Articulo 2

Volume 11 ⧫ Issue 1 ⧫ Winter 2021
eHearsay
eHearsay: Electronic Journal of the Ohio Speech-Language Hearing Association
Past and Current Experiences of Voice Handicap Symptoms of

Four Participants with Parkinson Disease
Zoë Sommers, Angela E. Reif & Susan Ruhlin
Abstract
Background: Voice symptoms associated with dysarthria are widely prevalent in individuals with Parkinson Disease (PD). Across
populations of individuals with voice disorders, perceived symptoms of voice deficits along physical, functional, and emotional
domains, are often measured using The Voice Handicap Index (VHI). Although some studies have reported the influence of voice
symptoms on psychosocial function in individuals with PD using the VHI, specific details of how psychosocial function is affected in
individuals with PD are lacking.
Methods: The current pilot study utilized an alternative administration of the VHI that included an oral, discussion-based, group
administration of the VHI items to examine descriptions of voice symptoms affecting four individuals with PD. These descriptions
were categorized by themes developed by two of the study’s authors.
Results: Results of discussion comments revealed six themes that were illustrated by participants’ discussion of the VHI items. These
themes and their implications for speech therapy are discussed.
Zoë Sommers, B.A., is a graduate student in the School of Speech-Language Pathology and Audiology at the University of Akron.
Financial – No relevant financial relationship exists
Nonfinancial - No relevant nonfinancial relationship exists
Angela E. Reif, Ph.D., CCC-SLP is employed at the University of Akron.
Financial – Assistant Professor in the School of Speech-Language Pathology and Audiology at the University of Akron.
Susan Ruhlin, M.A., CCC-SLP is employed at the University of Akron.
Financial – is an Associate lecturer and Clinical Supervisor in the School of Speech-Language Pathology and Audiology at the University of Akron.
Learning Objectives
1. Describe three voice deficits in Parkinson disease (PD).
2. Describe frequently reported symptoms of voice deficits in PD, as measured by the Voice Handicap Index (VHI).
3. Describe the implications of using a group discussion-based administration of the VHI for treatment planning
Parkinson Disease (PD) is a progressive disorder which causes a loss of neurons in a subcortical structure, the substantia
nigra. The loss of these neurons results in a shortage of dopamine that is needed for the basal ganglia to contribute to
normal motor movement (Seikel, et al., 2015). Disruption in basal ganglia function affects muscle movement
throughout the body, which is often evident in symptoms of bradykinesia (slowness of movement) and one or more
additional symptoms, such as rest tremor, rigidity or postural instability (Yarnall et al., 2012). Additionally, clients with
PD typically present with cognitive decline as well, such as slowed processing and tip-of-the-tongue phenomenon
(Jankovic, 2008; Yarnall et al., 2012). Although there is no determined cause of PD, research suggests that genetic and
environmental factors may have an influence on its development (Goldman et al., 2012; Satake et al., 2009).
Most individuals with PD begin experiencing symptoms sometime around 55-75 years of age, although earlier onset of
the disease is possible (Jankovic, 2008). Sex can also have an influence on a person’s susceptibility to PD as the disease
is more common in men (De Rijk et al., 1995). However, when considering the effects of PD on patients, it is important
| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 10
to recognize the influence of individual differences within this population. For example, patients sharing this diagnosis
vary in sex, age of onset, disease progression, type of symptoms, and range of severity in their symptoms (Gibbins et al.,
2017).
Consequences of PD on the Speech Mechanism

