An E-Survey of Current Voice Therapy Practices Amongst Speech Language Pathologists (SLPs) in India

Abstract

In India, Speech Language Pathologists (SLPs) generally work with ENT surgeons and use a variety of treatment approaches, service delivery methods, feedback modes, and outcome measures in clinical practice while dealing with voice disorders. The practice preferences of the SLPs are based on theoretical and practical exposure during their graduate course, guidance from professional bodies, evidence-based practices, etc. The facilities in the work setting also determine the practice style of the SLP. This study reports information on demographics of the SLPs, nature of patients served, intervention methods, and evidence-based practices followed by the SLPs via an E-survey. Analysis of the survey from 55 SLPs in India, who work in the area of voice revealed that most SLPs had postgraduate (67.27%; n = 37) and doctorate degree (23.63%; n = 13) and worked in medical-related settings (81.81%; n = 45). Therapeutic approaches were practiced as stated in literature by 43.64% (n = 24) of SLPs. Although 56.36% (n = 31) of SLPs modified therapeutic approaches based on the client’s needs (75%), literacy (16.66%) and cultural variations (8.33%). Attending Continuing Education Programs and training workshops were required to practice voice. Voice therapy methods (protocols) used by the SLPs were not uniform across India. The development of an indigenous protocol/method for voice therapy is the need of the hour.

Introduction

“Vocology” is evolving as a sub-specialty in the area of speech language pathology in India [1, 2]. Voice disorders are common and have been estimated to affect about 6% of the general population [3]. Whereas, the prevalence rates of voice disorders among professional voice users range between 11 and 21% [3]. In the Indian scenario, highest prevalence rates have been reported for politicians (86%) and vendors (74%) and singers (59%) and teachers (49%) as well [4]. From a NSSO survey, among the causes of speech disability, 8% has been attributed to voice disorders [5]. Speech Language Pathologists (SLPs) are involved in assessing the nature & severity of voice problems, devising treatment plans, and providing preventive education programs for voice users [6]. Voice therapy is a conservative mode of treatment for voice disorders that enhances the client’s vocal function ability and helps resolve the laryngeal pathology.

Establishing practice guidelines or protocols is a significant milestone in the growth of the field. It is important to have well-defined and uniform clinical practice guidelines for assessment and voice therapy procedures to maintain standards of care to the patient. Evidence-based guidelines developed with appropriate standards minimizes potential errors, variability in data across clinics, and improves the quality of care [7]. This promotes consistency in providing services and the use of feasible procedures. It will assist both ENTs and SLPs in decision making and improve the efficiency of voice assessment and therapeutic protocols.

Professional guidelines and scope of practice documents provide definitions, educational requirements, roles and responsibilities, clinical services, advocacy, clinical settings, service delivery, and research in the area of speech language pathology. These are provided by professional bodies such as American Speech and Hearing Association (ASHA) for SLPs practicing in the United States [8], Speech-Language Audiology Canada (SCA) in Canada [9], Speech Pathology Australian (SPA) in Australia [10], Royal College of Speech and Language Therapists (RCSLT) in the UK [11], etc. Rehabilitation Council of India (RCI) provides such guidance and scope of practice for Indian SLPs [12]. Other professional bodies such as Laryngology and Voice Association (LVA) and Association of Phono Surgeons of India (APSI) are professional bodies of SLPs and ENT surgeons with special expertise in voice disorders and management. These associations do not provide clinical guidelines for speech therapy practices.

For more than a decade, ASHA special interest group (SIG 3) has been working on devising guidelines and protocols for voice therapy. The expert panel of SIG 3 proposed a protocol for instrumental assessment of voice as the first step to uniformity in evidence-based practice [13]. It is perceived wisdom that the Indian community of SLPs has been largely influenced [2] through the guidelines provided by ASHA, CSA, SPA, RCSLT, and European Laryngological Society (ELS) [8–11] in clinical practice.

A few studies [13–15] focusing on assessment related protocols have been done in the recent past. Collecting a representative sample data from practicing clinicians across the country will provide a database to track the trend in voice therapy [16]. It is envisaged that this information on practice methods and preferences currently prevailing in India will help understand several aspects of standard of voice care and possibly develop practice guidelines or protocols for voice therapy that may be feasible for the Indian population [16].

