Original Article Singing voice handicap mapped by different

Artigo Original self-assessment instruments

Karla Paoliello1 Desvantagem vocal no canto mapeado por diferentes

Gisele Oliveira1
Mara Behlau1 protocolos de autoavaliação

Keywords ABSTRACT

Voice Purpose: To map voice handicap of popular singers with a general voice and two singing voice self-assessment
Quality of life questionnaires. Methods: Fifty singers, 25 male and 25 female, 23 with vocal complaint and 27 without vocal
Self-assessment complaint answered randomly the questionnaires. For the comparison of data, the following statistical tests
Evaluation studies were performed: Mann-Whitney, Friedman, Wilcoxon, Spearman and Correlation. Results: Data showed that
Voice quality the VHI yielded a smaller handicap when compared to the other two questionnaires (VHI x S-VHI – p=0.001;
Music VHI x MSVH – p=0.004). The S-VHI and MSVH produced similar results (p=0.723). Singers with vocal
complaint had a VHI total score of 17.5. The other two instruments showed more deviated scores (S-VHI –
24.9; MSVH – 25.2). There was no relationship between gender and singing style with the handicap perceived.
A weak negative correlation between the perceived handicap and the time of singing experience was found
(-37.7 to -13.10%), that is, the smaller the time of singing experience, the greater the handicap is. Conclusion:
The questionnaires developed for the assessment of singing voice, S-VHI and MSVH, showed to be more
specific and correspondent to each other for the evaluation of vocal handicap in singers. Findings showed that
the more the time of singer’s singing experience, the smaller the handicap is. Gender and singing styles did
not influence the perception of the handicap.

Descritores RESUMO

Voz Objetivo: Mapear desvantagens vocais em cantores populares por meio de protocolos de autoavaliação: um
Qualidade de vida genérico (IDV) e outros dois específicos para canto (IDV-C e IDCM). Métodos: Cinquenta cantores, 25 de cada
Autoavaliação gênero, 23 com queixa vocal e 27 sem queixa vocal responderam aos 3 protocolos, apresentados em ordem
Estudos de avaliação casual. Para a comparação dos resultados, foram utilizados os testes estatísticos: Mann-Whitney, Friedman,
Qualidade da voz Wilcoxon, Spearman e Correlação. Resultados: Os resultados mostraram que o protocolo IDV aponta menor
Música desvantagem que os protocolos específicos (IDV x IDV-C – p= 0,001; IDV x IDCM – p=0,004). O IDCM
e IDV-C foram correspondentes e intercambiáveis em sua comparação (p=0,723). Os cantores com queixa
apresentaram um escore total para o IDV de 17,5. Os outros protocolos apresentaram valores mais desviados
IDV-C – 24,9 e IDCM – 25,2. Não foi verificada influência do gênero e de estilo de canto na percepção da
desvantagem vocal em nenhum dos protocolos. Uma fraca correlação entre a desvantagem percebida e o
tempo de canto foi encontrada (-37,7 para -13,10%), sendo que quanto menor a prática no canto, maior a
desvantagem referida. Conclusão: O IDCM e o IDV-C mostraram-se mais específicos e são similares na
avaliação de cantores. Quanto maior o tempo de experiência do cantor, menor é sua desvantagem. O gênero e
o número de estilos de canto não influenciaram a percepção da desvantagem vocal.

Correspondence address: Study carried out at the Centro de Estudos da Voz – CEV – São Paulo (SP), Brazil.
Karla Paoliello (1) Centro de Estudos da Voz – CEV – São Paulo (SP), Brazil.
R. Marques do Herval, 682/03, Centro, Conflict of interests: nothing to declare.
Taubaté (SP), Brasil, CEP: 12080-250.
E-mail: [email protected]

