Functional voice assessment and therapy methods supported by telepractice, VoiceEvalU8, and Estill Voice Training.

Abstract

Functional assessment and therapy methods are necessary for a client-centered approach that addresses the client’s vocal needs across all environments. The purpose of this article is to present the approach with the intent to encourage discussion and implementation among educators, clinicians, researchers, and students. The functional approach is defined and its importance is described within the context of the World Health Organization’s International Classification of Functioning, Disability, and Health with support provided by synchronous and asynchronous telepractice, the VoiceEvalU8 app, server, and web portal, and a framework that defines voice qualities (e.g., resonance, twang, loud, and others) by the anatomy and physiology of the voice production system (i.e., Estill Figures for Voice). Case scenarios are presented to highlight application of the functional voice approach.

WHAT IS A FUNCTIONAL APPROACH AND WHY IS IT IMPORTANT?

A functional approach for the design and implementation of care plans is client-centered addressing all the client’s needs in their environment. Such an approach is considered best practice in reversing the effects of chronic disease,^1,2 rehabilitating injuries and activities,^3,4 and is supported by the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF).⁵ The term “functional” is defined as the essential elements that are necessary to support the client’s needs in their daily activities and environments, while promoting a meaningful quality-of-life (QOL). Related to chronic disease, the medical and nutritional professional uses the functional medicine model to develop achievable client-centered assessment and healthcare goals considering the client’s environment.⁶ Related to rehabilitation, the physical and occupational therapist design functional care plans to address the physical needs of the client in their environment (i.e., walking up 15 steps from the first to the second floor)^7–9 and in daily activities completed in the client’s home (i.e., dressing in the morning, brushing teeth, using the shower, etc.).^10–12 In designing a functional communication approach, the client’s environment, which may vary across types of settings (e.g., home, school, work, etc.), communicative partners (e.g., colleagues, boss, family member, etc.), and interactions (e.g., talking over the noise, talking quietly, yelling, etc.), plays a key role.

Common sense motivates consideration of using a functional approach. For example, clients will be more likely to participate in care plans if the approach is meaningful to them and will make a difference in their QOL. Shifting from the traditional concept of reducing or eliminating the problem in only one context is replaced by emphasizing function, in which the client has the potential or capacity to achieve preferred goals or perform desired activities based on their needs and environment. A functional approach that addresses the clients’ environment will increase the likelihood that the client will continue the tasks/activities after discharge.^6–12 The following example considers the traditional concept of training the new voice in the therapy room with no attempt to generalize to other environments. A client, who is a college student, works nights and weekends as a waitress in a noisy restaurant. She reports that her customers cannot hear her over the noise and that her voice is hoarse by the end of the night. She wants to improve her voice for her job. The speech-language pathologist (SLP) trains a “resonant” voice (facilitated through humming and facial vibrations) in the quiet therapy room with no application to the noisy restaurant. The SLP did not develop a functional approach that met all the client’s needs including talking over noise in the restaurant. In a functional approach, the SLP creates a care plan that addresses all the client’s vocal needs, which may include training more than one new voice across different environments, communicative partners, and interactions.

Third-party payers now require evidence of the client’s functional improvements within reasonable time frames and within the context of the clients’ life situation.^13–16 The Joint Commission on accreditation of healthcare organizations and the Commission for Accreditation of Rehabilitation Facilities require that providers address the individualized functional needs of each person served.^17,18 As another example in education, the Individuals with Disabilities Education Act¹⁹ continues to require measurable goals and objectives for students with disabilities that are functional, with input from parents and, when appropriate, from the students. Overall, creating and implementing client-centered care plans will meet the unique needs of clients, qualify for reimbursement of services, and uphold standards of accrediting bodies and federal law.

In speech-language pathology, functional approaches have been applied to clients with cognitive disorders (i.e., dementia and traumatic brain injury)^20–25 and speech and language disorders (i.e., autism, aphasia, speech and language delays in children)^26–32 with some application to voice. In voice assessment, clients’ vocal priorities can be determined based on acoustic correlates through a 16-item Vocal Priority Questionnaire.³³ The authors suggest that the client’s preferences can then be used to create a client-specific training program that would facilitate a functional approach to meet all the client’s vocal needs. In voice therapy, training the new voice in conversation rather than a speech hierarchy facilitates a functional approach by immediately applying the new voice in typical communication interactions.^34,35 Training multiple new voices rather than just one addresses the changing vocal needs of student teachers across environments (e.g., quiet talking, talking over noise, and yelling); thereby, facilitating a functional approach.^36–38 Using a Vocal Priority Questionnaire to help design client-specific training programs,³³ training the new voice in conversation,^34,35 and training more than one new voice to meet all the vocal needs of clients^36–38 offer important examples in creating and implementing client-specific functional approaches. More work is needed to apply functional approaches to voice assessment and therapy.

