A Comparison of Trained and Untrained Vocalists on

the Dysphonia Severity Index

*Shaheen N. Awan and †Anysia J. Ensslen, *Bloomsburg, Pennsylvania, yLexington, Kentucky

Summary: The purposes of this study were (1) to compare trained and untrained singers on the Dysphonia Severity
Index (DSI) and its component measures, and (2) to contribute to normative DSI data for trained singers. This study
included 36 untrained participants (15 males and 21 females) and 30 participants (15 males and 15 females) with singing
experience between the ages of 18 and 30 years. Measures of maximum phonation time (MPT), highest phonational
frequency, lowest intensity, and jitter were obtained for each subject and incorporated into the previously published mul-
tivariate DSI formula. Results indicated that vocally trained subjects have significantly higher DSI scores than untrained
subjects (mean DSI: 6.48 vs 4.00, respectively), with significant differences observed between trained and untrained
groups for three of the four components of the DSI (F0 high; I low; jitter). The findings of this study are consistent
with previous reports that indicate significant increases in the DSI with vocal training, and with various studies that
have observed increased vocal capability in trained singers versus their untrained counterparts. The results of this study
indicate that alternative normative expectations for the DSI may need to be taken into account when using the DSI with
patients who have participated in directed vocal training, such as choral participation and voice/singing lessons.
Key Words: Dysphonia Severity Index–Singers–Maximum phonation time–Jitter–Phonational frequency range.

INTRODUCTION supported by a substantial body of literature.4 Multiparameter

The perceptual evaluation of voice is considered to be an essen-
tial aspect of the conventional voice diagnostic that has rele-
vance to most voice-disordered patients and provides a global
measure of vocal performance readily available to all clini-
cians.1 Although perceptual evaluation of voice has obvious im-
portance, there are several limitations associated with this
method of assessment that clearly influence its clinical utility.
These limitations include problems with scale validity and reli-
ability, particularly for midscale (ie, mild to moderate) patho-
logical voices; lack of credibility for medical-legal purposes;
poorly defined and/or shifting definitions of severity; and the in-
trusive effects of voice and speech characteristics other than the
quality dimension that is meant to be judged.1–3 Many of these
limitations stem from the attempt to describe the voice via
a temporary auditory impression of the acoustic signal. As a re-
sponse, voice clinicians and researchers have added to the per-
ceptual assessment of voice quality with other methods that
provide a permanent record of the vocal behavior and allow
for a more objective analysis of the patient’s voice quality.
Acoustic methods of voice analysis have been primary tools
of both the clinician and the researcher for many years. These
methods have become widely used in both research and clinical
situations since the advent of relatively low-cost personal com-
puters and analog-to-digital acquisition hardware in the early
1990s, and have the benefits of being noninvasive; readily avail-
able at relatively low cost compared with other methods of
voice analysis; applicable to treatment and diagnosis; and are
Accepted for publication April 2, 2009.
Portions of this article were presented at the 37th Annual Symposium: Care of the Pro-
fessional Voice, Philadelphia, PA, in May 2008.
From the *Department of Audiology & Speech Pathology, Bloomsburg University of
Pennsylvania, Bloomsburg, Pennsylvania; and the yDepartment of Rehabilitation Sci-
ences, College of Health Sciences, University of Kentucky, Lexington, Kentucky.
