Relation between voice self-assesment and clinic evaluation data in dysphonic individuals

Purpose: to associate the rates of vocal self-assessment and clinic evaluation data from of dysphonic individuals. Methods: observational, descriptive and retrospective study. It were studied medical records of patients treated at a school-clinic of Speech Language Patology in the period from 2007 to 2011. Data were presented regarding the vocal self-assessment (voice related quality of life, vocal handicap index and assignment of note regarding the impact vocals), anamnesis (sex, age, occupation, type of abuse, duration of abuse, previous treatment for dysphonia), perceptual evaluation (vocal quality, degree of alteration, pitch, loudness, resonance, articulation and CPFA) and objective data (maximum fonation time and relation between consonants s / z). Data were statistically analyzed. Results: there was no difference in comparing the scores of voice related quality of life, vocal handicap index with variables related to gender, vocal quality, grade of dysphonia, pitch, resonance, articulation, rhythm of speech and type of dysphonia. Individuals with pneumophonoarticulatory incoordination, who use their voice professionally and who have made previous treatments for dysphonia were the worst rates in the vocal self-assessment. There were no correlations between rates of vocal self-assessment and other continuous variables (age, duration of abuse, maximum phonation time and relation s / z). Conclusion: the vocal self-assessment is a very subjective impression, and is independent of most of data collected in the clinical evaluation. Being professional voice, already have had other previous treatments for dysphonia, and incoordination pneumophonoarticulatory seem to influence negatively on the individual’s self-assessment about the impact of dysphonia in his/her daily life.

by the course professors.It was excluded only the data with wrong measurement proven.From vocal anamnesis were collected data as gender, age, profession, complaint time, and previous treatment undertaken to voice problems.From perceptual evaluation were collected data regarding voice quality, deviation degree, pitch, loudness, articulation, resonance, speech rate, pneumo-phonoarticulatory coordination (PPAC), and respiratory type.As for the objective measures, it was included only the data regarding Maximum Phonation Time (MPT), and s/z relation.Speech-language pathology diagnose hypothesis regarding the dysphonia type (functional, organic-functional or organic) were also collected.
It was still tabulated the results regarding voice self-assessment variables (voice related quality of life).It was considered only the total mean scores (main domain) from V-RQOL and VHI questionnaires.Furthermore, it was considered the "dysphonia impact value": About the V-RQOL 6 , quality of life questionnaire, as closer to 100 (maximum value) as better is the subject's self-assessment.Calculation is performed trough specific formula.About VHI 7 , total punctuation is 120 points.Since this is a handicap questionnaire as higher the obtained value as higher the dysphonia impact in subject's life.
The Dysphonia Impact Value is attributed by the patient with a simple question asked by the evaluator.The patient is guided to attribute a note from 0 to 10 to the voice problem impact in his daily life, as 0 pointing none impact and 10 pointing maximum impact.
From tab, the data were statistically analyzed.The non-parametric tests of Mann-Whitnney (two groups) and ANOVA of Kruskall-Wallis (more than two groups) were used in the association between the indexes of voice/quality of life in voice selfassessment and the other categorical variables.Pearson correlation was used to correlate the self-assessment data to continuous variables.To all analysis it was adopted the significance level of 0.05.
It was considered as real associations those that were at least related to two of the three vocal selfassessment indexes (V-RQOL, VHI, and Impact).Therefore, two or more values in determined crossing should be statistically significant or tending to difference to indicate possible real association and the other searched variable.It was opted to consider the tendencies to statistically significant differences (p>0.05 and <0.15), once the reduced size sample may exist an error type II 21 .
In Brazil most part of researches performed with the questionnaires quoted above has focus in the self-assessment specific group results, as for voice professionals' category or diverse pathology carriers [11][12][13][14][15] .In some cases, the data collection meet the subjects, which not necessarily have a voice disturb and/or sought for speech language pathology help 11,12 .
Although there are researches looking for relating voice self-assessment to voice clinic assessment of dysphonic subjects [16][17][18][19][20] , these relations still need to be more clarified and deeply investigated.That is because, in practice the results many times occur diverse from the expected or different from which is pointed out by literature as probably determined for that kind of case.
The Speech Language Pathology School Clinic of Universidade Estadual do Centro-Oeste/ Unicentro-PR attends every month patients with vocal complaints that seek for speech-language assistance.There are standards to assessment procedures and the collected data are included in the patients' individual record.It is considered fundamental to better understand the relation between the dysphonia impact in life of the person and clinical assessment in order to offer a service to the patient's real need, considering his own particularities and characteristics.
Therefore, the purpose of the present research was to associate the voice self-assessment to the voice clinic assessment data of dysphonic subjects.

