Successful voice training (e.g., singing lessons) and vocal rehabilitation (e.g., therapy for a voice disorder) involve learning complex, vocalbehaviors. However, there are no metrics describing how humans learn new vocal skills or predicting how long the improved behavior will persist post-therapy. To develop measures capable of describing and predicting vocal motor learning, a theory-based paradigm from limb motor control inspired the development of a virtual task where subjects throw projectiles at a target via modifications in vocal pitch and loudness. Ten subjects with healthy voices practiced this complex vocal task for five days. The many-to-one mapping between the execution variables pitch and loudness and resulting target error was evaluated using an analysis that quantified distributional properties of variability: Tolerance, noise, covariation costs (TNC costs). Lag-1 autocorrelation (AC1) and detrended-fluctuation-analysis scaling index (SCI) analyzed temporal aspects of variability. Vocal data replicated limb-based findings: TNC costs were positively correlated with error; AC1 and SCI were modulated in relation to the task's solution manifold. The data suggests that vocal and limb motor learning are similar in how the learner navigates the solution space. Future work calls for investigating the game's potential to improve voice disorder diagnosis and treatment.
This study examined the relationship between the magnitude of neck-surface vibration (NSVMag; transduced with an accelerometer) and intraoral estimates of subglottal pressure (P'sg) during variations in vocal effort at 3 intensity levels.
Twelve vocally healthy adults produced strings of /pɑ/ syllables in 3 vocal intensity conditions, while increasing vocal effort during each condition. Measures were made of P'sg (estimated during stop-consonant closure), NSVMag (measured during the following vowel), sound pressure level, and respiratory kinematics. Mixed linear regression was used to analyze the relationship between NSVMag and P'sg with respect to total lung volume excursion, levels of lung volume initiation and termination, airflow, laryngeal resistance, and vocal efficiency across intensity conditions.
NSVMag was significantly related to P'sg (p < .001), and there was a significant, although small, interaction between NSVMag and intensity condition. Total lung excursion was the only additional variable contributing to predicting the NSVMag-P'sg relationship.
NSVMag closely reflects P'sg during variations of vocal effort; however, the relationship changes across different intensities in some individuals. Future research should explore additional NSV-based measures (e.g., glottal airflow features) to improve estimation accuracy during voice production.
Relative fundamental frequency (RFF) has shown promise as an acoustic measure of voice, but the subjective and time-consuming nature of its manual estimation has made clinical translation infeasible. Here, a faster, more objective algorithm for RFF estimation is evaluated in a large and diverse sample of individuals with and without voice disorders.
Acoustic recordings were collected from 154 individuals with voice disorders and 36 age- and sex-matched controls with typical voices. These recordings were split into training and 2 testing sets. Using an algorithm tuned to the training set, semi-automated RFF estimates in the testing sets were compared to manual RFF estimates derived from 3 trained technicians.
The semi-automated RFF estimations were highly correlated ( r = 0.82-0.91) with the manual RFF estimates.
Fast and more objective estimation of RFF makes large-scale RFF analysis feasible. This algorithm allows for future work to optimize RFF measures and expand their potential for clinical voice assessment.
The aim of this study was to establish reliability and validity for self-ratings of vocal status obtained during the daily activities of patients with vocal hyperfunction (VH) and matched controls.
Eight-four patients with VH and 74 participants with normal voices answered 3 vocal status questions-difficulty producing soft, high-pitched phonation (D-SHP); discomfort; and fatigue-on an ambulatory voice monitor at the beginning, 5-hr intervals, and the end of each day (7 total days). Two subsets of the patient group answered the questions during a 2nd week after voice therapy (29 patients) or laryngeal surgery (16 patients).
High reliability resulted for patients (Cronbach's α = .88) and controls (α = .95). Patients reported higher D-SHP, discomfort, and fatigue (Cohen's d = 1.62-1.92) compared with controls. Patients posttherapy and postsurgery reported significantly improved self-ratings of vocal status relative to their pretreatment ratings (d = 0.70-1.13). Within-subject changes in self-ratings greater than 20 points were considered clinically meaningful.
Ratings of D-SHP, discomfort, and fatigue have adequate reliability and validity for tracking vocal status throughout daily lifein patients with VH and vocally healthy individuals. These questions could help investigate the relationship between vocal symptom variability and putative contributing factors (e.g., voice use/rest, emotions).
The purpose of this study was to determine the validity of preliminary reports showing that glottal aerodynamic measures can identify pathophysiological phonatory mechanisms for phonotraumatic and nonphonotraumatic vocal hyperfunction, which are each distinctly different from normal vocal function.
