Voice Therapy Telepractice; Voice Care For The 21st Century

Michael Towey
Fellow: American Speech Language Hearing Association
Voice & Swallowing Center of Maine
Waldo County General Hospital
Belfast, ME
Disclosures: Financial. The Voice and Swallowing Center of Maine at Waldo County General
Hospital is an accredited speech telepractice training program by the American Telemedicine
Association and has a financial interest in providing telepractice training.
Non-Financial: Michael Towey is author of Speech Telepractice in Kumar S. Cohn E.
Telerehabilitation. Springer (2012) and a Member of Executive Committee of American
Telemedicine Association Special Interest Group (Telerehabilitation).

Abstract
“America’s high schools are obsolete [. . .] designed 50 years ago to meet the needs of
another age.” – Bill Gates, National Governors’ Conference, 2005.
Obsolete and designed for another time—the same could be said for our existing health care
system, treatment approaches, and service delivery models. The emergence of outcome-based
payment by Accountable Care Organizations, severe restrictions in funding, and limited or
absent insurance coverage for voice treatment are powerful drivers for more effective voice
therapy treatment. Findings reported from the Voice and Swallowing Center of Maine
support significant cost reductions to payers when telepractice is used in voice treatment
(Towey, 2012a). This article describes three distinct applications of voice telepractice that
expands conventional thinking about voice therapy and voice therapy telepractice. It is
believed these presented cases are the first published examples that demonstrate the
efficacy of voice telepractice to: (1) assess and fit a device for a laryngectomee; (2) complete
virtual musculoskeletal assessment of a voice patient; and (3) provide virtual simultaneous
co-treatment in voice therapy.
Voice therapy telepractice, also referred to as telemedicine and telerehabilitation, has clear
advantages in meeting patient needs and improving outcomes and efficiency (American Speech-
Language-Hearing Association, 2013), and has been described as a “no brainer” (American
Telemedicine Association, 2013). There is also “ [. . .] growing evidence that telerehabilitation leads
to similar or better clinical outcomes when compared to conventional interventions” (World Health
Organization, 2011). Speech therapy telepractice offers the opportunity to transform voice therapy
using the power of an interactive, content-rich, and motivating web environment that people are
already using every day where they work, learn, and live (Towey, 2012b). Remarkably, it is estimated
that over 44 billion applications and programs will be downloaded by the year 2016 (Williams,
2013). A cursory search of online app stores identifies a number of programs that can be
implemented into voice therapy sessions (Sweeney, 2013).

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 The convergence of excellent clinical skills and voice telepractice using web-based
treatment actualizes the principles of deep practice, perceptual motor learning, patient adherence,
concordance, internal locus of control, and influencing changes that have been well described by
Titze and Verdolini (2012). The use of voice telepractice allows a change in the role of the voice
therapist. From “sage on the stage” in therapist-directed, clinic-based table top treatment to a
“guide by the side” cocreating telepractice treatment with patients, telepractice allows independent
access and completion of voice therapy techniques using smart phones, tablets, and laptops, the
results of which can be uploaded to the cloud (Cloud Computing, 2013) for patients to review and
practice using a variety of virtual tools (American Speech-Language-Hearing Association, 2012).
Speech therapy telepractice offers an emerging standard of care and improved access for
patients, as well as increased opportunities for service providers to extend their clinical skills
and reach. Voice telepractice requires strong clinical competencies and training in telepractice
competencies, including technical and procedural aspects of telepractice, virtual treatment
preparation, virtual patient engagement, management of the virtual environment, and regulatory
knowledge (Towey, 2012c). With the emergence of web-based technology, the limitations to service
delivery are primarily those that are self-imposed by the individual practitioners’ imaginations,
not the technology.
Healthcare systems continue to be ponderous and are now being shrunk by outside forces,
including funding limitations, rules and regulations, and increasing competition from retail health
and other service providers (Desjardins, 2013). With emergence of telepractice, patients are no
longer restricted to voice therapists who are locally available. Increasingly, patients will virtually
reach out in their communities, across the region, and around the world to seek the most efficient
and effective voice treatment available.
All of the voice therapy telepractice described in this article is provided using conventional
laptop computers and tablets with high-quality webcams connected to a secure web-based
telepractice platform, allowing patients to connect to the personal computers where they live,
work, and learn. The images of voice therapy telepractice treatment in this article were recorded
using commercially available screen capture and video editing software.

