Abstract: The present study was designed to answer the following questions: (a) What is the level of awareness patients with Bulimia Nervosa (BN) and the professionals who work with them regarding the vocal health risks associated with self-induced vomiting? (b) Is the bulimic population at risk for under-referral for assessment and treatment of vocal pathology? (c) How do patients and professionals perceive the role of the Speech-Language Pathologist (SLP) in the treatment of eating disorder-related vocal pathology? Three original surveys were developed to address the research questions. There was one survey for individuals with a history of BN, one for SLPs, and one for other health care professionals involved in the care of bulimic individuals. There were 89 total participants in the present study. Thirty were respondents to the Health Care Providers Survey, 28 were respondents to the SLP Survey, and 31 were respondents to the Patient Survey. Results indicate a general lack of awareness concerning these risks and treatment options to address them on the part of patients and health care professionals and a lack of specific knowledge of how to recognize and treat individuals with BN on the part of SLPs. Results from all three groups supported the notion that the bulimic population is at risk for under-referral for treatment for voice disorders. Finally, results suggest that SLPs do in fact provide services to persons with BN, but that at present, patients and other health care professionals do not seem to perceive the SLP as having a role in management of care of this population. / text

abstract: Individuals with voice disorders experience challenges communicating daily. These challenges lead to a significant decrease in the quality of life for individuals with dysphonia. While voice amplification systems are often employed as a voice-assistive technology, individuals with voice disorders generally still experience difficulties being understood while using voice amplification systems. With the goal of developing systems that help improve the quality of life of individuals with dysphonia, this work outlines the landscape of voice-assistive technology, the inaccessibility of state-of-the-art voice-based technology and the need for the development of intelligibility improving voice-assistive technologies designed both with and for individuals with voice disorders. With the rise of voice-based technologies in society, in order for everyone to participate in the use of voice-based technologies individuals with voice disorders must be included in both the data that is used to train these systems and the design process. An important and necessary step towards the development of better voice assistive technology as well as more inclusive voice-based systems is the creation of a large, publicly available dataset of dysphonic speech. To this end, a web-based platform to crowdsource voice disorder speech was developed to create such a dataset. This dataset will be released so that it is freely and publicly available to stimulate research in the field of voice-assistive technologies. Future work includes building a robust intelligibility estimation model, as well as employing that model to measure, and therefore enhance, the intelligibility of a given utterance. The hope is that this model will lead to the development of voice-assistive technology using state-of-the-art machine learning models to help individuals with voice disorders be better understood. / Dissertation/Thesis / Doctoral Dissertation Computer Science 2020

Analisou-se os níveis de sintomas de ansiedade e depressão em indivíduos disfônicos e indivíduos sem alterações vocais. Verificou-se correlação entre os traços de ansiedade e depressão com a percepção dos indivíduos disfônicos e não disfônicos sobre sua qualidade de vida em voz e os sinais e sintomas de desconforto do trato vocal. Participaram 62 indivíduos, 31 pacientes com disfonias funcionais ou organofuncionais, e 31 não disfônicos, com idades entre 18 e 55 anos. Todos responderam a Escala de Desconforto de Trato Vocal (EDTV), protocolo de Qualidade de Vida em Voz (QVV), Escalas de heteroavaliação de Hamilton para Ansiedade e Depressão (HAM A e HAM D), e Escalas de autoavaliação de Beck para depressão e IDATE traço e estado para ansiedade. Os resultados foram submetidos aos testes estatísticos de Mann-Whitney, Qui-quadrado e Teste de Correlação de Spearman, considerando significância de 5%. As médias de escores obtidas foram: HAM-A iguais a 17,72 e 7,53; HAM-D 11,22 e 4,28; IDATE-E 44,31 e 36,75; IDATE-T 44,63 e 35,47; BECK 12,22 e 6,72, para os disfônicos e para os não disfônicos, respectivamente (p≤0,03). Foi encontrada correlação entre o QVV e os sinais e sintomas de ansiedade e