Application of the ICF in Voice Disorders

Estella P.-M. Ma, Ph.D.,1 Edwin M.-L.Yiu, Ph.D.,2

and KatherineVerdolini Abbott, Ph.D.3

ABSTRACT

The aim of this article is to describe how the World Health

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Organization’s International Classification of Functioning, Disability and
Health (ICF) can be adapted to describe the consequences of voice
disorders. It first describes voice disorders under the four key components
of the ICF: Body Functions, Body Structures, Activities and Participation,
and Contextual (Environmental and Personal) Factors. It then describes the
assessment and treatment tools for voice disorders using the ICF framework.
Finally, a case example illustrating how the ICF frames the rehabilitation of
an individual with voice disorders is presented.

KEYWORDS: Dysphonia, functioning, voice disability, voice handicap,

functional communication

Learning Outcomes: As a result of this activity, the reader will be able to (1) describe voice disorders using
the key components of the ICF, and (2) outline the assessment and treatment of voice disorders under the
ICF framework.

V oice disorders exist ‘‘when quality, pitch,
loudness, or flexibility differs from the voices
of others of similar age, sex and cultural group’’
(p. 6).1 They can be classified into organic
causes (which also include neurogenic causes),
functional causes, or a combination of two.2
Voice disorders are common and affect at least
6% of the general population. Alarmingly, in
some professions, such as teachers, the preva-
lence rates can increase significantly to 11% to
21%. Although voice disorders are not life
threatening, they can have significant impacts
on the functioning of the individual.3–6 The
extent of impact has been reported to be similar
to that found in individuals with life-threat-
ening health conditions such as cancer.6 The
aim of this article is to describe voice disorders
using the framework of the World Health

1
Centre for Communication Disorders, Faculty of Educa-
tion, The University of Hong Kong, Hong Kong, People’s
Republic of China; 2Voice Research Laboratory, Division
of Speech and Hearing Sciences, The University of
Hong Kong, Hong Kong; 3Communication Sciences
and Disorders, University of Pittsburgh, Pittsburgh,
Pennsylvania.
Address for correspondence and reprint requests:
Estella P.-M. Ma, Ph.D., Assistant Professor, Centre for
Communication Disorders, Division of Speech and Hear-
ing Sciences, The University of Hong Kong, 5/F Prince
Philip Dental Hospital, 34 Hospital Road, Hong Kong
(e-mail: estella.ma@hku.hk).
The International Classification of Functioning, Dis-
ability and Health (ICF) in Clinical Practice; Guest
Editors, Estella P.-M. Ma, Ph.D., Linda Worrall, Ph.D.,
and Travis T. Threats, Ph.D.
Semin Speech Lang 2007;28:343–350. Copyright #
2007 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584–4662.
DOI 10.1055/s-2007-986531. ISSN 0734-0478.
343
344 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4 2007

Organization’s (WHO’s) International Classi- Table 1 ICF Codes Relevant to Voice

fication of Functioning, Disability and Health Disorders
(ICF).7 The article also discusses how the ICF ICF Components Codes and Description
frames clinical management of voice disorders.
Body Structures s110 Structure of brain
s1106 Structure of cranial nerves
THE ICF AND VOICE DISORDERS s340 Structure of larynx
The ICF provides a unique and standard lan- s3400 Vocal folds
guage to describe functioning and disabilities Body Functions b126 Temperament and
across range of communication disorders. The personality functions
ICF is the modified version of the original b152 Emotional functions
International Classification of Impairments, b310 Voice functions
Disabilities, and Handicaps (ICIDH).8 The b3100 Production of voice

