GRBAS and Cape-V Scales: High Reliability

and Consensus When Applied at Different Times

Katia Nemr, Marcia Simo~ es-Zenari, Gislaine Ferro Cordeiro, Domingos Tsuji, Allex Itar Ogawa,

Maysa Tiberio Ubrig, and Ma rcia Helena Moreira Menezes, S~ao Paulo, Brazil

Summary: Objectives. To evaluate whether the overall dysphonia grade, roughness, breathiness, asthenia, and
strain (GRBAS) scale, and the Consensus Auditory Perceptual EvaluationVoice (CAPE-V) scale show the same
reliability and consensus when applied to the same vocal sample at different times.
Study Design. Observational cross-sectional study.
Methods. Sixty subjects had their voices recorded according to the tasks proposed in the CAPE-V scale. Vowels /a/
and /i/ were sustained between 3 and 5 seconds. Reproduction of six sentences and spontaneous speech from the request
Tell me about your voice were analyzed. For the analysis of the GRBAS scale, the sustained vowel and reading tasks
of the sentences was used. Auditory-perceptual voice analyses were conducted by three expert speech therapists with
more than 5 years of experience and familiar with both the scales.
Results. A strong correlation was observed in the intrajudge consensus analysis, both for the GRBAS scale as well as
for CAPE-V, with intraclass coefficient values ranging from 0.923 to 0.985. A high degree of correlation between the
general GRBAS and CAPE-V grades (coefficient 0.842) was observed, with similarities in the grades of dysphonia
distribution in both scales. The evaluators indicated a mild difficulty in applying the GRBAS scale and low to mild dif-
ficulty in applying the CAPE-V scale. The three evaluators agreed when indicating the GRBAS scale as the fastest and
the CAPE-V scale as the most sensitive, especially for detecting small changes in voice.
Conclusions. The two scales are reliable and are indicated for use in analyzing voice quality.
Key Words: Voice disordersPerceptual ratingsVoice qualityReliabilityGRBASCAPE-VClinician ratings of
voice quality.

