), initially developed in English,14 was translated and validated for Brazilian Portuguese.15 The STAI is used to measure the subjective state of anxiety. This instrument contains two 20item subscales that are rated on a four-point scale. The scores on each subscale range from 20 to 80. One subscale evaluates individual self-perception of trait anxiety, which is related to the susceptibility to anxiety. The other subscale assesses state anxiety, which is a transient emotional state.15 Anxiety levels were classified into three categories according to the scores as follows: low level (LL), 20-40 points; intermediate level (IL), 40-60 points; and high level (HL), 60-80 points.16
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Voice self-assessment was performed using the Voice Symptom Scale (VoiSS) validated for Brazilian Portuguese17 and based on the original VoISS.18 This questionnaire contains 30 statements divided into three domains: impairment (15 items), emotional (8 items), and physical (7 items). Each statement is rated according to frequency on a four-point scale (“never,” “rarely,” “sometimes,” and “most of the time”). The sum of the scores of the three domains indicated the frequency of voice-related symptoms and limitations and could reach a maximum score of 120.17,19 It is of note that a previous study has shown that the cut-off value for VoiSS is 1620; that is, individuals with a value above this threshold are susceptible to developing voice problems. The selection of the VoiSS was motivated by being a reliable and robust self-assessment instrument in Brazil, once it presents specific domain for emotional issues. Initially, the volunteers were informed about the study and all existing doubts were solved. Then, the Free and Informed Consent Form (FIC) was presented, in order to obtain the participant's signature and their consent. The EG volunteers were assessed at the pre- and postgroup therapy moments through the VoiSS and the STAI, with application of both scales. Participants of the CG, however, composed of volunteers who were on the waiting list of the clinic, answered those questionnaires at the time of the initial evaluation (pre) and after six sessions they were called for reevaluation (post 6 weeks). After the re-evaluation of CG volunteers, therapy was initiated. As for the therapeutic groups, developed with the EG, they were formed by six patients on average, who presented dysphonia. Eight sessions were performed with each group, once a week, with an average time of 2 months and duration of 90 minutes per session, so that the first meeting was for evaluation and the last for reevaluation. In the other sessions, vocal therapy was performed from an eclectic approach, that is, combined direct and indirect approach, as described according to the voice therapy classification system proposed by Van Stan et al,21 presented in Table 1. The data were entered in a spreadsheet in Microsoft Excel version 2010 to create the database according to the criteria established in this study. Descriptive analysis was conducted to calculate the frequency, mean, and standard deviation of the studied variables. Subsequently, an inferential statistical analysis was performed from the parametric test, Student's t for paired and independent data, in order to compare the means of STAI-state scores and VoiSS domains of the preand postmoments of intra- and intergroups EG and CG, respectively. An inferential analysis was performed using Student's t − parametric test for paired data to compare the mean scores of the STAI-state and VoiSS domains before and after group therapy. The Pearson correlation test was used to determine the association between the scores of the STAI-state and VoiSS domains. The method proposed by Devore22 was used to indicate the degree of correlation according to Pearson's coefficients as follows: very weak,
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Group Voice Therapy Reduces Anxiety
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TABLE 1. Description of Activities Performed by Patients With Dysphonia During Group Voice Therapy Session 1 2
Intervention Evaluation Indirect
Direct 3
Indirect Direct
4
Indirect Direct
5
Indirect Direct
6
Indirect Direct
7
Indirect Direct
8
Re-evaluation
Instrument Application (State-Trait Anxiety Inventory and Voice Symptom Scale) Therapeutic interaction: Presentation dynamics Increase in knowledge: Anatomy and physiology of vocal production, voice in the vital cycle Respiratory intervention: Respiratory fitness Respiratory support and vocal function: Maximum phonation time (MPT) Pedagogical intervention; therapeutic interaction: Myths and truths about the voice Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal function, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle and use of lateral fricatives Intervention counseling; increase in knowledge: Vocal psychodynamics, voice, and emotion Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube Pedagogical intervention: Phonoarticulatory organs and pneumo-phono-articulatory coordination Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system Therapeutic interaction; increase in knowledge: Laryngeal diseases Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube; tongue rotation associated with nasal sounds Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system Intervention and pedagogical counseling; therapeutic interaction: Non-verbal communication and expressiveness Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises with a high-resistance tube; tongue rotation associated with nasal sounds Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system, overarticulation Application (State-Trait Anxiety Inventory and Voice Symptom Scale)
0.00-0.19; weak, 0.20-0.39; moderate, 0.40-0.69; strong, 0.70-0.89; very strong, 0.90-1.00. Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) version 20.0, and P values smaller than 0.05 were considered statistically significant.
RESULTS The sample consisted of 28 participants undergoing group therapy with a mean age of 47.4 § 12.5 years. The number of absences in therapy attendance varied from 0 to 2, such that 35.8% (n = 10) of participants were absent from two
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TABLE 2. Distribution of the Variables Gender, Professional Use of Voice, and Laryngeal Diagnosis in Patients Undergoing Group Voice Therapy Variable Gender Female Male Professional use of voice No Yes Laryngeal diagnosis Lesion in the membrane of the vocal folds Indefinite diagnosis Absence of laryngeal lesions Glottic chink without organic or neurological etiology Voice disorder secondary to GERD
N
%
22 6
78.6 21.4
17 11
60.7 39.3
9
32.1
7 5 4
25.0 17.9 14.3
3
10.7
Abbreviation: GERD, gastroesophageal reflux.
