Beyond the Treatment Protocol: Active Ingredients for Precision Voice Rehabilitation

Despite the growing body of research demonstrating voice therapy efficacy, only 12 of 100 people referred to a speech-language pathologist (SLP) for a voice evaluation will successfully complete therapy. One possible reason for this discrepancy is that clinical laboratory and clinical outcomes studies have focused on if voice therapy works while failing to explain how voice therapy works. While the if question is important, the yes or no response this question generates is of limited utility when those referred for voice therapy fail to complete. Consequently, the how question, which concentrates on the mechanisms and processes underlying effective voice therapy, is necessary to bridge the chasm between outcomes research and actual clinical practice. This dissertation addresses three related problems. First, SLPs routinely provide online, individualized rehabilitation to suit individual patient needs, an approach supported by the evidence-based practice model. Highly prescriptive voice therapy programs may require modification to be effective, yet treatment modifications are rarely documented or formally recognized in published treatment protocols. Second, uncertainty as to the active ingredients underlying voice therapy efficacy makes it difficult to determine whether treatment modification/ individualization undermines, preserves, or enhances treatment efficacy. Third, evidence-based practice requires incorporation not only of efficacious voice therapy techniques but also of patient preferences and clinical expertise. The SLP’s ability to recognize individual patient characteristics and respond appropriately may be a critical aspect of effective intervention. However, published voice therapy programs are often tested under controlled laboratory conditions and say little about the scaffolding and framework necessary for effective implementation. The overall objective of this dissertation was to elucidate how voice therapy works by (1) identifying discrepancies between a published voice therapy program and its clinical implementation, (2) identifying attributes underlying treatment efficacy of an evidence-based voice therapy program, and (3) developing a theory of the process of voice therapy with an individual patient. Together, stages I, II, and III of this dissertation addressed how voice therapy works by identifying the attributes and processes underlying voice therapy efficacy. Knowledge as to how voice therapy works supports the SLP’s ability to tailor treatments to individual patients, thereby improving therapeutic success rates and maximizing the benefits of efficacious voice therapies