As PD affects muscle functioning, the muscles responsible for typical functioning of the speech mechanism are no
exception. Dysarthria, a speech disorder due to a neurological disruption in muscular control of the speech articulators,
and speech dysfluencies are often experienced by individuals with PD (Goberman et al., 2010; Logemann et al., 1978;
Tjaden, 2008). Since PD can affect musculature in a variety of ways, leading to symptoms such as rigidity, slowness of
movement, or tremor, affected components of the speech system may result in variant symptoms and severity (Ruddy &
Sapienza, 2003). Some prevalent voice symptoms associated with PD include reduced vocal intensity, pitch changes, and
monotony of speech (Ramig et al., 1995; Scott & Caird, 1983). Other common voice symptoms include hoarse, breathy
voice quality resulting from partial or inconsistent vocal fold adduction (Baumgartner et al., 2001; Gallena et al., 2001).
Additionally, individuals with PD often demonstrate deficits with precise articulation. Effective articulation requires
accurate and rapid muscle movements to manipulate the jaw, tongue, lips, and soft palate in order to produce target
phonemes. However, individuals with PD have been found to demonstrate reduced velocities in movement of the
speech articulators, including the lips (Forrest et al., 1989) and tongue (Walsh & Smith, 2012). Additionally, articulatory
measures related to range of movement of speech articulators have been found to be reduced in PD relative to healthy
adults (McRae et al., 2002; Tjaden & Wilding, 2004; Whitfield & Goberman, 2014).
As each subsystem of speech may be affected in PD, it is understandable why an individual with PD may experience
trouble communicating effectively. “At least 75% of the…patients with PD have a speech disorder that may limit their
ability to function fully in society,” (Ramig et al., 1995, p. 1232). Furthermore, depression and social isolation are
common in those with PD (Scott & Caird, 1983). Thus, this disorder can heavily interfere with a person’s quality of life as
the ability to communicate connects one to family, friends, and one’s community.
Assessment of Voice in PD
A number of assessment tools are useful in examining voice in PD and commonly include acoustic and aerodynamic
measurement, perceptual assessment of voice function, and examination of the laryngeal mechanism. Additionally, self-
rating scales of voice symptoms and voice symptom severity may be administered to assess clients’ perceived quality of
life related to voice function and to examine the psychosocial impact of voice symptoms (Hogikyan & Sethuraman,
1999). These assessment tools are also often useful in measuring functional progress in rehabilitation programs
(Jacobson et al., 1997).
Voice Handicap Index

Among the assessment tools used in clinical assessment of voice to examine the psychosocial influence of voice
disorders, the Voice Handicap Index (VHI) has been found to have good validity, with moderately strong construct
validity between patients’ self-rating of voice severity and VHI scores (Jacobson et al., 1997). Additionally, the VHI has
been found to have strong test-retest reliability for total score (r=0.92; Jacobson et al., 1997) within populations of
individuals with voice disorders. The VHI allows for quantitative measurement of voice handicap severity. This
assessment tool was developed with participants with voice disorders from a broad range of etiologies with diagnoses
including mass lesions, laryngectomy, musculoskeletal tension, inflammation, atypical, as well as neurogenic diagnoses
(Jacobson et al., 1997). The items included in the VHI were developed from case history interviews from individuals
within these populations, and thus indicate voice symptoms from a broad range of voice disorders.

VHI in PD. The VHI has also been found to be a valid tool to quantitatively assess psychosocial symptoms of voice in PD
(Guimaraes et al., 2017). A number of studies have used the VHI assessment to examine voice symptoms in PD (e.g.,
Majdinasab et al., 2012; Gibbins et al., 2017). For example, Blumin et al. (2004) found some patients with PD (7 of 14
patients) considering deep brain stimulation surgery had a total VHI score indicative of severe impairment. Majdinasab
et al. (2012) found the severity of PD, measured by the Unified Parkinson Disease Rating Scale-III, to be correlated with
scores within the physical, emotional, and functional domains of the VHI. Furthermore, Gibbins et al. (2017) found that
64.3% of individuals with PD had severe voice handicap, as measured by the VHI, although the scores of the sixteen
individuals with PD in the study had a wide range (5 to 33; higher scores reflecting more severe impairment).
This assessment tool is also often used to examine the effect of various types of therapy on voice symptoms of
individuals with PD. For example, Elefant et al. (2012) found improved VHI scores following twenty weekly music
therapy sessions in 10 individuals with PD, although significant improvement was only found in the physical domain.
Additionally, the Lee Silverman Voice Treatment (LSVT®) program, developed by Ramig et al. 1987 (as cited in Ramig et
al., 2001), has also been found to improve scores on the VHI across domains (physical, functional, and emotional; e.g.,
Wight & Miller, 2015). Of note, however, Wight and Miller (2015) did not find useful clinical gain (defined as > 18 point
gain in raw VHI scores) in nine of the thirty-three participants who participated in their study.
Summary and Purpose of the Study