Glottal aerodynamic measures (estimates of subglottal air pressure, peak-to-peak airflow, maximum flow declination rate, and open quotient) were obtained noninvasively using a pneumotachograph mask with an intraoral pressure catheter in 16 women with organic vocal fold lesions, 16 women with muscle tension dysphonia, and 2 associated matched control groups with normal voices. Subjects produced /pae/ syllable strings from which glottal airflow was estimated using inverse filtering during /ae/ vowels, and subglottal pressure was estimated during /p/ closures. All measures were normalized for sound pressure level (SPL) and statistically tested for differences between patient and control groups.
All SPL-normalized measures were significantly lower in the phonotraumatic group as compared with measures in its control group. For the nonphonotraumatic group, only SPL-normalized subglottal pressure and open quotient were significantly lower than measures in its control group.
Results of this study confirm previous hypotheses and preliminary results indicating that SPL-normalized estimates of glottal aerodynamic measures can be used to describe the different pathophysiological phonatory mechanisms associated with phonotraumatic and nonphonotraumatic vocal hyperfunction.
To determine the validity of preliminary reports showing that glottal aerodynamic measures can identify pathophysiological phonatory mechanisms for phonotraumatic and non-phonotraumatic vocal hyperfunction that are each distinctly different from normal vocal function.
Glottal aerodynamic measures (estimates of subglottal air pressure, peak-to-peak airflow, maximum flow declination rate, and open quotient) were obtained non-invasively using a pneumotachograph mask with intra-oral pressure catheter in 16 adult females with organic vocal fold lesions, 16 adult females with muscle tension dysphonia, and two associated matched control groups with normal voices. Subjects produced /pae/ syllable strings from which glottal airflow was estimated using inverse filtering during /ae/ vowels, and subglottal pressure was estimated during /p/ closures. All measures were normalized for sound pressure level (SPL) and statistically tested for differences between patient and control groups.
All SPL-normalized measures were significantly lower in the phonotraumatic group as compared to measures in its control group. For the non-phonotraumatic group, only SPL-normalized subglottal pressure and open quotient were significantly lower than measures in its control group.
Results of this study confirm previous hypotheses and preliminary results indicating that SPL-normalized estimates of glottal aerodynamic measures can be used to describe the different pathophysiological phonatory mechanisms associated with phonotraumatic and non-phonotraumatic vocal hyperfunction.
Glottal inverse filtering aims to estimate the glottal airflow signal from a speech signal for applications such as speaker recognition and clinical voice assessment. Nonetheless, evaluation of inverse filtering algorithms has been challenging due to the practical difficulties of directly measuring glottal airflow. Apart from this, it is acknowledged that the performance of many methods degrade in voice conditions that are of great interest, such as breathiness, high pitch, soft voice, and running speech. This paper presents a comprehensive, objective, and comparative evaluation of state-of-the-art inverse filtering algorithms that takes advantage of speech and glottal airflow signals generated by a physiological speech synthesizer. The synthesizer provides a physics-based simulation of the voice production process and thus an adequate test bed for revealing the temporal and spectral performance characteristics of each algorithm. Included in the synthetic data are continuous speech utterances and sustained vowels, which are produced with multiple voice qualities (pressed, slightly pressed, modal, slightly breathy, and breathy), fundamental frequencies, and subglottal pressures to simulate the natural variations in real speech. In evaluating the accuracy of a glottal flow estimate, multiple error measures are used, including an error in the estimated signal that measures overall waveform deviation, as well as an error in each of several clinically relevant features extracted from the glottal flow estimate. Waveform errors calculated from glottal flow estimation experiments exhibited mean values around 30% for sustained vowels, and around 40% for continuous speech, of the amplitude of true glottal flow derivative. Closed-phase approaches showed remarkable stability across different voice qualities and subglottal pressures. The algorithms of choice, as suggested by significance tests, are closed-phase covariance analysis for the analysis of sustained vowels, and sparse linear prediction for the analysis of continuous speech. Results of data subset analysis suggest that analysis of close rounded vowels is an additional challenge in glottal flow estimation.
Purpose The purpose of this article is to examine the ability of an acoustic measure, relative fundamental frequency (RFF), to distinguish between two subtypes of vocal hyperfunction (VH): phonotraumatic (PVH) and non-phonotraumatic (NPVH).
Method RFF values were compared among control individuals with typical voices (N = 49), individuals with PVH (N = 54), and individuals with NPVH (N = 35).
Results Offset Cycle 10 RFF differed significantly among all 3 groups with values progressively decreasing for controls, individuals with NPVH, and individuals with PVH. Individuals with PVH also had lower Offset Cycles 8 and 9 relative to the other 2 groups and lower RFF values for Offset Cycle 7 relative to controls. There was also a trend for lower Onset Cycle 1 RFF values for the PVH group compared with the NPVH group.
Conclusions RFF values were significantly different between controls and individuals with VH and also between the two subtypes of VH. This study adds further support to the notion that the differences between these two subsets of VH may be functional as well as structural.
