ARTICLE IN PRESS

Effects of Voice Therapy: A Comparison Between

Individual and Group Therapy
*Malin Abrahamsson, *Moa Millgård, *,†Christina Havstam, and *,‡Lisa Tuomi, *†‡Gothenburg, Sweden

Summary: Objective. The primary aim of this clinical evaluation project is to study the effect of voice therapy
given in the speech-language pathology clinic, as individual and group therapy, as well as finding out some of the reasons
for not attending the recommended therapy.
Method. All patients visiting the speech-language department during the study period were asked to participate in a
clinical evaluation project. The project included filling out the questionnaire Swedish Voice Handicap Index (VHI-11)
twice: at their first visit at the clinic, and approximately 1 year later. Depending on the degree of voice problems, the
patients were offered either individual or group therapy.
Result. The study included 187 patients at their first visit to the clinic and 109 patients at follow-up. All participants
completed self-evaluation of voice function with the VHI-11 and separate questions regarding overall voice problems,
hoarseness, and vocal fatigue. For the patients who responded to the follow-up survey, statistically significant improve-
ments of self-perceived voice function were demonstrated in individual and group therapy. The improvement between
the first visit and the follow-up was found to be of moderate to large effect size, with statistically significant improve-
ments for both patients who attended individual therapy and those who attended group therapy. The most common
reason for not attending the recommended voice therapy was lack of time.
Conclusion. Individual and group therapy is effective, resulting in improved VHI-11 scores. The magnitude of im-
provement is similar when comparing individual and group therapy. Patients with higher scores of the VHI-11 were
generally recommended individual voice therapy.
Key Words: Voice therapy–Group therapy–Individual therapy–Speech language pathology–Self-evaluation.

INTRODUCTION most commonly used voice questionnaire is the Voice Handi-

Voice disorders are characterized by abnormalities in pitch, loud- cap Index (VHI).13 A short version of the VHI has been developed
ness, or quality of the voice that can limit the effectiveness of oral and validated, the VHI-10.14 Rosen et al performed an analysis
communication.1 Additionally, the problems may be experi- comparing the VHI with the shortened version, VHI-10, and found
enced as vocal fatigue or pain or discomfort in the throat.2 Voice that the VHI-10 performed similar to the longer version of the
disorders may occur because of functional problems, that is, that questionnaire, and that the VHI-10 could replace the VHI.14 In
the voice is used in an inappropriate way. They can also occur Sweden, the VHI has been translated and validated.15 Addition-
because of organic lesions such as vocal nodules, polyps, or tumors.3 ally, the short version has been translated and validated in a master
Great voice load, in work or leisure, contributes to the oc- thesis, which resulted in the VHI-11, a questionnaire consist-
currence of voice disorders.4,5 Several occupations are documented ing of the original 10 items from the VHI-10, with the addition
as having great voice load: teachers, singers, sales persons, thera- of one item regarding throat discomfort.16
pists, engineers, office workers, computer scientists, service Voice therapy aims to restore a person’s voice, to be functional
workers, social workers, priests, lawyers, and health-care in his or her everyday life, work, and, in general communication.17
professionals.5–7 The prevalence of voice disorders in general has A review on the effectiveness of voice therapy for functional dys-
been reported between 5% and 29%.4,6 Among teachers, voice phonia concluded that voice therapy may include direct or indirect
problems are more prevalent, between 15% and 80%.8,9 approaches.18 The direct approaches focus on the voice produc-
Voice function and quality can be measured in many ways; tion, for example, laryngeal relaxation, diaphragmatic breathing,
perceptually, acoustically, with videostroboscopy and and coordination of breathing with phonation. The indirect ap-
self-perceived,10 with questionnaires such as the Voice-Related proaches refer to therapy focused on factors that influence voice
Quality of Life11 and the Voice Performance Questionnaire.12 The production, such as patient information, general relaxation, vocal
hygiene, and environmental awareness. The direct and indirect
Accepted for publication June 13, 2017.
approaches are often combined, and have been found effec-
This research received no specific grant from any funding agency in the public, com- tive, such as in improving the person’s own perception of voice
mercial, or not-for-profit sectors. The project was performed in the clinical setting of the
Sahlgrenska University Hospital in Region Västra Götaland.
function.18 Several studies conclude that the patient’s self-
From the *Sahlgrenska University Hospital, Department of Otorhinolaryngology, perceived voice function improves after voice therapy.19–26 Most
Gothenburg, Sweden; †Department of Clinical Neuroscience and Rehabilitation/Speech and
Language Pathology, Institute of Neuroscience and Pathology, Sahlgrenska Academy at
commonly, voice therapy is given as individual therapy, but group
the University of Gothenburg, Gothenburg, Sweden; and the ‡Department of Otorhinolar- therapy is also available.18,23,27,28 Both therapy types have been
yngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy
at the University of Gothenburg, Gothenburg, Sweden.
shown to be effective in improving the voice function; however,
Address correspondence and reprint requests to Lisa Tuomi, Sahlgrenska Academy at few studies exist addressing the effect of group therapy in com-
the University of Gothenburg, Department of Otorhinolaryngology, Head and Neck Surgery,
Institute of Clinical Sciences, Sweden. E-mail: [email protected]
parison with individual therapy.
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■ The primary aim of the present clinical evaluation study is
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
to evaluate the effect of voice therapy given in our department,
http://dx.doi.org/10.1016/j.jvoice.2017.06.008 in individual and group therapy, respectively, and to compare
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2017