Overall, the VHI is a useful tool to examine functional, physical and emotional symptoms related to voice symptoms
across etiologies of voice disorders, including PD (e.g., Guimaraes et al. 2017). In voice therapy, the VHI is often used to
establish baseline symptoms and progress in voice therapy (e.g., Blumin et al., 2004; Elefant et al., 2012; Wight & Miller,
2015). However, there may be a wide range of severities of voice symptoms in PD (e.g., Gibbins et al., 2017).
Additionally, some individuals do not experience clinically useful gains (defined as >18 point gain in raw VHI score) in
voice disorder severity as measured by the VHI with treatment (Wight & Miller, 2015). Furthermore, dependent on the
type of voice therapy provided, those that do make gains in voice therapy may only present with significant
improvement as measured by the VHI within a single domain of voice symptoms (Elefant et al., 2012). Taken together,
these findings suggest that determining the specific psychosocial symptoms of individuals with PD participating in group
voice therapy may be improved by discussion data provided by individuals with PD in order to better understand the
psychosocial effects of voice deficits.
Previous research has reported the VHI scores of individuals with PD and the relationships of disease factors (such as
severity) and of treatment to VHI scores along the physical, functional and emotional domains (Majdinasab et al., 2012;
Wight & Miller, 2015). However, to the authors’ knowledge, no study has reported any qualitative comments from
participants with PD related to the VHI items. Thus, the purpose of the current pilot study was to gain a deeper
understanding of how voice symptoms influence participants’ daily lives using participant percent agreement with items
and discussion-based reporting of VHI items. The current pilot study utilized an oral, discussion-based, group
administration of the VHI within a group of four participants with PD to: (1) determine these individuals’ agreement of
presence of symptoms within the VHI and to; (2) provide descriptions of how these symptoms have influenced or
continue to influence participants’ lives. The results of this pilot study are important for informing treatment plans to
target individual group member’s specific psychosocial symptoms and may be relevant to other clinicians when
conducting group therapy with individuals with PD.
Methods
Four individuals (all male) that participate in The University of Akron’s Voice Clinic for PD took part in this group
discussion-based administration of the VHI. The Institutional Review Board at The University of Akron approved use of
data from the voice clinic for the study. Prior to the group discussion-based administration of the VHI, the administrator
explained the purpose of the VHI. It is important to note that only statements #1-28 from the VHI were included in the
group discussion, leaving out two statements focusing on the emotional consequences of a voice disorder. These two
items were not included in order to avoid emotional discomfort within the discussion, as these items asked participants
to relate feelings of incompetence and shame due to their voice.
The VHI was administered over two separate sessions held one week apart from each other. As each item was read
aloud for the group, participants were instructed to raise their hands if they felt that a statement applied to their
situation. After each statement, the administrator allowed time for participants to discuss their decision to agree or
disagree. By using discussion and indication of agreement rather than requiring written responses, this format was
considerate of any fine motor deficits. The first author of the paper took de-identified notes on participants’ comments
within the discussion of each of the items. This administration of the VHI presented an opportunity for participants not
only to report symptoms and their severity, but also to share their own views surrounding their voice impairments and
how these impairments affect them in their daily lives.
Thematic Analysis
Two of the study’s authors analyzed participants’ comments in order to develop a total of six themes that best captured
participants’ comments. To develop the themes, the second author read comments and developed a theme for each
comment. Next, the first author also read participants’ comments and developed a theme for each comment. The
second author then considered both authors’ themes to create a final set of themes that best reflected participants’
comments and that best incorporated both authors’ themes. For example, in the development of themes completed
independently by the authors, the second author included the theme, ‘Participation restriction’ for an item’s comments.
For this same item’s comments, the first author had developed the theme, ‘Social consequences.’ Upon reviewing both
themes, the second author created the theme, ‘Social and/or vocational participation restrictions,’ as it incorporated
both authors’ main theme, reflected the participant’s comment, and reflected other comments from other VHI items.
Using this method of theme development, a consensus was reached on the new themes by both authors, once the first
author reviewed the new themes and indicated 100% agreement with them.
Results
The results of this discussion-based administration of the VHI illustrate the views of participants’ voice symptoms that
they experience in their day-to-day lives due to their voice impairments (Table 1). Seventy-five percent of participants
agreed with eleven of the twenty-eight statements from the VHI. Five of the statements read to the group exhibited
100% agreement among the participants (3 Functional domain [F1, F5, F12], 1 Physical domain [P18], and 1 Emotional
domain [E24]), while six of the statements presented had 75% agreement, (4 Physical, 2 Emotional). Together, three of
the ten items from the functional domain; three of the eight items from the emotional domain; and five of the ten items
from the physical domain had 75% or more agreement. See Table 1 for discussion results; see Appendix for VHI items,
numbers and domains.
Discussion themes
The discussion component of the VHI uncovered six themes that related to participants’ discussion of their perceived
voice symptoms. As indicated by the first theme, participants reported physical symptoms, unrelated to voice. The
second theme related to several voice symptoms which were reported. Furthermore, social and vocational participation
restrictions (theme 3), social effects on family and others (theme 4), use of compensatory strategies during
communication (theme 5) and effects on participants’ communication interactions (theme 6) were reported. Of note,
although compensatory strategies used during communication might affect participants’ communication interactions,
these themes were divided into two separate themes to reflect the separation of comments related to perceived
feelings of participants related to communication interactions and participants’ reflections on communication partners
responses within interactions (theme 6) versus participants’ use of specific compensatory strategies for speech (theme
5). See Table 2 for details of comments and number of participants commenting on each theme.