This article focuses on therapeutic practices followed by SLPs in the management of voice disorders. It is important for ENT surgeons, as a part of the team, to be aware of how these decisions in therapeutic practices are made.

Materials and Methodology

A 40-item questionnaire based on the current clinical practices related to voice therapy was developed. Three SLPs with a minimum of 10 years of experience specializing in the area of voice and its disorders content validated the questionnaire. The number of questions was reduced and combined to thirty based on the suggestions given by the SLPs. Items in the questionnaire were categorized as follows—demographics, nature of clientele, voice therapy practices, and clinician reflection.

Demographics comprised questions on educational qualification, city of work, work setting, and work experience in the area of voice. Clientele related questions focused on the nature of the clientele population based on their age, voice use, and voice disorders. Questions on voice therapy practices focused on the number of clients they provided therapy on a weekly basis, sources of referral, therapeutic techniques employed, modification/adaptation of techniques, mode of service delivery, methods of providing feedback, outcome measures, counseling and discharge criteria. It also had questions about laryngectomy and preferred mode of rehabilitation for the same. Questions on clinician reflection enquired about how professionals updated their knowledge and skills on current trends in voice practice, and evidence-based practice. A combination of choice-based and open-ended questions were used. Participants had to choose among four choices namely, “Most frequently”, “Frequently”, “Occasionally” and “Not at all” for Likert-type questions and they had the option of choosing multiple answers for some questions.

The questionnaire was then converted to a web version through the website –www.esurv.org and was constructed as an e-survey. The link to the survey was shared via emails and in social networks. Email addresses of practicing SLPs were collected through personal contacts, institute websites, and state chapters of ISHA. E-mails consisting of a template and the link were sent to speech and hearing professionals. The template had a brief description of the investigators, a research study, and asked for consent to participate in the survey. SLPs who consented to participate, completed the survey.

Inclusion Criteria

The criterion for analyzing the responses was kept to filter (1) SLPs with more than 2 years of experience, (2) who were currently practicing in India, and (3) completed surveys. Responses to the survey were analyzed using frequency and percentage analysis.

Of 79 responses, 7 responses were incomplete and 17 responses did not meet the inclusion criteria. Thus, responses from 55 SLPs [Males—26; Females—29: Age range: 22–66; Mean: 33.63; SD: 8.95] were analyzed.

Results

Demographics

Educational qualification of the respondents was postgraduate (67.27%; n = 37), doctorate (23.63%; n = 13), and only undergraduate (9.09%; n = 5) degrees in speech and hearing. SLPs practiced in training institute hospitals (43.63%; n = 24), hospitals (38.18%; n = 21), ENT clinics (30.9%;n = 17), SLP private practice (21.82%; n = 12), training institutes (20%; n = 11), special schools (7.27%; n = 4) and research labs (5.45%; n = 3). Table 1 illustrates the various geographical locations across India where SLPs provided services. Average years of experience in the field of vocology was 7.1 years [SD: 6.8].

Table 1.

Geographical locations of SLPs working across India

Geographical location	Number of clinicians	Percentage of clinicians (%)
South	40	72.72
North	7	12.72
West	5	9.09
East	1	1.81
Central	1	1.81
North eastern	1	1.81

Clientele

The majority of SLPs worked with the adult population (96.36%; n = 53) most frequently and occasionally with pediatrics (63.64%; n = 35) & geriatrics (45.45%; n = 25). Figure 1 depicts the nature of voice use of the clientele. SLPs have dealt with elite vocal performers (61.82%; n = 34), non-vocal professional voice users (49.09%; n = 27) and non-vocal non-professional voice users (43.64%; n = 24) occasionally and frequently with professional voice users (43.64%; n = 46). Every week, 72.73% (n = 43) of SLPs provided therapy to less than 5 patients and 16.36% (n = 9) provided therapy for 5–10 patients. 7.27% (n = 4) of SLPs dealt with 10–15 patients and only 3.64% (n = 2) of SLPs dealt with more than 15 patients in a week for therapy. The common voice disorders dealt by SLPs for voice therapy are functional voice disorders with structural changes followed by neurogenic laryngeal pathologies and others, as depicted in Table 2.

Fig. 1.

Distribution of clientele in accordance to nature of voice use

Table 2.

