AJSLP

Research Article

Telepractice Versus In-Person Delivery

of Voice Therapy for Primary
Muscle Tension Dysphonia
Balaji Rangarathnam,a Gary H. McCullough,b Hylan Pickett,c Richard I. Zraick,d
Ozlem Tulunay-Ugur,e and Kimberly C. McCulloughb

Purpose: The purpose of this study was to investigate the measures improved in both groups, but changes did not
utility of telepractice for delivering flow phonation exercises reach statistical significance. Results for the 2 service
to persons with primary muscle tension dysphonia (MTD). delivery groups were comparable, with no significant
Method: Fourteen participants with a diagnosis of primary differences observed for perceptual and quality-of-life
MTD participated, 7 on site and 7 at remote locations. Each measures.
participant received 12 treatment sessions across 6 weeks. Conclusions: Although the American Speech-Language-
Treatment consisted of flow phonation voice therapy Hearing Association supports the use of telepractice for
exercises. Auditory–perceptual, acoustic, aerodynamic, and speech-language pathology services, evidence for the use
quality-of-life measures were taken before and after treatment. of telepractice for providing behavioral treatment to patients
Results: Perceptual and quality-of-life measures were with MTD has been lacking. The results of this study
significantly better posttreatment and were statistically indicate that flow phonation exercises can be successfully
equivalent across groups. Acoustic and aerodynamic used for patients with MTD using telepractice.

T
he American Speech-Language-Hearing Association commonplace in health-care service delivery. Research ev-
(ASHA; 2002) defines telepractice as the application idence to support the efficacy of the use of telepractice is
of telecommunications technology to delivery of growing but not extensive. It is important to define the
professional services at a distance by linking clinician to cli- utility of telepractice in general, but it is also important
ent, or clinician to clinician, for assessment, intervention, to focus on specific types of treatments for specific types
and/or consultation. Moreover, ASHA emphasizes that tele- of patients. Telepractice may be more effective for one
practice is an appropriate model of service delivery for the population or one type of treatment than another. In this
professions of speech-language pathology and audiology study, we investigated the use of a flow phonation voice
and may be used to overcome barriers of access to services treatment method for individuals with primary muscle ten-
caused by distance, unavailability of specialists and/or sub- sion dysphonia (MTD), delivered through telepractice.
specialists, and impaired mobility. With the growth of popu-
lations requiring services and a relative dearth of service Telepractice and Voice Treatment
providers in rural areas, telepractice is becoming more
There have been reports of successful outcomes with
delivery of voice treatment using telepractice. Mashima,
Birkmire-Peters, Holtel, and Syms (1999) randomly assigned
a
East Carolina University, Greenville, NC 10 patients to either a control condition (n = 4), in which
b
Appalachian State University, Boone, NC therapy was conducted on site, or to an experimental con-
c
University of Arkansas for Medical Sciences Medical Center, dition (n = 6), in which the therapy was offered through
Little Rock telepractice. Patients were assessed using laryngoscopy, per-
d
University of Central Florida, Orlando ceptual and acoustic voice measures, and patient-reported
e
University of Arkansas for Medical Sciences, Little Rock
treatment outcomes. The results indicated that posttreatment
Correspondence to Balaji Rangarathnam: [email protected] recordings on all four measures were rated better than
Editor: Krista Wilkinson pretreatment recordings for the telepractice group, whereas
Associate Editor: Katherine Verdolini Abbott
Received January 28, 2014
Revision received June 13, 2014
Accepted March 25, 2015 Disclosure: The authors have declared that no competing interests existed at the time
DOI: 10.1044/2015_AJSLP-14-0017 of publication.

386 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015 • Copyright © 2015 American Speech-Language-Hearing Association

