***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Manual circumlaryngeal therapy ( manual laryngeal musculoskeletal tension reduction ) was used to treat 25 consecutive functional dysphonia patients . Pre- and post-treatment audio recordings of connected speech and sustained vowel sample s were su bmi tted to auditory-perceptual and acoustical analysis to assess the immediate and long-term effects of a single treatment session . To complement audio recordings , subjects were interviewed in follow-up regarding the stability of treatment effects . Pre- and post-treatment comparisons demonstrated significant voice improvements . No significant differences were observed between post-treatment measures , suggesting that vocal gains were maintained . Interviews revealed 68 % of subjects reported occasional partial recurrences , typically less than 4 days in duration , which resolved spontaneously . These results replicate and extend previous research suggesting the utility of manual circumlaryngeal therapy for functional voice disorders A prospect i ve study was carried out to examine the degree to which a st and ard voice assessment  could discriminate between the potential benefits of two different voice therapy programmes for individual patients . The study encompassed 200 dysphonia subjects who were referred for voice therapy and had completed treatment within a prescribed two-year period . A st and ard assessment procedure was carried out on first attendance for each patient and guidelines were used to assign patients to different treatment programmes on the basis of the assessment results . The assessment discriminated well between patients requiring voice therapy to change physiological parameters of voice usage and patients able to self adjust voice usage , and provided an objective means of measuring outcomes Although the terms " breathy " and " rough " are frequently applied to pathological voices , widely accepted definitions are not available and the relationship between these qualities is not understood . To investigate these matters , expert listeners judged the dissimilarity of pathological voices  with respect to breathiness and roughness . A second group of listeners rated the voices on unidimensional scales for the same qualities . Multidimensional scaling analyses suggested that breathiness and roughness are related , multidimensional constructs . Unidimensional ratings of both breathiness and roughness were necessary to describe patterns of similarity with respect to either quality . Listeners differed in the relative importance given to different aspects of voice quality , particularly when judging roughness . The presence of roughness in a voice did not appear to influence raters ' judgments of breathiness ; however , judgments of roughness were heavily influenced by the degree of breathiness , the particular nature of the influence varying from listener to listener . Differences in how listeners focus their attention on the different aspects of multidimensional perceptual qualities apparently are a significant source of interrater unreliability ( noise ) in voice quality ratings After treatment for early glottic carcinoma , a considerable number of patients end up with voice problems that interfere with daily life activities . The objective of this r and omized and controlled study was to assess the efficacy of voice therapy  in these patients Abstract Objectives : To assess the overall efficacy of voice therapy for dysphonia . Design : Single blind r and omised controlled trial . Setting : Outpatient clinic in a teaching hospital . Participants : 204 out patients aged 17 - 87 with a primary symptom of persistent hoarseness for at least two months . Interventions : After baseline assessment s , patients were r and omised to six weeks of either voice therapy or no treatment . Assessment s were repeated at six weeks on the 145 ( 71 % ) patients who continued to this stage and at 12 - 14 weeks on the 133 ( 65 % ) patients who completed the study . The assessment s at the three time points for the 70 patients who completed treatment and the 63 patients in the group given no treatment were compared . Main outcome measures : Ratings of laryngeal features , Buffalo voice profile , amplitude and pitch perturbation , voice profile question naire , hospital anxiety and depression scale , clinical interview schedule , SF-36 . Results : Voice therapy improved voice quality as assessed by rating by patients ( P=0.001 ) and rating by observer ( P<0.001 ) . The treatment effects for these two outcomes were 4.1 ( 95 % confidence interval 1.7 to 6.6 ) points and 0.82 ( 0.50 to 1.13 ) points . Amplitude perturbation showed improvement at six weeks ( P=0.005 ) but not on completion of the study . Patients with dysphonia had appreciable psychological distress and lower quality of life than controls , but voice therapy had no significant impact on either of these variables . Conclusion : Voice therapy is effective in improving voice quality as assessed by self rated and observer rated methods . What is already known on this topic Many patients with dysphonia are treated by voice therapy The effectiveness of voice therapy in a diverse group of patients is unknown What this study adds Voice therapy is an effective treatment for dysphonia in terms of report by patients and perceptual ratings by an expert Psychological distress and reduction in general health status are common in patients with dysphonia but are not significantly affected by a course of voice For many years all patients with dysphonia referred to in the literature as result ing from non-organic ( functional ) voice disorders were sent to speech therapy .  