International Perspectives on Voice Disorders

By Edwin M-L. Yiu

Multilingual Matters

Copyright © 2013 Edwin M-L. Yiu and the authors of individual chapters
All rights reserved.
ISBN: 978-1-84769-873-5

Contents

Contributors,
Preface,
Part 1: Current Issues in Voice Assessment and Intervention: A World Perspective,
1 Current Issues in Voice Assessment and Intervention in Australia Jennifer Oates, Janet Baker and Anne Vertigan,
2 Current Issues in Voice Assessment and Intervention in Belgium Marc S. De Bodt, Bernadette Timmermans and Kristiane M. Van Lierde,
3 Speech Language Pathology and the Voice Specialist in Brazil: An Overview Mara Behlau, Gisele Oliveira, Glaucya Madazio and Rosiane Yamasaki,
4 Current Issues in Voice Assessment and Intervention in China Wen Xu and Demin Han,
5 Current Issues in Voice Assessment and Intervention in Hong Kong Estella P-M. Ma and Triska K-Y. Lee,
6 Current Issues in Voice Assessment and Intervention in Israel Ofer Amir,
7 Contemporary Phonosurgery in Japan Koichi Tsunoda,
8 Current Issues in Voice Assessment and Intervention in the United Kingdom Paul Carding,
9 Current Issues in Voice Assessment and Intervention in the USA Tanya L. Eadie and Edie R. Hapner,
Part 2: Contemporary Voice Research: A World Perspective,
10 Contemporary Voice Research in Japan Shigeru Hirano,
11 A USA Perspective: Vocal Fold Injuries and Their Management Nicole Yee-Key Li and Katherine Verdolini Abbott,
12 Cognitive Behavioural Therapy in the Treatment of Functional Dysphonia in the United Kingdom Paul Carding, Vincent Deary and Tracy Miller,
Introduction to Chapters 13 and 14: Contemporary Voice Research in Hong Kong,
13 Acupuncture and Voice Treatment Edwin M-L. Yiu,
14 Application of Motor Learning Principles in Voice Motor Learning Estella P-M. Ma and Edwin M-L. Yiu,
15 Contemporary Voice Research: A China Perspective Jiangping Kong and Gaowu Wang,
16 Analysis of Professional Voice Users in the Clinical Setting Cate Madill and Patricia McCabe,
17 Contemporary Voice Research: A Belgian Perspective Marc De Bodt and Youri Maryn,

CHAPTER 1

Current Issues in Voice Assessment and Intervention in Australia

Jennifer Oates, Janet Baker and Anne Vertigan

Introduction

Voice assessment and intervention in Australia share many features with voice practice internationally. However, because of the specific educational, public policy and cultural environment of Australia, it is likely that Australian practice is characterised by several unique features. This chapter describes the context for voice practice in Australia and discusses current practice in relation to speech pathology education, continuing professional development, service delivery and cultural influences.

Because there are limited published data on contemporary voice practice in Australia, the authors developed and implemented three surveys to ensure that the content of this chapter is as current and reflective of actual practice as possible. All three surveys were administered electronically with the target groups all being academics responsible for voice education in Australian universities, convenors of special interest groups in voice, and managers of speech pathology departments in a range of health and community agencies. The survey of academics was followed up with phone calls to explore responses in further depth.

The context of voice practice in Australia

Australia has a population of 22.8 million people spread over 7.6 million square kilometres (just slightly smaller than the USA). Some parts of the country are very remote. Australia is a wealthy country with a GDP in 2011 of US$1.03 trillion (the 13th largest economy in the world), low unemployment (5.3%), and a 99% literacy rate (Australian Bureau of Statistics, 2012). Mean household income is equivalent to US$61,650. Although school education is free, approximately one-third of children attend private schools. Seventy-five per cent of the population have completed 10 or more years of education and 42% of the population have completed 12 or more years. The majority of the population lives in urban areas. Health care in Australia is generally good, and life expectancy averages 81 years.

Australia has a long history of immigration with 24% of the current population having been born outside Australia. The majority of the population is monolingual and there are no recognised Australian dialects. Fifteen million Australians (68%) speak only English. Other common languages include Italian, Greek, Cantonese, Mandarin and Vietnamese. Recently, Australia has also had increased numbers of refugees from African countries, particularly Sudan. Only 2.5% of the population identify themselves as indigenous, that is Aboriginal or Torres Strait Islander. Unfortunately there is an inequitable health gap between indigenous and non-indigenous Australians and a generally low uptake of health and speech pathology services by both of these populations. Average life expectancy for indigenous Australians is approximately 70 years.

Epidemiological data on the prevalence of voice problems in Australia demonstrate that approximately 4% of the general adult population report that they experience voice problems in any one year (Russell et al., 2005). The prevalence rate for occupational voice users is considerably higher than for the general population. The equivalent prevalence rate for Australian school teachers, for example, is 20% (Russell et al., 1998). Few prevalence data are available for Australian children, but early parent-reported data from a large epidemiological study of 4-year-old children in Australia indicate a rate of 1.8% of 4-year-olds with a voice problem and 7% with hoarse voices (J. Skeat, personal communication, 3 August 2009).