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 voice recordings of only four of the six participants in the disease and hypokinetic dysarthria (Constantinescu et al.,
in-person group were rated as improved posttreatment. The 2011). They reported noninferiority of the online delivery
findings were reported as preliminary results in an article as compared to in-person delivery on the basis of a non-
addressing telepractice principles for speech-language inferiority analysis of the data; that is, effects of the online
pathology. Details about the voice therapy approaches used delivery were not worse than the effects of in-person delivery
were not provided. by more than a specified margin.
Extending upon their previous work, Mashima et al. The aforementioned studies suggest that voice treat-
(2003) compared voice treatment delivered in person and ment delivered through telepractice can be as effective as
through telepractice for two groups of individuals with la- treatment delivered in person. Although the primary goal
ryngeal conditions, including nodules, vocal fold paralysis, of the aforementioned studies by Mashima and colleagues
hyperfunction, and edema. Telepractice and in-person groups (1999, 2003) was to investigate the efficacy of telepractice,
consisted of 23 and 28 individuals, respectively. Participants control for participant homogeneity would add value to re-
were assigned to the groups randomly but were matched for search related to voice therapy and telepractice. Research
diagnostic category. Patient-specific treatment approaches in the online delivery of LSVT to individuals with Parkinson’s
were followed. Depending on the vocal pathology, facilitating disease has been shown to be useful. However, research
voice treatment approaches (Boone, McFarlane, Von Berg, demonstrating the efficacy of LSVT for improving vocal
& Zraick, 2013)—that is, focus, pitch adjustment, yawn–sigh, hypofunction in patients with Parkinson’s using telepractice
easy onset, open-mouth approach, pitch inflections, and does not essentially mean that other behavioral voice thera-
chant talk—“confidential voice” (Colton & Casper, 1990) pies, such as therapies for vocal hyperfunction, can be de-
or vocal function exercises (Stemple, Glaze, & Gerdeman, livered successfully via telepractice. It would be useful to
2000) were used. Vocal hygiene education was provided to establish the efficacy of various types of treatments used with
all participants in both groups as well. Perceptual and acous- telepractice before advocating routine clinical use.
tic voice assessments, patient satisfaction, and laryngoscopic
images were compared before and after treatment for both
groups. Posttreatment gains were shown in both groups and MTD
were comparable, implying that voice treatment delivered MTD has been defined as a behaviorally based voice
through telepractice was as effective as in-person treatment disorder (Morrison & Rammage, 1993) characterized by
for these participants. “imbalanced” laryngeal or perilaryngeal muscle activity that
Tindall, Huebner, Stemple, and Kleinert (2008) ex- putatively involves vocal fold hyperfunction, laryngeal con-
amined voice treatment outcomes delivered through tele- striction, or bowing (Altman, Atkinson, & Lazarus, 2005;
practice for a group of individuals with Parkinson’s disease Mathieson et al., 2009). MTD could be primary or secondary.
and compared those from a previously reported study (Ramig, Primary MTD is defined as a voice problem in the absence
Sapir, Fox, & Countryman, 2001) on individuals who were of known concurrent structural or neurologic abnormalities
treated in in-person sessions. Twenty-four individuals diag- (Awan & Roy, 2009; Roy, 2003; Verdolini, Rosen, & Branski,
nosed with idiopathic Parkinson’s disease were provided the 2006). Secondary MTD is defined as a response to organic
Lee Silverman Voice treatment (LSVT) approach through conditions and may affect voice quality, pitch, or loudness
video phone calling. Significant improvement in vocal in- (Mathieson et al., 2009; Van Houtte, Van Lierde, & Claeys,
tensity post therapy was reported, and the results were in 2011). Although there is no internationally accepted classifi-
good agreement with those obtained by Ramig et al. (2001) cation system, endoscopic assessment typically reveals con-
for in-person therapy. striction of the laryngeal mechanism in one or more of the
Constantinescu et al. (2010a, 2010b, 2011) reported a following ways: (a) anterior–posterior constriction of the
series of studies demonstrating the utility of telepractice in vocal folds, (b) lateral–medial constriction of the vocal folds,
voice assessment and treatment of individuals with Parkinson’s and/or (c) approximation of the ventricular or false vocal
disease. In their first study (Constantinescu et al., 2010a), folds. When severe enough, a sphincter-like closure of the
the authors examined the validity of assessing speech and entire larynx occurs (Rubin, Sataloff, & Korovin, 2006).
voice in 61 individuals with Parkinson’s disease in tele- MTD, whether primary or secondary, alters phona-
practice versus in-person sessions and reported comparable tory airflow substantially. It would be simplest if increased
results for vocal sound pressure level, phonation time, pitch “tension” equaled vocal fold hyperadduction, increased
range, sentence intelligibility, and communication efficiency laryngeal resistance to airflow (Rlaw), and decreased pho-
in reading. Furthermore, the authors reported a case report natory airflow, but this is not the universal case. Higgins,
(Constantinescu et al., 2010b) validating the utility of online Chait, and Schulte (1999) reported large interparticipant
delivery of LSVT. A patient with idiopathic Parkinson’s variations in aerodynamic characteristics of individuals with
disease was treated remotely for voice and speech impair- primary and secondary MTD. Five aerodynamic profiles
ments using LSVT and showed improvements in sound were recently identified in women with primary MTD as
pressure levels, duration of sustained vowel production, compared to women with normal voices (Gillespie, Gartner-
vocal quality, and intelligibility, as well as high satisfaction Schmidt, Rubinstein, & Abbott, 2013). These profiles were
with the treatment. The authors also reported successful (a) normal flow, normal estimated subglottic pressure
delivery of the LSVT in 34 participants with Parkinson’s (est-Psub); (b) high flow, high est-Psub; (c) low flow, normal

