Mashima Telehealth Voice Therapy Abstract Telehealth or telemedicine is the use of telecommunications technology to deliver health care services at-a-distance.. One of the most commonl
INTRODUCTION
Speech and language disorders affect a person’s ability to talk, understand, read, and write, and they can range from a few speech-sound errors to a total loss of the ability to use speech to communicate effectively In the United States, an estimated 46 million people have some form of disordered communication, highlighting how widespread these conditions are and their impact on daily life.
Speech-language pathologists (SLPs) evaluate, diagnose, and treat communication disorders across the lifespan, from infancy to old age, because untreated difficulties can limit learning, reduce employment opportunities, and lower overall quality of life The American Speech-Language-Hearing Association (ASHA) is the professional, scientific, and credentialing body for more than 140,000 members and affiliates who are SLPs, audiologists, and other professionals in the field, serving the United States and international communities.
Language-Hearing Association [ASHA], 2010a).One of its missions is to advocate on behalf of persons with communication and related disorders to ensure their access to quality services
A shortage of speech-language pathologists (SLPs) remains a significant challenge in many regions The U.S Bureau of Labor Statistics projects that employment for SLPs will grow by about 19 percent from 2008 to 2018, faster than the average for all occupations, with increasing demand in school settings This growth is driven by greater awareness of the importance of early identification and diagnosis of speech and language disorders in young children, and reinforced by the 2004 Individuals with Disabilities Education Act (IDEA), a federal law that guarantees special education and related services to all eligible children with disabilities.
2 survey of schools conducted by ASHA in 2006 identified school districts with significant personnel shortages; 68% of respondents reported that job openings were more numerous than job seekers (ASHA, 2006)
Demand for speech-language pathologists (SLPs) in health care facilities is rising alongside the need for services for individuals with disabilities or limited function As the baby-boom generation ages, the risk of neurological disorders and related speech, language, and swallowing impairments increases, while advances in medicine are improving survival rates for premature infants as well as trauma and stroke victims who commonly require SLP services (Bureau of Labor Statistics, U.S Department of Labor, 2010) A 2009 ASHA health care survey found that 25% of respondents had unfilled positions, with the highest vacancy rate (36%) in home health.
In 2009, reported vacancies for speech-language pathologists (SLPs) in healthcare had declined from the 2005 peak of 40% (ASHA, 2005a) Nonetheless, shortages persist, with rural and underserved areas feeling the impact most acutely.
In 1985, ASHA sponsored a National Colloquium on Underserved Populations to identify barriers to service delivery and to establish an action plan, with a central goal of reviewing alternative methods of speech-language pathology (SLP) service delivery that could overcome the personnel and geographic barriers inherent in remote or rural areas (ASHA, 1991).
2001 to 2003 was promoting the use of Web-based and advanced technology to enhance the provision of clinical services and personnel preparation
Telemedicine is defined as the use of telecommunications technologies to provide medical information and services (Perednia & Allen, 1995) Telemedicine evolved into telehealth with the passing of the 1997 Comprehensive Telehealth Act, which expanded the scope of remote healthcare delivery, broadened access to care, and laid the groundwork for policy and reimbursement frameworks for virtual services.
The field has shifted from physician-only services toward models that include other health professionals, such as speech-language pathologists (SLPs), as noted by ASHA (1998) A widely recognized advantage of telehealth is improved access to care, enabling patients to receive services that were previously unreachable due to distance, limited specialist availability in a region, or transportation challenges (Agency for Health Care Policy and Research, 2001) By removing geographic barriers, telehealth makes it possible to deliver health care on a global scale In 2001 ASHA introduced the term telepractice to cover a range of services delivered via telecommunications technology that extends beyond direct health care, including communication enhancement, education, and supervision in school and clinical settings (ASHA, 2001) ASHA also asserts that telepractice is an appropriate service delivery model for the SLP profession and can address access barriers stemming from distance, the lack of specialists or subspecialists, or mobility impairment (ASHA, 2005b).
Telehealth holds substantial potential for speech-language pathology (SLP) as the costs of telecommunications technology and devices decline, connectivity becomes more widespread, and demands for home health care rise amid ongoing personnel shortages By improving accessibility and expanding service availability, telehealth enables care to be delivered in the least restrictive environment, while enabling greater family participation in the clinical process and increasing efficiency in service delivery—especially for itinerant clinicians who serve multiple locations.