Address correspondence and reprint requests to Shaheen N. Awan, Department of Audi-
ology & Speech Pathology, Bloomsburg University of PA, Centennial Hall, 400, East Sec-
ond Street, Bloomsburg, PA 17815-1301. E-mail: sawan@bloomu.edu
Journal of Voice, Vol. 24, No. 6, pp. 661-666
0892-1997/$36.00
Ó 2010 The Voice Foundation
doi:10.1016/j.jvoice.2009.04.001
acoustic models, which may be used to characterize voice func-
tion and quantify the severity of dysphonia, have been pre-
sented by Michaelis et al,5 Callan et al,6 Fröhlich et al,7 and
Awan and Roy.8–10
An alternative method for encompassing the multidimen-
sional nature of the normal versus disordered voice is the Dys-
phonia Severity Index (DSI). The DSI was developed by Wuyts
et al,11 with the purpose of developing an index that would both
objectively and quantitatively correlate with perceived voice
quality. The DSI makes use of a combination of several voice
measures that may be obtained from voice-assessment proce-
dures, such as the voice range profile and basic aerodynamic
and acoustic analyses: the highest phonational frequency (F0
high in Hz), lowest intensity (I low in dB), maximum phonation
time (MPT in seconds), and jitter (%). Because voice has been
described as a multiparameter behavior, it appears reasonable
that a multiparameter model, such as that presented in the
DSI, may be useful in describing vocal function.12 The compo-
nents of the DSI form a specific combination of acoustic voice
measures that may aid in characterizing various types of vocal
dysfunction. Wuyts et al11 stated that, when extra mass is evenly
distributed along the true vocal fold(s), the higher vibratory
rates become dampened. The result is a decrease in the upper
reaches of the phonational frequency range. Structural changes
to the true vocal folds, such as distributed or organized mass le-
sions, may increase glottal resistance such that greater subglot-
tal pressures will be necessary to initiate and maintain vocal
fold vibration. Consequently, the lowest phonational intensity
will often be increased. In addition to changes in vocal intensity,
vocal fold pathology (eg, unilateral or bilateral organized le-
sions or distributed tissue change; organic pathology affecting
the ability to effectively tense or approximate the folds during
phonation) often results in disturbances in the periodicity of
phonation. These disturbances may be described in terms of jit-
ter, a measure of short-term instability that quantifies cycle-to-
cycle variations in frequency and has been used to assess the
degree of perturbation in the voice signal. Finally, MPT has
662
been regarded as a general measure of phonatory ability13 that
reflects the function of several mechanisms necessary for voice
production, such as respiratory capacity and control, subglottic
pressure, airflow resistance, and closure of the vocal folds. The
DSI was initially described and validated in a study by Wuyts
et al,11 in which the authors obtained various acoustic and com-
monly used aerodynamic measures from 387 subjects (68 nor-
mal controls vs 319 voice-disordered subjects). In addition,
each patient’s voice was perceptually rated using the grade,
roughness, breathiness, asthenia, strain (GRBAS) scale.13 The
DSI was obtained via multiple regression analyses and consists
of four weighted variables in the equation: DSI ¼ 0.13 3 MPT
(seconds) + 0.0053 3 F0 high (Hz)  0.26 3 I low (dB) 
1.18 3 jitter (%) + 12.4. Results of the study indicated an in-
verse relationship between the DSI and the grade (overall sever-
ity) of dysphonia, as well as between the DSI and the Voice
Handicap Index (VHI). The DSI was transformed such that
a DSI ¼ +5 corresponded to G0 (normal voice), and a DSI ¼ 5
corresponded to G3 (severe dysphonia). It was noted by these
authors that the DSI is not necessarily restricted to the +5 to
5 range. A DSI of +1.6 was determined to be the cutoff for
perceptually normal voices.
Several studies have used the DSI to objectively describe nor-
mal versus disordered voice characteristics and change in voice
over time. Timmermans et al14 evaluated voice quality change
in 68 students (49 received voice training; 19 served as an un-
trained control group). The vocally trained group was provided
with instruction regarding relaxation, posture, breathing pat-
tern, and active articulation. Results showed a significant in-
crease in the DSI for the trained group (from 2.3 to 4.5)
versus no significant change in the untrained group. In a second
study, Timmermans et al15 used the DSI as a method of evalu-
ating the effectiveness of a voice-training program for 23 pro-
fessional voice users. The DSI scores were again observed to
significantly increase from the time of training onset (mean
DSI ¼ 2.0) to 9 months post-training onset (mean DSI ¼ 3.7)
and to 18 months post-onset (mean DSI ¼ 4.6), with the most
prominent voice-characteristic change being increases in F0
high. Hakkesteegt et al16 investigated the possible influence
of age and gender on the DSI (69 females; 49 males between
20 and 79 years of age). Although significant differences be-
tween males and females were observed for F0 high and
MPT, the mean DSI between the genders was not significantly
different (mean DSI: females ¼ 4.3; males ¼ 3.8). The DSI was
observed to decrease significantly with age in both genders, pri-
marily because of reductions in F0 high and low intensity. These
authors inferred that the DSI of a particular voice patient should
be compared with appropriate normative data from comparable
age and gender subjects. Woisard et al17 examined the possible
correlation between a French version of the VHI and quantita-
tive methods of describing voice, including the DSI. In contrast
to Wuyts et al,11 no significant correlation between the VHI and
the DSI was observed. Woisard et al17 indicated that the DSI
should be seen as a source of clinical information independent
of the VHI. Hakkesteegt et al18 reported on the interobserver
and test-retest variability of the DSI. Thirty normal subjects
were measured by two speech pathologists on three different
Journal of Voice, Vol. 24, No. 6, 2010
days (approximate interval of 1 week between measurements).
