- Email: [email protected]
VHI-10 and SVHI-10 Differences in Singers' Self-perception of Dysphonia Severity
ARTICLE IN PRESS VHI-10 and SVHI-10 Differences in Singers’ Self-perception of Dysphonia Severity *Elizabeth Renk, †Lucian Sulica, ‡Chad Grossman, ‡Jenny Georges, and *Thomas Murry, *Loma Linda, California, and †‡New York, New York
Summary: Objective. Previous investigations of the Voice Handicap Index (VHI)-10 in clinical practice noted that specific information relevant to singers was not forthcoming. Consequently, a second index, the Singing Voice Handicap Index (SVHI) as well as its shortened counterpart the SVHI-10, was developed. The purpose of this study was to directly compare the differences in scores between the VHI-10 and the SVHI-10 in a group of 50 singers. Methods. A retrospective chart review of 50 singers (26 women, 24 men) was performed between June 2014 and November 2014 at Weill Cornell Medical College, New York. Subjects completed both the VHI-10 and the SVHI-10 at their initial evaluation. The results from the VHI-10 and the SVHI-10 were then compared using paired t test and two-way analysis of variance. Results. The SVHI-10 scores from the performers were significantly higher than those of the VHI-10 (P < 0.0001). The mean score on the VHI-10 was 12.1 compared with 20.4 on the SVHI-10 (maximum score for each questionnaire is 40). There were no significant gender differences when comparing the VHI-10 and the SVHI-10 on the overall scores or for individual items. The analysis of variance also found no significant gender difference (P = 0.865) and confirmed a significant difference between VHI-10 and SVHI-10 (P = 0.0003). Conclusion. Whereas singers may have general complaints about their voice, they also have specific complaints that relate only to their singing voice. Finding a significant difference between the scores of the VHI-10 and the SVHI-10 suggests the importance of assessing the singer’s perception of voice severity using a tool that focuses on the singing voice. Key Words: Singers–Voice–Dysphonia–Voice handicap index. INTRODUCTION Objective analysis of therapeutic results in the management of voice disorders has been a challenge.1 Consequently, outcomes research has been the mainstay for determining the need for clinical management of voice disorders and for voice research. Outcomes research places the focus of the impact of disease and subsequent treatment on the patients’ subjective evaluation of their voice disorder as well as the clinician’s impression of changes. In 1997, Jacobson et al published the Voice Handicap Index (VHI), a 30-item series of statements about the use of the voice, which is scored from zero (never) to 4 (always).2 The VHI was later shortened and validated to the VHI-10, a 10-item form now used by clinicians around the world.3 During the development of the VHI and the VHI-10, the statements that compose the indexes were organized into three categories—functional, physical, and emotional. The VHI comprises 10 functional items, 10 physical items, and 10 emotional items. From those 30 items, the VHI-10 was reduced to five functional items, three physical items, and two emotional items. As the VHI-10 was used in clinical practice, differences were noted between nonsinger and singer populations. VHI-10 lacked statements specifically about singers and the singing voice. Several investigators identified differences between singers and nonsingers in their use of the VHI-10. Phyland et al compared 167 vocal Accepted for publication August 26, 2016. From the *Department of Otolaryngology—Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California; †Department of Otolaryngology—Head and Neck Surgery, Weill Cornell Medical College, New York, New York; and the ‡Teachers College, Columbia University, New York, New York. Address correspondence and reprint requests to Elizabeth Renk, Department of Otolaryngology, Loma Linda University, 11234 Anderson Street, Suite 2586A, Loma Linda, CA 92354. E-mail: [email protected], [email protected] Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2016.08.017
performers with 86 nonperformers and found that the vocal performers were more likely to be diagnosed with a vocal condition in the past 12 months (44% compared with 21%) and were more likely to suffer vocal disability (69% compared with 41%).4 Despite these significant complaints regarding their voice, Rosen and Murry found that, when compared with nonsingers, singers scored significantly lower on the VHI (less severe).5 To explain this paradoxical finding, Murry et al compared the VHI-10 responses of 35 singers with that of 35 nonsingers. They found that the two groups ranked differently the 10 statements that compose the VHI-10. In addition, when Murry et al changed three statements to “my singing voice,” rather than simply “my voice,” the singers judged their voice complaints as more severe.6 The above findings led to the development of a second index, the Singing Voice Handicap Index (SVHI)7 and its shortened counterpart the SVHI-10,8 which were developed and validated on performers. To develop the SVHI, a clinical consensus conference (comprising laryngologists and speech pathologists) generated an 81-item list of voice complaints that they felt would be of particular concern to singers. This list was then narrowed to 36 items and then administered by Cohen et al to a group of 112 singers with dysphonia and 129 singers with normal voice. They found a high test-retest reliability, as well as a high internal consistency.7,8 In an effort to simplify the more cumbersome 36-item SVHI, Cohen et al undertook the development of the SVHI-10.8 Once again, a clinical consensus conference selected 16 items (from the original 36), which in their combined opinion had the highest content validity. Ultimately, 10 of the highest items in content validity were retained to create the SVHI-10. This shortened survey was then administered to a group of 91 singers with dysphonia at their initial evaluation. A second survey was mailed to them 1 day later. Once again, there was a high test-retest reliability, as well as a high internal consistency.
