ArticlePDF Available

Stand-alone Internet speech restructuring treatment for adults who stutter: A pilot study.

January 2012

January 2012
14(3):118-123

Authors:

La Trobe University

Waveform and spectrogram for the word "vegetables", as displayed in PRAAT, with the first vowel highlighted in the waveform (upper panel). In the spectrogram (lower panel), the top overlaid dotted line represents the fundamental frequency as it changes over the word (displayed in blue within PRAAT), the bottom overlaid line represents the vocal intensity (displayed in yellow within PRAAT). Note the erroneous pitch values just prior to the 'b' and at the onset of the final schwa.

…

. Key research articles identified

…

. Demographic and injury data for the three participants with dysarthria and three age-and gender-matched control participants

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. Articles included for review

…

. Study details

…

Figures - uploaded by Shane Erickson

Content may be subject to copyright.

Content uploaded by Shane Erickson

Content may be subject to copyright.

Journal of Clinical Practice in

Speech-Language Pathology

Volume 13, Number 1 2011

Technology

Print Post Approved PP352524/00383 ISSN 2200-0259

In this issue:

Stand-alone Internet treatment

for adults who stutter

Objective measurement of

dysarthric speech following TBI

What’s the evidence for use of

telerehabilitation for dysphagia

services

Webwords: Life online

Clinical insights into

international Skype delivery of

the Lidcombe Program

Journal of Clinical Practice in

Speech-Language Pathology

Volume 14, Number 3 2012

JOURNAL OF CLINICAL PRACTICE IN SPEECH-LANGUAGE PATHOLOGY

Volume 14, Number 3 2012

Level 2 / 11-19 Bank Place,

Melbourne, Victoria 3000

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Website:

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ABN 17 008 393 440 ACN 008 393 440

Speech Pathology Australia Council

Christine Stone

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Felicity Martin

Vice President Communications

Margeurite Ledger

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Felicity Burke

Member Networks

Michelle Foley

Scientiﬁc Affairs & Continuing

Professional Development

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Communications

Gaenor Dixon

Practice, Workplace & Government –

Operations

Stacie Attrill

Professional Standards

Tennille Burns

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(Kerry) Ttofari Eecen

c/- Speech Pathology Australia

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Samantha Turner

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Number 2, 2013

3 December 2012 (peer review)

1 February 2013 (non peer review)

Number 3, 2013

12 April 2013 (peer review)

27 June 2013 (non peer review)

Number 1, 2014

1 August 2013 (peer review)

14 October 2013 (non peer review)

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The Journal of Clinical Practice in Speech-Language Pathology

(JCPSLP) is a major publication of Speech Pathology Australia and

provides a professional forum for members of the Association.

Material may include articles on research, speciﬁc professional

topics and issues of value to the practising clinician, comments

and reports from the President and others, general information on

trends and developments, letters to the Editor, and information on

resources. Each issue of JCPSLP aims to contain a range of material

that appeals to a broad membership base.

JCPSLP is published three times each year, in March, July, and

November.

Our Most Popular Titles Include:

• WellCommKit-theBigBookofIdeas

• MouthyMouthAwarenessFingerPuppet

• MagneTalkBarrierGames

• AuditoryMemoryforShortStoriesFunDeck

• ConditionalFollowingDirectionsFunDeck

http://shop.acer.edu.au

ACER Product Update

Offering an extensive range of specialist

resources for Speech Pathologists

Thisrevisededition

ofCued Articulation,

Consonants and

Vowelscombines

theconsonants,

vowels,colourcoding

anddemonstrative

imagesoftheCued

Articulationsystemunderonecover.

............................................

Success and Dyslexia,

Sessions for coping in

the upper primary years

isaunique,evidence-

basedprogramthat

assistsallupper

primarystudents,

especiallythosewith

dyslexia,toincreasetheirabilitytotake

controlofandcopewiththeproblemsthat

occurintheirlives.

............................................

In Teaching Oral

Language,Building a rm

foundation using ICPALER

in the early primary

years,JohnMunro

demonstrateshow

teacherscanbestguide

studentstobecome

effectivecommunicatorsandlanguageusers.It

isdesignedtofacilitateteachingandassessment.

............................................

Auditory Communication

for Deaf Children, A guide

for teachers, parents

and health professionals,

presentsarationaleand

frameworkforauditory

learninginchildhood

anddescribesawide

rangeofpractical

listeningactivitiesthatadultscanapplyduring

everydayinteractionwiththechild.

............................................

Our Most Popular Titles Include:

• WellCommKit-theBigBookofIdeas

• MouthyMouthAwarenessFingerPuppet

• MagneTalkBarrierGames

• AuditoryMemoryforShortStoriesFunDeck

• ConditionalFollowingDirectionsFunDeck

http://shop.acer.edu.au

ACER Product Update

Offering an extensive range of specialist

resources for Speech Pathologists

Thisrevisededition

ofCued Articulation,

Consonants and

Vowelscombines

theconsonants,

vowels,colourcoding

anddemonstrative

imagesoftheCued

Articulationsystemunderonecover.

............................................

Success and Dyslexia,

Sessions for coping in

the upper primary years

isaunique,evidence-

basedprogramthat

assistsallupper

primarystudents,

especiallythosewith

dyslexia,toincreasetheirabilitytotake

controlofandcopewiththeproblemsthat

occurintheirlives.

............................................

In Teaching Oral

Language,Building a rm

foundation using ICPALER

in the early primary

years,JohnMunro

demonstrateshow

teacherscanbestguide

studentstobecome

effectivecommunicatorsandlanguageusers.It

isdesignedtofacilitateteachingandassessment.

............................................

Auditory Communication

for Deaf Children, A guide

for teachers, parents

and health professionals,

presentsarationaleand

frameworkforauditory

learninginchildhood

anddescribesawide

rangeofpractical

listeningactivitiesthatadultscanapplyduring

everydayinteractionwiththechild.

............................................

Technology

THIS ISSUE OF THE JOURNAL OF CLINICAL PRACTICE IN SPEECH-Language

Pathology (JCPSLP) on “Technology” reminds us of the advantages of technology. It

has made health care more accessible to many people who cannot access traditional

service delivery for one reason or another. Technology also gives us an avenue to

objectively document and assess clients’ communication and/or swallowing. The

world of information technology is rapidly evolving, however, and it is important to keep

abreast of these changes, particularly as there is such a reliance on the internet for

information and resources nowadays.

Kerry: Although being co-editor of the JCPSLP has been a time-consuming task

(mostly conﬁned to the hours after tucking my children in to bed at night), I enjoyed the

whole experience immensely and gained many skills. I had the pleasure of working

with authors, reviewers, our editing team, the JCPSLP committee, and Speech

Pathology Australia to produce six issues that I am extremely proud of. Being in this

position exposed me to a broad range of issues in our profession, whereas in the past

I would have conﬁned my reading to a narrower set of topics.

Marleen and I proposed a number of changes to shape the direction of this clinical

journal and increase its appeal to potential authors and readers. We would like to

thank Speech Pathology Australia Council for being so receptive to our ideas and

suggestions. We would also like to thank the reviewers who gave up their time to

give detailed constructive feedback to improve each submission; this was pertinent

especially for topics which Marleen and I know little about. Reviewers have an

invaluable role in shaping the ﬁnished product of all submissions, ones that carry the

“peer review” label and ones that do not, as all submissions are carefully appraised

and edited, by (blind) reviewers and/or the editors. Finally, it has been an absolute

pleasure working with my co-editor Marleen Westerveld who taught me so much

about the editing process and so much more, and whom I will always look up to as a

mentor.

Marleen: It is hard to believe it has been four years since I took on the position of

co-editor of this journal (in October 2009 with Nicole Watts-Pappas) and I would like to

ﬁnish up with a few thank-yous! Thank you to Natalie Ciccone for stepping in as guest

co-editor when Kerry was on maternity leave. Thank you to our former committee

members, Suze Leitão, Mary Claessen, Andrea Murray, and Julia Day; your input has

been invaluable. Welcome to Elizabeth Lea, David Trembath, and Samantha Turner

who recently joined the committee (see p. 160). Thank you also to all the Speech

Pathology Australia members who provided written or verbal feedback at the recent

Speech Pathology Australia National conference. There was overwhelming support

for the journal’s new name, the topic-based approach, and the publication of relatively

short, clinically relevant articles. And last, but not least, thank you to Kerry, for being

such a wonderful colleague these last few years. Although it will be difﬁcult to “let go”, I

am conﬁdent that the journal is in good hands with incoming editors Jane McCormack

and Anna O’Callaghan. I wish them all the best!

From the editors

Kerry Ttofari Eecen and Marleen Westerveld

109 From the editors

110 A survey of the clinical use of telehealth

in speech-language pathology across

Australia – Anne J. Hill and

Lauren E. Miller

118 Stand-alone Internet speech

restructuring treatment for adults who

stutter: A pilot study – Shane Erickson,

Susan Block, Ross Menzies, Mark Onslow,

Sue O’Brian, and Ann Packman

124 What’s the evidence? Use of

telerehabilitation to provide specialist

dysphagia services – Elizabeth C. Ward

and Clare Burns

129 Objective measurement of dysarthric

speech following traumatic brain injury:

Clinical application of acoustic analysis

– Christine Taylor, Vanessa Aird, Emma

Power, Emma Davies, Claire Madelaine,

Audrey McCarry, and Kirrie J. Ballard

136 Treatment of articulation disorders in

children with cleft palate: Evidence for

using electropalatography – Sarah Maine

and Tanya Serry

142 Clinical insights: Adapting speech

pathology practice: Delivering parent

education groups using technology

– Corinne Loomes and Alice Montgomery

146 Clinical insights: No boundaries:

Perspectives of international Skype

delivery of the Lidcombe Program

– Shane Erickson

149 Webwords 44: Life online

– Caroline Bowen

153 SPAD (Speech Pathologists in Adult

Disability) Top 10

155 Research update: Developmental

stuttering – A paediatric neuroimaging

study – Libby Smith

157 Around the journals

159 Resource reviews

160 Introducing the JCPSLP Committee

2013–2014

Contents

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 109

Technology

110 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 111

Anne J. Hill (top)

and Lauren

E. Miller

This arTicle

has been

peer-

reviewed

Keywords

clinical

pracTice

clinical Use

and

TechnoloGy

speech-

lanGUaGe

paTholoGy

TelehealTh

SLP services (Hill & Theodoros, 2002; McCue, Fairman, &

Pramuka, 2010). This research has explored the use of a

variety of technology such as videoconferencing, telephone,

videophone, email, and Skype (Mashima & Doarn, 2008;

McCue et al., 2010). While the research is dominated by

feasibility projects and case studies, a number of high-

quality randomised control trials and robust pilot studies

have produced an emergent evidence base for the use

of telehealth for some services (Reynolds, Vick, & Haak,

2009). It should be acknowledged that a discrepancy

is evident in the literature between paediatric and adult

studies, with the majority of research being undertaken

with adults (Reynolds et al., 2009). A growing body of

literature supports assessment via telehealth, particularly

for the following groups: adult dysarthria (Hill et al., 2006;

Hill, Theodoros, Russell, & Ward, 2009a), adult apraxia of

speech (Hill, Theodoros, Russell, & Ward, 2009b), adult

aphasia (Hill, Theodoros, Russell, Ward, & Wootton, 2008),

paediatric speech, language, and literacy disorders (Waite,

Theodoros, Russell, & Cahill, 2010a, b), patients post-

laryngectomy (Ward et al., 2009), and the assessment

and review of clients using alternative and augmentative

communication (Styles, 2008).

The literature around the use of telehealth in treatment

services is less diverse. Two adult telehealth treatment

programs found to be equivalent to traditional delivery modes

are the Lee Silverman Voice Treatment program (LSVT

LOUD; Constantinescu et al., 2011), and the Camperdown

Programs for adults who stutter (Carey et al., 2010). The use

of telehealth in the treatment of paediatric ﬂuency disorders

with the Lidcombe Program has also been examined

through a well-executed phased research program using

telephone and postal services (Lewis, Packman, Onslow,

Simpson, & Jones, 2008; Wilson, Onslow, & Lincoln, 2004).

It is interesting to note a tendency for researchers to

investigate the application of treatment programs that

already have established efﬁcacy in the face-to-face

environment. Nevertheless, there is an urgent need to

invest in high-quality telehealth research into other

intervention programs if the evidence base for intervention

delivered via telehealth is to become fully established.

While current research literature supports telehealth as an

effective service delivery model for some SLP services, the

question remains as to whether it has translated into clinical

practice. A survey of the use of telehealth in SLP and

audiology was conducted in the United States of America

by ASHA in 2002. Of the 825 SLPs who responded, 9%

reported using telehealth to deliver services; however,

47% of SLPs reported an interest in using it in the future.

Research into the use of telehealth

technology for speech-language pathology

(SLP) services has been conducted for over

30 years; however, it is unknown whether this

research has translated into clinical practice.

A web-based survey was deployed to

determine key factors around the clinical use

of telehealth by Australian SLPs. Quantitative

analysis revealed that clinicians are using a

wide range of technology to deliver a variety

of SLP services to both paediatric and adult

populations. A number of beneﬁts to using

telehealth in clinical practice were identiﬁed,

along with signiﬁcant barriers to the

expansion of telehealth in SLP. Suggested

facilitators for the further development of

telehealth in SLP included more professional

development in the area of telehealth,

demonstrations by experienced users of

telehealth, and access to electronic

assessment and treatment resources.

Limitations of the study are discussed with

directions for future research.

elehealth is deﬁned as the application of

telecommunications technology to the delivery

of professional health services at a distance by

linking clinician to client, or clinician to clinician, for

assessment, intervention, and/or consultation (American

Speech-Language-Hearing Association [ASHA], 2005).