sessions, 32.1% (n = 9) were absent from one session, and 32.1%) attended all sessions. There was a predominance of female (78.6%, n = 22) and voice nonprofessionals (60.7%, n = 17) in the EG. Regarding the laryngeal diagnosis presented by the patients, 32.1% (n = 9) presented lesions on the membranous portion of the vocal fold, followed by 25.0% (n = 7) with an indefinite diagnosis and 10.7% (n = 3) with voice disorder secondary to gastroesophageal reflux, according to Table 2. In the CG, most of the subjects were also female (66.7%, n = 16) Table 2. Table 3 shows the distribution of State-Trait Anxiety levels pre- and postgroup therapy in the EG, and between assessments in the CG. It was observed that in the EG 50.0% (n = 14) of the sample had average level of trace anxiety. The majority of patients (64.3%; n = 18) presented a low level of trace anxiety at the moment of pretherapy, and that frequency increased at the post-therapy moment to 71.4% (n = 20). The profile of anxiety in the CG is initially similar to the EG, in which the majority had an average level of trace anxiety (48.1%; n = 25) and low level of state anxiety (69.2%; n = 36). Table 4 shows the comparison of the means of VoiSS and STAI-state domains in the pre- and post-therapy moments in the EG and in the pre- and postassessment in the CG. It was observed that in the assessment of the participants of the group therapy, there was a reduction of the averages in all VoiSS scores, being statistically significant the reduction of the total symptoms VoiSS-T (P = 0.007) and physical symptoms VoiSS-F (P = 0.024). It was also observed a score reduction in the level of STAI-S (P < 0.001). In the CG group, there was an increase of all means, that is, state anxiety levels (P = 0.0001) and the vocal symptoms
TABLE 3. Distribution of STAI-Trait and STAI-State in Patients Undergoing Group Voice Therapy Variable
EG N
CG %
STAI-trait LL 13 46.4 IL 14 50.0 HL 1 3.6 STAI-state before group therapy LL 18 64.3 IL 9 32.1 HL 1 3.6 STAI-state after group therapy LL 20 71.4 IL 8 28.6 HL 00 00.0
N
%
12 10 2
50 41.7 8.3
16 5 3
66.7 20.8 12.5
16 7 1
66.7 29.2 4.1
Abbreviations: HL, high levels of anxiety; IL, intermediate levels of anxiety; LL, low levels of anxiety; STAI, State-Trait Anxiety Inventory.
in VoiSS-L (P = 0.049) and VoiSS-F (P = 0.021) domains increased significantly over time (Table 4). Table 5 shows the correlation between State-Trait Anxiety of post-therapy group (EG) with VoiSS domains. The existence of a moderate positive correlation between the post-therapy STAI-S and STAI-T (P < 0.001) was observed. In addition, a correlation between the post-therapy STAI-S with VoiSS-Total pretherapy (P = 0.023) and post-therapy (P = 0.028) was observed; with the pretherapy VoiSS limitation (P = 0.028) and with VoiSS emotional the pretherapy (P = 0.029) and post-therapy (P = 0.001). In the CG, there was no correlation between State-Trait Anxiety and vocal symptoms. DISCUSSION This study is the first to evaluate the effectiveness of group voice therapy in reducing anxiety and vocal symptoms in subjects with dysphonia. Studies that provide scientific evidence using a particular approach and/or therapeutic modality are essential. It is necessary to consider the results of previous studies and the adopted methodologies to increase the accuracy of the interventions and focus on the emotional traits of the patients to improve vocal symptoms and anxiety and consequently the quality of life of these patients. The results indicated that there was a greater demand for voice therapy by women, corroborating the results of previous studies, wherein the rate of dysphonia was higher among women than among men because the former group is more likely to develop vocal problems. The increased rate of vocal changes in women may be due to anatomical and physiological differences in the larynx, including smaller vocal folds and a lower glottal ratio.1,20
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Group Voice Therapy Reduces Anxiety
TABLE 4. Mean, Standard Deviation, and Significance of VoiSS and STAI-State Scores of Patients in the EG and CG Groups in the Pre- and Postevaluation Variable
EG VoiSS-T VoiSS-I VoiSS-E VoiSS-P STAI-E CG VoiSS-T VoiSS-I VoiSS-E VoiSS-P STAI-E
Before Therapy
After Therapy
P Value
t
Mean
SD
Mean
SD
47.25 27.04 8.68 11.71 39.25
21.633 11.893 9.047 5.785 8.699
41.79 25.14 7.11 10.04 34.11
22.444 12.018 8.474 5.751 7.690
2.897 1.487 1.540 2.386 7.221
0.007 * 0.149 0.135 0.024* <0.0001
52.67 27.00 11.85 12.47 34.08
23.816 12.296 8.730 5.114 9.737
54.05 28.00 12.61 13.42 38.29
22.143 12.518 7.908 4.664 8.948
¡1.17 ¡2.09 ¡2.09 ¡2.50 ¡5.847
0.256 0.049* 0.049* 0.021* 0.000*
* P < 0.05. Abbreviations: E, emotional domain; I, impairment domain; P, physical domain; STAI, State-Trait Anxiety Inventory; STAI-S = State-Trait Anxiety Inventory, state subscale; VoiSS, voice symptom scale.Student’s t-test for paired data.
With the data on the professional use of the voice, it was noticed through the EG that there was a greater demand of patients who did not use the voice as a working instrument, a fact that revealed that the vocal symptoms are present in different populations, considering that people with great vocal demand professions are at greater risk of developing voice issues.21 Most of patients from the EG had lesions on the membranous portion of the vocal fold. The presence of mass lesions may prevent adaptation of the vocal folds and impair vocal production, leading to significant changes in the voice and altering the ratio between the voice signal and the noise measured acoustically.23 It was observed that group voice therapy was effective in reducing vocal symptoms and anxiety levels in patients with dysphonia. This fact was observed due to the decrease of VoiSS and STAI scores in the EG and the increase of these
scores in the CG, when comparing the evaluations in the pre- and post-therapy moments. Group voice therapy is a therapeutic modality that has been observed to be effective in the rehabilitation of patients with voice issues.10 The increase in VoiSS and STAI scores in the CG shows that the absence of treatment further aggravates the clinical situation of the patient with dysphonia, as well as their anxiety levels, which grow together over time. Group voice therapy began in the mid-1980s, motivated by the insertion of speech-language pathologists in the public health network to meet the individual demands of patients.21 However, because studies indicated that group therapy could adequately meet these demands and provide a forum for the exchange of experiences and knowledge, individual therapy was modified over the years, and group therapy emerged as a critical form of speech-language pathology.23
TABLE 5. Correlation Between STAI-State Post-therapy and VoiSS Scores of Patients Undergoing Group Voice Therapy Dependent Variable
IDATE estado s-terapia Po
Independent Variables
STAI-trait VoiSS-T before group therapy VoiSS-T after group therapy VoiSS-I before group therapy VoiSS-I after group therapy VoiSS-E before group therapy VoiSS-E after group therapy
EG
G
Correlation
P Value
Correlation
P Value
0.676 0.428 0.415 0.416 0.293 0.413 0.588
0.000* 0.023* 0.028* 0.028* 0.130 0.029* 0.001*
0.338 0.198 0.252 0.230 0.303 0.116 0.117
0.096 0.390 0.270 0.316 0.181 0.617 0.614
* P < 0.05. Abbreviations: E, emotional domain; I, impairment domain; STAI, State-Trait Anxiety Inventory; T, total score; VoiSS, voice symptom scale.Statistical analysis using Pearson correlation.