Received: 10/26/2011

Accepted: 10/18/2012

CoDAS 2013;25(5):463-8
464 Paoliello K, Oliveira, G Behlau M

INTRODUCTION such as the Singing Voice Handicap Index (S-VHI)(14), the

S-VHI 10(15), Adaptation of the S-VHI(16), Modern Singing
According to the World Health Organization (WHO), health Handicap Index (MSHI), and Classical Singing Handicap
is the state of complete physical, mental, and social well- Index (CSHI)(17). The MSHI and CSHI are two versions of
being. This definition has been constantly extended, including the same instrument that focus on specific aspects of modern
important considerations about quality of life. Quality of life and classical singing in Brazilian Portuguese language(18,19).
is the perception a person has of his/her position in life, based It is not known whether these protocols are interchangeable,
on socioeconomic and cultural contexts; the value system in complementary, or reflect several perspectives of the same
which he/she lives; and the objectives, expectations, standards, problem. Therefore, the present study aimed to carry out a
and interests in his/her life(1). comparative analysis between VHI-30, which assesses the
Several studies in the past have attempted to measure the general impact of a dysphonia, and two specific protocols for
quality of life of their subjects who had disorders and/or dis- singing (S-VHI and MSHI), by identifying the similarities
eases. As a separate discipline, speech therapy has also focused and differences in a group of popular singers with and with-
on quality of life because objective evaluation, which provides out vocal complaint. It had also investigated the influence of
important data about the pathological process, does not report gender on patient’s perception about the voice handicap and
patient’s point of view about his/her problem and his/her pro- whether singing style influenced an individual’s perception
fessional and social perspectives(2,3). on his/her voice handicap and the length of time the patient
As would happen with research pursuits that attempt to had experienced the handicap.
evaluate a person’s general health status, the voice health as-
sessment, too, must analyze the perspective that a patient has METHODS
concerning his/her quality of life, by measuring the extent
of changes that have taken place in his/her quality of life on The study was approved by the Research Ethics Committee
account of problems related to impairment in voice health(4,5). of the Institution (REC 1316/08), and all the participants signed
Thus, it is possible to learn the functional, social, and emo- the Informed Consent granting their permission to participating
tional consequences for a person’s professional and financial and disclosure of this research and its results.
performances in light of his/her voice alteration(4). Fifty professional and nonprofessional singers took part in
Since the 1990s(6), several instruments that were used to this work, which included 25 male and 25 female; out of these,
evaluate a person’s voice perception became more refined and 23 were with vocal complaints and 27 were without it; study
carefully developed to include advanced test processes and volunteers included professional and nonprofessional singers,
validation methods, including tools such as self-assessment students, and teachers. Subjects were assigned to these two
psychometric measures. groups on the basis of the number of symptoms reported in
Following these, to better understand the perception that a the questionnaire of signs and symptoms developed by Roy
patient has of his/her voice, general protocols were developed, et al.(20). People with three or more voice symptoms were
such as the Voice Handicap Index (VHI)(7), an instrument that considered as having vocal complaints(21). They were aged
assesses the handicap caused by problems in spoken voice(7-11); between 16 and 74 years and were on average 34.8 years old;
the Voice-Related Quality of Life (V-RQOL) questionnaire(4), a the sample included 27 singing students, 12 nonprofessional
tool that measures the impact of a voice issue on the quality of singers, 11 professional singers, and 7 were singing teachers
life; and the Voice Activity and Participation Profile (VAPP)(12), as well. The mean singing period of the sample subjects was
a type of dysphonia perception assessment that focuses on the 13 years, ranging from a period as short as 1 year to a maxi-
limitation of activities and restriction of participation. These mum 55 of years. Concerning types of singing, it was found
three protocols have already been validated for use in Brazilian a variety of styles were used by the study subjects (some of
Portuguese language(13). them had experience singing in up to 5 different styles); 27
In order for self-assessment protocols to be regarded as of them sang in chorus, 26 were classical singers, 18 were
more efficient instruments, they must be designed for assess- popular singers, 13 were gospel singers, 6 were rock singers,
ing specific diseases, populations, occupations, and so on. 5 followed other styles, 4 were country singers, and 3 were
Therefore, in the voice area, after the VHI protocol implemen- samba/pagode singers. Another finding concerning source of
tation, which is current the most internationally diffused self- income for these subjects is that for 24 subjects singing was
assessment instrument(7,8), investigators are concerned about their primary source of income (17 primary and 7 second-
developing protocols specific to certain groups of people, ary) and 26 of them had incomes from other activities. The
for example, singers. Singers seem to be more susceptible following voice symptoms were identified: phlegm (24), dry
to factors that adversely affect their voice, like, for example, throat  (21), hoarseness and sore throat (17), difficulty with
gastroesophageal reflux and allergies. Such disorders, coupled singing in high pitches (11), discomfort in speaking, voice
with higher voice demand and/or use of inappropriate singing “gets tired or changes after using it in a short period” and
techniques, result in voice fatigue causing dysphonia; even acid and bitter taste in the mouth (8), difficulty in projecting
though this order hardly poses any risk to life, it can still the voice (7), voice instability or shivering (6), problems with
compromise his/her singing performance(14). Hence specific singing or talking softly or requiring greater effort to speak
protocols were developed to assess singers’ quality of life, (4), and flat voice and difficulty to swallow (2).

