Related to the reply to the letter to the editor about the application form and calculations of Voice Symptom Scale (VoiSS)

Dear Mrs. Scientific Editor of Magazine CEFAC

Prof. Dr. Simone Aparecida Capellini,

Greeting you and all the colleagues, through this we will hold the clarifications requested by the UNIFESP speech group on some highlighted aspects relating to research article "Vocal symptoms of professional voice future"¹, following the order of the scientific concerns raised in "Letter to the Editor" and thanking you for your contribution.

1. The wording of the inclusion criteria "female or male"¹ (p.35) shows that both sexes were included in the study and not just one of them, which consists with other papers that used the same criteria^2)-(7.

The wording of the inclusion criteria "be coursing college or technical will require the use of the spoken voice for acting"¹⁾ (p.35) explicit that would be included subjects who use the spoken voice as a requirement of their future profession, which included all those future voice professionals subject, considering the basic concept and extensive knowledge in the speech therapy that "the professional voice is the individual who depends on a certain production and or specific vocal quality for the professional survival⁸ (p.288)". The division between voice professionals and not professional voice users, directly or indirectly based on this concept, also occurred in other published works^2),(9)-(13.

Still, at the methods, it is clear who were the future professionals of the spoken voice considered in the study, after applying the inclusion and exclusion criteria: "The future professions of the participants of the study subjects were pedagogy, physical education, special education and social sciences (journalism and marketing)¹ (p.35)", which was also described similarly in other studies^2),(14.

2. Exclusion criteria "individuals in the present or past acted in occupations that required the professional use of voice"¹ (p.35) reinforces the objective of the research to assess future voice professionals, that is, subjects in training, inexperienced on professional voice.

The exclusion criterion "future professionals of the voice sung^"(1) (p.35) reinforces the inclusion criteria" to be performing on college or technical that will require the use of the spoken voice for action"¹ (p.35).

3. The group of speech colleagues states that "the screening tool was presented inappropriately. The VoiSS¹⁵, in the same way that the original instrument VoiSS¹⁶, is a self-assessment instrument of voice symptoms and the impact of a voice problem, consisting of 30 items, with partial and overall scores obtained by simple summation and not average. In that article¹, the authors incorrectly used the VoiSS¹⁵ as a list of symptoms, the individual may have from zero to 30 voice symptoms, giving a wrong interpretation of the instrument and its calculation method. The VoiSS¹⁵⁾ is not a vocal list of problems, from which is obtained an average value of quantity of vocal problems, expected frequency, positive and negative aspects, as calculated and shown in Tables 1 to 5 of the study. In addition, the VoiSS¹⁵ is a perfect classifier tool, with a cutoff value of 16 points, as previously published in easily access magazines ^15),(17. This amount could have been used as a criterion for passes or fails the screening. "

The VoiSS had just published its cultural equivalence for Brazilian Portuguese¹⁸⁾ at the time of closing and approval of our article, which occurred in mid-2013, although much later published¹, but still it was not published its validation and cut-off point¹⁵. Thus, contrary to the claims of colleagues, we applied the VOISS exactly as recommended by the available literature^16),(18, from 30 items, with responses by frequency of occurrence for each item, its partial and total scores obtained by simple addition, and explained in Tables 6, 7 and 8 and this form of application did not change with subsequent publications^15),(19. The means and other types of analysis were used to extend the characterization of groups and according to additional variables analyzed in the same study as described in the method of our article¹ (p.36).

In this context, considering the use of VoiSS adapted to Brazilian Portuguese and applied and tabulated according to the indications which have remained until now, even with the post-2013 publications^15),(19, our article did not apply the cutoff point published later in 2014: "A cutoff score of 16 was determined to discriminate individuals with dysphonia from the vocally healthy subjects confirming the use of this instrument as a screening measure for individuals with dysphonia and high-risk populations"¹⁵ (p.464).

Without access to a paper published in the future, we consider that the statistical analysis of the data and their interpretation were carried out in a logical and acceptable way in the absence of other parameters and not consider it as "a wrong interpretation of the instrument" and, yes, viable alternatives interpretation of the data shown in Tables 1-5 of our study¹.