ARTICLE IN PRESS 6 Recent studies have demonstrated the effectiveness of group voice therapy in preventing vocal changes; improving quality of life, acoustic measures, and auditory-perceptual skills; and reducing the disadvantage index, risk-factor exposure, and postintervention vocal symptoms.11 When comparing the pre- and post-therapy scores in the EG, the present study observed that the vocal symptoms were significantly reduced both in relation to the total and physical domains of VoiSS, as well as the levels of state anxiety. A study performed in Finland8 compared to individual therapy, there were no significant differences between vocal therapy and group therapy. These results corroborate those found in this study regarding the reduction in vocal symptoms after group therapy. The VoiSS-impairment scores were not significantly decreased, probably because this domain is more related to physical symptoms of the voice than to emotional factors.19 According to the International Classification of Functioning,19 this domain reflects the interaction between the health condition and intrinsic and extrinsic factors of the individual, and VoiSS-impairment scores are related to the performance of vocal, professional, and social function. It is of note that direct intervention was not used to reduce anxiety. It is possible that the group therapy environment together with the improvement of vocal symptoms affected dysphonia-related emotional states. It is known that group therapy enables participants to interact by sharing experiences and knowledge, which promotes the development of new perceptions regarding the self and others in the face of illnesses. These interactions may help reduce anxiety and enable patients to better address vocal problems.11 State anxiety levels were positively and moderately correlated with the total, impairment, and emotional domains of VoiSS after therapy. In this study, 50% of the participants from the EG had an IL of trait and state anxiety before group therapy. Patients with dysphonia have higher rates of psychological distress compared to patients without voice complaints.24 It is believed that group interventions provide several benefits to participants, tend to improve personal and interpersonal relationships, facilitate better coping with dysphonia via exchange of experiences, and help improve physical, social, and emotional well-being.8,13,23 In the present study, it was observed that in the EG, the values of state anxiety significantly decreased after performing the therapeutic intervention for voice. It is suggested that therapeutic practices, when handling vocal aspects and in addition to the environment provided by the group may help in the reduction of anxiety and dysphonia. In the CG, there was a significant increase in anxiety values, as well as in dysphonia. A previous study25 analyzed the association between dysphonia and anxiety in subjects diagnosed with obsessivecompulsive disorder (OCD), which is a type of anxiety disorder. These patients presented changes in vocal quality due to muscle tension, poor use of the voice, and stress. Other
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complications included changes in speech rhythm and velocity and a high rate of hoarseness compared to a CG. The relationship between anxiety and dysphonia remains unclear. It is known that emotion is directly associated with voice problems. However, there is no consensus regarding whether anxiety is the cause or consequence of dysphonia.3 Thus, it can be comprehended with this study through the EG, that the correlation between the anxiety and voice variables evidences that vocal symptoms are closely related to anxiety, from the pregroup therapy moments, so that the values decreased simultaneously after treatment. Consequently, anxiety and vocal symptoms followed the same direction. These results agree with those of another study4 that analyzed the relationship between the degree of anxiety and communicative performance. Those authors observed that an HL of trait and state anxiety affected communication processes, leading to changes in the body, speech, and voice. In a study5 that evaluated the association between vocal problems and anxiety in teachers, participants with the highest levels of anxiety exhibited the most significant changes in voice. Another study compared vocal and emotional characteristics among teachers and nonteachers and concluded that individuals with an HL of anxiety presented greater impairment of voice and quality of life and more vocal disadvantages and symptoms.6 It is notable that previous studies analyzed the correlation between voice disorders and anxiety symptoms.25−28 However, regarding the effect of dysphonia type on emotional problems, White et al27 observed that patients with spasmodic dysphonia were not more susceptible to emotional problems than individuals with other types of vocal problems. This outcome demonstrated that emotional problems were associated with dysphonia regardless of the type of dysfunction, probably because of the adverse effects of this condition and its limitations on quality of life. In conclusion, our results reveal an association between dysphonia and anxiety such that individuals with higher anxiety levels had more vocal symptoms before group voice therapy. In addition, after group therapy, anxiety levels were decreased concomitantly with vocal symptoms. Despite of this correlation, it is not possible to affirm the cause-effect relation between these two variables,6 but it is evidenced that in both groups anxiety and dysphonia increase and decrease together over time. Therefore, therapeutic strategies to reduce dysphonia and its symptoms help reduce state anxiety. However, further studies are necessary to better understand the cause-effect relationship between voice and emotions. CONCLUSIONS Group voice therapy was effective in reducing vocal symptoms and state anxiety in patients with dysphonia. There was a positive correlation between the state anxiety levels and vocal symptoms, and the higher the degree of anxiety was, the stronger the vocal symptoms. In addition, after
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Group Voice Therapy Reduces Anxiety
therapy, anxiety levels decreased concomitantly with the scores of the total, impairment, and emotional domains of the VoiSS scale. REFERENCES 1. Silva FT, Leite JR. Physiological modifications and increase in state anxiety in volunteers submitted to the Stroop Color-Word Interference Test: a preliminary study. Physiol Behav. 2000;70:113–118. 2. Braga JEF, Pordeus LC, Silva ATMC, et al. Ansiedade patol ogica: bases neurais e avan¸c os na abordagem psicofarmacol ogica. Revista Brasileira de Ci^encias da Saude. 2010;14:93–100. 3. Souza OC. Hanayama EM Fatores psicol ogicos relacionados a disfonia funcional e a n odulos vocais em adultos. Rev CEFAC. 2005;7: 388–397. 4. Almeida AAF, Behlau M, Leite JR. Correla¸c ~ao entre ansiedade e performance comunicativa. Rev Soc Bras Fonoaudiologia. 2011;16: 384–389. 5. Costa DB, Lopes LW, Silva EG, et al. Fatores de risco e emocionais na voz de professores com e sem queixas vocais. Rev CEFAC. 2013;15:1001–1010. 6. Almeida LNA, Lopes LW, Costa DB, et al. Características vocais e emocionais de professores e n~ao professores com baixa e alta ansiedade. Revista Audiol. 2014;19:179–185. 7. Seifert E, Koolbrunner J. Stress and distress in non-organic voice disorders. Swiss Med Wkly. 2005;135:387–399. 8. Simberg S, Sala E, Tuomainen J, et al. The effectiveness of group therapy for students with mild voice disorders: a controlled clinical trial. J Voice. 2006;20:97–109. 9. Kasama ST, Brasolotto AG. Percep¸c ~ao vocal e qualidade de vida. ProFono Revista de Atualiza¸c ~ao Científica. 2007;19:19–28. 10. Almeida LNA, Fahning AKCA, Trajano FMP, et al. Fonoterapia em grupo e sua efic acia para tratamento da disfonia: uma revis~ao sistematica. Rev CEFAC. 2015;17:2000–2008. 11. Silva WJN, Lopes LW, Macedo AERM, et al. Reduction of risk factors in patients with behavioral dysphonia after vocal group therapy. J Voice. 2017;31:123.e15–123.e19. 12. Law T, Lee KYS, Ho NY, et al. The effectiveness of group voice therapy: a group climate perspective. J Voice. 2012;26:41–48. 13. Ribeiro VV, Panhoca I, Dassie-Leite AP, et al. Grupo terap^eutico em fonoaudiologia: revis~ao de literatura. Rev CEFAC. 2012;14: 544–552.
