Effectiveness of Chewing Technique on the Phonation

of Female Speech-Language Pathology Students:

A Pilot Study
*Iris Meerschman, *Evelien D’haeseleer, *Elien De Cock, *Heidi Neyens, †Sofie Claeys, and *Kristiane Van Lierde,
*yGent, Belgium

Summary: Objectives. The purpose of this study was to determine how use of the vocal facilitating technique,
chewing, affected the phonation of speech-language pathology (SLP) students.
Study Design. A pretest-posttest randomized control group design was used.
Methods. Twenty-seven healthy female SLP students were randomly assigned into either an experimental group or a
control group. The experimental group practiced chewing exercises across 18 weeks, whereas the control group received
no vocal facilitating techniques. Both groups completed pre- and post- objective voice assessment measures (aerody-
namic measurement, acoustic analysis, voice range profile, and Dysphonia Severity Index). Differences between pre-
and post-data were compared between the experimental and control group using an independent sample t test.
Results. Compared to the control group, chewing resulted in a significant decrease in jitter and noise-to-harmonic ra-
tio (NHR), a significant increase in fundamental frequency (fo), a significant expansion of the voice range profile, and a
significant increase in Dysphonia Severity Index (DSI). Shimmer and maximum phonation time (MPT) were not signif-
icantly different between groups.
Conclusions. The results of this pilot study suggest that the vocal facilitating technique, chewing, may improve
objective vocal measures in healthy female SLP students.
Key Words: Chewing–Voice–Facilitating technique–Effectiveness–Phonation–Speech-language pathology students–
Dysphonia–Objective vocal measures–Pilot study.

