5. Limitations
fits, voice disorder, ’
VOICE DISORDER, EVENT
The present study is not without limitations. First, issues encountered the following app dissemination possibly that affected patient attrition rates. The app crashed during the first week of the study and participants reported difficulties with uploading videos. We believe that this event led to the higher dropout rate seen in the app group as compared to the traditional group as the greatest proportion of participants dropped out in the first week. There is no doubt that this event possibly led to greater frustration related to app use even with the existing participants and possibly influenced motivation levels. Second, we were limited to iOS-based smartphones as the app only works with the iOS interface. Resultantly, we missed valuable feedback from users of the Android platform. Third, we did not directly address patient motivation, as in the studies by Van Leer and colleagues. We can make indirect inferences based on usability results; however, we would be extrapolating. Fourth, although available through the app, study participants were not provided with immediate feedback to ensure that all participants received the same degree of attention from the clinician. Possibly, this decision led to the outcome of comparable MPTs in both groups. However, comparable outcomes are also representative of the non-inferiority of app-enhanced voice therapy delivery when compared to the standard of care. This is an important finding for a proof-of concept study. Fifth, the study participants were non-treatment-seeking normophonic individuals. As much as we attempted to replicate real-world settings, the absence of a voice disorder with no negative implications on quality of life has the potential to influence patient motivation to adhere to an intervention. Finally, the app includes only one voice intervention, Vocal Function Exercises. The VFE program is not a ‘one size fits all’ program and can limit the dissemination reach of the app.