Assessment and intervention services for people with voice problems in Australia are provided mainly by speech pathologists and otolaryngologists. Although many speech pathologists and otolaryngologists develop specialist skills in voice practice, it is rare for these health professionals to practice solely in the voice field. There are no phoniatricians in Australia and very few otolaryngologists title themselves as laryngologists. Otolaryngologists are responsible for making the medical diagnosis and for the implementation of medical and surgical intervention for people with voice disorders, but speech pathologists often assume the key coordinating role in the overall management of these clients. Speech pathologists and otolaryngologists often work closely together in client management as well as research and professional development. Other health professionals including neurologists, respiratory physicians and psychologists also contribute to the management of people with voice disorders, although not on a routine basis. In addition, singing and acting voice teachers, speaking voice coaches, physiotherapists, osteopaths and Alexander and Feldenkrais practitioners are sometimes involved in assessment and intervention.

Speech pathology in Australia is a relatively young profession, having been founded by a speech therapist from England in 1931. The first speech pathology training course commenced in 1939 as a hospital-based diploma. In 1967 the first university degree course in speech pathology commenced. As of 2010, there are 10 university degree courses that qualify graduates to practise. These qualifying or entry-level courses are offered as bachelors, bachelors/masters double degrees and graduate-entry masters degrees. It is not possible to specify the exact number of speech pathologists in Australia at the present time because speech pathology is not a nationally registered profession. However, the profession is strongly self-regulated through its professional association, Speech Pathology Australia (SPA), and eligibility for membership of SPA is normally required for employment. As of 2009, there were 4420 members. From the early days in the development of the profession in Australia, knowledge and skills in the management of people with voice disorders have been considered as key competencies for speech pathologists. SPA requires that all members are competent for voice practice and university programmes cannot be accredited by SPA unless they can demonstrate that their graduates have been assessed as being competent in voice (SPA, 2001).

Entry-Level Preparation of Speech Pathologists for Voice Practice

Competency-based occupational standards set by SPA (2001) specify that speech pathologists who are eligible for membership of SPA must be competent to work with both adults and children in each of the five key areas of voice, speech, language, fluency and swallowing. Entry-level clinicians are expected to be competent for voice practice across seven areas of professional activity: assessment; analysis and interpretation of assessment data; intervention planning; intervention; planning, maintaining and delivering speech pathology services; professional and community education; and continuing professional development. To be accredited by SPA, university programmes must demonstrate that all graduates meet these entry-level standards.

The findings from the authors’ email and telephone survey presented below provide more detailed information and qualitative insights on the education of speech pathologists than can be provided by the competency requirements outlined above. This additional information further explains the context and underpinnings of clinical practice in Australia. The survey revealed the following features of entry-level speech pathology education in voice.

The proportion of each course devoted to voice theory

The proportion of each course devoted to voice theory ranges between 10% and 22%, with the mode being 10%. Although respondents were not asked to specify the proportions allocated to the other four areas of competency, it is clear that voice and fluency receive less attention in entry-level education than do speech, language and swallowing. Some respondents felt that the proportion of their programmes devoted to voice was too small. However, an equal number stated that the amount of their courses devoted to voice was about right because clients with voice disorders constitute a relatively small proportion of the caseloads in many clinical settings. A sense that voice problems are a lower priority than other conditions, particularly dysphagia, was also expressed by some respondents. The latter was not, however, a strong or consistent opinion from this group of academics.

Multiple methods of learning and teaching

Several methods are employed in all the courses. That is, no one approach is the dominant method of teaching. Traditional methods such as lectures, demonstrations, tutorials, skills and laboratory classes are combined with less traditional approaches such as problem-based and case-based learning, workshops, online teaching and simulation approaches. The most common methods used are lectures, demonstrations and case-based learning.

A range of diagnostic classifications for voice disorders

Diagnostic classifications for voice disorders are taught with all courses, drawing on multiple approaches to classification (most commonly, Aronson & Bless, 2009; Baker et al., 2007; Boone et al., 2005; Colton et al., 2006; Mathieson, 2001; Rammage et al., 2001; Verdolini et al., 2005). Most do not require that students use a particular published system.

Auditory-perceptual voice analysis system

The primary auditory-perceptual voice analysis system taught in all Australian courses is the Perceptual Voice Profile (Oates & Russell, 1998). However, students in all courses are also exposed to a range of other systems including CAPE-V (Kempster et al., 2009), GRBAS (Hirano, 1981), Stockholm Voice Evaluation Approach (Hammarberg & Gauffin, 1995), and the Buffalo III Voice Profile (Wilson, 1987). Students’ perceptual evaluation skills are formally assessed in most courses, normally via a listening test on standard voice samples.