INTRODUCTION clinicians and researchers, whereas the Consensus Auditory

The auditory-perceptual evaluation of voice is one of the most
traditional approaches used to analyze voice quality. The evalu-
ation is based on the auditory impression of the evaluator when
listening to altered and nonaltered voices, and then it is further
compared with physiological findings by a speech therapist.
These aspects, added to the patients complaints, history of dys-
phonia, and vocal self-evaluation enable the speech therapist to
plan a series of activities aimed at improving the life quality of
people with vocal disorders.
Auditory-perceptual evaluation is a highly valued procedure
used worldwide1,2 and is often regarded as the gold standard for
voice disorder documentation.3 However, the evaluation de-
pends on the experience and training level of the evaluator.4
The use of evaluation tools, in which predetermined parameters
and scales are adopted, is therefore aimed at reducing potential
variability and inconsistencies in this analysis.3
The GRBAS scale, which assesses overall dysphonia
grade, roughness, breathiness, asthenia, and strain,5,6 is used
worldwide in several fields as a means of vocal evaluation by
Accepted for publication March 16, 2012.
This manuscript was reviewed by a professional scientific editor and by a native English-
speaking copy editor to improve its readability.
From the School of Medicine, University of S~ao Paulo, S~ao Paulo, Brazil.
Address correspondence and reprint requests to Katia Nemr, Department of Physiother-
apy, Communication Science & Disorders, Occupational Therapy, School of Medicine,
University of S~ao Paulo, Rua Cipot^anea, 51, CEP 05360-000, Cidade Universitaria, S~ao
Paulo, Brazil. E-mail: knemr@usp.br
Journal of Voice, Vol. 26, No. 6, pp. 812.e17-812.e22
0892-1997/$36.00
2012 The Voice Foundation
doi:10.1016/j.jvoice.2012.03.005
Perceptual EvaluationVoice (CAPE-V)7,8 also enables the
analysis of the same parameters analyzed with the GRBAS
scale, except asthenia. Additionally, CAPE-V adopts a visual an-
alog scale and has predetermined vocal tasks and analysis criteria.
It also evaluates pitch and loudness and enables the addition of
two more parameters that are not predetermined, besides allowing
classification of resonance and inclusion of additional features.
GRBAS considers the severity of a vocal disorder along a scale
divided in regular intervals, whereas the CAPE-V scale has an
asymmetric distribution representing mild, moderate, and severe
dysphonia. Both scales are widely used by professionals in the
voice field and together they cover all types of voice disorders,
regardless of etiology. These include Parkinsons disease,9 larynx
cancer,10,11 granuloma,12 glottis insufficiency,13 and Reinkes
edema.14
The GRBAS scale is reliable and valid and offers no discom-
fort or inconvenient to the patient or the therapist.15 Neverthe-
less, its sensitivity in detecting vocal alterations is lower than
that observed with CAPE-V, probably because GRBAS is an or-
dinal scale with only three alternatives (mild, moderate, and se-
vere). Indeed, GRBAS has been shown to be less sensitive than
CAPE-V to evaluate more subtle differences in vocal quality.16
On the other hand, CAPE-V represents a shift in the auditory-
perceptual evaluation of voice.17,18 Its greater sensitivity in
detecting small differences in the voice, as compared with
GRBAS, has been attributed to its visual analog scale for
recording the alteration perception.7,8,19 A slightly improved
rater reliability using the CAPE-V to make perceptual judg-
ments of voice quality, in comparison with the GRBAS scale,
has also been reported.18
Katia Nemr, et al Reliability And Consensus of GRBAS and Cape-V Scales
CAPE-V has been increasingly used both for research and for
clinical practice.17 Nevertheless, because CAPE-V is a more re-
cent tool than GRBAS, further research is needed to deter-
mine the consistency in the assessment produced by these
two scales. A previous study that correlated data from both
scales, applied at the same time, revealed an agreement
among evaluators and a positive correlation between the se-
verity grade of CAPE-V and the overall grade of GRBAS.19
Karnell et al19 proposed, however, that further research
should be conducted to determine the consistency between
the two protocols when applied at different times, as the
application of one scale may affect the results obtained
when the second scale is applied. The application of the
two scales at different times may thus provide the evaluator
