JSLHR
Research Article
Voice Therapy for Benign Voice Disorders
in the Elderly: A Randomized Controlled
Trial Comparing Telepractice and
Conventional Face-to-Face Therapy
Feng-Chuan Lin,a,b Hsin-Yu Chien,c Sheng Hwa Chen,c
Yi-Chia Kao,a,b Po-Wen Cheng,a and Chi-Te Wanga,b,d
Purpose: Previous studies have reported that voice therapy
via telepractice is useful for patients with nodules and
muscle tension dysphonia. Nevertheless, telepractice for
elderly patients with voice disorders has not yet been
investigated. We conducted this study to examine the
hypothesis that voice therapy via telepractice is not inferior
to conventional voice therapy.
Method: Eighty patients with dysphonia aged more than
55 years participated in this study from September 2016 to
June 2018. After screening the inclusion and the exclusion
criteria, 69 patients were randomized into telepractice
(33 patients) and conventional (36 patients) groups. The
outcome measurements included Voice Handicap Index-10,
videolaryngostroboscopy, maximum phonation time,
auditory-perceptual evaluation, and acoustic analysis. Paired
t test, Wilcoxon signed-ranks test, and repeated measures
analysis of variance were used to examine treatment outcomes.
Results: The diagnoses of voice disorders included atrophy
(n = 33), unilateral vocal paralysis (n = 13), muscle tension
a in Asian countries is estimated to treble. In 2017, there
Department of Otolaryngology–Head and Neck Surgery, Far Eastern
Memorial Hospital, Taipei, Taiwan
b
Department of Special Education, University of Taipei, Taipei,
Taiwan
c
Department of Audiology and Speech-Language Pathology, Asia
University, Taichung, Taiwan
d
Department of Electric Engineering, Yuan Ze University, Taoyuan,
Taiwan
Correspondence to Chi-Te Wang: drwangct@gmail.com
Editor-in-Chief: Bharath Chandrasekaran
Editor: Jack J. Jiang
Received November 27, 2019
Revision received February 19, 2020
Accepted April 3, 2020
https://doi.org/10.1044/2020_JSLHR-19-00364
2132 Journal of Speech, Language, and Hearing Research • Vol. 63 • 2132–2140 • July 2020 • Copyright © 2020 American Speech-Language-Hearing Association
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dysphonia (n = 7), nodules (n = 6), and polyps (n = 10).
No significant differences were observed in age, sex, and
baseline measurements between the two groups. Twenty-
five patients in the telepractice group and 24 patients in the
control group completed at least four weekly sessions.
Significant improvements were observed for all the outcome
measures (p < .05) in both groups. Improvements in Voice
Handicap Index-10 in the telepractice group (24.84 ± 5.49 to
16.80 ± 8.94) were comparable to those in the conventional
group (22.17 ± 7.29 to 13.46 ± 9.95, p = .764). Other
parameters also showed comparable improvements between
the two groups without statistically significant differences.
Conclusions: This is the first randomized controlled trial
comparing telepractice and conventional voice therapy in
elderly patients with voice disorders. The results showed that
the effectiveness of voice therapy via telepractice was not
inferior to that of conventional voice therapy, indicating that
telepractice can be used as an alternative to provide voice
care for elderly patients with vocal disorders.
T
he number of elderly people in the world is in-
creasing rapidly. According to the World Health
Organization, the global elderly population (aged
more than 65 years) was about 400 million in 1998. By
2025, it is estimated to double, and the elderly population
were 3.3 million nationals in Taiwan over the age of 65 years,
accounting for more than 14% of the total population.
By 2025, this figure is estimated to account for more than
20% of the total population. Voice disorders are one of
the commonest health issues in the elderly (Çiyiltepe &
Şenkal, 2017). The estimated incidence of voice disorders
in the elderly ranges from 12% to 35% (Çiyiltepe & Şenkal,
2017; Pontes et al., 2005), with a rising trend in recent years
(Yamauchi et al., 2014). Elderly individuals with voice
Disclosure: This study was presented during the 31st World Congress of the
International Association of Logopedics and Phoniatrics held in Taipei, Taiwan,
on August 18–22, 2019.
 disorders frequently require hospital visits and subsequent