depressão quando analisado o grupo todo, mas esta correlação não se repetiu quando analisado separadamente o grupo de disfônicos. O grupo de não disfônicos apresentou correlações regulares entre o domínio físico do QVV e HAM-A, IDATE-E, IDATE-E e Beck e correlação forte com HAM-D; correlações regulares entre o domínio sócio emocional do QVV e IDATE-T e Beck; no domínio total do QVV houve correlação regular com HAM-A, IDATE-T, IDATE-E e Beck e correlação forte com HAM-D. Em relação às queixas pesquisadas no EDTV e os escores das escalas de avaliação psicométrica, foi encontrado para o grupo todo correlações moderadas entre quase todos os parâmetros pesquisados, com exceção para cinco correlações fortes: entre frequência de queimação e IDATE-T, frequência e intensidade de coceira e HAM-A, frequência de garganta irritada e HAM A e entre intensidade de garganta irritada e IDATE-T. Analisando os indivíduos disfônicos foi encontrada correlação forte entre frequência de sensação de secura na garganta e HAM-A e graus moderados em apenas 11 dentre as 80 correlações analisadas, considerando-se frequência e intensidade dos sintomas do EDTV. No grupo de não disfônicos foi encontrada correlação forte entre frequência de aperto e IDATE-T e graus moderados em 40 das 80 correlações pesquisadas entre as queixas que compõem o EDTV e as escalas psicométricas. Os indivíduos disfônicos apresentaram maiores níveis de ansiedade e depressão do que os não disfônicos, assim como houve maior número de indivíduos disfônicos com ansiedade e depressão em categorias nosológicas mais graves em todos os protocolos psicométricos utilizados. Houve maior número de correlações entre as escalas de ansiedade e depressão com os escores de qualidade de vida em voz e de desconforto do trato vocal para os indivíduos não disfônicos do que para os disfônicos. / The levels of anxiety and depression in dysphonic individuals and individuals without voice alterations were analyzed. It was verified a correlation between anxiety traits and depression with the perception of dysphonic and non-dysphonic individuals over their quality of life in regards to voice and signs and symptoms of discomfort of the vocal tract. 62 individuals were involved, being 31 patients with functional or organic-functional dysphonia, and 31 non-dysphonic, with ages ranging from 18 to 55 years old. They have all answered to Vocal Tract Discomfort (VTD), Voice-Related Quality of Life (V-RQOL), Hamilton Rating Scale for Depression (HAMA and HAMD), and Beck Depression Inventory and State-Trait Anxiety Inventory (STAI). The results were submitted to Mann-Whitney U, Chi-Squared and Spearman Correlation tests considering 5% significance. The average score were: 17,72 and 7,53 at HAM-A; 11,22 and 4,28 at HAM-D; 44,31 and 36,75 at STAI-S; 44,63 and 35,47 at STAI-T; 12,22 and 6,72 at BECK, for dysphonic and non-dysphonic, respectively (p≤0,03). Correlation was found between V-RQOL and the signs and symptoms of anxiety and depression when the whole group was analyzed, however this correlation was not repeated when separately analyzed the dysphonic group. The non-dysphonic group has shown no regular correlation between the physical domain of V-RQOL and HAM-A, STAI-S, STAI-T and BECK and Strong correlation with HAM-D; regular correlation with the socio-emotional scores of V-RQOL and STAI-T and BECK; at the complete V-RQOL scores were found regular correlations with HAM-A, STAI-T, STAI-S and BECK and strong correlation with HAM-D. In regards to complaints reported at VTD and the scores at psychometric assessments, moderated correlations were found for the whole group in almost all of the researched parameters, with exception to 5 strong correlations: burning sensation frequency and STAI-T, itching frequency and intensity and HAM-A, sore throat frequency and HAM-A and between sore throat intensity and STAI-T. Upon analysis on the dysphonic individuals was found strong correlation between dry throat feeling frequency and HAM-A, and moderated levels in only 11 of the 80 analyzed correlations, considering frequency and intensity of VTD symptoms. In the non-dysphonic group was found strong correlation between tight throat and STAI-T and moderate levels in 40 of 80 researched correlations which compose the VTD and psychometric scales. The dysphonic individuals presented higher levels of anxiety and depression than the non-dysphonic, as well as a higher quantity of dysphonic individuals with depression and anxiety on more severe nosological categories in all psychometrical protocols utilized. There were a bigger number of correlations between the anxiety and depression scores and the voice-related quality of life and voice tract discomfort for non-dysphonic individuals than for dysphonic ones.