INTRODUCTION papilloma as well as in those suffering from hypo-or

The vocal facilitating technique, chewing, was first described
by Froeschels1 in 1943. He based the technique on the observa-
tion that someone can chew and speak at the same time.
According to the author, chewing and speaking must be some-
what identical because both functions require the same muscles
and nerves.2 In 1956, Beebe3 confirmed Froeschels observa-
tions and described voiced chewing as an inborn and intuitive
behavior. Voiced chewing refers to the ‘‘raw material’’ used
instinctively by the aboriginal human inhabitants of the earth.2
It serves the dual purpose of supporting life (eating) and oral
communication (speech).3 Because of etiquette, the voice has
not been used in conjunction with chewing food for thousands
of years. Despite this, voicing while chewing can still be easily
accomplished by individuals.2
The most convincing support of voiced chewing as an inborn
and intuitive behavior is found in clinical experience. A natural
behavior such as chewing may facilitate improved vocal pro-
duction4 through relaxation of the vocal tract5 and regulation
of the basic vocal pitch.6 According to Weiss and Beebe,7 chew-
ing also improves coordination between respiration and phona-
tion. Froeschels1,3 described improved vocal quality during
chewing aloud in individuals with vocal fold paresis, cyst, and
Accepted for publication June 29, 2015.
From the *Department of Speech, Language and Hearing Sciences, Ghent University,
Ghent, Belgium; and the yDepartment of Otorhinolaryngology, Ghent University, Ghent,
Belgium.
Address correspondence and reprint requests to Iris Meerschman, Department of
Speech, Language and Hearing Sciences, University Hospital, 2P1, De Pintelaan 185,
9000 Ghent, Belgium. E-mail: Iris.Meerschman@Ugent.be
Journal of Voice, Vol. -, No. -, pp. 1-5
0892-1997/$36.00
Ó 2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2015.06.016
hyperfunctional voice disorders, mutational disorders, and
hearing impairment. Furthermore, Brodnitz and Froeschels8
facilitated the resolution of vocal nodules after the using of
chewing in five of the six subjects under study. Boone et al5
recommend the technique for patients with muscle tension
dysphonia who speak with tension, hard glottal attacks, and
restricted mandibular movements. According to Weiss and
Beebe,7 chewing might also be useful in treating speech disor-
ders such as stuttering and dysarthria. However, to our knowl-
edge, no studies confirm this finding. Weiss and Beebe7
further described the application of chewing to train the healthy
speaking and singing voice.
The use of the chewing technique in improving vocal produc-
tion has mainly been supported by the results of case studies
that cannot be easily generalized. Additionally, conclusions
are based on observations and anecdotal clinical experience.
Furthermore, a detailed description of the method is lacking
and much of the published literature is outdated.1–8 More
recently, larger efficacy studies are available but those have
examined chewing as part of a broader therapy program,
rather than in isolation.916 Therefore, experimental studies
that specifically examine the effect of chewing on vocal
production are required.
Our pilot study aimed to make a first contribution to this
research gap. We wanted to investigate if the outdated and un-
proven assertions1–8 about the effect of chewing may be correct.
Therefore, in this first-stage investigation, we chose to focus on
chewing as a technique that could facilitate and train the healthy
voice.7
The purpose of this study was to determine how use of the
vocal facilitating technique, chewing, affected the phonation
2 Journal of Voice, Vol. -, No. -, 2015
of healthy women enrolled in a speech-language pathology
(SLP) program. A positive effect on the SLP students’ vocal ca-
pacities was hypothesized because, according to the litera-
ture,1–8 chewing may facilitate a more natural vocal
production through relaxation of the vocal tract, regulation of
the basic vocal pitch, and better coordination between
respiration and phonation.
MATERIAL AND METHODS
This study was approved by the human subjects committee of
Ghent University.
Subjects
Twenty-nine female students enrolled in the first year of the
bachelor program Speech-Language Pathology at Ghent Uni-
versity were randomly selected to participate in this study.
Exclusion criteria included diagnoses of mental health condi-
tions, voice disorders, nasal and ear diseases, and physically-
limiting diseases that might interfere with study completion.
Additionally, individuals who had previously participated in
voice therapy or training were excluded from participation.
To determine that participants were not currently suffering
from a voice disorder or nasal or ear disease, each subject
was assessed by an otorhinolaryngologist and audiologist per-
forming a nasopharyngeal and laryngeal evaluation, videolar-
yngostroboscopy, otoscopy, and audiometry. On the basis of
these results, two students were excluded because of vocal
fold edema and vocal fold nodules.
The remaining participants included a homogeneous group
of twenty-seven healthy female students with a mean age of
18.8 years (SD, 0.8 years; range, 17.9–21.2 years). They were
randomly assigned into either an experimental group (n ¼ 14)
or a control group (n ¼ 13). The experimental group practiced
chewing exercises across 18 weeks, whereas the control group
received no vocal facilitating techniques. Randomization was
based on the first letter of the students’ last name (A–M, control
group; N–Z, experimental group). There were no differences
between the two groups in mean age (Mann–Whitney U test;
P ¼ 0.239).
Material and methods
Voice questionnaire. At the beginning of the study, each
subject filled in a questionnaire based on the voice assessment
protocol of the European Study Group on Voice Disorders17 to
describe vocal complaints and risk factors.
Objective vocal measures. Both groups completed pre-
and post- objective voice assessment measures. Data were
collected by two SLPs (E.D.C. and H.N.) in a sound-treated
room at Ghent University Hospital.
Aerodynamic measurement. To measure the maximum phona-
tion time (MPT), the participants were asked to sustain the
vowel /a/ at their habitual pitch and loudness in free field while
seated. The MPT was modeled by the experimenters, and the
participants received visual and verbal encouragement to
produce the longest possible sample. The length of the
sustained vowel was measured in seconds. The best trial of
three attempts was retained for further analysis.
Acoustic analysis. The fundamental frequency (fo), jitter (%),
shimmer (%), and noise-to-harmonic ratio (NHR) were
obtained by the Multi Dimensional Voice Program from the
Computerized Speech Lab (CSL, model 4300, Kay Elemetrics
Corp., Lincoln Park, NJ). The subjects were instructed to
produce the vowel /a/ at their habitual pitch and loudness. A
midvowel segment from 3 seconds registered with a sampling
rate of 50 kHz was used.
Voice range profile. The voice range assessment was per-
formed with the CSL following the procedure outlined by
Heylen et al.18 This assessment includes determination of the
highest and lowest fundamental frequency and intensity. The
participants were instructed to produce the vowel /a/ for at
least 2 seconds using, respectively, a habitual pitch and
loudness, a minimal pitch, a minimal intensity, a maximal
pitch, and a maximal intensity. Each production was modeled
by the experimenters, and the participants received visual and
verbal encouragement.
Dysphonia Severity Index. The Dysphonia Severity Index
(DSI)19 is a multiparameter approach designed to establish
an objective and quantitative correlate of the perceived vocal
quality. The DSI is based on a weighted combination of the
following parameters: MPT (in seconds), highest frequency
(F-high, in Hz), lowest intensity (I-low, in dB), and jitter
(in %). The DSI is constructed as 0.13 MPT + 0.0053
F-high  0.26 I-low  1.18 jitter + 12.4. The index ranges
from 5 to +5 for severely dysphonic to normal voices. The
more negative the index, the worse is the vocal quality. A
DSI of 1.6 is the threshold separating normal voices from
dysphonic voices.20 The DSI can be calculated as a
percentage20 by increasing the value with five points and
then multiplying it by 10. A higher percentage indicates a
better vocal quality.
Facilitating technique chewing. The experimental group
received the facilitating technique chewing during 18 weeks.
In the first 8 weeks, the group participated in weekly 1-hour
training sessions organized by the experimenters. The experi-
menters provided verbal information, examples, and corrective
feedback. Incorrect posture or poor respiratory technique were
corrected. The content of the training sessions, based on the
procedure outlined by Boone et al,5 can be found in Table 1.
In addition to the exercises during training, the subjects were in-
structed to practice the chewing technique at home twice a day
during 10 minutes.
From week 9–17, the subjects repeated the technique inde-
pendently at home with a frequency of two times 10 minutes
a day. Meanwhile, they had the opportunity to contact the ex-
perimenters for feedback or questions.
In week 18, an interactive rehearsal session was organized
under the guidance of the experimenters. In this session, sub-
groups (two or three subjects) of the experimental group pre-
sented one of the steps learned in training. The other subjects
followed their instructions.
Iris Meerschman, et al Effectiveness of Chewing Technique 3

