ARTICLE IN PRESS

Voice Handicap Index-18 as an Instrument for Assessing

Subjective Voice Impairment Between Voice Pre- and
Post-treatment
Katharina Feige, Anne Strauss, and Gero Strauss, Leipzig, Germany

Summary: The Voice Handicap Index (VHI) is today regarded as the gold standard for measuring the subjec-
tive impairment of a voice disorder. The aim of our study is to present how the VHI in our version with 18 ques-
tions (VHI-18) can be evaluated with other patient collectives (practice visitors or everyday patients). The
previous publications have shown that most patient groups were stationary or clinical. A total of 100 adult
patients (72 female, 28 male) in our medical practice KOPFZENTRUM were examined. The reliability of the
VHI-18 results from a Cronbach's Alpha (0.92). The VHI-18 is suitable as a diagnostic instrument for medical
practices or logopaedic practices.
Key Words: Voice Handicap Index−VHI−voice disorders−patient assessment−VHI-18−medical practice−
logopaedic management−logopaedic patient orientation.

INTRODUCTION could not be qualified because of a high drop-out rate or

The daily meetings with other people are characterized by
many smaller and larger talks. We all use our voice every
day, but we take it for granted and we are unaware of its sig-
nificance. However, the prevalence of voice disorders is
reported to be 6% on average, with functional voice disor-
ders accounting for a share of 70−80%.1 The handicap is
described by WHO2 in terms of the consequences for indi-
viduals regarding their cultural, social, economic, and envi-
ronmental disadvantages. Voice disorders are likewise of
increasing importance in today's society.3
In phoniatrics, the dysphonia was assessed by first mea-
suring through the laryngoscopy and presenting findings of
acoustic and aerodynamic parameters. It is difficult to make
an objective image of the voice according to the variety of
injuries.4 For this reason, the patient should assess himself
to be able to collect the communicative and social meaning
of a voice disorder. The Voice Handicap Index (VHI) was
developed by Jacobson et al5 for selfassessment on the part
of the patients. To evaluate possible voice problems the
VHI-30 contains 30 questions, each with 10 items subdi-
vided: functional, physical, and emotional aspects. Rosen et
al6 developed a shorter version of VHI-10, with five func-
tional items, three physical items, and two emotional items.
This had been one reason for the shorter version: the 30
items in the VHI can take up to 15 minutes for patients.7
With many questions, the risk increases that patients would
cancel the survey because of a survey period that is too long
and frustrating, and the validity of results from the survey
Accepted for publication April 15, 2019.
Primary institution: Kopfzentrum Leipzig, Germany
The authors have no funding, financial relationships, or conflicts of interest to
disclose.
From the The International Reference and Development Centre for Surgical Tech-
nology (IRDC GmbH), Leipzig, Germany.
Address correspondence and reprint requests to Katharina Feige, Kopfzentrum,
K€athe-Kollwitz-Straße 64, 04109, Leipzig, Germany.
E-mail: katharina.feige@kopfzentrum-gruppe.de
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.04.005
rate of false statements.8 On the other hand, it is methodo-
logically not clear how the 10 items were selected. It was
briefly mentioned that the findings from the 10 items were
based on the result of pre- and post-treatment item analy-
sis.6 Hence, another intermediate methodological step
seems preferable: a factor analysis was performed, and the
VHI-12 was developed in German-speaking country,4 with
five functional items, three physical items, and four emo-
tional items. This was despite the fact that the international
argumentation for the VHI-10 is based on the high values
of Cronbach's Alpha.9
It should be noted here: among the treated patients were
clinic visitors, in other words, the most of the publications
seem to be clinically or university-oriented. It is not clear so
far whether or not a publication with the data of medical
practice visitors is available.
Therefore it is important for medical practice to under-
stand how a disorder of the voice requires subjective mea-
surement in order to better assess the impact on a patient's
life or therapeutic success. In addition to the impairment of
voice sound and voice image, the reduced capacity of the
voice plays an important role. How severely the affected
person is suffering from voice change−−this can vary
greatly and differ considerably among professional assess-
ments. With the help of the overall impression, the func-
tional-organic-emotional aspects can be estimated.
The study at hand presented another version on the fol-
lowing grounds: better understanding of patients, better
assessment of treatment success, and suitability of selected
items in the VHI for our medical practice. Furthermore,
this study examined to find out if there was a significant
difference in patient voice assessment before and after log-
opedics treatment at a medical practice. In addition, the
study also aims to show significant differences in the
selected items that are important for voice therapies.
It was hypothesized that there was a (high) therapeutic
effect on voice and a change in the voice assessment after
therapy.
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
The research questions addressed in this article include
the following:
1. Is there a significant difference in voice estimation
("How do you rate your voice today?") before and after
treatment?
2. Are there significant differences in all aspects with
selected items of VHI before and after treatment? If so,
can one make a statement as to which item is signifi-
cantly different before and after treatment (functional,
physical, and emotional aspects)?
3. It is also interesting to know if there is a significant dif-
ference in attitude for the patients who need their voice