CoDAS 2013;25(5):463-8
Singing handicap 465

Singers answered questions posed to them from three RESULTS

protocols (VHI-30, S-VHI, and MSHI); the protocols were
administered without the investigator’s support, with questions Table 1 presents total and partial scores of the three analyzed
posed in a random order and without consulting previously protocols in percentages. Total scores of MSHI and S-VHI
answered questionnaires. presented similar statistical values (p=0.723), but they were
VHI-30 is a protocol directed to assess voice handicap in statistically different from VHI (p=0.001).
a dysphonic patient and included 30 items and 3 domains:
emotional, functional, and organic. Each item is answered Table 1. Mean scores of the domains from the Handicap Voice Index,
using a 5-point Likert-type scale: 0=never, 1=hardly ever, Modern Singing Handicap Index, and Singing Voice Handicap Index
2=sometimes, 3=almost always, and 4=always. The total score protocols of the whole sample
varied from 0 to 120 points, with 0 indicating no handicap and Protocols Mean Standard deviation
120 indicating maximum handicap due to a voice problem. The VHI-30
domain scores varied from 0 to 40. Total 11.4 12.5
S-VHI includes 36 items developed to measure handicap Emotional 8.1 15.3
caused by damage to singing voice; the question were an- Functional 10.9 11.8
swered using five-point Likert-type scale: 0=never, 1=hardly Organic 15.2 15.0
ever, 2=sometimes, 3=almost always, and 4=always. The total MSHI
score varied from 0 to 144 points, and the higher the value, Total 15.8 17.6
the higher the voice handicap. This protocol does not present Inability 5.4 7.7
domains or subscales. Handicap 5.3 7.1
MSHI is also a protocol developed to measure singing-voice Flaw 8.3 7.9
handicap and includes 30 items, which were divided into 3 S-VHI 16.6 17.0
subscales: inability, handicap, and flaw, which correspond to Friedman’s test: VHI-30xMSHIxS-VHI – p-value of the total score = 0.001; Wilcox-
functional, emotional, and organic domains, respectively(18). on’s test: VHI-30xMSHI – p=0.004; VHI-30xS-VHI – p=0.001; S-VHIxMSHI=0.723
Caption: VHI-30 = Handicap Voice Index; MSHI = Modern Singing Handicap
Each subscale is composed of 10 items and were answered Index; S-VHI = Singing Voice
similar to that demonstrated in the other protocols. Items in this
instrument were also answered in a 5-point Likert-type scale:
0=never, 1=hardly ever, 2=sometimes, 3=almost always, and Table 2 presents a comparison of total and partial scores
4=always. The MSHI score calculation is carried out similar to of the three protocols between groups with and without voice
that of VHI-30 and S-VHI, and the total score varied from 0 to complaint. All scores from the three protocols were different
120 points, and the subscales from 0 to 40 points. when both groups were compared, with the exception of VHI
Scores from the three protocols were changed to percentage functional score (p=0.054). Furthermore, the vocal complaint
values in order to facilitate a comparison between different final group scored higher than the control group.
results; thus, the values presented correspond to the handicap Table 3 shows means and standard deviations found in
percentage but not to the gross values obtained. partial and total scores of protocols in relation to gender.