Creation of functional goals and methods is a collaborative experience between the client, possibly the client’s family or caregivers, and the SLP. Often the best way to begin is to simply ask, “What would you like to learn from this assessment?” and “What are your goals for voice therapy?” Clients tend to respond with a focus on function: “I want to understand why my voice is worse later in the day,” “I want to understand why my voice is worse first thing in the morning,” “I want to return to work,” “I need to project my voice in a noisy classroom of first graders,” “I want to attend my son’s high school football game and cheer for him,” or “I want to talk with my wife without her asking me to repeat what I just said.” The answers to these interview questions, along with the Vocal Priority Questionnaire,³³ can become the starting point for creating and implementing a client-centered functional approach.

Method of delivery for assessment and therapy may offer opportunities in using a functional voice approach. For example, telepractice, audiology and speech-language pathology delivered through synchronous videoconferencing (i.e., in real-time between client and clinician) and asynchronous methods (i.e., stored and accessed later by the client and clinician independently), provides opportunities to implement the functional approach more so than in-person service delivery models. Synchronous methods of prevention, assessment, and therapy allow for an approach in the client’s environment. Through videoconferencing platforms, the clinician and the client may work together in the client’s home, work setting, or school facilitating the opportunity for direct generalization of goals and methods with typical communication partners in common communication interactions. The in-person service delivery model is limited in its ability to work across environments. Through asynchronous methods, the clinician and client may exchange information with one another outside of the typical session. That information may include completion of daily voice assessments through smartphone/tablet app technology, presentation of vocal hygiene and education content, and generalization activities using the new voices in assigned tasks through app technology and client audio recordings of speech tasks.

Considering the COVID-19 pandemic, telepractice became a necessary solution to the cancellation of in-person services due to physical or social distancing and “shelter-in-place” orders by state and local governments. Telepractice was valuable to maintain continuity of care and payment of services during the pandemic, but it was also valuable for its inherent functional nature. Centers for Medicare and Medicaid Services and some state governors (e.g., Governor Wolf of Pennsylvania) also recognized the value of telehealth and telepractice by reversing prior rules that forbid reimbursement of telehealth and by relaxing state licensure to allow licensed practitioners from other states to provide services in the state where the client resides. Even before the pandemic, the American Speech-Language-Hearing Association (ASHA) supported the development of the Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC), which will go into effect when 10 states enact the legislation. The ASLP-IC will allow clinicians to practice across state lines without needing to pursue licensure in each state.

In sum, a functional voice approach is needed to support client-centered outcomes. The following sections will present functional voice assessment and therapy methods with hypothetical case scenarios.