medical intervention (Gregory et al., 2012; Lortie et al.,
2015; Verdonck-de Leeuw & Mahieu, 2004), accounting for
a considerable amount of health care expenditure and so-
cial welfare resources (Verdolini & Ramig, 2001).
The aging process of the larynx covers a wide spec-
trum including calcification of cartilage, muscle atrophy,
and altered histologic characteristics of the lamina propria
(Boone et al., 2013; Gregory et al., 2012; Kendall, 2007).
Moreover, degeneration of the respiratory system may cause
insufficient breathing support (Lundy et al., 1998; Takano
et al., 2010). Common symptoms of voice disorders in the
elderly include narrow pitch change, reduced volume,
and vocal fatigue (Çiyiltepe & Şenkal, 2017). These prob-
lems not only limit the ability of these patients to communi-
cate but also result in social withdrawal, anxiety, emotional
depression, and decreased quality of life (Gregory et al.,
2012; Lortie et al., 2015; Verdonck-de Leeuw & Mahieu,
2004).
Voice therapy is mostly recognized as the first-line
treatment for voice disorders with well-documented effec-
tiveness (Boone et al., 2013; Stemple et al., 2014). Com-
mon indications for voice therapy include muscular tension
dysphonia (MTD), nodules, and polyps (Chen et al., 2007,
2003; Lee et al., 2017; Salturk et al., 2019). Other studies
suggest that voice therapy might improve vocal fold clo-
sure in cases of unilateral vocal fold paralysis (UVFP; El-
Banna & Youssef, 2014; Schindler et al., 2008). Recent
studies also reported that voice therapy could effectively de-
crease the voice problems caused by vocal atrophy (Çiyil-
tepe & Şenkal, 2017; Gorman et al., 2008; Mau et al., 2010;
Sauder et al., 2010; Ziegler et al., 2014).
It is well known that the effectiveness of voice therapy
is closely related to patient adherence (Duarte de Almeida
et al., 2013; Portone et al., 2008). According to a previous
study, 47% of patients were unable to participate in voice
training and 65% of the participants failed to complete
the entire treatment course (Hapner et al., 2009). For indi-
viduals who have to work long hours, or who live in sub-
urban areas, routine hospital visits for regular therapy
sessions are challenging (Fu et al., 2015). These facts could
be responsible for early dropout before treatment comple-
tion (Hapner et al., 2009).
To maximize treatment adherence, telepractice was
proposed as an effective alternative modality to deliver
voice therapy and overcome inconvenient access to medical
services or facilities. Recent research has indicated that
providing telemedicine through telecommunication tech-
nology can effectively reduce participation thresholds, in-
crease motivation for participation, and enhance learning
or care outcomes (Keck & Doarn, 2014). Constantinescu
et al. (2011) reported a series of 34 individuals with Par-
kinson’s disease treated with the Lee Silverman Voice Treat-
ment via telepractice. Fu et al. (2015) conducted a pilot study
including 10 women with vocal nodules, who received
3 weeks of intensive telepractice. Both studies demon-
strated the practicability and effectiveness of voice ther-
apy via telepractice. In this study, we further expand the
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research scope to elderly people with voice disorders, for
whom telepractice may be even more helpful, considering
the physical disability and medical comorbidity of the el-
derly. We designed a prospective randomized controlled
trial to examine the study hypothesis that voice therapy
via telepractice is not inferior to conventional (face-to-face)
treatment for the elderly with voice disorders.
Method
Participants
Between September 2016 and June 2018, we invited
80 patients aged 55 years or older to participate in this
study (Mau et al., 2010). All of these patients visited the
voice clinic of a tertiary teaching hospital. The eligibility
criteria included (a) Voice Handicap Index-10 (VHI-10)
score > 10 points, (b) no mental disorders, and (c) accessi-
bility to a network connection. Six patients were excluded
due to VHI-10 scores ≤ 10 points. Five patients declined
to participate. Finally, 69 patients were randomly assigned
to the telepractice group (experimental group) or the con-
ventional group (control group) using sealed envelopes
and permuted block randomization of sizes 4 or 6. Diag-