Medical diagnoses were not taken into account . In our earlier Cochrane review on vocal cord nodules we discovered that evidence -based research in the area of benign voice disorders with dysphonia , and with or without slight benign swellings including nodules on the vocal cords , was lacking at that time . Therefore , a prospect i ve r and omised pilot study based on our Cochrane review has been made on dysphonic patients with non-organic ( function provoked ? ) voice disorders as the basis for further evidence -based studies .Medical treatment was based on the scientific approach that once a micro-organic disorder caused by reflux , infection , allergy or environmental irritatants ( e.g. , dust or noise in the workplace ) was discovered by very careful anamnesis and systematic objective routine analyses and was treated effectively , with documentation , the non-organic voice disorder disappeared , as , e.g. , in the case of a diagnosis and treatment of helicobakter pylori . The reason is that the mucosal swelling/dysfunction of the vocal cords is secondary .In order to try to underst and why the recommendation to all these patients for many years was only voice therapy , which the speech therapists “ felt to be effective ” , up date d voice-hygiene advice ( for posture , accents of the diaphragm , intonation pattern and resonance ) was given by experienced laryngologists , r and omised with the up date d medical diagnosis/therapy in order to eluci date what effect the training might have . No evidence -based studies in the literature document any effect . The crucial point seemed to be that doctors mostly did not examine any other diagnoses other than the “ dysphonia ” and did not dig down to any of the medical reasons when the vocal fold diagnosis of “ non- organic disorders ” was made . This should be changed in the future . This pilot study was based on a comparison of ten dysphonic patients with stroboscopic non- organic ( functional ) voice disorders , where a micro-organic diagnosis was search ed for and treated systematic ally in a medical regime ( for infections , allergies , gastrooesophageal reflux and environmental irritants such as dust , noise , etc . ) versus ten dysphonic patients with stroboscopically confirmed non-organic ( functional ) voice disorders , having only the traditional but optimal voice advice , which we can call medical voice-hygiene advice , including the use of the Accent method . A retrospective group of ten patients treated medically was included , too . A dem and can not be made that the functional group being treated by  r and omisation  with voice advice should also be medically treated at once , the medical approach being the new one . On the other h and , it is strange that no evidence -based research was made before . All patients were measured two times with stored videostroboscopy , a quality -of-life question naire and  phonetograms  with 1-month intervals . All patient groups improved . There was no statistical improvement in favour of the medical group with the voice-related quality -of-life score , also not for the group who received voice-hygiene advice . The geometrical mean values of the phonetogram areas in decibels times semitones were better in all groups , but a statistical difference was not found between the medically treated group and the voice-hygiene advice group . The pilot study showed that both medical treatment and medical voice-hygiene advice had a positive effect on  dysphonia in non-organic ( functional ) voice disorders . There is need of an extensive prospect i ve r and omised trial on dysphonia including vocal cord nodules to find out which treatment should be used for this group of patients . It is suggested that an eventual r and omisation for microsurgical treatment or regular voice therapy should be made after a period of systematic medical diagnosis and treatment including medical voice-hygiene advice Previous studies of students study ing to be teachers have indicated that these students commonly have voice disorders . Ideally , voice disorders should be treated before students start their work as teachers , but the re sources for this treatment are often limited . This study examines whether group voice therapy is effective for teacher students . Accordingly , 20 teacher students with mild voice disorders received  group voice therapy  ( in three small groups ) , whereas 20 students with similar voice disorders served as a control group and consequently did not receive voice therapy . Two out of three outcome measures ( perceptual evaluation of voice quality and a question naire on the occurrence of vocal symptoms ) indicated significant changes in the treatment group compared with the control group . No differences between groups were noted in the laryngeal status . The results suggest that group voice therapy seems to be an effective