Braz J Otorhinolaryngol.
2020;86(4):497---501
Brazilian Journal of
OTORHINOLARYNGOLOGY
www.bjorl.org
REVIEW ARTICLE
Normative values for singing voice handicap
index --- systematic review and meta-analysis夽
a,∗
Maria Sobol , Ewelina M. Sielska-Badurek b , Ewa Osuch-Wójcikiewicz b
a
Medical University of Warsaw, Department of Biophysics and Human Physiology, Warsaw, Poland
b
Medical University of Warsaw, Department of Otolaryngology, Warsaw, Poland
Received 22 August 2018; accepted 27 December 2018
Available online 20 February 2019
KEYWORDS Abstract
SVHI; Introduction: There are no official diagnostic protocols for singing voice assessment. In this
Singers; publication, on the basis of a literature review, standards for the singing voice handicap index
Normal voices; exclusively dedicated to voice disorders in singing have been given.
Meta-analysis Objective: The study aims to determine the normative values for the singing voice handicap
index.
Methods: The study is a systematic review and a meta-analysis. A systematic literature search
was performed using PubMed to access relevant databases and to locate outcome studies.
The ‘‘inclusion’’ criteria were as follows: English language, original papers and human studies
retrospective and prospective papers, cross-sectional and case-control studies.
Results: Eight articles were included for the final analysis. The normative value for the singing
voice handicap index was 20.35 with a confidential range of 10.6---30.1 for a group of 729 healthy
subjects whose voices were judged as normal, with an age range of 16---64 years.
Conclusion: The mean normative value of the singing voice handicap index was 20.35 with the
confidence levels between 10.6 and 30.1.
© 2019 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published
by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
夽 Please cite this article as: Sobol M, Sielska-Badurek EM, Osuch-Wójcikiewicz E. Normative values for singing voice handicap index ---
systematic review and meta-analysis. Braz J Otorhinolaryngol. 2020;86:497---501.
∗ Corresponding author.
Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.12.004
1808-8694/© 2019 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
498 Sobol M et al.
PALAVRAS-CHAVE Valores normativos para o índice de desvantagem vocal no canto - revisão sistemática
IDVC; e metanálise
Cantores;
Resumo
Vozes normais;
Introdução: Não há protocolos diagnósticos oficiais para avaliação de voz no canto. Nesse estudo
Meta-análise
baseado em uma revisão de literatura, são fornecidos padrões para o índice de desvantagem
vocal no canto exclusivamente dedicado a distúrbios vocais no canto.
Objetivo: Determinar os valores normativos para o índice de desvantagem vocal no canto.
Método: O estudo é uma revisão sistemática com metanálise. Uma busca sistemática da
literatura foi feito no PubMed para acessar bancos de dados relevantes e para localizar
estudos de desfecho. Os critérios de inclusão foram: estudos escritos em inglês, artigos
originais e estudos em seres humanos, retrospectivos e prospectivos, estudos transversais e de
caso-controle.
Resultados: Oito artigos foram incluídos na análise final. O valor normativo para o índice de
desvantagem vocal no canto foi de 20,35 com intervalo de confiança de 10,6 a 30,1 em um
grupo de 729 indivíduos saudáveis cujas vozes foram consideradas normais, de 16 a 64 anos.
Conclusões: O valor normativo médio do índice de desvantagem vocal no canto foi de 20,35
com intervalo de confiança entre 10,6 e 30,1.
© 2019 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado
por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http://
creativecommons.org/licenses/by/4.0/).
Introduction et al. in 2007.9 The SVHI questionnaire consists of 36 items:
physical, emotional, social and economic individually
Singers form a special group of professional voice users who graded on a five-point Likert scale (0 --- never, 1 --- almost
are particularly sensitive to vocal disability and are at a high never, 2 --- sometimes, 3 --- almost always, 4 --- always see
risk for voice impairment. Compared to non-singers they Appendix) to range from 0 to 144. It was proved that the SVHI
may have higher impact on their quality of life and have can be used to measure treatment outcomes in singers.10
more self-reported voice problems. They are also more likely A higher score in the SVHI indicates more singing voice
to seek medical care.1---3 handicap. The SVHI compared with the VHI questionnaire is
Prior reports show that voice disorders adversely impact more sensitive to singers with voice disorders.10
a patient’s physical, emotional, economic and social life.4---6 The main propose of this study was to determine the nor-
Taking these reports into account, the World Health Orga- mative values for the SVHI among singers whose voice were
nization has defined a handicap as a social, environmental judged as normal.
or economic disadvantage. Thus, measuring a patient’s
dysfunction resulting from voice problems in singers is Materials and methods
essential to provide their vocal health needs.