The interobserver variability in measurement was observed to
be low with very little influence on DSI variability. In addition,
any differences in DSI measurement between the observers
were reported as nonsignificant. These authors determined
that intrasubject DSI changes needed to exceed 2.49 to be sig-
nificant. Hakkesteegt et al19 investigated the possible relation-
ship between the GRBAS scale and the DSI. The subjects
included 294 voice-disordered patients and 118 normal con-
trols. Significantly lower DSI and higher grade (overall sever-
ity) scores were observed in disordered versus control groups.
In addition, a DSI score of 3.0 was observed to discriminate be-
tween control and disordered groups with sensitivity ¼ 0.72 and
specificity ¼ 0.75. It was observed that DSI scores may be re-
duced even for patients with overall grade/severity scores ¼ 0,
indicating that the voice complaints of some patients may not
be solely quality based. Most recently, Hakkesteegt et al20 ex-
amined the possible relationship between the DSI and the
VHI. Pre- and postintervention measures were obtained from
171 voice-disordered patients. The subjects were divided into
voice therapy, surgical intervention, and no intervention groups.
Consistent with Woisard et al,17 results indicated that the DSI
and VHI measure different aspects of a voice disorder, with
the VHI being a measure of patient perception and the DSI
a measure of vocal performance/capability. Although both
methods were able to show differences between pre- and post-
intervention groups, these authors indicated that DSI and VHI
are not necessarily related.
The DSI has been reported to be a valuable clinical tool for
the quantitative description of normal versus disordered voice.
However, as indicated by Hakkesteegt et al,16 extended norma-
tive data that will provide focused comparisons for subgroups
of the normal population are necessary for appropriate clinical
interpretations. A subgroup of the normal population that may
be seen for voice complaints is that of the trained singer. Voice
training has been said to influence the morphology and the con-
trol over the voice source.21 Although inconclusive, several re-
search studies have reported that trained singers may have
increased respiratory capacities and different respiratory pos-
tures as compared with untrained subjects;22–25 may have
greater F0 ranges than the normal untrained population;26–28
and greater dynamic range capability.27,29,30 In addition, Sulter
et al29 speculated that trained singers may have developed im-
proved breath control during voicing, resulting in the ability to
produce vocal fold oscillation at lower subglottal pressures.
Whether these reported differences between trained and un-
trained singers are specifically the result of training itself; the
regular participation in experiences such as choral singing; or
to inherent physiological differences in those who choose to
regularly participate in directed singing, is unclear. However,
with these possible differences in mind, it would appear that
DSI values for trained singers may be substantially different
from those reported for untrained participants. Because of pos-
sible increased vocal capabilities, it may be that a trained singer
who is experiencing some aspect of vocal dysfunction could
still obtain a DSI score within the expected values reported
by Wuyts et al.11 The availability of data from trained singers
Shaheen N. Awan and Anysia J. Ensslen Comparing Trained and Untrained Vocalists on DSI 663

will make normative expectations for this index more applica- data for age, height, and singing experience are provided in
ble to a greater base of potential patients, and allow for more Table 1.