To unlock the full potential of telehealth in speech-language pathology, targeted research is needed to identify appropriate applications and address diverse clinical needs The development and validation of telehealth clinical protocols must be pursued, with rigorous evaluation of clinical outcomes and patient reception to ensure quality and satisfaction By systematically examining which telehealth approaches deliver the best results for different speech and language disorders, practitioners can establish evidence-based guidelines that improve access, efficiency, and effectiveness in SLP services.
Ethnographic techniques can provide valuable insights into factors underlying patient satisfaction
Dissatisfaction with telehealth has been noted in the literature (May et al., 2003) Examining patient perceptions can reveal the reasons patients either like or dislike telehealth services, and help health-care providers better understand patients’ subjective definitions of telehealth’s acceptability and utility (Mair & Whitten, 2000).
Although a substantial body of literature supports telehealth across an expanding range of disciplines and environments, questions about its quality remain This uncertainty reflects the telehealth landscape’s inconsistency, spanning from anecdotal reports to well-designed randomized clinical trials As telehealth adoption grows across healthcare and related fields, researchers are continually assessing outcomes, reliability, and patient experience to determine when telehealth delivers high-quality care.
Current literature on telehealth in speech-language pathology is dominated by preliminary investigations and demonstration projects, with relatively few rigorous empirical studies Research is needed to support the integration of telehealth into the health-care continuum and to promote its long-term acceptance To realize the potential of delivering SLP services remotely, clinical protocols must be developed and aligned with technical requirements Data from controlled studies are essential to guide evidence-based practice and to ensure accurate diagnoses and efficacious treatment of communication disorders via telehealth.
Shortages of qualified personnel further limit access to speech-language pathology (SLP) services, and underserved areas are less likely to have SLP subspecialists with expertise in evaluating and treating voice disorders It’s estimated that voice disorders affect up to 10% of the U.S population, with higher rates among people who rely on their voice for work, such as teachers (ASHA, 2008) Vocal problems can threaten careers for voice-dependent professionals (e.g., receptionists, broadcasters) and can reduce company profits for roles like salespeople and telemarketers.
Miscommunication of key facts and directives can jeopardize public safety, particularly for emergency vehicle dispatchers, law enforcement officers, and armed forces service members For individuals with voice disorders, vocal rehabilitation can restore quality of life and may improve economic outcomes Speech-language pathologists (SLPs) play a key role in diagnosing and treating voice disorders, helping patients regain function and effective communication Technology offers promise for overcoming geographic and staffing barriers, expanding access to vocal rehabilitation for those in need.
REVIEW OF THE LITERATURE
Chapter 2 traces the historical arc from telemedicine, the use of telecommunications for medical, diagnostic, monitoring, and therapeutic care, to telehealth that spans the full spectrum of health sciences, and finally to telepractice, which includes services provided by speech-language pathologists (SLPs) and audiologists beyond traditional health care Because telepractice is an innovative model of service delivery rather than a new clinical procedure, the literature review applies telehealth and telepractice frameworks to assess and treat disorders across SLP subspecialties The chapter shows how remote approaches support the assessment and treatment of a range of communication and related disorders, extending beyond a single clinical domain It concludes with a synthesis of the practical, clinical, and regulatory issues involved in delivering SLP services at a distance.
While the vast majority of telemedicine applications have occurred in the last 20 to 30 years with concomitant advances in information technology, its history is much older The prefix
Derived from the Greek 'tele-' meaning at a distance, far away, the terms telemedicine and telehealth refer to medicine and health services delivered remotely If telehealth is understood as any medical service performed at a distance—regardless of how information is transmitted—the first public health surveillance networks originated in the Middle Ages, when plague information spread across Europe by methods such as bonfires (Craig & Patterson, 2006).
Mid-19th-century expansions of national postal systems and telegraph networks enabled remote health care delivery In the American Civil War, the telegraph was used to order medical supplies and to transmit casualty lists, illustrating how rapid communications could support medical operations on the battlefield Since the late 19th century, the telephone has been used to deliver health services, and as early as 1910 amplified stethoscope sounds were transmitted over the telephone network Today, similar devices and other evolving applications are expanding telemedicine and remote diagnostics beyond traditional care settings.
7 including transmission of electrocardiograms and electroencephalograms (Craig & Patterson,
By the end of the 19th century, radio made it possible to deliver medical advice to seafarers remotely, transforming maritime healthcare, and by 1920 the Seamen’s Church Institute of New York was among the first organizations to provide medical care using the radio, pioneering remote medical support for sailors.
As early as 1938, more than five maritime nations had established radio medical services, including the International Radio Medical Centre in Rome, which assisted over 42,000 patients from 1935 to 1995 Today, radio medical guidance for in-flight medical incidents is provided by on-call health care workers on the ground (Craig & Patterson, 2006).