The most popular questionnaire that has been designed Studies included in this research were selected from a sys-
to measure the impact of voice problems in individuals is tematic search of literature in PubMed. Studies published
the voice handicap index (VHI)(Table 1).7 It was created to up to 15 April 2018 were included. The ‘‘inclusion’’ crite-
assess voice problems in the general population concerning ria were as follows: English language, original papers and
mainly the speaking voice. The VHI is organized into three human studies retrospective and prospective papers, cross-
categories: functional, physical, and emotional, each sectional and case-control studies. The ‘exclusion’ criteria
having 10 items. From these 30 items five functional, three were as follows: median of SVHI, mean value of SVHI with-
physical and two emotional were chosen to create VHI-10 out standard deviation. We did not consider case reports.
questionnaire The screening of the results was based on the words and
During clinical practice, it was noticed that singers phrases: singing voice handicap index (SVHI), singers, pro-
scored significantly lower on the VHI and VHI-10 compared fessional voice users, normal voices. Unpublished reports
to non-singers.8 Rosen et al.2 and Behrman et al.3 found that and those without peer-review evaluations, abstracts, or
voice handicap of singers is lower than these of non-singers. incomplete text were not considered. Authors were not con-
It may be due to the fact that singers may be more sensitive tacted. Two reviewers, the first and second author, assessed
to voice changes. Moreover, non-singers voice problems may each abstract for potential inclusion and reached a consen-
differ from those of singers. The VHI may not be sensitive sus for the final article to be included in the review.
enough for singers, as it is focused on the speaking voice.
This observation led to the development of the second Eligibility criteria
index: the singing voice handicap index and its shortened
counterpart SVHI-10 for singers with voice problems. This The systematic review was conducted using the PRISMA
index was developed and validated on performers by Cohen guidelines.11 Specific requirements are listed as follows:
Normative values for singing voice handicap index 499
Table 1 Questionnaire of singing voice handicap index.9
(1) It takes a lot of effort to sing. Never Almost never Sometimes Almost always Always
(2) My voice cracks and breaks Never Almost never Sometimes Almost always Always
(3) I am frustrated by my singing. Never Almost never Sometimes Almost always Always
(4) People ask ‘‘What is wrong with your voice?’’ Never Almost never Sometimes Almost always Always
(5) My ability to sing varies day to day Never Almost never Sometimes Almost always Always
(6) My voice ‘‘gives out’’ on me while I am singing. Never Almost never Sometimes Almost always Always
(7) My singing voice upsets me. Never Almost never Sometimes Almost always Always
(8) My singing problems make me not want to sing/perform. Never Almost never Sometimes Almost always Always
(9) I am embarrassed by my singing. Never Almost never Sometimes Almost always Always
(10) I am unable to use my ‘‘high voice.’’ Never Almost never Sometimes Almost always Always
(11) I get nervous before I sing because of my singing problems. Never Almost never Sometimes Almost always Always
(12) My speaking voice is not normal. Never Almost never Sometimes Almost always Always
(13) My throat is dry when I sing. Never Almost never Sometimes Almost always Always
(14) I’ve had to eliminate certain songs from my Never Almost never Sometimes Almost always Always
singing/performances.
(15) I have no confidence in my singing voice. Never Almost never Sometimes Almost always Always
(16) My singing voice is never normal. Never Almost never Sometimes Almost always Always
(17) I have trouble making my voice do what I want it to. Never Almost never Sometimes Almost always Always
(18) I have to ‘‘push it’’ to produce my voice when singing. Never Almost never Sometimes Almost always Always
(19) I have trouble controlling the breathiness in my voice. Never Almost never Sometimes Almost always Always
(20) I have trouble controlling the raspiness in my voice. Never Almost never Sometimes Almost always Always
(21) I have trouble singing loudly. Never Almost never Sometimes Almost always Always
(22) I have difficulty staying on pitch when I sing. Never Almost never Sometimes Almost always Always
(23) I feel anxious about my singing. Never Almost never Sometimes Almost always Always
(24) My singing sounds forced. Never Almost never Sometimes Almost always Always
(25) My speaking voice is hoarse after I sing. Never Almost never Sometimes Almost always Always
(26) My voice quality is inconsistent. Never Almost never Sometimes Almost always Always
(27) My singing voice makes it difficult for the audience to Never Almost never Sometimes Almost always Always
hear me
(28) My singing makes me feel handicapped. Never Almost never Sometimes Almost always Always
(29) My singing voice tires easily. Never Almost never Sometimes Almost always Always
(30) I feel pain, tickling, or choking when I sing. Never Almost never Sometimes Almost always Always
(31) I am unsure of what will come out when I sing. Never Almost never Sometimes Almost always Always
(32) I feel something is missing in my life because of my Never Almost never Sometimes Almost always Always
inability to sing.
(33) I am worried my singing problems will cause me to lose Never Almost never Sometimes Almost always Always
money.
(34) I feel left out of the music scene because of my voice. Never Almost never Sometimes Almost always Always
(35) My singing makes me feel incompetent. Never Almost never Sometimes Almost always Always
(36) I have to cancel performances, singing engagements, Never Almost never Sometimes Almost always Always
rehearsals, or practices because of my singing.