Telehealth has been endorsed by ASHA as an appropriate

and suitable service delivery model for speech-language

pathology (SLP) provided that telehealth services are of the

same quality as those delivered face to face (ASHA, 2005).

As a service delivery model, telehealth has the capacity

to overcome issues relating to access to services such as

distance and immobility, as well as assisting in caseload

prioritisation, allowing for intensive treatment regimes,

reduced length of stay in hospital, longer term rehabilitation

management, and meeting the increased demand for SLP

services (ASHA, 2005).

Research into the use of telehealth delivery of SLP

services has been conducted for over 30 years, increasing

during the last decade due to the expansion of technology,

high-speed data transmission, and rising demand for

A survey of the clinical

use of telehealth in

speech-language pathology

across Australia

Anne J. Hill and Lauren E. Miller

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 111

Participants

The survey recruited practising SLPs in Australia who were

using telehealth in their clinical practice. Participants were

excluded if they were still completing their undergraduate

study, did not use telehealth in their clinical practice, or did

not fully complete the survey. The participant information

sheet and consent form were at the beginning of the web

survey and participants could not complete the survey until

they had consented to participate by choosing “accept”.

Consent was provided by 91 SLPs to participate in the

study; however, 36.3% of respondents (n = 33) did not fully

complete the survey and were therefore excluded from the

data analysis. Data analysis was conducted on 57

complete responses. The respondents were predominantly

female (98.2%), Australian born (89.5%), under the age of

45 years (77.3%), and worked full-time (70.2%), with the

remainder working part-time (28.1%) or in a locum position

(1.8%). The number of full-time equivalent years the SLPs

had been working ranged from 0.5 to 35 years with an

average of 10.9 years. Responses were received from SLPs

in Queensland (42.1%), New South Wales (36.8%), Victoria

(15.8%), Western Australia (3.5%), and the Northern

Territory (1.8%). There were no respondents from the other

states or territory.

Survey

The survey was developed and implemented through

SurveyMonkey

and consisted of 27 multiple choice

questions, in which the respondent could select multiple

responses and four open-ended questions, which related to

qualiﬁcations, number of years of practice, postcode of

workplace, and beneﬁts of using telehealth in clinical

practice. Participants had the option of completing the

survey anonymously or providing their contact details at the

end of the survey. The survey was available for 10 weeks

and contained questions relating to demographics,

technology used in the provision of services via telehealth,

client populations with whom telehealth is used, and the

facilitators, barriers, and beneﬁts of using telehealth in

clinical practice. The survey took approximately 10 minutes

to complete and had to be completed in one sitting.

Procedure

Speech Pathology Australia distributed the link to the

survey to all members via the association’s e-newsletter. An

email link was also sent through the heads of department at

all universities with SLP courses across Australia and heads

of SLP departments in Queensland Health and Education

Queensland. Time constraints prevented more widespread

distribution through public health and education facilities in

other states.

Statistics

The quantitative data were analysed using frequency counts

and some cross-tabulations for multiple response sets. The

qualitative data were analysed by two researchers using

content analysis to determine themes in the responses

(Creswell, 2009).

Results

Due to length restrictions, not all of the data gathered from

the survey are able to be reported here. This article will

focus on the settings and technology used in telehealth,

client populations with whom it is used, and users’

perceptions of the beneﬁts, barriers, and facilitators of

telehealth in SLP.

The SLP respondents to ASHA’s survey used telehealth

primarily for counselling and follow-up services, and to a

lesser degree for treatment and screening (ASHA, 2002).

Telehealth was used across a range of disorders (e.g.,

motor speech and cognitive communication disorders)

and settings (e.g., schools, client’s home) (ASHA, 2002).

Other key ﬁndings from the survey were the barriers to the

expansion of telehealth services, which included the cost

of technology and lack of professional standards (ASHA,

2002). Results of this survey prompted ASHA to provide

members with information on types of technology available

and endorse telehealth as a suitable service delivery model

where the quality of the service is equivalent to face-to-face

delivery. To date ASHA has not re-surveyed its members on

their use of telehealth.

Although not speciﬁcally focusing on the clinical use of

telehealth in SLP, a number of recent Australian surveys

have investigated service delivery models and attitudes

towards the use of technology in SLP (Department of

Health and Aging [DHA], 2011; Dunkley, Pattie, Wilson,

& McAllister, 2010; Zabiela, Williams, & Leitão, 2007).

The earliest of these surveys canvassed SLPs in non-

metropolitan areas across Australia and found that although

technology was available, only 8 of the 51 respondents

were using telehealth to deliver direct SLP services (Zabiela

et al., 2007). These ﬁndings were attributed to a lack of

training in the use of telehealth and a lack of evidence for its

effectiveness (Zabiela et al., 2007). Dunkley et al.’s (2010)

survey of both rural residents and SLPs in New South

Wales found that clients not only had greater access to a

range of technology than the SLPs expected, but also had

a positive attitude towards the use of telehealth as they

believed it would improve access to services that would

otherwise be infrequent or unavailable. In contrast, SLPs

reported less access to technology in their workplace,

with some clinicians believing that current technology

was not advanced enough for many client populations

such as those with dysphagia and intellectual disability

(Dunkley et al., 2010). The Department of Health and

Aging’s (DHA) eHealth readiness survey also looked at

barriers to the adoption of telehealth across 15 allied health

professions, including SLP. Reported barriers included a

lack of appropriate funding under Medicare for allied health

services, poor access to services, and a lack of relevant

technology (DHA, 2011). The DHA survey indicated that

education is needed if telehealth is to be embraced by

practitioners and that some allied health professionals

believe the barriers and cost of technology outweigh the

beneﬁts of telehealth (DHA, 2011).

Overall, the research literature points to an emergent

evidence base for the use of telehealth in the provision of

some SLP services, and a growing interest in alternative

service delivery models in SLP. This indicates a need for

speciﬁc research investigating the clinical use of telehealth

in SLP practice in Australia. Therefore, the current study

aimed to determine the types of technology being used

in the provision of direct telehealth services by SLPs in

Australia, and the client populations with whom telehealth

is being used clinically, and to examine the facilitators,

barriers, and beneﬁts to the clinical use of telehealth in SLP.

Method

Ethical clearance

The study was reviewed and granted ethical clearance from

the University of Queensland and from the Speech

Pathology Australia (SPA) council. Gatekeeper approval was

also obtained from leaders of SLP in Queensland Health.

112 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 113

metropolitan SLPs used stand-alone videoconferencing to

provide telehealth services, in contrast to 60.5% of regional

SLPs. Computer-based videoconferencing (excluding

Skype) was used by just six respondents, ﬁve of which

were regional SLPs. However, the use of Skype (video and

audio) was evenly distributed across metropolitan and

regional SLPs.

The majority of clinicians reported having used

telehealth for fewer than six years (80.8%); however

10.5% of clinicians reported using some modes of

telehealth (e.g., telephone and email) for more than 10

years. Videoconferencing was the ﬁrst real-time audio-

visual technology to be embraced by clinicians surveyed

approximately 8 years ago, followed by customised

telehealth systems and Skype at 2 and 4 years ago

respectively.

Direct telehealth services

Results revealed that 40.4% of clinicians used telehealth to

deliver assessment services including standardised

assessment (10.5%) and informal assessment (40.4%). The

majority of clinicians (86%) reported using telehealth to

deliver treatment services. These services included

consultations (70.2%), follow-up sessions (66.7%), family

Telehealth settings

The respondents reported providing telehealth services

from a number of settings, including public health facilities

(57.9%), private practice (22.8%), public education settings

(12.3%), community service (10.5%), and specialist services

(8.8%). Fewer respondents reported providing telehealth

services from private education settings (5.3%), private

health services (1.8%), or nursing homes (1.8%). Inspection

of the postcodes supplied by respondents revealed that 14

respondents worked in metropolitan centres, while the

majority of respondents (75.43%) worked in regional areas.

Regional areas included relatively large centres as well as

smaller towns.

Respondents reported that clients typically accessed

information and communication technology (ICT) for their

telehealth sessions from their home (70.2%), medical centre

(21.1%), school (21.1%), or work (10.5%).

Telehealth technology

The respondents reported most commonly using the

telephone, email, and videoconferencing in their provision of

telehealth services (see Figure 1). Cross-tabulation of

responses against postcode revealed that 23% of

Telephone

Videoconferencing system

DVD/VCR recordings

Fax

Mobile phone (audio only)

Skype (audio and video)

Other

Combinations of all

Computer-based videoconferencing

Custom-built telehealth system

Skype (audio only)

Mobile phone (audio and video)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 1. Technology used in the provision of SLP telehealth services

Expressive language therapy

Fluency therapy

Articulation/phonology/oromotor therapy

Receptive language therapy

Literacy therapy

Pragmatics therapy

Other

Auditory processing and memory therapy

AAC

Dysphagia therapy

Voice therapy

0% 5% 10% 15% 20% 25%

Figure 2. Types of direct therapy delivered to paediatric clients via telehealth

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 113

they would like to expand their telehealth service to provide

a more regular outreach service, to include new technology

such as Skype, and to broaden the client populations

assessed and treated via telehealth.

Barriers

A number of barriers to the current use of telehealth in

clinical practice were identiﬁed by respondents. The most

commonly reported barriers were problems with technology

(71.9%) and telecommunication connections (45.6%),

closely followed by a lack of assessment and treatment

resources suitable for telehealth (40.4% and 36.8%

respectively). Difﬁculty accessing ICT to conduct telehealth

(31.6%) and a lack of ICT support (31.6%) were also cited

support (59.6%), direct therapy (45.6%), and teacher

support (36.8%).

Client populations

The majority of respondents (73.6%) reported using

telehealth with 0–30% of their caseload while a small

number of clinicians (7%) reported use with 90–100% of

their caseload.

Paediatric populations

The majority of respondents (78.95%) who had a paediatric

or mixed caseload reported using telehealth to provide

direct therapy to paediatric populations across all age

groups. The types of direct therapy provided via telehealth

reﬂected the paediatric populations most often treated (see

Figure 2).

Adult populations

A smaller proportion of respondents (52.63%) reported

using telehealth with a variety of adult client populations,

but most commonly with those people with dysphagia,

degenerative neurological disorders, or stroke. Of these

respondents, 33.3% provided direct therapy to adult clients

via telehealth. Figure 3 displays the types of direct therapy

provided. Cross-tabulation of the type of treatment results

against postcode revealed that ﬂuency treatment via

telehealth is occurring only in NSW and Victoria, while

dysphagia management via telehealth is occurring only in

Qld.

Benefits, barriers, and facilitators to

using telehealth

Most respondents (71.9%) were conﬁdent or very conﬁdent

in their use of telehealth and satisﬁed or very satisﬁed

(71.9%) with the service they provided via telehealth.

Beneﬁts

Respondents reported a wide range of beneﬁts to using

telehealth in their clinical practice. Their responses to this

open ended question were analysed using content analysis

(Creswell, 2009) with ﬁve major themes emerging: access,

time efﬁciency, client focus, caseload management, and

cost efﬁciency. Each theme contained beneﬁts for both the

client and the clinician. A sample of open responses is

displayed in Table 1.

It was found that 70.2% of respondents considered

telehealth to be a cost-effective service delivery option for

SLP services. The majority of respondents (70.2%) reported

Fluency therapy

Dysarthria therapy

Voice therapy

Expressive language therapy

Dysphagia therapy

Apraxia therapy

Other

Receptive language therapy

Literacy tharapy

AAC

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Figure 3. Types of direct therapy delivered to adult clients via telehealth

Table 1. Respondents’ comments on the beneﬁts

of using telehealth in clinical practice

Beneﬁts Respondent comments

Access Equitable access to services

Easier to share materials with clients

Easily access support from other clinicians

The client can stay in their local area and receive

appropriate treatment

Time efﬁciency Time efﬁcient for both client and clinician

Reduce staff travel time

Efﬁcient for student supervision

Time efﬁcient for the client not having to travel to

the clinic

Client focus Increased intensity of treatment

Increased frequency of reviews

More realistic idea of client’s abilities in natural

environment

The client takes greater responsibility for the

treatment program

Caseload Increased client base in private practice

management Increased awareness of clinical issues

Increased ﬂexibility

Easier to manage clients one after another, less

preparation of materials, easy to organise

appointments

Cost efﬁciency Reduced cost

Reduced travel expenses

Reduced time away from work for clients

Reduced cost and resources required by the family

and clinician or service

114 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 115

most commonly used (McCue et al., 2010). The clinicians

who responded to this survey reported using the same

types of technology to deliver telehealth services, although

videoconferencing was the third most common form of

technology used. This is in contrast to the ﬁndings of

Dunkley et al. (2010) and Zabiela et al. (2007) who reported

that although rural SLPs had access to videoconferencing

facilities they were rarely used as an approach to service

delivery. Both Dunkley et al. (2010) and Zabiela et al.

(2007) attributed their ﬁndings to a lack of SLP training

and conﬁdence using the technology and lack of access

to videoconferencing for clients. The increased use of

videoconferencing by SLPs may reﬂect improvements

in training in the use of the technology. Indeed, a large

percentage of the respondents in this study reported

they were conﬁdent or very conﬁdent using telehealth

technology. The current survey reported clients accessing

technology from a wider variety of locations including their

home, medical centre, school, and work. There seems to

be greater access to telehealth for clients than found in the

previous surveys.