method to treat students with mild voice disorders The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules . Perceptual and physiological progressive changes were examined during a strictly structured , behaviorally based voice therapy protocol in which 11 women with vocal nodules participated . R and omized audio recordings from pretherapy and from each of the therapy approaches ( vocal hygiene , respiration , direct facilitation , carryover ) were used for perceptual evaluations . Six speech- language pathologists rated ten voice quality parameters . Two evaluation procedures were performed and compared . Interlistener reliability was sufficiently high in both tests . Significant effects of therapy were found for decreased overall dysphonia , press , instability , gratings , roughness , vocal fry , and " scrape . " Nonsignificant group effects were found for breathiness , aphonic instances , and lack of sonority . No significant parameter changes occurred between baseline assessment and the completion of the initial ( vocal hygiene ) phase of therapy . Significant changes were found following the direct facilitation and respiration phases of therapy . Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved . However , the nodules had decreased in size and edema was reduced after therapy for all clients , but one . Combined results suggest : ( 1 ) Alterations in vocal function were reflected in perceptual parameters , and ( 2 ) the voice therapy had a positive effect on voice quality , vocal status , and vocal function for the majority of the vocal nodule clients Traditional clinical review articles , also known as up date s , differ from systematic review s and meta-analyses . Up date s selectively review the medical literature while discussing a topic broadly . Non-quantitative systematic review s comprehensively examine the medical literature , seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment . Meta-analyses ( quantitative systematic review s ) seek to answer a focused clinical question , using rigorous statistical analysis of pooled research studies . This article presents guidelines for writing an evidence -based clinical review article for American Family Physician . First , the topic should be of common interest and relevance to family practice . Include a table of the continuing medical education objectives of the review . State how the literature search was done and include several sources of evidence -based review s , such as the Cochrane Collaboration , BMJ 's Clinical Evidence , or the InfoRetriever Web site . Where possible , use evidence based on clinical outcomes relating to morbidity , mortality , or quality of life , and studies of primary care population s. In articles su bmi tted to American Family Physician , rate the level of evidence for key recommendations according to the following scale : level A ( r and omized controlled trial [ RCT ] , meta- analysis ) ; level B ( other evidence ) ; level C ( consensus/expert opinion ) . Finally , provide a table of key summary points BACKGROUND The use of outcome measures to monitor improved quality of care has been advocated for 20 years but has only achieved prominence with the increasing re source pressures and related changed in health service provision in the past 6 years . OBJECTIVE This paper describes the development of an approach to outcome measurement suitable for all patients receiving speech and language therapy .  The measure , which is based on rating the dimensions of impairment , disability , h and icap and well-being , is tested to assess whether it can usefully be used to compare the services of different providers . METHOD Five trusts volunteered for the study . Service descriptions suggest that these services are typical for the purpose s of providing speech and language therapy .  Twenty-five therapists were trained to use the  Therapy Outcome Measure ( TOM ) ; their reliability was assessed and they provided prospect i ve data on clients with speech and language impairments related to dysphasia , stammering and dysphonia . RESULTS The study provides evidence indicating the differences in the types of patients being referred to different providers of  speech and language therapy . Different services have different impacts on the number and type of domains and that services discharge patients at different points in their recovery . DISCUSSION Different outcomes by different providers may be associated with different referral policies , base population s , skills and work policies of therapists . Differences in outcomes associated with certain therapy services can initiate the task of analysing attributions and progress endeavours to provide equitable quality of care which is the philosophy underpinning the move towards benchmarking in health service delivery Transnasal flexible laryngoscopy ( TFL ) is an examination of laryngeal anatomy and physiology using continuous light . TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it . The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool . The study used a prospect i ve r and omized controlled trial . Fifty dysphonic subjects were recruited and r and 
    Output:
    
In general , statistically significant positive but modest and varying therapy effects are found .