FUNCTIONAL VOICE ASSESSMENT

Before COVID-19, best practice involved visualization of the larynx via stroboscopy with a diagnosis provided by a physician prior to starting therapy. Laryngeal exams are being deferred due to concerns with the spread of COVID-19 through aerosolizing procedures. During the pandemic, SLPs may begin offering therapy prior to a stroboscopic evaluation and diagnosis following a careful review of the client’s medical history and results from the voice evaluation.³⁹ Typically, clients complete the voice evaluation with the SLP during one session before and after voice therapy. These two “snapshots” of the client’s vocal function are not representative of their daily vocal needs. To run a voice assessment in the client’s functional environment, new methods are needed that allow for a “landscape” view of the client’s daily vocal needs across multiple days, weeks, and even months. Recent work related to assessment and telemonitoring of voice has focused on ambulatory voice measures captured through accelerometer sensors placed on the neck.^40,41 The sensors communicate with a smartphone app to provide information on voice use through acoustic and aerodynamic measures that can be used in real-time with clients. Other work has demonstrated that VoiceEvalU8, a televoice evaluation smartphone/tablet app, Health Insurance Portability and Accountability Act (HIPAA)-compliant server, and web portal, can complete a voice evaluation remotely across acoustic, aerodynamic, and perceptual measures. VoiceEvalU8 uses the microphone within smartphones and tablets to capture audio recordings of the client for analysis of acoustic measures and the aerodynamic measures of s/z ratio and maximum phonation time (MPT). When recording the voice, the client must be in a quiet room and measure a 4 cm mouth-to-microphone distance by putting index and middle finger together. When ready to record, the fingers should be moved away to not block the acoustic signal. Prior work demonstrated no within-subject variability of acoustic voice measures across three trials recorded simultaneously from different devices (i.e., smartphones and head mounted microphone).⁴² Recent work using VoiceEvalU8 has demonstrated the in-person and telepractice Global Voice Prevention and Therapy Model (GVPTM) were successful in improving student teachers’ voices for fundamental frequency (f₀) and some acoustic perturbation measures while maintaining the improvements during student teaching.³⁸ Based on those results,^38,42 it is possible to capture within-subject voice change from pre to post and across multiple time points. Perceptual measures are also available in VoiceEvalU8 through impact on QOL (e.g., Vocal Handicap Index – 30 and 10) and vocal fatigue (e.g., Vocal Fatigue Index). These new methods involving apps were a necessity during the COVID-19 pandemic which eliminated in-person assessment and therapy methods. Using VoiceEvalU8, voice assessments can be completed asynchronously or synchronously.

Clinician case 1: Asynchronous televoice evaluations using VoiceEvalU8

Margaret is an SLP with a thriving private practice dedicated to clients with voice needs. Prior to COVID-19, her methods included only in-person voice evaluations at pre and post. When “shelter-in-place” orders were mandated by state and local governments due to COVID-19, Margaret switched to televoice evaluations using VoiceEvalU8 with Medicare and some private insurers allowing for reimbursement of CPT code 92524 (i.e., behavioral and qualitative analysis of voice and resonance) including a telehealth modifier. If using VoiceEvalU8 in-person, the SLP can bill both CPT codes 92524 and 92520 (i.e., laryngeal functional studies – acoustic and aerodynamic testing).

Margaret has a new client scheduled for her initial evaluation. She is a young working professional who is tech savvy, owns an iPhone XR, and has recently been diagnosed with muscle tension dysphonia. She complains that her voice is worse after talking all day with throat pain and fatigue increasing as the day progresses. Margaret contacts the client and asks if she would be interested in completing an televoice assessment asynchronously across multiple days in the morning and evening before the initial therapy session. The client agrees. Margaret follows up through email asking her to download the VoiceEvalU8 app to her phone and to watch short videos on the VoiceEvalU8 website on how to record her voice and answer questions in the app. In the VoiceEvalU8 web portal, Margaret adds the client as an app user and creates the logs for the next five days in the morning and in the evening. The client completes the scheduled logs. In fact, she does not miss one due to push and email reminders to complete each log session. A log session only takes 5 minutes to complete. She has made the sessions part of her morning and evening routine. Margaret billed for the evaluation using CPT code 92524 with a telehealth modifier. Before the first therapy session, Margaret has completed the evaluation report, which is reviewed with the client at the initial session. The report indicates that acoustic measures show a change in voice after talking all day. Specifically, the acoustic perturbation measures of jitter% (5%) and noise-to-harmonic ratio (NHR, 0.5 dB) are higher in the evening indicating more variability as compared to jitter% (1%) and NHR (0.01 dB) in the morning. Cepstral peak prominence (CPP, 25 dB) and smoothed CPP (9 dB) are decreased later in the day as compared to CPP (35 dB) and smoothed CPP (15 dB) in the morning indicating that her voice is not resonating as well after talking all day. The VHI-10 (25) and VFI factor 1 (35) and factor 2 (20) indicate an impact on QOL and vocal fatigue, respectively. MPT was sustained longer (24 s) earlier in the day as compared to later in the day (12 s). In sum, the five-day landscape view of acoustic, perceptual, and aerodynamic measures in the morning and evening of each day supported the client’s complaint of the voice becoming worse as the day progresses. If this evaluation was completed in-person at one time point, the clear picture of measures being worse later in the day would not have been captured. The functional application of VoiceEvalU8 to the client’s environment enabled the ability to compare morning and evening results.