appropriate clinical decisions regarding this population. There-
fore, the purposes of this study were (1) to compare trained ver-
sus untrained singers on the DSI and its component measures, Procedures
and (2) to contribute to normative DSI data for trained singers. Each subject was asked to complete the following tasks:

1. Highest phonational frequency (F0 high): Each subject

METHODOLOGY
Subjects
The methodology used in this study adhered to the basic ethical
considerations for the protection of human participants in re-
search and was approved by the Bloomsburg University Institu-
tional Review Board. This study included 66 subjects (36
untrained participants [15 males and 21 females]; 30 partici-
pants [15 males and 15 females] with singing experience) be-
tween the ages of 18 and 30 years. An untrained participant
had no formal voice/singing lessons and no directed singing ex-
perience (choral experience, etc) beyond middle school age. A
trained participant had participated in directed singing experi-
ence since middle school age. Directed singing experience in-
cluded private voice lessons and/or regular participation in
a choir or musical theater under the guidance of a trained mu-
sical director. The criteria used to gauge singing experience
in this study were similar to those used by Sulter and Peters31
and McCrae and Morris.32 The trained male and female sub-
jects reported receiving an average of 3.50 and 4.89 years of pri-
vate voice lessons, respectively (Table 1). At the time of testing,
all trained subjects were either (1) currently participating in
voice lessons, (2) were participating in choral singing or musi-
cal theater, or (3) had participated in choral singing or musical
theater within 2 years before testing. Seventeen of the 30 trained
subjects were simultaneously participating in voice lessons and
choir and/or musical theater.
Each subject was asked to complete a brief questionnaire,
which included the subjects’ contact information, age, height,
and a description of previous vocal training and vocal experi-
ence (choirs, theater, etc) since middle school age. All subjects
reported no history of significant injury or trauma to the vocal
folds or larynx, passed a hearing screening of 20 dB at 0.5, 1, 2,
and 4 kHz, and were perceived as having normal voice charac-
teristics of pitch, loudness, and quality. Subject demographic
was asked to go up a scale (using the vowel / /) until
they reached their highest pitch level without losing con-
trol of the voice (ie, no pitch or phonation breaks). The
highest pitch level was digitally recorded at 44.1 kHz,
16 bits of resolution using Sound Forge v. 4.033 and later
analyzed using the TF32 speech/voice analysis pro-
gram34 for the highest frequency level (in Hz). Three tri-
als were elicited.
2. Lowest intensity level (I low): Each subject was asked to
sustain the vowel /a/ at a comfortable pitch as quietly as
possible. Three trials were elicited. Each production was
analyzed for the intensity level (in dB) using Aerophone
II.35 Calibration of all key components of the Aerophone
II system was conducted according to the manufacturer’s
instructions. According to the manual, the microphone
included in the Aerophone II system (AKG type
CK77P-3L electret condenser microphone, AKG Acous-
tics GmbH, Vienna, Austria) is precalibrated by means of
a Bruel and Kjaer Integrating Precision Sound Level
Meter (Type 2230, Bruel & Kjaer Sound and Vibration
Measurement A/S, Naerum, Denmark). A calibration
factor is provided with the system and entered when in-
stalling the system. The mouth-to-microphone distance
was 15 cm. To convert this to the commonly used 30-
cm mouth-to-microphone distance, 6 dB may be sub-
tracted from the 15-cm mouth-to-microphone distance
intensity level. Sound intensity is expected to decrease
by 6 dB when the distance from the source is doubled.36
3. Jitter: To obtain a measure of jitter, the subject was in-
structed to chant ‘‘1, 2, 3, 4’’ at a comfortable pitch and
loudness and then sustain the vowel / / for 2–3 seconds
at that similar pitch level. This elicitation method was
used to obtain a vowel sample that closely approximates
the subjects’ habitual speaking pitch.4 Three trials were

TABLE 1.