Common voice disorders dealt by SLPs for therapy

Voice disorders	Most frequently (%)	Frequently (%)	Occasionally (%)	Not at all (%)
Functional voice disorder with structural changes (e.g.: vocal nodules, vocal polyps, etc.)	65.45	25.45	9.09	0
Functional voice disorder without structural changes (e.g.: puberphonia, juvenile voice etc.)	18.18	36.36	36.36	9.09
Neurogenic laryngeal pathologies (e.g.: vocal fold paralysis, spasmodic dysphonia etc.)	18.18	40	38.18	3.64
Inflammatory conditions (e.g.: laryngitis, Reinke’s edema etc.)	18.18	36.36	30.91	14.55
Systemic voice disorders (e.g.: hyperthyroidism, hypothyroidism etc.)	3.64	9.09	50.91	36.36
Laryngeal cancer	9.09	20	43.64	27.27
Transgender voice problems	1.82	0	16.36	81.82

Voice Therapy Practices

Team Involved

Out of 55 SLPs, 81.82% (n = 45) of them worked most frequently with ENT/Otorhinolaryngologist, and 52.73% (n = 29) of SLPs worked occasionally with psychologists. The majority of SLPs did not have an opportunity to work with endocrinologists (54.55%; n = 30) and singing teachers/music teachers (65.45%; n = 36) (Fig. 2).

Fig. 2.

Team members involved in management of voice disorders

Techniques Used

SLPs used a combination of various approaches to treat voice disorders. Figure 3 represents the different therapeutic approaches used by clinicians for the hyperfunctional and hypofunctional voice disorders. SLPs used breathing exercises (58.18%; n = 32), Boone’s facilitation techniques (52.72%; n = 29), Vocal Function Exercises (VFE) (41.81%; n = 23) and Resonant Voice Therapy (RVT) (38.18%; n = 21) for the hyperfunctional disorders. Other techniques used for treating the same, were vocal hygiene tips (25.45%; n = 14), Semi Occluded Vocal Tract exercises (SOVT) (18.18%; n = 10), circumlaryngeal massage therapy (12.72%; n = 7), voice rest (7.27%; n = 4), humming (7.27%; n = 4), yoga & pranayama (3.63%; n = 2), confidential voice therapy (3.63%; n = 2), Lax-vox therapy (1.81%; n = 1), and endurance exercises (1.81%; n = 1). Techniques used for hypofunctional voice disorders included VFE (32.72%; n = 18), Boone’s facilitation techniques (29.09%; n = 16), push–pull exercises (27.27%; n = 15), breathing exercises (23.63%; n = 13), adductory power exercises (21.81%; n = 12) and RVT (16.36%; n = 9). Other techniques used were vocal hygiene practices (10.9%; n = 6), digital manipulation (10.9%; n = 6), head positioning (9.09%; n = 5), Lee Silverman Voice Treatment (LSVT) (7.27%; n = 4), SOVT (5.45%; n = 3), Expiratory Muscle Strength Training (EMST) (1.81%; n = 1), Phonation Resistance Training Exercise (PhoRTE) (1.81%), half swallow boom (1.81%; n = 1) and pranayama (1.81%; n = 1). About 56.36% (n = 31) of SLPs modified the existing techniques based on the client’s needs to improve better understanding of tasks/instructions and thus improve their performance, or to enhance comfort and ease of the client.

Fig. 3.

Therapeutic approaches used by SLPs

Feedback and Counseling

Study participants reported the use of auditory feedback (96.36%; n = 53) and visual feedback (72.72%; n = 40) frequently during therapy. 89.09% (n = 49) of SLPs counsel clients after every therapy session. During the counseling session, SLPs predominantly focused on vocal hygiene practices (29.03%; n = 54) and therapy outcomes/expectations (26.34%; n = 49). The need for therapy (24.19%; n = 45) and prognosis (19.89%; n = 37) were also discussed during the session.

Laryngectomy and Intervention

Around 52.73% (n = 29) of SLPs have reported encountering laryngectomee patients occasionally in a year and have reported tracheo-esophageal speech (65.45%; n = 36) to be the most preferred mode of rehabilitation followed by oesophageal speech (50.91%; n = 28).