Rangarathnam et al.: Telepractice Versus In-Person Voice Treatment 387

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 est-Psub; (d) normal flow, high est-Psub; and (e) high flow, with the same database, Cohen, Kim, Roy, Asche, and
normal est-Psub. Estimated subglottic pressure can increase Courey (2012a) reported that nearly three fourths of the
as Rlaw increases. It is not feasible to establish a one-to-one population with a diagnosis of dysphonia were referred for
correlation between phonatory airflow and a particular medical treatment across a 12-month period. MTD is a
pattern of laryngeal constriction/hyperfunction. significant cause of dysphonia. Data from various studies
Voice therapy is considered the primary choice of (Roy, 2003; Sama, Carding, Price, Kelly, & Wilson, 2001)
treatment for improving the perceptually abnormal voice indicate that the caseload of primary MTD in voice clinics
caused by primary or secondary MTD (Roy, 2008). The can range from 40% to 60%, implying that it is one of the
goal of voice therapy is to bring about relaxation of the in- most common voice disorders seen in voice clinics. Outside
effectively tensed musculature and improve vocal quality. of regional voice clinics, this type of treatment may not be
Various muscle “rebalancing” approaches and research data available. Patients currently requiring voice treatment often
supporting their use have been proposed over the years. Some travel long distances to metropolitan areas with more ad-
of these include vocal function exercises (Stemple, Glaze, & vanced rehabilitation facilities. Traveling two or three times
Gerdeman, 2000), resonant voice therapy (Verdolini-Marston, per week for treatment imposes great hardships. Develop-
Burke, Lessac, Glaze, & Caldwell, 1995), the accent method ing a way to provide treatment to such patients closer to
(Kotby, 1995), voice facilitating approaches (Boone et al., home could greatly improve quality of care and quality of
2013), and circumlaryngeal massage (Roy, Ford, & Bless, life, reducing the burdens imposed by time off from work
1996; Roy & Leeper, 1993). One treatment method that has and costs of travel. A high percentage of people (65%) are
been used in voice clinics is the flow phonation method, ini- reported to drop out of voice treatment (Hapner, Portone-
tially proposed by Stone and Casteel (1982). Flow phonation Maira, & Johns, 2009). The interval between voice therapy
emphasizes the channeling of the airstream using a slightly referral and scheduling voice therapy has been reported
abducted laryngeal position, which eventually facilitates clear as an important variable affecting adherence to voice therapy
vocal quality. The approach uses exercises, such as blowing (Portone-Maira, Wise, Johns, & Hapner, 2011). Teleprac-
bubbles in a cup of water, gargling, and blowing air into tis- tice will offer an opportunity to decrease this time interval
sue paper, to facilitate airflow through a relaxed, balanced, for individuals who do not have easier access to clinics,
and open vocal tract (Gartner-Schmidt, 2010; Stone & Casteel, thereby reducing dropout from treatment (Tindall, 2012).
1982). Variants of these exercises have been used with reported Moreover, telepractice provides a “greener” method for
clinical success (Gartner-Schmidt, 2010). McCullough et al. treating patients. Less travel means reductions in greenhouse
(2012) recently provided the first data-based study of this gases and smaller carbon footprints on the planet (Masino,
method’s utility for improving airflow and decreasing symp- Rubinstein, Lem, Purdy, & Rossos, 2010).
toms of vocal hyperfunction. The authors reported data Telepractice offers the potential to extend clinical
from six participants who were treated for primary MTD services to remote, rural, and underserved populations and
using flow phonation exercises for a 6-week period. Patients to culturally and linguistically diverse populations as well.
were assessed on acoustic and perceptual measures as well A health care survey of speech-language pathologists across
as the Voice Handicap Index (Jacobson et al., 1997) before health care settings conducted by ASHA in 2009 indicated
and after treatment. A Phonatory Aerodynamic System that 25% of the respondents had unfilled positions in their
(PAS; KayPENTAX) was also used to measure phonatory facility. The highest percentage of vacancies (36%) was in
airflow (i.e., flow of air through the larynx during phona- home health (ASHA, 2009). Although the rate of reported
tion) and Rlaw, which is resistance to the flow of air at the vacancies of speech-language pathologists in health care
level of the vocal folds, before and after treatment as well has decreased from its high of 40% in 2005 (ASHA,
as in every therapy session. In addition to improvements in 2005), shortages are most likely to be felt in rural and un-
perceptual and acoustic measures of voicing and voice derserved areas. Telepractice offers one solution to all
handicap ratings, most of the patients with primary MTD these issues. Although the need for telepractice has been real-
who completed the flow phonation exercise protocol de- ized, actual clinical practice is relatively sparse. An ASHA
creased Rlaw values (i.e., laryngeal resistance) and increased survey (2002) reported that only 2% of 1,667 professionals
phonatory airflow. Given the apparent utility of this method who participated in the survey were actively involved in re-
in alleviating vocal signs and symptoms, as demonstrated search or clinical care using telepractice. This number has
by McCullough et al., it is of interest to determine if the certainly improved over the past decade, but there is a need
same method can be used with a telepractice delivery to develop, validate, and promote assessment/treatment pro-
model. The current investigation served to determine the tocols for telepractice. Therefore, this study was conducted
utility of telepractice for providing this type of treatment to with the primary objective of determining the utility of tele-
individuals with primary MTD. practice for delivering the flow phonation voice treatment
With the prevalence of a disorder such as MTD, mil- method to individuals with primary MTD. We hypothesized
lions of people are affected. For example, Cohen, Kim, Roy, that patients treated via telepractice would demonstrate im-
Asche, and Courey (2012b) reported about 536,943 individ- provements in phonatory airflow and Rlaw as well as im-
uals among 55 million individuals in a national database of provements in acoustic and perceptual measures and voice
patients treated by primary care physicians and otolaryngolo- handicap equivalent to those receiving in-person evaluation
gists received a diagnosis of dysphonia. In a similar study and treatment.

388 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015

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 Method comfortable speaking pitch and loudness as well as at his or
her lowest pitch and highest pitch, increasing and decreasing
The study had a prospective randomized control de- loudness generically. Vocal fold function and anatomy
sign. Randomization was done to eliminate bias and con- were examined in regular halogen mode and with stroboscopy.
founding in treatment assignment. Fourteen (11 women, The otolaryngologist and the first author reviewed video-
three men) participants (see Table 1) were evaluated in per- stroboscopic examinations to ensure proper fit with require-
son at an outpatient voice and swallowing clinic of a uni- ments of primary MTD. MTD was defined visually as
versity medical center and were randomly assigned, via a one of the four types described by Rubin et al. (2006) and
computer-generated random numbers table, to receive treat- further characterized according to criteria established by
ment either in person or via telepractice at an affiliated out- Koufman and Blalock (1982); that is, laryngoscopic studies
reach facility. The participants were 16 years and older and for each patient were examined for the presence of lateral–
presented with “muscle tension dysphonia” documented in medial compression, anterior–posterior compression, and
their medical record by an otolaryngologist, as discussed ventricular adduction/supraglottic compression. Lateral–
shortly. All participants had primary MTD, and those who medial compression was identified as hyperadduction of the
presented with organic vocal lesions, head and neck cancer, vocal folds in the lateral medial axis. Anterior–posterior
spasmodic dysphonia or other neurological disorders, respi- compression was identified as constriction of the vocal
ratory disorders including asthma, or oropharyngeal dyspha- tract at the level of the laryngeal vestibule in the anterior–
gia were excluded from the study. In addition, participants posterior axis. Ventricular adduction/supraglottic com-
who used other voice therapy methods at a different facility pression was identified as supraglottic muscle activity,
or pharmacological treatment (other than proton pump in- including partial or complete adduction of false vocal folds.
hibitors recommended for disorders of laryngopharyngeal All the participants presented with at least one of these
reflux–related symptoms) for the voice problem were excluded findings. Patients with organic conditions were excluded.
from the study. Baseline characteristics of the participants The otolaryngologist and a speech-language pathologist
are reported in Table 2. The study was approved by the arrived at a consensus on the presence of MTD through
medical center’s institutional review board, and all partici- running discussions.
pants provided written informed consent. Auditory–perceptual assessment. Assessment proce-
dures were carried out within 2 weeks of an established di-
agnosis. Auditory–perceptual assessment was conducted
Procedures using the Consensus Auditory Perceptual Evaluation of
Assessment Voice (CAPE-V; Kempster, Gerratt, Verdolini Abbott,
Laryngoscopic assessment. Laryngoscopic assessment Barkmeier-Kramer, & Hillman, 2009; Zraick et al., 2011).
was performed either by the study otolaryngologist (the This assessment provides a measure of the clinician’s per-
fifth author) or the first author. A flexible naso-endoscope ceptual ratings of a patient’s voice on a variety of parame-
was inserted into one of the nares, depending on patient ters, including breathiness, roughness, strain, pitch, loudness,
preference, after application of topical anesthesia (0.2 ml and overall severity. Voice samples consisted of sustained /a/
viscous lidocaine delivered on cotton-tip applicator). and /i/ for at least 3 s, reading of six sentences, and spontane-
Once a clear image of the larynx was obtained, the patient ous speech. All voice samples were rated at the beginning
was asked to sustain /i/ for at least 3 s at his or her most and the end of treatment by a speech-language pathologist