the outcomes. Additionally, we also aim to survey patients coming Patient-reported outcomes
to the speech-language pathology department with voice prob- The VHI-11 is a shortened version of the VHI, Swedish version.
lems regarding their self-perceived voice handicap and overall It consists of 11 items answered on a 5-point Likert scale. All
voice problems, and possibly find out the most common reasons items are assertions regarding different aspects of voice use, an-
for not attending therapy. swered on a scale ranging from never (0) to always (4). Total
maximum score is 44 points. The original version, VHI-10,14 has
a cutoff point of 11 points; however, this cutoff score has not
MATERIALS AND METHODS been calculated for the Swedish version.
Participants Rating of voice function was also performed using 3 ques-
All patients with voice problems who visited the Speech- tions answered on a 10-cm visual analog scale. The questions
language pathology (SLP) department at the Otorhinolaryngology were regarding Overall voice problems, Hoarseness, and Vocal
clinic, Sahlgrenska University hospital, during January 2014 to fatigue, where 10 represents maximum problems, and 0 repre-
January 2015 were asked to participate in a clinical evaluation sents no problem at all.
project. The project included filling out a questionnaire twice:
once at their first visit, and once approximately 1 year later. Ethical considerations
The study was conducted in accordance with the Declaration of
Helsinki. No ethical review was needed because this is a quality
Design evaluation of given care; thus, this does not fall under the Swedish
The study is a clinical evaluation project performed to investi- law on ethical review of research.
gate the degree of voice problems of patients referred to the
department as well as evaluate the effects of given interven- Statistical methods
tion. Patients are referred to the SLP department mostly from SPSS Statistics v 22 for Mac was used for the statistical anal-
other caregivers in the Otorhinolaryngology field. Some pa- ysis (SPSS Inc, Chicago, IL). Nonparametric, two-sided tests were
tients come to the SLP department through self-referral. All used. For categorical variables such as smoking habits and oc-
patients are offered a first visit where the voice problems are cupation, the chi-square test was used. For continuous variables
surveyed, and intervention alternatives are discussed and deter- such as age, time between first visit and follow-up, and all ques-
mined. Additionally, the patients receive general vocal hygiene tionnaire data, the Mann-Whitney U test was used. The level of
advice. The SLP determine in coalition with the patient whether significance was set at 5% throughout. The magnitude of group
the most suitable treatment is group or individual voice therapy. differences was analyzed using effect sizes (ES). ES of within-
group change was calculated as mean change between assessments
divided by the pooled standard deviation of change divided by
Intervention two. ES was interpreted according to Cohen standard criteria,
The group therapy given at our SLP department is called basic where size is classified as trivial (0 to <0.2), small (0.2 to <0.5),
voice awareness (BVA). BVA is an open group where patients moderate (0.5 to <0.8), or large (≥0.8).29
book their appointment themselves, choosing from three different
sessions each week. Each BVA session is led by an experienced RESULTS
SLP. A maximum of four patients are allowed at each group A total of 187 patients chose to enroll in the study at their first
session. The patients are recommended to participate in the group visit. Of these, 81 patients were recommended to participate in
three to five times; however, if the SLP in coalition with the patient individual therapy, and 105 in BVA. One patient was not rec-
believe that the patient needs more sessions, this is offered. Con- ommended any therapy and is hereafter excluded from the
sultation regarding the continuation of the treatment, and home analysis. Patient characteristics are listed in Table 1. Calcula-
exercises is discussed with each patient at each session. Mostly, tions to identify differences between the groups (individual therapy
patients with mild to moderate voice problems are recom- vs. BVA) were performed. Statistically significant differences
mended to participate in the BVA. were found regarding age (43.7 vs. 48.9, P < 0.05) and time
Patients with more extensive vocal problems, often with struc- between the first visit and the follow-up (10.9 months vs. 11.9
tural changes to the vocal folds, are commonly referred to months, P < 0.05). Retired, teacher or child care, student, and
individual therapy. The patients are told that they will receive health-care professional were the most common occupations, listed
approximately three to five voice therapy sessions, but that in- in Table 1.
dividual differences occur depending on the patient needs. The result of the VHI-11 from the first visit is demonstrated
Both therapy approaches include direct and indirect ap- in Figure 1. A statistically significant difference was found when
proaches, including vocal hygiene, general relaxation, and focus comparing the patients who were recommended individual therapy
on diaphragmatic breathing.18 In the BVA, the therapy is a bit more and patients who were recommended to participate in group
general, whereas in the individual therapy, more focus can be given therapy (24.5 vs. 20.6, P < 0.05, Figure 1). The patients who were
to more specifically adapt the therapy for each patient. In both recommended individual voice therapy demonstrated higher, that
therapy approaches, focus is set to generalize the vocal tech- is, inferior scores in the VHI-11. The result for the ratings of
niques learned to everyday life. The patients are encouraged to voice function is found in Figure 2. Overall rating of voice prob-
exercise daily at home. lems and hoarseness demonstrated statistically significant
 ARTICLE IN PRESS
Malin Abrahamsson, et al Effects of Voice Therapy 3