Recent strides in telemedicine are underpinned by innovations in electronic communication, including digital techniques, and by the pioneering work of organizations and individuals such as NASA's manned spaceflight program By the late 1950s, medical personnel were already using closed‑circuit television and video communications in clinical settings In 1964, a two‑way closed‑circuit television system enabled interactive, at‑a‑distance consultations between specialists and general practitioners at a psychiatric institute and a state mental hospital.
Nebraska In 1967, a two-way audiovisual microwave circuit was established to link
Massachusetts General Hospital and the Logan International Airport Medical Station for the provision of medical care to passengers and airport employees 24 hours a day From 1971 to
1975, a program in Alaska assessed the viability of using satellite-mediated video consultation to improve village health care (Craig & Patterson, 2006)
Bashshur (2002) identifies three eras in the evolution of telemedicine, each closely tied to advances in information technology, telecommunications, and computing The telecommunications era of the 1970s and early 1980s depended on broadcast and television technologies that were costly, complex, cumbersome, and often unreliable Digitization in telecommunications and improvements in computer processing marked the emergence of the digital era in the late 1980s In this transitional period, Integrated Service Digital Network (ISDN) technology enabled the simultaneous transmission of voice, video, and biometric data at relatively high speeds within a network.
“universal” network is a hallmark of this era The present era in telemedicine is dominated by the powerful, less expensive, ubiquitous Internet which allows open access to a global communication environment
Telecommunication technology has broadened healthcare delivery across many specialties, including radiology, dermatology, pulmonology, otolaryngology, ophthalmology, cardiology, oncology, surgery, psychiatry, psychology, rehabilitation, and home health care Among these, teleradiology stands as the most widespread and successful application of telemedicine Digital radiology enables access regardless of geographic distance and significantly improves efficiency, with web-based software allowing films to be accessed from any PC location with sufficient quality for most consultative needs (Burgess et al., 1999) However, despite these innovations, persistent challenges remain in access, availability, quality of service, and security (Bashshur, 2002).
A 2002 survey of telemedicine activity in the United States found that more than 85,000 teleconsultations (excluding teleradiology) were conducted by over 200 programs across more than 30 specialties Mental health, pediatrics, dermatology, cardiology, and orthopedics together accounted for almost 60% of these teleconsultations.
9 located in industrialized countries including the U.S., Canada, Australia, and the United
Kingdom (U.K.), there is evidence to suggest that global adoption is imminent in the future (Craig & Patterson, 2006)
Technology can establish telemedicine connectivity virtually anywhere, but other infrastructure elements must be addressed for widespread adoption In 2011, the American Telemedicine Association outlined policy priorities designed to help patients, providers, and payers realize the benefits of telemedicine Public policy changes needed to unlock these benefits include improving reimbursement parity across payers, streamlining licensure and cross-state practice, strengthening privacy and security standards, and expanding broadband access to underserved regions.
To boost federal coordination and impact on telemedicine, policies would mandate telehealth as a covered service under federal health benefit plans, integrate telemedicine into federal health care programs, and pursue opportunities to apply telemedicine in implementing national health insurance reform; extend Medicare coverage for telehealth services; resolve conflicts governing medical staff credentialing and privileging for telehealth networks; expand the rural health care program to provide broadband services to all physicians and health care offices; and provide financial and technical support for the development of telemedicine networks through a range of research, grant, and support programs.
2 increasing state support of telemedicine by:
Expanding access to telehealth involves expanding state Medicaid to cover telehealth services, supporting state-funded telehealth networks focused on conditions such as stroke, at-risk pregnancies, and traumatic brain injury, and extending telehealth benefit coverage for plans regulated at the state level; it also calls for collaborative agreements among states to facilitate licensure portability for physicians and other providers, enabling patients to receive prescriptions via the Internet for medications that are not federally controlled from licensed providers at the patient’s location, and requiring insurance carriers to provide malpractice coverage for telehealth services, including in settings like school-based clinics and correctional facilities.
To optimize emergency preparedness and response, coordinate and repurpose resources by assessing the capacity of existing public health and health-care networks to provide emergency services and determining how these networks’ resources can be best utilized and integrated into the overall emergency response.
4 working with international organizations to maintain policy priorities to address the globalization of telemedicine
Historical Perspective of Telehealth in Speech-Language Pathology
Early adoption of telecommunications in speech-language pathology focused on diagnosing and treating neurogenic communication disorders In 1976, the Tel-communicology health care delivery system was created to meet rising demand among veterans, upgrade available services, and overcome logistical challenges This system was designed to enhance traditional programs rather than replace them, supporting patients with communication disorders such as aphasia and dysarthria through remote assessment and treatment options.