Table 1. Demographic characteristics of study participants.

Days post-onset
Participant Age Gender Group Occupation of symptoms Additional information

TVS001 53 F Telepractice College professor 4 months —

TVS002 81 M In person Retired real estate agent 4 months —
TVS003 56 F Telepractice Retired teacher 3 months Prior history of thyroidectomy
TVS006 57 M In person Real estate agent 4 months Medications for reflux symptoms
TVS011 33 F In person Business manager 1 month —
TVS014 56 F Telepractice Part-time real estate agent 2 years —
TVS015 59 F In person Radio and media 5 months —
TVS016 39 F Telepractice Business manager 2 months Medications for reflux symptoms
TVS018 51 F Telepractice Nurse 1 month —
TVS021 60 F In person Unemployed during the initial 3 years —
assessment; previously a clerk
TVS022 59 F Telepractice Nurse 3 months Occasional shortness of breath
TVS023 16 F In person School student 8 months —
TVS024 60 F Telepractice Retired teacher 1 year —
TVS026 32 M In person Business manager 2 months —

Note. F = female; M = male.

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 Table 2. Baseline characteristics of study participants.

Participant Groupa NHR VTI Mean Airflow in CSP Mean Airflow in MSP Rlaw VHI CAPE-V severity

TVS001 1 0.150 0.017 0.09 0.10 41.47 36 25

TVS002 2 0.172 0.056 0.26 0.25 9.42 35 27
TVS003 1 0.151 0.046 0.37 0.34 10.53 16 18
TVS006 2 0.136 0.047 1.28 1.20 15.04 29 36
TVS011 2 0.122 0.033 0.22 0.19 50.80 22 28
TVS014 1 0.628 0.166 0.09 0.11 51.73 78 35
TVS015 2 0.144 0.067 0.28 0.20 46.32 19 25
TVS016 1 0.183 0.052 0.29 0.32 30.22 28 22
TVS018 1 0.148 0.045 0.09 0.10 55.70 20 26
TVS021 2 0.541 0.129 0.23 0.12 923.82 111 61
TVS022 1 0.164 0.034 0.09 0.07 53.06 62 33
TVS023b 2 114 100
TVS024 1 0.131 0.070 0.27 0.24 124.38 27 8
TVS026 2 0.150 0.039 0.26 0.19 11.76 40 18

Note. NHR = noise-to-harmonic ratio; VTI = voice turbulence index; CSP = comfortable sustained phonation; MSP = maximum sustained
phonation; Rlaw = laryngeal resistance; VHI = Voice Handicap Index; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice.
a
Group 1 = telepractice, Group 2 = in person. bThe patient was aphonic; therefore, measures were not recorded.

