White, Anna C.
(2025)
Pre- and post-operative voice therapy: complex intervention development and feasibility of a voice therapy programme for adults undergoing phonosurgery for benign vocal fold lesions.
PhD thesis, University of Nottingham.
Abstract
Background
Voice disorders affect one in three people during their lifetime. Consequential time off work alone costs the UK £200 million each year and direct healthcare costs are comparable with Chronic Obstructive Pulmonary Disease (COPD) and diabetes. Patients suffer considerable social, emotional and financial consequences as a result.
Benign vocal fold lesions (BVFLs) such as polyps and cysts account for up to half of those seeking help for voice disorders. Over 6500 surgical procedures are undertaken in England each year to remove BVFLs and emerging evidence suggests that the best outcomes occur when surgery is accompanied by voice therapy. Voice therapy is likely to help prepare patients for surgery, speed up recovery (facilitating return to work), reduce permanent disability and prevent recurrence. However, voice therapy is poorly described for patients with BVFLs. No management guidelines exist, and clinical practice varies. Surgical preparation, wound healing and re-establishing vocal fold vibration pose additional complexities in voice therapy programmes for those with BVFLs. There is no robust evidence to determine the effectiveness of voice therapy in this patient group.
This PhD aims to develop and evaluate the feasibility and acceptability of a pre- and post-operative voice therapy intervention (PAPOV) for patients with BVFLs, in preparation for future economic and clinical effectiveness research.
Methods
A mixed methods research plan, comprising four sequential studies was undertaken. A systematic review of pre- and post-operative voice therapy explored and synthesised the current evidence around the content, timing and intensity of voice therapy delivered to individuals with BVFLs. The second study involved triangulating findings from the systematic review with three other intervention development data sources to identify where convergence and divergence existed regarding potential components of a best practice pre- and post-operative voice therapy intervention (PAPOV). An international electronic Delphi study recruited expert voice therapists to seek consensus on the outstanding questions relating to components of the PAPOV intervention. The final study was a non-randomised, multi-centre feasibility trial with embedded process evaluation. This tested the feasibility of the PAPOV intervention and explored the acceptability of the intervention from the perspective of the participants and clinicians.
Results
The systematic review (n=35) found heterogeneity in the participants, outcome measures, and voice therapy intervention delivered to individuals undergoing phonosurgery. Detailed information on the content, timing and intensity of pre- and post-operative voice therapy was limited. In the triangulation study, areas of convergence, dissonance and silence across four sources of data were identified. There was evidence for the inclusion of 27/61 possible components into the PAPOV intervention. The triangulation study also highlighted outstanding questions which could be further explored. In the Delphi study, an international sample of expert voice therapists (n=42), reached consensus on 33 statements relating to the PAPOV intervention. Qualitative data offered further insights into aspects of dosing and tailoring. These, combined with findings from the triangulation study facilitated the development of a detailed protocol, described according to treatment theory using the RTSS-Voice. The PAPOV intervention was found to be feasible and acceptable to clinicians (n=4) and participants (n=41). Treatment fidelity and adherence to the PAPOV intervention was good, and clinical outcomes showed statistically significant changes post treatment in all patient reported outcome measures and clinician reported measures.
Conclusions
The aims of the thesis were met, and an intervention (PAPOV) was developed by following a structured intervention development framework and applying a mixed methods research approach. The intervention was feasible and acceptable when tested in two NHS departments. There are a number of avenues for further research in light of the findings of this PhD. This includes progressing to clinical and cost effectiveness research.
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