Objetivos: analisar a postura corporal em pacientes disfônicos e correlacioná-los com indivíduos sem alteração de voz, a fim de estabelecer novos recursos terapêutico para reabilitar o portador de disfonia. Método: estudo prospectivo. Foram avaliados 43 indivíduos (23 disfônicos e 20 sem alteração de voz) do sexo feminino,com idade entre 18 e 40 anos ,sem alterações neurológicas ,respiratórias e reumáticas. Todos os pacientes foram encaminhado pelo serviço de Otorrinolaringologia da Escola Paulista de Medicina ( UNIFESP- EPM),após anamnese, exame do otorrinolaringologista e laringoscopia ,tendo como diagnostico de disfonia funcional ou organofuncional. Nessa população foi avaliado: 1- Postura corporal in loco, 2 – Documentação fotográfica, 3 – Exame Eletromiografia, 4 – Questionário das algias. Resultados: não houve diferença estatisticamente significante em relação à queixa,porem foi encontrado um numero maior de tensão muscular e dor na região cervical, onde se encontra situado a laringe, nos portadores de disfonia. Na avaliação postural, os indivíduos disfônicos apresentarão assimetria de ombros, alteração no posicionamento da escapula, retificação com anteriorização da região cervical em relação ao grupo controle. Nos resultados da eletromiografia houve aumento das atividades nos músculos supra-hióideo em emissão prolongada, controlada e deglutição. Nos músculos infra-hióideo houve alteração no traçado eletromiógrafico na emissão prolongada. Conclusão: pode- se concluir que o estudo mostra a existência da correlação positiva entre indivíduos portadores de disfonia e alteração na postura, baseado nas diferenças dos achados clínicos e medidas eletromiográficas. / Objectives: This study analyzed the body posture of dysphonic patients and correlated them with individuals without voice alterations, in order to establish new therapeutic resources to rehabilitate the patients with dysphonia. Method: prospective study. A total of 43 individuals were analyzed (23 with dysphonia and 20 without voice alterations), of female gender, aged 18 to 40 years, without neurological, respiratory and rheumatic alterations. All patients were referred by the ENT Sector of Paulista Medical School (UNIFESP- EPM) after anamnesis, ENT examination and laryngoscopy, with diagnosis of functional or organofunctional dysphonia. The following parameters were investigated in this population: 1- Body posture in loco, 2- Photographic records, 3- Electromyographic examination, 4- Questionnaire on pain. Results: The results indicated no statistically significant difference with regard to the complaint, yet a larger number of individuals with dysphonia reported muscle tension and pain at the cervical region, where the larynx is located. Posture evaluation revealed that dysphonic individuals presented shoulder asymmetry, alterations in scapular positioning and rectification with forward displacement of the cervical region compared to the control group. The results of electromyographic analysis demonstrated increased activity of the suprahyoid muscle in prolonged emission, controlled emission and swallowing. The infrahyoid muscles exhibited altered electromyographic tracing during prolonged emission. Conclusion: It was concluded that there is correlation between individuals with dysphonia and posture alterations, based on the differences in clinical findings and electromyographic measurements.

Objetivos: analisar a postura corporal em pacientes disfônicos e correlacioná-los com indivíduos sem alteração de voz, a fim de estabelecer novos recursos terapêutico para reabilitar o portador de disfonia. Método: estudo prospectivo. Foram avaliados 43 indivíduos (23 disfônicos e 20 sem alteração de voz) do sexo feminino,com idade entre 18 e 40 anos ,sem alterações neurológicas ,respiratórias e reumáticas. Todos os pacientes foram encaminhado pelo serviço de Otorrinolaringologia da Escola Paulista de Medicina ( UNIFESP- EPM),após anamnese, exame do otorrinolaringologista e laringoscopia ,tendo como diagnostico de disfonia funcional ou organofuncional. Nessa população foi avaliado: 1- Postura corporal in loco, 2 – Documentação fotográfica, 3 – Exame Eletromiografia, 4 – Questionário das algias. Resultados: não houve diferença estatisticamente significante em relação à queixa,porem foi encontrado um numero maior de tensão muscular e dor na região cervical, onde se encontra situado a laringe, nos portadores de disfonia. Na avaliação postural, os indivíduos disfônicos apresentarão assimetria de ombros, alteração no posicionamento da escapula, retificação com anteriorização da região cervical em relação ao grupo controle. Nos resultados da eletromiografia houve aumento das atividades nos músculos supra-hióideo em emissão prolongada, controlada e deglutição. Nos músculos infra-hióideo houve alteração no traçado eletromiógrafico na emissão prolongada. Conclusão: pode- se concluir que o estudo mostra a existência da correlação positiva entre indivíduos portadores de disfonia e alteração na postura, baseado nas diferenças dos achados clínicos e medidas eletromiográficas. / Objectives: This study analyzed the body posture of dysphonic patients and correlated them with individuals without voice alterations, in order to establish new therapeutic resources to rehabilitate the patients with dysphonia. Method: prospective study. A total of 43 individuals were analyzed (23 with dysphonia and 20 without voice alterations), of female gender, aged 18 to 40 years, without neurological, respiratory and rheumatic alterations. All patients were referred by the ENT Sector of Paulista Medical School (UNIFESP- EPM) after anamnesis, ENT examination and laryngoscopy, with diagnosis of functional or organofunctional dysphonia. The following parameters were investigated in this population: 1- Body posture in loco, 2- Photographic records, 3- Electromyographic examination, 4- Questionnaire on pain. Results: The results indicated no statistically significant difference with regard to the complaint, yet a larger number of individuals with dysphonia reported muscle tension and pain at the cervical region, where the larynx is located. Posture evaluation revealed that dysphonic individuals presented shoulder asymmetry, alterations in scapular positioning and rectification with forward displacement of the cervical region compared to the control group. The results of electromyographic analysis demonstrated increased activity of the suprahyoid muscle in prolonged emission, controlled emission and swallowing. The infrahyoid muscles exhibited altered electromyographic tracing during prolonged emission. Conclusion: It was concluded that there is correlation between individuals with dysphonia and posture alterations, based on the differences in clinical findings and electromyographic measurements.

