Elsevier

Journal of Voice

Volume 18, Issue 2, June 2004, Pages 183-192
Journal of Voice

The relationship between ratings of voice quality and quality of life measures

https://doi.org/10.1016/j.jvoice.2003.11.003Get rights and content

Abstract

Summary

In the past several years, a number of scales have been developed that elicit a patient's self-assessment of the severity of his or her voice problem. The Voice Related Quality of Life Measure (V-RQOL) assesses a patient's perception of the impact of the voice problem on quality of life. Although this tool assesses the patient's perception of the voice disorder, it may not reflect the severity of dysphonia as perceived by a clinician. The GRBAS is an auditory-perceptual scale developed in Japan and used by clinicians to categorize the voice using five descriptive perceptual parameters: overall grade or severity (G), roughness of the voice (R), breathiness (B), asthenia (A), and strain (S). The purpose of this research is to determine the relationship between the patient's perception of voice related quality of life using the V-RQOL and the clinician's perception of voice severity using the GRBAS scale. Fifty patients with a complaint of a voice disorder completed the V-RQOL prior to their examination. In addition, 45 patients without voice complaints (controls) also completed the V-RQOL. All patients and control subjects were assessed by one of the voice clinicians using the GRBAS. For 25 of the subjects, both clinicians provided GRBAS perceptual ratings. Each of the two groups, were subsequently divided into subgroups consisting of those age 66 years and under and those over 66 years of age. The results indicate that the two clinicians were highly reliable in rating severity in the normal and voice disordered groups using the GRBAS scale. The results also indicate that perceived voice severity and voice-related quality of life are related; however, the relationship is a moderate one, which suggests that factors other than those directly related to voice quality may contribute to responses on voice assessment scales completed by patients. The relationship was stronger for the subgroup under 66 years old compared with the subgroup 66 years and older.

Introduction

The degree to which a voice disorder impacts an individual's day-to-day activities may vary significantly depending on the severity of the voice disorder and the voice needs of the patient. Factors, which determine the impact of a voice disorder generally go beyond the degree of hoarseness, the pathophysiology of the disorder, and the types of treatments. Thus, understanding the significance of a seemingly straightforward symptom, hoarseness or dysphonia, must include the patient's needs for voice use and how the dysphonia will alter his/her physical, social, and emotional well-being.

The Voice-Related Quality of Life Measure (V-RQOL) is a voice-specific outcome instrument developed by Hogikyan and Sethuraman1 to address the patient's perception of how the voice can affect quality of life. This questionnaire has undergone rigorous psychometric validation, and it has been shown to be valid, reliable, responsive to change, and of low burden in a population of patients with a diverse group of voice disorders. The V-RQOL Measure consists of 10 items in two domains (Appendix A), with a five-point forced choice rating scale. For each item, patients rate the “amount” of problem they are having using the five-point scale. The V-RQOL Measure contains two subscales. The social-emotional domain subscale (SE) includes items 4, 5, 8, and 10, and the physical functioning domain subscale (PF) consists of items 1, 2, 3, 6, 7, and 9. Domain and total standard scores are calculated using a scoring algorithm that determines a score from a low of “0” to a high of “100” (Appendix A). Thus, the lower the standard score, the worse the patient's V-RQOL. Using the V-RQOL Measure, a clinician can better understand the patients' perception of how a voice disorder is affecting his/her day-to-day activities. In the original validation study, V-RQOL scores were highly correlated with patients' own categorical rating of their voice quality using standard categories of poor, fair, good, very good, and excellent.

Subsequent to psychometric validation, the V-RQOL measure has been used to assess clinical outcomes in a variety of voice disorders. Hogikyan et al2 measured the V-RQOL scores of 44 patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores with 17 patients with untreated and uncompensated unilateral vocal fold paralysis and with 22 adults without vocal fold paralysis. Treated patients had significantly higher overall V-RQOL scores and domain scores than untreated patients, but they also scored lower than the normal group. These differences were true across both genders and a wide age range. Patients who were more distant from surgery had lower V-RQOL scores than those who had been treated more recently. They concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis.

Both short- and long-term changes in the V-RQOL of patients found to have adductor spasmodic dysphonia (ADSD) and treated with Botulinum toxin A (BOTOX) injections were studied by Hogikyan et al.3., 4. In the long-term prospective study, 42 were assessed with the V-RQOL Measure before and after each BOTOX injection. Numbers of injections per patient ranged from 1 to 7, with pretreatment and post-treatment V-RQOL data available for up to six injections. A statistically significant positive treatment effect was seen after the first treatment and in subsequent treatment cycles. The mean improvement was greater for the first treatment than for the second; however, the mean treatment effect remained stable for injections three through six. The authors concluded that injection of BOTOX has a positive effect on the V-RQOL of ADSD patients for at least six injections, and the magnitude of this effect becomes stable over time.

Clinicians also use a perceptual scale as part of the initial evaluation of the patient's voice to consistently describe the sound qualities of the voice. One scale that is widely used by clinicians is the GRBAS. The Committee for Phonatory Function Tests from the Japanese Society of Logopedics and Phoniatrics developed the GRBAS for the perceptual assessment of voice severity based on Isshiki's research.5 The scale has been widely used since 1981. The GRBAS scale is a four point (0–3) forced choice auditory-perceptual scale to assess severity of the voice disorder. The scale consists of five parameters: overall severity rating of the dysphonia (G) roughness, (R) breathiness, (B) asthenia, (A) and (S) strain. Ratings range from 0 to 3, where “0” means normal/absence of the voice disorder, “1” mild, “2” moderate, and “3” severe.