TABLE 1.
Content of the Chewing Training Sessions Based on the Procedure Outlined by Boone et al.
Session Content
1 Education and counseling
Creating awareness of the student’s mandibular movements while speaking (visual
feedback: mirror)
Demonstration of the facilitating technique chewing by the experimenters
Imitation and familiarization by the subjects (visual feedback: mirror)
2 Open-mouth chewing without phonation
Chewing with phonation of the sound ‘‘njamnjam’’
Chewing with phonation of nonsense words (eg, ‘‘ah-la-met-erah,’’ ‘‘wan-da-pan-da’’)
3, 4 Chewing with phonation of automatic sequences: counting, days of the week
Chewing with phonation of words: monosyllabic, polysyllabic
5, 6 Chewing with phonation of phrases
Chewing with phonation of sentences
Chewing while reading texts
7, 8 Phonation of sentences and texts with reduced chewing
Spontaneous speech with adequate oral openness and mandibular movements

Statistical analysis chewing resulted in a significant decrease in the acoustic mea-

SPSS Version 22 (SPSS Corporation, Chicago, IL) was used for
the statistical analysis of the data. All analyses were conducted
at a ¼ 0.05.
Voice questionnaire. A chi-square test of independence was
used to verify if there were differences between the experi-
mental and control group regarding vocal complaints and risk
factors.
Objective vocal measures. The differences between pre-
and post-data were measured for each subject. Normality of
these differences was verified using a QQ-plot and a Shapiro-
Wilk test.21 Because all data were normally distributed, an in-
dependent sample t test was used to compare the results of
the experimental and control group.
sures jitter (P ¼ 0.007) and NHR (P ¼ 0.048), a significant in-
crease in the acoustic measure fo (P ¼ 0.049), a significant
expansion of the voice range profile (I-low [P ¼ 0.044],
I-high [P ¼ 0.033], F-low [P ¼ 0.048], F-high [P ¼ 0.018]),
and a significant increase in DSI score (P ¼ 0.002). No differ-
ences were found between the experimental and control group
for the aerodynamic measure MPT (P ¼ 0.791) and the acoustic
measure shimmer (P ¼ 0.202).
Figure 1 represents the changes in DSI before and after
18 weeks of chewing in the experimental group, and before
and after the same time span without facilitating techniques
in the control group. An increase of 2.3 in the experimental
group was significantly higher than the difference (0.6)
measured in the control group.