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ICF has two parts covering four components: b3101 Quality of voice
Part 1 (Functioning and Disability), which com- Activities and d330 Speaking
prises of Body Functions and Structures, and Participation d350 Conversation
Activities and Participation; and Part 2 (Contex- d360 Using communication
tual Factors), which comprises of Environmental devices and techniques
Factors and Personal Factors. In the following d3600 Using telecommunication
sections, voice disorders are described under each devices
key component of the ICF. Table 1 is a summary d845 Acquiring, keeping, and
of ICF codes that are relevant to voice disorders terminating a job
for each component. d850 Remunerative employment
d920 Recreation and leisure
d9204 Hobbies
Voice Disorders and Body Functions/ d9205 Socializing
Structures Environmental e125 Products and technology
Under the ICF, voice impairments are described Factors for communication
in terms of Body Structures impairments and e225 Climate
Body Functions impairments. Body structures e2250 Temperature
are the ‘‘anatomical parts of the body such as e2251 Humidity
organs, limbs and their components’’1 (p. 10). e250 Sound
An example of Body Structures impairment is e2500 Sound intensity
vocal folds with bilateral nodules. Codes related e2501 Sound quality
to voice structural impairments mainly are listed e260 Air quality
in Chapter 3 of Body Structures: Structures e310-e399 Support and
involved in voice and speech, specifically the relationships
section Structure of larynx (s340). Neurogenic e410-e499 Attitudes
voice disorders with structural impairments in e515 Architecture and
the nervous systems (e.g., vocal fold palsy from construction services,
recurrent laryngeal nerve damage) are coded systems, and policies
under Structure of cranial nerves (s1106). e580 Health services, systems,
Body functions are the ‘‘physiological and policies
functions of body systems (including psycho- ICF, International Classification of Functioning,
logical functions)’’1 (p. 10). Codes listed in Disability and Health.
Chapter 3 of Body Functions, Voice and speech
functions (b3), specifically Voice functions loudness (b3100) and of good vocal qualities
(b310), are the most directly relevant to voice (b3101). Psychological consequences are also
impairments. An individual with a voice disor- classified under the Body Functions com-
der may demonstrate impairments with the ponent. The emotional reactions that the
production of voice of adequate and appropriate dysphonic individual experiences because of
 APPLICATION OF THEICF TO VOICE DISORDERS/MA ET AL
the voice impairments can be coded under
Temperament and personality functions (b126)
and Emotional functions (b152).
Voice Disorders and Activities and
Participation
Activity is defined as ‘‘the execution of a task or
activity by an individual,’’ and participation is
defined as the nature and extent of an individual’s
‘‘involvement in a life situation’’1 (p. 10). Activ-
ities and Participation can be expressed nega-
tively as activity limitations and participation
restrictions, respectively, to denote disabilities.
Ma and Yiu4 applied the WHO definition of
Activities and Participation in voice disorders.
They define voice activity limitations as the
‘‘constraints imposed on voice activities,’’ and
voice participation restrictions as ‘‘reduction or
avoidance of voice activities by an individual’’
(p. 513). Individuals with voice impairments may
experience limitations in different voice activities
such as speaking (d330), having conversations
with others (d350), calling someone on the tele-
phone (Using telecommunication devices,
d3600), and socializing with friends and col-
leagues (Socializing, d9205). Professional voice
users whose occupation has high vocal demands
such as teachers and professional singers may also
experience limitations in carrying out occupa-
tion-related voice activities. They may consider
changing jobs because their voice conditions
do not satisfy the occupation-related vocal de-
mands (Acquiring, keeping and terminating a
job, d845; Remunerative employment, d850).
The ICF proposes that how individuals
experience the disorders at the Activities and
Participation level is related to the dynamic
interactions between impairments and Contex-
tual Factors. Along this line, it has been docu-
mented that dysphonic individuals with vocal
fold paralysis (neurogenic voice disorders) ex-
perience greater extents of voice activity limi-
tations than those dysphonic individuals with
functional voice disorders associated with pho-
notrauma.5
Voice Disorders and Contextual Factors
Contextual Factors (part 2 of the ICF) include
both Environmental Factors and Personal Fac-
345
tors components. They serve as the external
influences (Environmental Factors) and inter-
nal influences (Personal Factors) on the indi-
vidual’s functioning and disability.1
ENVIRONMENTAL FACTORS
Environmental factors ‘‘make up the physical,
social and attitudinal environment in which
people live and conduct their live’’1 (p. 10).
An environmental factor can either promote
communication (as a facilitator) or hinder com-
munication (as a barrier). Understanding how
environmental factors facilitate or hinder the
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functioning of dysphonic individuals guides
therapeutic directions as to how the environ-
ments should be modified to facilitate partic-
ipation in the tasks. The ICF provides a
comprehensive list of environmental factors
that are organized in five chapters. Some exam-
ples that are relevant to voice impairments
include the following:
*
Chapter 1 (Products and technology): Are