ARTICLE IN PRESS 2
Journal of Voice, Vol. ■■, No. ■■, 2016
TABLE 1. Voice Handicap Index-10 F1 F2
F8 F9 F10 P5 P6 E4 E6 P3
My voice makes it difficult for people to hear me. People have difficulty understanding me in a noisy room My voice difficulties restrict personal and social life I feel left out of conversations because of my voice My voice problem causes me to lose income I feel as though I have to strain to produce voice The clarity of my voice is unpredictable My voice problem upsets me My voice makes me feel handicapped People ask “What is wrong with your voice?”
TABLE 2. Patient Demographics 0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0 0
1 1
2 2
3 3
4 4
0
1
2
3
4
Abbreviations: E, emotional; F, functional; P, physical.
The SVHI and the SVHI-10 were developed differently from the VHI and the VHI-10. No attempt was made to identify an equal number of items related to physical, functional, and emotional parameters in the SVHI or the SVHI-10. Nonetheless, by examining the statements, the current authors categorized the 10 statements into the broad categories of physical, functional, and emotional (Table 1). Presently, there are no data that directly compare responses of a large group of singers on both self-assessment tools. The purpose of this study was twofold. First, to directly compare the scores from the VHI-10 and the SVHI-10 in a group of 50 singers and to examine the relative importance of each item as it relates to singers’ perception of voice severity. Second, to use the same analysis to explore differences between male and female singers. METHODS A retrospective chart review of 50 singers (26 women, 24 men) presenting to a laryngology clinic was performed between June 2014 and November 2014 at Weill Cornell Medical College, New York. This group consisted of both professional singers and students in a university vocal performance program. Table 2 presents the demographics of the group. There were 24 men and 26 women. The age range was between 18 and 55 years. Of the 50 subjects, 34 were performers earning their living from performing, 14 were graduate students enrolled in a voice performance program, and 2 were professional singers currently not performing because of their voice problems. At their initial visit, all subjects completed the VHI-10 and the SVHI-10 before their evaluation. For comparison, two of the authors (E.R., T.M.) also reviewed the items of the SVHI-10 and compared them to the original statements of the VHI to classify them as functional, physical, or emotional items (Table 3).
Groups n Male, n (%) Female, n (%) Age 11–20, n (%) 21–30, n (%) 31–40, n (%) 41–50, n (%) 51–60, n (%) Type of performer Current performers, n (%) Graduate students, n (%) Previous performers, n (%)
N (%) 50 24 (48%) 26 (52%) 6 (12%) 27 (54%) 10 (20%) 5 (10%) 2 (4%) 34 (68%) 14 (28%) 2 (4%)
DATA ANALYSIS The data were submitted to a subjects (male vs female) by conditions (VHI-10 vs SVHI-10) two-way analysis of variance (ANOVA), with repeated measures on subjects for each of the two assessment tools. To have an equal number of male and female vocal singers (n = 24) to perform the ANOVA, two female singers whose VHI-10 and SVHI-10 scores were closest to the mean were eliminated from the calculations. Finally, the mean values of each statement were ranked from highest to lowest for both men and women. RESULTS A two-way ANOVA of gender by assessment type with repeated measures on gender demonstrated that there were no significant differences in VHI-10 or SVHI-10 scores between genders (P = 0.865). For the assessment types, there was a significant difference between VHI-10 and SVHI-10 (P = 0.0003). There was no significant interaction term indicating that men and women performed similarly on both assessment tools. TABLE 3. Singing Voice Handicap Index-10 P It takes a lot of effort to sing F I am unsure of what will come out when I sing P My voice “gives out” on me while I am singing E My singing voice upsets me F I have no confidence in my singing voice P I have trouble making my voice do what I want it to P I have to “push it” to produce my voice when singing P My singing voice tires easily E I feel something is missing in my life because of my inability to sing P I am unable to use my “high voice” Abbreviations: E, emotional; F, functional; P, physical.