Analisou-se os níveis de sintomas de ansiedade e depressão em indivíduos disfônicos e indivíduos sem alterações vocais. Verificou-se correlação entre os traços de ansiedade e depressão com a percepção dos indivíduos disfônicos e não disfônicos sobre sua qualidade de vida em voz e os sinais e sintomas de desconforto do trato vocal. Participaram 62 indivíduos, 31 pacientes com disfonias funcionais ou organofuncionais, e 31 não disfônicos, com idades entre 18 e 55 anos. Todos responderam a Escala de Desconforto de Trato Vocal (EDTV), protocolo de Qualidade de Vida em Voz (QVV), Escalas de heteroavaliação de Hamilton para Ansiedade e Depressão (HAM A e HAM D), e Escalas de autoavaliação de Beck para depressão e IDATE traço e estado para ansiedade. Os resultados foram submetidos aos testes estatísticos de Mann-Whitney, Qui-quadrado e Teste de Correlação de Spearman, considerando significância de 5%. As médias de escores obtidas foram: HAM-A iguais a 17,72 e 7,53; HAM-D 11,22 e 4,28; IDATE-E 44,31 e 36,75; IDATE-T 44,63 e 35,47; BECK 12,22 e 6,72, para os disfônicos e para os não disfônicos, respectivamente (p≤0,03). Foi encontrada correlação entre o QVV e os sinais e sintomas de ansiedade e depressão quando analisado o grupo todo, mas esta correlação não se repetiu quando analisado separadamente o grupo de disfônicos. O grupo de não disfônicos apresentou correlações regulares entre o domínio físico do QVV e HAM-A, IDATE-E, IDATE-E e Beck e correlação forte com HAM-D; correlações regulares entre o domínio sócio emocional do QVV e IDATE-T e Beck; no domínio total do QVV houve correlação regular com HAM-A, IDATE-T, IDATE-E e Beck e correlação forte com HAM-D. Em relação às queixas pesquisadas no EDTV e os escores das escalas de avaliação psicométrica, foi encontrado para o grupo todo correlações moderadas entre quase todos os parâmetros pesquisados, com exceção para cinco correlações fortes: entre frequência de queimação e IDATE-T, frequência e intensidade de coceira e HAM-A, frequência de garganta irritada e HAM A e entre intensidade de garganta irritada e IDATE-T. Analisando os indivíduos disfônicos foi encontrada correlação forte entre frequência de sensação de secura na garganta e HAM-A e graus moderados em apenas 11 dentre as 80 correlações analisadas, considerando-se frequência e intensidade dos sintomas do EDTV. No grupo de não disfônicos foi encontrada correlação forte entre frequência de aperto e IDATE-T e graus moderados em 40 das 80 correlações pesquisadas entre as queixas que compõem o EDTV e as escalas psicométricas. Os indivíduos disfônicos apresentaram maiores níveis de ansiedade e depressão do que os não disfônicos, assim como houve maior número de indivíduos disfônicos com ansiedade e depressão em categorias nosológicas mais graves em todos os protocolos psicométricos utilizados. Houve maior número de correlações entre as escalas de ansiedade e depressão com os escores de qualidade de vida em voz e de desconforto do trato vocal para os indivíduos não disfônicos do que para os disfônicos. / The levels of anxiety and depression in dysphonic individuals and individuals without voice alterations were analyzed. It was verified a correlation between anxiety traits and depression with the perception of dysphonic and non-dysphonic individuals over their quality of life in regards to voice and signs and symptoms of discomfort of the vocal tract. 62 individuals were involved, being 31 patients with functional or organic-functional dysphonia, and 31 non-dysphonic, with ages ranging from 18 to 55 years old. They have all answered to Vocal Tract Discomfort (VTD), Voice-Related Quality of Life (V-RQOL), Hamilton Rating Scale for Depression (HAMA and HAMD), and Beck Depression Inventory and State-Trait Anxiety Inventory (STAI). The results were submitted to Mann-Whitney U, Chi-Squared and Spearman Correlation tests considering 5% significance. The average score were: 17,72 and 7,53 at HAM-A; 11,22 and 4,28 at HAM-D; 44,31 and 36,75 at STAI-S; 44,63 and 35,47 at STAI-T; 12,22 and 6,72 at BECK, for dysphonic and non-dysphonic, respectively (p≤0,03). Correlation was found between V-RQOL and the signs and symptoms of anxiety and depression when the whole group was analyzed, however this correlation was not repeated when separately analyzed the dysphonic group. The non-dysphonic group has shown no regular correlation between the physical domain of V-RQOL and HAM-A, STAI-S, STAI-T and BECK and Strong correlation with HAM-D; regular correlation with the socio-emotional scores of V-RQOL and STAI-T and BECK; at the complete V-RQOL scores were found regular correlations with HAM-A, STAI-T, STAI-S and BECK and strong correlation with HAM-D. In regards to complaints reported at VTD and the scores at psychometric assessments, moderated correlations were found for the whole group in almost all of the researched parameters, with exception to 5 strong correlations: burning sensation frequency and STAI-T, itching frequency and intensity and HAM-A, sore throat frequency and HAM-A and between sore throat intensity and STAI-T. Upon analysis on the dysphonic individuals was found strong correlation between dry throat feeling frequency and HAM-A, and moderated levels in only 11 of the 80 analyzed correlations, considering frequency and intensity of VTD symptoms. In the non-dysphonic group was found strong correlation between tight throat and STAI-T and moderate levels in 40 of 80 researched correlations which compose the VTD and psychometric scales. The dysphonic individuals presented higher levels of anxiety and depression than the non-dysphonic, as well as a higher quantity of dysphonic individuals with depression and anxiety on more severe nosological categories in all psychometrical protocols utilized. There were a bigger number of correlations between the anxiety and depression scores and the voice-related quality of life and voice tract discomfort for non-dysphonic individuals than for dysphonic ones.

