The Vocal Fold Dysfunction Questionnaire: Validity and

Reliability of the Persian Version

*Hamide Ghaemi, *Seyyedeh Maryam Khoddami, *Zahra Soleymani, †Fariborz Zandieh, ‡Shohreh Jalaie,
§Hamid Ahanchian, and ||Ehsan Khadivi, *†‡Tehran and §‖Mashhad, Iran

Summary: Objectives. The aim of this study was to develop, validate, and assess the reliability of the Persian version
of Vocal Cord Dysfunction Questionnaire (VCDQP).
Study Design. The study design was cross-sectional or cultural survey.
Materials and Methods. Forty-four patients with vocal fold dysfunction (VFD) and 40 healthy volunteers were
recruited for the study. To assess the content validity, the prefinal questions were given to 15 experts to comment on
its essential. Ten patients with VFD rated the importance of VCDQP in detecting face validity. Eighteen of the patients
with VFD completed the VCDQ 1 week later for test-retest reliability. To detect absolute reliability, standard error of
measurement and smallest detected change were calculated. Concurrent validity was assessed by completing the Persian
Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) by 34 patients with VFD. Discriminant va-
lidity was measured from 34 participants. The VCDQ was further validated by administering the questionnaire to 40
healthy volunteers. Validation of the VCDQ as a treatment outcome tool was conducted in 18 patients with VFD using
pre- and posttreatment scores.
Results. The internal consistency was confirmed (Cronbach α = 0.78). The test-retest reliability was excellent (intraclass
correlation coefficient = 0.97). The standard error of measurement and smallest detected change values were accept-
able (0.39 and 1.08, respectively). There was a significant correlation between the VCDQP and the CAT total scores
(P < 0.05). Discriminative validity was significantly different. The VCDQ scores in patients with VFD before and after
treatment was significantly different (P < 0.001).
Conclusions. The VCDQ was cross-culturally adapted to Persian and demonstrated to be a valid and reliable self-
administered questionnaire in Persian-speaking population.
Key Words: Vocal fold dysfunction–Asthma–Questionnaire–Self-report assessment–Validity and reliability.

INTRODUCTION including diseases of the upper respiratory tract, vagus or re-

Vocal fold dysfunction, henceforth termed VFD, is recognized
as reversed vocal fold motion syndrome, which is frequently con-
sidered as a disorder in typical adduction of the vocal folds, mainly
during inspiration. It is a respiratory condition characterized by
laryngeal airflow limitation.1 In the literature, the term “vocal
cord dysfunction” was used for this disease. However, as the term
of fold is a more suitable alternative to the cord, the term VFD
is used throughout the present paper. The precise prevalence of
this syndrome has not been reported so far. It was estimated by
Morris that the comorbidity of COPD and VFD is 12%, but it
has a greater incidence among women.2,3,8 The most prominent
symptoms of the VFD consist of coughing, dysphonia, dyspnea,
and throat tension, which are regularly inattentive at relaxation
and are usually serious after particular irritations.4–6 The exact
reason for the VFD is mysterious.7,8 Psychosocial features have
been detected to be responsible for it as well.9,10 Differential di-
agnosis of VFD is necessary to rule out similar clinical conditions,
Accepted for publication August 22, 2017.
From the *Department of Speech Therapy, School of Rehabilitation, Tehran University
of Medical Sciences, Tehran, Iran; †Department of Pediatric, School of Medical, Tehran
University of Medical Sciences, Tehran, Iran; ‡Department of Physiotherapy, School of
Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran; §Department of Pe-
diatrics, School of Medical Sciences, Mashhad University of Medical Sciences, Mashhad,
Iran; and the ‖Department of Otorhinolaryngology, School of Medical Sciences, Mashhad
University of Medical Sciences, Mashhad, Iran.
