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Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice
Abstract
INTRODUCTION
Since the beginning of the new pandemic, COVID-19 health services have had to face a new scenario. Voice therapy faces a double challenge, interventions using telepractice, and delivering rehabilitation services to a growing population of patients at risk of functional impairment related to the COVID-19 disease. Moreover, as COVID-19 is transmitted through droplets, it is critical to understand how to mitigate these risks during assessment and treatment.
OBJECTIVE
to promote safety, and effective clinical practice to voice assessment and rehabilitation in the pandemic COVID-19 context for SLPs.
METHODS
A group of 11 experts in voice and swallowing disorders from 5 different countries conducted a consensus recommendation following the American Academy of Otolaryngology-Head and Neck Surgery rules building a clinical guide for SLPs during this pandemic context.
RESULTS
The clinical guide provides 79 recommendations for clinicians in the management of voice disorders during the pandemic and includes advice from assessment, direct treatment, telepractice, and teamwork. The consensus was reached 95% for all topics.
CONCLUSION
This guideline should be taken only as recommendations; each clinician must attempt to mitigate the risk of infection and achieve the best therapeutic results taking into account the patient's particular reality.
... Furthermore, the relevance of auditory perceptual assessment of speech was highlighted in the context of speech-language services during the Covid-19 pandemic [35]. With the urgent need to make the transition to telepractice and the impossibility of performing instrumental examinations, several authors have emphasized the use of auditory perceptual assessment due to its compatibility with remote connections [36][37][38]. ...
... The findings presented in Table 7 highlight the significant disparity among Colombian speech-language pathologists in terms of adhering to established quality standards when recording vocal signals [36]. This is of utmost importance, considering that inaccurately or inadequately recorded voices can impact the reliability of auditory-perceptual judgments [38]. ...
... Lastly, it is important to note that half of the surveyed speech-language pathologists reported conducting real-time auditory perceptual evaluation during consultations. This raises concerns regarding the validity of the results obtained through this approach, as many published reports emphasize the need to record voices and listen to them repeatedly to mitigate the potential impact of auditory memory or attention lapses [36]. ...
Objective. To explore the training and use of auditory perceptual evaluation of the voice reported by Colombian speech-language pathologists. Study Design. Cross-sectional observational research with a quantitative approach. Methods. A digital questionnaire was designed and distributed to gather information regarding professionals' training process and implementation of auditory-perceptual evaluation procedures. Descriptive statistics were applied, and several generalized linear models were adjusted to determine the influence of certain variables on others. Results. The survey received responses from 40 speech-language pathologists, revealing that the most used scales for training and evaluating vocal quality within this group are direct magnitude estimations (82.5% and 77.5%). Similarly, in this group, the tasks most frequently used to train and use as an evaluation strategy are vowel assessments (38%) followed by spontaneous speech (30%). Practitioners of this group were mostly trained using a conceptual framework involving multiple exposures to rating (42.5%). The use of direct magnitude estimation in training with a normal voice showed significance (p = 0.015), as did the use of the vowel /i/ in training with an equal-appearing interval (p = 0.013). The statistical models relating the scale used to the scale on which participants were trained were also significant (p < 0.05). Conclusions. The GRBAS scale is the training tool most used by the group of speech-language pathologists of the study group in Colombia. Future efforts should focus on improving training practices for auditory-perceptual evaluation, exploring alternative conceptual frameworks, and incorporating external references to enhance validity and reliability.
... Guidelines that are specific to each profession and report on implementation, financial, and technical considerations [68] should also be integrated into the development of curricula. For instance, incorporating strategies for executing telehealth practices in fields such as OT [69], musculoskeletal physiotherapy [70], SLT [71], and nursing [72] can be beneficial. ...
Background
The COVID-19 pandemic has highlighted the growing relevance of telehealth in health care. Assessing health care and nursing students’ telehealth competencies is crucial for its successful integration into education and practice.
Objective
We aimed to assess students’ perceived telehealth knowledge, skills, attitudes, and experiences. In addition, we aimed to examine students’ preferences for telehealth content and teaching methods within their curricula.
Methods
We conducted a cross-sectional web-based study in May 2022. A project-specific questionnaire, developed and refined through iterative feedback and face-validity testing, addressed topics such as demographics, personal perceptions, and professional experience with telehealth and solicited input on potential telehealth course content. Statistical analyses were conducted on surveys with at least a 50% completion rate, including descriptive statistics of categorical variables, graphical representation of results, and Kruskal Wallis tests for central tendencies in subgroup analyses.