primarily for their profession or for singing.
MATERIALS AND METHODS
Patient collective
In this work, 100 patients were examined who from May
2016 to July 2018 in our medical practice Kopfzentrum in
Leipzig were treated (mean duration of therapy is 7.6
months (SD: 5.1); range: 2−38 months; skewness: 3.2).
Data collection was done from patient records and ques-
tionnaires that patients had completed before and after the
treatment. All 100 patients were therapeutically treated in
our logopedics practice. Surgical procedures were not per-
formed. A variety of specific therapeutic approaches in the
field of voice therapy depending on the patient (cognitive
abilities, age, motivation, and compliance) and diagnoses
was used. For this reason, no information can be given here
for certain voice treatments.
Formation of VHI-18
The VHI questionnaire is an internationally used instru-
ment for assessment of the quality of life for patients with
voice disorders, specifically: the intrapsychic, communica-
tive, and social significance of a voice disorder4 and was
developed in the Unite States.5 In order to reduce the dura-
tion of the VHI, it is necessary to evaluate which questions
would be reasonable for the patients. For example, are
questions about income or other highly personal issues,
according to experience, answered only with great unwill-
ingness, and could they sometimes lead to drop-outs?8 For
our study, the German Version of the VHI questionnaire
according to the protocol of the German Society for Phoni-
atrics and Pedaudiology was selected and shortened as the
VHI-18 questionnaire. The grounds for selected items are
shown in Table 1. A subjective opinion on voice quality
should be obtained, and less connected with the patient's
feelings. Furthermore, it should be ensured that the time
needed to complete the questionnaire is substantially lower
than for the VHI-30. The statements in the VHI-18 are
divided into three sub-groups each consisting of five func-
tional, seven physical, and six emotional statements and are
rated on a five-point Likert scale between zero (never), one
(almost never), two (sometimes), three (almost always), and
four (always). In addition to the 18 questions, there is a
question at the end of the VHI questionnaire self-assessment
of the patient ("How do you rate your voice today?"). For
answering this last question, gradations between zero (nor-
mal), one (slightly disturbed), two (moderately disturbed),
and three (highly disturbed) are possible.
Evaluation of VHI questionnaire and statistical
calculations
The subjective evaluation questionnaires VHI-18 were to be
filled out by the patients (n = 100) before and after treat-
ment. The patient should indicate in the self-assessment
items to what extent the statement applies to him (zero
[never], one [almost never], two [sometimes], three [almost
always], and four [always]). The items are divided into three
areas (sub-groups): functional, physical, and emotional
aspects of the voice disorder. Fifty-six patients were classi-
fied as a group with a “speaking voice mainly for the profes-
sion” as well as “occupational voice users” and 46 patients
as a group with a “singing voice mainly for free time” as
“nonprofessional singers” according to their own assess-
ment. The data of “professional singers” (n = 9) could not
be included in this study due to the small sample. The distri-
bution of patients according to age, gender, speaking, and
singing voice is shown in Table 2.
Data collected from the questionnaire were collected in
Excel. The t test was used to evaluate whether there were
any differences between the groups. All reported P values
were two-tailed. Statistical significance was set at P < 0.05.
The internal consistency reliability of VHI-18 was evaluated
using Cronbachs alpha coefficient. All analysis was con-
ducted using Microsoft Excel statistical software.
RESULTS
Figure 1 shows the percentages of the groups “Occupational
voice users” and “Nonprofessional singers”. Female
patients account for the largest share of these two groups
(66.07% and 73.91%, respectively). The number of different
groups and their ages are listed in Table 1. The average age
of patients in this study is 46−47 years and is slightly higher
than the median age (42−44 years) (Table 2).
Table 3 demonstrates values of the total score of the voice
assessment (How do you rate in the following areas on a scale
from zero [normal] to three [high-grade impairment],
today?) before and after the treatment. According to the
percentage distribution, most groups show a significant
improvement, ie a decrease of more than 11 points in the
voice assessment total score. Although groupings "Occupa-
tional voice users, female," "Nonprofessional singers, male,"
and “Age between 20−39 years” show a percentage
improvement of at least 25%, they are not statistically sig-
nificant. No significant deterioration, ie an increase in voice
assessment total score was to be noticed. Apart from the
total number of groups, in groupings “Female,” “Male”
and particularly “Age between 60−90 years” the differences
 Katharina Feige, et al
TABLE 1.
Overview of different VHIs and grounds for the VHI-18. VHI-30 described by Jacobcon et al.5; VHI-18 this study; VHI-12 by Nawka et al4; VHI-10 by Rosen et al6
Item No. refers to the item number of the VHI-30. Grey-marked grounds show rejections of items of the VHI -12 and VHI-10
Item No. VHI-30 VHI-18 VHI-12 VHI-10 Reasons for Selection and Rejection of Items
F1 My voice makes it difficult for people to hear me. x x x In accordance with VHI10/VHI-12
P2 I run out of air when I talk. x Breath technique used in the treatment
F3 People have difficulty understanding me in a noisy room. x x Definition of noice is unclear for patients
P4 The sound of my voice varies throughout the day. x Selected
F5 My family has difficulty hearing me when I call them throughout the x Not everyone has a family, nonoption is necessary
house.

