Patient Candidacy for Voice Therapy: Stimulability Assessment

Imagine this scenario:

You’ve just started high school, and you happen to be tall for your age. As you circle the commons, checking out the various booths at the activities fair, you are approached by the basketball coach, who insists you join the team without even trying out. The coach doesn’t know anything about your ability to play the sport, but simply presumes that you will be a good asset to the team because of a particular characteristic—namely, your height.

As clinicians, we may also tend to presume how our patients will perform in voice therapy and even research based on particular characteristics, such as a patient’s diagnosis or age. While a diagnosis is a characteristic of a patient, it does not indicate the patient’s ability to attain better voice via voice therapy in the same way that a person’s height does not indicate their ability to shoot a basketball.

Wouldn’t it be great to have some kind of way for patients to “try out” for voice therapy so that you know whether a patient has the ability to benefit from direct voice therapy before you refer them to their first voice therapy session? Although indirect voice therapy may help them, direct voice therapy may not. This knowledge could save time and money as well as help with prognosis.

The good news is that you can! So how do we do this?

Enter stimulability assessment.

What Is Stimulability Assessment?

Stimulability is defined as an immediate ability to change the performance of voice production as a result of modeling or cues, and it can have a significant impact on patient success in voice therapy. Stimulability assessment helps determine patient candidacy for voice therapy by allowing SLPs insight into a patient’s capabilities to modify their vocal production.

Studies show that concurrent voice evaluation (including stimulability assessment) done by both an SLP and ENT at a patient’s initial visit impacts therapy adherence, outcomes, and SLP billing revenue.¹ By priming patients to voice-by-feel via stimulability techniques such as flow phonation, resonant voice, and clear speech, and then emphasizing noticed improvements in voice, the SLP can more easily assure patients of the success that they may have in voice therapy. Most importantly, it allows the clinician to determine if someone is a good candidate for intervention before referring or accepting a patient for voice therapy.

To date, there is no objective, standardized assessment that exists to guide voice-specialized speech-language pathologists on which patients are likely to succeed in voice therapy and which are not. This means that referrals are mostly based on characteristics such as a patient’s diagnosis or age rather than the patient’s ability.

Stimulability assessment acts as a quasi-litmus test, eliminating the trial and error of voice therapy and quantifying a patient’s ability to get better before referring them to voice therapy. It gives proof to the clinician, patient, and otolaryngologist that voice therapy will or will not work. Including qualitative measures—like a patient’s perception of change—is vital in stimulability assessment, because those who are able to perceive a change in the sound and feel of their voice may be better candidates for voice therapy.

By implementing a standardized stimulability assessment protocol in your voice and upper airway clinic, you could streamline patient referrals for therapy and improve overall patient outcomes.

Who Is a Good Candidate for Voice Therapy?

While stimulability is the ability to change voice production, there are other considerations about a patient’s abilities that may or may not make them a good candidate for treatment.

Although a patient can still be a candidate for voice therapy, be sure to also ask yourself the following questions:

• Does the patient have the cognitive abilities to complete treatment?
• Is the patient too frail to do voice therapy?
• Does the patient have any potential psychosocial issues that may impact treatment?
• Is the patient motivated for change?

These details are important because you aren’t simply providing voice therapy; SLPs treat the whole patient.

No Voice Lab? No Problem!

A voice lab, although commonly used in research, is not needed to assess stimulability. Clinicians can use subjective evaluations like:

• Patient-reported outcome measures (PROMs)
• Auditory-perceptual evaluations
• Questionnaires on issues such as cognition, anxiety, stress, and depression

Clinicians can also apply pen-to-paper objective data to determine stimulability as well.

With all of that said, the best stimulability assessment is you, the SLP! By listening to the patient as they perform stimulability probes as well as vegetative sounds such as laughing or throat clearing, and everything else mentioned above, you can determine their prognosis for treatment.

Ready to learn more about stimulability assessment so you can add it to your evaluation toolbox? Discover the science behind stimulability assessment, observe a demonstration of stimulability assessment in action, and gain useful troubleshooting tips in my MedBridge course, “Patient Candidacy for Voice Therapy: Stimulability Assessment.”