In our article¹, there are: analysis of age and amount of vocal symptoms reported by the future voice professionals, averaging 11.38 problems of a total possibility of 30; frequency of occurrence of symptoms, most often symptoms "you cough or clear your throat" and "you have trouble speaking in noisy places" and statistically significant difference; occurrence of symptoms between the sexes without significant difference between men and women; comparing amount of symptoms with gender, body mass index (BMI) and age group, without significant differences; correlating the amount of symptoms with age and BMI, without significant differences; comparison of the subscales of the VoiSS between men and women, without significant differences; crossing the subscales of VoiSS and age groups, with no significant differences; Comparison of subscales of VoiSS and BMI of individuals, with no significant differences.

The analyzes mentioned above were thoroughly discussed in the literature, as explained in the item "discussion" of our article, lying similarities with other research papers¹ (p.40). Even if the work was completed today, I find some similarities with the findings of Santos et al.²⁰⁾ on self-perception and vocal quality of journalism students (future voice professionals) and the work of FABRON et al.²¹⁾ performed with students of Pedagogy (future professionals of the voice).

It is observed that many studies on spoken voice use these types of analyzes, which enables more effective discussion between the results of work^{2),(3),(6),(7),(11),(12),(14),(19)-(30}.

It should be noted also, the work published using the VOISS in dysphonic patients and presented, for example, its Table 1¹⁹ (p.332) with the same kind of data structure and results of Tables 6, 7 and 8¹ (p.39-40), occurring even in Tables 1, 3, 4 and 5 of validation work of VoiSS¹⁵ (p.460-2), both further studies to ours.

In addition to the balance sheet date and approval of the article¹ be earlier (mid-2013) to the validation of VoiSS¹⁵, on our analyzes about the means and frequency feature (described statistically) of our sample we didn't make inferences to the entire target population of future professional voice.

4. The value obtained with the total mean score of VoiSS of the study group ranged from 43.28 to 55 points (Tables 7 and 8)¹ (p.39-40) and the opinion of the working group is that such an outcome "does not characterize them as future voice professionals, but as a dysphonic group that sought a screening in a campaign share of voice for treatment of a pre-existing condition"

The group consisted mainly of future professional voice prior to data collection and obtaining results through the inclusion and exclusion criteria. It was precisely the found results that showed that group of future professional voice had higher scores on VOISS¹(Tabelas 6, 7 e 8, p.39-40), evidencing that could be considered at high risk for vocal disorder when initiate their demands as voice professionals, which is explained in the conclusion¹ (p.41).

Even if we had access in 2013, to the VoiSS valid article published in 2014, the conclusion of the same says: "A cutoff score of 16 was determined to discriminate individuals with dysphonia from the vocally healthy subjects confirming the use of this instrument as a screening measure for individuals with dysphonia and high-risk populations"¹⁵ (p.464). This reinforces that our sample could be considered at risk of voice disorders and not necessarily as a group of dysphonic because of their high scores, as the conclusion of our article: "The group of future voice professionals analyzed showed high average of vocal symptoms, highlighting the cough or hoarseness and difficulty on speaking in noisy places directly related to incorrect vocal uses. With the increase of professional vocal demand, these individual may be at risk for the development of voice disorders " ⁽¹ (p.41).

Colleagues still place: "It is not clear how many individuals failed to evaluation; However, the occurrence of dysphonia in the general population varies from 3 to 8% and can reach 20% in professional use categories of voice. The article suggests that this percentage is much higher. It should also be considered possible biases in the collection and analysis of data. We still do not know what was done with these subjects, if they were referred for medical and / or clinical assessment. "

In our article does not appear that any of the subjects failed on the evaluation. However, as provided in the Free Consent and Informed, there are mandatory criteria such as routing and guidance of the subjects participants (expected benefits), as the objective of the research, which took place in this as in all other work of our own. It is noteworthy that most of the work cited in this document does not provide this information, probably for the same reason that we aimed.

Regarding the literature on the prevalence of dysphonia, values vary according to the assessed region, the target population, sample, data collection instruments, among other variables. Studies about spoken voice show that the prevalence of some degree of dysphonia, assessed or self-reported in individuals who use their voice at work can reach 35,5%²⁹, 43,3%³¹, 48%⁷, 50%^22),(32, 70%^33),(34, 80,7%³⁵, 85%²⁶ e até 97,2%³⁶, among others, a percentage higher than the 20% mentioned by colleagues.