Voice Handicap Index-18

F6 I use the phone less often than I would like. x Phone is part of our everyday life
E7 I’m tense when talking with others because of my voice. x The tension may lead to higher voice load
F8 People seem irritated with my voice. In accordance with VHI10/VHI-12
E9 I tend to avoid groups of people because of my voice. x x In accordance with VHI-12
P10 People ask, “What’s wrong with your voice?” x x In accordance with VHI10

ARTICLE IN PRESS
F11 I speak with friends, neighbors, or relatives less often x Indicates a social problem
because of my voice.
F12 People ask me to repeat myself when speaking face-to-face. x Objective recognition of other people
P13 My voice sounds creaky and dry. x Offers important information how voice does work
P14 I feel as though I have to strain to produce voice. x x x In accordance with VHI10/VHI-12
E15 I find other people don’t understand my voice problem. In accordance with VHI10/VHI-12
F16 My voice difficulties restrict my personal and social life. x Too general, in accordance with VHI-12
P17 The clarity of my voice is unpredictable. x x x In accordance with VHI10/VHI-12
P18 I try to change my voice to sound different. In accordance with VHI10/VHI-12
F19 I feel left out of conversations because of my voice. x x x In accordance with VHI10/VHI-12
P20 I use a great deal of effort to speak. In accordance with VHI10/VHI-12
P21 My voice is worse in the evening. x Voice can be worse during the day
F22 My voice problem causes me to lose income. x Too personal, in accordance with VHI-12
E23 My voice problem upsets me. x x In accordance with VHI10
E24 I am less outgoing because of my voice problem. x Similar to F11
E25 My voice makes me feel handicapped. x x In accordance with VHI10
P26 My voice “gives out” on me in the middle of speaking. x Same as P13
E27 I feel annoyed when people ask me to repeat. x x In accordance with VHI12
E28 I feel embarrassed when people ask me to repeat. x Similar to P26
E29 My voice makes me feel incompetent. In accordance with VHI10/VHI-12
E30 I’m ashamed of my voice problem. x x In accordance with VHI12
How do you rate your voice, today? x x ? In accordance with VHI12
VHI, Voice Handicap Index.

3
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2019

TABLE 2. positive affect, which consists of 18 items from the total

Age of 100 Patients VHI-18. The internal consistency of the questionnaire is sat-
isfying, with Cronbach’s alpha for positive affect = 0.92
Number Age (pretreatment) and 0.93 (post-treatment). Cronbachs alpha
(n) Mean (§SD) Range coefficient was calculated for each item of three aspects
All patients 100 46 (§19) 20−90
from the VHI-18 before and after the treatment. The result-
Occupational voice users 56 39 (§14) 20−74 ing alpha coefficient is presented in Table 5. Table 6 demon-
Nonprofessional singers 46 43 (§18) 21−78 strates the VHI-18 total score in the groups "Male,"
All male patients 28 47 (§18) 21−90 "Female," "Occupational voice users," and "Nonprofes-
Occupational voice users 19 40 (§14) 21−74 sional singers" before and after the voice treatment. Most
Nonprofessional singers 12 40 (§14) 24−66 significant differences (P < 0.05) were found between
All female patients 72 46 (§20) 20−82 “before” and “after” treatment, excepting male patients. In
Occupational voice users 37 38 (§14) 20−64 this group the differences between before and after treat-
Nonprofessional singers 34 44 (§19) 21−78 ment are the lowest. A strong percentage improvement of a
minimum of 50% shows subgroup F11 (I speak with friends,
neighbors, or relatives less often because of my voice) in all
groups. A similar improvement on items in both groups
“Occupational voice users” and “Nonprofessional Singers”
between pre- and post-treatment are statistically highly sig- were found in P26 (I feel as though I have a strain to produce
nificant (P < 0.01). sound.) and E25 (My voice makes me feel handicapped.).
Table 4 illustrates the total collective (all patients) in The subscale F11 shows a high percentage improvement in
VHI-18 total score before and after the vocal treatment. It all groupings, also in accordance with Table 4 (all patients),
continues to show frequent significant improvements in whereby there are no statistically significant differences for
total VHI-18 total score after therapy (P < 0.05), ie an aver- "Male" and "Nonprofessional Singers". P2 (I run out of air
age decrease of 40.7 points (range 13−71 points) in each of when I talk.) shows in all groupings a slight percentage dete-
the 18 subgroups. The mean of the VHI-18 total score at rioration or least improvement, in accordance with Table 5
starting therapy varies between 0.40 and 2.21 in the sub- (all patients). However, this difference is not statistically sig-
scales and between 0.19 and 1.69 at the end of the therapy. nificant (P > 0.05), for F12 (People ask me to repeat myself
Highest numbers of significant improvement (at least P < when speaking face-to-face).
0.01) in the functional (F), physical (P), and emotional (E)
aspects are found in questions F11 (60.42%), P14 (35.45%),
and E25 (48.70%), respectively. DISCUSSION
On the overall functional (F), physical (P), and emotional With regard to applicability in the logopedic practice, the
(E) aspects, the improvement was at least 28.83% after professionally motivated requirements will increasingly
treatment in n = 100 patients (data not shown). The VHI have to comment on the question: To what extent are medi-
total score for the functional aspects was 148 points, of the cal services provided that measure rehabilitative/therapeutic
physical aspects 337 points, and of the emotional aspects effects? Specific parameters should be developed in order to
248 points. The difference is statistically highly significant categorize criteria for therapy initiation. In addition to
(P < 0.001). organ- and function-related aspects and the social dimen-
For reliability of analysis, Cronbach’s alpha was calcu- sion, the self-assessment by the patient should also be of
lated to assess the internal consistency of the subgroup for high interest. Validated, internationally accepted methods