Service Delivery

About 89.09% of SLPs followed traditional one–one methods frequently. Tele-practice (18.18%; n = 10) and intensive short-term therapy (27.27%; n = 15) were used occasionally. The use of self-instructional DVDs and group therapy was not preferred by 83.64% (n = 46) and 78.18% (n = 43) of SLPs respectively (Fig. 4). The session duration varied between 20 and 60 min [Mean: 39.4 min; SD: 9.4]. An average of three sessions/week was given over 2 to 12 weeks.

Fig. 4.

Different service delivery models used by SLPs

Outcome Measures

SLPs used both instrumental and subjective measures to monitor the outcomes of therapy (Table 3). Commonly used software for acoustic analysis (85.45%; n = 47) were free to download version PRAAT (40.42%; n = 19) [17], Dr. Speech (Tiger DRS) (31.91%; n = 15), Vaghmi (Voice and Speech System), Computerised Speech Lab (CSL) (KayPENTAX), Multi-Dimensional Voice Program (MDVP), Lingwaves (WEVOSYS). SLPs have also used laryngeal visual imaging techniques (29.09%; n = 16), aerodynamic measures (18.18%; n = 10), electroglottography (5.45%; n = 3), and electromyography (1.81%; n = 1). Among subjective measures, predominantly used perceptual tools (72.72%; n = 40) were CAPE-V [18], GRBAS [19], and Buffalo Voice Profile (BVP) [20]. Around 33% (n = 18) used self-assessment measures of voice. Majorly used self-reported measures were Voice Disorder Outcome Profile (VDOP) [21, 22], Voice Handicap Index (VHI) [23], Vocal Fatigue Index (VFI) [24, 25].

Table 3.

Outcome measures used by clinicians in therapy

Subjective measures			Instrumental measures
	Number	Percentage (%)		Number	Percentage (%)
Perceptual	40	72.72	Acoustics	47	85.45
Self-assessment	18	32.72	Visualization	16	29.09
MPT	4	7.27	Aerodynamics	10	18.18
s/z ratio	3	5.45	EGG	3	5.45
Others	4	7.27	EMG	1	1.81
None	4	7.27	None	6	10.9

Termination of Therapy

Clinicians preferred terminating therapy only when the disorder was remediated to near normal state (30.53%; n = 51). Patient variables like—unwillingness to attend therapy (14.97%; n = 25), request for discharge (14.37%); n = 24, relocation (13.17%; n = 22), irregularity (12.57%; n = 21), and lack of progress (7.18%; n = 12) seem to be the other major reasons for discontinuing/termination of therapy.

Clinician Reflection and EBP

Clinicians updated with current trends by engaging frequently in discussions with colleagues/professors (100%; n = 55), referring online resources (98.18%; n = 54) and by attending general speech and hearing conferences (91%; n = 50). SLPs also had attended specific voice conferences/symposium (41.82%; n = 23) and training workshops (43.64%; n = 24). Some SLPs attended certification programs (3.64%; n = 2) related to vocology. Of the 55 SLPs, 87.27% (n = 48) of them had indicated that they used EBP in their workplace. The resource materials used by clinicians for practicing EBP were journal articles (22.61%; n = 45), case studies (19.59%; n = 39), own clinical judgments (18.59%; n = 37), research work (16.08%; n = 32), online browsing, blogs, periodicals (12.56%; n = 25) and patient caseloads (9.55%; n = 19). About 1.01% (n = 2) of SLPs did not refer to any resource materials to follow EBP in their practice. Time constraints, lack of norms, irregular follow-ups, and insufficient manpower were listed as major barriers for practicing EBP.

Discussion

This study aimed at profiling current trends in voice therapy clinical practices followed by SLPs and also serve as baseline data for future research.

The majority of the SLPs who participated in the study had masters and doctorate degrees in speech and hearing. The amount of clinical exposure and skill training received to voice and its disorders in the undergraduate programs are very limited [26]. In this study, the participants with undergraduate degrees who worked in the area of vocology were less. Advanced training during a masters and/or a doctorate degree program possibly improved the chances of working in vocology after post-graduate degrees. This also reflected the prevailing perception towards educational requirements to practice ‘voice’ as a sub-specialty in speech language pathology. Most SLPs practiced in hospitals and hospital-based institutions. Earlier in India, the scope of practice of a SLP was predominantly restricted to a rehabilitation setup. It has now shifted from a rehabilitation model to a medical model especially in the area of voice [2]. As depicted in Fig. 2, ENT/otolaryngologists were the most involved professionals in the management of voice disorders. The multidisciplinary team approach is considered as a gold-standard in assessment and management of voice disorders as it improves patient adherence and overall outcomes [2, 27].