(the second author), and then 10% of the data were rerated and loudness for as long as they could sustain voicing
blindly in random order by two other speech-language pa- in one breath.
thologists (the fourth author and another speech-language
pathologist), both with extensive experience in evaluation (b) Comfortable sustained phonation (CSP): Participants
were instructed to take a deep breath, then to produce
of voice disorders. Pre- and posttreatment ratings for each
a sustained open vowel (/a/) at a comfortable pitch
participant were made together, and the conditions of time
and loudness for at least 5 s once data capture was
point and participant information were blinded; that is, pre-
initiated.
and posttreatment samples of each participant’s voice were
provided to each rater with order of occurrence randomized. (c) Voicing efficiency: Participants were instructed to
Thus, each rater had two samples to rate without the knowl- repeat the voiced vowel /a/ and the voiceless stop
edge of whether they had been obtained prior to or after plosive /p/ nine times in vowel/consonant format (i.e.,
treatment. Only the overall severity measure was considered /apapapapapapapa/), placing equal stress on each
for analysis purposes. syllable as described by Zraick, Smith-Olinde, and
Acoustic assessment. Acoustic measures were made Shotts (2012). To ensure consistent rhythm, participants
from recordings on the KayPENTAX Computerized were trained on the speaking task until they produced
Speech Lab 4500 (KayPENTAX, Inc.) in a room with the syllable trains evenly and at a comfortable loudness
nominal ambient noise. The default calibration settings of level.
the Computerized Speech Lab Model 4500 were used,
Three trials of each of the foregoing tasks were con-
and the microphone (Shure SM48) was kept at a consistent
ducted, and the average of the three trials was used for analy-
distance of approximately 6 in. from the speaker’s mouth.
sis. Participants were provided with instructions for each
For the multidimensional voice profile analysis, the voice
task before every trial. Mean phonatory airflow (liters per
sample consisted of an /a/ vowel sustained for 5 s, which
second) was derived from CSP and MSP tasks individually.
was then analyzed for noise-to-harmonic ratio (NHR),
CSP protocol is based on analysis of a sustained portion
voice turbulence index (VTI), and frequency and intensity
of voicing that is comfortable in pitch and loudness for the
perturbation measures. NHR has been demonstrated to
participant. We were, however, interested in the total expi-
correlate well with perceptual roughness (Bhuta, Patrick, &
ratory volume and phonation time as well, and therefore
Garnett, 2004; de Krom, 1995), whereas VTI represents
the MSP protocol was also used. Estimates of subglottal
the turbulence caused by incomplete adduction of the vocal
pressure, mean phonatory sound pressure level, Rlaw
folds (Di Nicola, Fiorella, Spinelli, & Fiorella, 2006).
and phonatory airflow were derived from the voicing effi-
Aerodynamic measurement. Aerodynamic assessment
ciency task. Measures of average peak (intraoral) air pres-
of phonatory airflow and Rlaw were derived using the PAS
sure during adjacent productions of the consonant /p/
Model 6600 (KayPENTAX). The following tasks were
(across syllables 2–8) provided the estimate of subglottal
conducted:
pressure (Zraick et al., 2012). Mean airflow during voic-
(a) Maximum sustained phonation (MSP): Participants ing was derived from the oral airflow measures during
were instructed to take a deep breath, then to produce the vowel segments. Two measures (peak air pressure and
a sustained open vowel (/a/) at a comfortable pitch mean airflow during voicing) were subsequently used by

390 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015

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 the PAS software to calculate Rlaw value, which is defined on the basis of their responses to the questionnaire. Vocal
as the ratio of peak pressure/airflow. The airflow signal hygiene instructions included information on intake of ap-
was examined to ensure a baseline (zero) was reached for propriate fluids (noncaffeinated), controlled use of voice,
each pressure peak so as to not underestimate subglottic and control of reflux or allergies if applicable. Recommen-
pressure. dations were discussed, and problem areas were highlighted
Patient perception. All participants completed the for each participant on the basis of clinical judgment. In
30-item Voice Handicap Index before and after the treat- each of the additional 11 sessions, participants conveyed
ment. This provided the patient perceptions of the handicap- the vocal hygiene instructions back to the clinician and
ping effects of their voice. discussed successes and problem areas since the previous
session.
Treatment
Part II: Airflow Exercises (Flow Phonation; 20–25 Min
Participants were randomly assigned to one of two per Session)
groups. The random assignment of participants was car- Each treatment session typically used two of three
ried out after the assessment session before initiation of airflow exercises: gargling, cup bubble blowing, and stretch
any treatment. Participants in Group 1 received treatment and flow phonation, depending on the participant’s success
in person at the medical center. Participants in Group 2 with each exercise. Each exercise uses a built-in form of
received treatment at one of 13 regional affiliated satellite biofeedback (water or tissue) and the same basic progres-
clinics through an Internet protocol–based videoconferenc- sion of activities: (a) airflow task without voicing to establish
ing system supported by a Tandberg interactive audio– positive airflow; (b) adding voicing to the task; (c) moving
video unit. The farthest satellite clinic was 190 miles from up and down the pitch range during the voicing task; and
the on-site clinic, and the closest was 1 mile. Participants (d) moving to a speaking/voicing task, removing biofeedback.
in Group 2 traveled not more than 15 miles to the satellite During each vocalization attempt, the clinician listened for
clinic. Participants in Group 2 signed an additional form a clear and effortless vocal quality and trained the partici-
granting permission to be photographed and video recorded. pant to listen and feel relaxation within the throat.
The clinician worked with the patient from the host medical In greater detail, the gargling exercise required the
center. The participants in both groups attended 12 sessions participant to place a small amount of water in the mouth,
of voice therapy across 6 weeks (two sessions per week). The recline the head, and gargle without voice 10 times for 5–6 s
number of sessions was initially established considering re- with breaks in between. The participant was instructed to
imbursement that is currently available for speech-language relax the throat and gargle with enough airflow to make the
therapy. Also, because each patient differs in terms of base- bubbles pop up out of the mouth. After this was accom-
lines, compliance, and general attitudes toward treatment, it plished, the next step was to gargle the same way but with
is difficult to determine a specific number of sessions to be the voice—again ensuring bubbles popped up out of the mouth.
standard for all patients. Six weeks of treatment have been The third step was to gargle with the head back with the
targeted in previous studies on voice therapy (MacKenzie, voice moving up and down pitch scales freely and relaxed.
Millar, Wilson, Sellars, & Deary, 2001). McCrory (2001) This was done 10 times as well. The fourth step began with
conducted a retrospective audit of various parameters de- the participant gargling with voice and then rolling the head
fining best practice in voice therapy and reported an av- forward while gargling, closing the mouth, and allowing
erage of two to 12 sessions of therapy for vocal fold nodules. the sound to come out the nares into a hum. The partici-
Lockhart, Paton, and Pearson (1997) reported the average pant then swallowed the water, took an easy breath, and
number of treatment sessions for vocal strain was two to repeated “mmmmama mama,” “mmmmay, may, may, may,”
14 and about two to 15 for ventricular fold overaction in and then continued with /m/ and other vowels. When voicing
two different voice centers. Considering these factors, a uni- sounded sufficiently relaxed without laryngeal tension, it was
form number of 12 sessions for all patients was determined. carried over into words, such as mamma, marry, many, maybe,
Additional research into the average number of treatment marble. This method was used to transition voice with gar-
sessions necessary for varying pathologies and patterns of gling into voice without gargling and on into a more natural
baseline measures is underway. All treatment sessions were pattern of voice use. The focus was not about nasal sounds
conducted by the first author, who was, at the time, a doc- or frontal focus as much as moving the hum, which occurred
toral student in communication sciences and disorders with a from the head roll, into speech.
focus in voice disorders and dysphagia and with about 4 years’ The cup bubble blowing exercise required the partici-
clinical experience in voice care. pant to take a clear plastic cup of water filled about two
thirds of the way up, place the mouth over the cup, and
Part I: Vocal Hygiene (Approximately 10–15 Min) tip it up until the top lip was in the water. The participant
The protocol established by Nanjundeswaran et al. drew in a breath and blew bubbles without using voice,
(2012) was used for vocal hygiene education. In Session 1, again to establish positive airflow. Bubbles were supposed
each participant completed a vocal hygiene questionnaire, to be actively popping up from the cup. This was done
which was reviewed with the participant. Participants were 10 times, and then voicing was added for 10 trials to make
then provided instructions for improving vocal hygiene a “motorboat” sound. When voicing was added, bubbles