FIGURE 1. Demographics of 100 patients participating in this study

 Katharina Feige, et al
TABLE 3.
Comparison of mean voice assessment scores before and after treatment overall and for each group. T-Test was applied to determine if the change in VHI-18
within each group was most statistically significant
Evaluation: How do you Rate Your Voice in the Following Areas on a Scale From 0 (normal) to 3 (High-Grade Impaired), Today?

Voice Handicap Index-18

Pretreatment Post-treatment Change and Before and After Treatment
Improvement
Total Total
Included in Score Mean Score Mean
Patient groups this Study (n) (0−3) Median (§SD) (0−3) Median (§SD) (n; %) P value Significance

ARTICLE IN PRESS
Overall Total 98 143 1.00 1.46 (§0.90) 93 1.00 0.95 (§0.76) 50; 34.97% 0.00003 Statistically highly
significant
Male 28 40 1.00 1.43 (§1.07) 21 1.00 0.75 (§0.80) 19; 47.50% 0.00948 Statistically high
significant
Female 70 103 1.00 1.47 (§0.83) 72 1.00 1.03 (§0.74) 31; 30.10% 0.00111 Statistically high
significant
Occupational Total 56 78 1.00 1.39(§0.89) 53 1.00 0.95 (§0.82) 25; 32.05% 0.00665 Statistically high
voice users significant
Male 19 26 1.00 1.37 (§0.83) 15 1.00 0.79 (§0.79) 11; 42.31% 0.03394 Statistically
significant
Female 37 52 1.00 1.41 (§0.93) 38 1.00 1.03 (§0.83) 14; 26.92% 0.06883 Statistically no
significant
Nonprofessional Total 45 66 2.00 1.47 (§0.89) 46 1.00 1.02 (§0.75) 20; 30.30% 0.01252 Statistically
singers significant
Male 12 15 1.00 1.25 (§0.87) 9 0.50 0.75 (§0.87) 6; 40.00% 0.17128 Statistically no
significant
Female 33 51 2.00 1.55 (§0.9) 37 1.00 1.12 (§0.07) 14; 27.45% 0.03660 Statistically
significant
Age (yr) 20−39 48 57 1.00 1.21 (§0.83) 42 1.00 0.89 (§0.76) 15; 26,32% 0.05509 Statistically no
significant
40−59 23 42 2.00 1.83 (§0.78) 28 1.00 1.22 (§0.85) 14; 33,33% 0.01495 Statistically
significant
60−90 29 44 1.00 1.57 (§1.00) 23 1.00 0.82 (§0.67) 21; 47,73% 0.00170 Statistically high
significant

5
 6
TABLE 4.
Grouping of 100 patients rating their voices before and after treatment (18 subscale score with the subscale number of VHI-30(5)). P value, change in voice assess-
ment score (change in VHI-18) and improvement in % after treatment are presented
Functional Aspects Physical aspects Emotional aspects

F1 F6 F11 F12 F19 P2 P4 P10 P13 P14 P17 P26 E7 E9 E23 E25 E27 E30
I Speak With
My Voice Friends, Im tense I tend to
Makes it I use the Neighbors, People ask I Feel Left The Sound I feel as My voice when avoid
Difficult Phone Less or Relatives me to Repeat out of I Run out of my Voice People ask, My voice through I The clarity "gives out" talking with groups of I feel annoyed
for Often Than Less Often Myself When Conversations of Air Varies "Whats sounds have to strain of my voice on me in others people My voice My voice when people Im ashamed
All
People to I Would Because of Speaking Because of my When Throughout wrong with creaky and to produce is unpredict- the middle because of because of problem makes me feel ask me to of my voice
Patients
Hear me. Like. my Voice. Face-to-face. Voice. I Talk. the Day. your voice?" dry. voice. able. of speaking. my voice. my voice. upsets me. handicapped. repeat. problem.
Pretreatment