RESULTS
Voice questionnaire
The results of the questionnaire about vocal complaints and risk
factors are presented in Table 2. Occurrence of the vocal com-
plaints ‘‘vocal fatigue,’’ ‘‘decreased vocal quality in the morn-
ing,’’ ‘‘laryngeal irritations,’’ and ‘‘decreased breath support’’
was not significantly different between the experimental and
control group. Significantly higher percentages of ‘‘hoarse-
ness’’ (40.6%; c2(1) ¼ 4.464; P ¼ 0.035) and ‘‘decreased vocal
range’’ (30.8%; c2(1) ¼ 5.057; P ¼ 0.025) were found in the
control group versus the experimental group.
Occurrence of the vocal risk factors ‘‘vocal abuse,’’ ‘‘nasal
airway obstructions,’’ ‘‘smoking,’’ ‘‘reflux,’’ and ‘‘allergy’’
was not significantly different between the experimental and
control group. A significantly higher percentage of ‘‘stress’’
(40.6%; c2(1) ¼ 4.464; P ¼ 0.035) was found in the control
group versus the experimental group.
Objective vocal measures
Table 3 summarizes the results of the objective vocal measures
at pre- and post-condition. Compared to the control group,
DISCUSSION
The purpose of this pilot study was to determine how use of the
vocal facilitating technique, chewing, affected the phonation of
healthy female SLP students. A positive effect on the SLP stu-
dents’ vocal capacities was hypothesized because, according to
the literature,1–8 chewing may facilitate a more natural vocal
production through relaxation of the vocal tract, regulation of
the basic vocal pitch and better coordination between
respiration and phonation.
The hypothesis that vocal function would increase via the
chewing facilitating technique has been supported by the signif-
icantly decreased acoustic voice measures jitter and NHR, the
expanded voice range profile (I-low, I-high, F-low, F-high),
and the increased objective measure of vocal quality (DSI) in
the experimental group compared with the control group. The
DSI increased from 0.6 (44%) before chewing to +1.7 (67%)
after chewing, which indicates a 23% improvement as measured
by the index. Similarly, fo significantly increased in the experi-
mental group relative to controls. A possible explanation for
this increase may be that chewing facilitated subjects to speak
4 Journal of Voice, Vol. -, No. -, 2015

TABLE 2.
Percentage of Participants Having Vocal Complaints and Percentage of Participants Exposed to Vocal Risk Factors Based on
the European Study Group on Voice Disorders Voice Assessment Protocol
Vocal complaints and risk factors Experimental Group (%) Control Group (%) c2 P Value
Vocal complaints
Vocal fatigue 35.7 (5/14) 53.8 (7/13) 0.898 0.343
Hoarseness 28.6 (4/14) 69.2 (9/13) 4.464 0.035*
Decreased vocal quality in the 28.6 (4/14) 38.5 (5/13) 0.297 0.586
morning
Decreased vocal range 0 (0/14) 30.8 (4/13) 5.057 0.025*
Laryngeal irritations 14.3 (2/14) 46.2 (6/13) 3.283 0.070
Decreased breath support 14.3 (2/14) 46.2 (6/13) 3.283 0.070
Risk factors
Vocal abuse 71.4 (10/14) 92.3 (12/13) 1.947 0.163
Shouting 35.7 (5/14) 69.2 (9/13) 3.033 0.082
Overpassing noise 50.0 (7/14) 69.2 (9/13) 1.033 0.310
Member youth organization 57.1 (8/14) 30.8 (4/13) 1.899 0.168
Throat clearing 42.9 (6/14) 51.5 (8/13) 0.942 0.332
Nasal airway obstructions 35.7 (5/14) 46.2 (6/13) 0.304 0.581
Smoking 0 (0/14) 0 (0/14) No smokers
Reflux 7.1 (1/14) 23.1 (3/13) 1.356 0.244
Allergy 42.9 (6/14) 30.8 (4/13) 0.422 0.516
Stress 28.6 (4/14) 69.2 (9/13) 4.464 0.035*
Note: P is the level of significance and was set at 0.05.
* Indicates a significant difference in vocal complaint or vocal risk factor between the experimental group (chewing technique) and the control group (no facil-
itating techniques).

at their more natural pitch.6 However, the frequency change was chewing, the fo (226.2 Hz) was situated further from the mean
relatively small and a similar magnitude of decline, observed in norm for female adults (212 Hz; but within the normal range
the control group, must be taken into account. Moreover, after of 167–258 Hz).22 The assumption that chewing improves

TABLE 3.
Comparison of the Differences in Pre- and Post- Objective Vocal Measures Between the Experimental Group and the
Control Group
Experimental Group Control Group