Clinician case 2: Synchronous introduction to VoiceEvalU8

Steven is an SLP working for a large health system. His caseload tends to include older clients with voice disorders. Due to the pandemic, he was forced to cancel in-person sessions. He transitioned to telepractice for voice assessment and therapy. Most of his older clients are not comfortable with accessing new apps on their own; therefore, Steven plans the initial synchronous videoconferencing session to include an introduction to the VoiceEvalU8 app. Steven and his client download the app together and run through a typical log session to review recording procedures. After the initial session, the client continues to use the app for the next five days in the morning and in the evening asynchronously. The push and email alerts prompt the client to complete each log session. Steven accesses the results through the web portal and writes the report before the next session.

Clinician case 3: Asynchronous televoice monitoring of voice therapy goals using VoiceEvalU8

Betsy is an SLP who works in an outpatient clinic. Just like Margaret and Steven, she was forced to transition all in-person services to telepractice. Once her clients complete the initial voice assessment using VoiceEvalU8, she begins voice therapy. As her client progresses in therapy, she runs logs sessions asynchronously with VoiceEvalU8 to assess generalization of goals to the clients’ daily environment. Her clients report that receiving the push and email alerts twice a day reminds them to think about their voice. Betsy compares the acoustic measures captured during therapy to the baseline 5-day measures at pre. In addition, she listens to the audio recordings to perceptually evaluate her clients’ voice. Betsy is not billing these “during therapy” log sessions as an evaluation, rather she is using VoiceEvalU8 as a therapy method to determine generalization of goals. When her clients complete training, Betsy schedules post 5-day log sessions in the morning and in the evening to document change in vocal function from pre to post. At that time, she will provide a clear rationale for billing the CPT 92524 evaluation code with telehealth modifier again because the voice has changed and she needs to document the change for her clients and for insurance companies to receive payment of services.

In sum, the voice assessment evolved from an in-person snapshot in the SLP’s office at only two timepoints to a functional approach through asynchronous and synchronous telepractice using VoiceEvalU8, which provides a realistic summary of what happens to the client’s voice in their environment. In addition, VoiceEvalU8 can be used during therapy to assess generalization of training goals. Telepractice and app technology facilitated this needed transition to functional voice assessment methods.

FUNCTIONAL VOICE THERAPY

A functional approach to voice therapy relies on the WHO’s ICF⁵ to create and implement client-centered voice care plans (see Figure 1). Under Health Condition, the SLP and the client work collaboratively to determine the client’s desired outcomes through the initial interview and perhaps the Vocal Priority Questionnaire.³³ In Environment and Personal Factors, the relevant environments, settings, communication partners, and interactions for the vocal needs of the client are determined while considering the client’s personal factors (e.g., age, cultural background, gender identification, caregiver support, motivation, etc.) when creating and implementing the functional approach. Both synchronous and asynchronous telepractice will provide opportunities to address goals in the client’s environments. For Body Systems and Functions, the SLP relies on the anatomy and physiology of the voice production system to define new voice targets. For Activities and Participation, the voice assessment needs to be relevant to the client in their environment across multiple days to provide a more accurate representation of the client’s daily vocal demands. Using the anatomy and physiology of the system to define voice qualities will facilitate training of more than one new voice to meet all vocal demands across environments. Considering the functional approach, voice training should occur in connected speech tasks that the client needs for communication. Vocal exercises can be used to find the new voices, but the majority of the time should be dedicated to facilitating the new voices in speech.

Figure 1.

The World Health Organization’s International Classification of Functioning, Disability, and Health applied to a functional voice approach

Define voice qualities by anatomy and physiology of the system

When referring to therapy approaches, SLPs have used voice quality terms (e.g., resonant, loud, yawn-sigh, stretch and flow, etc.) to guide training. Using only these terms can be confusing to clients and clinicians with documented low reliability between listeners.^43–45 For example, the voice quality term of “loud” has different meanings across clinicians and voice therapy models. A loud vocal quality is achieved in Lee Silverman Voice Treatment (LSVT)⁴⁶ and in production of oral twang. Therefore, which loud voice is intended? It is not clear, if just the vocal quality term of loud is used. Fex⁴⁷ suggested that voice quality “terminology is a serious problem in need of a solution.” Kreiman and Gerratt⁴⁸ stated that the acceptance and inability to “move beyond the longstanding familiar descriptive framework” for identifying voice qualities can be viewed as a missed opportunity. Sonninen and Hurme⁴⁹ stated that the ideal voice term helps the clinician and client identify the anatomical and physiological state of the system. For 50 years, voice scientists have discussed the problem and called for a new framework.^48,50