KASAMA, S.T. Programa de Saúde Vocal para Professores: estudo em uma escola particular de Ribeirão Preto. 2008. 142p. Dissertação (Mestrado em Saúde na Comunidade). Faculdade de Medicina de Ribeirão Preto USP. Introdução: os professores são profissionais com alto risco para disfonia. A intensa demanda vocal e a falta de conhecimento a respeito de cuidados com a própria voz são aspectos comuns entre os professores. Experiências anteriores para orientar este profissional, com relação a sua própria voz, demonstram sucesso e a opinião dos professores, assim como a prática de novos hábitos são de grande importância. As Escolas Waldorf têm uma pedagogia baseada na Antroposofia, sendo freqüente o uso da voz falada e cantada em suas atividades. Objetivo: Propor uma ação de promoção de saúde vocal para professores, capaz de fornecer uma percepção mais ampla, além da conscientização dos fatores que determinam ou interferem no processo saúde-doença da disfonia. Método: 13 professores (2 do sexo masculino) de uma Escola Waldorf de Ribeirão Preto, com média de idade de 43 anos (mín=24, máx=56), participaram das 3 etapas da pesquisa, que compreendia uma avaliação inicial individual (etapa 1), o Programa de Saúde Vocal com duração de 12 encontros semanais (etapa 2) e uma reavaliação individual após o término dos encontros (etapa 3). Houve a participação de 5 professores do ensino infantil, 8 do fundamental e 2 do médio. O programa abordou anatomia e fisiologia da fonação, higiene vocal e exercícios de aquecimento e desaquecimento vocal. Logo após o término dos encontros, os professores preencheram um questionário de avaliação do programa. Resultados: a comparação dos dados coletados nas avaliações individuais pré e pós-intervenção não revelaram mudanças significativas, porém tiveram a função de monitoramento do aspecto vocal dos professores. De acordo com os professores, o aspecto negativo do processo foi a falta de tempo para comparecer aos encontros e para realizar os exercícios diariamente. As mudanças citadas como mais importantes foram aspectos gerais de higiene vocal (destacando-se a hidratação), respiração, efeitos benéficos dos exercícios, atenção para a própria voz e dos alunos e o reconhecimento da importância da voz. Conclusão: a ação de promoção de saúde proposta obteve grandes êxitos em ampliar a percepção e conscientizar os professores a respeito dos fatores que atuam de maneira favorável ou prejudicial à voz. O resultado foi muito favorecido pelo espaço criado para reflexão, troca de experiências e vivências de situações proporcionadas pelo Programa de Saúde Vocal. / KASAMA, S.T. Vocal Health Program: study in a private school in Ribeirão Preto. 2008.142p. Dissertation (Master Degree). Faculdade de Medicina de Ribeirão Preto USP. Introduction: teachers are professionals with high risk for dysphonia. The intense demand voice and lack of knowledge about voice care are common among teachers. Previous experiences demonstrate success and the teachers opinion as well as the practice of new habits are of great importance. The Waldorf Schools have a pedagogy based on Anthroposophy, and the frequent use of spoken and sung voice in their activities. Purpose: to propose an action of promoting vocal health for teachers capable to provide great perception and awareness of the factors that determine or interfere in health disease process of the dysphonia. Method: 13 teachers (2 male) from a Waldorf School in Ribeirão Preto, with an average age of 43 years (min = 24, max = 56), attended the 3 stages of research, which included an initial individual assessment (step 1), the Vocal Health Program with duration of 12 weekly meetings (step 2) and a individual reassessment after the end of meetings (step 3). There was the participation of 5 teachers of kindergarten, 8 of the elementary school and 2 of the high school. The program addressed anatomy and physiology of speech, hygiene and vocal exercises. After the end of meetings, the teachers filled out a questionnaire to evaluate the program. Results: the comparison of data collected on individual assessments pre-and post-intervention did not reveal significant changes, but had the task of tracking the vocal aspect of teachers. According to teachers, the negative aspect of the process was the lack of time to attend the meetings and to perform the exercises daily. The changes were cited as most important aspects of general hygiene voice (especially hydration), respiration, beneficial effects of exercise, attention to their own voice and students and recognition of the importance of voice. Conclusion: the action of health promotion proposal obtained great achievements in expanding the awareness and perception teachers about the factors that act in a manner favorable or detrimental to the voice. The result was much favored by the opportunnity for discussion and experience of situations offered by the Program for Health Vocal.