Number of 100 100 100 100 100 99 98 100 100 100 99 99 100 100 100 99 99 100
entries
Total 149 63 48 118 41 123 217 136 211 189 185 108 128 62 160 115 72 40
Median 2 0 0 1 0 1 2 1 2 2 2 1 1 0 1.5 1 0 0
Mean 1.49 0.63 0.48 1.18 0.41 1.24 2.21 1.36 2.11 1.89 1.87 1.09 1.29 0.62 1.60 1.16 0.73 0.40
SD (§) 1.11 0.99 0.95 0.99 0.79 1.02 1.05 1.33 1.20 1.16 1.32 0.94 1.24 0.99 1.44 1.36 1.05 0.82
Total 95 40 19 91 26 110 166 91 140 122 132 71 74 33 92 59 47 24
treatment

Median 1 0 0 1 0 1 2 1 1 1 1 1 0 0 1 0 0 0
Post-

Mean 0.95 0.40 0.19 0.91 0.26 1.11 1.69 0.91 1.40 1.22 1.33 0.72 0.75 0.33 0.92 0.60 0.47 0.24

ARTICLE IN PRESS
SD (§) 0.93 0.80 0.58 0.90 0.58 0.91 1.01 1.06 1.06 0.95 1.04 0.78 0.96 0.73 1.08 0.96 0.80 0.57
P-value 0.00024 0.07309 0.00978 0.04478 0.12816 0.34145 0.00050 0.00867 0.00002 0.00001 0.00179 0.00266 0.00066 0.01932 0.00020 0.00087 0.05813 0.10983
treatment
and after

Change in 54 23 29 27 15 13 51 45 71 67 53 37 54 29 68 56 25 16
Before

VHI-18 (n)
Improve- ment 36.24 36.51 60.42 22.88 36.59 10.57 23.50 33.09 33.65 35.45 28.65 34.26 42.19 46.77 42.50 48.70 34.72 40.00
in VHI-18 (%)

VHI, Voice Handicap Index.

TABLE 5.
Correlation Matrixes for Total Score (VHI-18) and Subscale Scores Before and After Treatment (see Cronbach Alpha)
Pretreatment Post-treatment Change in VHI-18

All Patients VHI - Functional (F) VHI- Physical (P) VHI - Emotional (E) VHI-18 VHI - Functional (F) VHI- Physical (P) VHI - Emotional (E) VHI-18
(n = 100) Max score = 20 Max score = 28 Max score = 24 Max score = 72 Max score = 20 Max score = 28 Max score = 24 Max score = 72 (n) (%) P value

p < 0.001

Journal of Voice, Vol. &&, No. &&, 2019

Total 419 1169 577 2165 271 832 329 1432 733 33.86
Median 3.5 12.0 5.0 21.0 2.0 7.0 2.0 12.0 9.0 42.86 p < 0.001
Mean (§SD) 4.19 (§3.56) 11.69 (§5.72) 5.77 (§5.19) 21.65 (§12.64) 2.71 (§2.84) 8.32 (§5.35) 3.29 (§3.93) 14.32 (§10.84) 7.33 33.86 p < 0.001
SEM 0.36 0.57 0.52 1.26 0.28 0.53 0.39 1.08 - - -
Minimum 0 1 0 1 0 0 0 0 - - -
Maximum 18 25 20 54 12 23 20 55 - - -
Cronbach alpha 0.79 0.84 0.83 0.91 0.79 0.89 0.85 0.93 - - -
VHI, Voice Handicap Index.
 Katharina Feige, et al
TABLE 6.

Voice Handicap Index-18

Demographics of Different Groups Rating Their Voices Before and After Treatment (18 Subscale Score With the Subscale Number of VHI-30(5)). P Value, Change
in Voice Assessment Score (change in VHI-18) and Improvement in % After Treatment are Shown.
Functional Aspects Physical Aspects Emotional aspects

F1 F6 F11 F12 F19 P2 P4 P10 P13 P14 P17 P26 E7 E9 E23 E25 E27 E30
People ask
I use the I Speak with me to

ARTICLE IN PRESS
My Voice Phone Friends, Repeat I feel as
Makes it Less Neighbors, Myself I Feel Left The Sound through I My voice Im tense I tend to avoid
Difficult Often or Relatives When out of of my Voice People ask, My voice have to “gives out” when talking groups of I feel annoyed
for Than I Less Often Speaking Conversations I Run out of Varies “Whats wrong sounds strain to The clarity of on me in with others people My voice My voice when people Im ashamed
People to Would Because of Face-to- Because of Air When Throughout with your creaky and produce my voice is the middle because of because of problem makes me feel ask me to of my voice
Hear me. Like. my Voice. face. my Voice. I Talk. the Day. voice?” dry. voice. unpredictable. of speaking. my voice. my voice. upsets me. handicapped. repeat. problem.