noses were based on videolaryngostroboscopy (VLS), in-
cluding 33 cases of vocal atrophy, six cases of nodules,
10 cases of polyps, 13 cases of UVFP, and seven cases of
MTD. Table 1 demonstrates the comparison of baseline
demographics between the telepractice and conventional
groups.
Intervention
The study protocol was approved by the Research
Ethics Review Committee of the Far Eastern Memorial
Hospital (FEMH–104193–E) and was registered online (No:
NCT02922309, clinicaltrials.gov). Voice therapy sessions
were conducted by the senior therapist (F.-C. L.), who had
more than 10 years of experience in voice therapy. All par-
ticipants were scheduled for individual voice therapy. For
patients in the conventional group, voice therapy was de-
livered in a therapy room. For patients in the telepractice
group, voice therapy was delivered using a social media
app (Line; LINE Corporation). The therapist used a high-
definition 720p video camera (Logitech C310; Logitech In-
ternational S.A.) with a lavalier microphone (AT9901;
Audio-Technica) and an earphone in the therapy room,
whereas most of the patients used their own mobile phones
at home. We tested the Internet connection before the first
session of each patient receiving telepractice.
We applied the same predefined treatment protocol
for both the telepractice and conventional groups (see
Table 2), which included (a) Session 1: education about the
concept of vocal hygiene and the mechanism of phonation,
(b) Sessions 2–4: semi-occlusive vocal tract exercises
(Simberg & Laine, 2007) and vocal function exercises
(VFE; Stemple et al., 2014), and (c) sessions 5–8: Resonant
Voice Therapy (Stemple et al., 2014). Other treatment strat-
egies such as pushing exercises were delivered based on the
Lin et al.: Voice Therapy via Telepractice for the Elderly 2133
 Table 1. Demographics of the enrolled patients in the two treatment
individual needs of the patients (e.g., UVFP). Both groups
groups.
received one therapy session per week, lasting for 30–45 min,
Telepractice Conventional
with continual self-practice at home after each session. We
p provided the same printed handout to all the patients of
Characteristic (N = 33) (N = 36) value the two groups, including useful illustrations and materials
for the patients to practice at home (e.g., pearls of vocal
Diagnosis .74*
Nodules 3 3 hygiene, four steps of VFE; words, phrases, and sen-
Polyp 3 7 tences of Resonant Voice Therapy), and a self-filling
Atrophy 18 15 sheet for completion of homework and feedback. During
UVFP 6 7 the process, once the patients could accurately repeat the
MTD 3 4
Age therapy technique by themselves, treatment then moved
M ± SD 66 ± 5.9 69 ± 6.9 .06** to the next therapy technique. We also guided all the pa-
Min ~ Max 57 ~ 82 58 ~ 81 tients through the hierarchy with carryover into running
Sex .12* speech.
Female 14 19
Male 19 17
Baseline measurement
MPT 9.13 ± 4.64 8.36 ± 4.87 .51** Evaluation
VHI-10 23.97 ± 5.51 21.21 ± 7.36 .11** The primary outcome was VHI-10, whereas second-
G 1.88 ± 0.65 1.83 ± 0.74 .98***
R 0.75 ± 0.75 1.06 ± 0.63 .10***
ary outcomes included auditory-perceptual evaluation
B 1.72 ± 0.62 1.46 ± 0.81 .43*** (Grade of hoarseness, Rough, Breathy, Asthenia, Strain
A 0.78 ± 0.82 0.69 ± 0.71 1.00*** scale; Hirano, 1981), acoustic analysis, maximum pho-
S 0.25 ± 0.43 0.34 ± 0.47 .44*** nation time (MPT), and VLS exams. We recorded voice
Jitter (%) 3.11 ± 2.70 3.58 ± 2.75 .49**
samples of sustained vowel /a/ and reading a standard
Shimmer (dB) 0.62 ± 0.38 0.81 ± 0.51 .09**
NHR 0.21 ± 0.14 0.22 ± 0.12 .68** Mandarin passage (Chen, 1996) at a comfortable loudness
CPPs 3.69 ± 1.25 3.88 ± 1.77 .62** level, using a unidirectional microphone (SM58; Shure)
in a quiet room with a background noise level < 50 dB.
Note. UVFP = unilateral vocal fold paralysis; MTD = muscular
tension dysphonia; NHR = noise-to-harmonic ratio; CPPs = smoothed
The microphone was held at a distance of 10 cm from the
cepstral peak prominence. mouth. The middle 3-s segment of sustained vowel /a/ was
*p < .05, chi-square test. **p < .05, independent t test. ***p < .05, selected for measuring jitter (%), shimmer (dB), and noise-
Wilcoxon signed-ranks test. to-harmonic ratio using a computerized multidimensional
voice program (Model 5105; PANTEX Medical). The voice