Means of Subjects’ Age and Height, As Well As Mean Number of Years of Participation in Directed Singing Experiences for
the Trained Subjects
Demographics Trained Males Trained Females Untrained Males Untrained Females
Age (y) 20.40 (1.76) 21.46 (2.92) 21.66 (2.47) 22.57 (4.03)
Height (cm) 175.43 (5.03) 164.25 (9.44) 179.15 (6.91) 164.13 (5.53)
Voice lessons (y) 3.50* (1.84) 4.89* (4.01) N/A N/A
Participation in choir, 7.93y (3.98) 8.00y (2.93) N/A N/A
musical theater (y)
SDs are provided in parentheses.
Abbreviation: N/A, not applicable; y, years.
* Average of 2.0 h/wk.
y
Average of 3.5 h/wk.
664
elicited. Each production was digitally recorded at
44.1 kHz, 16 bits of resolution using Sound Forge v.
4.0. The central 1 second of each sustained vowel was
later analyzed for jitter (%) using the TF32 program.
4. MPT: When measuring MPT, the subject was asked to
hold out a sustained vowel / / for as long as possible after
a maximum inhalation. Three trials were elicited. Each
trial was timed with a digital stopwatch to calculate the
duration (in seconds).
Dysphonia severity index formula
As previously mentioned, the DSI formula is derived from
a weighted combination of the following vocal parameters:
highest frequency (Hz), lowest intensity (dB), MPT (seconds),
and jitter (%). For each subject, the DSI was calculated using
the maximum performances for F0 high and MPT, the lowest in-
tensity, and the lowest jitter.18 The results were entered into the
following formula:
DSI ¼ 0:133MPT ðsecondsÞ þ 0:00533F0 high ðHzÞ
 0:263I low ðdBÞ  1:183jitter ð%Þ þ 12:4
RESULTS
All statistical procedures were conducted using SPSS v. 15.0 for
Windows.37 Where necessary, significant interaction effects
were analyzed using Tukey Honestly Significant Different
(HSD) means comparison tests.
Analysis of maximum phonation time (Seconds)
A two-way analysis of variance (ANOVA) was conducted to
assess the possible differences in MPT (two levels of group—
trained vs untrained subjects; two levels of gender). Results
indicated no significant difference between the trained versus
untrained groups (F (1, 62) ¼ 0.76; P ¼ 0.38). Although there
was a tendency for males to produce longer MPTs than females
(22.78 seconds [standard deviation (SD) ¼ 6.94] vs 19.71 sec-
onds [SD ¼ 6.62], respectively), no significant gender effect
(F (1, 62) ¼ 3.56; P ¼.06) and no significant interaction effects
(F (1, 62) ¼ 0.02; P ¼ 0.90) were observed. Means and SDs for
the MPTs of the trained versus untrained subjects, as well as for
male and female subgroups are provided in Tables 2 and 3.
Analysis of maximum frequency (Hz)
A two-way ANOVA was conducted to assess the possible differ-
ences in maximum phonational frequency (F0 high). Results
indicated significant main effects of group (F (1, 62) ¼ 26.71;
P < 0.0001), and gender (F (1, 62) ¼ 24.31; P < 0.0001). Results
indicated that the mean F0 high for the trained subjects was
significantly greater than that observed for untrained subjects
(805.01 vs 591.86 Hz, respectively). As expected, female sub-
jects produced significantly greater mean F0 high than male sub-
jects (776.01 Hz [SD ¼ 226.69] vs 584.03 Hz [SD ¼ 190.15],
respectively). No significant interaction of group and gender
Journal of Voice, Vol. 24, No. 6, 2010
TABLE 2.
Means and Standard Deviations for the DSI and Its
Component Measures for the Trained vs. Untrained
Groups (Males and Females Combined)
Trained Vocalists Untrained Vocalists
Variable n ¼ 30 n ¼ 36
MPT (s) 20.43 (5.30) 21.67 (8.01)
F0 High (Hz) 805.01 (227.01) 591.86 (185.64)
I low (dB) 47.97 (5.99) 53.34 (4.26)
Jitter (%) 0.31 (0.11) 0.41 (0.20)
DSI 6.48 (2.19) 4.00 (2.04)
SDs are provided in parentheses.
was observed (F (1, 62) ¼ 1.85; P ¼ 0.18). Means and SDs for
F0 high are provided in Tables 2 and 3.