Rangarathnam et al.: Telepractice Versus In-Person Voice Treatment 391

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 were to remain as active as they were without the voice. treatment exercise. Support staff in each center ensured
In the third step, the participant blew bubbles with voice that the camera and microphone were positioned appro-
moving freely and relaxed up and down in pitch. In the priately. Staff also provided materials needed for treatment,
fourth step, the participant began by blowing bubbles with such as a clear cup, water, and tissue papers. Information
the voice and then slowly pulled the cup away from the technology support staff were accessible for all 12 treatment
mouth. As the cup was pulled away, the participant main- sessions for each participant in case of technical difficul-
tained pursed lips and continued voicing with a relaxed, ties. There was one instance of a delayed connection during
breathy “oooh.” This step was repeated 10 times. For all the sixth session for Participant TVS022 and another in-
the trials, the clinician provided feedback on vocal quality stance of poor audio and reverberation in the first session
and perceived relaxation in the voice. for Participant TVS003. The information technology sup-
The final exercise involved stretch and flow phona- port staff resolved these issues quickly. The treatment was
tion. For this exercise, the participant took a piece of tissue delivered the same way for both in-person and telepractice
paper, separated the layers, and folded one layer in half. groups.
The tissue was held between the index and middle fingers All 14 participants completed the entire research
near the top of the tissue, and the tissue was held in front protocol. All 14 participants underwent a pretreatment
of the face hanging where the mouth is centered. In the assessment within 2 weeks of a diagnosis of MTD and a
first part of the exercise, the participant blew air into the posttreatment assessment within 5 days of completion
tissue such that the tissue moved back parallel to the floor of treatment.
for 4–5 s. This was done 10 times with breaks in between.
Then the participant began as in Step 1, blowing air into Statistical Analysis of Data
the tissue. When the tissue was parallel to the floor, the
participant added voice. The tissue was to remain parallel Acoustic measures of VTI and NHR, aerodynamic
to the floor, so the voice would be very breathy. This was measures of mean airflow during CSP and MSP tasks,
done 10 times with sufficient breaks. In Step 3, the par- aerodynamic resistance, overall severity of voice quality as
ticipant began blowing air into the tissue and voicing simul- measured by the CAPE-V, and the total Voice Handicap
taneously, ensuring it was parallel to the floor, and then Index score were subjected to separate statistical analyses
said “one” with the same easy, breathy voice. This was using SPSS Version 20. In an ideal situation, we would
repeated for numbers 2, 3, and so forth, up to 10. The have performed two-way analyses of variance for within-
fourth step was done the same way but with “H” and “WH” participant (time point) and between-participant (treat-
initiated phrases rather than words (i.e., “How are you?” ment delivery mode) variables. However, our sample size of
“What time is it?”). only seven per group would have posed threats to interpre-
Participants started with gargling and cup bubble tation of the data. The likelihood of both underpowered
blowing. As they mastered one or both of these exercises, analyses and violations of fundamental assumptions of the
they were moved into stretch and flow exercises, typically distribution of the data was high, and therefore nonpara-
in the fifth session for 13 patients and the seventh session metric analyses were performed as follows.
for one patient who took longer to master relaxation with
the former exercises. The sessions, including vocal hygiene Analysis 1: Telepractice Versus In Person
reviews and voice work, typically lasted for about 45 min. To analyze the outcome of treatment across the two
groups, a change variable was first derived. For example,
ChangeNHR was calculated by subtracting posttreatment
Telepractice Component NHR values from pretreatment NHR values (NHRPre −
A hybrid approach was used in the telepractice group; NHRPost). A change variable was similarly obtained for
that is, all the participants were evaluated in person during all acoustic, aerodynamic, auditory–perceptual, and self-
the pre- and posttreatment sessions, but treatment was perception of voice handicap measures. The change vari-
delivered using telepractice. Because the primary aim of the able of each measure was then subjected to Mann–Whitney
study was to determine the use of telepractice for a thera- U test to examine if a change in a variable as an effect of
peutic activity and because participants were not random- treatment is comparable across the two treatment delivery
ized to the groups until after initial assessment, pre- and modes.
posttreatment evaluations were carried out in person. The
treatment was delivered using a Tandberg interactive Analysis 2: Pretreatment Versus Posttreatment
video–audio unit. As noted earlier, all sessions for both The Wilcoxon signed-ranks test was performed to ex-
groups of participants were delivered by one clinician (the amine the magnitude and significance of changes in out-
first author). Care was taken to ensure a quiet environ- come measures after treatment. Actual pretreatment and
ment, and confirmation was sought from participants to posttreatment measures (and not change in a measure) were
ensure they could see and hear the clinician before each compared across the two time points. Additionally, Cohen’s
session was begun. The clinician also made sure the posi- d measures as part of effect sizes of treatment were com-
tioning of the participant was appropriate for adequate puted. Marginal means of change in outcome measures
visualization of breathing patterns, and assessment of each from before versus after treatment were also calculated.