Address correspondence and reprint requests to Zahra Soleymani, Department of Speech
Therapy, Tehran University of Medical Sciences, Pich-e Shemiran, Enghelab Ave, Tehran,
Iran. E-mail: soleymaniz@sina.tums.ac.ir
Journal of Voice, Vol. 32, No. 6, pp. 710–714
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2017.08.022
current laryngeal nerve injuries, laryngeal edema, and asthma.11–13
Mostly, a diagnosis of VFD is typically made by immunolo-
gists, allergists, and otolaryngologists through a thorough medical
history, detection of irregular vocal fold motion during
videolaryngoscopy, pulmonary function tests, and a treadmill stress
test to produce VFD symptoms.1,9,14 Because of the similarity
of symptoms between VFD and asthma, the former is often mis-
diagnosed and can result in unnecessary pharmaceutical treatment
of asthma.15,16 The failure in identification can lead to in-
creased medication treatment of asthma.17,18 Laryngoscopic
evidence (when the patient is symptomatic) is one of the golden
standards for diagnosis of VFD9; however, patients are not always
symptomatic during laryngoscopy and present with normal phys-
iology. Spirometry test is difficult because of its complex executive
maneuvers so it is not recommended for children younger than
7 years old.19 Therefore, there is a general lack of fast and ef-
fective tools to evaluate, monitor, and detect treatment efficacy
for patients with VFD.
One of the most well-structured questionnaires for self-
reported assessment and screening for VFD is the Vocal Fold
Dysfunction Questionnaire (VFDQ), which originally, termed
“vocal cord dysfunction questionnaire,” was suggested by Fowler
et al.18 The VFDQ is a valid and responsive instrument suit-
able to determine changes of the symptoms in patients with VFD.
It also helps to detect the symptoms, which are important to pa-
tients and could offer future therapy cues.1,9 Noticeable correlation
between the VFDQ and other highly used standardized evalu-
ation approaches, such as St. George’s Respiratory
Hamide Ghaemi, et al The Persian Version of Vocal Cord Dysfunction Questionnaire
Questionnaire,20 shows the scientific value of this questionnaire.18
Moreover, the VFDQ can be used as a tool to detect respon-
siveness after speech rehabilitation.18 This questionnaire is consists
of 12 items related to the most marked symptoms of the pa-
tients with VFD. The patients should answer each item based
on the Likert scale.18 There are several author-made question-
naires, which had been designed to evaluate vocal fold dysfunction
symptom severity. However, their psychometric properties had
not been detected.21,22 The VFDQ was the latest self-reported ques-
tionnaire, which can be used to investigate VFD symptoms and
responsiveness to treatment. It is a validated and reliable stan-
dard questionnaire, which had been performed in Britain.18 It
should be noted that there is another valid and reliable ques-
tionnaire, known as Dyspnea Index (DI) which was designed by
Gartner-Schmidt, to evaluate the severity of dyspnea symptom
relating to upper airway. However, DI differs from VFDQ in terms
of target symptoms and population.23 Because available instru-
ments such as videolaryngoscopy and spirometry, which assess
the severity or changes in the symptoms of VFD, are costly, time-
consuming, and sometimes invasive, the VFDQ is the only tool
that allows monitoring of the symptoms with less time and cost.
In contrast, treatment protocol for VFD suggests a multidimen-
sional approach, which considers different etiologies and treatment
including speech and language therapy. The speech therapy that
includes laryngeal relaxation and breathing exercises is recom-
mended as the main treatment particularly for chronic VFD.15–18
With the aim of validating a questionnaire for monitoring treat-
ment response, the researchers aimed to adapt and evaluate validity
and reliability of the Persian version of VFDQ questionnaire.
MATERIALS AND METHODS
The study protocol was approved by the Institutional Review
Board, School of Rehabilitation, and the Ethics Committee of
Tehran University of Medical Sciences. The ethical code was
IR.TUMS.VCR.1395.204. Assessing validity and reliability of
the VFDQ was conducted in two phases: translation and cross-
cultural adaptation, as well as validity, reliability, and performance
investigations.