Analysis of low intensity (dB)
A two-way ANOVA was conducted to assess the possible differ-
ences in low intensity phonation (I low). Results indicated a sig-
nificant main effect of group (F (1, 62) ¼ 26.02; P < 0.0001),
with trained subjects observed to produce significantly lower-
intensity productions than untrained subjects (47.97 vs
53.34 dB, respectively—see Table 2). No significant effect of
gender was observed (F (1, 62) ¼ 0.01; P ¼ 0.98). However,
a significant interaction of group and gender was observed
(F (1, 62) ¼ 18.94; P < 0.0001). Post hoc investigation of the
significant interaction effect using Tukey HSD means compari-
son tests indicated that untrained females produced significantly
lower intensity phonations compared with untrained males. In
contrast, trained males produced significantly lower-intensity
phonations than trained females. In addition, trained males pro-
duced significantly lower-intensity phonations than untrained
males. No significant difference was observed between un-
trained and trained females (Table 3).
Analysis of jitter (%)
A two-way ANOVA was conducted to assess the possible differ-
ences in jitter (%). Results indicated a significant main effect of
group (F (1, 62) ¼ 4.81; P ¼ 0.03), with results indicating that
trained subjects had significantly lower jitter than untrained
subjects (0.31% vs 0.41%, respectively—see Table 2). No sig-
nificant effects of gender (F (1, 62) ¼ 0.25; P ¼ 0.62) or group
and gender interaction (F (1, 62) ¼ 0.52; P ¼ 0.47) were ob-
served (Table 3).
Analysis of the dysphonia severity index
A two-way ANOVA was conducted to assess the possible differ-
ences in the DSI. Results indicated a significant main effect of
group (F (1, 62) ¼ 26.15; P < 0.0001), with the trained subjects
observed to have significantly higher DSI scores than untrained
subjects (6.48 vs 4.00, respectively—see Table 2). No signifi-
cant gender effect was observed (F (1, 62) ¼ 1.85; P ¼ 0.18).
Although a tendency was observed for untrained females to
have greater DSI scores than untrained males, no significant
Shaheen N. Awan and Anysia J. Ensslen Comparing Trained and Untrained Vocalists on DSI
TABLE 3.
Means and SDs for the DSI and Its Component Measures for the Trained Versus Untrained Males and Females
Trained Males Trained Females
Variable (n ¼ 15) (n ¼ 15)
MPT (s) 22.14 (5.53) 18.73 (4.61)
F0 high (Hz) 667.31 (197.89) 942.71 (164.16)
I low (dB) 45.49 (6.63) 50.45 (4.17)
Jitter (%) 0.32 (0.12) 0.31 (0.10)
DSI 6.61 (2.52) 6.35 (1.90)
SDs are provided in parentheses.
group and gender interaction was observed (F (1, 62) ¼ 3.49;
P ¼ 0.07—see Table 3).
DISCUSSION
The results of this study indicate that vocally trained subjects
have significantly higher DSI scores than untrained subjects.
Significant differences were observed between trained and un-
trained groups for three of the four components of the DSI (F0
high, I low, jitter). The findings of this study are consistent with
the reports of Timmermans et al,14,15 which indicated signifi-
cant increases in the DSI with vocal training, and with various
studies which have observed increased vocal capability in
trained singers versus their untrained counterparts.23–30 Al-
though it is unclear from the results of this study as to whether
the significantly increased DSI scores for the trained subjects
are specifically the result of training, consistent participation
in singing/choral activities, innately increased vocal capabil-
ities in these subjects, or some combination of these factors,
the difference in the mean DSI scores (6.48 for trained subjects
vs 4.00 for untrained) is substantial and primarily related to in-
creased frequency and dynamic range.
In light of previous reports of increased vital capacity in
trained singers, it was somewhat surprising that there was no
significant difference between the trained singers and the un-
trained subjects on measures of MPT. However, this finding
has some similarity to the observations of Sulter and Meijer,21
in which MPT was observed to decrease post-vocal training.