Male (n = 28)
P value 0.289 0.800 0.169 0.524 0.706 0.875 0.038 0.192 0.003 0.057 0.130 0.101 0.126 0.873 0.007 0.043 0.263 0.072
Change in VHI-18 (n) 8 2 6 4 2 ¡1 18 11 28 16 13 8 12 1 27 18 8 8
Improvement in 19.05 11.11 60.00 12.50 18.18 ¡3.85 31.03 32.35 48.28 32.65 30.23 38.10 35.29 8.33 57.45 56.25 33.33 80.00
VHI-18 (%)
Female (n = 72)
P value 0.0003 0.040 0.027 0.055 0.121 0.243 0.005 0.023 0.001 0.0001 0.006 0.009 0.003 0.009 0.008 0.008 0.127 0.372
Change in VHI-18 (n) 46 21 23 23 13 14 33 34 43 51 40 29 42 28 41 38 17 8
Improvement in 42.99 46.67 60.53 26.74 43.33 14.43 20.75 33.33 28.10 36.43 28.17‘ 33.33 44.68 56.00 36.28 45.78 35.42 26.67
VHI-18 (%)
Occupational voice
users (n = 56)
P value 0.007 0.151 0.009 0.082 0.246 0.316 0.002 0.039 0.001 0.0002 0.021 0.009 0.052 0.340 0.012 0.039 0.083 0.266
Change in VHI-18 (n) 28 14 22 17 8 10 35 28 41 42 29 25 21 8 35 26 17 8
Improvement in 37.33 40.00 73.33 25.37 40.00 13.70 27.34 36.36 36.61 38.89 29.59 39.06 36.84 29.63 42.68 45.61 41.46 40.00
VHI-18 (%)
Nonprofessional
singers (n = 46)
P value 0.001 0.491 0.063 0.315 0.339 0.237 0.015 0.043 0.002 0.001 0.034 0.011 0.008 0.159 0.027 0.010 0.151 0.146
Change in VHI-18 (n) 29 6 17 9 7 11 25 23 37 34 24 22 30 13 28 29 14 11
Improvement in 41.43 19.35 54.84 16.67 30.43 14.29 23.58 35.38 34.91 35.42 25.26 37.93 45.45 37.14 35.90 50.00 35.00 44.00
VHI-18 (%)

VHI, Voice Handicap Index.

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8 Journal of Voice, Vol. &&, No. &&, 2019
are available to measure these parameters: “voice related
quality of life”10 and “voice-related impairment” VHI. To
illustrate the extent of subjective impairment, the "Voice
Handicap Index" questionnaire ("Gold Standard") devel-
oped by Jacobson et al5 is currently being used internation-
ally for clinical diagnostics as well as in scientific studies.11
Caution should nevertheless be exercised here regarding the
VHI results, since value outliers could represent human
error in which the subjects believed that the larger numbers
actually referred to a higher function rather than a higher
handicap.12 After the end of voice therapy, the number of
VHI totals could vary and provide the insignificant result.
One possible reason behind this is that the patients would
get greater awareness of the subjectively perceived
impairment of the voice disturbance during the voice ther-
apy.
This study concerns itself with the suitability of the
shorter version of VHI referred to as the VHI-18. The VHI-
18 is an assessment procedure used in outpatient care.
Unlike the current studies on the VHI which focus on inpa-
tient data collected in a clinic or hospital, the shorter version
focuses on the data collected in a physician's medical prac-
tice for outpatients. The different locations may reflect dif-
ferences in the gravity of the medical concern, assessment,
and corresponding treatment. For this reason, we empha-
size that the data collected in the VHI-18 is based on outpa-
tients collected at a physician's medical practice.
In particular, it should be examined how the result of a
voice rehabilitation measure can be mapped with the VHI-
18. In order to make a better statement on the success of
treatment, the VHI-18 was prepared in particular toward
our logopedics treatment.
Apart from the time gain by reducing VHI to 18 ques-
tions, these were chosen with emphasis on patients’ self-
awareness’ of its voice problems and especially in regard to
the social importance of voice functionality. With the
increasing number of voice disorders in recent years, their
social importance has also increased. Disorders of the voice
often lead to social disintegration, especially in vocally
intensive occupations, causing psychic stress which itself
might increase the already existing voice problems. Many
studies prove that singing−−apart from professional or
commercial singing−−has a great importance in our soci-
ety. For many, singing is a hobby that brings satisfaction,
because amateur singing includes everyone.13 Therefore,
voice disorders could also cause mental strain in nonprofes-
sional singers.
The patients were asked what they predominantly use
their voice for, and categorized into occupational voice
users, due to the importance of social dependence, and non-
professional singers, due to their mental and social well-
being. The group of professional singers were excluded
from this study due to the limited sample size (n = 9). It
should also be noted that questionnaires for professional
singers14 were not utilized. Patients in this trial are predomi-
nantly female. There is hardly any dependency on this
group, because the earlier assumption that female patients
in particular tend to "overemphasize" their condition cannot
be confirmed here.
Our strategic focus is on better management and perhaps
development of logopedic treatment and, of course, on the
expectations of patients. From a medical or logopedics
point of view and of course from a patient's point of view, a
good voice quality result from a therapeutic intervention is
the main objective. Evaluations are also useful to set new
objectives and points of interest as well as working methods.
In this context an attempt should be made to continuously
assess the expectations of the patients, to recognize changes
and to react accordingly. Patient orientation means uncov-
ering and eliminating deficits through continuous quality
management.15
The results from the subscale P2 are worth mentioning,
especially in male patients (¡3.85%), and show no improve-
ment. They therefore indicate the necessity for a different
therapeutic approach and/or methods in this group. How-
ever, a significant deterioration or change is not shown.
One of the important tasks of the therapy is the preserva-
tion of work skills. The study collective has shown that at
the beginning of therapy, 56% of patients have a speech
requirement for their profession. In the comparison between
before and after the treatment, the voice assessment
(Table 4) differed according to statistical criteria only in the
groups “Occupational all and male voice users" in contrast
to the “occupational female voice users” group which shows
no significant improvement. An explanation for later could
be the different professional backgrounds and possibly
higher expectations toward the therapy. With regard to the
change in voice assessment, all nonprofessional singers,
female nonprofessional singers, and patients over the age of
40 show a statistically significant change in the voice assess-
ment score of at least 14 points. A significant statement
regarding the male nonprofessional singers cannot be made
due to the small number of samples.
With regard to the talkativeness assessment by the
patients, the result with a rating scale of 1−10 (one = quiet
listener, four = average talker, 10 = extremely talkative)
cannot be considered as a successful parameter. This meth-
odological deficit is not controllable in this study due to the
unclear dimension of scale. A recommendation would be
appropriate to include only five check boxes with options
such as “strongly agree,” “agree,” “partly disagree,” and
“strongly disagree.”
This study provides no normative values to better estab-
lish the responsiveness of the VHI-18. Studies evaluating
whether or not the change in pre/post absolute values or
percentage change best reflects patient’s satisfaction and
subjective improvement are thus necessary. The different
evaluation methods may be due to a different regional expe-
rience of disease.16 Nevertheless, the VHI-18 is suitable for
use as an indication and success criterion for therapeutic
measures.
It would also be worth considering that the speech thera-
pists are instructed as additional consultants to educate
patients, especially professional speakers, that it is necessary
 ARTICLE IN PRESS
Katharina Feige, et al Voice Handicap Index-18 9