Table 2. Summary of the treatment protocol for each type of voice disorders.

Diagnosis Topic Homework

Nodules, polyp, MTD

Session 1 Vocal hygiene Reading a handout of vocal hygiene
Sessions 2–4 VFE + SOVT VFE: 4 times/day
SOVT: 2 times of 5–10 min practice/day
Sessions 5–8 RVT VFE: 2 times/day
SOVT: 2 times of 5–10 min practice/day
RVT: 2 times of 10 min practice/day
Atrophy
Session 1 Vocal hygiene Reading a handout of vocal hygiene
Sessions 2–4 VFE + SOVT VFE: 4 times/day
SOVT: 2 times of 5–10 min practice/day
Sessions 5–8 RVT VFE: 4 times/day
SOVT: 2 times of 5–10 min practice/day
RVT: 2 times of 10 min practice/day
UVFP
Session 1 Vocal hygiene Reading a handout of vocal hygiene
Sessions 2–4 VFE + SOVT + Pushing exercise VFE: 4 times/day
SOVT: 2 times of 5–10 min practice/day
Pushing: 2 times of 10 min practice/day
Sessions 5–8 RVT VFE: 4 times/day
SOVT: 2 times of 5–10 min practice / day
RVT: 2 times of 10 min practice/day

Note. MTD = muscular tension dysphonia; VFE = vocal function exercises; SOVT = semi-occlusive
vocal tract exercises; RVT = Resonant Voice Therapy; UVFP = unilateral vocal fold paralysis.