Difference Difference
Pre Post Pre  Post Pre Post Pre  Post
Parameters Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) P Value
Aerodynamic
MPT (s) 17.6 (5.6) 17 (4.1) 0.6 (4) 22.5 (8.1) 21.5 (5.7) 1 (4.2) 0.791
Acoustic analysis
fo (Hz) 217.8 (18.1) 226.2 (14.1) +8.4 (15.3) 218.7 (28.4) 209.7 (13.1) 9 (27.4) 0.049*
Jitter (%) 2 (1.1) 1.2 (0.6) 0.8 (0.9) 1.6 (0.7) 2 (0.9) +0.4 (1.2) 0.007*
Shimmer (%) 4.8 (1.2) 4.6 (1.2) 0.2 (1.7) 4.6 (1.1) 5.2 (1.5) +0.6 (1.5) 0.202
NHR 0.13 (0.02) 0.12 (0.02) 0.01 (0.02) 0.13 (0.02) 0.14 (0.02) +0.01 (0.03) 0.048*
Voice range profile
I-low (dB) 63.1 (3.1) 60.1 (2.5) 3 (3.6) 60.6 (3.5) 60.3 (1.9) 0.3 (3) 0.044*
I-high (dB) 99.7 (6.8) 107.6 (3.9) +7.9 (6.4) 103.4 (6.6) 106.3 (3.9) +2.9 (5) 0.033*
F-low (Hz) 173.9 (24.9) 159.5 (24.9) 14.4 (13.2) 173.5 (15.3) 170.9 (7.5) 2.6 (16.4) 0.048*
F-high (Hz) 661.1 (173.5) 777.6 (168.5) +116.5 (145.5) 644.5 (145.1) 638.8 (172.4) 5.7 (97.3) 0.018*
DSI 0.6 (2.3) 1.7 (1.5) +2.3 (2.3) 1.1 (2.1) 0.5 (2) 0.6 (2.1) 0.002*
Note: P is the level of significance and was set at 0.05.
Abbreviations: SD, standard deviation; MPT, maximum phonation time; I-low, lowest intensity; I-high, highest intensity; F-low, lowest frequency; F-high, high-
est frequency; fo, fundamental frequency; NHR, noise-to-harmonic ratio; DSI, Dysphonia Severity Index.
* Differences in pre- and post-data were significantly different between the experimental group (chewing technique) and the control group (no facilitating
techniques).
Iris Meerschman, et al Effectiveness of Chewing Technique
3 CONCLUSIONS
2
1 healthy female SLP students. The extent to which the chewing
Experimental group
DSI
0
Control group
-1
-2
-3
pre post
FIGURE 1. The changes in DSI before and after 18 weeks of chew-
ing technique (experimental group) and before and after the same time
span without facilitating techniques (control group).
coordination between respiration and phonation7 could not be
supported because the aerodynamic measure MPT did not
improve in the experimental group. Furthermore, no improve-
ment could be observed for the acoustic measure shimmer.
Limitations of the study design should be recognized and
taken into account for further research. A first limitation is that
subjects and experimenters were not blinded to the purpose of
the study, and no sham training was provided for the control
group. A second limitation is that, despite randomization, signif-
icant differences were found between the experimental and con-
trol group in symptoms of ‘‘hoarseness’’ and ‘‘decreased vocal
range,’’ and in the risk factor ‘‘stress’’ before the initiation of
the 18-week training period. Those differences suggest that the
study groups were too small to obtain perfectly homogeneous
groups and that larger study groups would improve future
work. Furthermore, no voice data were obtained on participants
during the 18-week time span. Follow-up assessment during
these weeks, including both the voice questionnaire and the
vocal measures, would have provided valuable information.
Follow-up assessment could also have been extended to examine
the long-term outcome of the technique. Besides, evaluation of
vocal capacities was limited to objective measures, excluding
subjective perceptual evaluations of the voice (eg, GRBASI
scale23) and a patient’s self-report (eg, Voice Handicap Index24).
Another shortcoming of the study is the lack of information
about whether home instructions were followed in week 9–17.
Hence, adherence to the practice schedule for the chewing tech-
nique cannot be ensured. Finally, other factors such as clinician-
facilitated changes in subjects’ posture and respiratory technique
and overlap of the production ‘‘njamnjam’’ with resonant voice
techniques might possibly have contributed to the improved
vocal capacities detected on postmeasures.
Despite the previously described limitations, this pilot study
provides useful first-stage results about the effect of an old and