Case Presentations
This article presents three cases that illustrate the application of voice treatment that
was previously provided by only direct hands of clinicians, the speed that telepractice can be
implemented to provide treatment following an urgent referral, and the utilization of telepractice
technology to access additional resources and clinical expertise to support treatment.
Case #1
This case describes a 75-year-old laryngectomee 10 years postsurgery. He lives in a rural
area, has very limited means, and is unable to access care in regional or out-of-state specialty
centers. The patient communicates using an electolarynx.
The problem. The patient has been unable to use a heat moisture exchange (HME) device.
He has had multiple recurrent hospitalizations due to inability to breathe, mucous plugs, and
other related respiratory complications. There have been attempts to fit him with an HME, but due
to limited local resources, these efforts were inconsistent and ineffective. With 1.3 million people
and improved early cancer detection and organ preservation techniques, there are few laryngectomees
in rural Maine. Maine’s largest population is in southern Maine, with easier access to local healthcare
through state specialty centers. Unfortunately, patients who live in rural areas must travel for
specialty care, resulting in long and expensive travel in addition to excessive caregiver burden
(Tindall & Huebner, 2009).
The solution. Voice therapy telepractice was viewed as a good option for this patient to
allow access to a range of HME devices and expertise required to help assure product selection, fit

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 the product, and provide support to increase adherence to treatment and improve the patient’s
health. A medical supplier of HME devices was contacted to assist in this patient’s management.
Lindsey Lambert, Clinical Specialist for ATOS Medical, was contacted to provide teleconsultation
to help the treating therapist (this author) assess, fit, and maintain an HME for this patient. Note:
the teleconsultant provided direct consultation to the licensed treating therapist and did not engage
in any therapeutic treatment or decision-making directly with the patient. Although there have been
published studies about the assessment of swallow function post laryngectomee via telemedicine
(Ward et al., 2007), we believe that this is the first published report of fitting an HME device via
telemedicine/telepractice.
The procedure. Utilizing the Voice & Swallowing Center of Maine’s secure telepractice
platform, the teleconsultant was coached in the proper telepractice connection procedures and
screen management strategies necessary to complete a consultation from her office in New York
City, 400 miles away. Prior to the consultation, the teleconsultant provided a variety of HME
samples to the treating therapist. The treating therapist was trained and experienced in both
telepractice and voice treatment. The treating therapist had never previously fitted or placed a
similar HME device. During the initial telepractice visit, the teleconsultant advised the treating
therapist on the proper evaluation of the stoma size and shape, commenting at one point, “I can
see hairs in the stoma. It’s a great picture,” (see Figure 1).

Figure 1. Teleconsultant, 400 Miles Away, Sees the Patient on her Screen in a Full-Screen Size.

The treating therapist was coached by the teleconsultant in the selection, preparation, and
insertion of a lary tube. The teleconsultation was complete in 42 minutes. During the telepractice
session, it was evident that the teleconsultant was able to fully engage with the treating therapist
and provide detailed analysis. As shown in the Figure 2, the treating therapist manipulated a
cotton-tipped applicator to illustrate the fit of the device. The treating therapist was able to advise
the teleconsultant on the fit and distance between the stoma sidewall and the tube.

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 Figure 2. The Treating Therapist is Advised by the Teleconsultant on how to Assess the Fit and Size
of Lary Button. The Teleconsultant Can Clearly See the Device in the Stoma and Advice on the Seal
and Fit.

Outcomes. Unfortunately, this patient did not tolerate the lary tube. A second telepractice
visit was promptly scheduled. During the second visit, the treating therapist was coached by the
teleconsultant to assess the patient for fitting an adhesive base plate and HME cassette. In
Figure 3, the teleconsultant advised about proper skin preparation and in Figure 4, the correct
placement of the adhesive baseplate and successful application of the HME device.

Figure 3. Teleconsultant Advises Treating Therapist About Proper Skin Preparation.

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 Figure 4. Teleconsultant Advises and Coaches Treating Therapist About Correct Placement of the
Adhesive Baseplate Over the Stoma.

