Patient Scales

Individuals have different requirements and expectations of their voices; thus, the same level of dysphonia can differentially limit participation in typical daily activities. As part of a complete voice evaluation, the effect of the voice problem on each individual’s life should be assessed. Patient measures are scales completed by the patient and sometimes a caregiver or significant other. These scales typically measure patient satisfaction, quality of life, general health, handicap or loss as a result of the voice disorder, or some aspect of voice production (e.g., ease of phonation, effort, quality). Several scales specific to voice have been published in the last decade. The scales vary in length, construction, and what they assess.

Each published scale measures a different aspect of the voice. Some scales were constructed more carefully than others, so reliability and validity characteristics differ. Scale selection should be made according to variables of interest and reliability requirements. In general, patient scales are a wonderful addition to a voice evaluation and provide novel information about the patient’s point of view. A patient scale can guide discussion between health care providers and patients and help the team determine treatment goals.

Two commonly used scales, the Voice Handicap Index (VHI)¹ and Voice-Related Quality of Life (V-RQOL),² are described here. Details and information about scale construction can be found in the reference articles, and a synopsis of current scales can be found in Table 58-1.

Table 58-1 Patient Scales

Voice Handicap Index

The Voice Handicap Index was designed to assess handicap, “a social, economic, or environmental disadvantage resulting from an impairment or disability.”³ The instrument consists of 30 statements that patients rate on a 5-point equal-appearing interval scale that reflects the frequency of occurrence. The total possible score is 120, with higher scores reflecting greater handicap. Although the initial publication suggests division into functional, physical, and emotional subscales,¹ other writers have questioned the subscale structure,^4,⁵ suggesting that total score appears more meaningful. Since its publication in 1997, the Voice Handicap Index has been widely used to show voice handicap in specific groups of patients, comparisons between handicap and vocal function measures, and change with treatment.

Voice-Related Quality of Life

Other Patient Scales

The Voice Symptom Scale (VoiSS)^4,⁶ is a psychometrically sound 30-item scale representing physical impairment, emotional response, and related physical symptoms. The Voice Activity and Participation Profile (VAPP)⁷ follows the terminology and framework of the World Health Organization’s 1997 revision⁸ of the International Classification of Functioning, Disability, and Health. Patients indicate their extent of limitation in daily activities and restriction of participation in corresponding activities.

The Reflux Symptom Index (RSI), the Patient Questionnaire of Vocal Performance (VPQ), and the Voice Outcome Survey (VOS) are more limited in scope. The Reflux Symptom Index, made up of 9 items, is designed to document patient symptoms of laryngopharyngeal reflux.⁹ The Patient Questionnaire of Vocal Performance is a 12-item scale designed to assess the physical, social, and emotional impacts of a nonorganic voice disorder.^10,¹¹ The Voice Outcome Survey is a 5-item survey designed for patients with unilateral vocal fold paralysis.¹²

Perceptual Evaluation

Auditory Perceptual Assessment

Several formal measures and scales have been proposed to rate voice quality; two of the most commonly used scales are described here. Auditory perceptual ratings are appealing because the ultimate goal of voice treatment is to improve perceived voice quality. Unfortunately, such measures are fraught with definition, rating, and interpretation difficulties. Voice quality is difficult to define, leading to many, often circular, definitions of each term. Raters have different internal representations of the parameters and severity. It is difficult to differentiate between related qualities, and univariate ratings do not often correlate well with global ratings or measurements (for a detailed discussion, see Kreiman and Gerratt ¹³). Although auditory perceptual assessment often results in a number, the number represents a perceptual judgment rather than a measurement and should be treated accordingly.

GRBAS

GRBAS is a well-known standard scale that was developed by the Committee for Phonatory Function of the Japanese Society of Logopedics and Phoniatrics. As described by Hirano,¹⁴ the G represents grade or overall quality. The other four letters represent dimensions of voice quality, as follows: R for roughness, B for breathiness, A for asthenia, and S for strain. Descriptions of each parameter are given in Table 58-2. Each parameter is rated on a 4-point scale: 0 means that there is no deficit in this parameter, 1 is a mild deficit, 2 is a moderate deficit, and 3 indicates a severe deficit. There is no standard recommendation for the type of utterance(s) to use with GRBAS, so specific information about testing conditions should be documented in the report.