Purpose Ambulatory voice biofeedback has the potential to significantly improve voice therapy effectiveness by targeting carryover of desired behaviors outside the therapy session (i.e., retention). This study applies motor learning concepts (reduced frequency and delayed, summary feedback) that demonstrate increased retention to ambulatory voice monitoring for training nurses to talk softer during work hours.
Method Forty-eight nurses with normal voices wore the Voice Health Monitor (Mehta, Zañartu, Feng, Cheyne, & Hillman, 2012) for 6 days: 3 baseline days, 1 biofeedback day, 1 short-term retention day, and 1 long-term retention day. Participants were block-randomized into 3 different biofeedback groups: 100%, 25%, and Summary. Performance was measured in terms of compliance time below a participant-specific vocal intensity threshold.
Results All participants exhibited a significant increase in compliance time (Cohen's d = 4.5) during biofeedback days compared with baseline days. The Summary feedback group exhibited statistically smaller performance reduction during both short-term (d = 1.14) and long-term (d = 1.04) retention days compared with the 100% feedback group.
Conclusions These findings suggest that modifications in feedback frequency and timing affect retention of a modified vocal behavior in daily life. Future work calls for studying the potential beneficial impact of ambulatory voice biofeedback in participants with behaviorally based voice disorders.
Purpose Ambulatory voice biofeedback (AVB) has the potential to significantly improve voice therapy effectiveness by targeting one of the most challenging aspects of rehabilitation: carryover of desired behaviors outside of the therapy session. Although initial evidence indicates that AVB can alter vocal behavior in daily life, retention of the new behavior after biofeedback has not been demonstrated. Motor learning studies repeatedly have shown retention-related benefits when reducing feedback frequency or providing summary statistics. Therefore, novel AVB settings that are based on these concepts are developed and implemented.
Method The underlying theoretical framework and resultant implementation of innovative AVB settings on a smartphone-based voice monitor are described. A clinical case study demonstrates the functionality of the new relative frequency feedback capabilities.
Results With new technical capabilities, 2 aspects of feedback are directly modifiable for AVB: relative frequency and summary feedback. Although reduced-frequency AVB was associated with improved carryover of a therapeutic vocal behavior (i.e., reduced vocal intensity) in a patient post-excision of vocal fold nodules, causation cannot be assumed.
Conclusions Timing and frequency of AVB schedules can be manipulated to empirically assess generalization of motor learning principles to vocal behavior modification and test the clinical effectiveness of AVB with various feedback schedules.
indirect physiological signal to predict the phase of the vocal fold vibratory cycle for sampling. Simulated stroboscopy (SS) extracts the phase of the glottal cycle directly from the changing glottal area in the high-speed videoendoscopy (HSV) image sequence. The purpose of this study is to determine the reliability of SS relative to VS for clinical assessment of vocal fold vibratory function in patients with mass lesions.
Methods VS and SS recordings were obtained from 28 patients with vocal fold mass lesions before and after phonomicrosurgery and 17 controls who were vocally healthy. Two clinicians rated clinically relevant vocal fold vibratory features using both imaging techniques, indicated their internal level of confidence in the accuracy of their ratings, and provided reasons for low or no confidence.
Results SS had fewer asynchronous image sequences than VS. Vibratory outcomes were able to be computed for more patients using SS. In addition, raters demonstrated better interrater reliability and reported equal or higher levels of confidence using SS than VS.
Conclusion Stroboscopic techniques on the basis of extracting the phase directly from the HSV image sequence are more reliable than acoustic-based VS. Findings suggest that SS derived from high-speed videoendoscopy is a promising improvement over current VS systems.
Purpose The purpose of this study was to evaluate the potential for estimating subglottal air pressure using a neck-surface accelerometer and to compare the accuracy of predicting subglottal air pressure relative to predicting acoustic sound pressure level (SPL).
Method Indirect estimates of subglottal pressure (Psg′) were obtained from 10 vocally healthy speakers during loud-to-soft repetitions of 3 different /p/–vowel gestures (/pa/, /pi/, /pu/) at 3 pitch levels in the modal register. Intraoral air pressure, neck-surface acceleration, and radiated acoustic pressure were recorded, and the root-mean-square amplitude of the acceleration signal was correlated with Psg′ and SPL.
Results The coefficient of determination between accelerometer level and Psg′ was high when data were pooled from all vowel and pitch contexts for each participant (r2 = .68–.93). These relationships were stronger than corresponding relationships between accelerometer level and SPL (r2 = .46–.81). The average 95% prediction interval for estimating Psg′ using accelerometer level was ±2.53 cm H2O, ranging from ±1.70 to ±3.74 cm H2O across participants.
Conclusions Accelerometer signal amplitude correlated more strongly with Psg′ than with SPL. Future work is warranted to investigate the robustness of the relationship in nonmodal voice qualities, individuals with voice disorders, and accelerometer-based ambulatory monitoring of subglottal pressure.