TABLE 1.
Patient Characteristics at First Visit
Recommended Recommended
Individual Group Therapy Difference
Total (n = 187) Therapy (n = 81) (n = 105) Between
Mean Mean Mean the Groups
Age mean (SD) 46.5 43.7 48.9 *
Time between first visit 11.4 11.9 10.9 *
and follow-up, mo

n (%) n (%) n (%)

Smoking
Nonsmoker 99 (53) 42 (52) 57 (54)
Quit smoking 79 (42) 33 (41) 45 (43)
Smoker 6 (3) 4 (5) 2 (2)
Information missing 3 (2) 2 (2) 1 (1)
Occupation
Student 25 (13.4) 17 (21.0) 7 (6.7)
Retired 30 (16.0) 12 (14.8) 18 (17.1)
Teacher or child care 29 (15.5) 9 (11.1) 20 (19)
Customer support or sales person 11 (5.9) 5 (6.2) 6 (5.7)
Health-care professional 19 (10.2) 4 (4.9) 15 (14.3)
Singer 5 (2.7) 4 (4.9) 1 (1)
Administration 11 (5.9) 9 (11.1) 2 (1.9)
Engineer 8 (4.3) 4 (4.9) 4 (3.8)
Other occupation 41 (21.9) 14 (17.3) 27 (25.7)
No work 3 (1.6) 1 (1.2) 2 (1.9)
Social worker 5 (2.7) 2 (2.5) 3 (2.9)
* P < 0.05.

FIGURE 1. Results from the VHI-11 for all patients recommended individual therapy and group therapy at first visit (n = 187). *P < 0.05 when
comparing the patients who where recommended individual therapy and patients who were recommended group therapy.
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2017

FIGURE 2. Ratings of voice function for all patients recommended individual therapy and group therapy at first visit (n = 187). Numbers above
each bar indicate mean (standard deviation [SD]). *P < 0.05 when comparing the patients who where recommended individual therapy and pa-
tients who were recommended group therapy. Overall voice problems, Hoarseness, and Vocal fatigue were rated on a 10-cm visual analog scale,
where 10 indicates the most problems.