Functional voice disorders with/without structural (morphological) changes are commonly treated by voice therapy [28, 29]. Voice disorders due to laryngeal cancers, neuro-laryngeal pathologies are not dealt with SLPs largely as medical/surgical management is considered as the first line of treatment. Regarding the rehabilitation of laryngectomee patients, SLPs have reported tracheo-esophageal speech to be the most preferred mode of treatment and artificial larynx to be the least preferred. These findings coincide with the results of a survey done by Culton and Gerwin [30] on recent trends in laryngectomy rehabilitation. The transgender client load was very less and can be attributed to a lack of awareness among such clients and a lack of knowledge and skill training in providing services to such clients [31]. The clinician must be sensitive and should possess skills in voice and communication services, masculinization/feminization communication processes [31, 32] while working with such specialized groups. Elite professional voice users seek voice specialty clinics not only for assessments and treatments, as they prefer customized services from the SLPs [4, 33]. However, in the current study, a reduced number of elite vocal performers as clients among Indian SLP’s could indicate the need for specialized training [34], and more specialty clinics with adequate infrastructure and facility in such focused areas such as singing voice management, etc.

SLPs have expanded their modes of service delivery by providing intensive short-term therapy and teletherapy among other methods. Teletherapy enables clients to receive treatment without travel, and this has developed in areas of speech language pathology, including voice disorders [35]. Studies illustrating the efficacy between face-to-face and online therapy have been established [36–38] and SLPs in India have begun to explore the tele-therapy mode of service delivery [39]. Intensive short-term voice therapy has been established as an efficient way to manage voice disorders [40, 41]. However, group therapy options have not been considered much as its effectiveness has been rarely reported [42, 43]. Self-instructional DVDs were the least preferred mode of service delivery among the surveyed SLPs.

A variety of voice treatment approaches/techniques are available. SLPs used various therapy approaches in isolation and/or combination for the treatment of voice disorders. Modifications in techniques based on client needs, cultural sensitivities, and literacy levels should be considered due to the influence of language and cultural values in the therapeutic process [44]. Burg et al. (2015) conducted an online survey regarding the selection of voice therapy approaches among SLPs in three German-speaking countries and reported that the majority of SLPs used a combination of direct voice therapy methods [45]. Auditory feedback is used more frequently as it is easier for self-monitoring and understanding, and needs very little/no investment in monetary terms. In India, clinicians have reported using both instrumental and subjective tools to measure outcomes of voice therapy. Of the instrumental measures, acoustic analysis and visualization techniques were highly used and among subjective measures, perceptual and self-reported measures were popular. These findings conform to recommended protocols given by ASHA expert panel [13].

The majority of SLPs offer counseling after every session focusing on vocal hygiene, the need for therapy, and therapy outcomes. Lavorato & McFarlane [46] have discussed the benefits, definitions, and goals of counseling clients and the role of the clinician when addressing knowledge of the voice disorder, resistance towards therapy, and acceptance of the new voice. The reasons for discharge reported by the SLPs surveyed, majorly included—voice disorder remediated and is within clinical limits, patient unwilling to attend therapy or requests to be discharged [47]. A study by Gillespie and Gartner-Schmidt [48] has reported the ability of the patient to transfer the learned voice therapy techniques at the conversation level to be the indicator for discharge [48].

This study revealed that many clinicians attended specialized voice-related conferences and certification programs in India, highlighting the desire for specialized and focal training in voice therapy among Indian clinicians. Many reported using evidence-based practice in clinical settings. However, there were some challenges such as time and financial constraints, lack of standardized tools/instruments, language, and cultural barriers to implementing EBP. This indicated the need to bring in evidence-based research practice in Indian clinical scenarios.

Conclusion

This study has provided several leads to practicing clinicians (ENTs and SLPs), clinic administrators, policymakers and academic leaders to establish practice guidelines for voice therapy in India. These findings can be considered (though in a limited sense) as a reflection of practice trends currently in vogue, and the need to develop indigenous protocols to suit the Indian population.

Funding

Not Applicable.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Institutional Ethics Committee approval has been obtained prior to the study.