Client populations

The literature supports a growing evidence base for the

telehealth delivery of some SLP services, with stronger

evidence for its use in adult populations (Reynolds et al.,

2009). Furthermore, reviews of the literature have revealed

higher quality research into the use of telehealth for

assessment rather than treatment services (Reynolds et al.,

2009). Interestingly, the respondents to this survey reported

using telehealth for the delivery of treatment services (86%)

over twice as often as assessment services (40.4%), and

the respondents used telehealth with paediatric clients

(78.95%) more often than adult clients (52.63%). While it

could be speculated that these ﬁndings suggest that some

SLPs who responded to this survey have not waited for a

ﬁrmly established evidence base before applying new

service delivery options to their practice, it is important to

remember that the types of treatment services provided via

telehealth more often included consultation (70.2%),

follow-up (66.7%), and support services (59.6%) than direct

therapy (45.6%). In the case of paediatric treatment

services this may have increased the proportion of

respondents reporting use of telehealth with this population.

Nevertheless, further exploration of the types of direct

treatment services provided to children via telehealth is

as signiﬁcant barriers to current use. Respondents identiﬁed

similar barriers to the expansion of telehealth services in

their clinical practice.

Facilitators

Respondents suggested a number of potential facilitators

for the further development of telehealth as a service

delivery option for SLP services (Figure 4). “Other”

suggestions (17.5%) included promotion and support of

telehealth and its growing evidence base in SLP, funding for

allied health assistants to be based in rural outreach clinics,

increased options for clients to access telehealth within the

community, clinical capacity to trial new things without

impacting on waiting lists, introduction of telehealth into

university courses to prepare new clinicians, and education

of clients about telehealth.

Discussion

The literature supports an emergent evidence base for the

use of telehealth in the provision of some SLP services;

however, it is unclear whether this has led to an expansion

in the use of telehealth in clinical practice. The responses to

the current survey provide information on the types of

technology being used in clinical telehealth in SLP, as well

as on the populations with whom telehealth is used. The

respondents to the survey provide an insight into some of

the beneﬁts, barriers and facilitators to the use of telehealth

in clinical SLP in Australia. It is important to note that the

small sample size and skewed geographic distribution of

the respondents place some limitations on the conclusions

which can be drawn. However, despite the sample being

small (n = 57), the respondents to this survey were

demographically similar to the SLP population in Australia

(SPA, 2005; Speech Pathologists Board of Queensland,

2010).

Telehealth settings and technology

The respondents to the current survey predominately

provided telehealth services from public health services and

private practice, contrasting with the ﬁndings of the ASHA

survey in 2002 in which most respondents provided

telehealth services from schools or non-residential health

care facilities. However, both surveys reported that the

majority of their clients accessed telehealth services from

their home. It remains unclear what type of technology

clients are using in their home.

A range of telehealth technology has been reported in

the research literature with videoconferencing being the

Professional development

Demonstrations by clinicians

Access to electronic resources

Funding to establish service

Formal training

Ethical guidance

Position paper by SPA

Patient education

University courses

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 4. Suggested facilitators to the development of telehealth in SLP

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 115

bodies are displaying in the use of telehealth bodes well for

the future of telehealth SLP services in Australia.

Limitations and future directions

This study is the ﬁrst of its kind examining the clinical use of

telehealth in SLP practice across Australia. The responses

from the study provide insight into how telehealth is being

used in clinical practice and suggests facilitators to enhance

this mode of service delivery; however, a number of

limitations around the design and distribution of the survey

were evident. A major limitation in the survey design was

the omission of a deﬁnition of telehealth at the beginning of

the survey. Inclusion of an unambiguous deﬁnition would

have provided respondents with a clearer understanding of

the nature and purpose of the survey and would have

reduced potential confusion between computer-based

therapy and telehealth. The other major limitation of the

survey was the exclusion of the clinicians not using

telehealth. Their inclusion would have substantially

enhanced the survey by providing a measure of the extent

of telehealth use in SLP, in addition to valuable information

on why these clinicians don’t use telehealth, the barriers

they have encountered, and their views on facilitators to

their future use of telehealth. Other limitations of the survey

design included a lack of questions regarding the types of

technology used by clients to receive telehealth services

and a clear delineation between direct therapy services to a

client and consultation or support services around a client,

particularly with regard to paediatric populations.

The authors made use of the national professional

association’s (Speech Pathology Australia) network

for distribution of the survey which afforded potential

participation by SLPs throughout Australia. However, other

distribution channels were also utilised (e.g., heads of

university SLP courses and leaders in Queensland Health).

The bias in using mainly Queensland-based organisations

may have produced a degree of bias in the results with

Queensland having the highest percentage of respondents

(42.1%). Furthermore, the survey was available only for 10

weeks. A longer timeframe and reminder emails may have

enabled a higher response rate.

The relatively small response to the survey (n = 57) may

have been due to a number of factors. The distribution and

design ﬂaws evident in the survey have almost certainly

contributed; however, another explanation may be that

the uptake of telehealth within SLP is still not widespread.

The broader telehealth literature has found that the clinical

use of telehealth is not as widespread as had been

predicted (Walker & Whetton, 2002). While the barriers to

using telehealth clinically as reported by the respondents

may provide some insight into reasons for low uptake of

telehealth, information from non-users would further clarify

the factors around uptake.

In order to track the clinical use of telehealth in SLP

practice, this study could be repeated every three to

four years to determine if telehealth has expanded or if

the aforementioned facilitators have been implemented.

Future studies should address the design and distribution

limitations of the current study to provide comprehensive

data on the clinical use of telehealth in SLP.

Conclusion

This study was conducted to determine the clinical use of

telehealth by SLPs in Australia. A wide variety of paediatric

warranted. Robust clinical research will be vital to the

establishment of a strong evidence base.

With regard to providing services to adults via telehealth,

ﬂuency treatment was most often delivered, followed by

dysarthria and voice therapy. These ﬁndings are in keeping

with the evidence base for using telehealth in the delivery

of ﬂuency and the LSVT

LOUD treatment programs (Carey

et al., 2010; Constantinescu et al., 2011). Closer analysis

revealed that ﬂuency treatment via telehealth was occurring

only in NSW and Victoria, while dysphagia management

via telehealth was occurring only in Qld. This may reﬂect

clinicians’ access to appropriate technology and hands-on

training by the actual centres or to researchers working

on establishing the telehealth evidence base for these

programs (Reynolds et al., 2009). These may well be

examples of the research translating into clinical practice.

Benefits, barriers, and facilitators

Respondents identiﬁed a range of beneﬁts to using

telehealth in clinical practice which were classiﬁed into ﬁve

major themes; access, time efﬁciency, client focus,

caseload management, and cost efﬁciency (see Table 1).

These beneﬁts have also been identiﬁed and discussed in

the research literature; indeed overcoming the issue of

access and promoting time efﬁciency are well-established

drivers of telehealth (Bashshur, 1995). Additional beneﬁts

telehealth may garner include meeting the needs of house-

bound clients and treatment in non-clinic environments

promoting generalisation (Mashima & Doarn, 2008; McCue

et al., 2010; Tindall, Huebner, Stemple, & Kleinert, 2008).

Telehealth has also been promoted as enabling clinicians to

cover a larger geographic area while providing more

services to patients (Mashima & Doarn, 2008) and this was

conﬁrmed by the current survey. This last point is especially

important in Australia as a third of the country’s population

lives in regional or remote areas (ABS, 2008).

Interestingly, 70.2% of survey respondents felt that

telehealth is a cost-effective service delivery option despite

a paucity of cost-beneﬁt research in SLP (Mashima &

Doarn, 2008; Tindall et al., 2008). True cost effectiveness

requires a beneﬁt-cost analysis to be examined within

the clinical evidence base (Davalos, French, Burdick, &

Simmons, 2009) and this remains an area in which more

research is required. Although the respondents considered

telehealth to be cost effective, they also expressed concern

about the cost of technology and availability of resources.

Similar barriers were identiﬁed in the ASHA survey (2002)

and the eHealth readiness survey by the DHA (2011). It will

be important for SLPs wanting to implement or expand

their telehealth services to use this increasing body of data

on barriers to lobby for change.

Respondents were generous in their suggestion of

facilitators to further develop telehealth as a service delivery

option. Professional development courses, demonstrations,

electronic assessment and treatment resources, and

funding to establish telehealth services were the most

desired, closely followed by formal training and ethical

guidance. The responses closely align to those reported

in the surveys by Dunkley et al. (2010) and ASHA (2002).

The ASHA survey (2002) also revealed that education and

training in telehealth through university or professional

development had facilitated the use of telehealth clinically in

the United States. Furthermore, the continued rollout of the

National Broadband Network and the interest government

116 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 117

and adult clients were reported to access SLP services via

telehealth with clinicians delivering a diverse range of direct

therapy. However, the results of the survey appear to show

a deviation from the emergent evidence base for telehealth

in SLP, with the majority of respondents using telehealth to

provide clinical treatment services to paediatric populations

despite a paucity of evidence in the literature. Clinicians

reported high levels of conﬁdence and satisfaction in the

services they delivered via telehealth.

Respondents identiﬁed a range of beneﬁts to using

telehealth in clinical practice and expressed a strong desire

to expand their telehealth services. However, signiﬁcant

barriers to this expansion were identiﬁed especially in

relation to technology, telecommunication infrastructure,

and resources. Clinicians suggested a number of facilitators

for the further development of telehealth in SLP and these

comments require careful consideration by the institutions

responsible for the education of SLPs and the provision of

SLP services to all client populations. With the Australian

government showing interest in telehealth, now is the time

for education and training into the telehealth delivery of

SLP services so that our profession is ready to respond to

new technologies, new telecommunication infrastructure,

and client demands for alternative service delivery options.

Telehealth will be part of the future for SLP in Australia and

should be embraced to facilitate the increased access to

services that clients with communication and swallowing

problems require.

Acknowledgments

We thank the participants. We also acknowledge Speech

Pathology Australia, the heads of department at all

universities with SLP courses across Australia, and the

heads of SLP departments in Queensland Health and

Education Queensland for helping distribute the survey.

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Lauren Miller graduated with ﬁrst class honours from The

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Dr Anne J. Hill

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9(2), 39–47.

Technology

118 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 119

Shane Erickson

(top), Susan

Block (centre)

and Ross

Menzies

This arTicle

has been

peer-

reviewed

Keywords

adUlT

inTerneT

sTUTTerinG

TreaTmenT

pattern), as well as the removal of strict programmed

schedules (O’Brian et al., 2001). The essential features

of the Camperdown Program make it suitable to be

adapted to models not requiring direct face-to-face contact

between clinician and client. This was demonstrated in

recent research investigating a telehealth version in which

participants received treatment via the telephone (Carey et

al., 2010; O’Brian, Packman, & Onslow, 2008). Telehealth

delivery particularly beneﬁts those clients isolated from

speech pathology services for geographical reasons –

in Australia, this is around one-third of clients (Wilson,

Lincoln, & Onslow, 2002). Rural areas in Australia have

low population density and large distances between urban

settlements making adequate provision of health services

difﬁcult.

Even in metropolitan areas difﬁculties accessing stuttering

treatment still exist because of the demands that traditional

treatment programs place on clinics and clinicians. Lifestyle

factors also present a barrier for metropolitan-based

clients seeking treatment. In addition to clinic fees for

treatment, direct and indirect costs are signiﬁcant and often

overlooked. These may include direct expenses such as

transportation and indirect costs including time off work

for clients and family members and childcare costs. Such

costs may make treatment prohibitively expensive.

Despite a reduced demand for resources compared with

traditional delivery models, there are still some limitations

with telehealth delivered stuttering treatments. First,

telehealth delivery requires specialist training and second, a

considerable amount of clinician time is still required (Carey

et al., 2010). Therefore, even though client travel time is

reduced, some indirect costs including client time away

from work remain.

Internet-based treatment may present a solution to

these problems by overcoming clinical infrastructure,

travel, and logistical issues for clinic administrators,

clinicians, and clients. Several Internet-based treatments

are now well established in other areas of health care, for

example, the “MoodGYM” site (MoodGYM, n.d.) provides

cognitive behaviour therapy (CBT) for depression. A recent

randomised controlled trial found that this Internet program

was a feasible and powerful intervention (Christensen,

Grifﬁths, & Jorm, 2004). “Fearﬁghter” is another computer-

based CBT program for the treatment of phobias and

panic attacks (Marks et al., 2003). It has been shown

to be efﬁcacious for more than 700 patients (Hayward,

MacGregor Peck, & Wilkes, 2007). While such programs

This Phase I pilot study assessed the viability

of a clinician-free Internet presentation of

speech restructuring treatment for chronic

stuttering. Two participants reduced their

percentage of stuttered syllables by 59% and

61% respectively from pre-treatment to

immediately following completion of the

program. Additionally, self-reported stuttering

severity and situation avoidance were also

reduced. These results were attained with

optimal clinical efﬁciency, without any

clinician contact, after 6 weeks for one

participant and 4 weeks for another.

Participants did not incur costs such as clinic

fees, travel, or time away from work for clinic

attendance. We conclude that further

development of this stand-alone Internet

treatment and clinical trialling is warranted.

tuttering is a developmental speech disorder that

usually begins when children are 3 or 4 years old.

It is common for those affected to not fulﬁl their

educational and occupational potential (Klein & Hood,

2004). Stuttering is associated with considerable personal

ﬁnancial cost (Blumgart, Tran, & Craig, 2010), and poses

obvious economic problems for society. Social anxiety

is common among those who stutter with social phobia

reported for up to 60% of clinical cohorts (Blumgart et al.,

2010; Iverach et al., 2009a), with those cohorts also at risk

for anxiety related mood and personality disorders (Iverach

et al., 2009b).

Considerable progress has been made with treatment

methods for chronic stuttering, with reviews of replicated

clinical trials favouring speech-restructuring procedures

(Bothe, Davidow, Bramlett, Franic, & Ingham, 2006;

Onslow, Jones, O’Brian, Menzies, & Packman, 2008).

Speech restructuring refers to the use of a new speech

pattern to reduce or eliminate stuttering while aiming to

sound as natural as possible (Onslow & Menzies, 2010).