Results
A total of 261 students from 7 bachelor’s and 4 master’s health care and nursing programs participated in the study. Most students expressed interest in telehealth (180/261, 69% very or rather interested) and recognized its importance in their education (215/261, 82.4% very or rather important). However, most participants reported limited knowledge of telehealth applications concerning their profession (only 7/261, 2.7% stated profound knowledge) and limited active telehealth experience with various telehealth applications (between 18/261, 6.9% and 63/261, 24.1%). Statistically significant differences were found between study programs regarding telehealth interest (P=.005), knowledge (P<.001), perceived importance in education (P<.001), and perceived relevance after the pandemic (P=.004). Practical training with devices, software, and apps and telehealth case examples with various patient groups were perceived as most important for integration in future curricula. Most students preferred both interdisciplinary and program-specific courses.
Conclusions
This study emphasizes the need to integrate telehealth into health care education curricula, as students state positive telehealth attitudes but seem to be not adequately prepared for its implementation. To optimally prepare future health professionals for the increasing role of telehealth in practice, the results of this study can be considered when designing telehealth curricula.
... 45 b. a combination of pain education, skills training on energy conservation techniques for the management of fatigue, tailored physical exercise training, psychological support for the management of anxiety and depression, olfactory training for the management of olfactory impairment, goal-oriented skills training for the management of swallowing and voice impairment. 79 18. it is recommended that the rehabilitation needs of pcc patients be met by a well-coordinated and organised interdisciplinary/multi-professional team composed of a prM physician and other pertinent medical professionals (pulmonologists, cardiologists, neurologists, internal medicine physicians, neuropsychiatrists, and primary care physicians). the multi-professional team should include rehabilitation and other relevant health professionals such as physiotherapists, occupational therapists, nurses, clinical (neuro)psychologists, dieticians, speech and language therapists, and social workers to manage patients with pcc. ...
Although multiple factors still pose challenges to inpatient/outpatient rehabilitation for survivors of COVID-19, rehabilitation plays a key role for this patient population. This study aimed to improve Physical and Rehabilitation Medicine (PRM) physician's professional practice for persons with COVID-19-related functioning limitations, to promote functional recovery and reduce activity limitations and/or participation restrictions. A systematic review of the scientific literature was performed from December 2019 to August 2022, followed by production of recommendations through 5 Delphi rounds, by consensus among the delegates of all European countries represented in the Union of European Medical Specialists PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The PRM physician's role for persons with COVID-19-related limitations of functioning is to develop, foster, and monitor the implementation of an individual rehabilitation project tailored to the patient's age, previous medical and functional status, current comorbidities and complications, activity limitations and participation restrictions and personal and environmental factors. This is done by applying the concept of a multi-specialty integrated service model with multi-professional/interdisciplinary teams, providing care at all stages of COVID-19 illness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section.
... In fact, the voice treatment guidelines mentioned telerehabilitation as a valid solution during the pandemic emergency period. 36 The paucity of evidence of voice telerehabilitation includes the work of Dias et al., 37 which tested the efficacy of the LSVT-Loud method delivered by telerehabilitation in Parkinson's disease, reporting non-inferiority effects compared to conventional delivery paths. Recently, Crispiatico et al. 19 showed that LSVT-Loud could be a valid treatment to increase voice intensity in MS, but no evidence is available on the efficacy of voice treatment delivered by telerehabilitation. ...
Objective
Alterations in voice intensity and quality may constitute a social life limitation in people with multiple sclerosis (MS), but only 2% of cases receive speech therapy. Especially the Lee Silverman Voice Treatment (LSVT)-Loud is a highly effective intensive method for voice intensity, requiring subjects’ repeated attendance at the clinic. Telerehabilitation may represent a feasible solution to bypass potential barriers related to speech therapy attendance, scaling up the beneficial effects of the treatment to a broader population. The proposed protocol aims to test the feasibility and the pilot efficacy of the LSVT-Loud delivered in telerehabilitation (Tele-LSVT-Loud), compared to the same treatment delivered in the clinic (LSVT-Loud).
Methods
A single-blinded, parallel, two-arm, pilot randomized (1:1 ratio) controlled trial will be performed involving 20 people with MS. Patients will be allocated to 4 weeks of Tele-LSVT-Loud by accessing a telerehabilitation platform at home or LSVT-Loud conventionally delivered in the clinic. Feasibility and pilot effectiveness will be evaluated three times: before (T0), after the treatment (T1), and 3-month follow-up (T2). Feasibility measures will include adherence, adverse events, user experience, motivation, engagement, and acceptability. Vocal intensity during a 1-minute monologue will be the primary outcome measure. Secondary outcome measures will be the vocal quality during a 1-minute monologue, sustained /a/ voice intensity, quality and stability, voice use in daily life, voice subjective perception in daily life, and quality of life.