One solution may involve Estill Voice Training (EVT), established over 40 years ago by Jo Estill.⁵¹ There are 13 Figures for Voice with corresponding conditions that have hand or physical gestures based on the anatomy and physiology of the vocal mechanism (e.g., aryepiglottic sphincter (AES) with narrow or wide conditions).⁵¹ There are also Figure Combinations for six Voice Qualities defined by the anatomy and physiology of the Figures.⁵¹ For example, oral twang is a Voice Quality defined by the 13 Figures. One might suggest that the most relevant of the 13 Figures for oral twang are AES narrow and velum high. The Figure conditions for each Voice Quality are recipes, which can change depending upon the needs of the client. Current voice quality terms can still be used, but to advance the field, the terms need to be defined using an anatomical and physiological framework (i.e., Estill Figures). For example, if one SLP prefers to use “oral twang” and another SLP prefers “loud,” both terms can be used, if the terms are further defined as AES narrow, velum high, and thick or thin true vocal fold body-cover.

The literature has indicated success in using anatomy and physiology (e.g., Estill Figures) to define voice qualities in training oral twang with patients with hypophonia,⁵² facilitating an implicit-explicit approach to voice therapy with EVT,^53,54 using EVT for developing voice quality control in contemporary commercial singers,⁵⁵ and training four new voices for vocally healthy student teachers.³⁸ In addition, the literature indicates that the Estill Voice Quality of oral twang defined by the anatomy and physiology of EVT Figures demonstrated a smaller pharyngeal area (i.e. AES narrow), elevated laryngeal height, and a closed or high velopharyngeal port as compared to the Estill Voice Quality of speech under magnetic resonance imaging (MRI).⁵⁶ With laryngeal videostroboscopy, AES narrow was seen in low- and high-pitched singing^57,58 and at average pitches.^59,60 Related to another Figure of EVT, true vocal fold body-cover and its four conditions can be distinguished from each other using acoustic and aerodynamic measures.⁶¹ In sum, voice qualities defined by anatomy and physiology have been successful in vocal training and distinguished on MRI, laryngeal videostrobosocpy, and by acoustic and aerodynamic measures.

The author’s approach to voice therapy began with the original presentation of the GVPTM which is “global” in not supporting one voice production technique or voice quality, but rather focused on stimulability to determine the techniques or qualities that facilitate the best new vocal output.⁶² In contrast, most voice therapy models in the literature are driven by one technique or quality (e.g., resonant voice in LMRVT⁶³ and clear speech in Conversation Training Therapy^34,35). Originally, the GVPTM assessed stimulability through voice quality terms only with a focus on training one new voice.⁶² Through a desire to improve client-centered outcomes, the GVPTM has evolved to a more functional approach training multiple new voices to meet clients’ vocal needs. The GVPTM facilitates changes in voice production by determining stimulability for the best “new” vocal output(s) through defining voice qualities according to the anatomy and physiology of the voice production system, a bottom-up speech hierarchy, production of “new” and “other/old” voice at each step of the hierarchy, and any additional methods that augment and support vocal output (i.e., vocal hygiene, education, etc.).^36–38

The author’s recent work was successful in using anatomy and physiology (e.g., EVT’s 13 Figures) to define and train voice quality targets.³⁸ The telepractice and in-person GVPTM trained four new voice qualities by the anatomy and physiology of the system with 82 vocally healthy student teachers. The voices trained were: 1) a new resonant voice for connected speech (i.e., defined by true vocal fold body-cover thin or thick, false vocal folds retracted, thyroid tilted, and head/neck anchored, if needed), 2) falsetto for talking quietly with a student at an f₀ that is consistent with conversational speech (i.e., defined by true vocal fold onset-offset aspirate or smooth, true vocal fold body-cover stiff or thin, and larynx mid), 3) oral twang for talking over noise (i.e., defined by false vocal folds retracted, true vocal fold body-cover thin or thick, thyroid tilted, AES narrow, and head/neck anchor, if needed), and 4) belt for healthy yelling (i.e., defined by false vocal folds retracted, true vocal fold body-cover thick, cricoid tilted, AES narrow, head/neck anchor, and torso anchor) (see Videos 1 and 2).³⁸ All the new voices were contrasted with the old voice (i.e., poor vocal output before therapy) at each step of the hierarchy (see Video 3). Week 1 involved the additional methods component of the GVPTM including vocal hygiene and education with an introduction to EVT’s 13 Figures and six Voice Qualities. Weeks 2-4 included vocal training in three 45-60 minute weekly sessions. The vocal training focused on the anatomy and physiology of the system by training the relevant EVT Figures combined to create the four voice qualities in a bottom-up speech hierarchy from word level up to conversation. Participants achieved open-ended speech tasks (e.g., monologue and conversation) for all four voices in just three 45-60 minute voice therapy sessions. The GVPTM was successful and efficient in facilitating voice changes and meeting all the vocal needs of the student teachers.