Table 1. Voice Handicap Index Results

Domain Item Percent Client Discussion
Number Agreement
Functional 1 100% N/A
Physical 2. 50% One client shared that he compensates by repeating himself. Another client shared that he had to
quit his job as a pastor because it became too difficult for him.
Functional 3. 50% One client shared that he had trouble hearing in this setting and experienced trouble
understanding others.
Physical 4. 75% One client expressed that the sound of his voice depends on the time of day and can often be
unpredictable. Another client shared that his voice is the strongest in the morning and grows
softer around noon as his medications wear off.
Functional 5. 100% N/A
Functional 6. 25% One client shared that he used to enjoy using the telephone, but not anymore.
Emotional 7. 75% N/A
Emotional 9. 25% One client shared that his wife gets frustrated with him because of his voice.
Physical 10. 25% One client shared that in these situations, his best advice is to be upfront and explain so that
others can understand.
Functional 11 0% N/A
Functional 12. 100% One client expressed that he has been asked to speak louder because others want to hear him.
Another client commented that speaking loudly requires more effort than you think you need.
Sometimes you feel as if you’re yelling. Another client shared that he notices that he speaks softer
when he is unsure.
Physical 13. 25% One client shared that he has trouble speaking after a long period of silence.
Physical 14. 75% One client expressed that he experiences voice strain in crowded areas. Another client shared that
he struggled with inflection.
Emotional 15. 50% One client shared that this misunderstanding includes his wife along with other people. People
often think strictly about the physical signs of Parkinson’s Disease.
Functional 16. 50% One client expressed that his voice caused him to quit his job as a pastor which has restricted him.
Physical 17. 75% N/A
Physical 20. 75% One client expressed that he has issues with projecting his voice, especially in meeting room
settings.
Functional 22. 50% One client reiterated the loss of his job as a pastor due to his voice.
Emotional 25. 25% One client shared that he often feels tired as if he is not getting enough sleep.
Emotional 27. 0% One client commented that he feels challenged by it. He often feels annoyed with himself, or as if
the other person is annoyed with him.
Note. Percent in agreement is percent out of 4 clients. Items refer to the VHI assessment (Jacobson et al., 1997)