Clinical trials have demonstrated the efﬁcacy of the

Camperdown Program, a speech restructuring treatment

(O’Brian, Cream, Onslow, & Packman, 2001; O’Brian,

Onslow, Cream, & Packman, 2003). This program utilises

an exemplar to model Prolonged Speech (PS) (and

no direct instruction in how to re-produce the speech

Stand-alone Internet speech

restructuring treatment for

adults who stutter

A pilot study

Shane Erickson, Susan Block, Ross Menzies, Mark Onslow, Sue O’Brian, and Ann Packman

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 119

were unknown to the participants, made one “routine” call

and one “challenging” call. Routine calls allowed the

participant to discuss self-initiated topics. Challenging calls

involved controversial topics and comprised a

predetermined number of interruptions and disagreements.

Participants were unaware of when the calls would be

made and that challenges would be included. Calls were

made to the participants’ mobile phones. Participants were

permitted to decline a call, for example, if it interrupted

work, but the subsequent call was not re-scheduled for a

speciﬁc time.

All eight audio recordings (two recordings at each

assessment for each participant) were de-identiﬁed

and presented in random order to a speech pathologist

specialising in stuttering treatment but independent of

the study. As well as being blind to the identity of the

participant, the speech pathologist was unaware of

the assessment from which the sample was obtained.

Measures of %SS were made using an EasyRater button-

press counting and timing device. To establish intra-rater

reliability, all recordings were re-presented to the observer

on a second occasion in random order. To establish

inter-rater reliability, all recordings were presented blind to

another experienced rater not associated with the study

and unaware of its purpose, who measured %SS with the

same button-press counting and timing device. The second

rater was also unaware of the identity of the participants

and the assessments from which their samples came.

Secondary outcome measures

Severity ratings. Participants provided self-ratings of their

stuttering severity in eight common speaking situations

using a written questionnaire before and after treatment.

These were talking with a family member, a familiar person,

an authority ﬁgure, a group, a stranger, talking by

telephone, when ordering food, and providing name and

address details. The participants were asked to rate their

“typical severity” for each situation using a scale of 1–9

where 1 = no stuttering, 2 = extremely mild stuttering, and

9 = extremely severe stuttering. Typical was deﬁned as the

score which would have been given for around 75% of

speaking time in each situation.

Avoidance. Participants also reported their avoidance of

these speaking situations, before and after treatment on the

aforementioned questionnaire. Participants were asked to

record their level of avoidance of these situations by circling

either never, sometimes, or usually for each situation.

Impact of stuttering. Impact was measured before

and after treatment using the Overall Assessment of the

Speaker’s Experience of Stuttering (OASES). This 100-

item scale has previously been established as a valid

and reliable method of establishing the overall impact of

stuttering (Yaruss & Quesal, 2006). Multiple aspects of the

condition are scored on a Likert scale and the total scale

takes approximately 20 minutes to complete. The OASES

contains four sections: (a) general information, (b) reactions

to stuttering, (c) communication in daily situations, and (d)

quality of life. An overall impact score is calculated based

on scores from all subscales.

Reliability

Given the small number of recordings, analysis of

agreement was considered more informative than

correlation analysis. For intra-rater agreement, all ratings of

the two observations (eight recordings) differed by less than

1.0 %SS. Regarding the inter-rater agreement, 75% of

have mostly shown similar outcomes to comparable

in-clinic services (Kenwright, Liness, & Marks, 2001), it

should be noted that long-term follow-up of participants

in these trials has been absent and drops outs have been

a considerable problem. Additionally, Internet-based

treatments raise signiﬁcant ethical issues such as how

to assess the appropriateness of clients for this delivery

method and whether clients are monitored for their

response to treatment.

Because of the prominence of social anxiety among

those who stutter, and hence the possibility of social

avoidance, the Internet would have the additional

advantage of allowing treatment to be accessed with

anonymity (Tate & Zabinski, 2004). Clinical trials of the

stand-alone “CBTpsych.com” site for social anxiety in

adults who stutter have shown encouraging compliance

rates and effect sizes (Helgadóttir, Menzies, Onslow,

Packman, & O’Brian, 2011).

In consideration of the aforementioned potential beneﬁts

Internet-based treatment could offer, including increased

access to treatment and a potential reduction in costs and

resources, the aim of the current study was to develop and

trial an Internet-based, clinician-free modiﬁed Camperdown

Program. This pilot study was designed to assess the

viability and safety of the program. A positive outcome for

a preliminary trial would justify continued development of

such a delivery model for adult stuttering treatment.

Method

Participants

Participants were two stuttering adults who had sought

treatment at the La Trobe University Communication Clinic

in Melbourne, Australia. Participant 1 was a male 22-year-

old full-time university student who worked part-time as a

hospital ward clerk. Participant 2 was a 30-year-old female

with secondary school education who worked part-time as

a masseuse. Neither participant had received speech

restructuring treatment previously. Participant 1 had

received stuttering treatment focusing on reading as a child

while Participant 2 had completed tongue exercises,

singing, reading, and rate control more than 10 years

previously.

Procedure

The participants were invited to participate during an initial

clinic assessment. After this session no personal contact

was made with either participant. The participants received

hard copies of the questionnaires outlined below during the

initial assessment and returned these via mail prior to

commencing treatment. Post-treatment questionnaires

were sent to the participants and returned via mail after the

completion of their speech measures.

Immediately after pre-treatment measures were taken,

the participants were emailed a link to the treatment

website and login details. Emergency contact details of a

technical person involved in the construction of the website,

but not familiar with the aims of the study, were provided at

the beginning of the program in case of technical problems.

Primary outcome measure

The primary outcome measure was percentage of syllables

stuttered (%SS). At each assessment point, during the

week prior to starting the program, and immediately after

completion of the ﬁnal phase of the program, two randomly

scheduled 10-minute telephone conversations were

recorded for each participant. Research assistants who

Mark Onslow

(top), Sue

O’Brian (centre)

and Ann

Packman

120 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 121

Phase 4

Participants make a series of 1–2 minute recordings of

self-generated monologues at naturalness 9 and severity 1.

As in the previous phase, participants are asked to evaluate

and compare their recordings with the exemplar.

Participants are required to complete three recordings of

1–2 minutes using their new speech pattern to remain

stutter free.

Phase 5

Participants are required to complete three consecutive

self-generated 3-minute monologues and then three

consecutive 10-minute monologues at naturalness 9 and

severity 1. Participants are asked to reﬂect on any changes

to the daily severity ratings made for their nominated ﬁve

representative speaking situations. In this phase, the site

suggests that participants regularly practise using their new

speech pattern by completing subsequent monologues at

naturalness 9 and severity 1. It is suggested that

participants enlist a “speech buddy” to help with practice or

continue to self-evaluate using recordings.

Phase 6

The site introduces participants to the concept of improving

speech naturalness using the speech pattern, and how to

measure changes with the naturalness scale. Example

recordings of stutter-free speech produced at different

naturalness levels from 1 to 9 (as judged by expert consensus)

are presented. Participants complete a quiz to identify the

naturalness of speech examples at different levels.

Phase 7

The site provides a video tutorial which explains (a) the

Camperdown Program procedure for instating natural-

sounding stutter-free speech using speech cycles (practice,

trial and evaluation), and (b) the performance-contingent

protocol for progression through the cycles (see O’Brian,

Cream, Onslow, & Packman, 2001). Participants are

required to produce at least six consecutive cycles with

severity 1–2 and naturalness 1–3 practising alone, as well

as at least six cycles talking with a friend or family member.

Links are provided to assist participants with a range of

clinical problems typically encountered such as sounding

less natural than intended or conversely stuttering when

trying to improve naturalness. In the event of repeated

failure to attain program criteria, the site provides possible

reasons for this and strategies for solving the problem

during the next cycle attempt.

Phase 8

During this phase participants are required to make speech

recordings and self-reports of their severity and naturalness

in representative, everyday situations. Participants use the

ﬁve speaking situations nominated during Phase 1, ranking

them in order from easiest to hardest based on their

average daily severity scores since starting treatment.

Participants are encouraged to make a series of 10-minute

conversations with a goal of maintaining a naturalness of

1–3 and a severity of 1–2. Participants start with their

easiest situation and progress to more difﬁcult situations as

they meet progression criteria.

Phase 9

This maintenance phase has been built into the Internet site

using the standard Camperdown Program format. However,

participants did not complete this phase because this trial

was intended only to establish the viability and possibility of

a treatment effect using the program. Nonetheless, the

ratings (6 recordings) differed by less than 1.0 %SS and

100% differed by less than 2.0 %SS.

The Internet program

The program adopts the primary methods of the

Camperdown Program (O’Brian et al., 2008). These are (a)

an operationalised video model for teaching the speech

restructuring pattern, (b) no programmed instruction to

instate natural-sounding stutter-free speech, (c) no formal

transfer tasks to assist generalisation of stutter-free speech,

and (d) a 9-point severity rating scale to replace %SS

measures and a 9-point naturalness rating scale to evaluate

speech quality. As this trial aimed to test only the feasibility

of the program to reduce stuttering, participants did not

complete the maintenance stage.

A linked administration website was developed as a

database for storage of participant responses. Researchers

were able to locate the time and date of a participant’s

use of the program and determine their current stage

of treatment. Additionally, responses to the program’s

interactive questions were able to be stored and reviewed

by the researchers. These questions related mainly to the

participants’ understanding of treatment concepts.

The program consists of nine phases and begins by

presenting background information and the requirements

of the program. Participants require a recording device with

sufﬁcient memory to record 10 minutes of conversation.

The participants are informed that phases of treatment will

only become unlocked once they have completed the goals

for the previous phase. However, they can always return

to past phases if more practice at that level is required. At

the start of every phase, participants are informed of the

anticipated time required to complete the phase.

Phase 1

Participants identify ﬁve speaking situations representative

of their daily life and assign and graph a typical and worst

severity score for each. Typical is deﬁned as around 75% of

speaking time in the situation and worst as the most severe

level that occurred. The participants are required to begin

assigning a severity score to at least one of the ﬁve

situations each day. The site provides audio examples of

stuttered speech and corresponding severity scores (as

judged by expert consensus) to guide participants with

scoring.

Phase 2

Participants are provided with the Camperdown speech-

restructuring model along with instructions to imitate the

speech pattern without stuttering. They are required to read

in unison with the model, record each attempt and then

judge, during playback, whether the imitation closely

approximated the model.

Phase 3

When participants are satisﬁed that they can imitate the

model in unison with the recorded exemplar, they are

required to practise reading it aloud without the recording.

These attempts are recorded and reviewed for accuracy

and ﬂuency. The target is to achieve three consecutive

attempts to criteria of speech naturalness 9 and stuttering

severity 1. In other words, the goal is to produce highly

unnatural sounding speech with no stuttering. If participants

have difﬁculty imitating the target speech pattern or are

unable to use it to stop stuttering, they are required to

repeat the above sequence of tasks, recruiting help from a

friend or family member, if needed, to explore differences

between the model and their attempted imitations.

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 121

treatment hours could not be accurately determined

because it was unclear how much time during each login

the participants spent doing the treatment. For example,

the participants may have logged in and left the computer

unattended. Neither participant contacted the researchers

for technical support.

Per cent syllables stuttered

Figure 1 presents %SS scores for each beyond clinic

telephone call pre-treatment and post-treatment. Marked

improvements were noted for both participants in each of

the assessment calls after treatment. Participant 1 recorded

a 61% reduction in stuttering frequency for the routine call

and a 57% reduction for the challenging call. Participant 2

recorded a 79% reduction in stuttering frequency for the

routine call and a 42% reduction for the challenging call.

Severity ratings

The mean self-reported typical stuttering severity in the

eight situations for Participant 1 (Figure 2) pre-treatment

was 7.0 (range 3–9) and post-treatment was 5.1 (range

1–7). For Participant 2 (Figure 3) the mean severity rating

was 6.0 (range 6–6) before treatment and 1.4 (range 1–2)

after treatment. Participant 1 reported an improvement in

seven of the eight situations. Interestingly, the only speaking

situation with no improvement was the telephone (where

the speech measure was obtained). Further, Participant 1

reported only small improvements when speaking to a

stranger. Participant 2 reported a large improvement for

each of the speaking situations, with typically no stuttering

(severity 1) in ﬁve of the eight situations and very mild

stuttering (severity 2) in the other three situations (group,

stranger, authority).

importance of maintenance cannot be understated and

future users will be encouraged to make regular recordings

of their speech in everyday speaking situations and evaluate

them for naturalness and severity. Users will be able to

record results from these attempts on the Internet site and

graph their progress. Additionally, the site will provide

prompts to encourage problem solving should they not

achieve a naturalness of 1–3 and severity of 1–2 in each

recording.

Results

Clinical progress

Participant 1 completed the program in just over 6 weeks,

logging in 26 times. Participant 2 completed the program in

4 weeks and logged in 35 times. The speciﬁc number of

% Syllables stuttered

P1 Routine P1 Challenge P2 Routine P2 Challenge

Participant and recording type

Pre-treatment

Post-treatment

Typical severity

Family Familiar Group Stranger Authority Phone Ordering Name

Situation

Note: 1 = no stuttering, 2 = extremely mild stuttering, 9 = extremely severe stuttering

Pre-treatment

Post-treatment

Typical severity

Family Familiar Group Stranger Authority Phone Ordering Name

Situation

Note: 1 = no stuttering, 2 = extremely mild stuttering, 9 = extremely severe stuttering

Pre-treatment

Post-treatment

Figure 1. Primary speech outcome – %SS

Figure 2. Participant 1 – Self-report

Figure 3. Participant 2 – Self-report

122 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 123

Clinical implications

These results were attained with optimal clinical efﬁciency,

without any clinician contact. Participants had the

convenience and ﬂexibility of accessing a treatment without

visiting a clinic, thereby eliminating costs associated with

clinic fees, travel, and time away from work. The program

also allowed the participants to complete the program at

their own pace. One participant required 6 weeks to

complete the treatment and another required 4 weeks. This

suggests that the Internet-based treatment was sufﬁcient to

motivate these participants. Further research could

establish the number of hours required to complete

treatment.