Introdução: Para o tratamento das disfonias comportamentais associadas à tensão muscular são recomendadas técnicas de relaxamento cervical e laríngeo, concomitantemente à estimulação da onda de mucosa das pregas vocais, bem como adequação do fechamento glótico e suavização da emissão. Nesse sentido, o recurso da Estimulação Elétrica Nervosa Transcutânea (TENS), corrente elétrica aplicada por meio de eletrodos de superfície, tem sido utilizada no tratamento vocal de mulheres com nódulos vocais. Esta prática tem demonstrado bons resultados na qualidade vocal e na redução da dor muscular, porém, verifica-se escassez de comprovação científica dos seus efeitos somados à terapia vocal. Objetivo: verificar a efetividade da TENS de baixa frequência associada à terapia vocal no tratamento de voz em mulheres disfônicas. Método: Este estudo foi aprovado pelo Comitê de Ética em Pesquisa em Seres Humanos, número 556.273. Participaram 27 mulheres com nódulos vocais, de 18 a 45 anos de idade (média de 33 anos de idade), divididas, de forma randomizada, em: Grupo Experimental (GE) 13 mulheres que receberam 12 sessões de aplicação de TENS (pulso: 200 μs, frequência: 10 Hz, no limiar motor), com eletrodos posicionados no músculo trapézio - fibras descendentes e na região submandibular, bilateralmente, por 20 minutos, associada a 30 minutos de terapia vocal; e Grupo Controle (GC) 14 mulheres que receberam 12 sessões de aplicação de TENS placebo (mesmas condições do GE, incluindo posicionamento dos eletrodos, porém sem receber o estímulo em forma de corrente elétrica) por 20 minutos, associada a 30 minutos de terapia vocal. Todas foram submetidas à avaliação da qualidade vocal por meio das análises perceptivo-auditiva e acústica da voz; da laringe por meio de análise perceptivo-visual; autopercepção sobre a voz, qualidade de vida por meio do protocolo de Qualidade de Vida em Voz (QVV); queixas e sintomas vocais/laríngeos e dor musculoesquelética, antes, imediatamente após o tratamento e um mês após. Resultados: Observou-se, após análise estatística, que não houve modificação da qualidade vocal em ambos os grupos tratados. Verificou-se na análise acústica diminuição do parâmetro acústico Índice de Fonação Suave (SPI) imediatamente após tratamento e um mês após, em ambos os grupos. Em relação à laringe, observou-se melhora do tamanho da lesão nas pregas vocais apenas no GE, imediatamente após tratamento e um mês após.Não houve diferença significativa quanto à qualidade de vida em voz, em ambos os grupos. Houve melhora na autopercepção da voz em ambos os grupos, após o tratamento, assim como os sintomas vocais/laríngeos e de dor musculoesquelética se apresentaram em menor ocorrência após tratamento e um mês após. Conclusão: A TENS de baixa frequência associada à terapia vocal foi efetiva em relação à diminuição da lesão das pregas vocais em mulheres disfônicas. A associação da TENS com a terapia vocal produziu resultados semelhantes à terapia vocal, em relação à qualidade da voz, autopercepção e qualidade de vida em voz, sintomas vocais e dor musculoesquelética. / Introduction: For the treatment of the behavior dysphonia associated muscle tension are recommended techniques of cervical and laryngeal relaxation, concurrently with stimulation of the mucosa wave of the vocal folds, such as adequacy of glottal closure and smoothing the emission. Thereby, the use of Transcutaneous Electrical Nerve Stimulation (TENS), electrical current applied through surface electrodes, have been used in the vocal treatment of women with vocal nodules. This practice has shown good results in vocal quality and in reducing muscle pain, however, there are few scientific evidence about their effects added to voice therapy. Proposal: to verify the effectiveness of low frequency TENS associated with voice therapy on vocal quality and laryngeal dysphonic women. Methods: This study was approved by the Research Ethics Committee, number 556.273. Twenty seven women with vocal nodules participated, 18-45 years of age (mean 33 years), divided, randomly into: experimental group (EG) - 13 women who received 12 sessions of application TENS (pulse: 200 μs, frequency 10 Hz, motor threshold), with electrodes placed on the trapezius muscle descending fibers and submandibular area, bilaterally, for 20 minutes, associated with 30 minutes of vocal therapy; and Control Group (CG) - 14 women who received 12 sessions of application TENS placebo (same conditions as EG, including the placed of the electrodes, but without receiving the stimulus in the form of electrical current) for 20 minutes, associated with 30 minutes of vocal therapy. All were submitted to vocal quality through auditory perceptual and acoustic voice analyzes; ENT evaluation through visual perceptual analysis; vocal self-perception; voice-related quality of life through the Voice-Related Quality of Life Protocol (V-RQOL); complaints and vocal/laryngeal and musculoskeletal pain symptoms, before, immediately after treatment and one month after. Results: It was observed, after statistical analysis, that there was no change vocal quality in both treated groups. In the acoustic analysis, there was decrease of the Soft Phonation Index (SPI) parameter, immediately after treatment and one month after, in both groups. In relation to larynx, there was improvement in the size of the lesion on the vocal folds only GE, immediately after treatment and one month after. There was no significant difference in the voice related quality of life, in both groups. There was improvement in the vocal self-perception in both groups after treatment, as well as lower frequency of the voice/laryngeal and musculoskeletal pain symptoms present immediately after treatment and one month after. Conclusion: The low frequency TENS associated with vocal therapy was effective in the reduction of the size of the lesion on the vocal folds in dysphonic women. The association of the TENS with vocal therapy produced similar results to vocal therapy, in relation to vocal quality, self-perception and voice-related quality of life, vocal and musculoskeletal pain symptoms.