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
ARTICLE IN PRESS Elizabeth Renk, et al
VHI-10 and SVHI-10 Differences in Singers’
3
TABLE 4. Comparison of VHI-10 and SVHI-10
Notes: Highlighted texts denote the average scores of items with the highest weighting among the 10 statements for each questionnaire.
The mean score for VHI-10 was 12.1 and that of SVHI-10 was 20.39 (both out of a possible 40). Five of 50 subjects had a score equal to or lower in the SVHI-10 than in the VHI-10. When the scores of the 24 male vocal performers were compared with those of the 26 female vocal performers, there was no significant gender difference in the overall score between the VHI-10 or the SVHI-10. For the VHI-10, men had a mean score of 11.75, compared with 12.42 for women. On the SVHI-10, men had a mean score of 20.39, compared with 20.38 for women. We provide both t test and ANOVA statistical analysis of our data. Historically, some authors have considered the responses to the questions of the VHI or SVHI as ordinal data, which should be analyzed using nonparametric methods, such as a t test. More recently, authors have begun to view the data as interval data, which would be better analyzed using parametric methods, such as ANOVA or Pearson correlations.9,10 As there is no concensus in the literature, it seems to the authors of this paper that including both methods strengthened the statistical analysis. When ranking the most severe items in the SVHI-10, as ranked by the singers, we found that specific statements within the SVHI10 were of note. The statements “My voice problem upsets me” (statement 8 on the VHI-10) and “My singing voice tires easily” (statement 8 on the SVHI-10) each had the highest weighting (most severe) among the 10 statements, with average scores of 2.8 and 2.4, respectively (Table 4). Statement 8 in the VHI-10 falls under the category of emotional statements. Statement 8 on the SVHI-10 could be considered a physical statement. When we compared men and women, both ranked statement 8 on the SVHI-10 as the most severe, with a score of 2.2 and 2.5, respectively. The second highest scores on each of the two forms were for statements “The clarity of my voice is unpredictable” (question number 7 on the VHI-10) and “I am unable to use my high voice” (question number 10 on the SVHI-10) with average scores of 1.8 and 2.3, respectively. These questions both address the physical dimension of voice. Interestingly, performers gave the statement “People ask, ‘What’s wrong with your voice?’” (question 10 on the VHI10) the lowest (least severe) average score, 0.7, despite their overall concern with their singing voice. The lowest average score on the SVHI-10 was an average score of 1, for the statement “I have no confidence in my singing voice” (question 5).
DISCUSSION This study demonstrates the significant difference in how singers perceive their singing voice in comparison with their speaking voice. The VHI-10 was designed to analyze spoken voice and uses words like “my voice” or “when I talk,” whereas the SVHI10 uses “singing” or “my singing voice.” Our data indicate that when singers respond to the SVHI-10, they identify their voice problem as more severe than when responding to the VHI-10, with scoring of 20.4 and 12.1, respectively. Whereas singers may have general complaints about their voice, they also have specific complaints that relate only to their singing voice. This is demonstrated by the fact that performers rated the statement “People ask, ‘What’s wrong with your voice?’” on the VHI-10 very low in severity (average score of only 0.7) even though their singing voice was still very bothersome to them. The statements in the two assessment tools demonstrate a different focus. The VHI-10 lists five statements related to voice function, whereas the SVHI-10 appears to have only two statements related to function, and the remaining eight are related to emotional and physical needs. Although our data show that certain questions were more concerning to singers, no further statistical analysis was performed. Further research is warranted to explore differences in ranking of the individual items that compose each survey. In the current study, all of the 36 professional singers come to the voice center with a primary complaint related to singing. They were either not able to perform well in their current roles or not performing at all because of their singing voice. All of the 14 graduate students were in a vocal performance program and could not maintain their class load because of their singing voice. Clearly, these singers perceive an inability to perform a physically demanding task, much like an athlete having little trouble walking but having a significant problem running or jumping. Moreover, it appears that the inability to perform the physical task of singing contributes to emotional concern. These data suggest the need to assess the physical needs of singers.