The reliability of the GRBAS for the perceptual assessment of voice quality has been examined by Wuyts et al using the ordinal 0-3 scale and a visual analog scale.6 Using either scale resulted in high reliability of perceptual judgments; however, agreement was found to be higher with the original four-point scale than with the visual analog version for each of the five-scale items. They concluded that a visual analog scale may enable a more precise judgment of voice quality; however, with increased freedom of judgment, interrater agreement decreased considerably. Therefore, they recommend the use of the original four-point version of the GRBAS scale.

In another study, De Bodt et al7 examined the influence of a judge's background on perceptual rating of voice quality. Pathological voice samples were presented twice to a group of 23 judges, consisting of experienced and inexperienced otolaryngologists and speech-language pathologists. The time interval between ratings was 14 days. Test-retest reliability was moderate. The best agreement between the observers was obtained for the G (grade) parameter and the worst for the S (strained) parameter. Considering the medians of the GRBAS ratings, no significant influence was found for level of experience or professional background. Dejonckere et al,8 in a study of pathological voice quality, also tested the reliability of the GRBAS and its relationship to acoustic measurements. The authors found a significant relationship between the GRBAS scale with an instability (I) parameter added and with several acoustic measures. The GRBAS scale has been proposed by others as the scale of choice when doing a perceptual evaluation of a patient's voice. Pretreatment and post-treatment assessments using the GRBAS scale have been reported by Neuenschwander et al9 to demonstrate the value of the scale as a perceptual tool. Other investigations have used the GRBAS to assess results after thyroplasty type I.10., 11., 12., 13.

The GRBAS has been used to compare outcomes of auditory perceptual assessment with instrumental assessment. Instrumental measurements were compared with results of perceptual analysis using either the conventional ordinal (ORD) scale or the modified visual analog (mVA)14 scale. Objective measurements included acoustic, aerodynamic, and physiologic parameters as well as parameters based on nonlinear mathematics (Lyapunov coefficient). Results demonstrate that the correlation between perceptual and objective voice judgments is better using an mVA scale than a conventional ORD scale (concordance, 88% versus 64%). Data also indicate that the mVA scale described herein improves the correlation between objective and perceptual voice analysis.

Other studies have used the GRBAS to examine the interrelationship between acoustic parameters.15., 16. These investigators showed that the acoustic and physiologic measures and GRBAS measures were significantly related to each other.

The present study seeks to improve the understanding of the relationship between patient-based measures of quality of life using the V-RQOL Measure and the clinician's perceptual assessment of dysphonia severity. The specific purpose of this study was to determine the relationship between clinician's assessment of voice disorder severity using the GRBAS scale and the patients' perception of voice-related quality of life using the V-RQOL Measure in a group of patients whose primary complaint was voice related. It was hypothesized that there is a relationship between ratings of voice-related quality of life using the V-RQOL Measure and clinician's rating of voice severity using the GRBAS scale in patients with voice disorders. A group with no history of voice disorders was also included.

Section snippets

Subject population

Fifty consecutive patients with a chief complaint related to their voice seen at the Voice and Swallowing Center at Columbia University during the period from September 1 through December 21, 2002 completed the V-RQOL questionnaire prior to being examined. The 50 patients consisted of 29 women and 21 men who ranged in age from 22 to 90 years (mean, 59.7 years). Only patients with no history of neurological disease, previous laryngeal disease, or laryngeal surgery composed the total voice group

Reliability

Two experienced speech-language pathologists independently scored 25 subjects with a voice disorder. Reliability measures were obtained for each of the five parameters of the GRBAS. Thus, a total of 225 judgments were made by each of the clinicians. For the normal control group, there was near-perfect agreement on all GRBAS parameters between the two judges. For the voice subjects, the two judges had reliability coefficients that ranged from 0.88 on the S parameter to 0.98 on the G parameter as

Discussion

The two clinicians were found to be reliable in their ratings of severity using the GRBAS scale. These results agree with previous studies of reliability that found that clinicians reliably rate the five parameters of the GRBAS.6., 7. For both the normal subjects who had no voice complaints and those with a chief complaint of a voice disorder, the two clinicians had very little disagreement. As with a previous study,8 in this study, the greatest number of disagreements was found for the S

Cited by (104)

  • Radiofrequency ablation of intubation granulomas

    2022, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
  • Adaptation and Validation of the Voice-Related Quality of Life Measure into Kannada

    2022, Journal of Voice
    Citation Excerpt :

    These tools include the Voice-Related Quality of Life (V-RQOL),9 the Voice Handicap Index (VHI),10 and Voice Activity and Participation Profile (VAPP).11 Of all these assessment tools, V-RQOL is one of the essential self-reported tool to document the quality of life in relation to voice.12 It also helps to understand the individual's perception of their voice and their present reaction to voice disorders.

View all citing articles on Scopus

Presented at 32nd Annual Symposium: Care of the Professional Voice, June 7, 2003, Philadelphia, PA.

View full text