Clinician case 4: Example of using anatomy and physiology to guide voice therapy methods

Jaime, an SLP in private practice, is working with Sarah, a kindergarten teacher with benign vocal fold lesions. Her biggest concern is her voice at work. Her voice is hoarse by the end of the day and she cannot project her voice over noise. She also needs to yell on the playground and during lunch duty when she monitors the cafeteria. Using the original GVPTM,⁶² Jaime proceeds with training one new voice to help Sarah be “more resonant” (facilitated through humming and facial vibrations). The resonant voice will improve her voice for one-on-one conversation, but probably not for Sarah’s main concerns, which are talking over noise and yelling on the playground. Sarah loses interest in vocal training because she does not see how the new resonant voice will transfer to talking over noise of her classroom and yelling. She does not practice and begins missing appointments. Sarah’s vocal needs have not been addressed.

Considering the recent GVPTM,³⁸ Jaime proceeds with a training approach that meets all Sarah’s vocal needs. Sarah does need a more resonant voice for one-on-one conversation, but she also needs a new voice for talking over noise and a new voice for healthy yelling. Using the anatomy and physiology of the voice production system to guide training will make these new voices possible. Jaime defines the more resonant voice by EVTs Figures and conditions of true vocal fold onset/offset smooth, true vocal fold body-cover thick or thin, thyroid tilted, false vocal folds retracted, and perhaps head/neck anchor. In addition, Jaime trains oral twang for projecting in the classroom with AES narrow, velum high, true vocal fold body-cover thick or thin, and perhaps head/neck anchor. She also trains belt for healthy yelling on the playground and in the cafeteria by cricoid tilt, AES narrow, true vocal fold body-cover thick, head/neck anchor, and torso anchor. Jaime and Sarah can work on the relevant Figures alone and then in combinations for the voice qualities. Oral twang presents the biggest challenge for Sarah. Jaime trials different facilitator phrases (e.g., beep-beep, meep-meep, quack-quack, nyae-nyae) all on one pitch to find the best AES narrow production regardless of whether velum Figure is high or low (Video 4). As Sarah maintains AES narrow across longer speech utterances, then Jaime will help her vary pitches to sound less robotic (see Video 5). To ensure successful training, the Figures and conditions are produced with visual and verbal cues (see Video 6). The visual cues of the hand and body gestures mimic the hidden changes in the vocal tract. Gestures increase learning in speech,⁶⁴ language,⁶⁵ and other cognitive tasks⁶⁶ by decreasing cognitive load on working memory⁶⁷ and creating connections between visual and verbal areas of the brain to enhance long term behavioral change.⁶⁵ The verbal cues are the auditory productions of each Figure manipulation. The new voices are facilitated in a bottom-up treatment hierarchy in speech tasks.^38,62 As Sarah progresses through the treatment hierarchy, she produces all the voices at each step to build awareness of the voices, generalize goals/targets, and become her own clinician.^38,62 Sarah is excited to use all her new voices at work and reports that she feels more confident in her ability to project her voice in the classroom. She indicates that using oral twang immediately grabs the attention of the children and they stop, look, and listen. She reports practicing in the car on the way to work and has no problem finding and using all the new voices. Sarah indicates that she feels empowered because she is in control of her voice rather than her voice controlling her. She has the tools to be successful in her many vocal environments.