CONCLUSION It is important for clinicians to understand that their patients who are vocal performers perceive a marked distinction between talking and singing. This study highlights the importance of using the
ARTICLE IN PRESS 4 VHI-10 and the SVHI-10 as complementary questionnaires for performers. When used in this manner, the clinician can identify specific complaints relating to the voice concerns of the patient when singing and speaking. Furthermore, clinicians can use this knowledge to guide clinical decision-making.
REFERENCES 1. Roy N, Barkmeier-Kraemer J, Eadie T, et al. Evidence-based clinical voice assessment: a systematic review. Am J Speech Lang Pathol. 2012;22:212– 226. 2. Jacobson BJ, Johnson A, Grywalski C, et al. The voice handicap index (VHI). Am J Speech Lang Pathol. 1997;6:66–70. 3. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice handicap index-10. Laryngoscope. 2004;114:1549–1556.
Journal of Voice, Vol. ■■, No. ■■, 2016 4. Phyland DJ, Oates J, Greenwood KM. Self-reported voice problems among three groups of professional singers. J Voice. 1999;13:602–611. 5. Rosen CA, Murry T. Voice handicap index in singers. J Voice. 2000;14:370– 377. 6. Murry T, Zschommler A, Prokop J. Voice handicap in singers. J Voice. 2009;23:376–379. 7. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and validation of the Singing Voice Handicap Index. Ann Otol Rhinol Laryngol. 2007;116:402– 406. 8. Cohen SM, Statham M, Rosen CA, et al. Development and validation of the Singing Voice Handicap-10. Laryngoscope. 2009;119:1864–1869. 9. Niebudek-Bogusz E, Woznicka E, Zamyslowska-Szmytke E, et al. Correlation between acoustic parameters and Voice Handicap Index in dysphonic teachers. Folia Phoniatr Logop. 2010;62:55–60. 10. Timmermans B, De Bodt M, Wuyts F, et al. Analysis and evaluation of a voice-training program in future professional voice users. J Voice. 2004;19:202–210.
Summary: Objective. Previous investigations of the Voice Handicap Index (VHI)-10 in clinical practice noted that specific information relevant to singers was not forthcoming. Consequently, a second index, the Singing Voice Handicap Index (SVHI) as well as its shortened counterpart the SVHI-10, was developed. The purpose of this study was to directly compare the differences in scores between the VHI-10 and the SVHI-10 in a group of 50 singers. Methods. A retrospective chart review of 50 singers (26 women, 24 men) was performed between June 2014 and November 2014 at Weill Cornell Medical College, New York. Subjects completed both the VHI-10 and the SVHI-10 at their initial evaluation. The results from the VHI-10 and the SVHI-10 were then compared using paired t test and two-way analysis of variance. Results. The SVHI-10 scores from the performers were significantly higher than those of the VHI-10 (P < 0.0001). The mean score on the VHI-10 was 12.1 compared with 20.4 on the SVHI-10 (maximum score for each questionnaire is 40). There were no significant gender differences when comparing the VHI-10 and the SVHI-10 on the overall scores or for individual items. The analysis of variance also found no significant gender difference (P = 0.865) and confirmed a significant difference between VHI-10 and SVHI-10 (P = 0.0003). Conclusion. Whereas singers may have general complaints about their voice, they also have specific complaints that relate only to their singing voice. Finding a significant difference between the scores of the VHI-10 and the SVHI-10 suggests the importance of assessing the singer’s perception of voice severity using a tool that focuses on the singing voice. Key Words: Singers–Voice–Dysphonia–Voice handicap index. INTRODUCTION Objective analysis of therapeutic results in the management of voice disorders has been a challenge.1 Consequently, outcomes research has been the mainstay for determining the need for clinical management of voice disorders and for voice research. Outcomes research places the focus of the impact of disease and subsequent treatment on the patients’ subjective evaluation of their voice disorder as well as the clinician’s impression of changes. In 1997, Jacobson et al published the Voice Handicap Index (VHI), a 30-item series of statements about the use of the voice, which is