Clearly this clinician-free delivery will not be suitable for all

clients and it is not the intention of this development to aim

for this. Some clients will prefer and/or need the continued

input of a clinician; however, it may also be that clients can

use a combination of Internet delivery and clinician input. A

more reﬁned version of the program also will be useful for

generalist clinicians who may have limited experience or

limited skills treating adults who stutter. For these clinicians,

the program also may act as a guide for treatment.

Limitations and future research

The limitations of this pilot study are clear but should be

acknowledged. The paper presents the results of just two

participants and provides only descriptive analysis of their

results. Generalisations beyond these two participants

cannot be made. Additionally, this study does not report

long-term follow-up data. However, given it is essentially a

proof of concept study the primary aim was to establish the

feasibility of the program. The ﬁndings suggest that further

development of this Internet-based program may make

treatment available to many adult stuttering clients who

have access to the Internet but who, for geographic and

other reasons, are isolated from treatment services.

Future research could also address issues beyond the

scope of this preliminary study. For example, larger scale

trials may be able to identify particular client characteristics

that predict success. Additionally, ethical issues should

be considered such as responsibility for clients who

don’t respond to treatment, deciding how clients access

the treatment (i.e. open access or only via a speech

pathologist) and whether safeguards are needed to ensure

that only adults access the program.

During the course of this trial we discovered many

potential improvements to the program, and plan further

development and reﬁnement. Some of these improvements

include improved website design for better client

interactivity and increased database monitoring of client use

of the program. Judging by the process of development

and reﬁnement of a stand-alone site for cognitive behaviour

therapy for stuttering clients (Helgadóttir et al., 2011),

such pursuits may be productive. In principle, there is no

reason why continued development and clinical trialling

of this treatment method should not produce outcomes

comparable to the in-clinic or telehealth delivered

Camperdown Program.

References

Blumgart, E., Tran, Y., & Craig, A. (2010). Social anxiety

disorder in adults who stutter. Depression and Anxiety, 27,

687-92.

Bothe, A. K., Davidow, J. H., Bramlett, R. E., Franic, D.

M., & Ingham R. J. (2006). Stuttering treatment research

1970–2005: II. Systematic review incorporating trial quality

Avoidance

After treatment, Participant 1 reported never avoiding three

situations that he previously avoided sometimes or usually

(family, familiar person, group). Two further situations

(ordering food and providing name and address) reduced

from usually avoided to sometimes avoided. The remaining

three situations were unchanged. Participant 2 reported

that after treatment she never avoided three situations she

previously avoided sometimes (phone, ordering food, and

providing name and address). Additionally, after treatment

the “group” situation was avoided sometimes after

previously avoiding it usually. The remaining four situations

were unchanged; however, two (family and familiar people)

were previously never avoided and two (stranger and

authority) were sometimes avoided.

Impact of stuttering

After treatment, both participants improved their scores in

each of the four sections assessing the impact of stuttering

as well as the “overall” OASES scale. Participant 1’s

“overall” impact was reduced from a severe level (77) to a

moderately severe level (62), and Participant 2 from a

moderate level (58) to a mild-moderate level (34).

Participant 1 recorded the largest impact reduction

post-treatment in the “communication in daily situations”

section (from 74 severe to 54 moderate) while Participant 2

recorded the largest reductions in “quality of life” (57

moderate to 25 mild) and “reactions to stuttering” (75

severe to 38 mild-moderate).

Discussion

This pilot study assessed the viability of a stand-alone

Internet speech restructuring program for the reduction of

stuttering with two participants. It is the ﬁrst published

investigation of Internet-delivered treatment for adults who

stutter. Positive outcomes suggest the program is

manageable and has the potential to reduce stuttering

without any clinician input.

Stuttering reduction was conﬁrmed with both objective

and self-report data. The two participants reduced their

stuttering by an average of 59% and 61% respectively

from pre-treatment to post-treatment. Despite the obvious

advantages this program provides, the stuttering reductions

are not as substantial as previously reported Camperdown

Program variants in a similar phase of research. For

example, the 10 participants who completed O’Brian et

al.’s (2008) pilot study using telehealth delivery reduced

their stuttering by an average of 82%. However, it should

be noted that there was considerable individual variation,

with 3 of the 10 participants reducing their stuttering by

less than 80%. Additionally, O’Brian et al.’s (2003) clinician-

delivered Camperdown Program yielded a mean 95%

reduction immediately after treatment.

Participant reports of typical severity during everyday

speaking situations in this trial were consistent with

the objective data. Similarly, both participants reported

considerable reduction in avoidance of speciﬁc speaking

situations post-treatment. This is an important ﬁnding in

light of the social anxiety that is typical for many stuttering

adults (Iverach et al., 2009a). Furthermore, the treatment

improved quality of life measures for both participants,

albeit to a small degree. Therefore, while both participants

were still stuttering mildly after treatment, it appears the

program yielded further positive effects beyond reducing

surface stuttering behaviours.

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 123

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MoodGYM. (n.d). The MoodGYM training program mark

III. Retrieved from http://moodgym.anu.edu.au/welcome

O’Brian, S., Cream, A., Onslow, M., & Packman, A.

(2001). A replicable, non-programmed, instrument-free

method for the control of stuttering with prolonged speech:

Paper presented at the 2nd Asia Paciﬁc Conference on

Speech, Language and Hearing, Part IV. Asia Paciﬁc

Journal of Speech, Language and Hearing, 6, 91–96.

O’Brian, S., Onslow, M., Cream, A., & Packman, A.

(2003). The Camperdown Program: Outcomes of a new

Shane Erickson is a speech pathologist, researcher, and clinical

placement supervisor at La Trobe University. Susan Block is the

co-ordinator of the undergraduate speech pathology program at La

Trobe University. Ross Menzies is a clinical psychologist and

director of the Anxiety Clinic at Sydney University. Sue O’Brian is

senior research ofﬁcer at the Australian Stuttering Research

Centre. Mark Onslow is director of the Australian Stuttering

Research Centre. Ann Packman is senior research ofﬁcer at the

Australian Stuttering Research Centre.

Correspondence to:

Mark Onslow

Director

Australian Stuttering Research Centre

The University of Sydney,

PO Box 170, Lidcombe 1825, NSW

phone: +61 (0)2 9351 9061

email: mark.onslow@sydney.edu.au

Technology

124 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 125

Keywords

dysphaGia

head and necK

cancer

TelehealTh

Tele-

rehabiliTaTion

This arTicle

has been

peer-

reviewed

Elizabeth C.

Ward (top) and

Clare Burns

What’s the evidence?

Use of telerehabilitation to provide specialist

dysphagia services

Elizabeth C. Ward and Clare Burns

In this edition of “What’s the evidence?” the

scenario explores the challenge of providing

specialist rehabilitation services for a rural

patient on their return home from a metro-

politan centre following head and neck (H&N)

cancer management. Within Queensland, two

hospitals located in the capital city provide

the majority of the state-wide specialist care

services for patients with H&N cancers. Hence

many non-metropolitan patients are required

to travel signiﬁcant distances to access these

specialist services during and post treatment.

As part of their role, the specialist clinicians

at the metropolitan centres provide outreach

and clinical support to non-metropolitan

clinicians who support the patients on their

return home. This scenario explores the

potential of using telerehabilitation as a

service delivery model for a patient located

outside the metropolitan centre. It also

highlights the use of telehealth to provide

mentoring and support for the local clinician.

Clinical scenario

Mr Jones (58) manages a large cattle property in western

Queensland. He presented to his general practitioner with a

4-month history of dysphagia, weight loss, and

odynophagia (pain on swallowing). He was subsequently

referred to the combined head and neck (H&N) clinic of a

large metropolitan hospital (1,400 km away) for specialist

services where he was diagnosed with a tumour of the left

pyriform fossa with nodal involvement (T2 N1 SCC) and

underwent chemoradiotherapy.

On completion of treatment Mr Jones continues to

experience moderate dysphagia. A modiﬁed barium

swallow (MBS) assessment establishes he is safe for

small amounts of puree diet and moderately thick ﬂuids;

however, he requires nasogastric tube (NGT) feeds to meet

his hydration and nutritional requirements. Due to ﬁnancial

difﬁculties and work commitments he is desperate to

go home and the team support this, providing adequate

speech pathology follow-up can be arranged. Mr Jones

requires intensive swallowing intervention to enable

transition to full oral intake and removal of the NGT. You are

aware that the speech pathologist working in Mr Jones’

local health service is a recent graduate who has no clinical

experience in managing patients with H&N cancer. You

contact her and she expresses concern with independent

management of this case and requests support. In your

role as the specialist clinician in the metropolitan cancer

service, you provide mentoring and clinical support to

colleagues within your cancer service district. Support is

typically provided via email and telephone. However, given

(a) the severity of Mr Jones’ dysphagia, and (b) the novice

clinician’s request for mentoring, you feel that more direct

assistance with his ongoing rehabilitation is needed. To

help address these issues, you consider the possibility

of a specialist consultation service via telerehabilitation to

provide some shared clinical sessions with this patient and

his local clinician on his return home.

Response to this scenario

Addressing the difﬁculties encountered by patients

accessing health care demands the adoption of different

modes of service delivery (Bashshur, 1997; Yellowlees &

Brooks, 1999). Telehealth, the delivery of health care

services using technology, is one mode of health care

service delivery that allows patients to access specialist

services by alleviating the barriers of distance, immobility,

travel time, and cost (Kuo, Delvecchio, Babayan, &

Preminger, 2001; Mun & Turner, 1999). Furthermore, it has

been suggested that this mode has the potential to help

clinicians optimise the timing, intensity, and sequencing of

therapy services to help facilitate patient outcomes (Winters

& Winters, 2004). This case scenario provides an

opportunity to explore telehealth/telerehabilitation services

and address questions including: “Is telerehabilitation

suitable for this patient?”, “Do I have access to technology

to provide the service?”, and then “What’s the evidence?”

Recent guidelines note that “the candidacy and

appropriateness for telerehabilitation should be determined

on a case by case basis with selections ﬁrmly based on

clinical judgement, client’s informed choice and professional

standards of care” (Brennan et al., 2011, p. 664). You

consider your patient and his situation, his pressing

need for ongoing swallowing rehabilitation, his age and

motivation, and the concerns of the remote new graduate

clinician and determine that there are multiple factors

favouring the use of telerehabilitation. You then consider

the issue of equipment availability. You are aware there is

general videoconferencing as well as specialist technology

available in your metropolitan hospital setting. You contact

the local coordinating service and establish that there is

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 125

videoconferencing equipment (with standard single ﬁxed

adjustable zoom camera) available to use and that similar

equipment is available at the regional setting.

With the answers to your initial questions largely positive,

you now seek the evidence for providing telerehabilitation.

You need evidence for two reasons. First, you need

evidence to justify this alternate mode of service delivery

to your line manager. Second, you are seeking information

from the literature to inform how best to deliver the service.

Developing an answerable

clinical question

You begin by using the PICO framework to develop your

clinical question (Sackett, Richardson, Rosenberg, &

Haynes, 1997). This involves considering the Patient or

Problem, the Intervention, any Comparison intervention,

and speciﬁc Outcomes you are seeking (Asking a good

Question PICO: http://www.usc.edu/hsc/ebnet/ebframe/

PICO.htm). Studies have found a trend for higher

percentages of relevant citations found when searching

using PICO formatted questions (Schardt, Adams, Owens,

Keitz, & Fontelo, 2007).

Patient or problem

Your actual speciﬁc “patient/problem” group is H&N

patients with dysphagia following chemoradiotherapy.

However, you are aware that telerehabilitation is a relatively

new area of service delivery for speech pathology and the

chances of ﬁnding data on this particular subset of patients

are remote. Hence you feel it is more beneﬁcial to further

widen your “patient/problem” group to patients with

dysphagia to ensure you access all relevant literature, then

narrow this down further to the H&N clinical subgroup if

evidence is available.

Intervention

In this situation, you are not necessarily examining an

intervention but rather a model of care, hence your

“intervention” in this case is telerehabilitation. In this

emerging ﬁeld of technology, many terms are used to

describe the provision of health services through a remote

manner. Although telerehabilitation is the speciﬁc term used

to deliver rehabilitation services via technology, not all

studies use this term. For instance in policy documents of

the American Speech Hearing Association (ASHA) the term

“telepractice” is the adopted terminology (Brown, 2011). As

such, it will be important to search all main terms used in

this ﬁeld such as: telehealth, telemedicine, telepractice,

telecare, and telerehabilitation.

Comparison intervention

The comparison intervention is traditional face-to-face (FTF)

practice.

Outcomes

The standard for evaluating a tele-service is to ensure that

the quality of the services delivered via this modality are

comparable with those delivered via traditional FTF services

(American Speech-Language-Hearing Association, 2005).

Hence, the outcome you are seeking in your evidence

search is whether or not dysphagia services can be

delivered via telerehabilitation, and to standards comparable

to traditional clinical practice.

Clinical question

In light of the considerations above, your clinical question

for this scenario is “Can telerehabilitation be used to provide

management services for an individual with dysphagia

following chemoradiotherapy?”

Searching for the evidence

You don’t have access to database searches via your ofﬁce

desktop so the hospital librarian assists you to run searches

through PubMed, CINAHL, PsychINFO, the Cochrane

library, and SpeechBITE

. In your search terms you use *

to truncate terms, – e.g., swallow* (note: some databases

use $ instead of * to truncate words eg., swallow$) – to

indicate to the search engine to ﬁnd words with those ﬁrst

letter strings (e.g., swallow, swallows, swallowing). When

you try using tele* to cover all possible telehealth terms you

ﬁnd over 600 hits with the majority not relevant due to

unrelated words, e.g., telephone. Hence you proceed using

all telehealth terms you know linked by or (NHMRC, 2000).