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14. Spielberger CD, Gorsuch RI, Lushene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970. 15. Biaggio AMB, Natalicio L. Manual para o Inventario de Ansiedade Tra¸c o-Estado (IDATE). Rio de Janeiro: Centro Editor de Psicologia Aplicada (CEPA); 1979. 16. Chaves EG. Stress e trabalho do enfermeiro: a influ^encia de características individuais no ajustamento e toler^ancia ao turno noturno, S~ao Paulo: Instituto de Psicologia/USP; 1994. 17. Moreti F, Zambon F, Oliveira G, et al. Equival^encia cultural da vers~ao brasileira da voice symptom scale − VoiSS. J Soc Bras Fonoaudiol. 2011;23:398–400. 18. Deary IJ, Wilson JA, Carding PN, et al. VoiSS: a patient-derived voice symptom scale. J Psychosom Res. 2003;54:483–489. 19. Moreti F, Zambon F, Oliveira G, et al. Cross-cultural adaptation, validation, and cutoff values of the Brazilian version of the voice symptom scale−VoiSS. J Voice. 2014;28:458–468. 20. Behlau M, Madazio G, Moreti F, et al. Efficiency and cutoff values of self-assessment instruments on the impact of a voice problem. J Voice. 2016;30.506.e9−e18. 21. Ara ujo MLB, Freire RMAC. Atendimento Fonoaudi ologo em grupo. Rev CEFAC. 2011;13:362–368. 22. Devore JL. Probabilidade e estatística: para engenharia e ci^encias. S~ao Paulo: Thomson Pioneira; 2006:706. 23. Souza AP, Crestani AH, Vieira CR, Machado FCM, Pereira LL. O grupo na Fonoaudiologia: origens clínicas e na Sa ude Coletiva. Rev CEFAC. 2011;13:140–151. 24. Millar A, Deary IJ, Wilson JA, et al. Is an organic/functional distinction psychologically meaningful in patients with dysphonia? J Psychosom Res. 1999;46:497–505. 25. Cassol M, Reppold CT, Ferr~ao Y, et al. Analise de características vocais e de aspectos psicol ogicos em indivíduos com transtorno obsessivo-compulsivo. Revista da Sociedade Brasileira de Fonoaudiologia. 2010;15:491–496. 26. Nerriere E, Vercambre M-N, Gilbert F, et al. Voice disorders and mental health in teachers: a cross-sectional nationwide study. BMC Public Health. 2009;9:370. 27. White LJ, Hapner ER, Klein AM, et al. M. Coprevalence of anxiety and depression with spasmodic dysphonia: a case-control study. J Voice. 2012;26:667. 28. Trajano FMP, Almeida LNA, Ara ujo FA, et al. Níveis de ansiedade e impactos na voz: uma revis~ao da literatura. Revista Disturbio de comunica¸c ~ao. 2016;28:423–433.
Group Voice Therapy Reduces Anxiety in Patients With Dysphonia via Maiele Pedroza Trajano, †Larissa Nadjara Alves Almeida, †Sauana Alves Leite de Alencar, *,†Fla ~ ‡Joao Euclides Fernandes Braga, and §Anna Alice Almeida, *yzxJo~ao Pessoa, Brazil Summary: Objective. To evaluate the impact of group therapy in patients with dysphonia, as well as to verify the correlation between vocal symptoms and levels of anxiety. Methods. The study was composed of 52 patients subdivided into two groups, named the Experimental Group (EG) with 28 volunteers and the Control Group (CG) with 24 volunteers. Anxiety and voice protocols were used for data collection. The State-Trait Anxiety Inventory (STAI) was used to measure trait levels of anxiety that after collection were categorized according to the variation in scores value: low anxiety (20-40 points); average anxiety (40-60 points); high anxiety (60-80 points). In addition, the Voice Symptom Scale (VoiSS) was used for voice assessment. Inferential statistical analysis from the Student’s t test for paired and independent data, in order to compare the average scores of STAI trait levels and VoiSS domains of the pre- and postmoments, intra- and intergroups, EG and CG, respectively. For that purpose, the program Statistical Package for Social Sciences (SPSS) was used. Results. Half of the patients in the survey presented an average trait level of anxiety. Regarding the EG, there was a significant reduction of state anxiety when comparing the moments before and after group therapy. There was also a significant reduction in the values of the VoiSS-Total and VoiSS-Physical domains when compared to the pre- and postgroup therapy moments. It was verified the existence of a positive correlation between the levels of anxiety after group therapy and VoiSS-Total, VoiSS-Limitation, and VoiSS-Physical domains. As for the CG, there was an increase in anxiety levels as well as in all domains of the VoiSS scale when compared to the pre- and postmoments. Conclusions. Group voice therapy was effective for a significant reduction of vocal symptoms and anxiety − common conditions in patients with dysphonia. It was possible to perceive the positive correlation between anxiety levels and vocal symptoms. Key Words: Anxiety−Behavior−Dysphonia−Speech therapy−Voice−Group practices.