there provision of voice amplifiers available
for individuals with low-volume speech
(Products and technology for communica-
tion, e125)?
*
Chapter 2 (Natural environment and human-
made changes to environment): How do the
communication environments of very high/
low temperature (Temperature, e2250), low
level of air humidity (Humidity, e2251), high
background noise (Sound intensity, e2500;
Sound quality, e2501) and polluted air quality
(Air quality, e260) impact on voice impair-
ments and limit/restrict voice activities?
*
Chapter 3 (Supports and relationships): Does
the dysphonic teacher receive supports from
the school principal to take paid leave for voice
rest (People in positions of authority, e330)?
*
Chapter 4 (Attitudes): How does the society
view individuals with spasmodic dysphonia
(Societal attitudes, e460)?
*
Chapter 5 (Services, systems, and policies):
Are there any health policy for the teaching
profession to prevent development of voice
problems, such as compulsory preventive voice
care programs for teachers, and teaching en-
vironments with good noise-isolation facili-
ties (Health services, systems, and policies,
e580)?
346 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
PERSONAL FACTORS
Personal factors are included in the ICF to
acknowledge their contribution to full descrip-
tions of health. However, they are not classified
in the ICF because of the great variance across
different societies and cultures. Personal factors
exist before the onset of the disorders. In other
words, they do not co-occur with the health
condition.9 Examples of personal factors in-
clude gender, race, age, coping styles, profes-
sion, personality, and past and current
experience. Personal factors can influence how
the individual reacts to the limitations.9 In the
realm of voice disorders, it is not uncommon
that a retired elderly man who is living alone
and has an introverted personality might expe-
rience fewer activity limitations and participa-
tion restrictions than a young, energetic
university student who has an extraverted per-
sonality and enjoys socializing with friends. An
individual’s profession can also influence how
he or she is affected by the voice disorder. It is
generally accepted that professionals whose jobs
require greater vocal demands have greater
disabilities because the voice problems have
increased influence on adequate functioning.
A recent study by Ma10 compared voice impair-
ments, activity limitations, and participation
restrictions in a group of dysphonic teachers
and a group of dysphonic employed nonteach-
ers. Results revealed that although both groups
of participants reported similar extents of lim-
itations and restrictions in carrying out voice
activities, the severity of voice impairment in
the teachers was significantly less than that in
the nonteachers with vocal complaints.
THE ICF AND ASSESSMENT OF
VOICE DISORDERS
An effective clinical voice assessment should
comprehensively document the impacts of dys-
phonia on the individual. Traditional voice
assessment batteries focus primarily at the im-
pairments of laryngeal structures and functions,
with little emphasis on the functional impacts
on the dysphonic individuals and their quality
of life. The ICF provides an excellent frame-
work for extending voice assessment from
merely an impairment approach to a more
holistic approach by taking all the four ICF
2007
components: (1) Body Structures, (2) Body
Functions, (3) Activities and Participation,
and (4) Contextual Factors (both Environmen-
tal and Personal) into consideration.11 This
section describes the tools available for assess-
ing each component. Readers may note that
apart from applying in the voice-disordered
population, the assessment processes are also
used to assess speech functions in alaryngeal
speakers (see Eadie,12 this issue).
Voice Impairments
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Endoscopy and stroboscopy are two common
clinical processes to visually examine for any
structural abnormalities or pathologies of the
vocal folds. However, these processes involve a
certain degree of invasiveness that can bring
discomfort to the patient. Other processes,
such as ultrasonography, are relatively noninva-
sive to assess body structures but they are less
useful than the endoscopy and stroboscopy in
diagnosing Body Structures impairments.
Body Functions impairments of dysphonia
are primarily assessed using auditory–percep-
tual evaluation, which is commonly regarded as
the gold standard in documenting voice impair-
ment severity.13–16 Pitch (high/low), loudness
(high/low), and vocal qualities (e.g., roughness
and breathiness) are judged by listeners. How-
ever, auditory–perceptual evaluation is subjec-
tive in nature and is influenced by listener bias.
Therefore, objective instrumental assessments
including acoustic voice analyses, aerodynamic
measurements, and physiological measure-
ments (e.g., electroglottography, electromyog-
raphy) are often included in the clinical
assessment battery to supplement the subjective
auditory–perceptual evaluation. Voice disorders
of psychogenic origin can be assessed through
case history, or referred to the psychologists for
psychological evaluation.
With the assessments of Body Functions
impairment, care should be taken to ensure the
assessment procedure reflects true vocal fold
functioning. The use of simple utterances,
such as sustained vowel prolongations or read-
ing a short phrase aloud, may not always reflect
the impairments on body functions. Evaluating
naturalistic speech materials such as mono-
logues would give a more realistic evaluation
 APPLICATION OF THEICF TO VOICE DISORDERS/MA ET AL