Table 58-2 GRBAS Scale for Auditory-Perceptual Evaluation

Parameter	Hirano Definition*	National Center for Voice and Speech Definition^†
Grade (G)	Overall severity
Roughness (R)	Psychoacoustic impression of irregular vocal-fold vibration	An uneven, bumpy quality that appears to be unsteady in the short term but stationary in the long term; acoustically, the waveform is often aperiodic, with the modes of vibration lacking synchrony, but voices with subharmonics can also be perceived as rough.
Breathiness (B)	Psychoacoustic impression of air leakage through the glottis	Containing the sound of breathing (expiration) during phonation; acoustically, breathy voice, like falsetto, has most of its energy in the fundamental, but a significant component of noise is present owing to turbulence in the glottis. In hyperfunctional breathiness, air leakage may occur in various places along the glottis, whereas in normal voice, air leakage is usually at the vocal processes.
Asthenia (A)	Weakness or lack of power in the voice	A voice that appears too low in effort, weak; hypofunction of laryngeal muscles is apparent.
Strain (S)	Psychoacoustic impression of a hyperfunctional state of phonation	A voice that appears effortful; visually, hyperfunction of the neck muscles is apparent; the entire larynx seems compressed.

* From Hirano M. Clinical Examination of Voice. New York: Springer-Verlag; 1981.

† From Titze IR. Workshop on Acoustic Voice Analysis: Summary Statement. Iowa City, IA: National Center for Voice and Speech; 1995.

CAPE-V

The Consensus Auditory-Perceptual Evaluation–Voice (CAPE-V) was developed at a 2003 consensus conference sponsored by the American Speech-Language-Hearing Association Special Interest Division 3, Voice and Voice Disorders.¹⁵ Six core and additional examiner-selected parameters are rated on a visual analog scale. The clinician uses a tick mark to rate function on a 100-mm line and then measures the distance from the left end of the line to establish a score; higher scores reflect a more severe deviation from normal quality. Core parameters are overall severity, roughness, breathiness, strain, pitch, and loudness. The judged parameters are identified as consistent or intermittent, and resonance differences can be noted. The CAPE-V is to be scored from two sustained vowels, six standard sentences, and at least 20 seconds of natural running speech. Recommendations about testing and recording environments are included.

Other Aspects of Speech Production

The speech-language pathologist might comment on other aspects of speech production that can indicate structural or neurologic disorders that affect voice production. Examples are imprecise articulation, resonance, and prosody disturbances. Resonance is described as hypernasal, hyponasal, or cul-de-sac. Prosody refers to rate, repeated or prolonged syllables, rushes of speech, intonation (i.e., monopitch or monoloudness), and stress patterns.

Auditory perceptual correlates of speech breathing are often assessed. Breath group length, average loudness, loudness variability, and inspiratory duration provide important information about lung volume expended, adequacy and consistency of alveolar pressure, and shape of rib cage and abdominal walls during talking.

Visual Perceptual Examination

The visual perceptual examination refers to visible and physical aspects of voice production related to etiology, maintenance, or effect of dysphonia. Koschkee and Rammage ¹⁶ have divided the visual perceptual examination into the following five categories: (1) general appearance; (2) posture, breathing, and musculoskeletal tension; (3) neurologic dysfunction; (4) physical dysmorphology; and (5) clinical manifestations of disease. Several components of the visual perceptual evaluation are described in more detail here.

General appearance factors, such as apparent age, height and weight, facial expression, skin, hair, and nails, personal hygiene and dress, and head and neck observations, can be indicative of underlying systemic disease, previous treatment, or emotional disorder. One example is the masked face of parkinsonism.

Posture, breathing, and musculoskeletal tension are key components of a voice evaluation because they frequently affect pitch, loudness, and quality. Postural assessment likely involves information about the alignment of the head, neck, torso, pelvis, and legs. Visual assessment of breathing includes observations of neck, shoulder, chest, and abdominal movement. Reports of musculoskeletal tension contain information about extent of jaw motion, chin jut, neck extension, bulging of the neck muscles while talking, or raised shoulders.

Neurologic dysfunction is indicated by observations such as unsteadiness, asymmetry, rigidity, hesitation, slowness, weakness, incoordination, inconsistency, and extraneous movements. Weakness, asymmetry, and incoordination of the tongue, jaw, lips, or soft palate are especially noteworthy. The presence of focal dystonias, such as writer’s cramp, blepharospasm, torticollis, and oromandibular dysphonia, usually leads the examiner to consider a neurologically based voice disorder, such as spasmodic dysphonia.