scored from zero (never) to 4 (always).2 The VHI was later shortened and validated to the VHI-10, a 10-item form now used by clinicians around the world.3 During the development of the VHI and the VHI-10, the statements that compose the indexes were organized into three categories—functional, physical, and emotional. The VHI comprises 10 functional items, 10 physical items, and 10 emotional items. From those 30 items, the VHI-10 was reduced to five functional items, three physical items, and two emotional items. As the VHI-10 was used in clinical practice, differences were noted between nonsinger and singer populations. VHI-10 lacked statements specifically about singers and the singing voice. Several investigators identified differences between singers and nonsingers in their use of the VHI-10. Phyland et al compared 167 vocal Accepted for publication August 26, 2016. From the *Department of Otolaryngology—Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California; †Department of Otolaryngology—Head and Neck Surgery, Weill Cornell Medical College, New York, New York; and the ‡Teachers College, Columbia University, New York, New York. Address correspondence and reprint requests to Elizabeth Renk, Department of Otolaryngology, Loma Linda University, 11234 Anderson Street, Suite 2586A, Loma Linda, CA 92354. E-mail: [email protected], [email protected] Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2016.08.017
performers with 86 nonperformers and found that the vocal performers were more likely to be diagnosed with a vocal condition in the past 12 months (44% compared with 21%) and were more likely to suffer vocal disability (69% compared with 41%).4 Despite these significant complaints regarding their voice, Rosen and Murry found that, when compared with nonsingers, singers scored significantly lower on the VHI (less severe).5 To explain this paradoxical finding, Murry et al compared the VHI-10 responses of 35 singers with that of 35 nonsingers. They found that the two groups ranked differently the 10 statements that compose the VHI-10. In addition, when Murry et al changed three statements to “my singing voice,” rather than simply “my voice,” the singers judged their voice complaints as more severe.6 The above findings led to the development of a second index, the Singing Voice Handicap Index (SVHI)7 and its shortened counterpart the SVHI-10,8 which were developed and validated on performers. To develop the SVHI, a clinical consensus conference (comprising laryngologists and speech pathologists) generated an 81-item list of voice complaints that they felt would be of particular concern to singers. This list was then narrowed to 36 items and then administered by Cohen et al to a group of 112 singers with dysphonia and 129 singers with normal voice. They found a high test-retest reliability, as well as a high internal consistency.7,8 In an effort to simplify the more cumbersome 36-item SVHI, Cohen et al undertook the development of the SVHI-10.8 Once again, a clinical consensus conference selected 16 items (from the original 36), which in their combined opinion had the highest content validity. Ultimately, 10 of the highest items in content validity were retained to create the SVHI-10. This shortened survey was then administered to a group of 91 singers with dysphonia at their initial evaluation. A second survey was mailed to them 1 day later. Once again, there was a high test-retest reliability, as well as a high internal consistency.
ARTICLE IN PRESS 2
Journal of Voice, Vol. ■■, No. ■■, 2016
TABLE 1. Voice Handicap Index-10 F1 F2
F8 F9 F10 P5 P6 E4 E6 P3
My voice makes it difficult for people to hear me. People have difficulty understanding me in a noisy room My voice difficulties restrict personal and social life I feel left out of conversations because of my voice My voice problem causes me to lose income I feel as though I have to strain to produce voice The clarity of my voice is unpredictable My voice problem upsets me My voice makes me feel handicapped People ask “What is wrong with your voice?”
TABLE 2. Patient Demographics 0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0 0
1 1
2 2
3 3
4 4
0
1
2
3
4
Abbreviations: E, emotional; F, functional; P, physical.