Stage 1: Translation and cross-cultural adaptation
procedure
Translation and cultural adaptation of the English version of the
VFDQ into Persian language has been accomplished using the
forward and backward translation procedure, as mentioned in
Kristjansson guideline for translating and adapting measurement.24
Before translating the VFDQ, permission was obtained from the
VFDQ developer, Stefan Fowler. Initially, a bilingual English
translator and a speech and language pathologist (SLP), whose
native language was Persian, were asked to translate the origi-
nal English version of the VFDQ into Persian. Except SLP, the
other translator was not aware of the objective of the study. Then,
a group of experts including the two translators, an experienced
methodologist expert in the field of instruments validation, and
two SLPs reviewed the translated version and finally developed
a Persian version of the VFDQ (VFDQP). The consensus version
was backtranslated into English by two independent bilingual
translators, who were blinded to the study and had no prior knowl-
711
edge of the VFDQ. The aim of this stage was to find meaning
errors and concept deficits.24 To finalize the adaptation proce-
dure, considering the original English questionnaire, as well as
forward-backward translations, the expert committee produced
a prefinal version of the VFDQP. To assess content validity, the
prefinal questions were given to 15 experts, consisting of 3 ear,
nose, and throat specialist (ENTs), 3 immunologists, and 9 SLPs,
and asked them to comment about essential of VFDQP using Likert
scale. The final Persian version of the VFDQ was established
according to the comments of experts. To investigate face va-
lidity, the final version of VFDQP was given to 10 patients that
have been diagnosed with VFD and were asked to rate the im-
portance of each question using the Likert scale (1 = not important,
5 = strongly important). If an item was unnecessary, it would be
removed. All items were approved by all patients.
Stage 2: Validity and reliability investigation
Participants and procedure
The clinical data were gathered from 34 patients with VFD (11
male and 23 female), with a mean age of 37.08 ± 10.8 years (range
18–60 years). This sample size was based on the criteria pro-
posed by Terwee et al.25 The patients were randomly selected
from those who attended the allergy and immunology clinics of
Ghaem and Imam Reza hospitals in Mashhad, Iran. The aller-
gist and ENT diagnosed all participants with VFD based on the
videolaryngoscopy and spirometry examination. To evaluate the
concurrent validity, all patients that participated in the study com-
pleted both the VFDQP and the Persian version of Chronic
Obstructive Pulmonary Disease (COPD) Assessment Test
(CAT1).26 Furthermore, 40 healthy volunteers (22 men and 18
women) with no voice disorder and no breathing problem were
asked to complete the VFDQP to assess the discriminative va-
lidity. Their healthiness was confirmed by the videolaryngoscopy
examination, spirometry test, and perceptual voice evaluation.
The mean age of the participants in the healthy group was
37.87 ± 10.6 years, with the age range of 18–60 years. To measure
the test-retest reliability, 18 patients completed the VFDQ with
an interval of 1 week. To assess VFDQ performance to speech
and language therapy, we compared the VFDQ score before and
after voice therapy in the same 18 patients. Treatment was pro-
vided to patients for 5 weeks (two sessions per week) by focusing
on breathing techniques by an SLP (H.G.). It should be consid-
ered that all participants were able to read and write. All patients
and healthy participants signed the written informed consent form
before the study was initiated.
Statistical analysis
Content validity index (CVI) and content validity ratio (CVR)
were calculated to determine content validity.27 According to Waltz
and Bausell,28 if the mean of CVI is higher than 79%, content
validity is confirmed. In accordance with Lawshe, because the
number of specialists was 15, the CVR which is higher than 49%
will be accepted.29 To determine the face validity, 10 patients
with VFD were asked to rate the importance of each question
based on the Likert scale (1 = not important, 5 = strongly im-
portant). The face validity of VFDQP was detected by computing
impact score (IS) (IS = Frequency % × Importance [score 4 or
712 Journal of Voice, Vol. 32, No. 6, 2018

tained from the total scores of the VFDQP in both patient and
TABLE 1.
Characteristics of the Patients and Healthy Group
healthy groups.

Groups
VFD Group Healthy Group
Characteristics (N = 34) (N = 40)
Age, mean ± SD (y) 37.08 ± 10.8 37.8 ± 10.6
Gender (%) male 33.3% 55.00%
VFDQP score (mean ± SD) 56.33 ± 2.26 12.6 ± 1.05
5]). Each question with an IS of more than 1.5 has face validity.29
The discriminative validity of the VFDQP was analyzed by com-
paring the VFDQP scores between the 34 patients with VFD and
40 healthy subjects by the independent samples t test. The con-
current validity was tested by calculating Pearson correlation
coefficient between the VFDQP and the Persian version of CAT.