INTRODUCTION Anxiety presents itself as an emotional reaction experienced by individuals in certain moments of their lives, which when exacerbated can generate a mood, behavior, and even thought disorders, leading to a physiological repercussion.1 The combination of these factors subjects the individual to an anxious condition that can be characterized by a feeling of insecurity, catastrophic thinking, insomnia, tachycardia, pallor, muscle tension, tremors, among other symptoms.2 Accepted for publication March 12, 2019. Funding: This study is part of a research project funded by the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnol ogico - CNPq), under Process No. 482337/2013-3. Conflicts of interest: None. Authors’ contributions: All authors contributed significantly to the design and development of this study. F.M.P.T., L.N.A.A., and S.A.L.A. contributed to data collection, tabulation, and analysis; J.E.F.B. participated in data analysis and revision of the manuscript; A.A.F.A. (research project coordinator) was involved in study supervision, data and statistical analysis, and manuscript review. From the *Cognitive Neuroscience and Behavior at the Federal University of Paraíba (Universidade Federal da Paraíba − UFPB), Jo~ao Pessoa, Brazil; yDecision and Health Models, UFPB, Jo~ ao Pessoa, Brazil; zDepartment of Nursing and Collective Health, UFPB, Jo~ ao Pessoa, Brazil; and the xDepartment of Speech-Language Pathology, UFPB, Jo~ ao Pessoa, Brazil. Address correspondence and reprint requests to Anna Alice Almeida, Departamento de Fonoaudiologia, Centro de Ci^encias da Sa ude, Cidade Universitaria − Campus I, Bairro Castelo Branco, Jo~ao Pessoa, PB CEP: 58051-900, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.03.003
Anxiety may cause impairment in the life of sufferers, including changes in the communication process, for example, voice characteristics, as noted in by several studies.3−7 Voice changes or difficulties are known as dysphonia and are classified as organic or functional. Organic dysphonia is characterized by tissue changes in the vocal folds, whether of genetic or mechanical etiology. Functional dysphonia is related to the use of voice.8 Genetic and environmental factors contribute to the onset of voice problems, which become even greater when the individual makes professional use of the voice. Dysphonia may have a strong impact on the social and professional life of affected individuals. A study on voice professionals and nonprofessionals indicated that the greater the perception of dysphonia by the subjects was, the stronger the impact of dysphonia on their quality of life.9 Voice therapy for dysphonia is historically centered on individual treatments based on the curative model of health care, with a focus on the disease only in an attempt to find healing alternatives. However, this reality has changed over the years, and group therapies are more common today.10 Group therapy is considered valuable by health professionals because it provides the patient knowledge and experience while offering the ability to cope with disease and exchange experiences. The latter favors the formation of personal bonds and the patient's involvement in a relationship of subjectivity.10,11
ARTICLE IN PRESS 2 Group voice therapy has been gaining prominence as a therapeutic modality for treating dysphonia. Several studies have demonstrated the effectiveness of this method in treating dysphonia in different target populations.8,12,13 The objective of this study is to determine the anxiety levels and vocal symptoms before and after group voice therapy in patients with dysphonia and assess the relationship between anxiety and vocal symptoms. METHOD This quantitative and interventional field study evaluated the impact of a therapeutic modality in a population with dysphonia over time. The study was approved by the Human Research Ethics Committee of the Health Sciences Center of a public university under Protocol No. 383.061/ 2013. Patients with dysphonia who sought care in the Voice Laboratory of a higher education institution participated in the study. They were divided into two groups: Experimental Group (EG), who participated in group therapy care; and the Control Group (CG), who were waiting for care and during the data collection period did not participate in any type of voice treatment. The EG was constituted, initially, by 44 patients, with which 7 therapeutic groups were formed, with an average of 6 participants each. The meetings took place between March and December 2014. However, there were 14 dropouts during the process, remaining 30 individuals. Of these, 28 patients met the following eligibility criteria: having a laryngological report and diagnosis of dysphonia; receiving exclusively group care; presenting no more than two absences in the therapeutic process; performing no previously Speech Therapy before; responding to the research instruments of pre- and postgroup therapy; and not presenting comorbidity that could affect cognition or communication. The CG was constituted by 24 participants with dysphonia who were not submitted to any type of vocal intervention, and who were awaiting care. The obtained demographic data were gender, age, work activities, and laryngeal diagnosis. In addition, two questionnaires were used to assess the anxiety levels and voice characteristics. The State-Trait Anxiety Inventory (STAI), initially developed in English,14 was translated and validated for Brazilian Portuguese.15 The STAI is used to measure the subjective state of anxiety. This instrument contains two 20item subscales that are rated on a four-point scale. The scores on each subscale range from 20 to 80. One subscale evaluates individual self-perception of trait anxiety, which is related to the susceptibility to anxiety. The other subscale assesses state anxiety, which is a transient emotional state.15 Anxiety levels were classified into three categories according to the scores as follows: low level (LL), 20-40 points; intermediate level (IL), 40-60 points; and high level (HL), 60-80 points.16
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Voice self-assessment was performed using the Voice Symptom Scale (VoiSS) validated for Brazilian Portuguese17 and based on the original VoISS.18 This questionnaire contains 30 statements divided into three domains: impairment (15 items), emotional (8 items), and physical (7 items). Each statement is rated according to frequency on a four-point scale (“never,” “rarely,” “sometimes,” and “most of the time”). The sum of the scores of the three domains indicated the frequency of voice-related symptoms and limitations and could reach a maximum score of 120.17,19 It is of note that a previous study has shown that the cut-off value for VoiSS is 1620; that is, individuals with a value above this threshold are susceptible to developing voice problems. The selection of the VoiSS was motivated by being a reliable and robust self-assessment instrument in Brazil, once it presents specific domain for emotional issues. Initially, the volunteers were informed about the study and all existing doubts were solved. Then, the Free and Informed Consent Form (FIC) was presented, in order to obtain the participant's signature and their consent. The EG volunteers were assessed at the pre- and postgroup therapy moments through the VoiSS and the STAI, with application of both scales. Participants