Clinician case 5: Example of using telepractice to promote voice therapy across different environments

John, an SLP, has built a successful synchronous and asynchronous voice telepratice program. For synchronous telepractice, John uses pre-made lists of phrases, sentences, memorized speech acts, specific spontaneous speech, monologue, and conversational topics (e.g., see ^38,62 for a description of the hierarchy) in Word documents that John shares with the client during sessions through the “share screen” function. These same lists can be emailed to the client for practice at home. Powerpoint slide presentations of interesting pictures are also presented to facilitate different levels of the hierarchy. John moves from shaping the new voice in one- to two-word facilitator phrases (e.g., “oh you” for thyroid tilt and false vocal folds retracted or “quack-quack” for AES narrow) into a bottom-up speech hierarchy supporting the functional approach to voice training.^38,62 In addition, John uses the chat function in the videoconferencing platform to post comments as the client is talking while using the new voices. If John wants his client to switch between voices, he will type in the chat function instead of interrupting with his voice.^36–38 The use of the Estill Figure hand/physical gesture tied to each condition is important to use during synchronous telepractice. For example, John makes sure his hands are visible and performs the hand gesture for AES narrow, while the client is talking in oral twang.

For asynchronous materials, John has created a private YouTube channel. He has placed recorded presentations of himself discussing vocal hygiene, general information about power, source, and filter, and an introduction to EVT’s Figures and Qualities. After clients complete the videos, they are prompted to take 10-question multiple choice quizzes to ensure mastery of the material through a password-protected Google Drive account. The clients may review the presentations at any time during therapy.

During synchronous sessions, when a client is demonstrating an outstanding example of the new voice, John will record locally to his computer and edit the recording down to a 30-second example. He will then share the edited video with the client via a password protected Google Drive account. The client may download the file to her device and listen to it throughout the day to remind her of what the new voice sounds like. Once the client is discharged from therapy, John will delete the recording from his computer. When John and his clients are working on generalization of training targets to outside the session, John’s clients record a conversational exchange using one or more of the new voices with one communicative partner. The client shares the recording with John via a password protected Google Drive account. John will listen to the recording and provide feedback to the client via email. The same procedure can be implemented for earlier steps of the hierarchy. For example, the client can record the new voices in sentences and share the recordings with John. John will provide feedback via email.

Telepractice inherently supports functional training methods that are immediately trialed in the client’s environment. For example, John is working with a defense attorney with a voice disorder. The attorney supports her clients by going to trial and arguing their case in the courtroom. Often, she increases the loudness of her voice to make a clear point. For three weeks, John has been working with the attorney in her home. The client has progressed well and can produce the multiple new voices to meet her daily occupational and social needs. John wants to assess generalization of the “new” voices to other environments like the courtroom. A synchronous telepractice session is conducted in a large space (i.e., conference room or ideally, the actual courtroom). The client places the webcam in the center of the room so that she can move freely around the room and use the various new voices that were trained in her opening and closing remarks, questioning a witness, and communicating with the judge and other attorneys. John role plays the Judge, other attorneys, and witnesses to offer typical communicative partners and interactions that she may encounter in the courtroom. John and the client discuss her performance and offer opportunities for continued practice and client self-monitoring throughout the session. Telepractice allows for training in the client’s functional environment to meet her needs in speech tasks.

As another example, John frequently invites a client’s typical communicative partner (e.g., family member, parent, nursing aid, friend, etc.) to attend the final 5-10 minutes of sessions, if the client grants permission. John asks his client to explain the goals of the vocal training approach to the person and demonstrate all the new voices. To continue the goal, John facilitates a discrimination task in which the client produces 10 sentences and the person needs to guess what voice was used in each sentence. The step of the hierarchy can change depending upon the step mastered in the session. John is facilitating the exchange and offering feedback.

In summary, functional voice therapy methods need to consider the WHO’s ICF framework (see Figure 1).⁵ The approach must be client-centered with clients’ desired outcomes for prevention, assessment, and therapy leading the way. Using only voice quality terms can be confusing to clients and clinicians. We need to define voice quality terms by the anatomy and physiology of the voice production system (e.g., EVT’s Figures). The anatomy and physiology of the system allows for training multiple new voices to meet the clients’ needs in their environments across settings, communicative partners, and interactions. Telepractice is the ideal method to support the functional approach by conducting assessment and therapy in the client’s environment.