Internal consistency reliability was assessed using Cronbach α
coefficient.27 The intraclass correlation coefficient (ICCagreement)
was determined to measure relative reliability.30 The paired
samples t test was used to compare test-retest VFDQP scores of
the patients. To detect absolute reliability, standard error of mea-
surement (SEM) and smallest detected change (SDC) were
calculated (SEM = Standard deviation from the first test
[√(1 − ICC)]).25 SDC shows real change in SEM for a single
subject at the 95% confidence level (SDC = 1.96 × SEM × √2).25
To analyze the performance of VFDQP, the paired samples t test
was used to evaluate the differences in VFDQP scores, before
and after treatment for each diagnosis group. The Pearson cor-
relation coefficient was calculated by considering both the VFDQ
and the CAT scores obtained after treatment and the differ-
ences between the baseline and the posttreatment scores. Statistical
tests were performed using the SPSS 17.0 statistical software
(SPSS, Inc., Chicago, IL).
RESULTS
Characteristics of participants
The mean ± standard deviation (SD) of age in the patients and
healthy groups were 37.87 ± 10.6 (range 18–60) and 37.08 ± 10.8
(range 18–60), respectively. All patients had the laryngoscopic
evidence of classical inspiratory VFD. Table 1 summarizes the
demographic details and the mean and standard deviation ob-
Validity
To detect content validity, CVR and CVI were determined ac-
cording to the specialist’s answers (Table 2). The CVR for the
test materials was found to be 0.63–1.0. In this study, the re-
sulting CVI for all questions was 87%.29 As shown in Table 2,
all the questions on the VFDQP have content validity. As all par-
ticipants favorably accepted and understood the questionnaire
and were able to answer it without difficulty, all items of the
questionnaire were responded, and there were no missing data.
All VFDQP questions had face validity (IS > 1.5). The mean score
of VFDQP was worse in the patients compared with the healthy
group (12.6 ± 1.05 vs. 56.33 ± 2.26). Discriminative validity anal-
ysis showed the significant differences in VFDQP score between
the VFD and the healthy participants (t = 109.51; P = 0.001). Con-
current validity between the VFDQP (total score) and the Persian
version of CAT scores based on Pearson correlation was r = 0.39,
P = 0.016. There was also a significant difference between pre-
and posttreatment VFDQP scores, as evidenced by paired samples
t test (pre-VFDQ P : M = 55.57, SD = 2.65; post-VFDQ P :
M = 13.10, SD = 1.90; P < 0.001). Patients, on average, re-
ported 76.42% improvement in treatment.
Reliability
The measurement of the internal consistency reliability showed
a high Cronbach coefficient for the VFDQP (0.78) with total cor-
relation ranging from 0.67 to 0.81. To determine relative
consistency (test-retest reliability), the ICC agreement for the
VFDQP was 0.97 (95% confidence interval [CI] 0.95–0.96,
P < 0.001) (Table 3). There was no significant difference between
test-retest VFDQP scores. Absolute reliability measures of the
SEM and the SDC for the VFDQP were 0.39 (CI 95% ± 2.16)
and 1.08, respectively.
DISCUSSION
The aim of the present study was to explore the psychometric
properties of the VFDQ in Persian. The results illustrated that
the VFDQP is a valid and reliable questionnaire (Appendix). All
patients with VFD completed the VFDQP without any problem,

TABLE 2.
The CVR Results for Each Question of the VFDQP
VFDQ Questions 1 2 3 4 5 6 7 8 9 10 11 12 Mean
CVR 1 1 1 1 1 1 1 0.81 0.81 0.69 0.69 0.69 0.87

TABLE 3.