METHODS
This is an observational, descriptive, and retrospective study.The project was approved by the Ethic Committee of Universidade Estadual do Centro-Oeste, under protocol number 216/2009.The data collection was performed in School Clinic of Speech and Language Pathology of Universidade Estadual Centro-Oeste -UNICENTRO-PR.
It was analyzed 116 patients' records of voice clinic from 2007 to 2011.Hence, it was searched to select the records having information regarding voice self-assessment and voice related quality of life.From total, only 51 had the information regarding the indexes of Voice-Related Quality of Life (V-RQOL) 6 , 34 had the Voice Handicap Index (VHI) 7 , 37 had the "Impact of Dysphonia Value", and only 18 had Voice Activity and Participation Profile (VAPP) 8 .Due to the significant loss it was chosen to not include the data regarding VAPP in the present study, once statistical analysis was frustrated.
Records data were collected as they were reported at evaluation moment, in which the procedure follows the specific protocol developed In table 2 are presented the values regarding the relation among the scores of V-RQOL, VHI, and "Impact Value" and the categorical values regarding the main data of voice perceptual evaluation.There was no difference in the comparison among the indexes of self-assessment and the variables of voice quality, deviation degree, pitch, and loudness.Other variables not presented in the table, as resonance articulation, speech rate, and respiratory type did not had association statistically significant when compared to the vocal self-assessment indexes.Subjects that had pneumo-phono-articulatory incoordination (PPAI) had the worst selfassessment indexes in V-RQOL and VHI.

RESULTS
Table 1 has data of the association among the V-RQOL, VHI, and "Dysphonia Impact Value" and the categorical variables regarding anamnesis (gender, profession, and previous treatment undertaken due to dysphonia).There was no statistical difference in the comparison between men and women.However, subjects that reported had already searched by other treatments to dysphonia had worst vocal selfassessment index in V-RQOL and VHI.The voice professionals attributed higher values regarding the measurement of dysphonia impact (from 0 to 10) in their daily lives and presented the worst indexes in V-RQOL and VHI.similarly to V-RQOL, VHI, and the question about the dysphonia impact in life (note from 0 to 10)table 3.
Speech language diagnose hypothesis did not had statistical association when compared to self-assessment indexes.Subjects with functional, organic-functional, and organic dysphonia respond Table 4 shows the correlation among the V-RQOL, VHI, and "Impact Value" to the other continuous variables.There was no statistical difference among the scores of self-assessment and the complaint time, maximum phonation time (MPT), s/z relation variables.In variable age correlation there was a slight difference pointing a correlation (<0.4).Therefore, none correlation was considered significant.