The SVHI and the SVHI-10 were developed differently from the VHI and the VHI-10. No attempt was made to identify an equal number of items related to physical, functional, and emotional parameters in the SVHI or the SVHI-10. Nonetheless, by examining the statements, the current authors categorized the 10 statements into the broad categories of physical, functional, and emotional (Table 1). Presently, there are no data that directly compare responses of a large group of singers on both self-assessment tools. The purpose of this study was twofold. First, to directly compare the scores from the VHI-10 and the SVHI-10 in a group of 50 singers and to examine the relative importance of each item as it relates to singers’ perception of voice severity. Second, to use the same analysis to explore differences between male and female singers. METHODS A retrospective chart review of 50 singers (26 women, 24 men) presenting to a laryngology clinic was performed between June 2014 and November 2014 at Weill Cornell Medical College, New York. This group consisted of both professional singers and students in a university vocal performance program. Table 2 presents the demographics of the group. There were 24 men and 26 women. The age range was between 18 and 55 years. Of the 50 subjects, 34 were performers earning their living from performing, 14 were graduate students enrolled in a voice performance program, and 2 were professional singers currently not performing because of their voice problems. At their initial visit, all subjects completed the VHI-10 and the SVHI-10 before their evaluation. For comparison, two of the authors (E.R., T.M.) also reviewed the items of the SVHI-10 and compared them to the original statements of the VHI to classify them as functional, physical, or emotional items (Table 3).
Groups n Male, n (%) Female, n (%) Age 11–20, n (%) 21–30, n (%) 31–40, n (%) 41–50, n (%) 51–60, n (%) Type of performer Current performers, n (%) Graduate students, n (%) Previous performers, n (%)
N (%) 50 24 (48%) 26 (52%) 6 (12%) 27 (54%) 10 (20%) 5 (10%) 2 (4%) 34 (68%) 14 (28%) 2 (4%)
DATA ANALYSIS The data were submitted to a subjects (male vs female) by conditions (VHI-10 vs SVHI-10) two-way analysis of variance (ANOVA), with repeated measures on subjects for each of the two assessment tools. To have an equal number of male and female vocal singers (n = 24) to perform the ANOVA, two female singers whose VHI-10 and SVHI-10 scores were closest to the mean were eliminated from the calculations. Finally, the mean values of each statement were ranked from highest to lowest for both men and women. RESULTS A two-way ANOVA of gender by assessment type with repeated measures on gender demonstrated that there were no significant differences in VHI-10 or SVHI-10 scores between genders (P = 0.865). For the assessment types, there was a significant difference between VHI-10 and SVHI-10 (P = 0.0003). There was no significant interaction term indicating that men and women performed similarly on both assessment tools. TABLE 3. Singing Voice Handicap Index-10 P It takes a lot of effort to sing F I am unsure of what will come out when I sing P My voice “gives out” on me while I am singing E My singing voice upsets me F I have no confidence in my singing voice P I have trouble making my voice do what I want it to P I have to “push it” to produce my voice when singing P My singing voice tires easily E I feel something is missing in my life because of my inability to sing P I am unable to use my “high voice” Abbreviations: E, emotional; F, functional; P, physical.
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
ARTICLE IN PRESS Elizabeth Renk, et al
VHI-10 and SVHI-10 Differences in Singers’
3
TABLE 4. Comparison of VHI-10 and SVHI-10
Notes: Highlighted texts denote the average scores of items with the highest weighting among the 10 statements for each questionnaire.
The mean score for VHI-10 was 12.1 and that of SVHI-10 was 20.39 (both out of a possible 40). Five of 50 subjects had a score equal to or lower in the SVHI-10 than in the VHI-10. When the scores of the 24 male vocal performers were compared with those of the 26 female vocal performers, there was no significant gender difference in the overall score between the VHI-10 or the SVHI-10. For the VHI-10, men had a mean score of 11.75, compared with 12.42 for women. On the SVHI-10, men had a mean score of 20.39, compared with 20.38 for women. We provide both t test and ANOVA statistical analysis of our data. Historically, some authors have considered the responses to the questions of the VHI or SVHI as ordinal data, which should be analyzed using nonparametric methods, such as a t test. More recently, authors have begun to view the data as interval data, which would be better analyzed using parametric methods, such as ANOVA or Pearson correlations.9,10 As there is no concensus in the literature, it seems to the authors of this paper that including both methods strengthened the statistical analysis. When ranking the most severe items in the SVHI-10, as ranked by the singers, we found that specific statements within the SVHI10 were of note. The statements “My voice problem upsets me” (statement 8 on the VHI-10) and “My singing voice tires easily” (statement 8 on the SVHI-10) each had the highest weighting (most severe) among the 10 statements, with average scores of 2.8 and 2.4, respectively (Table 4). Statement 8 in the VHI-10 falls under the category of emotional statements. Statement 8 on the SVHI-10 could be considered a physical statement. When we compared men and women, both ranked statement 8 on the SVHI-10 as the most severe, with a score of 2.2 and 2.5, respectively. The second highest scores on each of the two forms were for statements “The clarity of my voice is unpredictable” (question number 7 on the VHI-10) and “I am unable to use my high voice” (question number 10 on the SVHI-10) with average scores of 1.8 and 2.3, respectively. These questions both address the physical dimension of voice. Interestingly, performers gave the statement “People ask, ‘What’s wrong with your voice?’” (question 10 on the VHI10) the lowest (least severe) average score, 0.7, despite their overall concern with their singing voice. The lowest average score on the SVHI-10 was an average score of 1, for the statement “I have no confidence in my singing voice” (question 5).