Results of Test-Retest Reliability for VFDQP (n = 18)
Mean ± (SD)
Questionnaire Test Retest ICCagreement (95% CI) T Sig (2-Tailed)
VFDQP 55.2 ± 2.6 55.0 ± 2.3 0.97 (0.95–0.98) 2.75 0.009
Hamide Ghaemi, et al The Persian Version of Vocal Cord Dysfunction Questionnaire
indicating the cultural acceptability of the questionnaire. The
VFDQP, consistent with the previous validation study in pa-
tients with vocal fold dysfunction,18 is a valid and reliable tool
for measuring symptom and monitoring functional status in pa-
tients with VFD. To the best of researcher’s knowledge, except
Fowler et al study, which developed and validated VFDQ first,
there is not any study on VFDQ validation. This is the first study
on self-administered instrument for assessing VFD in Persian
language exclusively. However, Gartner-Schmidt et al devel-
oped and validated the DI as a severity index for upper airway–
related dyspnea.23 Their target population in their questionnaire
was patients with PVFMD. The DI is an effective and efficient
instrument to quantify patients’ symptoms of upper airway dyspnea.
It is a statistically robust index, with significant reliability and
validity, and can be dependably used as a treatment outcome
measure.23 In contrast, there are several author-made question-
naires that have been designed to monitor symptoms caused by
VFD. However, psychometric properties were determined for none
of them. Vertigan et al21 and Dunn et al22 provided author-made
questionnaire, which investigated severity and change of symp-
toms resulting from their treatment. Meanwhile, there is no
published document about their psychometric properties.21,22 As
the VFDQ has been recently prepared,18 there is no evidence of
detecting its psychometric characteristics in other languages. Even
though systematic screening of patients with breathlessness com-
plaint indicated, diagnosis of VFD is an important problem for
patients referring to the chest clinic31,32 and designing a tool for
this purpose was required. This study established the face and
content validity of the VFDQ designed for Persian patients with
VFD. The content and face validity of the questionnaire were
confirmed as reported by Fowler et al18 and did not apply any
changes. However, Fowler et al did not detect CVR, CVI, and
IS. Accordingly, the researchers decided to determine the men-
tioned item in the Persian version of VFDQ. The CVR and CVI
measurement indicated that agreement existed with that of the
group of experts. With the CVR and CVI results, there is an ac-
ceptable agreement among experts regarding the VFDQ. Impact
scores of each question demonstrated the necessity of the ques-
tions. As this study, which had determined CVR, CVI, and IS,
is the first one, there is no possibility to compare the results from
VFD with those of the previous studies. When VFDQP scores of
the patients were compared with those of healthy participants,
the patients with VFD had significantly weak scores and func-
tion. This finding suggests that the VFDQP is able to discriminate
patients with VFD from healthy controls. In Fowler et al study,
which tested the ability of the VFDQ to discriminate patients
with VFD from healthy group, a similar finding was found.18 Con-
current validity was assessed by correlating the VFDQP with the
Persian version of CAT, and as hypothesized, excellent associ-
ation was observed between them. In other words, the correlation
between the VFDQP total score and the Persian version of CAT
suggests the concurrent validity of the VFDQP in patients with
VFD. This finding is in accordance with the Fowler results that
used St. George’s Respiratory Questionnaire to detect concur-
rent validity of the VFDQ.18 The great correlation between VFDQP
and Persian version of CAT suggests that these two question-
naires measure similar concurrent. This is not probably amazing.