CONCLUSIONS

The application of functional assessment and therapy methods have been applied to medicine, nutrition, physical and occupational therapy, and some aspects of speech-language pathology. Functional voice approaches are needed to address all the vocal needs of the client across multiple environments. Moving beyond “snapshots” of voice assessment at only pre and post to capturing a “landscape” view of voice across multiple days, weeks, and even months supports the idea of a functional voice assessment in the client’s environment. App technology provides a solution. VoiceEvalU8 is a smartphone/tablet app, HIPAA-compliant server, and web portal that offers a landscape view. Considering a client-centered approach, multiple new voices should be trained to meet all the vocal needs of the client. SLPs and clients can still use voice quality terms, but they should be defined by the anatomy and physiology of the system. EVT has been around for 40 years and it is the only available framework that applies anatomy and physiology (i.e., Figures with conditions) to voice qualities with evidence available in the literature. Telepractice allows for a functional approach in the client’s environment through both synchronous and asynchronous methods. With COVID-19, telepractice has become a necessity due to cancellation of in-person services. SLPs need to see the advantages of telepractice beyond the pandemic. Training targets can be generalized to other environments, communicative partners, and interactions. Educators, clinicians, researchers, and students need to embrace the idea of a functional voice approach. This article is meant to be the beginning of the discussion. Let’s move forward together.

Supplementary Material

Videos

Video 1. Oral twang, new resonant voice, and falsetto in monologue

Video 2. Oral twang and belt in automatic speech and phrases

Video 3. Falsetto, new resonant voice, and old voice in monologue

Video 4. Training oral twang

Video 5. Extreme oral twang vs. functional oral twang in memorized speech acts and a functional phrase

Video 6. Review of relevant Estill Voice Training Figures with gestures

Learning Outcomes

The learner will

• Define the functional approach applied to voice

• Summarize the importance of a functional voice approach

• Describe functional voice assessment and therapy methods

• Apply the functional voice approach to teaching methods, clinical practice, and research objectives

CEU Questions

1. Applying a functional voice approach to assessment and treatment will……

   1. support the desired needs of the client in their environment.
   2. support only the perspective of the speech-language pathologist in designing and implementing functional plans.
   3. not be effective because the approach is not meaningful for the client.
   4. not be supported by synchronous and synchronous telepractice methods.
   5. not include the needs of the client.
2. Define a functional voice approach.

   1. An approach that considers only one context of voice assessment and therapy in one setting.
   2. An approach that includes the essential voice assessment and therapy elements that are necessary to support the client’s needs in their daily activities and environments while promoting a meaningful quality-of-life.
   3. An approach that does not see the value of training new voices across multiple environments.
   4. An approach that captures “snapshots” of voice assessment at only pre and post timepoints.
   5. An approach that is clinician-focused.
3. VoiceEvalU8 provides…..

   1. a voice assessment through app technology at only in-person sessions.
   2. a voice assessment through app technology only through synchronous telepractice.
   3. a voice assessment through app technology that the client completes either asynchronously on the client’s own time or synchronously with the clinician either in-person or via telepractice.
   4. a voice assessment through app technology only through asynchronous telepractice.
   5. a voice assessment through typical in-person methods.
4. In the World Health Organization’s International Classification of Functioning, Disability, and Health applied to voice……

   1. The Body Functions & Structures and Activities & Participation uses anatomy and physiology of the voice productions system to identify and train multiple new voices.
   2. The Health Condition does not consider the client’s desired outcomes for assessment and therapy.
   3. The Environmental and Personal Factors do not determine all the vocal needs across environments.
   4. The Activities & Participation uses voice quality targets only to train one new voice.
   5. The Environmental and Personal Factors do not consider personal factors when creating functional care plans.
5. Telepractice…..

   1. provides only the option of synchronous videoconferencing to facilitate training goals.
   2. does not facilitate training across settings, communicative partners, and communication interactions.
   3. is an effective method only during the COVID-19 pandemic to substitute for the cancellation of in-person services.
   4. offers the ability to assess and train voice in the client’s environment through both synchronous and asynchronous methods.
   5. does not include synchronous and asynchronous options.

Biosketch

Dr. Elizabeth Grillo is a professor in the Department of Communication Sciences and Disorders at West Chester University (WC), West Chester, Pennsylvania. She is the President of VoiceEvalU8, LLC and creator of the Global Voice Prevention and Therapy Model (GVPTM). Her research has been supported by the National Institute on Deafness and Other Communication Disorders of the National Institutes of Health. In 2018, she was awarded the Certificate of Recognition for Special Contributions in Higher Education from the American Speech-Language-Hearing Association. She maintains state licenses in Pennsylvania and Delaware and the certificate of clinical competence in speech-language pathology. She is also a Certified Healthcare Simulation Educator and has achieved the certificate of Estill Figure Proficiency.