Your ﬁnal search term looks like this: (dysphagia OR

swallow*) AND (telecare OR telemedicine OR telehealth OR

telerehabilitation OR telepractice). You limit you search to

English papers only.

Your searching provides the following results: PubMed

= 17, CINAHL = 9, PsychINFO = 4, Cochrane = 0, and

SpeechBITE

= 0. After removing duplicates, erroneous

hits, and excluding papers determined as unsuitable, you

ﬁnd you have a list of 13 possible papers. On return to

your ofﬁce you run a ﬁnal search in Google Scholar from

your work desktop using the advanced search builder. This

produces 589 hits. All 13 papers found in the databases

were located on the ﬁrst few pages of Google Scholar

search, and a further 7 possible articles were located. A

further 10 pages (at 10 hits per page) were scanned. When

no further new scientiﬁc literature was identiﬁed the search

was terminated.

After reading the 20 publications you found, 7 were

subsequently excluded as they either (a) were general

discussion papers, (b) covered aspects of telehealth

practice other than speech pathology, (c) discussed

the use of technology for remote assessments for other

scientiﬁc purposes, not telerehabilitation, (d) did not involve

adult patients, or (e) neither the publication source nor

year of publication could be veriﬁed (Internet document).

This left 6 general review papers and 7 scientiﬁc papers.

Cross searching of the reference lists of these papers

revealed one further paper for consideration. As the review

papers were general discussions of the literature, were

not systematic reviews, and contained all articles you had

found, these were ultimately excluded, bringing your total

set of papers for review to 8. Of these, there were 3 papers

speciﬁcally related to studies using telehealth to assess

and manage H&N cancer populations. A further 5 papers

were speciﬁc to swallowing management via telehealth for

other clinical populations; however, only 3 of these were

relevant. The others related to the equipment (Perlman &

Witthawaskul, 2002) and then the application of remote

MBS assessments of swallowing (Malandraki, McCollough,

He, McWeeney, & Perlman, 2011). As performing

remote MBS is beyond the nature of the service you are

considering right now, these 2 papers were not included

in your review . Table 1 lists the 6 papers relevant to this

review.

Using the NHMRC matrix for evaluating a body of

evidence (NHMRC, 2009) you classify the body of evidence

in Table 1 in relation to your clinical question as follows:

Evidence base – good; Consistency – good; Clinical

impact – satisfactory; Generalisability – satisfactory; and

Applicability – good. Furthermore, your overall decision

126 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 127

from cancer care patients. Although it is an assessment

paper not research evidence for rehabilitation, the ability

to assess and detect aspiration risk when dealing with a

patient remotely is a primary safety issue addressed by this

paper. Your critique is detailed in Table 2.

Clinical bottom line

There is currently Level III-2 evidence to support the

assessment of dysphagia and weak Level IV evidence for

the provision of ongoing dysphagia rehabilitation via

telerehabilitation. Hence there is some positive evidence to

support the use of telerehabilitation for this client, though

you acknowledge that this recommendation is only at

NHMRC level “C” – meaning that this recommendation

regarding the Grade of Recommendation (NHMRC,

2009) is a “C” meaning “Body of evidence provides some

support for recommendation but care should be taken

in its application”, largely because there is evidence for

assessment but only very weak evidence for rehabilitation.

Equally, the evidence base is still small, with limited

numbers and patient diversity to date.

One of the primary concerns of your line manager is the

relative safety of managing dysphagia via the telehealth

modality, so you decide to critique in more detail the paper

presenting the strongest evidence. The paper by Ward,

Sharma, Burns, Theodoros, and Russell (2012) has the

largest cohort studied; it includes patients with actual

aspiration risk; and you note that 45% of the cohort came

Table 1. Key research articles identiﬁed

Author

(date)

Nature of telerehabilitation

consultation

Clinical

population

Evaluation Outcome Level of

evidence*

Lalor et al.

(2000)

Assessment of language

and swallowing via satellite

connection

Single case post

CVA

Case discussion and

review of problems

and solutions faced

during assessment

Concluded it was possible to

determine the nature and extent

of the swallowing and language

problems despite the challenges

Myers

(2005)

Case descriptions (n = 3)

of providing (a) speech and

psychological support, (b)

support and therapy for voice

and swallowing issues, and (c)

voice prosthesis management

via videoconferencing

2 total

laryngectomy and 1

chemoradiotherapy

patients

Limited case

discussion of

management

provided via

telerehabilitation for

3 cases

Concluded utility for telehealth in

the management of patient with

H&N cancer is promising

Sharma et

al. (2011)

Performed CSE using a

customised videoconferencing

system with additional

capabilities (store and

forward; free standing zoom

capable web camera, lapel

microphone) and including

modiﬁcations incorporated

into the CSE protocol to assist

online assessment

10 standardised

patients portraying

2 each of normal,

mild, moderate,

and severe

dysphagia

Levels of agreement

between diagnostic

decisions from

simultaneous

FTF and online

assessments

High levels of agreement found

between online and FTF decisions

across all aspects of the clinical

swallow assessment: general

orientation, alertness, and

posture; oromotor and laryngeal

assessment; and decisions and

recommendations

III-2

Ward et al.

(2007)

Assessment of alaryngeal

speech and swallowing

via a system providing

videoconferencing and

additional capabilities (store

and forward)

20 laryngectomy

patients

Compared diagnostic

decisions from

simultaneous

FTF and online

assessments of

communication,

swallowing, and

stoma status

Found acceptable levels of

agreement between online and FTF

ratings for oromotor, speech, and

swallowing clinical decisions, but

issues with limited vision from ﬁxed

webcameras. Clinicians reported

reduced satisfaction. Patient

satisfaction was high

III-2

Ward et al.

(2009)

Assessment of alaryngeal

speech and swallowing using

custom built telerehabilitation

units providing real-time

videoconferencing with

additional capabilities (store

and forward; additional free

standing zoom capable

webcameras)

10 laryngectomy

patients

Compared diagnostic

decisions from

simultaneous

FTF and online

assessments of

communication,

swallowing, and

stoma status

With new system modiﬁcations

since the Ward et al. (2007) paper

this study found acceptable levels

of agreement between online and

FTF ratings for oromotor, speech,

swallowing, and stoma status.

Clinicians and patients reported

high satisfaction

III-2

Ward et al.

(2012)

Performed CSE using the

customised videoconferencing

system with additional

capabilities plus the CSE

modiﬁcations as detailed in

Sharma et al. (2011)

40 patients from

inpatient and

outpatient caseload

Levels of agreement

between diagnostic

decisions from

simultaneous

FTF and online

assessments

Clinically acceptable levels of

agreement found between online

and FTF decisions across: oral,

oromotor, and laryngeal function;

food and ﬂuid trials; aspiration risk;

and clinical management decisions

III-2

Note: * NHMRC (2009); FTF = face-to-face; CSE = clinical swallow examination; CVA = cerebrovascular accident

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 127

administer and evaluate a MBS assessment (Perlman &

Witthawaskul, 2002; Malandraki et al., 2011), unfortunately

the rural service to which the patient is returning does not

have MBS facilities. Although you can commence treatment

based on the instrumental study performed at the

metropolitan hospital prior to your client being discharged

home, it is acknowledged that it may be necessary in the

future for the client to return to the metropolitan setting for

further instrumental review.

Patient perceptions of this mode of service

In your readings you noted that studies report positive

patient perceptions regarding receiving speech pathology

services via telerehabilitation. This gives you further

conﬁdence to try this mode of service delivery. In particular,

the positive patient satisfaction data reported by Ward et al.

(2007) and Ward et al. (2009) for laryngectomy patients

following a telerehabilitation assessment of their

communication and swallowing has most relevance to your

current client. You do acknowledge that this data was

based on perceptions of a single assessment session only,

so you plan to monitor your client’s perceptions and

concerns closely over the course of the sessions.

Conclusion

Although there is only weak evidence for the use of

telehealth for dysphagia rehabilitation, the overall results of

the review, and the evidence supporting telehealth

“must be applied carefully to individual and organisational

circumstances and should be interpreted with care”

(NHMRC, 2009, p. 8).

Technology concerns

From your review you realise that although many elements,

such as the appropriate connection bandwidth, and use of

modiﬁed utensils and throat markers during dysphagia

assessments (see Ward et al., 2012) can be easily

implemented in your own sessions, most research has

used more advanced technology systems than are available

to you. In particular, you can see the limitation of not having

components such as store-and-forward capabilities (Ward

et al., 2007; Ward et al., 2009; Ward et al., 2012), which

record the session and allow playback for later clinical

decision-making, or free-standing cameras with lighting for

better oral cavity visualisation. However, you reﬂect that you

do have a speech pathologist in the room with the patient

who is simultaneously assessing the patient and can assist

with clariﬁcation and veriﬁcation of any missed information.

Managing remote instrumental

swallowing assessment

Your primary concern is the rehabilitation of safe swallowing

for this client. While the evidence supports the use of

telerehabilitation for conducting clinical swallowing

assessments, for ongoing rehabilitation you will want

access to instrumental assessment data. Although there is

preliminary evidence to support the use of technology to

Table 2. Critically appraised article

Article purpose Establishing the validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment

via telerehabilitation

Citation Ward, E. C., Sharma, S., Burns, C., Theodoros, D., & Russell, T. (2012). Validity of conducting clinical dysphagia assessments

for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia. doi: 10.1007/s00455-011-9390-9

Design Non-inferiority cohort study

Level of evidence NHMRC Level III-2 (for diagnostic studies)*

Quality of evidence Only 14% of the 47 items in the “Recommended reporting elements” of the extended Strengthening the Reporting of

Observational Studies in Epidemiology (STROBE) checklist

were not reported (40% not applicable). Average non-reporting

rates across 60 published cohort studies has been found to be 23.6%

Participants 40 participants with mild (28%), moderate (55%), moderate-severe (7%), and severe (10%) dysphagia from inpatient and

outpatient caseload of a large metropolitan hospital. Aetiology: 55% acquired or progressive neurological conditions and

45% cancer care patients. Patients with greater than mild cognitive impairment were excluded.

Experimental group Telerehabilitation assessment of a clinical swallow assessment. Assessments conducted simultaneously by an online

clinician and a FTF clinician (located in the room with the participant). Speciﬁc system modiﬁcations and modiﬁcations to

the clinical swallow exam were detailed.

Results Levels of agreement between the diagnostic decisions made online and FTF reached clinically acceptable levels of

agreement (criteria: 80% exact agreement and/or Kappa >0.6): agreement for the oral, oro-motor, and laryngeal function

tasks ranged from 75%–100% (Kappa 0.36–1.0); ratings of food and ﬂuid trials ranged from 79%–100% (Kappas

0.61–1.0); and parameters related to aspiration risk and clinical management had exact agreement ratings between 79%

and 100% (Kappas 0.49–1.0). High clinician ratings for: overall satisfaction, ease of use, ability to competently assess the

patient, ability to generate rapport, and audio and visual quality.

Summary When using the described purpose-built telerehabilitation system with the described modiﬁcations to the CSE and the use

of an assistant at the patient end, there is comparable clinical accuracy between diagnostic decisions on the CSE made

online and FTF in patients with normal to mild cognitive impairments. Further research is needed to assess accuracy using

other types of technology to perform dysphagia assessments and the use of these systems with more clinically diverse

patient populations.

Clinical bottom line Performing a CSE via telerehabilitation can achieve comparable clinical decisions to those made in the FTF clinical

environment for individuals with normal to mild cognitive impairment.

Note: FTF = face-to-face; CSE = clinical swallow examination

* Classiﬁcation for diagnostic studies, NHMRC, 2009

Poorolajal, Cheraghi, Irani, & Rezaeian (2011)

128 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 129

Professor Liz Ward is the professor of the Centre for Functioning

and Health Research (Queensland Health) and has an active

research agenda in the ﬁeld of telerehabilitation. She is also a

professor in the School of Health and Rehabilitation Sciences, at

the University of Queensland. Clare Burns is a speech pathologist

at the Royal Brisbane and Women’s Hospital. She conducts a

weekly telehealth head and neck cancer clinic.

Correspondence to:

Professor Liz Ward

Centre for Functioning and Health Research (CFAHR)

P.O. Box 6053, Buranda

Brisbane, QLD 4102, Australia

phone: +61 (0)7 3406 2265

email: liz.ward@uq.edu.au

assessments support a trial of this service delivery model to

manage dysphagia in this clinical scenario. You decide to

progress with the delivery of dysphagia rehabilitation

services via telerehabilitation, maintaining regular monitoring

of patient status and patient and clinician satisfaction

throughout.

Acknowledgement

The authors wish to thank Dr Monique Waite who assisted

with the search strategy and evidence ratings.

References

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(Eds.), Telemedicine: Theory and practice (pp. 265–290).

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blueprint for telerehabilitation guidelines – October 2010.

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impairment via telerehabilitation. Dysphagia. doi: 10.1007/

s00455-011-9390-9

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Technology

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 129

Christine Taylor

(top), Vanessa

Aird (centre) and

Emma Power

This arTicle

has been

peer-

reviewed

Keywords

acoUsTic

analysis

assessmenT

dysarThria

TechnoloGy

TraUmaTic

brain inJUry

Weisiger, 1987). Kent (1996) provided a comprehensive

review of factors that undermine reliability of perceptual

judgements within and across clinicians. For example, our

accuracy of judgements is vulnerable to effects of drift over

time, as one becomes more familiar with a client’s speech,

as well as our level of expertise and familiarity with the

possible range of severity.