Results. The HME device was successfully fitted and well tolerated by the patient. The
patient continued utilizing the HME 3 months following the telepractice consultation.
Case #2
This case describes voice treatment for a +30-year-old female vocal performer, referred
specifically for telepractice following a voice evaluation at an out-of-state specialty center. This
case illustrates the efficacy of speech telepractice to:
 rapidly deliver services to patient requiring urgent treatment,
 rapidly deliver services to patients who are unable to access therapy, and
 quickly and efficiently bring access specialized resources to support treatment not
otherwise available in a clinical tabletop in the setting.
The problem. The patient was seen for a voice evaluation due to hoarseness, vocal fatigue,
and loss of upper register. Evaluation identified bilateral vocal fold lesions, with the possibility of a
cyst. The patient’s home is not in the United States. She was performing for 8 weeks (two shows
weekly) at a resort location in southern Maine. She did not have access to transportation to travel
to receive voice therapy.
The procedure. Referral for telemedicine voice treatment was received at 10:00 a.m. on a
Friday morning and by 1:00 p.m. that same day, the patient was connected for an initial voice
telemedicine treatment. The patient was scheduled to perform that evening at a local club. The
patient completed her performance following the initial telepractice treatment and was seen again
the next day (Saturday) for additional follow-up telepractice treatment to support her vocal
performance. She progressed in both improved speaking and performance voice use. The patient
was seen for a total of five telepractice treatments over a 3 week period to support her speaking
voice use and vocal performance schedule.
During one telepractice treatment visit (a Saturday at 10:00 a.m.) the patient had become
increasingly distressed and “scared” about her voice and her career. The treating therapist
recognized that the patient needed additional support and a higher level of vocal training.
Immediately following that appointment, the treating therapist contacted a singing voice specialist,
Mary Klimek, an Estill trained specialist. The singing voice specialist agreed to meet with the
patient via telepractice at 1:00 p.m. that same day. The treating therapist contacted the patient
and rescheduled a telemedicine session with the singing voice specialist. The patient successfully
stabilized her voice and remarked that her singing voice was much improved and that vocal pain
was gone. She successfully completed her performance that night and subsequent performances
to fulfill her contract (Figure 5). Note: The singing voice specialist limited her interaction with the

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 singer to Estill vocal performance techniques and did not engage in any therapeutic treatment,
diagnosis, or clinical decision-making with the patient.

Figure 5. Treating Therapist, Singing Voice Specialist and Patient all Online. Patient Comment,
“My Voice Feels Great, There is no Pain and I Can Get the High Notes Without Going Into my Other
Voice.”

Outcome. The patient completed all her scheduled performances, with no cancellations
and improved voice and vocal performance. She has gone on to tour clubs in North America and
Mexico. She will be receiving otolaryngological follow up when she returns to her home in
November. She provided the treating therapist with an autographed copy of her latest CD.
Case #3
This case describes s voice assessment using laryngeal manipulation (Rubin, Lieberman, &
Harris, 2000) applied virtually in voice therapy telepractice treatment. Published studies in the
physical therapy literature report positive results for the diagnosis of musculoskeletal disorders by
telerehabilitation. Results of this research indicate the diagnosis for musculoskeletal disorders
was just as accurate via telemedicine as it would have been if conducted in a clinic with a “hands-on”
physical therapist (Russell, 2013; Steele, Lade, McKenzie, & Russell, 2012). It seemed as if
telerehabilitation could be successful in diagnosis of musculoskeletal disorders, certainly those
principles could be applied to circumlaryngeal palpation and assessment of laryngeal muscle tone
and tightness in voice telepractice.
The problem. A 42-year-old computer programmer and professional speaker from Africa
was unable to locate voice treatment in his country. The patient contacted the Voice & Swallowing
Center of Maine via Google search, seeking voice therapy telepractice. He complained of “two
voices,” vocal strain, effort, hoarseness, and work-affected dysphonia. He had a medical review
with no abnormal laryngeal findings. Note: There is no licensing or registration of speech-language
pathologists or logopedists in this patient’s country.
The solution. The patient was contacted via e-mail. A description of the services available
and cost was provided. After several e-mail exchanges, an initial voice therapy telepractice session
was scheduled and completed. In the initial session, the patient was instructed in identification
of laryngeal landmarks for circumlaryngeal palpation. As he manipulated his laryngeal structure,
he was guided in describing his findings (Figure 6).

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 Figure 6. Patient Completes Self-Examination Circumlaryngeal Palpation and Reports Results to
Voice Therapist More Than 8000 Miles Away to Assist in Voice Diagnosis and Treatment.

Outcomes. The patient identified left posterior hyoid pain and “a clicking sound” when
he perturbated his larynx. This provided valuable treatment information for identifying likely
puberphonia/muscle tension dysphonia. His voice was returned to normal at the end of the
53-minute voice telepractice session.