Results were submitted to statistical treatment with a 0.05 Table 4 presents correlations between scores of protocols
significance level (5%), and the confidence intervals were and singing experience time. It was verified that correlation
developed with 95% statistical confidence. For the analysis of singing experience time was negative in all scores of
of nonparametric variables, Mann-Whitney’s U test was used across the protocols (varying from -37.70 to -13.10%). In
to compare the results between genders in all domains and other domains, correlations were positive. Correlation was
the results of all protocols between the complaint group and the high between VHI-30 total score and VHI-30 (emotional,
control group. Friedman’s test was used to compare between physical, and organic scores), between total MSHI and
the total scores of the three protocols. Wilcoxon’s test was used MSHI (inability, handicap, and flaw), and between S-VHI
to carrying out paired comparisons between the total scores. and MSHI (flaw and total). Correlation was good between
Spearman’s test was used to measure the degree of relation- VHI-30 total score and MSHI (inability, handicap, flaw,
ship between musical styles and results of protocols, and the and total) and S-VHI and between VHI-30 emotional score
correlation test was used to confirm the values of correlations and VHI-30 (physical and organic scores) and total MSHI.
obtained by Spearman’s test. Spearman’s correlation was used Correlation was regular between VHI-30 emotional score
to the study the correlation between the scores measured by and MSHI (inability, handicap, and flaw) and S-VHI  and be-
using VHI-30, MSHI, and S-VHI protocols that assessed mu- tween VHI-30 functional score and MSHI (inability and
sical style and perceived handicap. A correlation matrix was handicap) and S-VHI. The analysis was done based on
developed and used for identifying correlation signals (positive Kappa’s concordance index(22).
or negative), that is, voice handicap determination and quality, Table 5 presents values of associations between scores
in addition to the Kappa concordance index, which measures and quantity of styles experienced. Correlations found in
the degree of concordance between two qualitative variables this analysis were classified as unimportant because all
(quality <20%=unimportant, 21% to 40%=minimum; 41% to values were lower than 20%, according to Kappa’s con-
60%=regular, 61% to 80% = good, and above 81% = great)(22). cordance index(22).

CoDAS 2013;25(5):463-8
466 Paoliello K, Oliveira, G Behlau M

Table 2. Mean scores of the domains of the Handicap Voice Index, Modern Singing Voice Handicap Index, and Singing Voice Handicap Index for
the groups with and without vocal complaint
With complaint Without complaint
Protocols p-value*
Mean Standard deviation Mean Standard deviation
VHI-30
Total 17.5 15.0 6.2 6.4 0.001
Emotional 15.0 20.1 2.2 4.6 <0.001
Functional 14.1 13.1 8.1 10.0 0.054
Organic 23.4 17.3 8.2 7.7 <0.001
MSHI
Total 25.2 21.3 7.7 7.6 0.001
Inability 9.5 9.6 1.9 2.2 0.004
Handicap 8.5 8.8 2.5 3.5 0.004
Flaw 12.2 9.0 5.0 4.8 0.004
S-VHI 24.9 21.2 9.5 7.3 0.012
Mann-Whitney’s Test
Caption: VHI-30 = Handicap Voice Index; MSHI = Modern Singing Handicap Index; S-VHI = Singing Voice