understudied vocal facilitating technique and its potential abil-
ity to facilitate and train the healthy voice.7 Examining the
effect of chewing in patients with voice disorders is subject
for further research. The present study suggests that chewing
may facilitate expansion of the patients’ vocal range and
improvement in their vocal quality.
5
The results of this pilot study suggest that the facilitating tech-
nique chewing may improve objective vocal measures in
technique may be useful in improving voice measures in the
presence of vocal pathology awaits further study.
REFERENCES
1. Froeschels E. Hygiene of the voice. Arch Otolaryngol. 1943;38:122–130.
2. Froeschels E. Chewing method as therapy. Arch Otolaryngol. 1952;56:
427–434.
3. Beebe HH. Practical aspects of chewing therapy. Folia Phoniatr Logop.
1956;8:107–117.
4. Thomas LB, Stemple JC. Voice therapy: does science support the art?
Comm Dis Rev. 2007;1:49–77.
5. Boone DR, McFarlane SC, Von Berg SL, Zraick RI. The Voice and Voice
Therapy. 8th ed. Boston: Allyn & Bacon; 2009:194–196.
6. Brodnitz FS. Rehabilitation of the human voice. Bull N Y Acad Med. 1966;
42:231–240.
7. Weiss DA, Beebe HH. The Chewing Approach in Speech and Voice Ther-
apy. Basel-New York: S. Karger Publishers; 1950.
8. Brodnitz FS, Froeschels E. Treatment of nodules of vocal cords by chewing
method. Arch Otololaryngol. 1954;59:560–565.
9. McCrory E. Voice therapy outcomes in vocal fold nodules: a retrospective
audit. Int J Lang Commun Disord. 2001;36:19–24.
10. Bovo R, Galceran M, Petruccelli J, Hatzopoulos S. Vocal problems among
teachers: evaluation of a preventive voice program. J Voice. 2007;21:705–722.
11. Carding PN, Horsley IA. An evaluation study of voice therapy in non-
organic dysphonia. Eur J Disord Commun. 1992;27:137–158.
12. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice
therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice.
1999;13:72–104.
13. Rattenbury HJ, Carding PN, Finn P. Evaluating the effectiveness and effi-
ciency of voice therapy using transnasal flexible laryngoscopy: a random-
ized controlled trial. J Voice. 2004;18:522–533.
14. Rodriguez-Parra MJ, Adrian JA, Casado JC. Comparing voice therapy and
vocal hygiene treatments in dysphonia using a limited multidimensional
evaluation protocol. J Commun Dis. 2011;44:615–630.
15. Vashani K, Murugesh M, Hattiangadi G, et al. Effectiveness of voice ther-
apy in reflux-related voice disorders. Dis Esophagus. 2010;23:27–32.
16. Teczaner CZ, Ozgursoy SK, Sati I, Dursun G. Changes after voice therapy
in objective and subjective voice measurements of pediatric patients with
vocal nodules. Eur Arch Otorhinolaryngol. 2009;266:1923–1927.
17. De Bodt M, Wuyts FL, Raes J, Qiu J. Research work of the Belgian Study
Group on Voice Disorders. Acta Otorhinolaryngol Belg. 1996;50:325–329.
18. Heylen L, Wuyts F, Mertens F, De Bodt M, Pattyn J, Croux C, Van de
Heyning PH. Evaluation of the vocal performance of children using a voice
range profile index. J Speech Lang Hear Res. 1998;41:232–238.
19. Wuyts FL, De Bodt MS, Molenberghs G, et al. The Dysphonia Severity In-
dex: an objective measure of vocal quality based on a multi-parameter
approach. J Speech Lang Hear Res. 2000;43:796–809.
20. Raes J, Wuyts FL, De Bodt M, Clement P. The Dysphonia Severity Index
used with a percentage scale. Stem-, Spraak-, Taalpath. 2002;11:30–37.
21. Razali NM, Wah YB. Power comparisons of Shapiro-Wilk, Kolmogorov-
Smirnov, Lilliefors and Anderson-Darling tests. J Stat Mod Anal. 2011;2:
21–33.
22. De Bodt M, Heylen L, Mertens F, Vanderwegen J, Van de Heyning P. Stem-
stoornissen: handleiding voor de klinische praktijk. Antwerpen: Garant; 2008.
23. Hirano M. Clinical Examination of Voice. New York: Springer Verlag; 1981.
24. Jacobson BH, Johnson A, Grywalski C, Sirbergleit A, Jacobson G,
Benninger MS. The Voice Handicap Index (VHI): development and valida-
tion. Am J Speech Lang Pathol. 1997;6:66–70.