with the necessary temporal distance to ensure the reliability
of the test.
In this study, whether these two voice-related auditory-
perceptual evaluation scales show the same reliability and
consensus when applied on the same vocal sample at different
times was evaluated. The correlation between the two scales
was determined considering the severity grade of CAPE-V
and the overall grade of GRBAS. The degree of intra- and inter-
judge agreement was also measured. Additionally, if
the Portuguese translation of the CAPE-V scale2022
produces results consistent with those in which this scale was
used in its original language was examined, thus determining
the validity of its use independently of cultural and language
differences.
METHOD
The study was approved by the Ethics Committee of the home
institution (protocol 0481/08).
An observational cross-sectional design with a sample size of
60 subjects was used (Table 1). Of these, 50 patients had vocal
disorders and dysphonia diagnosis, as determined by profes-
sionals at the Otorhinolaryngology Clinic, Hospital das Clini-
cas, Medical School, University of S~ao Paulo, S~ao Paulo,
Brazil. Ten volunteers (control group) were also selected
among students and patient companions who had no vocal com-
plaints, dysphonia, or laryngeal disorders to enable testing both
scales in the absence of vocal alterations.
TABLE 1.
Distribution of Subjects by Age and Classification of
Dysphonia
Age (y) N Classification of Dysphonia N nosis or the fact that individuals with no alteration in voice were
1129 18 Without dysphonia 10
3039 15 Functional dysphonia 10
4049 9 Organofunctional dysphonia 21
5059 5 Organic dysphonia 19
6069 5 Total 60
7079 2 in the speech therapy clinic (very feasible, feasible, somewhat
80 6 feasible, or not feasible).
Total 60
812.e18
Patients with different laryngeal diagnoses were selected re-
gardless of gender or age and classified into three dysphonia
categories: functional, organofunctional, or organic.23 Individ-
uals with limited ability to communicate or to be understood
were excluded. All participants signed an informed consent.
Vocal register
All subjects had their voices recorded according to the tasks
proposed in the CAPE-V protocol,7,8 using the translation
into Portuguese proposed by Behlau.20 The reading of six sen-
tences and spontaneous speech following the request Tell me
about your voice were analyzed. For the analysis using the
GRBAS scale, the sustained vowel and reading tasks of the sen-
tences was used.
Vocal emissions were recorded in a Sound Forge 6.0 program
(Sonic Foundry Inc., Madison, WI), using a Sennheiser brand
(model PC-20) headset microphone (Sennheiser, Wedemark,
Germany), positioned about 2 in. from the labial commissure
of the subject. All recordings were made in an acoustically
treated room, with noise below 50 dB.
Auditory-perceptual voice evaluation
The auditory-perceptual voice analysis was conducted by three
expert speech therapists with more than 5 years of experience
and familiar with both the scales.
The final voice sample included the voices of all 60 indi-
viduals with 10% random repetition to enable the intrajudge
reliability analysis. Voice recordings were stored in two
different sequences where the order of the voices in each
sample was established randomly. On one sequence, the
GRBAS scale was applied (Appendix 1), and on the other,
the CAPE-V (Appendix 2) was applied with a 7-day inter-
val from the first evaluation done with GRBAS. The voices
were reproduced to the evaluators in a quiet room, through
speakers connected to the computer, and were released in
three blocks of 20 voices each, with a 10-minute interval
between consecutive blocks.
Although the evaluators had experience with both the
scales, each evaluator received a review of the guiding param-
eters and concepts68 of each scale before the evaluation to
ensure high reliability of the evaluations performed by these
professionals.
After listening to each voice, each evaluator conducted the
analysis individually and no information was shared among
evaluators. Each vocal sample could be listened one more
time on request. Evaluators were not aware of the patient diag-
included in the sample, as this could compromise their
judgment.2
In the end of each evaluation, evaluators were asked to indi-
cate the level of difficulty associated with each scale (high,
moderate, mild, or absent) and the feasibility of using the scale
The flowchart below shows all steps taken to evaluate the two
scales in this study.
812.e19 Journal of Voice, Vol. 26, No. 6, 2012