713
Although CAT was developed to explore symptoms of respira-
tory diseases, it had been tested for lung diseases and upper airway
diseases such as VFD and so would be likely to cover a various
range of symptoms and signs. It is worth mentioning that this
questionnaire was not planned to be a diagnostic instrument for
VFD.26 The VFDQP showed excellent internal consistency as
Cronbach α value was well beyond the minimum recom-
mended value. In the original version of VFDQ, Fowler et al
did not report internal consistency.18 The test-retest reliability
of the VFDQP in the patients with VFD was found to be excel-
lent. In agreement with the results of Fowler et al (ICCagreement =
0.93), test-retest reliability of the VFDQP was similarly confirmed.18
The high value of ICCagreement found in this study indicated ex-
cellent reproducibility of the VFDQP and consistency of the scores
in two measurement sessions. The SEM found in this study was
small, which shows the reliability of the VFDQP.25 The SDC is
a useful estimate to identify real change score of individual pa-
tients after an intervention.25 The SDC in the present study was
1.08%, which is clinically acceptable. This indicates only a change
score greater than 3% can be interpreted as a clinical change of
a 95% CI using the VFDQP. As far as we know, estimation of
SEM and SDC was not reported for the VFDQ until now. Di-
agnostic and treatment services for the patients with VFD are
not broadly accessible.33 Therefore, it is important for health-
care specialists to consider any symptoms of wheezing and note
any changes in symptoms of the VFD reported by the patient.34
The VFDQ was able to demonstrate treatment effects and we
recommend it for future clinical use. Also, Fowler et al sug-
gested that VFDQ may be useful to monitor response to speech
and language therapy and any future treatment developments.18
This study demonstrates that the VFDQ can be used as a con-
venient and affordable tool to assess the severity of VFD and
the effectiveness of a particular treatment of VFD. Although the
shortness of the VFDQ makes it effective for everyday clinical
use, it is only an assessment tool. Further evaluation is neces-
sary for differential diagnosis between VFD and asthma.
The present study has several limitations. The sample size of
the patients with VFD was limited because of the low preva-
lence among patients with “laryngeal air flow limitation disorder.”
This limitation was also evident in the study by Fowler et al,
who recommend using the questionnaire before and after speech
therapy.
CONCLUSIONS
The VFDQ has been successfully cross-culturally adapted into
the Persian language and demonstrated to be the validated and
reliable questionnaire for monitoring symptoms in patients with
VFD and to demonstrate the efficacy of treatment for VFD when
performed before and after speech therapy.
Acknowledgments
This study is part of PhD thesis of the first author majoring in
speech and language pathology. The authors would like to thank
the Research Deputy at Tehran University of Medical Sci-
ences. They also thank Mona Mashhadi, YeganehSamadi, and
Sepideh Seyyed Hosseyni for helping to detect and to engage
participants in the present study.
714
APPENDIX
Persian version of Vocal Fold Dysfunction Questionnaire (VFDQP)
Questions
1 My symptoms are limited to my throat and the upper side of
chest
2 Due to limitation in some part of my throat/the upper side of
my chest, I feel I can’t breath
3 The feeling of lack of breath , is usually worsen when I am
going to breath
4 My attacks are usually get started suddenly
5 I feel that there is something in my throat that I can’t clear it
6 My breath attacks are along with changes in my voice
7 While attacks, my breath has some noise
8 I am aware of factors which may irritate my breath attacks
9 My symptoms are a long with pain in my throat
10 I am upset science my symptoms are not truly recognized
11 I can’t tolerate the low pressure impressed on my neck, e.g.
tight clothes or bending the neck
12 My breath attacks have completely affected my life
Total score
REFERENCES
1. Newman KB, Mason UG, Schmaling KB. Clinical features of vocal cord
dysfunction. Am J Respir Crit Care Med. 1995;152:1382–1386.
2. Vasudev M. Evaluation of paradoxical vocal fold motion. Ann Allergy Asthma
Immunol. 2012;109:233–236.
3. Ibrahim WH, Gheriani HA, Almohamed AA, et al. Paradoxical vocal cord
motion disorder: past, present and future. Postgrad Med J. 2007;83:164–
172.
4. Hira HS. Vocal cord dysfunction masquerading as bronchial asthma. J Assoc
Physicians India. 2002;50:712–716.
5. Bahrainwala AH, Simon MR. Wheezing and vocal cord dysfunction
mimicking asthma. Curr Opin Pulm Med. 2001;7:8–13.
6. Christopher KL, Wood RP II, Eckert RC, et al. Vocal-cord dysfunction
presenting as asthma. N Engl J Med. 1983;308:1566–1570.
7. Varney V, Parnell H, Evans J, et al. The successful treatment of vocal cord
dysfunction with low-dose amitriptyline—including literature review. J
Asthma Allergy. 2009;2:105–110.
8. Morris MJ, Allan PF, Perkins PJ. Vocal cord dysfunction: etiologies and
treatment. Clin Pulm Med. 2006;13:73–86.
9. Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion:
classification and treatment. Laryngoscope. 2012;122:844–853.
10. Haines J. Diagnosing and treating vocal cord dysfunction. Nurs Times.
2011;107:18–20.
11. Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know? Eur
Respir J. 2011;37:194–200.
12. Rundell KW, Spiering BA. Inspiratory stridor in elite athletes. Chest.
2003;123:468–474.
13. Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord
dysfunction. J Occup Environ Med. 1998;40:136–143.
14. Mitika J, Parker J. High levels of medical utilization by ambulatory patients
with vocal cord dysfunction as compared to age- and gender-matched
asthmatics. Chest. 2006;129:905–908.
15. Maillard I, Schweizer V, Broccard A, et al. Use of botulin toxin type A to
avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord
movement. Chest. 2000;118:874–877.
16. Parsons JP, Benninger C, Hawley MP, et al. Vocal cord dysfunction: beyond
severe asthma. Respir Med. 2010;104:504–509.
17. Bisaccioni C, Aun MV, Cajuela E, et al. Comorbidities in severe asthma:
frequency of rhinitis, nasal polyposis, gastroesophageal reflux disease, vocal
cord dysfunction and bronchiectasis. Clinics. 2009;64:769–773.
Journal of Voice, Vol. 32, No. 6, 2018
Totally Neither Agree Totally
Disagree Disagree nor Disagree Agree Agree
1 2 3 4 5
12–60
18. Fowler SJ, Thurston A, Chesworth B, et al. The VCDQ—a Questionnaire
for symptom monitoring in vocal cord dysfunction. Asthma Rhinitis J.
2015;45:1406–1411.
19. Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Ann Allergy
Asthma Immunol. 2011;106:267–274.
20. Jones PW, Quirk FH, Baveystock CM. The St George’s Respiratory
Questionnaire. Respir Med. 1991;85:25–31.
21. Vertigan AE, Bone SL, Gibson PG. Development and validation of the
Newcastle laryngeal hypersensitivity questionnaire. Cough. 2014;10:2–13.
22. Dunn MN, Katial RK, Hoyte CL. Vocal cord dysfunction: a review. Asthma
Res Pract. 2015;1:117–123.
23. Gartner-Schmidt JL, Shembel AC, Zullo TG, et al. Development and
validation of the Dyspnea Index (DI): a severity index for upper airway–
related dyspnea. J Voice. 2014;28:775–778.
24. Kristjansson EA, Desrochers A, Zumbo B. Translating and adapting
measurement instruments for cross-linguistic and cross-cultural research:
a guide for practitioners. Can J Nurs Res. 2003;35:127–142.
25. Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were proposed for
measurement properties of health status questionnaires. J Clin Epidemiol.
2007;60:34–42.
26. Jones PW, Harding P, Berry P, et al. Development and first validation of
the COPD Assessment Test. Eur Respir J. 2009;34:648–654.
27. Al-Alwan A, Kaminsky D. Vocal cord dysfunction in athletes: clinical
presentation and review of the literature. Phys Sportsmed. 2012;40:22–27.
28. Waltz C, Bausell R. Nursing Research: Design, Statistics, and Computer
Analysis. FA Davis Company; 1981.
29. Lawshe CH. Quantitative approach to content validity. United States. Pers
Psychol. 1975;28:563–575.
30. Gravetter FJ, Forzano L-AB. Research Methods for the Behavioral Sciences.
4th ed. Belmont, CA: Wadsworth; 2012:78. ISBN 978-1-111-34225-8.
31. Balkissoon R, Kenn K. Asthma: vocal cord dysfunction (VCD) and other
dysfunctional breathing disorders. Semin Respir Crit Care Med.
2012;33:595–605.
32. Husein OF, Husein TN, Gardner R, et al. Formal psychological testing in
patients with paradoxical vocal fold dysfunction. Laryngoscope.
2008;118:740–747.
33. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal
cord dysfunction. Chest. 2010;138:1213–1223.
34. Christopher KL, Wood RP, Eckert RC, et al. Vocal cord dysfunction
presenting as asthma. N Engl J Med. 1983;208:1566–1570.