of the voice impairment severity. Clinicians can
also evaluate vocal functioning (e.g., vocal qual-
ities) under the actual communication situa-
tions (e.g., in classrooms).
Activities and Participation
The extent of activity limitations and participa-
tion restrictions experienced by the dysphonic
individual can be obtained from case history
simply by asking the individual the following:
To what extent is your daily life (or job, etc.)
limited or restricted by your voice problem?
Clinicians can also use standardized self-report
questionnaires, which are developed for quanti-
fying extents of voice activity limitations and
voice participation restrictions. Some of the
more popular tools are described in the follow-
ing sections. Readers are referred to the article
by Franic et al17 for a comprehensive review of
the psychometric properties of these tools.
*
Voice Disability Index (VDI)18 is a self-
report questionnaire with three items. The
VDI was a first attempt to measure the
impact of voice disorders on work, social
life, and family life in dysphonic individuals.
*
Voice Handicap Index (VHI)19 is a self-
report questionnaire with 30 items. The
VHI assesses the impact of voice disorders
in the physical, functional, and emotional
domains, with 10 items in each domain.
Examples of VHI items are ‘‘My voice sounds
creaky and dry’’ (physical domain), ‘‘I use the
phone less often than I would like’’ (func-
tional domain), and ‘‘I feel embarrassed when
people ask me to repeat’’ (emotional domain).
To facilitate clinical use, the original 30-item
version of the VHI was recently modified to a
10-item new version (VHI-10).20
*
Voice-Related Quality of Life (V-RQOL)21
is a self-report questionnaire with 10 items. It
assesses quality of life in the social–emotional
and physical functioning domains. Examples
of the V-RQOL items are ‘‘I have trouble
speaking loudly or being heard in noisy sit-
uations’’ (physical functioning domain), and ‘‘I
am sometimes anxious or frustrated (because
of my voice)’’ (social–emotional domain).
*
Voice Outcomes Survey (VOS)22 is a ques-
tionnaire with five items and is designed
347
specifically for patients with unilateral vocal
fold paralysis. Examples of items are ‘‘During
the past 2 weeks, to what extent has your voice
interfered with your normal social activities or
with your work?’’ and ‘‘To what extent does
your voice now limit your ability to be under-
stood in a noisy area?’’
*
Voice Activity and Participation Profile
(VAPP)4 is a self-report questionnaire with
28 items. It was developed based on the
previous ICIDH-2 framework.23 The profile
assesses differentially the activity limitations
and participation restrictions using pairs of
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questions. The first question of each pair
ascertains activity limitations, and the second
question of that pair ascertains participation
restrictions. Ten communication situations in
the domains of job, daily communication,
social communication, and emotion are eval-
uated. Examples of items in the daily commu-
nication domain are ‘‘Does your voice problem
affect your communication in noisy environ-
ments?’’ (ascertaining activity limitations) and
‘‘In the last 6 months, you’re you ever avoided
having conversations in noisy environments
because of your voice problems?’’ (ascertaining
participation restrictions).
Under the ICF, the Activities and Partic-
ipation component is coded with four qualifiers
on performance and capacity: performance, ca-
pacity (without assistance), capacity (with assis-
tance), and performance (without assistance).
The first two qualifiers are compulsory, whereas
the last two are optional. Capacity describes the
ability of the individual to carry out a task under
standardized environments such as clinic rooms.
Performance describes how the individual func-
tions under the actual life situations. For exam-
ple, a teacher with bilateral vocal nodules who
has difficulties speaking aloud in teaching
(Speaking, d330) can be coded as d330.32.
She experiences severely reduced performance
when using her voice under teaching environ-
ments of high background noise (the first digit
after the point, that is 3, denotes the rating for
severe restrictions in performance). However,
her voice problems are only moderately affected
under quiet clinic room and one-to-one con-
versational situation (the second digit after the
point, that is 2, denotes the rating for moderate
348 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
limitations in capacity without assistance).
Gathering information on performance and
capacity provides the clinician with a more
realistic and functional evaluation of the dys-
phonic individual’s functioning and disabilities.
Environmental Factors and Personal
Factors
The influence of environmental factors, either
as communication barriers or facilitators, on the
dysphonic individual’s functioning can be gath-
ered by case-history taking and clinical obser-
vations. Personal factors can also be gathered
through clinical observations and case-history
taking.
THE ICF AND TREATMENT OF VOICE
DISORDERS
Similar to assessment, treatment of voice dis-
orders should take a holistic approach by tar-
geting each of the four key components with a
therapeutic goal. Treatment for voice impair-
ments typically involves introduction of con-
servative (nonsurgical) voice therapy, which
aims to modify vocal behaviors and to maximize
vocal efficiency. The modification of vocal be-
haviors is expected to reduce vocal fold injury,
with the potential of improving the structural
impairments of vocal folds. Readers are referred
to Ramig and Verdolini24 and Pannbacker25 for