to either reduce noise in the workplace, or move to another
location. Reducing background and activity noise levels
should be the first intervention to improve voice ergonomic
conditions in communication-intensive and vocally
demanding workplaces,17 and an attempt to offer tailored
strategies to prevent the individual from developing voice
disorders.18 Another consideration would also be a compar-
ative study of voice disorder and allergic rhinitis. There is
limited literature regarding voice disorders in the allergic
population.19
the success of voice therapy. It is advisable in the future to
further investigate a connection between objective voice
examinations and actual occupational consequences.
This research was limited only to patients who fill in the
VHI-18; no other clinical evaluation was performed (eg,
voice sampling and acoustic analysis or laryngeal endos-
copy, etc).

SUPPLEMENTARY MATERIALS
CONCLUSIONS Supplementary material associated with this article can be
In principle, a part of the conclusive evaluation of the VHI found in the online version at https://doi.org/10.1016/j.
can be derived from the results as a method for measuring jvoice.2019.04.005.

APPENDIX

Numbering Item in German Item in English

VHI-18_F1 Man ho € rt mich wegen meiner Stimme schlecht. My voice makes it difficult for people to hear me.
VHI-18_P2 Beim Sprechen geht mir die Luft aus. I run out of air when I talk.
VHI-18_P3 Der Klang meiner Stimme a €ndert sich im Laufe des The sound of my voice varies throughout the day.
Tages.
VHI-18_F4 Ich benutze das Telefon seltener, als ich eigentlich I use the phone less often than I would like.
mo€ chte.
VHI-18_E5 Wegen meiner Stimme bin ich angespannt, wenn I’m tense when talking with others because of my
ich mich mit anderen unterhalte. voice.
VHI-18_E6 Ich meide gro € ere Gruppen wegen meiner Stimme. I tend to avoid groups of people because of my
voice.
VHI-18_P7 Ich werde gefragt, was mit meiner Stimme los sei. People ask, “What’s wrong with your voice?”
VHI-18_F8 Wegen meiner Stimme spreche ich seltener mit I speak with friends, neighbors, or relatives less
Freunden, Nachbarn und Verwandten. often because of my voice.
VHI-18_F9 Im direkten Gespra €ch werde ich gebeten zu wieder- People ask me to repeat myself when speaking
holen, was ich gesagt habe. face-to-face.
VHI-18_P10 Meine Stimme klingt unangenehm kratzig und rau. My voice sounds creaky and dry.
VHI-18_P11 Ich habe das Gefu € hl, dass ich mich anstrengen I feel as though I have to strain to produce voice.
muss, wenn ich meine Stimme benutze.
VHI-18_P12 Bevor ich spreche, wei ich nicht, wie klar meine The clarity of my voice is unpredictable.
Stimme klingen wird.
VHI-18_F13 € hle mich bei Unterhaltungen wegen meiner
Ich fu I feel left out of conversations because of my voice.
Stimme ausgeschlossen.
VHI-18_E14 Mein Stimmproblem bedru € ckt mich. My voice problem upsets me.
VHI-18_E15 Ich empfinde mein Stimmproblem als My voice makes me feel handicapped.
Behinderung.
VHI-18_P16 Meine Stimme versagt mitten im Sprechen. My voice “gives out” on me in the middle of
speaking.
VHI-18_E17 €rgere mich, wenn man mich bittet, etwas zu
Ich a I feel annoyed when people ask me to repeat.
wiederholen.
VHI-18_E18 €me mich wegen meines Stimmproblems.
Ich scha I’m ashamed of my voice problem.
VHI-18_00 Wie scha€tzen Sie Ihre Stimme heute ein? How do you rate your voice, today?
The German Version of VHI-18 Questionnaire and the Original English Version with their own number and additional questions regarding voice assessment