DISCUSSION This study demonstrates the significant difference in how singers perceive their singing voice in comparison with their speaking voice. The VHI-10 was designed to analyze spoken voice and uses words like “my voice” or “when I talk,” whereas the SVHI10 uses “singing” or “my singing voice.” Our data indicate that when singers respond to the SVHI-10, they identify their voice problem as more severe than when responding to the VHI-10, with scoring of 20.4 and 12.1, respectively. Whereas singers may have general complaints about their voice, they also have specific complaints that relate only to their singing voice. This is demonstrated by the fact that performers rated the statement “People ask, ‘What’s wrong with your voice?’” on the VHI-10 very low in severity (average score of only 0.7) even though their singing voice was still very bothersome to them. The statements in the two assessment tools demonstrate a different focus. The VHI-10 lists five statements related to voice function, whereas the SVHI-10 appears to have only two statements related to function, and the remaining eight are related to emotional and physical needs. Although our data show that certain questions were more concerning to singers, no further statistical analysis was performed. Further research is warranted to explore differences in ranking of the individual items that compose each survey. In the current study, all of the 36 professional singers come to the voice center with a primary complaint related to singing. They were either not able to perform well in their current roles or not performing at all because of their singing voice. All of the 14 graduate students were in a vocal performance program and could not maintain their class load because of their singing voice. Clearly, these singers perceive an inability to perform a physically demanding task, much like an athlete having little trouble walking but having a significant problem running or jumping. Moreover, it appears that the inability to perform the physical task of singing contributes to emotional concern. These data suggest the need to assess the physical needs of singers.
CONCLUSION It is important for clinicians to understand that their patients who are vocal performers perceive a marked distinction between talking and singing. This study highlights the importance of using the
ARTICLE IN PRESS 4 VHI-10 and the SVHI-10 as complementary questionnaires for performers. When used in this manner, the clinician can identify specific complaints relating to the voice concerns of the patient when singing and speaking. Furthermore, clinicians can use this knowledge to guide clinical decision-making.
REFERENCES 1. Roy N, Barkmeier-Kraemer J, Eadie T, et al. Evidence-based clinical voice assessment: a systematic review. Am J Speech Lang Pathol. 2012;22:212– 226. 2. Jacobson BJ, Johnson A, Grywalski C, et al. The voice handicap index (VHI). Am J Speech Lang Pathol. 1997;6:66–70. 3. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice handicap index-10. Laryngoscope. 2004;114:1549–1556.
Journal of Voice, Vol. ■■, No. ■■, 2016 4. Phyland DJ, Oates J, Greenwood KM. Self-reported voice problems among three groups of professional singers. J Voice. 1999;13:602–611. 5. Rosen CA, Murry T. Voice handicap index in singers. J Voice. 2000;14:370– 377. 6. Murry T, Zschommler A, Prokop J. Voice handicap in singers. J Voice. 2009;23:376–379. 7. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and validation of the Singing Voice Handicap Index. Ann Otol Rhinol Laryngol. 2007;116:402– 406. 8. Cohen SM, Statham M, Rosen CA, et al. Development and validation of the Singing Voice Handicap-10. Laryngoscope. 2009;119:1864–1869. 9. Niebudek-Bogusz E, Woznicka E, Zamyslowska-Szmytke E, et al. Correlation between acoustic parameters and Voice Handicap Index in dysphonic teachers. Folia Phoniatr Logop. 2010;62:55–60. 10. Timmermans B, De Bodt M, Wuyts F, et al. Analysis and evaluation of a voice-training program in future professional voice users. J Voice. 2004;19:202–210.