Table 2. Discussion Themes

Theme Paraphrase of participant comments N
1. Physical symptoms unrelated to voice Difficulty hearing in noise. 1
Trouble understanding others. 1
2. Voice symptoms Changes throughout the day in voice function 2

Trouble speaking after a long period of silence 1
Vocal strain in crowded areas 1
Struggling with vocal inflection 1
Difficulty projecting his voice, especially in meeting room settings 1
3. Social and/or vocational participation Not enjoying using the phone anymore. 1
restrictions Quitting his job as a pastor because it was too difficult. 1
4. Social Effects on family and others Wife gets frustrated due to his voice. 1
Wife misunderstanding his voice problem, along with other people. 1
5. Compensatory strategies for voice deficits Repeating himself so others could understand. 1
His advice is to be upfront and explain so that others can understand. 1
6. Effects on Participants’ Communication Being asked to speak louder. 1

Interactions Feeling like he is yelling and feeling like he is using more effort than he would think 1
one would need.
He feels challenged by it. He often feels annoyed with himself, or as if the other 1
person is annoyed with him.
Note. N=number of participants who provided specific comments (versus only indicating agreement with other participant comments) for each
theme.
Discussion
Participants related voice symptoms, which were consistent with previous literature. Participants in the current study
reported reduced vocal intensity, reduced intonation, and changes in voice throughout the day. Several studies
examining voice symptoms in PD have reported similar symptoms (Goberman et al., 2002; Ramig et al., 1995; Scott &
Caird, 1983).
Results revealed that all participants agreed to experiencing symptoms assessed within five VHI items. These five items
included three items from the functional, one from the physical, and one from the emotional domain. Interestingly,
participants did not provide comment on any of these items. Consequently, no themes were analyzed from group
discussion of these items. However, it is important to note all participants reported being less outgoing because of their
voice, as the prevalence of clinically significant depressive symptoms in PD is substantial (present in 35% of individuals
with PD; Reijnders et al., 2008) and as social isolation is also commonly reported (Brod et al., 1998; Scott & Caird, 1983).
Other previous research examining the VHI in individuals with PD found five factors of the VHI which explained 71.5% of
the total variance and which related to voice severity; one factor, item F11(‘I speak with friends, neighbors, or relatives
less often because of my voice’), explained 53.8% of the total variance of the VHI (Guimaraes et al., 2017). Interesting,
this item reached 0% agreement among participants in the current study. It is possible that individual participant
characteristics influenced the differing result in the current study; for example, only male participants were included in
this study, whereas the study by Guimaraes et al. (2017) included 43% female participants. However, speculation on
how specific participant characteristics may have influenced participants’ responses and comments is beyond the scope
of this study.

Non-voice symptoms were related in discussion of item 3 of the VHI (within the Functional domain); a participant
related trouble being understood in a noisy setting as well as trouble understanding others in a noisy setting. This finding
may indicate the importance of hearing screenings in individuals with PD, as individuals with PD begin experiencing
symptoms typically around 55-75 years of age, although earlier onset of the disease is possible (Jankovic, 2008), and age
is associated with presbycusis.
Social and vocational participation restrictions included lack of enjoyment in using the phone and inability to continue
employment. These comments may underscore the importance of working with individuals with PD and voice deficits on
strategies to improve communication, specifically on the phone, and to improve ability to participate in employment
tasks through therapy, focusing on increased function or compensation for voice deficits.
Participants with PD also reported using compensatory strategies including repeating themselves as well as being
upfront and explaining their voice disorder to others. This finding may underscore the importance of training individuals
with PD in the most efficient and effective strategies to explain their voice disorder to others to improve communication
interactions. Of note, in the literature on individuals who stutter, disclosing stuttering was found to improve listeners’
perception of the friendliness of the person who stuttered (Healey et al., 2007). Taking the current study results into
consideration with results in the stuttering literature, it may be highly important for individuals with PD to explain
dysarthria to communication partners to improve psychosocial aspects of communication (such as perceived
friendliness), as facial expression for emotion is often reduced in PD (e.g., Jankovic, 2008).
Finally, the effects of participants’ voice disorder also included effects on family and others. Participants related that
others, including wives, did not understand their voice disorder. This theme is in line with the above compensatory
strategy of needing to explain voice disorders to others. Thus, in addition to training individuals with PD on how to
explain voice deficits, the misunderstanding of participants’ voice deficits by others, including a spouse, suggests training
of frequent communication partners and other communication-oriented strategies (Tjaden, 2008) may be useful in
improving social effects of voice deficits in PD.
Limitations and Future Directions