(Vaughn, 1976) Beginning in 1987, investigators in Mayo Clinic facilities provided SLP telemedicine consultations for patients with communication disorders including dysarthria, apraxia, and cognitive-communication impairment They concluded that telemedicine provides an appropriate medium for speech-language consultations that is reliably accurate in identifying various acquired neurogenic and psychogenic speech disorders (Duffy, Werven, & Aronson,
ISSUES RELATED TO VOICE THERAPY
Chapter 3 highlights issues related to treatment efficacy for voice disorders including outcome measures and patient compliance Evidence from several studies suggests that patient compliance and adherence to treatment play a greater role in vocal rehabilitation than any specific therapy approach A stepwise process for developing a telehealth vocal rehabilitation program is described to address the problem of the “ultimate non-adherence” or patient
Voice disorders encompass a spectrum from mild hoarseness to complete voice loss and are typically characterized by changes in pitch, loudness, and vocal quality that can impair intelligibility and effectiveness in oral communication They stem from disordered laryngeal, respiratory, and/or vocal tract function, and can be influenced by everyday behaviors such as excessive throat clearing, yelling, or prolonged talking over loud background noise, as well as muscular imbalances that produce physical changes in the vocal folds In addition to behavioral and structural factors, voice disorders may arise from other medical or physical conditions (such as trauma, neurological disorders, or allergies) or psychological factors (such as stress, conversion reactions, or personality disorders), or a combination of these factors (Ramig & Verdolini, 1998).
Evidence shows that individuals with voice disorders can benefit from services delivered by speech-language pathologists (SLPs), but the efficacy literature for voice therapy remains sparse and often hampered by methodological limitations Although a range of voice-treatment approaches has been described, there is limited guidance on their relative value, with therapies spanning specific techniques, loosely organized principles, and eclectic blends of strategies The choice of voice treatment typically depends on diagnostic category, patient characteristics, and the SLP’s clinical preference, underscoring the need for more research to establish evidence-based voice therapy.
Voice therapy effectiveness is typically judged by parents or patients, clinicians, and otolaryngologists (Pannbacker, 1998) Treatment outcomes are determined by applying identical measurements before and after therapy Various aspects of voice production are used to assess success, with vocal quality serving as an important indicator However, unstable perceptual standards for comparing speech stimuli and a lack of consensus on defining perceptual concepts create significant problems in classifying vocal quality A more objective assessment uses acoustic analyses that quantify voice variability, including measures of jitter (pitch-period variability) and peak-to-peak amplitude.
Shimmer, or the ratio of energy between inharmonic components and harmonic components (noise), is used to characterize voice quality, but it can be affected by pitch-tracking errors, inadequate acoustic analysis of aperiodic vocal vibrations common in dysphonic voices, and the use of unnatural speech samples such as sustained vowels Laryngostroboscopy, or video recordings of laryngeal structures and vocal fold vibration, has been used to evaluate outcomes related to the source of voice production through visual-perceptual assessment of vocal fold morphology and function When measuring the effects of therapy, it is important to assess the beneficial or negative changes experienced by the patient, including self-evaluation of the patient’s perceived handicap resulting from the voice disorder (Speyer, 2008).
One study reported that voice therapy produced clearly significant improvements in chronically dysphonic patients with diverse diagnoses, as shown by group comparisons of pre- and post-treatment data across perceptual rating, acoustic analysis, and laryngostroboscopic recordings Improvement occurred in 40% to 50% of patients on each of the three outcome measures, though the relationships among these evaluation tools in reflecting pre- to post-treatment changes were weak Additionally, the effects of therapy for individual patients varied, indicating heterogeneous responses to treatment.
Out of 36 patients, outcomes varied in ways that could not be explained by pretreatment status, age, gender, or diagnostic group Because no restrictions were placed on the type of voice therapy, the study aimed to reflect real-world practice and assess the efficacy of voice therapy in actual clinical settings The low correlation among the three evaluation methods suggests that a multidimensional approach to voice assessment is necessary to reliably capture treatment outcomes (Speyer, Wieneke, & Dejonckere, 2004).