Brazilian studies on the occurrence of dysphonia in the general population suggest variation higher than the 3-8% mentioned by colleagues. "From a total of 963 medical records present in the speech therapy outpatient file at Hospital of the Federal University of Minas Gerais, representing 336 individuals with complaints and / or voice disorders(...). "This number represents 34.8% of all records ", The most aren't professional of the voice⁹ (p.3222). Eighty-four subjects, half with arterial hypertension and half not carrier, responded to the Quality Protocol life in Voice (QLV) noting in conclusion that "(...) Hypertensive and non-hypertensive individuals had scores below what is expected for subjects with healthy voices, without vocal complaints(...)³⁷ (p.133)". At the National Campaign of Voice in 2012 in São Paulo / SP, through information from 1,800 records of attendance, it was found among the complaints: Hoarseness / changed voice (15.4%), dysphagia (9.4%) , cough (4.1%), neck pain (3.6%), other complaints (5.3%), and 50.4% of the sample with more than one complaint, which is higher than the 3-8% referred by colleagues, even considering that 36.1% (1358 subjects) reported their use of the voice¹⁰.

A group of 20 young women, not voice professional, without history of previous dysphonia, without vocal training or sports and leisure activities that characterized the continued use of the voice, without gastroesophageal reflux disease, hormonal changes, allergies, respiratory diseases ,hearing impairment, neurological or psychiatric, non-smokers, drug users and continuous medications such as antihistamines, antidepressants, antihypertensives, hypoglycemic and anti-inflammatory, passed through perceptual voice assessment carried out by five judges through GRBASI scale.

The results showed the presence of general degree change, roughness and breathiness in mild¹³.

5. At this point, colleagues put: "Uncertainty in the references of the article. The correct reference VoiSS¹⁵⁾ is the validation of the article published in 2014 and not the thesis of the abstract published in 2012, as used by the authors. Moreover, the reference of the adjustment culture¹⁸ of VOISS was spelled wrong as 'Cross-cultural adaptation of the Brazilian version of the voice symptoms scale: VoiSS' when in fact the correct title of the publication is 'Cultural equivalence of the Brazilian version of the Voice Symptom Scale - VoiSS'¹⁸."

There was an error in the spelling of 'Cultural equivalence of the Brazilian version of the Voice Symptom Scale - VoiSS'¹⁸. And as mentioned earlier, the questioned survey was conducted based on the references available until the year 2012, closing time and subsequent review and approval of Article 2013 (published only in 2015) ⁽¹⁾ and, therefore, even without the existence of the later works cited by the group of colleagues, including the study of validation of VOISS⁽¹⁵⁾ .

In the end, colleagues put; "We are deeply concerned at the consequences of the errors and inaccuracies pointed out in that Article. (...) Concerned by the serious results of a survey that is characterized as a screening action for the World Voice Day which, in conclusion, to characterize the subjects as people with voice disorders. "

We reiterate that we described statistically, and ethically, our sample, we never did inferences for the whole target population, did not claim that the group had vocal disorder and emphasize two sections discussing our article¹: "From this perspective, it can be seen that future voice professional of this work may already have one installed vocal disorder, or develop it with increasing vocal demand (p.40)"; "The high frequency of occurrence of vocal problems or limitations in this study shows that future voice professionals may already be considered a risk group for development of vocal disorders (p.41).

The same applies to the conclusion of the article¹ (p.41) that does not match on what colleagues wrote: "The group of futures voice professionals analyzed showed high average of vocal symptoms, highlighting the cough or hoarseness and difficulty speaking in noisy places directly related to incorrect vocal uses. With the increase of professional vocal demand, these individual may be at risk for the development of voice disorders."

And yet, these inferences are consistent with the passage cited above from further publication, "A cutoff score of 16 was determined to discriminate Individuals with dysphonia from the vocally healthy subjects confirming the use of this instrument as a screening measure for Individuals with dysphonia and high-risk populations " ⁽¹⁵ (p.464).

The results found through our research were properly collected and interpreted and correspond to the reality, even if they differ from some work (and consistent with others), showing that the search for truth in science is never exhausted, is a path taken by many professionals and must continue in its inquiries.

Finally, we thank the detailed attention of the group of the colleagues dedicated to criticism of our article on the grounds of improving the Speech and Hearing Science.

We also thank the editor of Magazine CEFAC and referees, qualified colleagues who contributed technically and in style, ethics and scientific during the evaluation process and adequacy of the manuscript and upon approval of the same by mid-year 2013.

Regards,

Dra. Carla Aparecida Cielo e Ms. Carla Franco Hoffmann

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Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  08 Nov 2015
• Accepted
  08 Dec 2015