Monitoring subglottal neck-surface acceleration has received renewed attention due to the ability of low-profile accelerometers to confidentially and noninvasively track properties related to normal and disordered voice characteristics and behavior. This study investigated the ability of subglottal necksurface acceleration to yield vocal function measures traditionally derived from the acoustic voice signal and help guide the development of clinically functional accelerometer-based measures from a physiological perspective. Results are reported for 82 adult speakers with voice disorders and 52 adult speakers with normal voices who produced the sustained vowels /A/, /i/, and /u/ at a comfortable pitch and loudness during the simultaneous recording of radiated acoustic pressure and subglottal necksurface acceleration. As expected, timing-related measures of jitter exhibited the strongest correlation between acoustic and necksurface acceleration waveforms (r 0:99), whereas amplitudebased measures of shimmer correlated less strongly (r 0:74). Additionally, weaker correlations were exhibited by spectral measures of harmonics-to-noise ratio (r 0:69) and tilt (r 0:57), whereas the cepstral peak prominence correlated more strongly (r 0:90). These empirical relationships provide evidence to support the use of accelerometers as effective complements to acoustic recordings in the assessment and monitoring of vocal function in the laboratory, clinic, and during an individual’s daily activities.
Objectives: Clinical management of phonotraumatic vocal fold lesions (nodules, polyps) is based largely on assumptions that abnormalities in habitual levels of sound pressure level (SPL), fundamental frequency (f0), and/or amount of voice use play a major role in lesion development and chronic persistence. This study used ambulatory voice monitoring to evaluate if significant differences in voice use exist between patients with phonotraumatic lesions and normal matched controls.Methods: Subjects were 70 adult females: 35 with vocal fold nodules or polyps and 35 age-, sex-, and occupation-matched normal individuals. Weeklong summary statistics of voice use were computed from anterior neck surface acceleration recorded using a smartphone-based ambulatory voice monitor.Results: Paired t tests and Kolmogorov-Smirnov tests resulted in no statistically significant differences between patients and matched controls regarding average measures of SPL, f0, vocal dose measures, and voicing/voice rest periods. Paired t tests comparing f0 variability between the groups resulted in statistically significant differences with moderate effect sizes.Conclusions: Individuals with phonotraumatic lesions did not exhibit differences in average ambulatory measures of vocal behavior when compared with matched controls. More refined characterizations of underlying phonatory mechanisms and other potentially contributing causes are warranted to better understand risk factors associated with phonotraumatic lesions.
Purpose Ambulatory biofeedback has potential to improve carryover of newly established vocal motor behaviors into daily life outside of the clinic and warrants systematic research that is lacking in the literature. This proof-of-concept study was designed to establish an empirical basis for future work in this area by formally assessing whether ambulatory biofeedback reduces daily vocal intensity (performance) and the extent to which this change remains after biofeedback removal (retention). Method Six participants with normal voices wore the KayPENTAX Ambulatory Phonation Monitor for 3 baseline days followed by 4 days with biofeedback provided on odd days. Results Compared to baseline days, participants exhibited a statistically significant decrease in mean vocal intensity (4.4 dB) and an increase in compliance (16.8 percentage points) when biofeedback was provided above a participant-specific intensity threshold. After biofeedback removal, mean vocal intensity and compliance reverted back to baseline levels. Conclusions These findings suggest that although current ambulatory biofeedback approaches have potential to modify a vocal motor behavior, the modified behavior may not be retained after biofeedback removal. Future work calls for the testing of more innovative ambulatory biofeedback approaches on the basis of motor control and learning theories to improve retention of a desired vocal motor behavior.
Many common voice disorders are chronic or recurring conditions that are likely to result from inefficient and/or abusive patterns of vocal behavior, referred to as vocal hyperfunction. The clinical management of hyperfunctional voice disorders would be greatly enhanced by the ability to monitor and quantify detrimental vocal behaviors during an individualâ€™s activities of daily life. This paper provides an update on ongoing work that uses a miniature accelerometer on the neck surface below the larynx to collect a large set of ambulatory data on patients with hyperfunctional voice disorders (before and after treatment) and matched-control subjects. Three types of analysis approaches are being employed in an effort to identify the best set of measures for differentiating among hyperfunctional and normal patterns of vocal behavior: (1) ambulatory measures of voice use that include vocal dose and voice quality correlates, (2) aerodynamic measures based on glottal airflow estimates extracted from the accelerometer signal using subject-specific vocal system models, and (3) classification based on machine learning and pattern recognition approaches that have been used successfully in analyzing long-term recordings of other physiological signals. Preliminary results demonstrate the potential for ambulatory voice monitoring to improve the diagnosis and treatment of common hyperfunctional voice disorders.