Instrumentation for voice evaluation

A range of instrumentation for voice evaluation is used in all courses. Students are exposed to instrumentation though either hands-on practice or via demonstration. Exposure is greatest for commercially available acoustic analysis systems such as the KayPENTAX tools (e.g. Computerised Speech Laboratory), downloadable acoustic analysis programs such as PRAAT, andlaryngeal endoscopy and stroboscopy. Few courses provide experience with high-speed vocal fold imaging, electroglottography or aerodynamic analysis systems. The amount of exposure to instrumentation varies considerably, with a range of 1–7 hours. Although several academics stated that they had a good range of voice analysis tools, others expressed the desire to acquire further instrumentation, for increased technical support and for their students to be given greater access to instrumentation for practice in their own time. For a small number of respondents, the wish for greater access to instrumentation was tempered by the comment that by no means all clinicians in the field have access to instrumentation, the implication being that perhaps extensive training on instrumentation is not warranted in entry-level courses.

Wide range of voice therapy techniques

Various voice therapy techniques are covered in theory classes and demonstrations in all courses. Virtually every voice therapy technique documented in the literature is covered, including programmatic methods such as Lee Silverman Voice Therapy, Lessac–Madsen Resonant Voice Therapy and Vocal Function Exercises, holistic approaches such as the Accent Method, as well as the more recently promoted vocal tract semi-occlusion exercises. Specific hands-on training is provided, but for a limited number of techniques (mostly respiratory control exercises, head and neck relaxation, resonance methods and vocal endurance/flexibility techniques). While students in several courses are required to demonstrate basic competence in using one or two voice therapy techniques through a viva voce, this is not the case for every course and few courses require students to demonstrate competence in using more than one or two therapy methods. Several academics commented that intervention skills are mostly evaluated during clinical placements rather than during the theory course and that there is little time available in the theory course to assess students’ competence in voice therapy.

Clinical experience in voice

Clinical experience in voice practice is provided for most students in all courses, either in a specialist voice clinic (for up to 40% of students) or via general placements where clients present with voice problems in conjunction with their primary speech, language or swallowing problems (for 60–100% of students). For students who do not gain voice experience in their clinical placements, a standardised patient, video or simulated patient programme is implemented. Voice experience is gained mainly in health settings and university clinics with patients having a wide range of functional and organic voice disorders. Although paediatric clinical experience in voice is provided in several courses, adult experience is far more common.

Health promotion/prevention in the voice area

Prevention is important, therefore health promotion/prevention in the voice area is addressed in all courses. While not all programmes provide opportunities for every student to participate in health promotion/prevention activities, most students have the option to undertake a health promotion project as part of their theory course. They may also participate in health promotion activities while undertaking clinical placements, or observe an experienced clinician deliver voice care education and training to occupational voice users.

Opportunity for students to undertake training of their own voices

This type of experience is not common, but most respondents stated that they would like to provide students with such training. Three university programmes require all students to undergo a small amount (2–4 hours) of group training of their own voices. The main reason cited for not providing voice training to students was the lack of time in the curriculum. Most academics reported, however, that they notify students of any voice training workshops offered in the community and that they encourage students to participate.

Speech pathologists with substantial clinical and/or voice research expertise

Experienced speech pathologists are invited to teach the voice components of entry-level speech pathology courses in all universities. While half of the Australian university programmes have a voice expert on the staff, the remainder employ their voice teaching staff on a casual basis. The universities employing casual teaching staff do so because they have found it difficult to attract experienced individuals to substantive academic roles and/or because the programme has a relatively small student load that makes employing an academic with voice experience on a permanent basis less viable.

Research and evidence-based practice in voice

Research and evidence-based practice in voice are integrated and emphasised within all programmes. Several programmes also devote teaching time to evidence-based practice issues in voice through separate research-based subjects. In this case, the focus is usually on evidence for the effectiveness of voice therapy methods. The academics’ responses on their own opportunities to undertake research in the voice field were, however, more variable. Several academics reported that their positions provide considerable scope for them to undertake research; these academics were those employed in substantive positions. Those employed on a casual basis reported that there is limited opportunity for them to conduct research, although some do assist in the supervision of research students and one individual is able to undertake research outside her university role (through a government-funded centre for clinical research excellence).

In general, the academics responsible for voice education in Australian universities reported that their voice programmes are of high quality and that graduates have the strong theoretical understanding required for practice. They felt that the main factors contributing to the quality of education in voice are the extensive and current clinical experience of teaching staff, the explicit links made between theory and practice, the availability of good quality clinical case examples on DVD/video, and the high quality of the training provided in auditory-perceptual evaluation of voice. However, all of these academics stated that they would like to be able to provide increased opportunities for hands-on practice of voice therapy techniques and more clinical placements in voice for their students.

Post-Entry Level Practice

Specialisation in voice is not common among newly graduated speech pathologists in Australia. Instead, new graduates are encouraged to seek employment across a range of public sector settings including acute hospitals, rehabilitation centres, education departments, community and mental health services, and centres for children with hearing impairment and other disabilities. Although a substantial number of new graduates are interested in undertaking specialist voice practice, most do not commence such practice until they have several years of more general experience.

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