of the CG, however, composed of volunteers who were on the waiting list of the clinic, answered those questionnaires at the time of the initial evaluation (pre) and after six sessions they were called for reevaluation (post 6 weeks). After the re-evaluation of CG volunteers, therapy was initiated. As for the therapeutic groups, developed with the EG, they were formed by six patients on average, who presented dysphonia. Eight sessions were performed with each group, once a week, with an average time of 2 months and duration of 90 minutes per session, so that the first meeting was for evaluation and the last for reevaluation. In the other sessions, vocal therapy was performed from an eclectic approach, that is, combined direct and indirect approach, as described according to the voice therapy classification system proposed by Van Stan et al,21 presented in Table 1. The data were entered in a spreadsheet in Microsoft Excel version 2010 to create the database according to the criteria established in this study. Descriptive analysis was conducted to calculate the frequency, mean, and standard deviation of the studied variables. Subsequently, an inferential statistical analysis was performed from the parametric test, Student's t for paired and independent data, in order to compare the means of STAI-state scores and VoiSS domains of the preand postmoments of intra- and intergroups EG and CG, respectively. An inferential analysis was performed using Student's t − parametric test for paired data to compare the mean scores of the STAI-state and VoiSS domains before and after group therapy. The Pearson correlation test was used to determine the association between the scores of the STAI-state and VoiSS domains. The method proposed by Devore22 was used to indicate the degree of correlation according to Pearson's coefficients as follows: very weak,
ARTICLE IN PRESS via Maiele Pedroza Trajano, et al Fla
Group Voice Therapy Reduces Anxiety
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TABLE 1. Description of Activities Performed by Patients With Dysphonia During Group Voice Therapy Session 1 2
Intervention Evaluation Indirect
Direct 3
Indirect Direct
4
Indirect Direct
5
Indirect Direct
6
Indirect Direct
7
Indirect Direct
8
Re-evaluation
Instrument Application (State-Trait Anxiety Inventory and Voice Symptom Scale) Therapeutic interaction: Presentation dynamics Increase in knowledge: Anatomy and physiology of vocal production, voice in the vital cycle Respiratory intervention: Respiratory fitness Respiratory support and vocal function: Maximum phonation time (MPT) Pedagogical intervention; therapeutic interaction: Myths and truths about the voice Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal function, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle and use of lateral fricatives Intervention counseling; increase in knowledge: Vocal psychodynamics, voice, and emotion Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube Pedagogical intervention: Phonoarticulatory organs and pneumo-phono-articulatory coordination Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system Therapeutic interaction; increase in knowledge: Laryngeal diseases Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises using a high-resistance tube; tongue rotation associated with nasal sounds Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system Intervention and pedagogical counseling; therapeutic interaction: Non-verbal communication and expressiveness Respiratory intervention: Respiratory fitness Respiratory support and vocal function: MPT Intervention − auditory; vocal, musculoskeletal, somatosensory, and respiratory function: Stretching/relaxation of the cervical region and pectoral girdle; use of lateral fricatives; semioccluded vocal tract exercises with a high-resistance tube; tongue rotation associated with nasal sounds Musculoskeletal − orofacial and somatosensory manipulation: Myofunctional exercises for structures of the stomatognathic system, overarticulation Application (State-Trait Anxiety Inventory and Voice Symptom Scale)
0.00-0.19; weak, 0.20-0.39; moderate, 0.40-0.69; strong, 0.70-0.89; very strong, 0.90-1.00. Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) version 20.0, and P values smaller than 0.05 were considered statistically significant.
RESULTS The sample consisted of 28 participants undergoing group therapy with a mean age of 47.4 § 12.5 years. The number of absences in therapy attendance varied from 0 to 2, such that 35.8% (n = 10) of participants were absent from two
ARTICLE IN PRESS 4
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TABLE 2. Distribution of the Variables Gender, Professional Use of Voice, and Laryngeal Diagnosis in Patients Undergoing Group Voice Therapy Variable Gender Female Male Professional use of voice No Yes Laryngeal diagnosis Lesion in the membrane of the vocal folds Indefinite diagnosis Absence of laryngeal lesions Glottic chink without organic or neurological etiology Voice disorder secondary to GERD
N
%
22 6
78.6 21.4
17 11
60.7 39.3
9
32.1
7 5 4
25.0 17.9 14.3
3
10.7
Abbreviation: GERD, gastroesophageal reflux.
sessions, 32.1% (n = 9) were absent from one session, and 32.1%) attended all sessions. There was a predominance of female (78.6%, n = 22) and voice nonprofessionals (60.7%, n = 17) in the EG. Regarding the laryngeal diagnosis presented by the patients, 32.1% (n = 9) presented lesions on the membranous portion of the vocal fold, followed by 25.0% (n = 7) with an indefinite diagnosis and 10.7% (n = 3) with voice disorder secondary to gastroesophageal reflux, according to Table 2. In the CG, most of the subjects were also female (66.7%, n = 16) Table 2. Table 3 shows the distribution of State-Trait Anxiety levels pre- and postgroup therapy in the EG, and between assessments in the CG. It was observed that in the EG 50.0% (n = 14) of the sample had average level of trace anxiety. The majority of patients (64.3%; n = 18) presented a low level of trace anxiety at the moment of pretherapy, and that frequency increased at the post-therapy moment to 71.4% (n = 20). The profile of anxiety in the CG is initially similar to the EG, in which the majority had an average level of trace anxiety (48.1%; n = 25) and low level of state anxiety (69.2%; n = 36). Table 4 shows the comparison of the means of VoiSS and STAI-state domains in the pre- and post-therapy moments in the EG and in the pre- and postassessment in the CG. It was observed that in the assessment of the participants of the group therapy, there was a reduction of the averages in all VoiSS scores, being statistically significant the reduction of the total symptoms VoiSS-T (P = 0.007) and physical symptoms VoiSS-F (P = 0.024). It was also observed a score reduction in the level of STAI-S (P < 0.001). In the CG group, there was an increase of all means, that is, state anxiety levels (P = 0.0001) and the vocal symptoms
TABLE 3. Distribution of STAI-Trait and STAI-State in Patients Undergoing Group Voice Therapy Variable
EG N
CG %
STAI-trait LL 13 46.4 IL 14 50.0 HL 1 3.6 STAI-state before group therapy LL 18 64.3 IL 9 32.1 HL 1 3.6 STAI-state after group therapy LL 20 71.4 IL 8 28.6 HL 00 00.0
N
%
12 10 2
50 41.7 8.3
16 5 3
66.7 20.8 12.5
16 7 1
66.7 29.2 4.1
Abbreviations: HL, high levels of anxiety; IL, intermediate levels of anxiety; LL, low levels of anxiety; STAI, State-Trait Anxiety Inventory.