Results
Expected results will be (1) high feasibility of Tele-LSVT-Loud and (2) a non-inferiority effect of Tele-LSVT-Loud compared with face-to-face treatment delivery on voice intensity and quality outcomes.
Conclusions
Tele-LSVT-Loud may be a feasible intervention for MS alteration in voice intensity and quality with a non-inferior effect compared to LSVT-Loud.
... The maintenance of amateur choral groups was greatly challenged by the onset of the COVID-19 pandemic. Group singing became infeasible due to the dispersion of aerosols (21) and this activity was shifted to a virtual format, placing singers and their conductors in foreign situations in respect to education and learning. Participation in amateur choirs, despite lacking the levels of responsibility of their professional counterparts, is considered to be an activity that gives great pleasure and personal satisfaction. ...
Purpose
To analyze the perception of choristers who perform online rehearsals about symptoms, vocal disadvantages, adaptations in the singing routine and difficulties in rehearsals during social distancing due to the COVID-19 pandemic.
Method
Application of an online questionnaire investigating perceptions about the voice and singing routine and rehearsal of 141 choristers who did not have COVID-19 disease and continued in remote activity until April 2021. Participants were divided in two groups according to the age: G1 (18 to 54 years old) and G2 (55 years old or more). The data underwent descriptive and inferential analysis, considering a significance level of 5%.
Results
During distancing, both groups reported a decrease in singing time and felt more difficult to sing alone. Choir singers reported fewer throat infections during this period. Choir singers from G1 noticed a huskier voice, reported difficulty concentrating via videoconferencing, felt nervous to singing alone in virtual rehearsals and stressed recording the same song several times. G2 choristers reported more physical vocal symptoms such as: tired voice, varying throughout the day, and a weaker and more breathy voice.
Conclusion
In social distancing, the choristers found it more difficult to sing by videoconference and had reduced singing practice time. Younger choir singers reported more emotional symptoms and older choir singers reported more vocal symptoms.
Keywords:
Voice; Singing; Coronavirus Infections; Pandemics; Education Distance
... O Figura 1, abaixo, faz uma síntese dos achados estatisticamente significantes evidenciando os aspectos positivos e negativos relatados por cada grupo e em comum entre eles, com base nas tabelas de 1 a 4. (21) e essa atividade passou a ser realizada em plataformas virtuais, o que colocou cantores e regentes frente a uma situação até então desconhecida para o ensino e a aprendizagem. Coros amadores, embora não tenham a responsabilidade dos coros profissionais, são vistos como atividade de grande prazer e satisfação pessoal. ...
Purpose
To analyze the perception of choristers who perform online rehearsals about symptoms, vocal disadvantages, adaptations in the singing routine and difficulties in rehearsals during social distancing due to the COVID-19 pandemic.
Method
Application of an online questionnaire investigating perceptions about the voice and singing routine and rehearsal of 141 choristers who did not have COVID-19 disease and continued in remote activity until April 2021. Participants were divided in two groups according to the age: G1 (18 to 54 years old) and G2 (55 years old or more). The data underwent descriptive and inferential analysis, considering a significance level of 5%.
Results
During distancing, both groups reported a decrease in singing time and felt more difficult to sing alone. Choir singers reported fewer throat infections during this period. Choir singers from G1 noticed a huskier voice, reported difficulty concentrating via videoconferencing, felt nervous to singing alone in virtual rehearsals and stressed recording the same song several times. G2 choristers reported more physical vocal symptoms such as: tired voice, varying throughout the day, and a weaker and more breathy voice.
Conclusion
In social distancing, the choristers found it more difficult to sing by videoconference and had reduced singing practice time. Younger choir singers reported more emotional symptoms and older choir singers reported more vocal symptoms.
Keywords:
Voice; Singing; Coronavirus Infections; Pandemics; Education Distance
Artykuł poświęcono zaburzeniom głosu w następstwie choroby COVID–19. Autorka przedstawia patomechanizm dysfonii u osób zakażonych koronawirusem SARS‑CoV–2. Prezentuje najczęściej występujące objawy niepełnosprawności głosowej w wyniku zakażenia patogenem, a także zarys logopedycznego postępowania diagnostyczno‑terapeutycznego. Zwraca również uwagę na ryzyko powstania nieprawidłowości głosowych związanych z upowszechnioną w okresie pandemii pracą zdalną i towarzyszącym jej wzmożonym wysiłkiem głosowym.