2134 Journal of Speech, Language, and Hearing Research • Vol. 63 • 2132–2140 • July 2020

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 sample of reading passage (8–12 s) was applied for the mea-
surement of smoothed cepstral peak prominence (ADSV,
Model 5109; PANTEX Medical). The same voice sample
of reading passage was used for auditory-perceptual evalu-
ation by a blinded rater not involved in the treatment or
the data analysis, who had more than 3 years of experience
in voice therapy. We used the GRBAS scale to rate voice
quality, which was scored as 0 (normal ), 1 (slightly devi-
ated ), 2 (moderately deviated ), or 3 (extremely deviated ;
Hirano, 1981). MPT was measured by instructing each pa-
tient to produce a sustained vowel /a/ for as long as possible
at a comfortable loudness and pitch. The longest record
among the three consecutive trials was selected for the
analysis. For VLS exams, we rated the vibration of mucosal
wave as follows: 0 (normal ), 1 (mildly decreased ), 2 (se-
verely decreased), and 3 (absent ; Hsu et al., 2019). We also
analyzed glottic closure by measuring the normalized glottal
gap area using the following equation: [maximally closed
glottic area/the square of vocal fold length] ×100 (Wang
et al., 2015; Image J software, Wayne Rasband, National
Institutes of Health). All the aforementioned measurements
were conducted before treatment (after signing informed
consent, prior to randomization) and within 2 weeks after
the completion of voice therapy.
Statistical Analysis
Based on our clinical experience, voice therapy can
result in an average decrease of 8 points in VHI-10 (un-
published results). According to the literature, the minimal
clinically important difference in VHI-10 is 4 points (Hsu
et al., 2017; Young et al., 2018). Therefore, telepractice
should have an improvement of at least 5 points in VHI-10
to be considered comparable (not inferior) to conventional
voice therapy. Accordingly, we calculated that 50 patients
(1:1 allocation, 25 patients in each group) were required to
achieve 80% power with an alpha level of .05 (G power,
Version 3.1; Faul et al., 2007).
Outcome parameters were analyzed using SPSS
Version 24 (IBM Corp.) and the level of significance was
set at a p value of .05. Treatment outcomes before and
after the voice therapy in each group were analyzed using
the paired t test and the Wilcoxon signed-ranks test. Re-
peated measures analysis of variance (ANOVA) were con-
ducted to compare the outcomes between the telepractice
and conventional groups.
Results
Figure 1 shows a flowchart outlining the patient re-
cruitment and allocation process. The telepractice group
consisted of 33 participants. Table 1 shows the distribution
of the participants’ characteristics according to diagnosis, age,
sex, and baseline measurements. No significant differences
were noted in any of these characteristics between the groups.
Out of these, three participants discontinued the interven-
tion due to unstable network connection and five partici-
pants were lost to follow-up. In the conventional group,
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36 participants were enrolled in this study with eight partic-
ipants discontinued the intervention due to traffic inconve-
nience and four participants lost. The average number of
treatment sessions were 5.5 and 5.6 in the telepractice group
and the conventional group, respectively.
Table 3 shows significant improvements in all mea-
sured parameters including VHI-10, MPT, auditory-
perceptual evaluation, and acoustic analysis in patients who
received voice therapy via telepractice ( p < .05, paired
t test and Wilcoxon signed-ranks test). In patients who re-
ceived conventional voice therapy, significant improvements
were also noted in VHI-10, MPT, auditory-perceptual eval-
uation, and acoustic analysis ( p < .05, see Table 4).
Subsequent analyses were conducted to compare the
improvements following telepractice and conventional
therapy. Figure 2 shows that the VHI-10 score decreased
by 8.25 points in the telepractice group, while decreasing
by 8.87 points in the conventional group. Further investiga-
tion did not show a significant difference in VHI-10 im-
provement between the two groups ( p = .764, repeated
measures ANOVA). Similarly, changes in the values of
MPT, GRBAS, jitter, shimmer, noise-to-harmonic ratio, and
cepstral peak prominence did not show significant differ-
ences between the two groups ( p > .05, repeated measures
ANOVA; see Figures 3 and 4).
VLS exams of the patients receiving telepractice
showed severely and mildly decreased mucosal waves in
10 and 15 patients, respectively (see Figure 5). After voice
treatment via telepractice, 17 patients receiving VLS exams
revealed mildly decreased mucosal wave in 11 patients,
whereas six patients returned to normal (see Figure 5). In
the conventional group, VLS exam revealed severely and
mildly decreased mucosal wave in 11 and 13 patients, respec-
tively, before treatment. After conventional voice therapy,
available VLS results showed mildly decreased mucosal
wave in 10 patients, whereas five patients returned to nor-
mal (see Figure 5). The results also showed significantly
decreased normalized glottal gap area in both groups (see
Tables 3 and 4), indicating better glottic closure after voice
therapy via telepractice or conventional method.
Discussion
In the modern aging society, voice disorders in the
elderly are one of the most common problems for speech-
language pathologists (Shingo Takano et al., 2010). Previ-
ous studies have well demonstrated that voice therapy is
effective for the treatment of voice disorders in the elderly.
Gorman et al. (2008) used VFE in 19 elderly patients. Af-
ter 6 weeks of treatment sessions, they found that MPT,
subglottal pressure, and resonance of voice all increased
significantly. The authors concluded that, after training,
patients showed better vocal fold closure and greater dis-
tance of voice transmission. Sauder et al. (2010) trained nine
elderly patients with voice disorders by weekly 60-min
sessions for 6 weeks. The results showed that breathy and
strained voice characteristics, the severity of self-reported
voice quality, and the degree of vocal effort all reduced
Lin et al.: Voice Therapy via Telepractice for the Elderly 2135
 Figure 1. Flow diagram outlining patient recruitment, random allocation, and treatment progress. VHI-10 = Voice
Handicap Index-10.

significantly. Tay et al. (2012) applied voice therapy for el-
derly singers. After treatment, roughness decreased, MPT
increased, and acoustic parameters were significantly im-
proved. Despite this persuading evidence showing that voice
therapy was helpful for the treatment of voice disorders
in the elderly, adherence can significantly affect treatment
outcomes (Duarte de Almeida et al., 2013; Henriques et al.,
2012; Nesello et al., 2016; Portone et al., 2008). Key factors
influencing adherence of therapy include travelling distance
and physical impairment (Grillo, 2017; Mohan et al., 2017).

Table 3. Outcome measurements in the 25 patients before and Table 4. Outcome measurements in the 24 patients before and
after voice therapy via telepractice. after voice therapy via conventional method.