Voice therapy involves modifying voice and speech production while also addressing internal, environmental, and voice-use factors that contribute to a voice disorder Because behavioral change is central to success, patient adherence is critical to the effectiveness of voice therapy Across multiple studies, patient compliance and adherence appear to influence outcomes in voice rehabilitation more than the specific therapy approach used Therapy dropout is a common clinical challenge and may represent ultimate non-adherence In four trials, the dropout rate prior to completing prescribed voice therapy ranged from 16% to 25% (Behrman, 2006; Behrman, Rutledge, Hembree, & Sheridan, 2008).
Across two large voice centers, a retrospective analysis found that only 35.4% of 147 participants completed the voice therapy course, while 64.6% (n=95) discontinued before completion The study evaluated demographics (gender, age, race/ethnicity), otolaryngology diagnosis, severity of quality-of-life handicap, and severity of dysphonia, but none of these variables reliably predicted dropout The investigators call for future research to reduce therapy dropout by addressing barriers such as transportation and by exploring alternative service delivery models, including telehealth, as suggested by Hapner, Portone-Maira, and Johns (2009).
Delivering Voice Therapy At-A-Distance
Burgess et al (1999) describe a stepwise framework for building a comprehensive telemedicine program in Otolaryngology-Head and Neck Surgery that includes audiology and Speech-Language Pathology (SLP) The process begins with a needs assessment or problem definition to identify which parts of the practice are most suitable for telemedicine deployment, followed by usability studies to select the optimal equipment and workflows for the chosen problem It then advances to a proof-of-concept in-house investigation to evaluate the solution in a controlled setting and to normalize the technology to the current standard of care Finally, the framework calls for operationalization or deployment of remote units to validate the in-house findings, especially when the advance involves transmission of data.
Figure 1 outlines the stepwise process used to develop a speech pathology vocal rehabilitation protocol that complements a comprehensive otolaryngology telemedicine service in an urban medical center De-identified data collected from the protocol’s operationalization phase were used for the present study.
Over 18 months, a speech pathology clinic in an urban medical center received 26 referrals for voice disorders from otolaryngologists across a broad geographic area Patients were air evacuated up to 4,000 miles to receive an abbreviated course of voice therapy, incurring direct travel costs and indirect costs such as time away from work and family This pattern indicates that vocal rehabilitation could be delivered via telecommunications technology, enabling patients to complete a standard course of voice therapy remotely without traveling to the urban center.
Figure 1 Stepwise Process (Burgess et al., 1999) Used to Develop the Telehealth Vocal
Rehabilitation Protocol in This Study
Conduct needs assessment to define problem and examine what part of practice would lend itself to the telemedicine model of service delivery
Identified voice therapy as service requested most often for patients medically evacuated from remote sites to Speech Pathology Clinic at urban medical center
Select the best equipment for the problem
Conducted usability studies in consultation with technical specialists to select hardware and software to meet requirements for remote delivery of voice therapy
Conduct in-house investigation to study the problem in a highly controlled environment and normalize technology to the current standard of care
Conducted pilot study to evaluate the feasibility of delivering telehealth vocal rehabilitation protocol; results indicated no difference in outcome measures between in-person and "remote" groups
Operationalization or Deployment of Remote Units
Validate data from proof-of-concept study if telehealth application involves transmission of data
This study compares treatment outcomes of a telehealth vocal rehabilitation protocol delivered in-person and via video-teleconferencing, using data collected from deployed remote units to assess the effectiveness and feasibility of remote delivery.
Usability studies conducted with technical specialists guided the selection of hardware and software to best support the telehealth vocal rehabilitation protocol, with requirements defined first for the in-house investigation and then for data transmission using remote units to validate the in-house data Off-the-shelf voice analysis and real-time feedback programs were evaluated for functionality, usability, cost, and support, focusing on five key features: real-time acoustic analysis of the voice signal, visual display of the voice signal on a video monitor, PC compatibility, reasonable cost, and manufacturer technical support Based on these criteria, Kay Elemetrics Multi-Speech, Model 3700 was chosen for the pilot study, and Sona-Speech II, Model 3600 was selected for the deployment study.
Pilot Study: Proof-of-Concept
This pilot study evaluated the feasibility of delivering a telehealth vocal rehabilitation protocol in a highly controlled urban medical center setting before deploying remote units, with the protocol approved by the medical center’s Institutional Review Board and conducted under protections for human subjects Seventy-two patients with voice disorders (34 males and 38 females; mean age 45) were enrolled, matched by diagnostic category, and randomly assigned to an in-person therapy group or a remote VTC group In the in-person group, therapy was conducted with the clinician in the same room, while in the remote VTC group therapy was delivered via telehealth.
VTC group received therapy conducted with the clinician in an adjacent room interacting via a real-time audio–video monitoring system