Patient/population: Professional voice users, adults with Results
normal voices and no identifiable vocal fold pathology, all
age groups. Our search strategy identified 21 articles among the PubMed
Limits used: Human subject studies, studies published in database. After screening using the phrases: singing voice
English. handicap index (SVHI), adults and normal voices, and
Search string: Search string details are shown in Fig. 1. professional voice users, eight studies were identified12---19
and therefore included. In Table 2 e characteristics of
the studies are summarized. In the meta-analysis we only
considered professional singers who identified themselves
Statistical analysis as being healthy, which was defined as having no known
vocal problems.
Statistical analysis was performed using the Statistica 13 Most of the studies were from Europe (n = 6), followed by
package. The statistical heterogeneity was assessed using Egypt (n = 1), and India (n = 1).
the inconsistency index I2 measure. The analysis was con- Data analysis was conducted using meta-analysis. The
ducted with a fixed-effects model and the standardized range of age was 16---64 years. The received mean normative
mean difference with 95% Confidence Intervals (95% CI). value of the SVHI for a group of 729 healthy professional
500 Sobol M et al.
Meta-Anasysis
SVHI
Records identified through database
Study Mean SVHI ( L CL U CL ) p %
PubMe d April 2018 ( n= 21 )
[12] 15,00 (-9,89 39,89) 0,2376 15,33%
[13] 28,43 (-7,99 64,85) 0,1260 7,16%
[14] 29,26 (-21,15 79,67) 0,2553 3,74%
[15] 19,81 (-0,71 40,33) 0,0585 22,56%
[16] 19,84 (-5,33 45,01) 0,1223 15,00%
[17] 22,40 (-9,61 54,41) 0,1702 9,27%
Records remaining after selection was [18] 19,40 (-2,55 41,35) 0,0832 19,71%
applied stage one SVHI (n= 20) [19] 21,80 (-14,46 58,06) 0,2386 7,23%
Summary 20,35 (-10,60 58,06) 0,0000 100,00%
-100 -60 -20 20 60 100
-80 -40 0 40 80
Figure 2 Forest plot of the SVHI score, p-value indicating
level of statistical significance.
Records remaining after selection Discussion
was applied stage two normal
voices (n= 15) The purpose of this study was to find the normative value
for the SVHI for a large population of healthy professional
singers. Singers represent a unique group of professional
voice users. They are at risk of developing voice problems
that affect not only their speaking but also their singing
voice. To maximize treatment of this special group of peo-
ple, it is essential to understand how voice problems impact
them. Although the VHI was applied to evaluate singing
Studies included in analysis voice,8 it was noticed that it had poor sensitivity to evaluate
(n= 8) singing voice problems. As a result, there was a need to cre-
ate a more specific self-reported instrument --- the singing
voice handicap index. It is a specific questionnaire to asses
Figure 1 Flow chart for inclusion of articles. singing voice under emotional, social, physical and economic
domains. It was shown10 that SVHI is sensitive to clinical
changes and helps to identify specific singing problems.
Validation and adaptation of SVHI was done in many lan-
Table 2 The SVHI scores and standard deviations. guages: English,9 German,12 Italian,14 Turkish,19 Spanish13
Study SVHI control group Numbers of
and Polish.18 Most of the studies considered small groups
mean (SD) subject
of healthy participants so it is very difficult to give a credi-
ble score of normative voices for singers. To receive a more
Lorenz et al.12 15.0 (12.7) 130 appropriate score we considered a relatively large group of
Garcia-Lopez 28.43 (18.58) 81 healthy individuals without voice or hearing complaints from
et al.13 multicentre studies. To do this we did a systematic litera-
Baracca et al.14 29.26 (25.72) 117 ture search of the PubMed electronic database. Eligibility
Gunjawate et al.15 19.81 (10.74) 84 criteria included type of publication, participant character-
Lee et al.16 19.84 (12.84) 90 istic (for our analysis we chose only healthy subjects) and
Castelblanco 22.4 (16.33) 47 report of outcomes.
et al.17 The received mean normative value of the SVHI for a
Sielska-Badurek 19.4 (11.2) 57 group of 729 healthy singers was 20.65 with 95% confidence
et al.18 levels from 10.6 to 30.10. The normal value of VHI is known
Denizoğlu et al.19 21.8 (18.5) 123 to be between 0 and 30, however, itshould be noted that
a result above 30 will not always be synonymous with the
existence of actual voice disorders.20 Our result is in agree-
ment with Renk et al.21 who showed that the mean value of
VHI-10 (12.1) scores of singers were significantly lower than
those of SVHI-10 (20.4). They noticed that these two groups
voice users was 20.65 with 95% confidence levels of ranked differently in 10 statements. In addition, when Murry
10.6---30.1 (Fig. 2). A heterogeneity for the different studies et al. changed statements from ‘‘my voice’’ to ‘‘my singing
included in the meta-analysis was I2 = 0% so the fixed effect voice’’ the group of singers judged their voice complaints
model was used. as more severe and it probably caused some differences in
Normative values for singing voice handicap index 501
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