Telepractice Group (N = 25) Conventional Group (N = 24)

Pre-VT Post-VT p Pre-VT Post-VT p
Variable M ± SD M ± SD value Variable M ± SD M ± SD value

VHI-10 24.84 ± 5.49 16.80 ± 8.94 < .01* VHI-10 22.17 ± 7.29 13.46 ± 9.95 < .01*
MPT 8.55 ± 4.09 9.83 ± 3.20 .01* MPT 8.20 ± 5.47 10.15 ± 5.85 < .01*
G 1.92 ± 0.69 1.52 ± 0.75 < .01** G 1.96 ± 0.79 1.67 ± 0.75 .02**
R 0.80 ± 0.80 0.52 ± 0.75 .02** R 1.08 ± 0.70 0.83 ± 0.75 .03**
B 1.72 ± 0.66 1.32 ± 0.55 < .01** B 1.63 ± 0.81 1.33 ± 0.75 < .01**
A 0.88 ± 0.86 0.40 ± 0.49 < .01** A 0.88 ± 0.73 0.42 ± 0.70 < .01**
S 0.16 ± 0.37 0.00 ± 0.00 < .05** S 0.38 ± 0.48 0.21 ± 0.41 < .05**
Jitter (%) 3.15 ± 2.91 1.73 ± 1.16 .01* Jitter (%) 3.67 ± 3.11 2.63 ± 2.01 .03*
Shimmer (dB) 0.58 ± 0.32 0.44 ± 0.17 .01* Shimmer (dB) 0.81 ± 0.44 0.67 ± 0.53 < .01*
NHR 0.22 ± 0.15 0.14 ± 0.03 .01* NHR 0.23 ± 0.13 0.19 ± 0.09 < .01*
CPPs 3.75 ± 1.20 4.39 ± 1.30 .01* CPPs 3.52 ± 1.40 4.32 ± 1.47 .01*
NGGA 1.45 ± 1.28 0.73 ± 0.84 .03** NGGA 1.13 ± 1.08 0.91 ± 1.17 .04**

Note. Boldface data indicate statistical significance (p < .05). VT =
Voice Therapy; VHI-10 = Voice Handicap Index-10; MPT = maximum
phonation time; NHR = noise-to-harmonic ratio; CPPs = smoothed
cepstral peak prominence; NGGA = normalized glottal gap area.
*p < .05, paired t test. **p < .05, Wilcoxon signed-ranks test.
Note. Boldface data indicate statistical significance (p < .05). VT =
Voice Therapy; VHI-10 = Voice Handicap Index-10; MPT = maximum
phonation time; NHR = noise-to-harmonic ratio; CPPs = smoothed
cepstral peak prominence; NGGA = normalized glottal gap area.
*p < .05, paired t test. **p < .05, Wilcoxon signed-ranks test.

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 Figure 2. Voice Handicap Index-10 (VHI-10) scores before and
after treatment in the telepractice (from 24.84 to 16.80 points) and
conventional groups (from 22.17 to 13.46 points). These results
were not statistically significantly different between the two groups
(p = .764, repeated measures analysis of variance).
To overcome these limitations and improve adher-
ence, previous studies demonstrated positive outcomes by
delivering voice treatment via telepractice. Tindall et al.
(2008) reported significant improvement in vocal intensity
of 24 patients with Parkinsonism receiving Lee Silverman
Voice Treatment through video calling. Fu et al. (2015) in-
vestigated 10 women diagnosed with bilateral vocal fold
Figure 3. Maximum phonation time (MPT) and acoustic analysis measured before and after treatment in the telepractice and conventional
groups, which did not show a statistically significant difference. CPPs = smoothed cepstral peak prominence; NHR = noise-to-harmonic ratio.
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nodules who received voice therapy through telepractice.
The authors found significant improvements in percep-
tual parameters, vocal fold function, acoustic parameters,
physiological parameters, nodule sizes, and VHI; partici-
pants were highly positive about their first experience with
telepractice. Mashima et al. (2003) investigated 51 partici-
pants with voice disorders including nodules, vocal fold
paralysis, hyperfunction, and edema. Participants were
assigned to telepractice or conventional treatment, using a
protocol consisting of forward focus, pitch adjustment, yawn-
sigh, easy onset, open-mouth approach, pitch inflections,
and VFE. The results showed positive changes in both groups,
without significant differences in perceptual judgments of
voice quality, acoustic analyses of voice, patient satisfac-
tion ratings, and fiberoptic laryngoscopy between the two
groups. Rangarathnam et al. (2015) examined treatment
outcomes delivered through telepractice or conventional
methods in 14 patients with MTD. After 6 weeks, auditory-
perceptual evaluation and VHI all significantly improved,
without statistical differences between the two groups.
To our knowledge, no study has reported the appli-
cation of telepractice in elderly patients with voice disor-
ders. To facilitate the recruitment of sufficient patients, we
adopted a lower threshold for the elderly to participate
this study based on a study by Mau, Jacobson, and Garret
(Mau et al., 2010), in which they selected patients over
55 years old as the eligible criteria for the diagnosis of pres-
byphonia. Our results yielded significant improvements in
Lin et al.: Voice Therapy via Telepractice for the Elderly 2137
 Figure 4. Perceptual rating using Grade of hoarseness, Rough, Breathy, Asthenia, Strain (GRBAS) scales before and after treatment in the
telepractice and conventional groups.