392 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015

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 Results Pretreatment Versus Posttreatment (Across Time Points)
The Wilcoxon signed-ranks test yielded statistically
Reliability of Perceptual Voice Ratings significant improvements in the CAPE-V (clinician percep-
The data corpus was rated for vocal quality by the tion of severity; Z = 3.30, p = .001), Voice Handicap Index
second author, and 10% of the data were rerated by two (patient perception of handicap; Z = 3.17, p = .002), pre-
other speech-language pathologists (the fourth author and to posttherapy, and some aerodynamic measures: mean
another speech-language pathologist) on the basis of audio airflow during CSP (Z = 2.04, p = .04) and MSP (Z =
recordings using the CAPE-V, which in turn uses a 100-mm 2.12, p = .034), on the basis of norms reported by Zraick
visual analog scale. Pre- and posttreatment samples of et al. (2011; see Table 4). Changes in acoustic measures of
each participant’s voice were provided to each rater with NHR (Z = 1.92, p = .055) and VTI (Z = 1.78, p = .075)
order of occurrence randomized. Thus, each rater had and the aerodynamic measure of laryngeal airway resis-
two samples to listen to and rate without the knowledge of tance (Rlaw; Z = 1.01, p = .311) moved in the same di-
whether it had been obtained prior to or after treatment. rection of a therapeutic effect pre- to posttherapy (see
The .nsp files obtained from the CSL program were con- Figures 1–5) for the in-person and telepractice groups,
verted to wave files (.wav) and were presented through a demonstrating clinical improvement, but did not reach sta-
computer program (Windows 7 Media Player) through tistical significance. In addition, Cohen’s d effect sizes were
high-fidelity headphones. The judges completed voice qual- computed for each outcome measure. The effect sizes for
ity ratings in one session. Because the data are continuous, CAPE-V severity, NHR, VTI, mean airflow in CSP, mean
intraclass correlations were calculated to measure interrater airflow in MSP, Rlaw, and VHI were 1.73, 0.59, 0.82, 0.29,
reliability of ratings. Intraclass correlation values for overall 0.27, 0.41 and 1.24, respectively. It is important to observe
severity were high, on the order of .92 for pretreatment that there were differences in baseline values of phonatory
samples and .84 for posttreatment samples, demonstrating a airflow measures across participants.
strong interrater reliability of ratings.

Telepractice Versus in Person (Across Groups) Discussion

The Mann–Whitney U test indicated that outcome The primary purpose of this study was to determine
measures for change in CAPE-V overall severity (U = 15, whether flow phonation treatment for primary MTD could
p = .62), change in NHR (U = 14, p = .21), change in VTI be delivered equally well via telepractice and in-person
(U = 19, p = .84), change in mean airflow for MSP (U = treatment. Results of across-groups comparison yielded no
8.5, p = .073), change in mean airflow for CSP (U = 11, significant differences, demonstrating that participants with
p = .181), change in Rlaw (U = 11, p = .181), and change primary MTD enrolled randomly in telepractice sessions
in Voice Handicap Index scores (U = 20, p = .259) did not performed similarly to participants enrolled in in-person
differ significantly between the groups (see Table 3). This treatment. It was also important to determine whether the
is further depicted in Figures 1–5, which demonstrate the treatment approaches were similarly effective or ineffective;
direction of change of marginal means in the two groups that is, it is possible that neither group improved, or both
from pretreatment to posttreatment. Graphical depictions did, or even got worse. Considering the across-groups
of the data (see Figures 1–5) indicate that effects of treat- and across–time points analyses, the quality of voicing, as
ment on both groups appear visually comparable, and most judged by the clinician (CAPE-V) and the patient’s percep-
changes posttreatment occurred in the same direction be- tion of handicap (Voice Handicap Index) improved, again,
tween in-person and telepractice groups (see Figures 1–5). irrespective of the treatment delivery mode. The majority
The one exception was mean airflow for voicing (see Fig- of participants also improved on acoustic and aerodynamic
ure 4). Mean airflow during MSP and CSP tasks increased measures regardless of the method of delivery, although
as an effect of treatment in the telepractice group and de- improvements were not statistically significant.
creased as an effect of treatment in the in-person group, These results are consistent with earlier investigations
although the change was not statistically significant. supporting the use of telepractice in delivering voice

Table 3. Results of a Mann–Whitney U test for auditory–perceptual, acoustic, aerodynamic, and quality-of-life measures across the two groups
(telepractice vs. in person).

Change in Change Change Change in mean Change in mean Change Change

CAPE-V severity in NHR in VTI airflow in CSP airflow in MSP in Rlaw in VHI

U = 15 U = 14 U = 19 U = 11 U = 8.5 U = 11 U = 20
p = .620 p = .209 p = .836 p = .181 p = .073 p = .181 p = .259

Note. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; NHR = noise-to-harmonic ratio; VTI = voice turbulence index; CSP =
comfortable sustained phonation; MSP = maximum sustained phonation; Rlaw = laryngeal resistance; VHI = Voice Handicap Index.