The current study examined responses from a discussion-based administration of the VHI from four individuals with PD.
One limitation of the current study included data collection through clinician notes versus recording participants’
comments verbatim. Additionally, although the information collected from the discussion was useful for planning
therapy for this group of participants, results from this small sample size may not be generalizable across group therapy
interventions for individuals with PD. Future research is needed to examine the usefulness of a discussion-based
administration of the VHI in larger therapy groups for individuals with PD. Additionally, as participants’ responses were
collected within a group discussion, it is possible that participants were influenced by other group members’ comments.
Future research is needed to determine if responses from the VHI are similar when collected from participants with PD
independently versus through group discussion.
Conclusions and Clinical Implications

The results from this group discussion based VHI, provided insight into the psychosocial impacts that voice disorders
have on four individuals with Parkinson Disease. Specifically, the use of group discussion of items on the VHI within this
pilot study enabled the authors to determine the most frequently reported symptoms associated with voice deficits in
these participants with PD. Additionally, it allowed the authors to determine how these voice impairments have
influenced participants’ lives from a patient’s perspective.
Although previous research suggests overall scores of voice symptoms may improve given treatment, determining which
items are most frequently affected by PD and how individuals with PD are affected by the symptoms assessed within
these items may be useful in informing treatment decisions for voice symptoms. The group discussion based
administration of the VHI provided useful information into the participation restrictions caused by voice symptoms
across domains, which may be helpful in informing treatment both inside and outside of the clinical setting. For instance,
one participant reported no longer enjoying talking on the phone. Thus, therapy goals for group members could be
targeted within a phone conversational task.
In hindsight, the oral, group discussion based administration of the VHI could allow clinicians to plan therapy sessions
that are more productive and more individualized for group members. In the current study, the discussion-based
administration of the VHI was found to be a productive way to evaluate the needs of the group and provided clinicians
with specific themes related to participants’ deficits to target in therapy. Due to the usefulness of the discussion based
administration of the VHI, it will be implemented in future therapy sessions. Future research is needed to determine if
development of therapy goals and activities is improved with discussion based administration versus traditional
administration of the VHI in group voice therapy, and if so, if the improved goals and therapy activities relate to
improved patient outcomes. ⧫
Correspondence
Zoë Sommers
School of Speech-Language Pathology and Audiology
The University of Akron
Akron, OH, 44325-3001
Email: zes7@uakron.edu
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Volume 11 ⧫ Issue 1 ⧫ Winter 2021

Past and Current Experiences of Voice Handicap Symptoms of

Zoë Sommers, Angela E. Reif & Susan Ruhlin

Consequences of PD on the Speech Mechanism

Voice Handicap Index

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 11

Summary and Purpose of the Study

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 13

Table 1. Voice Handicap Index Results

Emotional 7. 75% N/A

Functional 8. 25% N/A

Physical 17. 75% N/A

Physical 18. 100% N/A

Functional 19. 50% N/A

Emotional 23. 75% N/A

Emotional 24. 100% N/A

Physical 26. 50% N/A

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 14

Table 2. Discussion Themes

2. Voice symptoms Changes throughout the day in voice function 2

6. Effects on Participants’ Communication Being asked to speak louder. 1

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 15

Limitations and Future Directions

Conclusions and Clinical Implications

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 17

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 18

| eHearsay • Volume 11 • Issue 1 • Winter 2021 Page 19

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