Table 3. Mean scores of the Voice Handicap Index, Modern Singing Handicap Index, and Singing Voice Handicap Index protocols according to gender
Female Male
Protocols p-value*
Mean Standard deviation Mean Standard deviation
VHI-30
Total 12.8 15.7 10.0 8.2 0.823
Emotional 11.6 20.3 4.6 6.3 0.401
Functional 11.5 14.2 10.2 9.0 0.769
Organic 15.2 16.7 15.2 13.4 0.689
MSHI
Total 16.9 21.2 14.6 13.5 0.801
Inability 5.5 9.1 5.3 6.1 0.319
Handicap 6.3 9.1 4.2 4.2 0.791
Flaw 8.5 8.6 8.1 7.2 0.953
S-VHI 18.3 20.1 14.9 13.4 0.915
Mann-Whitney’s Test
Caption: VHI-30 = Handicap Voice Index; MSHI = Modern Singing Handicap Index; S-VHI = Singing Voice

Table 4. Valores da correlação entre escores dos protocolos Índice de Desvantagem Vocal, Índice de Desvantagem Canto Moderno e Índice de
Desvantagem Vocal para o Canto e Tempo de canto
VHI-30 VHI-30 VHI-30 VHI-30
Singing MSHI MSHI MSHI MSHI
Protocols (total (emotional (functional (organic
experience time (inability) (handicap) (flaw) (Total)
score) score) score) score)
VHI-30 Corr -25.90%                
Total p-value 0.069#                
Corr -13.10% 85.40%              
Emotional
p-value 0.363 <0.001*              
Corr -37.10% 83.80% 64.20%            
Physical
p-value 0.008* <0.001* <0.001*            
Corr -30.00% 92.50% 73.10% 68.20%          
Organic
0.034* <0.001* <0.001* <0.001*          
MSHI Corr -20.50% 73.60% 59.50% 58.80% 74.70%        
Inability p-value 0.153 <0.001* <0.001* <0.001* <0.001*        
Corr -37.60% 64.50% 57.90% 48.70% 63.50% 65.80%      
Handicap
p-value 0.007* <0.001* <0.001* <0.001* <0.001* <0.001*      
Corr -26.40% 74.90% 57.90% 61.00% 78.40% 79.30% 71.90%    
Flaw
0.064# <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*    
Corr -33.40% 78.10% 64.80% 63.10% 79.60% 86.00% 85.80% 94.50%  
Total
p-value 0.018* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*  
Corr -37.70% 69.50% 53.70% 51.10% 78.00% 71.20% 70.50% 80.10% 81.10%
S-VHI
p-value 0.007* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*
*p-values considered statistically significant for the adopted significance level; #p-values that tend to be significant because they are close to the acceptance limit
Caption: Corr = correlation; VHI-30 = Handicap Voice Index; MSHI = Modern Singing Handicap Index; S-VHI = Singing Voice Handicap Index