Laryngostroboscopy Evaluation
TABLE 2.
Intrajudges Intraclass Correlation Coefficients for the G
Control Group: Study group: of GRBAS and General Grade of CAPE-V
participants without vocal disorders participants with vocal disorders and
laryngeal diagnoses 95% Confidence
Interval
Intraclass
Vocal assessment of all participants Correlation Lower Upper
JudgeVariable Coefficient Limit Limit
Evaluators Analysis of voice
recordings through the GRBAS scale
J1 GGRBAS 0.935 0.536 0.991
J1 General Grade 0.927 0.478 0.990
Interval of 7 days CAPE-V
Evaluators Analysis of voice
J2 GGRBAS 0.923 0.450 0.989
recordings through the CAPE-V J2 General Grade 0.985 0.892 0.998
Preparation of the database with
CAPE-V
the analysis of the evaluators J3 GGRBAS 0.935 0.536 0.991
J3 General Grade 0.947 0.619 0.993
Comparisons from the analysis of the evaluators: CAPE-V
1. intra-judges GRBAS and CAPE-V Abbreviations: GRBAS, grade, roughness, breathiness, asthenia, and
strain; CAPE-V, Consensus Auditory Perceptual EvaluationVoice.
2. inter-judges GRBAS and CAPE-V

3. GRBAS vs CAPE-V

in the intrajudge consensus analysis, both for the GRBAS scale

Data analysis
Data analysis was performed using the SPSS program, version
17.0 (Statistical Package for the Social Science; SPSS Inc.,
Chicago, IL), and a 5% significance level. To determine intra-
judge consensus grade (intraclass correlation coefficient calcu-
lation), the general vocal alteration grade both from GRBAS
and from CAPE-V was used. For interjudge analysis (intraclass
correlation coefficient calculation), the following parameters:
overall grade, roughness, breathiness, and tension were used
from both the scales.
We analyzed the correlation (Spearman-rank correlation test)
between the overall GRBAS grade and the CAPE-V severity
score as proposed by Karnell et al.19
and for CAPE-V, with intraclass coefficients ranging from
0.923 to 0.985 (Table 2). A high correlation was also observed
in the interjudge analysis for all variables (Table 3).
In terms of interscale correspondence, a strong correlation
between the overall GRBAS grade and the CAPE-V severity
grade was observed (coefficient 0.842; Figure 1), with simi-
larities in the grades of dysphonia distribution in both scales
(Table 4).
The evaluators indicated a mild difficulty in applying the
GRBAS scale and low to mild difficulty in applying the
CAPE-V scale. Both scales were considered viable or very
viable for use. The three evaluators agreed when indicating
the GRBAS scale as the fastest and the CAPE-V scale as the
most sensitive, especially for detecting small changes in voice.

RESULTS DISCUSSION
Subjects were between 11 and 85 years old, and 72% were The high levels of intra- and interjudge consensus obtained for
women and 28% were men. A strong correlation was observed the GRBAS and CAPE-V scales emphasize their reproducibility

TABLE 3.
Interjudges Analysis for Both Protocols
95% Confidence Interval
Intraclass Correlation
Protocol Variable Coefficient Lower Limit Upper Limit
GRBAS G 0.881 0.817 0.925
R 0.829 0.737 0.892
B 0.867 0.796 0.916
S 0.793 0.683 0.870
CAPE V General grade 0.911 0.864 0.944
Roughness 0.870 0.800 0.918
Breathiness 0.897 0.841 0.935
Tension 0.828 0.735 0.891
Abbreviations: GRBAS, grade, roughness, breathiness, asthenia, and strain; CAPE-V, Consensus Auditory Perceptual EvaluationVoice.
Katia Nemr, et al Reliability And Consensus of GRBAS and Cape-V Scales 812.e20

thus being suitable for more complete evaluations and conse-

80
60
40
20
0
FIGURE 1. Graphic representation for correlation among the overall
alteration grades obtained by CAPE-V Protocol and GRBAS Scale
(Spearman r 0.842). The various symbols represent individual
CAPE-V and GRBAS data points. The bold X represents the mean
CAPE-V ratings for each level of the GRBAS scale. The line formed
by the means shows the linearity of the relationship. GRBAS, grade,
roughness, breathiness, asthenia, and strain; CAPE-V, Consensus Audi-
tory Perceptual EvaluationVoice.
and validity for clinical use, as similarly observed in other pub-
lications,915,18,19,24 and support their continued use. These
findings indicate that either scale can be chosen depending on
the specific goals of assessment and the time and conditions
available for data collection.
Although high in both cases, the interscale correlation found
by Karnell et al19 was higher than that found in the present study
(0.95 vs 0.842). This difference may reflect a reduction in the
crossover effect or may be related to the size of the sample in
each study (130 in the Karnell et al19 study and 60 in the present
study). In the present study, however, each scale was used by the
same evaluator at a different time, and voices were reproduced
randomly, making it unlikely that evaluations were affected by
crossover effects.
Although our results support the idea that both scales are suit-
able for any context where voice-related auditory-perceptual
evaluation is relevant,15 CAPE-V includes the assessment of ad-
ditional parameters (pitch, loudness, two further parameters,
resonance classification, and display of additional features),
quently a broader understanding of vocal patterns. The presence
of predefined procedures for data collection and evaluation also
facilitates its implementation and documentation of samples, al-
lowing greater exchange of information between experts. This is
especially relevant in view of the fact that the CAPE-V scale has
not yet been widely used in many countries, so our results en-
courage its use. Owing to its great applicability, the use of the
GRBAS scale should not be, however, interrupted. Indeed, all
evaluators were unanimous in stating that both scales meet the
needs of voice auditory-perceptual evaluation and that they
can be selected according to specific requirements. The GRBAS
scale provides more promptitude and objectivity, with focus on
the glottic level, regardless of sample type, whereas the CAPE-V
scale considers more detail and analytical parameters, with pre-
defined voice sample collection and evaluation.
In this study, the Portuguese-translated version of CAPE-V20
was used, similarly to some previous studies.21,22 The fact that
our findings are similar to those in which the scale was used in
its original language helps validate the Portuguese-translated
version of the CAPE-V scale and supports the idea that the scale
can be used in different populations, regardless of cultural and
language differences.
Professional experience depends on the quality of practice
and time dedicated to it. Therefore, exposure to auditory-
perceptual analysis should be reinforced in speech therapist
qualification. In a study carried out with undergraduates, audi-
tory training involving the GRBAS scale improved the stu-
dents initial skills and prepared them better to perform
evaluations.25 Considering the potential for the increased use
of the CAPE-V scale as based on the present findings, it remains
to be determined whether these latter results are also valid for
CAPE-V. It is also necessary to develop a curriculum for grad-
uate students, which includes theory and hands-on training
focusing on both scales.