Telepractice offers the opportunity to receive care at home without risk of exposure to healthcare acquired infections, especially during a pandemic. Hence, establishing the reliability of the diagnosis of dysphonia via a smartphone is fundamental to providing an alternative service delivery model. A total of 20 participants participated in the study. Recordings of sentence-based voice samples were done using a standardized microphone and the software used in labs and on smartphones. Comparisons were made of acoustic and perceptual voice in real-time and recorded samples speech in persons with typical vs pathological voice. Results revealed no significant differences perceptually between real-time voice and recorded voice in individuals with typical and pathological voices. In acoustic analysis, there was no significant difference in Fundamental frequency (F0) and Auditory Voice Quality Index (AVQI) between real-time voice and recorded voice in individuals with typical and pathological voice.
Background
During the COVID‐19 pandemic, Ireland implemented a series of stringent public health measures, including lockdowns and suspension of non‐urgent clinical services.
Aims
To investigate the impact of the COVID‐19 pandemic on the demand for and delivery of speech and language therapy (SLT) services in Ireland in 2020.
Methods & Procedures
Two iterations of a cross‐sectional, mixed‐methods online survey were distributed to speech and language therapists (SLTs) and SLT students in Ireland in the spring and autumn of 2020 using a combination of purposive and snowball sampling. The spring survey yielded 407 responses (including 14 from SLT students), while 197 respondents took part in the autumn (13 students). Survey analysis focused on questions related to the impact of the COVID‐19 pandemic on delivery and demand for SLT services (student responses were excluded from analysis owing to low response rate). The largest group in respect of experience were senior SLTs (58% in both surveys). The work settings most strongly represented were HSE primary care (34.4%) and disability services (26.5%) in the spring, and HSE primary care (39.1%), acute hospitals (22.8%) and disability services (20.8%) in the autumn. We used descriptive statistics, including distribution analysis, to analyse the quantitative data. Free text data were interrogated through a variant of a conventional qualitative content analysis.
Outcomes & Results
In the spring, cessation of face‐to‐face services featured prominently (reported by 65.6% versus 14.2% in the autumn), across SLTs’ work settings, except acute hospitals. Lower demand was reported by 42.5% in the spring, while in the autumn, 48.7% indicated that demand was higher. SLTs experienced large‐scale redeployment (spring: 45.9%, autumn: 38.4%), with HSE primary care SLTs redeployed most (spring: 71.7%; autumn: 62.3%). The need to suddenly pivot to telehealth was a significant challenge in terms of training, technology and logistics. New ways of working emerged and gradually, telehealth became more embedded. SLTs also had to adapt to working with evolving public health measures, such as space restrictions and personal protective equipment (PPE) requirements. Across the two survey iterations, SLTs reported tensions between demands and capacity: while referrals and demand initially decreased in the spring, this led to increased backlog and longer waiting lists, ongoing and increasing pressure on clinicians and services, and negatively impacted clients and families.
Conclusions & Implications
The COVID‐19 pandemic had a significant negative impact on SLT services in Ireland. Going forward, the SLT profession and its services will require sustained support to mitigate long‐term negative consequences, such as increased waiting lists.
WHAT THIS PAPER ADDS
What is already known on this subject
The negative impact of the COVID‐19 pandemic on SLT services has been examined in several countries. Ireland imposed more stringent pandemic‐management measures than many other countries, and it was therefore warranted to investigate how SLT services in the country were affected.
What this study adds to the existing knowledge
Face‐to‐face SLT services effectively ceased in most non‐urgent contexts in spring 2020. This coincided with large‐scale redeployment of SLTs to non‐SLT contexts. By autumn 2020, demand had increased again, but not all services had recommenced, and redeployment was still a factor. Although SLTs adapted to the ongoing changes imposed by the pandemic, they voiced concern about increasing backlogs and longer waiting lists, ongoing and increasing pressure on both SLTs and services, and negative impacts on clients and families.
What are the actual and clinical implications of this work?
The COVID‐19 pandemic had a significant negative impact on SLT services in Ireland. Going forward, the SLT profession and its services will require sustained support to mitigate long‐term negative consequences, such as increased waiting lists.
Purpose: This document outlines initial recommendations for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting.
Method: The authors initially developed these recommendations by adapting those developed for physical therapists working with patients with COVID-19 by Thomas et al. (2020). The recommendations then underwent review by 14 speechlanguage pathologists and rehabilitation-focused academics representing seven countries (Belgium, Brazil, Canada, Ireland, Japan, New Zealand, the United States). The authors consolidated and reviewed the feedback in order to decide what should be included or modified. Applicability to a global audience was intended throughout the document.