KASAMA, S.T. Programa de Saúde Vocal para Professores: estudo em uma escola particular de Ribeirão Preto. 2008. 142p. Dissertação (Mestrado em Saúde na Comunidade). Faculdade de Medicina de Ribeirão Preto USP. Introdução: os professores são profissionais com alto risco para disfonia. A intensa demanda vocal e a falta de conhecimento a respeito de cuidados com a própria voz são aspectos comuns entre os professores. Experiências anteriores para orientar este profissional, com relação a sua própria voz, demonstram sucesso e a opinião dos professores, assim como a prática de novos hábitos são de grande importância. As Escolas Waldorf têm uma pedagogia baseada na Antroposofia, sendo freqüente o uso da voz falada e cantada em suas atividades. Objetivo: Propor uma ação de promoção de saúde vocal para professores, capaz de fornecer uma percepção mais ampla, além da conscientização dos fatores que determinam ou interferem no processo saúde-doença da disfonia. Método: 13 professores (2 do sexo masculino) de uma Escola Waldorf de Ribeirão Preto, com média de idade de 43 anos (mín=24, máx=56), participaram das 3 etapas da pesquisa, que compreendia uma avaliação inicial individual (etapa 1), o Programa de Saúde Vocal com duração de 12 encontros semanais (etapa 2) e uma reavaliação individual após o término dos encontros (etapa 3). Houve a participação de 5 professores do ensino infantil, 8 do fundamental e 2 do médio. O programa abordou anatomia e fisiologia da fonação, higiene vocal e exercícios de aquecimento e desaquecimento vocal. Logo após o término dos encontros, os professores preencheram um questionário de avaliação do programa. Resultados: a comparação dos dados coletados nas avaliações individuais pré e pós-intervenção não revelaram mudanças significativas, porém tiveram a função de monitoramento do aspecto vocal dos professores. De acordo com os professores, o aspecto negativo do processo foi a falta de tempo para comparecer aos encontros e para realizar os exercícios diariamente. As mudanças citadas como mais importantes foram aspectos gerais de higiene vocal (destacando-se a hidratação), respiração, efeitos benéficos dos exercícios, atenção para a própria voz e dos alunos e o reconhecimento da importância da voz. Conclusão: a ação de promoção de saúde proposta obteve grandes êxitos em ampliar a percepção e conscientizar os professores a respeito dos fatores que atuam de maneira favorável ou prejudicial à voz. O resultado foi muito favorecido pelo espaço criado para reflexão, troca de experiências e vivências de situações proporcionadas pelo Programa de Saúde Vocal. / KASAMA, S.T. Vocal Health Program: study in a private school in Ribeirão Preto. 2008.142p. Dissertation (Master Degree). Faculdade de Medicina de Ribeirão Preto USP. Introduction: teachers are professionals with high risk for dysphonia. The intense demand voice and lack of knowledge about voice care are common among teachers. Previous experiences demonstrate success and the teachers opinion as well as the practice of new habits are of great importance. The Waldorf Schools have a pedagogy based on Anthroposophy, and the frequent use of spoken and sung voice in their activities. Purpose: to propose an action of promoting vocal health for teachers capable to provide great perception and awareness of the factors that determine or interfere in health disease process of the dysphonia. Method: 13 teachers (2 male) from a Waldorf School in Ribeirão Preto, with an average age of 43 years (min = 24, max = 56), attended the 3 stages of research, which included an initial individual assessment (step 1), the Vocal Health Program with duration of 12 weekly meetings (step 2) and a individual reassessment after the end of meetings (step 3). There was the participation of 5 teachers of kindergarten, 8 of the elementary school and 2 of the high school. The program addressed anatomy and physiology of speech, hygiene and vocal exercises. After the end of meetings, the teachers filled out a questionnaire to evaluate the program. Results: the comparison of data collected on individual assessments pre-and post-intervention did not reveal significant changes, but had the task of tracking the vocal aspect of teachers. According to teachers, the negative aspect of the process was the lack of time to attend the meetings and to perform the exercises daily. The changes were cited as most important aspects of general hygiene voice (especially hydration), respiration, beneficial effects of exercise, attention to their own voice and students and recognition of the importance of voice. Conclusion: the action of health promotion proposal obtained great achievements in expanding the awareness and perception teachers about the factors that act in a manner favorable or detrimental to the voice. The result was much favored by the opportunnity for discussion and experience of situations offered by the Program for Health Vocal.