Several researchers have developed objective measure-

ment protocols to address problems with perceptual

judgements but, generally, these have not made their way

into routine clinical practice (Kent & Kim, 2003; Ludlow &

Bassich, 1984; Murdoch, 2011). Barriers may include

perceived or real difﬁculties with access to technical

equipment, reduced expertise, entrenched clinical practices,

and lack of time to collect and analyse objective measures.

Also, it has been argued that some objective measures

(e.g., vocal jitter or shimmer) may not correlate well with

perceptual features (e.g., vocal roughness or harshness)

(Bhuta, Patrick, & Garnett, 2004). One possible reason for a

low relationship for some measures may be the use of

nonspeech or quasi-speech tasks or simple word-level tasks

to avoid the highly varied nature of connected speech.

In the contemporary delivery of health care, where

accountability is paramount, the use of objective

measurements can strengthen our assessment methods

and tracking of improvement. Understanding which

measures have a strong relationship to perceptual

features at all levels of speech production is critical to this

endeavour. A comprehensive review of such measures

is beyond the scope of this paper and several excellent

overviews are already available (e.g., Kent, Weismer, Kent,

Vorperian, & Duffy, 1999; Thompson-Ward & Theodoros,

1998). Instead, we will provide a brief overview of some

acoustic measures developed for measuring vocal quality

and prosody, features commonly affected in dysarthria.

When evaluating vocal quality, one usually measures

fundamental frequency (f0) and intensity, and signal to

noise ratios in a stable production task (e.g., sustained ah)

to capture features such as habitual pitch, hoarseness,

and breathiness. Frequency measures quantify the rate,

range, and variability of vocal fold vibration. Jitter and

shimmer measure cycle-to-cycle change in frequency and

amplitude, respectively, with elevated values thought to

indicate pathology (Kent et al., 1999). High jitter values

may correlate with perceived roughness (Colton, Casper, &

Leonard, 2006; but see Bhuta et al., 2004). Harmonics-to-

noise ratio (HNR) reﬂects abnormal vibratory characteristics

of the folds and correlates with perceived hoarseness (e.g.,

Speech pathologists typically use perceptual

features and clusters of features to diagnose

dysarthria type. Although ecologically valid,

perceptual assessment remains largely

subjective. This paper describes a sample of

readily available acoustic measures and their

perceptual correlates that can be applied in

the clinical setting in order to objectively

evaluate the degree of impairment and

outcomes of intervention. The speech of

three individuals with acquired dysarthria

secondary to traumatic brain injury was

perceptually rated for diagnosis. The samples

were then analysed acoustically using

measures that potentially quantify these

perceptual features. Results indicated that

most features were well quantiﬁed by an

acoustic measure(s), while others were less

clear. Some acoustic measures may be less

sensitive to mild impairments while more

extensive normative data are required for

other measures. However, the acoustic

measures used here provide a starting point

to objectively describe dysarthric features,

document treatment outcomes, and support

accountability in service provision.

ysarthria is a disorder of speech motor control that

affects one-third of individuals with traumatic brain

injury (TBI) (Duffy, 2005). Dysarthria has a signiﬁcant

and sustained effect on quality of life. People with dysarthria

have a reduced ability to communicate effectively in

everyday activities, which can lead to social, vocational and

life participation restrictions (WHO, 2001). The current gold

standard for clinical diagnosis of dysarthria is subjective

perceptual judgement of speech behaviours across a range

of tasks. Perceptual measures are considered of highest

value in terms of ecological validity (Duffy 2005). However,

characterising dysarthria types can present challenges

due to the inherent variability seen both within and across

speakers. In addition, inter-rater agreement among non-

expert clinicians on presence and severity of perceptual

speech dimensions can be as low as 50–60% (Zyski &

Objective measurement of

dysarthric speech following

traumatic brain injury

Clinical application of acoustic analysis

Christine Taylor, Vanessa Aird, Emma Power, Emma Davies, Claire Madelaine, Audrey McCarry, and Kirrie

J. Ballard

130 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 131

www.fon.hum.uva.nl/praat). PRAAT was ﬁrst released

in 1995 and is regularly maintained by its developers (P.

Boersma and D. Weeninck, University of Amsterdam). It

has been used extensively for analysis of both healthy and

impaired speakers. Comprehensive manual and tutorials

on the website provide guidelines for checking for errors in

measurement that can occur more frequently with the more

variable speech of dysarthria.

Aims

The aim of this study was to demonstrate the use of a small

number of easy-to-collect acoustic measures using a free

software program, PRAAT (Boersma & Weenink, 2010), for

three prototypical dysarthria cases: one spastic, one ataxic,

and one ﬂaccid dysarthria case. The list of measures

presented here is by no means comprehensive, but rather

provides an introduction to using the PRAAT software and

perhaps an incentive to explore it more fully. We report the

results of these acoustic analyses, compare them with

available normative data, and how they relate to perceptual

judgements.

We predicted that the individuals with spastic or ﬂaccid

dysarthria would demonstrate abnormal vocal quality

measures (e.g., jitter, shimmer, HNR), associated with

perceived abnormal vocal quality. The individual with ataxic

dysarthria and notable pitch breaks and vocal tremor was

expected to show high variability of f0 during sustained

ah production. We expected that all would demonstrate

reduced speech rate in diadochokinetic and connected

speech tasks. Further, the individuals with spastic and

ataxic dysarthria would deviate from normal on objective

measures of prosody (i.e., relative duration, f0 and/or

intensity across syllables in connected speech as measured

by the PVI), reﬂecting the perception of equal stress or

scanning speech, respectively. Perception of monopitch or

monoloudness should be reﬂected as lower PVI values for

f0 and dB (PVI_f0, PVI_dB), respectively.

Yumoto & Gould, 1982). Of note, software programs have

different algorithms for calculating these measures which

may yield differing results (Maryn, Corthals, De Bodt, Van

Cauwenberge, & Deliyski, 2009). It is best to use norms

generated by the selected software and standardise data

collection methods to achieve highly reliable measurement

over time. Further, the software may generate some

erroneous f0 measurements (e.g., excessively high values

at the edges of vowels) that distort maximum and average

measures. Care is taken to omit these from the selection

used for calculations (see Figure 1).

Analysis of prosody also involves measuring frequency

and intensity, as well as segment or syllable durations, but

at word or connected speech level. English is a stress-

timed language that generally alternates stressed and

unstressed syllables in a word or sentence. One measure

proving useful for capturing this pattern is the pairwise

variability index (PVI), which is a normalised measure of

relative duration, f0, or intensity over a word or speech

sample (Ballard, Robin, McCabe, & McDonald, 2010;

Courson, Ballard, Canault, & Gentil, 2012; Low, Grabe,

& Nolan, 2000; Vergis & Ballard, 2012). Speciﬁcally, one

calculates the difference in duration (or f0 or intensity)

over two consecutive vowels and divides the difference

by their average. This calculation is done pairwise for

the whole sample and the average PVI value used as an

index of stress variability. Low et al. (2000) reported that in

British-English average PVI for vowel duration (PVI_Dur) in

sentences containing all stressed words (100% stressed)

is ~30 and rises to ~78 for sentences with alternating

stressed and unstressed words (50% stressed). The

Grandfather passage (Darley, Aronson, & Brown, 1975)

contains about 60% stressed words so PVI values below

30 indicate equal and excess stress.

Most of the recommended acoustic measures of

speech can be made using free downloadable speech

acquisition and analysis programs, such as PRAAT (http://

Audrey McCarry

(top), and Kirrie

J. Ballard

Table 1. Demographic and injury data for the three participants with dysarthria and three age- and gender-matched control participants

Participant Age Sex PTA

(months)

CT results TPO Injury Dysarthria ASSIDS

Participant 1 39 M 3.5 Large left SAH and SDH and 10 mm

midline shift, craniotomy and evacuation of

haemorrhage

3 Fall Mild-

moderate

Spastic

84% (single

words)

94%

(sentences)

Control 1 41 M

Participant 2 27 F 1 Left occipital penetrating wound with bullet

fragmentation and swelling of bilateral

cerebellar hemispheres, SAH and SDH

surrounding occipital lobes and cerebellar

hemispheres, left parietal craniectomy and

debridement of foreign body

18 Focal

open

head

injury

Moderate

Ataxic

86% (single

words)

95%

(sentences)

Control 2 30 F

Participant 3 26 M 6 EDH, left SDH, base of skull, temporal

and sphenoid fracture, left cerebellar

haematoma, bilateral craniotomy,

hydrocephalus and meningitis, CSF

drainage and ventriculoperitoneal shunt

15 Motor

vehicle

accident

Severe

Flaccid

26% (single

words)

Sentences not

attempted

Control 3 25 M

Note: PTA: post-traumatic amnesia; TPO: time post-onset; ASSIDS: Assessment of Intelligibility for Dysarthric Speech (Yorkston, Beukelman &

Traynor, 1984); SAH: subarachnoid haemorrhage; SDH: subdural haemorrhage; EDH: extradural haemorrhage; CSF: cerebrospinal ﬂuid.

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 131

with normal hearing and vision (corrected or uncorrected).

The human research ethics committees of the Royal

Rehabilitation Centre and the University of Sydney

approved the experimental procedures and all participants

provided informed written consent.

Procedures

Tasks

A subset of tasks from the above speech motor

examination (Duffy, 2005) was selected for acoustic

measurement of each individual’s speech. These same

speech samples were used for both the perceptual and

acoustic analysis. These included (a) sustained production

of the vowel [a], (b) alternating and sequential motor tasks

(AMR and SMR; also known as diadochokinesis tasks), and

passage. These three tasks were selected as they captured

the main features noted in the speech of these individuals

and covered a range of speaking contexts. The nonspeech/

speech-like tasks of sustained phonation, AMR and SMR

allow for assessment of neuromuscular function without the

additional cognitive and linguistic demands of connected

speech tasks (Wang, Kent, Duffy, Thomas, & Weismer,

2004). Note that all participants were able to read the

Grandfather passage without assistance.

Apparatus

All samples were recorded with an Audio-Technica ATM75

cardioid headset microphone 5 cm from the mouth,

connected to a desktop computer running free PRAAT

software, (http://www.fon.hum.uva.nl/praat/) (Boersma &

Weenink, 2010), using the industry-standard sampling rate

of 44.1 kHz and .wav ﬁle format (see website for

instructions for recording, viewing, and editing ﬁles in

PRAAT). Speech samples for all participants were collected

in a quiet environment in a speech pathology clinic room.

This is representative of conditions in a standard clinic

setting where sound treated rooms are not typically

available.

Method

Participants

Three participants with TBI were recruited from a specialist

metropolitan brain injury unit. Individuals were selected

based on an unequivocal clinical diagnosis of a single

dysarthria type based on the Mayo clinic oral motor and

speech motor examinations (Duffy, 2005). Perceptual

judgements were made by three judges (authors 1, 2, 7). In

addition, impact on intelligibility at single word and sentence

level, as a coarse index of severity, was deﬁned using the

Assessment of Intelligibility for Dysarthric Speech (ASSIDS;

Yorkston, Beukelman, & Traynor, 1984). Demographic and

injury details are provided in Table 1.

Participant 1 (P1) was a 39-year-old native English-

speaking male with mild-moderate spastic dysarthria three

months post-trauma. Dysarthria diagnosis was supported

by perceptual features of strain-strangled vocal quality,

monopitch and pitch breaks, reduced loudness variability,

slow speaking rate, equal-excess stress, short phrases,

but minimal articulatory imprecision (Duffy, 2005). P2 was a

27-year-old native English-speaking female with moderate

ataxic dysarthria 18 months post-trauma. She presented

with irregular pitch breaks, vocal tremor, adequate volume,

slow speaking rate, equal and excess stress, but minimal/

no articulatory imprecision. P3 was a 26-year-old bilingual

Mandarin- and English-speaking male with severe ﬂaccid

dysarthria 15 months post-trauma. He presented with

breathy vocal quality, reduced pitch variability, low volume,

slow speaking rate, imprecise articulation, and vowel and

consonant prolongations that all judges perceived as being

related to severe dysarthria rather than accent.

Three healthy participants were recruited from the

University of Sydney community to serve as age- and

gender-matched controls for each participant with

dysarthria, for those measures that did not have published

normative data. All healthy participants reported no history

of speech, language, or neurological impairment along

Table 2. Instructions for calculating the Pairwise Variability Index for duration, pitch, or loudness of the vowel in words or

connected speech

Task/Step Instruction

1 Record your sound ﬁle using PRAAT, then Open and View the ﬁle. Zoom in to the word you want to measure.

2 Measuring duration, pitch, and loudness:

(a) To measure Vowel Duration, highlight the vowel from its onset to its offset (as shown in Figure 1) and the duration of the

highlighted segment will be displayed in seconds at the top (0.072760 sec, or 72.76 msec, in Figure 1). Type the value into

Column A – Row 1 (A1) of an Excel spreadsheet.

(b) To measure Vowel Pitch (i.e., f0), with the vowel still highlighted as in (a), go to the Pitch menu and select Get Maximum. Make

sure not to include any erroneous pitch data-points at the edges of the vowel for this measure. Copy and paste the value into

Column A – Row 1 (A1) of an Excel spreadsheet.

(c) To measure Vowel Intensity (i.e., dB), with the vowel still highlighted as in (a), go to the Intensity menu and select Get Maximum

Intensity. Copy and paste the value into Column A – Row 1 (A1) of an Excel spreadsheet.

3 Repeat steps 1-3 for each vowel, moving syllable by syllable through the sample and placing each new value into the next row in

Column A of the spreadsheet.

4 When you have ﬁnished the measures for consecutive vowels in the sample (at least 20 measures, but the more the better), enter

=ABS(100*((A1-A2)/((A1+A2)/2))) into the ﬁrst row of Column B (B1). This will calculate the PVI for the two duration values in A1

and A2.

