Daniela Barros, post graduate student of the Surgical Clinic Program at Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.
A collaboration between researchers from Universidade Federal de Sergipe (Brazil) and The Johns Hopkins University School of Medicine Baltimore (Maryland; USA), assessed the social and auditory-perceptual impacts of artistic- intervention voice therapy with semioccluded vocal tract exercises (SOVTE) and choral singing, on their voices (ANDRADE et al., 2022).
The brazilian group have described large kindred with IGHD due to a GHRH receptor mutation, resulting in severe short stature and high-pitched voice. These IGHD individuals have little interest in GH treatment, as they consider themselves “short long-lived people”, rather than patients. Interestingly, they report normal general quality of life, but they rate their Voice-Related Quality of Life (V-RQOL) as low (ANDRADE et al., 2022).
In the present trial, 17 GH-naïve adult IGHD individuals (9 female and 8 male) were enrolled in a single-arm interventional pre-post study with 13 weekly sessions of choir singing over 90 days. Outcome measures were V-RQOL scores, self-assessment of voice, and auditory-perceptual analysis (GRBAS scale, G: grade of the severity of dysphonia; R: roughness; B: breathiness; A: asthenia; and S: strain) (ANDRADE et al., 2022).
The IGHD status was previously confirmed in this cohort based on abnormal GH responsiveness (with peak values less than 1 ng/mL) to clonidine, GHRH, and insulin-induced hypoglycemia associated with very low, often undetectable, IGF-1 levels (SALVATORI et al.; AGUIAR-OLIVEIRA, 1999).
The inclusion criteria were Brazilian Portuguese language native speakers and homozygosity for the GHRHR gene c.57+1G>A mutation (BARBOSA et al.). The exclusion criteria were age under 19 years, previous GH treatment, presence of dysmorphic syndromes, speech cognitive impairments, and laryngeal diseases (BARRETO et al.).
The vocal intervention consisted of 13 combined weekly sessions of choir training (60 min) and voice therapy with SOVTE carried out between September and December of 2018. The individuals were instructed to perform the SOVTE for 10 minutes, with a silicone tube 35 cm long and 0.9 cm in diameter submerged for 2 cm in a 500-mL bottle of mineral water (ANDRADE et al., 2022).
Marked improvements in total (p = 0.0001), physical (p = 0.0002), and socioemotional (p = 0.0001) V-RQOL scores and in self-assessment of voice (p = 0.004) were found. The general grades of vocal deviation (p = 0.0001), roughness (p = 0.0001), breathiness (p = 0.0001) and strain (p = 0.0001) exhibited accentuated reductions (ANDRADE et al., 2022).
The impact of severe IGHD on voice is so important that it counteracts the effect of puberty and aging on the structure of the vocal fold, thereby preventing the variation of its fundamental frequency associated with aging (VALENÇA et al.). High-pitched voice is also found in subjects with a different mutation in the GHRHR gene (MOORE, et al.) and in GH insensitivity syndrome (BURREN et al.). Accordingly, low-pitched voice is a common finding of acromegaly (BOGAZZI et al.).
In the present work, voice therapy and artistic intervention (choir singing) were used to test the hypothesis that voice training can affect quality of life. To this end, Andrade et al. took advantage of extended IGHD kindred with both severe short stature and a high-pitched voice (SALVATORI et al.; VALENÇA et al.). Their voice also has an accentuated grade of roughness, breathiness, and strain (BARRETO et al.), and they exhibit low V-RQOL scores (VALENÇA et al.).
Noteworthy, they rarely complain about their severe short stature, as evidenced by their normal general quality of life (BARBOSA et al.), while they often complain about their voices. These vocal complaints are not apparently related to stature, as they are very active professionally and sexually, often marrying normal-statured people, with affected or heterozygous offspring, and well accepted in the community (ANDRADE et al., 2022).
GH replacement therapy (GHRT) during childhood is a natural way to improve stature and voice. Nevertheless, these IGHD individuals consider themselves ‘short long-lived people’, not patients. Therefore, after an initial curiosity for treatment, most of them (and their parents) became uninterested in a daily injectable GHRT (AGUIAR-OLIVEIRA et al., 2021). Besides, they believe that they can live normally, with overall good functionality until advanced ages, a fact that was confirmed by the previous studies of the same Brazilian Group (AGUIAR-OLIVEIRA et al., 2019; AGUIAR-OLIVEIRA et al., 2021; AGUIAR-OLIVEIRA et al., 2010).
In a previous trial, they demonstrated a positive effect of singing and voice therapy with SOVTE on the acoustic parameters of their voices depicted by a spectrogram (ANDRADE et al., 2019). However, the impact of choir singing on the most relevant measures of social life, such as V-RQOL scores, vocal self-assessment, and auditory-perceptual analysis, the gold standard for characterizing vocal problems, was not evaluated. This assessment is the principal purpose of this work, as singing is often used to improve not only the voice but also, more importantly, general health (MULLER et al.).
In conclusion, in adult IGHD individuals, an artistic intervention – choir singing and voice therapy with semioccluded vocal tract exercises – markedly improved V-RQOL scores, voice self-assessment, and auditory- perceptual analysis, thus improving their quality of life related to voice (ANDRADE et al., 2022).
AGUIAR-OLIVEIRA, M.H., et al. Effect of severe growth hormone (GH) deficiency due to a mutation in the GH-releasing hormone receptor on insulin-like growth factor (IGFs), IGF-binding proteins, and ternary complex formation throughout life. J Clin Endocrinol Metab.[online]. 1999, vol. 84, no. 11, pp. 4118-26. [viewed 28 June 2022]. https://doi.org/10.1210/jcem.84.11.6133. Available from: https://academic.oup.com/jcem/article/84/11/4118/2864572?login=false
BARROS, D. Impact of semioccluded vocal tract exercises and choral singing in congenital GH deficiency’s subjects [online]. SciELO in Perspective | Press Releases, 2022 [viewed ]. Available from: https://pressreleases.scielo.org/en/2022/06/28/impact-of-semioccluded-vocal-tract-exercises-and-choral-singing-in-congenital-gh-deficiencys-subjects/
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