These authors attributed a decrease in phonation time to a de-
crease in glottal resistance and a more relaxed vocal fold pos-
ture. It is also speculated that the trained subjects may not
have performed to their maximum potential on this particular
task, despite prompting during the elicitation of all DSI compo-
nent measures, because they were hesitant to ‘‘stress’’ their vo-
cal mechanism. In addition, it may have seemed unnatural for
the trained subjects to continue sustained phonation even as
breath support became substantially reduced.
Several studies have indicated that there may be increased
frequency ranges and high frequency production in trained
singers.26–28 In addition, in studies by Mendes et al38 and LeB-
orgne and Weinrich,39 significant increases in frequency range
when compared before and after vocal training are reported. As
Western singing training generally includes exercises and/or
665
Untrained Males Untrained Females
(n ¼ 15) (n ¼ 21)
23.42 (8.26) 20.42 (7.78)
500.75 (144.47) 656.94 (187.15)
56.19 (4.24) 51.30 (2.94)
0.38 (0.13) 0.43 (0.24)
3.04 (1.98) 4.69 (1.83)
warm-ups that may involve pitch matching, pitch glides, and
pitch (musical) scales, it is of no surprise that trained subjects
may be able to produce greater frequency ranges and maximum
frequencies than untrained subjects.38 The observation of sig-
nificantly higher maximum frequency (F0 high) production in
females versus males is expected, and consistent with previous
findings by Wuyts et al11 and Hakkesteegt et al.16 Even though
females characteristically produce higher maximum frequency
productions as compared with males, this difference is
generally offset by greater MPTs in males than females. The
result is that the DSI scores for the genders tend not to differ
significantly.11
The trained singers were observed to have significantly lower
minimum intensity (I low) productions than untrained subjects.
This finding is consistent with literature that has indicated in-
creased phonatory control and a lowering of the minimum in-
tensity capability for subjects who have undergone focused
vocal training.21,27,39 Vocal-training exercises that promote in-
creased vocal fold thickness and increase breath support and
control tend to be conducive to lower minimum intensity pro-
ductions.21 In addition, Western singing training often includes
various respiratory exercises/warm-ups that focus on the proper
use and strengthening of the abdominal muscles and dia-
phragm,38 as well as a focus on optimal posture and respiratory
support during both singing and speech tasks, which may en-
able those with vocal training to produce greater ranges of vocal
intensities.
The results of this study showed that trained subjects had sig-
nificantly lower jitter than untrained subjects. Although a signif-
icant difference in jitter between the trained and untrained
groups was observed, both groups produced jitter values well
within normative expectations (generally expected to be sub-
stantially less than 1%4,40). In addition, the normal jitter results
for both groups are consistent with the perception of normal
voice quality of all the subjects included in this study. It is
known that subjects can have normal voice quality and mea-
sures of jitter, and yet differ in terms of the DSI. This result
clearly emphasizes that the DSI should be interpreted as a mea-
sure of vocal function/performance, and is not necessarily a cor-
relate of perceived or measured vocal quality.19
The DSI has the potential to be a useful diagnostic and clin-
ical tool in regard to a variety of patients who may be experienc-
ing voice difficulties. Although the DSI results of untrained
666
vocalists reported in this study are consistent with the data of
untrained vocalists reported in previous literature,11,16,19 the re-
sults of this study indicate that alternative normative expecta-
tions for the DSI may need to be taken into account when
using the DSI with patients who have participated in directed
vocal training or singing experience. The results of this study
clearly indicate that DSI scores for subjects with vocal/singing
training may substantially exceed previously reported mean
DSI values for normal untrained subjects. Although the current
literature includes results showing changes in DSI for those
who undergo vocal training, specific norms for subjects who
have continued their participation in vocal training or singing
tasks over multiple years of experience are lacking. The results
of this study provide preliminary DSI expectations for more ex-
perienced vocalists. Future studies should extend these prelim-
inary norms to include larger samples and alternative forms of
vocal experience beyond the choral/musical theater background
for the subjects in this study.
Acknowledgment
The authors of this study would like to thank Dr. P. Milenkovic
for the download and use of the TF32 speech/voice analysis
program.
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