in VoiSS-L (P = 0.049) and VoiSS-F (P = 0.021) domains increased significantly over time (Table 4). Table 5 shows the correlation between State-Trait Anxiety of post-therapy group (EG) with VoiSS domains. The existence of a moderate positive correlation between the post-therapy STAI-S and STAI-T (P < 0.001) was observed. In addition, a correlation between the post-therapy STAI-S with VoiSS-Total pretherapy (P = 0.023) and post-therapy (P = 0.028) was observed; with the pretherapy VoiSS limitation (P = 0.028) and with VoiSS emotional the pretherapy (P = 0.029) and post-therapy (P = 0.001). In the CG, there was no correlation between State-Trait Anxiety and vocal symptoms. DISCUSSION This study is the first to evaluate the effectiveness of group voice therapy in reducing anxiety and vocal symptoms in subjects with dysphonia. Studies that provide scientific evidence using a particular approach and/or therapeutic modality are essential. It is necessary to consider the results of previous studies and the adopted methodologies to increase the accuracy of the interventions and focus on the emotional traits of the patients to improve vocal symptoms and anxiety and consequently the quality of life of these patients. The results indicated that there was a greater demand for voice therapy by women, corroborating the results of previous studies, wherein the rate of dysphonia was higher among women than among men because the former group is more likely to develop vocal problems. The increased rate of vocal changes in women may be due to anatomical and physiological differences in the larynx, including smaller vocal folds and a lower glottal ratio.1,20
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Group Voice Therapy Reduces Anxiety
TABLE 4. Mean, Standard Deviation, and Significance of VoiSS and STAI-State Scores of Patients in the EG and CG Groups in the Pre- and Postevaluation Variable
EG VoiSS-T VoiSS-I VoiSS-E VoiSS-P STAI-E CG VoiSS-T VoiSS-I VoiSS-E VoiSS-P STAI-E
Before Therapy
After Therapy
P Value
t
Mean
SD
Mean
SD
47.25 27.04 8.68 11.71 39.25
21.633 11.893 9.047 5.785 8.699
41.79 25.14 7.11 10.04 34.11
22.444 12.018 8.474 5.751 7.690
2.897 1.487 1.540 2.386 7.221
0.007 * 0.149 0.135 0.024* <0.0001
52.67 27.00 11.85 12.47 34.08
23.816 12.296 8.730 5.114 9.737
54.05 28.00 12.61 13.42 38.29
22.143 12.518 7.908 4.664 8.948
¡1.17 ¡2.09 ¡2.09 ¡2.50 ¡5.847
0.256 0.049* 0.049* 0.021* 0.000*
* P < 0.05. Abbreviations: E, emotional domain; I, impairment domain; P, physical domain; STAI, State-Trait Anxiety Inventory; STAI-S = State-Trait Anxiety Inventory, state subscale; VoiSS, voice symptom scale.Student’s t-test for paired data.
With the data on the professional use of the voice, it was noticed through the EG that there was a greater demand of patients who did not use the voice as a working instrument, a fact that revealed that the vocal symptoms are present in different populations, considering that people with great vocal demand professions are at greater risk of developing voice issues.21 Most of patients from the EG had lesions on the membranous portion of the vocal fold. The presence of mass lesions may prevent adaptation of the vocal folds and impair vocal production, leading to significant changes in the voice and altering the ratio between the voice signal and the noise measured acoustically.23 It was observed that group voice therapy was effective in reducing vocal symptoms and anxiety levels in patients with dysphonia. This fact was observed due to the decrease of VoiSS and STAI scores in the EG and the increase of these
scores in the CG, when comparing the evaluations in the pre- and post-therapy moments. Group voice therapy is a therapeutic modality that has been observed to be effective in the rehabilitation of patients with voice issues.10 The increase in VoiSS and STAI scores in the CG shows that the absence of treatment further aggravates the clinical situation of the patient with dysphonia, as well as their anxiety levels, which grow together over time. Group voice therapy began in the mid-1980s, motivated by the insertion of speech-language pathologists in the public health network to meet the individual demands of patients.21 However, because studies indicated that group therapy could adequately meet these demands and provide a forum for the exchange of experiences and knowledge, individual therapy was modified over the years, and group therapy emerged as a critical form of speech-language pathology.23
TABLE 5. Correlation Between STAI-State Post-therapy and VoiSS Scores of Patients Undergoing Group Voice Therapy Dependent Variable
IDATE estado s-terapia Po
Independent Variables
STAI-trait VoiSS-T before group therapy VoiSS-T after group therapy VoiSS-I before group therapy VoiSS-I after group therapy VoiSS-E before group therapy VoiSS-E after group therapy
EG
G
Correlation
P Value
Correlation
P Value
0.676 0.428 0.415 0.416 0.293 0.413 0.588
0.000* 0.023* 0.028* 0.028* 0.130 0.029* 0.001*
0.338 0.198 0.252 0.230 0.303 0.116 0.117
0.096 0.390 0.270 0.316 0.181 0.617 0.614
* P < 0.05. Abbreviations: E, emotional domain; I, impairment domain; STAI, State-Trait Anxiety Inventory; T, total score; VoiSS, voice symptom scale.Statistical analysis using Pearson correlation.