(Five functional items, seven physical items, and six emotional items)
 ARTICLE IN PRESS
10
REFERENCES
1. Grohnfeldt M. (2018). Kompendium der akademischen Sprachtherapie
und Logop€ adie: Band 4: Aphasien, Dysarthrien, Sprechapraxie, Dys-
phagien- Dysphonien. Kohlhammer Verlag, pages 256.
2. WHO - World Health Organization. (1980). International Classification of
Impairments, Disabilities, and Handicaps. Geneva. ISBN 92 4 154126 1.
3. Fleischer, S. & Hess, M. (2016). Springer Medizin, HNO Nachrichten,
46: 26. https://doi.org/10.1007/s00060-016-5169-9.
4. Nawka T, Wiesmann U, Gonnermann U. Validierung des Voice
Handicap Index (VHI) in der deutschen Fassung. HNO. 2003;51:921–
929. https://doi.org/10.1007/s00106-003-0909-8.
5. Jacobson B H, Benninger M S, Newman C W, et al. The Voice Handi-
cap Index (VHI): development and validation. Am J Speech-Lang
Pathol. 1997;6(3):66–70.
6. Rosen CA, Lee AS, Osborne J, et al. Development and validation of
the Voice Handicap Index-10. Laryngoscope. 2004;114:1549–1556.
7. Forti S, Amico M, Zambarbieri A, et al. Validation of the Italian Voice
Handicap Index-10. J Voice. 2014;28:263.e17–263.e22. https://doi.org/
10.1016/j.jvoice.2013.07.013.
8. Reinboth C. 10 Fehler, die man bei der Erstellung von Frageb€ ogen
unbedingt vermeiden sollte. Wissenschafts-Thurm − Clevere Aussichten.
2016. https://wissenschafts-thurm.de/?s=10+Fehler&submit=Suche.
9. Nawka T, Verdonck-De Leeuw I M, De Bodt M, et al. Item reduction
of the Voice Handicap Index based on the original version and on
European translations. Folia Phoniatr Logop. 2009;61:37–48. https://
doi.org/10.1159/000200767.
10. Hogikyan N D, Sethuraman G. Validation of an instrument to measure
Voice-Related Quality of Life (V-RQOL). J Voice. 1999;13:557–569.
Journal of Voice, Vol. &&, No. &&, 2019
11. Kasper C, Schuster M, Psychogios G, et al. Eur Arch Otorhinolaryngol.
2011;268:401. https://doi.org/10.1007/s00405-010-1374-0).
12. Arffa R E, Krishna P, Gartner-Schmidt J, et al. Normative values for
the Voice Handicap Index-10. J Voice. 2012;26:462–465. https://doi.
org/10.1016/j.jvoice.2011.04.006.
13. Smith B. The art and science of lifelong singing. J Voice. 2018;32:291–
299. https://doi.org/10.1016/j.jvoice.2017.04.021.
14. Barsties B, Kropp J, Dicks P, et al. Reliability and validity of the
“Voice Handicap Index (VHI) adapted to the singing voice” (German
version). Laryngo-Rhino-Otol. 2015:441–446. https://doi.org/10.1055/s-
0034-1387765. https://doi.org/http://dx.doi.org/.
15. Bleses H. Patientenorientierung als Qualit€atsmerkmal (online docu-
ment). Berlin: Medizinische Fakult€at der Charite; 2005.
16. Weigelt S, Krischke S, Klotz M, et al. Voice Handicap Index: instru-
ment zur Bestimmung der subjektiven Beeintr€achtigung durch organi-
sche und funktionelle Dysphonien. HNO. 2004;52:751–756. https://doi.
org/10.1007/s00106-003-1039-z.
17. Szabo Portela A, Granqvist S, Ternstr€ om S, et al. Vocal behavior in envi-
ronmental noise: comparisons between work and leisure conditions in
women with work-related voice disorders and matched controls. J Voice.
2018;32:126.e23–126.e38. https://doi.org/10.1016/j.jvoice.2017.04.010.
18. Remacle A, Garnier M, Gerber S, et al. Vocal change patterns during a
teaching day: inter- and intra-subject variability. J Voice. 2018;32:57–
63. https://doi.org/10.1016/j.jvoice.2017.03.008.
€ T, Baran R T. Evaluation of Pediatric Voice Handicap
19. Filiz S, Selçuk O
Index in children with allergic rhinitis. J Voice. 2018. pie: S0892-1997
(17)30586-6. (Epub ahead of print). https://doi.org/10.1016/j.jvoice.
2018.02.021.