differences when comparing the patients who were recom- recommended individual therapy; the remaining 23 were rec-
mended individual therapy and those recommended group therapy. ommended BVA. The most common reasons for not attending
Patients who were recommended individual therapy rated their voice therapy was that they had no time, they no longer expe-
voice problems as higher, that is, worse, than patients who were rienced voice problems, or other reasons (Table 5).
recommended group therapy.
In total, 109 patients chose to participate in the follow-up, a DISCUSSION
response rate of 58%. Forty-two of them attended individual This clinical evaluation project aimed to study and compare the
therapy, 41 attended group therapy, and 26 did not attend any effect of voice therapy, in individual and group therapy, respec-
therapy. Table 2 demonstrates the questionnaire data from the tively. Additional aims were to survey the degree of voice
first visit and follow-up for the patients who participated in in- problems of patients coming to the speech-language pathology
dividual therapy compared with group therapy. In both groups, department with voice problems regarding their self-perceived
there were statistically significant improvements in all ques- voice handicap and overall voice problems, and find out common
tionnaire data. When comparing the changes in both groups, we reasons for not attending the recommended voice therapy. The
found no statistically significant differences, that is, the mag- study demonstrated that all patients experienced voice prob-
nitude of the change was similar for patients who received lems at their first visit according to a threshold value, indicating
individual and for those who received group therapy. voice problems developed for the original VHI-10. For the pa-
The patients who participated in voice therapy of some kind tients who responded to the follow-up survey, statistically
also stated the amount of therapy sessions they attended. When significant improvements of self-perceived voice function were
comparing the patients who attended individual therapy and BVA, demonstrated for patients in both individual therapy and group
there was a statistically significant difference, where patients who therapy. The improvement between the first visit and the follow-
attended individual therapy participated in more therapy ses- up was found to be of moderate to large ES, with statistically
sions than the patients who participated in BVA (6.9 vs. 4.6 times, significant improvement both for patients who attended indi-
P < 0.05) (Table 3). vidual and for those who attended group therapy (Table 2).
Twenty-six patients who did not attend any voice therapy Steen et al demonstrated similar results, where patients
participated in the follow-up (Table 4). Three of them were who received voice therapy were found to improve regarding
 ARTICLE IN PRESS
Malin Abrahamsson, et al Effects of Voice Therapy 5

TABLE 2.
Data for Patients Who Participated in the Follow-up, Divided Into Patients Who Attended Individual and Those Who At-
tended Group Therapy
Individual Therapy (n = 42) Group Therapy (n = 41)
Difference Difference
Within Within
First Visit Follow-up Group First Visit Follow-up Group
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Overall voice problems 6.7 (1.8) 4.2 (2.4) −2.4 (2.5)* 6.2 (1.9) 4.2 (2.6) −2.4 (2.5)*
ES 1.19 ES 0.89
Hoarseness 6.4 (2.0) 4.6 (2.7) −1.8 (2.9)* 6.1 (2.1) 4.2 (2.5) −1.9 (3.2)*
ES 0.76 ES 0.83
Vocal fatigue 6.5 (2.1) 4.4 (2.8) −2.0 (3.3)* 6.0 (2.8) 4.1 (2.7) −1.8 (2.6) *
ES 0.86 ES 0.69
VHI-11 total 24.5 (8.0) 17.8 (10.1) −8.7 (8.9) * 20.6 (6.8) 14.5 (8.7) −8.0 (6.8)*
ES 0.74 ES 0.79
* P < 0.05. According to Cohen, standard criteria size is classified as trivial (0 to <0.2), small (0.2 to <0.5), moderate (0.5 to <0.8), or large (≥0.8).
Values in italics indicate statistically significant difference (P < 0.05) between groups at this time point.
Abbreviation: ES, effect size.

TABLE 3. TABLE 5.
Number of Visits Attended in Individual or Group Therapy Reasons for Not Attending Voice Therapy
Attended Attended n (%)
Individual Group Difference Had no time 12 (46%)
Therapy Therapy Between No voice problems 5 (19%)
Mean (SD) Mean (SD) Groups Other reasons 7 (27%)
No. of visits 6.9 (3.3) 4.6 (3.2) * Did not state reason 2 (8%)
* P < 0.05. Examples of other reasons: “could not afford,” “scared of traffic when
driving to the hospital,” and “did not understand how to make the
appointment.”