details about the types of different vocal facil-
itating techniques and the efficacy of the ap-
proaches. However, for individuals who do not
respond well to conservative voice therapy,
surgical interventions can be introduced that
directly target at the Body Structures compo-
nent. Examples are medialization thyroplasty
for patients with vocal fold palsy and Botuli-
num Toxin A (Botox) injection for patients
with spasmodic dysphonia.
It is generally assumed that a reduction in
voice impairment will automatically lead to
reductions in activity limitations and participa-
tion restrictions. In fact, vocal rehabilitation can
target directly at Activities and Participation
component. The qualifiers of performance and
Capacity provide directions for therapy stem-
ming from this component. Referring to the
previous example, the teacher with bilateral
2007
vocal nodules who experiences severe limita-
tions in speaking aloud under noisy teaching
environments (performance) might experience
only moderate limitations in quiet clinic room
environment (capacity without assistance).
Voice therapy can involve practicing vocal fa-
cilitating techniques (such as resonant voice) in
the clinic room with simulated background
noise that approaches classroom acoustic level
in the actual situations.
Treatment targeting the Environmental
Factors component involves reducing barriers
and enhancing facilitators for effective voice
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use. Clinicians can enhance understanding
and support from the dysphonic individual’s
family members by educating them about the
voice problems. Modifying workplace environ-
ments such as ensuring an optimal level of
relative humidity in classrooms to avoid dehy-
dration of vocal folds, installation of voice
amplifiers in every classroom, and installation
of sound-absorbing materials (e.g., thin carpet
on the floor and ceiling) in classrooms to
improve classroom acoustics are also encour-
aged. Goals at the society level include endors-
ing laws for safe voice-use limits, such as setting
a maximum number of teaching hours per day,
or provision of funding for teachers to purchase
voice amplifiers.
CASE EXAMPLE
Mary is a 36-year-old secondary school teacher,
teaching physical education at school. She was
diagnosed with a mild hyperfunctional dyspho-
nia. Video-stroboscopic examination revealed
bilateral vocal nodules (Body Structures; Vocal
folds, s3400). Her voice quality was evaluated
perceptually based on conversational speech.
Results revealed mild roughness and breath-
iness (Body Functions; Quality of voice,
b3101). She also expressed that she used to be
an outgoing person, but was now worried and
insecure (Temperament and personality func-
tions, b126), and had high mental stress levels
(Emotional functions, b152) as a result of her
voice problems. Mary completed the Voice
Activity and Participation Profile.4 She re-
ported severe limitations in carrying out teach-
ing-related voice activities such as instructing
students in physical education classes in an
 APPLICATION OF THEICF TO VOICE DISORDERS/MA ET AL
open area (Speaking, d330). She also reported
that she has considered changing jobs because
of the voice problems (Terminating a job,
d8452). She tried to avoid gathering with
friends after work (Socializing, d9205). Voice
therapy for Mary targeted each of the four ICF
components:
*
Body Functions and Structures. Lassac-Mad-
sen Resonant Voice Therapy (LMRVT) was
introduced.11 The LMRVT program targets
a laryngeal configuration, which tends to
produce the strongest voice output using the
least amount of pulmonary effort, and also
coincides with relatively low vocal fold impact
stresses. The goal of the LMRVT is a well-
functioning and clear voice that can be heard
in most environments, and that is produced
easily, with minimum risk of injury to the
vocal folds.
*
Activity Limitations and Participation. Strat-
egies to enhance voice activities and partic-
ipation were discussed with Mary. She was
encouraged to use a voice amplification sys-
tem to enhance her vocal performance during
teaching.26 Compensatory strategies included
getting closer to the students while teaching
and using gestures to convey the message
were also introduced.
*
Contextual Factors. Mary was encouraged to
talk to her school principal about her voice
problems. She received positive support from
the school principal, and was allowed to take
a week of paid leave for voice rest. At home,
her husband shared the responsibilities with
Mary such as supervising homework and tell-
ing stories and reading to their son, Jacob, to
maximize voice rests for Mary. In addition,
Mary was also referred to a psychologist for
counseling and to develop strategies for
work-related stress.
Mary received eight sessions of LMRVT
on a weekly basis. Outcomes of the therapy were
positive and encouraging. It was believed that
her outgoing personality played an important
role for the positive therapy outcomes. Post-
therapy assessment revealed decrease in size of
the vocal nodules and significant improvement
in vocal quality. She also reported fewer limi-
tations in carrying out teaching activities.
349
CONCLUSIONS
Voice disorders are not life threatening. How-
ever, the daily dysfunctions encountered by an
individual with a dysphonia should not be
underestimated. The ICF provides an excellent
and comprehensive framework for clinical man-
agement of individuals with voice disorders.
The application of the ICF in dysphonia in
the assessments and treatments is essential to
achieve the ultimate goal of enhancing the
quality of life of the individual.
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