DISCUSSION
The obtained data in the present study allow inferring that are still a long way to better understand the factors, the characteristics, and the situations that cause in the dysphonic subject more or less affected by the voice problem in his daily life.It seems clear that the self-assessment is quite subjective and overlaps major part of the attempt to relate with voice characteristics and patient history.
When the indexes of self-assessment are related to identity and history data interesting associations were obtained.In the comparison between men and women there was no difference in the mean scores of V-RQOL, VHI, and Impact Value.This finding corroborates previous research that compared the indexes of men and women with vocal complaint deserve to be more studied.It is believed that the big discomfort generated by PPAI during the communication process may justify its association with worst indexes in quality of life in voice.
Some previous studies point out that subjects with organic dysphonia have worst scores in selfassessment voice questionnaires [6][7][8] .In the present study, self-assessment was similar among the patients, independent of the speech language diagnose hypothesis assigned.This aspect also deserves a broad discussion about dysphonia classification.Some types of functional dysphonia, for instance, may generate a damaged quality of life, which is the case of dysphonia due to incomplete vocal change.On the other hand, some types of organic dysphonia, as the ones related to gastro-esophageal reflux or presbyphonia, for instance, may generate lower impact regarding selfassessment.The patients included in the sample are quite heterogeneous about the probable voice problem etiology.It is possible that if there were in this study a higher demand of organic dysphonia, by head and neck cancer, the obtained results would be different, with a worst self-assessment of these subjects when compared to others.
Other aspect that deserves spotlight is the absence of statistical correlation between selfassessment indexes and the subjects' age.A previous study pointed out that dysphonic patients aging from 20 to 29 years had better indexes in quality of life in voice when compared to patients in higher age range 16 .In other research with subjects without vocal complaint, it was not observed differences in voice self-assessment in different age ranges 23 .It is believed that the obtained results may have relation with the sample heterogeneity of the present study and with the subjectivity existent in voice self-assessment.Similarly to age, the complaint duration time/symptoms also did not influence the subject's self-assessment, pointing out that this variable also do not allow inferences about the dysphonic subjects profile regarding quality of life in voice.
It is pointed out that in a retrospective study may imply an important loss of data.This was clear in the present study, once from the 116 records analyzed less than half had the information about the voice self-assessment and the dysphonia impact in subject's life.It is important that the student of Speech Language Pathology graduation course to be more and more investigative and reflect about the important relation existent among these indexes and patient clinic evolution (prognosis, adherence, etc).This will allow higher sensibility facing the particularities and specificities of the patients that seek for specialized help due to vocal complaints.and obtained similarity between them 16 .This data call the attention since it points out that even history reporting women present more voice problems and seek more assistance than men 22 , it is likely that independent of gender, hence the subject seek for specialty help is because he already realized the dysphonia impact in his daily life.
Another interesting data was finding that subjects that had already sought other types of assistance to dysphonia had the worst vocal self-assessment index and voice related quality of life.It is possible to infer that these patients had already demands, symptoms, and complaints longer and that could generate permanent voice disturbances, without great improvement and worsening factors, consequently with higher vocal impact in daily quality of life.It is also possible to infer that subjects that undertake voice therapy develop higher voice self-perception.
Regarding occupational data, voice professionals self-evaluated themselves with more criticism than non-professionals.That may occurred because this group, in general, develops higher voice perception through time.Besides, a small voice problem to a patient with reduced voice demand (not a voice professional) may be a big impact to those needing their voices as main work tool.A study that sought to relate the quality of life in voice indexes to socialdemographic variables in subjects without voice complaints observed that the voice professionals tend to be more rigorous in self-assessment and, therefore, to present worst questionnaires indexes 23 .
In a previous study, performed with teachers, the authors concluded that VAPP is a quite sensible tool to evaluate the dysphonia impact in the voice professional life 24 .This reinforces the idea that even longer and more complex to respond by the patient it is worthy to include this questionnaire in voice clinic routine.Remembering that, VAPP data were not considered in statistical analysis, because only 18 records had this instrument data.
When self-assessment data were compared to the perceptual evaluation, few associations could be observed.Subjects with pneumo-phono-articulatory incoordination (PPAI) had the worst index of quality of life in voice.Loudness variable was not considered since only had association to one tool, which may indicate association by chance.It was not found researches that related indexes of selfassessment with each one of the perceptual evaluation apart.Therefore, to elucidate and confirm these possible relations, it is suggested the development of new studies, with a higher number of analyzed patients.Although it is clear in literature that PPAI may also damage communication fluency 25 , the relation between the "damage" and quality of life

CONCLUSION
Vocal self-assessment is quite subjective impression and independent from major part of collected data in voice assessment.To be a voice professional, to have already searched previously treatment to dysphonia, and to have pnemo-phonoarticulatory incoordination are factors that may influence negatively self-assessment of the dysphonic subject regarding the dysphonia impact in daily life.
On the other hand, this kind of study allows to make a real diagnose about the functioning of a service and this aspect is of the main importance to draw speech-language actions.
It is important that the next studies search to relate the self-assessment indexes to other important variables, as the vocal complaint type, the symptoms and vocal habits reported by the patient.Besides, to have a bigger sample may be fundamental to elucidate some of the hypothesis raised in the present study.

Table 1 -Association among voice self-assessment indexes, and gender, profession and previous treatment variables.
*p<0.05; Mann-Whitnney.-** n values correspond to the number of patient records that had the information regarding the two analyzed variables.** Possibility of error type 2 due to frontier p-values Subtitles -VHI: Voice Handicap Index; V-RQOL: Voice-related quality of life; Impact: Dysphonia impact in daily life; n: subjects number; SD: standard deviation; CI: confidence interval.

Table 2 -Association among vocal self-assessment and categorical variables regarding voice perceptual evaluation.
*p<0.05; *ANOVA of Kruskall-Wallis and *Mann-Whitnney.-**n values correspond to the number of records that had the information regarding the two analyzed variables -***value probably attributed by chance; **** possibility of error type 2.Subtitles -VHI: Voice Handicap Index; V-RQOL: Voice-related quality of life; Impact: Dysphonia impact in daily life; n: subjects number; SD: standard deviation; CI: confidence interval.

Table 3 -Association among vocal self-assessment indexes and speech-language diagnose hypothesis.
*p<0.05; ANOVA of Kruskall-Wallis.-** n values correspond to the number of records that had the information regarding the two analyzed variables.Subtitles -VHI: Voice Handicap Index; V-RQOL: Voice-related quality of life; Impact: Dysphonia impact in daily life; n: subjects number; SD: standard deviation; CI: confidence interval.

Table 4 -Correlation among vocal self-assessment indexes and the others quantitative variables.
*p<0.05; Pearson Correlation.Subtitles -MPT: maximum phonation time; VHI: Voice Handicap Index; V-RQOL: Voice-related quality of life; Impact: Dysphonia impact in daily life.