TABLE 4.
Results of the VHI-11, Ratings of Voice Function for Pa- evaluating the effects of voice therapy for muscle tension dys-
tients Who Were Recommended Group Therapy But Did phonia, where the patients who received voice therapy
Not Attend demonstrated a statistically significant improvement of VHI scores
compared with the patients who did not receive any therapy.25
Recommended Group Therapy
But Did Not Attend (n = 23) Similarly, Kaneko et al demonstrated a statistically significant
improvement of VHI-10 scores following voice therapy with vocal
Difference
function exercises.26 The present study demonstrated similar results
Within
to previous studies, where VHI-11 scores improved signifi-
First Visit Follow-up Group
cantly following voice therapy, performed both individually and
Mean (SD) Mean (SD) Mean (SD) in a group setting.
Overall voice 4.9 (2.1) 4.3 (2.8) −0.7 (2.1) Voice therapy in a group setting is sometimes used clinically;
problems however, few studies exist addressing the effect of the voice therapy
Hoarseness 4.6 (2.4) 4.2 (2.8) −0.5 (2.1) given in a group setting. Law et al investigated the effect of voice
Vocal fatigue 5.1 (2.4) 5.1 (3.1) −0.1 (2.1) therapy in a group of teachers with hyperfunctional dysphonia.27
VHI-11 total 17.2 (9.1) 14.8 (12.5) −5.1 (7.2) The study suggested that it was effective not only in terms of
Abbreviation: SD, standard deviation. self-perceived voice function, but also in terms of an engaging
therapy approach. Studies covering the group perspective of therapy
indicate that observing the process of how other people learn is
self-perceived voice function measured by the VHI following effective, perhaps even more effective, than observing the expert.
voice therapy.30 Additionally, a study by Schindler et al evalu- In the present study, the participants had the opportunity to observe
ated the effects of voice therapy for benign vocal fold lesions different therapists and participants, as they could attend which
and found a statistically significant improvement following weekly session they preferred. However, Law et al note the im-
therapy.22 Craig et al demonstrated similar results in their study portance of group cohesion as an important factor.27 The setup
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2017

for the BVA is that it is an open group. Therefore, the group com- 9. Roy N, Merrill RM, Thibeault S, et al. Prevalence of voice disorders in
position might differ from time to time, even if some patients teachers and the general population. J Speech Lang Hear Res. 2004;47:281–
293.
met several times over the course of therapy. Therefore, the pos- 10. Dejonckere PH, Bradley P, Clemente P, et al. A basic protocol for functional
itive effects yielded from group therapy demonstrated in the study assessment of voice pathology, especially for investigating the efficacy of
by Law et al might not correlate with the group effectiveness in (phonosurgical) treatments and evaluating new assessment techniques.
this study.27 However, there were positive effects regarding the Guideline elaborated by the Committee on Phoniatrics of the European
VHI-11 scores in the group setting and, therefore, it is probable Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2001;258:77–
82.
that the group therapy is effective in terms of self-perceived voice 11. Hogikyan ND, Sethuraman G. Validation of an instrument to measure
function. To demonstrate the effects of group dynamics and group voice-related quality of life (V-RQOL). J Voice. 1999;13:557–569.
cohesion, additional studies are needed. 12. Deary IJ, Webb A, Mackenzie K, et al. Short, self-report voice symptom
This study is limited by the low response rate (58%). It is pos- scales: psychometric characteristics of the Voice Handicap Index-10 and
sible that a larger response rate would have yielded different the vocal performance questionnaire. Otolaryngol Head Neck Surg.
2004;131:232–235.
results. A noteworthy result is that improvement of VHI-11 scores 13. Jacobson BH, Johnson A, Grywalski C, et al. The Voice Handicap Index
was found among the 23 patients who were recommended group (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–
therapy but chose not to participate. This improvement may reflect 70.
that some of the patients stated that they did not experience voice 14. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the
problems at follow-up, and therefore chose not to participate in voice handicap index-10. Laryngoscope. 2004;114:1549–1556.
15. Ohlsson AC, Dotevall H. Voice handicap index in Swedish. Logoped
their recommended therapy. It could also be because some pa- Phoniatr Vocol. 2009;34:60–66.
tients might have experienced that the advice given at their first 16. Nyman M, Åradson S. Voice Handicap Index-Lund-11. Ett
visit helped them, and that they therefore experienced less symp- självskattningsformulär för patienter med röstbesvär. Översättning,
toms. The most common reason for not participating in the therapy bearbetning och validering. [Master thesis]: Avdelningen för logopedi,
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tients themselves need to contact the department to book their 17. Colton R, Casper J, Leonard R. Understanding Voice Problems:
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voice therapy in the treatment of benign vocal fold lesions. Acta
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Otorhinolaryngol Ital. 2012;32:304–308.
23. Niebudek-Bogusz E, Sznurowska-Przygocka B, Fiszer M, et al. The
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