Results: The authors had 100% agreement on the elements of the recommendations that needed to be changed/modified or added. The final document includes recommendations for speech-language pathology workforce planning and preparation, caseload management, service delivery and documentation, as well as recommendations for the selection of appropriate personal protective equipment and augmentative and alternative communication equipment in the acute care hospital setting.
Conclusions: Speech-language pathologists play a critical role in the assessment, management, and treatment of patients with COVID-19. Several important considerations
need to be made in order to meet the needs of this unique patient population. As more is learned about the impact of the virus on swallowing and communication, the role of the
speech-language pathologist on interdisciplinary care teams will remain paramount.
Purpose
As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection.
Method
Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference.
Results
Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection.
Conclusions
Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.
OBJECTIVE
To describe postinfubation phonatory insufficiency, a routinely overlooked complication of prolonged intubation. This entity results from an erosive injury with permanent divots of the medial surfaces of the arytenoid cartilages and/or scarring of the anterior cricoarytenoid joint capsule so that during pronation there is incomplete adduction and a glottic gap remains.
SETTING
Tertiary care center.
STUDY DESIGN/RESULTS
We present a retrospective review of the findings of 138 patients evaluated for chronic intubation injuries in our voice laboratory using a diagnostic model composed of pertinent history, elicited vocal capabilities and limitations, and an intense fiberoptic laryngeal examination directed at revealing the suspected injuries.
CONCLUSION/SIGNIFICANCE
In many patients, the diagnosis of postintubation phonatory insufficiency was made years after the intubation injury occurred and after numerous nondiagnostic examinations elsewhere. Mechanisms of intubation injury are reviewed, and prevention and treatment of the condition are discussed.
Objectives
Psychological stress may have an adverse impact on the voice. The purpose of the present cross-sectional study was to investigate the relationship between the change in levels of perceived psychological stress and vocal symptoms among Israeli academic college professors required to shift to synchronous online teaching during the global COVID-19 pandemic.
Methods
. An online questionnaire was completed by 313 professors (156 men and 157 women) from 14 academic colleges in Israel at the end of the first week of online synchronous teaching during the COVID-19 pandemic, which was assumed to be the most burdened and stressful week of the transition. Participants provided self-reports for the current levels of psychological stress and vocal symptoms during the transition to online synchronous teaching, as well as general psychological stress and general vocal symptoms during previous periods of teaching.
Results
The results revealed higher levels of psychological stress but not vocal symptoms during the transition to online synchronous teaching compared with previous periods of teaching. Psychological stress during the transition to online synchronous teaching was positively associated with vocal symptoms during this period but this association was moderated by general stress. Although there was a positive association between psychological stress and vocal symptoms for individuals who reported low levels of psychological stress during previous periods of teaching, this association was especially strong for individuals who reported high levels of psychological stress during previous periods of teaching.
Conclusions
. It is important to examine vocal symptoms of professors in specific contexts that are potentially stressful. The psychological stress surrounding the transition to online synchronous teaching was associated with elevated levels of vocal symptoms especially for those who reported high levels of psychological stress during previous periods of teaching. These results with professors accord with the notion that psychological stress may have a negative impact on the voice.
Introduction
To explore the prevalence of dysphonia in European patients with mild-to-moderate COVID-19 and the clinical features of dysphonic patients.
Methods
The clinical and epidemiological data of 702 patients with mild-to-moderate COVID-19 were collected from 19 European Hospitals. The following data were extracted: age, sex, ethnicity, tobacco consumption, comorbidities, general and otolaryngological symptoms. Dysphonia and otolaryngological symptoms were self-assessed through a 4-point scale. The prevalence of dysphonia, as part of the COVID-19 symptoms, was assessed. The outcomes were compared between dysphonic and non-dysphonic patients. The association between dysphonia severity and outcomes was studied through Bayesian analysis.
Results
A total of 188 patients were dysphonic, accounting for 26.8% of cases. Females developed more frequently dysphonia than males (p=0.022). The proportion of smokers was significantly higher in the dysphonic group (p=0.042). The prevalence of the following symptoms was higher in dysphonic patients compared with non-dysphonic patients: cough, chest pain, sticky sputum, arthralgia, diarrhea, headache, fatigue, nausea and vomiting. The severity of dyspnea, dysphagia, ear pain, face pain, throat pain and nasal obstruction was higher in dysphonic group compared with non-dysphonic group. There were significant associations between the severity of dysphonia, dysphagia and cough.
Conclusion
Dysphonia may be encountered in a quarter of patients with mild-to-moderate COVID-19 and should be considered as a symptom list of the infection. Dysphonic COVID-19 patients are more symptomatic than non-dysphonic individuals. Future studies are needed to investigate the relevance of dysphonia in the COVID-19 clinical presentation.