Abstract There is a need in medicine and research for noninvasive, painless, safe and simple bed-side techniques to measure physiological processes associated with muscle function and activity. Bioelectrical Impedance Analysis (BIA) is a widely used, noninvasive, painless, safe and simple procedure for the measurement of body composition. However, although capable of producing accurate and reproducible data, it is known to be prone to movement artifacts. This poses the interesting question “Could impedance changes be used to monitor movement and, consequently, be related to muscle function or activity?” This project investigated the utility of impedance change as a monitoring technique for physiological processes that involve movement such as muscular contraction, the calf muscle pump, and swallowing. The impedance of leg muscle segments during locomotion, whilst riding a stationary exercise cycle, was measured at discrete frequencies and by bioimpedance spectroscopy to monitor muscle function or activity. Impedance traces were compared to information obtained by electromyography (EMG). Impedance, at a discrete frequency, was able to measure the cadence of cycling and its magnitude was related to the position of the pedal during the pedal cycle. When the cycling action was measured by bioimpedance spectroscopy, R0 and Zc showed a statistically significant difference, (p<0.05), between all angles of the pedal crank cycle while R∞ showed a statistically significant difference between angles in the lower hemisphere of the pedal crank cycle. The cyclical changes in impedance during cycling may be attributed to changes in shape and volume of the muscle during contraction as well as a volume change due to blood and lymph being pumped from the limb by the action of the calf muscle pump. Based on procedures used in the cycling studies, an impedance-based method for the measurement of calf muscle pump function during an exercise protocol, originally designed for use with air plethysmography, was developed. It was shown that impedance measured at 5 kHz provides a simple, non-invasive method for the measurement of the ejection fraction and ejection volume of the calf muscle pump as well as other haemodynamic variables. The impedance-based method was less technically challenging than accepted volumetric methods, such as air plethysmography and strain gauge plethysmography, and non-invasive c.f. ambulatory venous pressure, enabling it to be used repeatedly. Muscle function and activity is not confined to the legs so impedance changes in the arm and forearm during exercise were measured. Impedance measurements, at discrete frequencies and using bioimpedance spectroscopy, of the forearm during contractions of the hand were able to distinguish the difference between a ramp and a pulse contraction. When the impedance of the arm and forearm were plotted against the angle of the forearm to the horizontal during a bicep curl, there was an hysteresis effect. Impedance traces of a bicep curl were compared to an EMG trace of the same action. The larynx is a hollow muscular organ situated in the front of the neck above the trachea consisting of a framework of cartilages bound together by muscles and ligaments. The two major functions of the larynx are deglutition and phonation. Dysphagia, which is becoming more prevalent as the population ages, is defined as difficulty in swallowing thin liquids such as water or juices which splash into the trachea because the patient is unable to control the thin liquid bolus. Aspiration pneumonia and dehydration can be prevented by using thickened liquids which allow patients to achieve a safer swallowing response, but it is difficult to assess this response without interfering with the swallowing process. Impedance pharynography (IPG) is a technique using BIA to monitor an impedance waveform of the swallowing process that presents no radiation hazard to the patient, is non-invasive and does not require specialist trained personnel to operate it. Resistance changes across the neck were measured while subjects swallowed solutions of different viscosities. The resistance changes were distinctive and reproducible for each of the solutions of different viscosities which were swallowed. Measuring the function of the larynx by this method could be useful in the diagnosis and treatment of dysphagia. In conclusion, the studies described in this thesis demonstrate the potential usefulness of the measurement of change in impedance as a measure of muscle activity. Impedance-based methods can measure volume changes associated with changes in cross-sectional area of the muscles involved in contraction as well as compartmental fluid changes caused by the force of the contraction on the surrounding tissues including the vasculature. In particular, measuring the ejection fraction and other haemodynamic variables of the calf muscle pump by impedance has the potential to become the method of choice in the future because it is easy to use, inexpensive, non-invasive, safe, and hygenic. Measuring resistance changes across the neck during swallowing yields distinctive waveforms with features corresponding to the physiological phases of the swallowing process as well as identifying distinctive swallowing patterns associated with the different viscosities of liquids swallowed. Function of the larynx and the associated diseases of the larynx will potentially be easier to diagnose and treat with a safe, non-invasive, inexpensive, portable bed-side method of assessment such as BIA.