most of the outcome parameters of both treatment groups
(see Tables 3 and 4), which in turn support our rationale
that voice therapy should be the first-line treatment for most
voice disorders of benign etiologies. Because voice therapy
itself is a continuous interaction between therapists and pa-
tients, no voice therapy session can be identical to another,
whether via telepractice or conventional approaches. Hence,
we followed the same predefined protocol for all treatment
sessions (see Table 2) to minimize potential variations for each
patient. Further analysis demonstrated that improvements
in VHI-10, auditory-perceptual evaluation, acoustic analysis,
and aerodynamic measures were not statistically different in
patients receiving telepractice or conventional face-to-face
voice therapy (see Figures 2–4). These study results suggest

Figure 5. Mucosal waves revealed on videolaryngostroboscopy exams before and after voice therapy in the telepractice and conventional
groups. (Some patients did not receive posttreatment videolaryngostroboscopy exams.)

2138 Journal of Speech, Language, and Hearing Research • Vol. 63 • 2132–2140 • July 2020

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 that voice therapy via telepractice for the elderly could result in
an outcome not inferior to that with conventional treatment.
There were some limitations in this study. First, we
recruited cases of different diagnoses (see Table 1) and ap-
plied multiple treatment strategies (see Table 2). Despite
the study results (see Table 3) supported the clinical use of
telepractice, this was certainly compromised by the lack of
control regarding disorder and treatment type. Although
the available VLS results showed the same trend of compa-
rable effectiveness between the telepractice and conventional
groups (see Figure 5), a more complete data set would
have added value to the outcome measurements. In addition,
our recorded voice samples contained only sustained vowel
/a/ and the standard reading passage. Another recording
of running speech would have better measured the true voice
quality of the patients. In the process of telepracticing,
three patients in the telepractice group discontinued the
treatment due to network instability or equipment dysfunc-
tion. For individuals who are not familiar with mobile
phones or computer, it may be difficult to solve these techni-
cal problems timely during treatment sessions. These factors
could inevitably affect the progress and the efficiency of
voice therapy via telepractice. Future studies might consider
providing ready-to-use equipment for the patients (e.g.,
laptop, cell phone, or webcam) to avoid encountering tech-
nical issues. Lastly, the importance of in-person evaluation
for diagnosis and determining candidacy prior to voice
therapy should not be understated, especially considering
that certain therapy techniques cannot be performed by
telepractice. For example, in cases where the mechanism
of dysphonia is more related to increased tension of the
neck muscles, conventional face-to-face therapy is preferred
for the delivery in-person treatment techniques such as la-
ryngeal manual therapy.
The objective of this study was to explore the use of
telepractice in delivering voice therapy to elderly individ-
uals with voice disorders. Our study revealed comparable
results between the two treatment groups, suggesting that
voice therapy delivered via telepractice is not inferior to
conventional face-to-face therapy. Future practice may im-
prove care quality by providing telepractice to patients
who are not able to visit medical facilities regularly, albeit
with the prerequisites of familiarity with computer devices
and good quality network connections.
Acknowledgments
This study was funded by the Ministry of Science and Technol-
ogy Grant 105-2410-H-468 -015 -MY3 (awarded to Sheng Hwa Chen,
Tzu-Yu Hsiao, and Chi-Te Wang) and Far Eastern Memorial
Hospital Grant FEMH-2018-C-083 (awarded to Feng-Chuan Lin
and Chi-Te Wang).
Trial Registration: clinicaltrials.gov Identifier: NCT02922309
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