Conclusion
The cases presented in this article identify the emergence of voice therapy telepractice as a
game changer and force multiplier for voice therapists and voice patients. Clearly, telepractice
marries well to voice therapy. Voice therapy telepractice, in the hands of a trained, skilled
telepractitioner, allows for cost-effective treatment, reduced travel and health care costs, and
reduced caregiver burden, while providing high-quality voice therapy choices for individuals where
they work, live, and learn. Beyond the obvious immediate benefits of voice telepractice, one can
only recall the words of Wayne Gretzky, perhaps the greatest hockey player of all time. When
asked what made him so great, he replied “I skate to where the puck is going to be” (Mindes,
2013). Excuse me while I lace on my skates and head out for the rink.
Comments/questions about this article? Visit SIG 3’s ASHA Community and join the discussion!

References
American Speech-Language-Hearing Association. (2012). Online buyers guide. Retrieved from http://
buyersguide.asha.org/Listing/Index/Augmentative__Alternative_Communication_-_Software/
Speech_Therapy_Apps/1685/1102175
American Speech-Language-Hearing Association. (2013). Telepractice. Retrieved from http://www.asha.org/
Practice-Portal/Professional-Issues/Telepractice/
American Telemedicine Association. (2013). What is telemedicine? Retrieved from http://www.
americantelemed.org/learn
Cloud Computing. (2013). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Cloud_computing
Desjardins, D. (2013). Telemedicine is retail health clinics’ newest tool. Health Leaders Media. Retrieved from
http://www.healthleadersmedia.com/page-1/TEC-291947/Telemedicine-is-Retail-Health-Clinics-Newest-
Tool##
Johnson, L., Adams, S., & Cummins, M. (2012). NMC horizon report: 2012 higher education edition. Austin,
TX: The New Media Consortium. Retrieved from Nikjeh.docxhttp://net.educause.edu/ir/library/pdf/
hr2012.pdf
Mindes, M. (2013, June 29). Be exceptional—Wisdom from the quotes of Wayne Gretzky [Web log post].
Retrieved from http://michaelmindes.com/wisdom-wayne-gretzky-quotes

80

Downloaded From: http://sig3perspectives.pubs.asha.org/ by a University College London User on 09/11/2017

Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
 Rubin, J., Lieberman, J., & Harris, T. (2000). Laryngeal manipulation. Otolaryngologic Clinics of North
America, 33, 1017–1034.
Russell, T. (2013, March). Diagnostic accuracy of telerehabilitation assessment in physical therapy: Results of
six trials. ATA Telerehabilitation SIG Webinar. Retrieved from http://www.americantelemed.org/events-
detail/2013/03/15/ata-telerehabilitation-sig-webinar
Steele, L., Lade, H., McKenzie, S., & Russell, T. (2012). Assessment and diagnosis of musculoskeletal
shoulder disorders over the Internet. International Journal of Telemedicine and Applications. Retrieved from
http://www.hindawi.com/journals/ijta/2012/945745/
Sweeney, S. (2013, March 1). App-titude: Vocal workouts go mobile. The ASHA Leader. Retrieved from
http://www.asha.org/Publications/leader/2013/130301/App-titude–Vocal-Workouts-Go-Mobile.htm
Tindall, L., & Huebner, R. (2009). The impact of an application of telerehabilitation technology on caregiver
burden. International Journal of Telerehabilitation, 1, 3–8.
Titze, I. R., & Verdolini, K. (2012). Vocology: The science and practice of voice habilitation. Salt Lake City, UT:
National Center for Voice and Speech.
Towey, M. (2012a). Speech therapy telepractice for vocal cord dysfunction (VCD): Mainecare (medicaid) cost
savings. International Journal of Telerehabilitation, 4, 37–40. doi:10.5195/ijt.2012.6095
Towey, M. (2012b). Speech telepractice: Installing a speech therapy upgrade for the 21st century.
International Journal of Telerehabilitation, 4, 73–78.
Towey, M. (2012c). Speech telepractice. In S. Kumar, Telerehabilitation (pp. 101–124). London, UK: Springer.
Ward, E., White, J., Russell, T., Theodoros, D., Kuhl, M., Nelson, K., & Peters, I. (2007). Assessment of
communication and swallowing function post laryngectomy: A telerehabilitation trial. Journal of
Telemedicine and Telecare, 13, Suppl 8, 88–92.
Williams, S. (2013). Telepractice: New and emerging technologies that promise change. Perspectives on
Telepractice, 3, 23–30.
World Health Organization. (2011). World report on disability. Geneva, Switzerland: World Bank Group.
Available from http://www.who.int/disabilities/world_report/2011/en/index.html

81

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