TABLE 4.
Distribution of Findings According to the Classification of GRBAS Scale General Grade in Relation to the Score Regarding
Severity Grade of CAPE-V Protocol
General Grade CAPE-V N G0 G1 G2 G3
0 0 0 0 0 0
19 0 0 0 0 0
1019 4 0 3 1 0
2029 9 0 7 2 0
3039 9 0 5 4 0
4049 3 0 0 3 0
5059 9 0 0 9 0
6069 8 0 0 6 2
7079 7 0 0 5 2
8089 8 0 0 0 8
9099 3 0 0 0 3
100 0 0 0 0 0
Total 60 0 15 30 15
Abbreviations: GRBAS, grade, roughness, breathiness, asthenia, and strain; CAPE-V, Consensus Auditory Perceptual EvaluationVoice.
Bold values indicate numeric distribution equivalence of general classification of GRBAS grade scale and the score regarding severity grade of CAPE-V
protocol.
812.e21
Finally, it should be noted that the high correlation levels
found in this study refer to those parameters common to both
scales (namely GRBAS overall grade and CAPE-V severity
grade). Still, voice auditory-perceptual evaluation is part of
the multidimensional evaluation process,15 so possible associa-
tions among voice auditory-perceptual, physiological, and
acoustic parameters may also provide valuable information to
researchers in this field.
CONCLUSION
There is high reliability and consensus between the GRBAS and
CAPE-V scales, supporting the idea that they can be both used
in any situation in which voice-related auditory-perceptual
evaluation is relevant. Both scales meet the needs of voice
auditory-perceptual assessment and can be selected depending
on specific practical, clinical, or research requirements.
REFERENCES
1. Saenz-Lech on N, Godino-Llorente JI, Osma-Ruiz V, Blanco-Velasco M,
Cruz-Roldan F. Automatic assessment of voice quality according to the
GRBAS scale. Conf Proc IEEE Eng Med Biol Soc. 2006;1:24782481.
2. Eadie T, Sroka A, Wright DR, Merati A. Does knowledge of medical diag-
nosis bias auditory-perceptual judgments of dysphonia? J Voice. 2011;25:
420429.
3. Oates J. Auditory-perceptual evaluation of disordered voice quality: pros,
cons and future directions. Folia Phoniatr Logop. 2009;61:4956.
4. Eadie TL, Baylor CR. The effect of perceptual training on inexperienced
listeners judgments of dysphonic voice. J Voice. 2006;20:527544.
5. Isshiki N, Olamura M, Tanabe M, Morimoto M. Differential diagnosis of
hoarseness. Folia Phoniatr (Basel). 1969;21:923.
6. Hirano M. Clinical Examination of Voice. New York, NY: Springer-Verlag;
1981.
7. ASHA. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)
Special Interest Division 3, Voice and Voice Disorders. Available at:
http://www.asha.org. Accessed June 18, 2010.
8. Kempster GB, Gerratt BR, Abbott KV, Barkmeier-Kraemer J, Hillman RE.
Consensus Auditory-Perceptual Evaluation of Voice: development of a stan-
dardized clinical protocol. Am J Speech Lang Pathol. 2009;18:124132.
9. Midi I, Dogan M, Koseoglu M, Can G, Sehitoglu MA, Gunal DI. Voice
abnormalities and their relation with motor dysfunction in Parkinsons dis-
ease. Acta Neurol Scand. 2008;117:2634.
Journal of Voice, Vol. 26, No. 6, 2012