Rangarathnam et al.: Telepractice Versus In-Person Voice Treatment 393

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 Figure 1. Marginal means of the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) severity for the treatment groups at two time
points 1 and 2 (pre- and posttreatment, respectively).

therapy. To be specific, the results are in general agreement It is important to clarify the types of treatment used when in-
with those from studies by Mashima et al. (2003), Tindall vestigating telepractice given that telepractice is not a treat-
et al. (2008), and Constantinescu et al. (2010a, 2010b, ment but rather a method of delivering treatment. Different
2011), all of whom reported positive outcomes of delivering treatments may be more suited for telepractice than others.
voice treatment for different pathologies through telepractice. Although it may not be necessary to provide data supporting

Figure 2. Marginal means of noise-to-harmonic ratio (NHR) and voice turbulence index (VTI) from multidimensional voice profile for the
treatment groups at two time points (pre- and posttreatment). The y-axis has no units because the measures indicate a ratio.

394 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015

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 Figure 3. Marginal means for laryngeal resistance for the treatment groups at two time points (pre- and posttreatment).

every type of voice therapy for use with telepractice, a phonation exercises. The impact of the results of this study
relatively small number of studies using voice treatments could be very positive for many individuals who suffer this
have been published, and thus far, none have dealt with MTD. disorder and might not otherwise receive adequate care for
The current data support the use of telepractice for deliv- the problem. The goal of the speech-language pathologist
ering voice therapy for treating primary MTD with flow is to maximize functional abilities and promote quality of

Figure 4. Marginal means of mean airflow during comfortable (CSP) and maximum (MSP) sustained phonation for the treatment groups at
two time points (pre- and posttreatment). sec = second.

Rangarathnam et al.: Telepractice Versus In-Person Voice Treatment 395

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 Figure 5. Marginal means for ratings on the Voice Handicap Index (VHI) for the treatment groups at two time points (pre- and posttreatment).

life for individuals with communication disorders. Some in- creates a constriction of the glottis. Reducing the tension
dividuals live in rural, underserved areas far from a medi- should then open the glottis and allow for increased phona-
cal center or a health facility that offers speech pathology tory airflow. Phonatory airflow might also be increased in
services. Others have physical impairments (e.g., mo- some patients with MTD because tension, especially anterior–
bility issues) that prevent them from going somewhere to posterior tension, may inhibit glottal closure. Thus, when air-
receive treatment. Still others may have no means of trans- flow is too high, normalization would mean that it is reduced.
portation. Telepractice is one tool that may help reach such When airflow is too low normalization would mean it is in-
individuals, and the results of this study suggest that tele- creased. Phonatory airflow increased more in the telepractice
practice can, for certain disorders and treatments, be as group than the in-person group, but individuals in the in-
beneficial as treating patients for their vocal symptoms in person group started with a higher mean phonatory airflow,
person. Moreover, it can reduce or eliminate travel time indicating less of a need to increase it. The difference in this
and inconveniences associated with travel as well as costs, particular measure, therefore, does not indicate one group
and it provides a “greener” option for those who live far did better than the other but rather that the groups had some
away, with less of a negative impact on our planet. differences in the effects of putative muscle tension on the co-
The results also shed some light on specific outcomes of ordination of the respiratory and phonatory systems. This
the flow phonation exercises and why a benefit was observed. premise has been documented in studies by Higgins et al.
Phonatory airflow is often decreased when laryngeal tension (1999) and Gillespie et al. (2013), who have reported wide

Table 4. Results of a Wilcoxon signed-ranks test for auditory–perceptual, acoustic, aerodynamic, and quality-of-life measures across the two
time points (pre- and posttreatment).

CAPE-V severity NHR VTI Mean airflow in CSP Mean airflow in MSP Rlaw VHI

Z = −3.297 Z = −1.922 Z = −1.779 Z = −2.040 Z = −2.119 Z = −1.013 Z = −3.170

p = .001* p = .055** p = .075** p = .041* p = .034* p = .311 p = .002*

Note. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; NHR = noise-to-harmonic ratio; VTI = voice turbulence index; CSP =
comfortable sustained phonation; MSP = maximum sustained phonation; Rlaw = laryngeal resistance; VHI = Voice Handicap Index.
*p < .05. **Approaching significance at p < .05.

396 American Journal of Speech-Language Pathology • Vol. 24 • 386–399 • August 2015

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 variability in aerodynamic characteristics in participants with on treatment issues such as this should ensure some sort of
MTD and different aerodynamic subtypes in participants stratification on the basis of baseline severity.
with primary MTD, respectively. The fact that all patients
improved on perceptual measures of voice by the clinician as
well as self-perceived voice handicap indicate the direction Conclusions
and amount of the changes in airflow were likely beneficial. The specific aim of this study was to explore the use
This method of treatment was designed to increase airflow of telepractice in delivering flow phonation exercises for
in patients with severely limited flow of air, but our results primary MTD. MTD is one of the most common behavioral
suggest it may also be beneficial for patients with some- voice disorders seen in clinics, and data supporting the use
what greater airflow initially. A closer examination of Rlaw of telepractice for providing behavioral interventions to
could shed additional light on these findings, although dif- individuals with this form of dysphonia are scarce. These
ferences in Rlaw were present before treatment across the data support the use of telepractice to deliver this treat-
two groups in our study, limiting further interpretation. ment successfully and may improve patient care by provid-
Additional research should be conducted to determine ing treatment to underserved individuals in rural or other
whether levels of airflow and Rlaw may predict who would populations without the ability to come to medical centers
benefit most from this treatment method. where such treatment is available.
It is important to note that these findings are specific
to primary MTD alone. As noted earlier, primary MTD
is a stand-alone laryngeal tension abnormality causing Acknowledgments
changes to Rlaw and consequently airflow. The patterns of
This study was funded by the Center for Distance Health,
airflow and Rlaw impairments could be significantly differ-
University of Arkansas for Medical Sciences, Little Rock. We thank
ent in cases of secondary MTD that are concurrent with Amanda Davis for her help with the perceptual voice analysis.
another physical impairment, such as spasmodic dyspho-
nia or laryngopharyngeal reflux disorders. Therefore, the
results have to be interpreted in view of primary MTD References
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