ARTICLE IN PRESS 6 Recent studies have demonstrated the effectiveness of group voice therapy in preventing vocal changes; improving quality of life, acoustic measures, and auditory-perceptual skills; and reducing the disadvantage index, risk-factor exposure, and postintervention vocal symptoms.11 When comparing the pre- and post-therapy scores in the EG, the present study observed that the vocal symptoms were significantly reduced both in relation to the total and physical domains of VoiSS, as well as the levels of state anxiety. A study performed in Finland8 compared to individual therapy, there were no significant differences between vocal therapy and group therapy. These results corroborate those found in this study regarding the reduction in vocal symptoms after group therapy. The VoiSS-impairment scores were not significantly decreased, probably because this domain is more related to physical symptoms of the voice than to emotional factors.19 According to the International Classification of Functioning,19 this domain reflects the interaction between the health condition and intrinsic and extrinsic factors of the individual, and VoiSS-impairment scores are related to the performance of vocal, professional, and social function. It is of note that direct intervention was not used to reduce anxiety. It is possible that the group therapy environment together with the improvement of vocal symptoms affected dysphonia-related emotional states. It is known that group therapy enables participants to interact by sharing experiences and knowledge, which promotes the development of new perceptions regarding the self and others in the face of illnesses. These interactions may help reduce anxiety and enable patients to better address vocal problems.11 State anxiety levels were positively and moderately correlated with the total, impairment, and emotional domains of VoiSS after therapy. In this study, 50% of the participants from the EG had an IL of trait and state anxiety before group therapy. Patients with dysphonia have higher rates of psychological distress compared to patients without voice complaints.24 It is believed that group interventions provide several benefits to participants, tend to improve personal and interpersonal relationships, facilitate better coping with dysphonia via exchange of experiences, and help improve physical, social, and emotional well-being.8,13,23 In the present study, it was observed that in the EG, the values of state anxiety significantly decreased after performing the therapeutic intervention for voice. It is suggested that therapeutic practices, when handling vocal aspects and in addition to the environment provided by the group may help in the reduction of anxiety and dysphonia. In the CG, there was a significant increase in anxiety values, as well as in dysphonia. A previous study25 analyzed the association between dysphonia and anxiety in subjects diagnosed with obsessivecompulsive disorder (OCD), which is a type of anxiety disorder. These patients presented changes in vocal quality due to muscle tension, poor use of the voice, and stress. Other
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complications included changes in speech rhythm and velocity and a high rate of hoarseness compared to a CG. The relationship between anxiety and dysphonia remains unclear. It is known that emotion is directly associated with voice problems. However, there is no consensus regarding whether anxiety is the cause or consequence of dysphonia.3 Thus, it can be comprehended with this study through the EG, that the correlation between the anxiety and voice variables evidences that vocal symptoms are closely related to anxiety, from the pregroup therapy moments, so that the values decreased simultaneously after treatment. Consequently, anxiety and vocal symptoms followed the same direction. These results agree with those of another study4 that analyzed the relationship between the degree of anxiety and communicative performance. Those authors observed that an HL of trait and state anxiety affected communication processes, leading to changes in the body, speech, and voice. In a study5 that evaluated the association between vocal problems and anxiety in teachers, participants with the highest levels of anxiety exhibited the most significant changes in voice. Another study compared vocal and emotional characteristics among teachers and nonteachers and concluded that individuals with an HL of anxiety presented greater impairment of voice and quality of life and more vocal disadvantages and symptoms.6 It is notable that previous studies analyzed the correlation between voice disorders and anxiety symptoms.25−28 However, regarding the effect of dysphonia type on emotional problems, White et al27 observed that patients with spasmodic dysphonia were not more susceptible to emotional problems than individuals with other types of vocal problems. This outcome demonstrated that emotional problems were associated with dysphonia regardless of the type of dysfunction, probably because of the adverse effects of this condition and its limitations on quality of life. In conclusion, our results reveal an association between dysphonia and anxiety such that individuals with higher anxiety levels had more vocal symptoms before group voice therapy. In addition, after group therapy, anxiety levels were decreased concomitantly with vocal symptoms. Despite of this correlation, it is not possible to affirm the cause-effect relation between these two variables,6 but it is evidenced that in both groups anxiety and dysphonia increase and decrease together over time. Therefore, therapeutic strategies to reduce dysphonia and its symptoms help reduce state anxiety. However, further studies are necessary to better understand the cause-effect relationship between voice and emotions. CONCLUSIONS Group voice therapy was effective in reducing vocal symptoms and state anxiety in patients with dysphonia. There was a positive correlation between the state anxiety levels and vocal symptoms, and the higher the degree of anxiety was, the stronger the vocal symptoms. In addition, after
ARTICLE IN PRESS via Maiele Pedroza Trajano, et al Fla
Group Voice Therapy Reduces Anxiety
therapy, anxiety levels decreased concomitantly with the scores of the total, impairment, and emotional domains of the VoiSS scale. REFERENCES 1. Silva FT, Leite JR. Physiological modifications and increase in state anxiety in volunteers submitted to the Stroop Color-Word Interference Test: a preliminary study. Physiol Behav. 2000;70:113–118. 2. Braga JEF, Pordeus LC, Silva ATMC, et al. Ansiedade patol ogica: bases neurais e avan¸c os na abordagem psicofarmacol ogica. Revista Brasileira de Ci^encias da Saude. 2010;14:93–100. 3. Souza OC. Hanayama EM Fatores psicol ogicos relacionados a disfonia funcional e a n odulos vocais em adultos. Rev CEFAC. 2005;7: 388–397. 4. Almeida AAF, Behlau M, Leite JR. Correla¸c ~ao entre ansiedade e performance comunicativa. Rev Soc Bras Fonoaudiologia. 2011;16: 384–389. 5. Costa DB, Lopes LW, Silva EG, et al. Fatores de risco e emocionais na voz de professores com e sem queixas vocais. Rev CEFAC. 2013;15:1001–1010. 6. Almeida LNA, Lopes LW, Costa DB, et al. Características vocais e emocionais de professores e n~ao professores com baixa e alta ansiedade. Revista Audiol. 2014;19:179–185. 7. Seifert E, Koolbrunner J. Stress and distress in non-organic voice disorders. Swiss Med Wkly. 2005;135:387–399. 8. Simberg S, Sala E, Tuomainen J, et al. The effectiveness of group therapy for students with mild voice disorders: a controlled clinical trial. J Voice. 2006;20:97–109. 9. Kasama ST, Brasolotto AG. Percep¸c ~ao vocal e qualidade de vida. ProFono Revista de Atualiza¸c ~ao Científica. 2007;19:19–28. 10. Almeida LNA, Fahning AKCA, Trajano FMP, et al. Fonoterapia em grupo e sua efic acia para tratamento da disfonia: uma revis~ao sistematica. Rev CEFAC. 2015;17:2000–2008. 11. Silva WJN, Lopes LW, Macedo AERM, et al. Reduction of risk factors in patients with behavioral dysphonia after vocal group therapy. J Voice. 2017;31:123.e15–123.e19. 12. Law T, Lee KYS, Ho NY, et al. The effectiveness of group voice therapy: a group climate perspective. J Voice. 2012;26:41–48. 13. Ribeiro VV, Panhoca I, Dassie-Leite AP, et al. Grupo terap^eutico em fonoaudiologia: revis~ao de literatura. Rev CEFAC. 2012;14: 544–552.
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