10. Dedivitis RA, Queija DS, Barros AP, et al. The impact of the glottic config-
uration after frontolateral laryngectomy on the perceptual voice analysis:
a preliminary study. J Voice. 2008;22:760764.
11. Torrejano G, Guimar~aes I. Voice quality after supracricoid laryngectomy
and total laryngectomy with insertion of voice prosthesis. J Voice. 2009;
23:240246.
12. Lin DS, Cheng SC, Su WF. Potassium titanyl phosphate laser treatment of
intubation vocal granuloma. Eur Arch Otorhinolaryngol. 2008;265:
12331238.
13. Dursun G, Boynukalin S, Bagis Ozgursoy O, Coruh I. Long-term results of
different treatment modalities for glottic insufficiency. Am J Otolaryngol.
2008;29:712.
14. Dursun G, Ozgursoy OB, Kemal O, Coruh I. One-year follow-up results of
combined use of CO2 laser and cold instrumentation for Reinkes edema
surgery in professional voice users. Eur Arch Otorhinolaryngol. 2007;
264:10271032.
15. Carding PN, Wilson JA, MacKenzie K, Deary IJ. Measuring voice out-
comes: state of the science review. J Laryngol Otol. 2009;123:823829.
16. Wuyts FL, De Bodt MS, Van de Heyning PH. Is the reliability of a visual
analog scale higher than an ordinal scale? An experiment with the GRBAS
scale for the perceptual evaluation of dysphonia. J Voice. 1999;13:508517.
17. Solomon NP, Helou LB, Stojadinovic A. Clinical versus laboratory ratings
of voice using the CAPE-V. J Voice. 2011;25:e7e14.
18. Zraick RI, Kempster GB, Connor NP, et al. Establishing validity of the Con-
sensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Am J Speech
Lang Pathol. 2011;20:1422.
19. Karnell MP, Melton SD, Childes JM, Coleman TC, Dailey SA,
Hoffman HT. Reliability of clinician-based (GRBAS and CAPE-V) and
patient-based (V-RQOL and IPVI) documentation of voice disorders.
J Voice. 2007;21:576590.
20. Behlau M. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V),
ASHA 2003. [Refletindo sobre o novo]. Rev Soc Bras Fonoaudiol. 2004;9:
187189.
21. Menezes MHM, Ubri-Zancanella MT, Cunha MG, Cordeiro GF, Nemr K,
Tsuji DH. The relationship between tongue trill performance duration
and vocal changes in dysphonic women. J Voice. 2011;25:e167e175.
22. Ubrig MT, Goffi-Gomes MVS, Weber R, Menezes MHM, Nemr NK,
Tsuji DH, Tsuji RK. Voice analysis of postlingually deaf adults pre- and
postcochlear implantation. J Voice. 2011;25:692699.
23. Behlau M. Voice. The book of the specialist. Vol 2. Rio de Janeiro,
Brazil: Revinter; 2001.
24. Kazi R, Kanagalingam J, Venkitaraman R, et al. Electroglottographic and
perceptual evaluation of tracheoesophageal speech. J Voice. 2009;23:
247254.
25. Silva RSA, Sim~oes-Zenari M, Nemr NK. Impact of auditory training for
perceptual assessment of voice executed by undergraduate students in
Speech-Language Pathology. J Soc Bras Fonoaudiol. 2012;24:1925.
Katia Nemr, et al Reliability And Consensus of GRBAS and Cape-V Scales 812.e22

APPENDIX 1

CAPE-V Form

APPENDIX 2

GRBAS Scale

GRBAS Scale

Protocol number:_________ Voice number: ___________ Date: ____ / _____/ ______

G____ R____ B____A____S____