CoDAS 2013;25(5):463-8
Singing handicap 467

Table 5. Correlation values between scores of the protocols Voice

Handicap Index, Modern Singing Handicap Index, and Singing Voice handicap. Since there were no studies specific to the Brazilian
Handicap Index and quantity of styles practiced context that managed these protocols, we do not have values
for comparison (Table 1).
Style
Protocols
Correlation (%) p-value*
It is seen that the highest scores of VHI-30 happened in the
VHI-30
organic and emotional domains (p<0.001), a finding similar to
Total 7.00 0.628 the those reported in other literature studies(8,13), which were
Emotional 0.20 0.987 carried out for dysphonic individuals who were not singers.
Functional -0.70 0.963 Singers with complaint had higher scores than dysphonic
Organic 5.80 0.692 people, probably because of the attention given to the vocal in-
MSHI strument, with more demands placed on their quality. In MSHI,
Total -3.30 0.819 the group of singers with complaint scored higher in the flaw
Inability -1.90 0.895 subscale, followed by inability. A study with nonprofessional
Handicap -8.40 0.562 singers(18) also found similar results. The word flaw is defined
Flaw 1.20 0.933 as any psychological, physiological, anatomic, structural, tem-
S-VHI -1.10 0.938 porary, or permanent loss or abnormality. Inability means any
Spearman’sTest restriction or decrease in the ability to perform an activity that
Caption: VHI-30 = Handicap Voice Index; MSHI = Modern Singing Handicap is usually expected of a subject. Otherwise, handicap is a result
Index; S-VHI = Singing Voice
of a flaw or inability, characterized by limitations or restraints
in accomplishing a role expected of a person, which in turn has
social, cultural, development, and economic consequences(27,28).
DISCUSSION Thus, singers notice there is something wrong with their voice
production and perceive this to be a limitation or disadvantage.
A singer is a voice professional who belongs to a group As previously mentioned, majority of the study sample included
exposed to the risk of developing voice problems; therefore, both singing students and nonprofessional singers; therefore,
his/her voice health requires more care(14,15). the perception of a voice handicap in their lives can have a lower
Recently, it has come to light that voice disorders in this value than would be the case with the population of professional
population result in changes, adaptations, and/or interruptions in singers. Although S-VHI results were statistically different
their daily as well as professional life. In addition, lifestyle, social from groups with and without vocal complaint, as shown in
environment, and the place where voice is professionally used can literature findings(14,28), scores were lower than those observed
contribute to the emergence or persistence of vocal disorders(23,24). by Cohen et al.(14). Furthermore, all mean scores of the group
Measuring how such changes and adaptations affect a pa- without complaint were lower than the other group (Table 2).
tient’s life facilitates the evaluation and management of these As for gender, it was observed that even though women in
professional singers(14) because the degree of limitation in a the speech therapy clinic asked for help due to dysphonia(29), in
subject’s quality of life does not necessarily point to degree of the present study it was found that the impact of a possible voice
severity of dysphonia(25). Hence, use of quality-of-life protocols problem was perceived by both genders on a similar level. This
in dysphonic patients is important(26), specially in singers, be- was reported in other studies as well(18,30), which noticed the self-
cause it could provide an appropriate orientation in therapeutic reported impact of voice alteration on the quality of life varied
management and voice use during treatment. according to gender, age, and professional singing (Table 3).
Thus, in order to optimize singers’ evaluation process, we It has been noticed that correlations between voice handicap
comparatively analyzed the VHI-30 protocol, which is the and singing experience time indicated a negative association
most widely used questionnaire in the world, and two specific in all protocols, evidencing that there is higher disadvantage if
proposals for singing, the S-VHI and MSHI, for identifying the singing voice was developed within a shorter period. This
similarities and differences. is understandable, since singing classes provide training for
It was seen that VHI-30 under-evaluated the sample, which muscle adjustments that differ substantially with spoken voice,
is expected since it is a generic protocol. As for MSHI, in leading to discomfort and voice problems in the early learning
comparing the three subscales, the flaw subscale, which is stages(22). Although the said finding relates to a negative correla-
the organic domain, presented the highest scores, followed by tion, its strength is low, and therefore, deviations in the protocol
inability and handicap subscales that represent the functional of singers who are at an early stage of practice must be carefully
and emotional domains, respectively. Since the majority in assessed. Other correlations between protocols were all posi-
the study group were nonprofessional singing students, for tive and statistically significant, indicating association between
whom singing is not the primary source of income, their per- the various scores of protocols, although at different levels of
ception on restriction or a decrease in their ability to sing did strength. For example, correlation between S-VHI and VHI-30
not point to a severe handicap vis-à-vis the scores obtained and MSHI total score is strong and higher than that observed
through this protocol. In S-VHI, however, the average score between S-VHI and VHI-30, which is only moderate. Thus, both
of the assessed group of singers indicated a discrete, perceived specific singing protocols have higher correspondence between

CoDAS 2013;25(5):463-8
468 Paoliello K, Oliveira, G Behlau M

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*KP was in charge of data collection, tabulation and analysis, and writing
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