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Kendrea Focht and Paula Leslie debate the motion that speech and language therapy clinicians should advise clients with adductor spasmodic dysphonia to receive botulinum toxin injections.
This House Believes explained
In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate at the forum: http://members.speechmag.com/ forum/.
who reported that their voice had returned to normal during the time the treatment was maximally effective. Some also reported improved participation within social and community activities but details on exactly how many were not reported. POINT OF INFORMATION: Although the interviews were guided around three general questions regarding their experience with Botox injections, it is unclear how many interviewers were involved. The authors also did not disclose how the interviews were verified to determine if phenomenological guidelines for conducting qualitative research were followed.
Overwhelmingly positive
Symptom relief
Nonetheless, this is one of the few studies that attempted to understand the impact of Botox intervention on quality of life. The results were overwhelmingly positive. Hogikyan and colleagues (2001) also examined the effects on quality of life. Twentyseven clients completed the Voice-Related Quality of Life Measure (V-RQOL) (Hogikyan & Sethuraman, 1999) prior to their first Botox injection and were then reassessed 6-8 weeks later. This cycle was repeated prospectively for each subsequent injection during an 18month period (Hogikyan et al., 2001). V-RQOL is a validated and reliable self-reported measure that has been shown to be responsive to change in a variety of populations, although Hogikyan and colleagues never mentioned whether the V-RQOL had been validated on people with adductor spasmodic dysphonia. The researchers found that, prior to injection, V-RQOL scores were significantly lower then the published normative data (approximately 70 points) (Hogikyan et al., 2001). Participants scores significantly improved from pre-treatment to post-treatment for each subsequent injection, although the magnitude of the treatment effect was significantly less after the second injection.
Kendrea
Paula
Kendrea L. Focht is a clinical fellow in the medical speech-language pathology clinical doctoral program at the University of Pittsburgh, USA, e-mail klf59+@pitt.edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt. edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.
In conclusion, the studies reviewed have shown significant and dramatic improvements on participants quality of life after receiving Botox injections. As clinicians, we have an obligation to encourage botulinum toxin injections so that our clients can improve their social participation and overall quality of life.
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eves in Botox
Clinicians should not advise people with adductor spasmodic dysphonia to receive botulinum toxin injections. Botulinum toxin injections offer the possibility (not a guarantee) for temporary improvement. There have been some concerns with introducing a toxin into a clients body. Those who have received injections report post treatment symptoms such as swallowing difficulties, inability to speak, swelling / soreness at the injection site, breathy vocal quality, burning sensation, and irritation (Fisher et al., 1998; Galardi et al., 2001). Clinicians need to be aware of the harmful side effects of botulinum toxin, especially when the failure rate of treatment is one in three (Galardi et al., 2001).
Judgement:
Side effects
Laryngeal tissues receive autonomic innervation which is thought to control muscle tone, laryngeal blood flow and regulation of secretions (Fisher et al., 1998). Botox injections may alter the secretions near the larynx and result in client discomfort. Fisher and colleagues (1998) retrospectively examined 26 people with adductor spasmodic dysphonia one or more weeks after injection. Prior to injection there were no reports of symptoms relating to autonomic failure to maintain balance of secretions. Within one hour of injection, and lasting over a week, 14 per cent of participants reported symptoms possibly due to altered balance of secretions such as irritation, thick mucus and swallowing difficulties. Botox may exacerbate the effects of xerostomia (dry mouth) due to side-effects from medication or disease. POINT OF INFORMATION: As the study was retrospective, the researchers were unable to determine whether or not there was a direct link between the symptoms and altered laryngeal secretions. Subsequent botulinum toxin injections do not always give the same results concerning the degree and extent of efficacy, time needed to achieve maximum results, and occurrence of side effects (Galardi et al., 2001). Galardi and colleagues (2001) examined the failure rates of 15 people with adductor spasmodic dysphonia given either Botox or Dysport (Ipsen, Milan, Italy) injections over the course of three years (total of 148 injections). Failure rates were 26 per cent and 30 per cent for Dysport and Botox respectively. This difference in failure rates between the two types of injection was not statistically significant (Galardi et al., 2001). Response failure was found to be unpredictable and a client with success after one injection may have a failure after the next one. POINT OF INFORMATION: The study was retrospective and the success against failure rate was judged by the participants during a telephone interview (Galardi et al., 2001).
Lack of evidence
The opposition point here is that there is a lack of evidence that Botox really works. Watts et al. (2006) attempted a systematic Cochrane review examining the efficacy of botulinum toxin injections for treatment of spasmodic dysphonia. Only one study (Truong et al., 1991) met the inclusion criteria, which included a treatment / no treatment comparison. POINT OF INFORMATION: Readers should note that Truong et al. (1991) was a double-blind, placebo-controlled study. It compared saline versus Botox and showed improvement in both acoustical measurements and patient self-assessment in people receiving the Botox injections. Effect sizes were calculated and demonstrated a significant improvement in fundamental frequency (pitch), pitch range and clinicians overall rating of severity.
References
Treatment failure
In summary there is a lack of supporting evidence from sound methodological studies and the possibility that reported improvement may be the result of a placebo effect. Clinicians cannot draw conclusions regarding the efficacy of botulinum toxin as a treatment for people with adductor spasmodic dysphonia.
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