5 If you measure duration for 20 consecutive vowels, you will have a value in cells A1 to A20. Now, copy the formula from B1 into all

the cells in column B, down to the second last row of data (B19). The formula will automatically change to calculate the PVI for each

pair of values in Column A (A1-A2, A2-A3, etc).

6 Once you have your 19 PVI values, calculate their average by entering = AVERAGE(B1:B19) into cell B21.

132 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 133

dysarthria (P2), and ﬂaccid dysarthria (P3) (Duffy, 2005).

Acoustic measures are presented in Table 3 along with

comparative data from healthy age- and sex-matched

adults. The nonparametric Wilcoxin Matched Pairs Signed

Ranks test was used to compare the PVI for each syllable

pair in a patient’s sample with those for the matched

control. The relationships between perceptual and acoustic

measures are reported below.

Participant 1

Vocal quality

Duration of sustained ah was reduced, consistent with the

reduced respiratory-phonatory control and short phrase

length. P1’s average f0 was higher than normal, although

low pitch has been more often associated with the

increased laryngeal tone of spasticity (Duffy, 2005). While

variability of f0, jitter, and shimmer for the sustained ah

production were within normal limits, the harmonics-to-

noise ratio (HNR) was slightly below the recommended

threshold, indicative of mild vocal hoarseness. This likely

relates to the perception of P1 having a strained-strangled

voice quality.

Speech rate and prosody

P1’s speech rate was perceived as mildly slow, consistent

with AMR and SMR rates being about 1 syllable/sec below

the normal range and 1.7 syllables/sec slower than normal

for reading. Prosodic variation in the reading task was

measured with the Pairwise Variability Index. PVI_Dur was

signiﬁcantly reduced compared to the control sample,

consistent with the perception of mild equalisation of stress.

PVI_f0 and PVI_dB were not signiﬁcantly different to the

control, despite the perception of reduced pitch and

loudness variation in the reading sample.

Participant 2

Vocal quality

Duration of sustained ah was well below the average

expected for healthy speakers, suggestive of poor

respiratory-phonatory control. P2 displayed irregular pitch

breaks and vocal tremor. Average f0 was within the normal

range but standard deviation of f0 was very high, possibly

inﬂuenced by brief pitch breaks. Jitter was below the

Acoustic measurements

Vocal quality. Vocal quality was assessed during sustained

phonation, which represents stable vocal performance with

minimal demands for vocal tract adjustments. First, the

average duration (msec) was measured over three

successive attempts at sustained phonation. Second, a

3-second stretch of the sustained vowel was selected for

measurement from the middle of the sustained phonation,

not including the ﬁrst 25 msec or the terminal part of the

phonation (Kent et al., 2000). The PRAAT Voice Report

function was used to calculate average f0, standard

deviation of f0, jitter (local), shimmer (local), and HNR

(http://www.fon.hum.uva.nl/praat/manual/Voice.html; e.g.,

Kent et al., 2000).

Speech rate and prosody. Speech rate was measured as

syllables spoken per second for AMR, SMR, and reading. In

connected speech, stress variability was measured with the

Pairwise Variability Index (PVI). Instructions for calculating

PVI_Dur, PVI_f0 and PVI_dB for the ﬁrst 20 syllables/vowels

in the Grandfather reading are given in Table 2 and Figure 1.

Higher PVI values represent greater variation; PVI values

close to zero indicate equal stress, monopitch, or

monoloudness (i.e., dysprosody).

Reliability of measurement

Inter-rater reliability was calculated on all manual

measurements using intra-class correlation coefﬁcients

(inter-rater reliability: ICC 2, 1, absolute agreement, single

measures). Inter-rater reliability was excellent (≥0.75;

Cicchetti, 1994) for vowel duration (ICC: 0.78, 95% CI 0.51

–0.89), vowel peak f0 (ICC: 0.78, 95% CI 0.62 –0.86) and

vowel peak dB (ICC: 0.75, 95% CI 0.02 –0.92). Absolute

agreement resulted in the wide CI band for vowel peak dB

however, the average difference in dB measures was not

clinically signiﬁcant at 2.07 dB (SD = 1.12). Intra-rater

reliability was also high for the three measures (ICC: 0.85,

95% CI 0.72 –0.93; ICC: 0.92, 95% CI 0.84 –0.96; and

ICC: 1.0, 95% CI 0.99 –0.1, respectively).

Results

Each participant presented with prototypical perceptual

features consistent with spastic dysarthria (P1), ataxic

Figure 1. Waveform and spectrogram for the word “vegetables”, as displayed in PRAAT, with the ﬁrst vowel highlighted in the

waveform (upper panel). In the spectrogram (lower panel), the top overlaid dotted line represents the fundamental frequency as it

changes over the word (displayed in blue within PRAAT), the bottom overlaid line represents the vocal intensity (displayed in yellow

within PRAAT). Note the erroneous pitch values just prior to the ‘b’ and at the onset of the ﬁnal schwa.

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 133

Participant 3

Vocal quality

Duration of sustained ah was considerably reduced,

suggestive of reduced respiratory-phonatory control and

more rapid loss of air with breathiness. Average f0,

standard deviation of f0, jitter and shimmer were within the

normal range on ah production. HNR was reduced relative

to the threshold, suggestive of hoarseness, although the

participant was perceived to have a breathy rather than

hoarse quality.

Speech rate and prosody

The perception of slowed speech rate was upheld with

slowed repetition rates on AMR and SMR tasks and

particularly for connected speech, compared to normal.

P3’s PVI_Dur was signiﬁcantly reduced compared to the

control participant, suggesting equalisation of stress in

connected speech, despite this not being reported

perceptually. However, the participant was perceived to

have vowel and consonant prolongations, which may

threshold for pathological voice, and this was consistent

with the absence of any perception of vocal roughness. The

value for shimmer was close to the conservative threshold

supporting the perception of loudness variations and vocal

tremulousness. HNR was slightly below the recommended

threshold, indicative of mild vocal hoarseness although this

was not noted in the perceptual evaluation.

Speech rate and prosody

Performance on AMR and SMR tasks was characteristic of

ataxic dysarthria with fewer syllables per second and the

perception of slowed speech rate and disrupted rhythm.

Speech rate was considerably reduced in the reading task,

compared to healthy adults.

The predominant prosodic features perceived in P2’s

speech were equal and excess stress, irregular pitch

breaks, and higher than normal loudness variation. This

participant showed the lowest PVI_Dur value, signiﬁcantly

lower than the control, which is consistent with equal and

excess stress. PVI_f0 and PVI_dB were slightly elevated,

but not signiﬁcantly different to the control speaker.

Table 3. Results of acoustic analyses with normative comparisons

Measures P1 – M

(Spastic)

Comparison data P2 – F

(Ataxic)

Comparison data P3 – M

(Flaccid)

Comparison data

Vocal quality

Sustained /a/

Average duration (sec)

14.2 25.9 12.76 21.3 9.53 25.9

Average f0

174.0 145.2

Range: 121.8–168.6

256.5 243.9

Range: 216.5–271.4

156.2 145.2

Range: 121.8–168.6

Standard deviation f0

1.2 1.3

Range: 0.7–2.0

11.4 2.7

Range: 0.6–4.8

2.4 1.3

Range: 0.7–2.0

Jitter (local)

0.54 ≤1.04% 0.55 ≤1.04% 0.64 ≤1.04%

Shimmer (local)

2.87 ≤3.81% 3.74 ≤3.81% 2.76 ≤3.81%

Harmonic-to-noise ratio

19.47 >20 19.38 >20 19.96 >20

Speech rate and prosody

Alternating Motion Rate tasks

‘pa’ repetition (syll/sec) 3.4 Range: 4.5–7.5 2.5 Range: 4.6–8.6 2.5 Range: 4.5–7.5

‘ta’ repetition (syll/sec) 3.3 Range: 4.4–8.2 2.3 Range: 4.3–8.5 2.5 Range: 4.4–8.2

‘ka’ repetition (syll/sec) 3.6 Range: 4.4–7.5 2.0 Range: 4.3–7.9 2.3 Range: 4.4–7.5

Sequential Motion Rate task

‘pataka’ repetition (syll/sec) 3.6 Range: 4.8–7.2 3.4 Range: 4.8–7.2 2.8 Range: 4.8 – 2.0

Connected speech (Grandfather)

Speech rate (syll/sec)

2.1 4.3 (± 0.5) 1.4 4.3 (± 0.5) 0.7 4.3 (± 0.5)

Pairwise Variability Indices

duration 29.3** 46.6 25.8** 47.8 28.5** 58.4

f0 10.4 9.4 9.1 7.0 4.7** 7.3

dB 4.5 3.8 4.5 3.1 3.1** 5.6

Note: Underline = values outside normal range

Colton et al. (2006)

Norms from Multi-Dimensional Voice Program (MDVP; Kay PENTAX, Lincoln Park, USA): MDVP Jitt and Shim cut-off values are used, but are

conservative here as the Jitter and Shimmer measures in PRAAT are less inﬂuenced by noise (http://www.fon.hum.uva.nl/praat/manual/Voice.

html; Maryn et al., 2009)

Kent (1997)

Tauroza & Allison (1990)

Comparison data from matched controls; controls’ duration values are comparable to Low et al. (2000) for “reduced vowel set” sentences;

**p<0.01 and *p<0.05 for Wilcoxin Matched Pairs tests between participant and matched control.

134 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 135

correlate with reduced PVI_Dur measures (see Discussion).

The signiﬁcantly reduced PVI_f0 and PVI_dB values were

consistent with the perception of reduced pitch variability

and possibly low speaking volume.

Discussion

The aim of this study was to demonstrate the use of a small

set of acoustic measures of speech using accessible

software and readily executed measurements. By exploring

the relationships between various acoustic measures and

our perceptions of different aspects of speech and voice

quality, we can develop more objective and reliable

measures of change with time and with treatment. We can

also start to unpack the different acoustic signals that come

together to form our perceptions of, at times, more

wholistic constructs (Kent, 1997).

We predicted that the individuals with spastic or

ﬂaccid dysarthria would demonstrate abnormal vocal

quality measures (e.g., jitter, shimmer, HNR), associated

with perceived abnormal quality. The individual with

ataxic dysarthria and pitch breaks and vocal tremor was

expected to show high variability of f0 on sustained ah. All

participants were expected to have reduced speech rate

in diadochokinetic and connected speech tasks. Reduced

PVI_Dur should be associated with perception of equal

stress and reduced PVI_f0 and PVI_dB with perception of

reduced pitch and loudness variability in connected speech.

Vocal quality

HNR appears to be a useful indicator of abnormal vocal

quality (Bhuta et al., 2004; Kent et al., 2000; Yumoto &

Gould, 1982). It has been linked to hoarseness, although

here P1 and P3 were perceived to have strained-strangled

and breathy quality, respectively. It is possible that HNR is

useful as an indicator of pathology, rather than a speciﬁc

type, or alternatively that the different vocal quality

descriptors are difﬁcult to differentiate in clinical practice

(Kreiman & Gerratt, 2000). As reported here, previous

studies have not found strong links between jitter and

shimmer measures and abnormal vocal quality (e.g., Bhuta,

et al., 2004; see Thompson-Ward & Theodoros, 1998).

Inclusion of HNR in a diagnostic protocol is worthwhile to

aid objective identiﬁcation of abnormal quality or to track

changes with intervention, provided recording and

measurement methods are controlled across time points.

The measures of average f0 and standard deviation of

f0 during sustained ah production were equivocal here.

P1 had elevated average f0, counter to the tendency for

reduced pitch with laryngeal spasticity (Duffy, 2005). This

was not likely to be due to perceived mild pitch breaks,

as these were minimal during the ah sample. The average

f0 was 5.2 Hz outside the normal range; possibly the

threshold for perceiving high pitch does not correspond

precisely with the normal range. As predicted, the elevated

variability of P2 supported the perception of irregular pitch

breaks and vocal tremor in sustained ah.

Speech rate and prosody

The measures of speech rate are by no means novel but

are made considerably easier within the visual spectro-

graphic display of PRAAT. As reported numerous times, all

participants showed slowed rate in all tasks (Duffy, 2005).

The measures of prosody are less widespread. The PVI

is a useful measure that correlates well with perceptions

of stress production in words and connected speech

(Ballard et al., 2010; Low et al., 2000). Our hypotheses

were largely supported with equal stress and monopitch

and monoloudness reﬂected in reduced PVI values. Kim,

Hasegawa, and Perlman (2010) have reported similar

ﬁndings in spastic dysarthria from cerebral palsy. The lack

of a signiﬁcant difference for PVI_f0 and PVI_dB for P1 and

P2 suggests that poor control over syllable/vowel duration

was mainly responsible for the perception of equal stress.

This result is not surprising for P2, as her irregular pitch and

loudness variations were distributed relatively randomly with

respect to the distribution of stress. P1 was perceived to

have monopitch and monoloudness, but this was not borne

out in the PVI measures.

P3 had signiﬁcantly reduced PVI for all three measures.

While he was not perceived to have equal or excess stress,

the reduced duration variability may be related to perceived

vowel and consonant prolongations. Such prolongations

are also a feature of acquired apraxia of speech, with

these individuals disproportionately prolonging vowels

in unstressed syllables (Vergis & Ballard, 2012). P3 was

perceived to have consistently reduced pitch variation,

which appeared more related to PVI_f0 than the irregular

pitch variation of P1 and P3.

Conclusions

The aim of this paper was to demonstrate how some

acoustic measurements are within easy reach of standard

speech pathology clinics and can provide quick objective

measures for supporting diagnostic and treatment

decisions. While not all measures match squarely onto

perceptual constructs, there is value in exploring how

different acoustic features may combine to map onto more

holistic percepts. We must also be aware that the inherent

variability of the pathological speech signal and/or

limitations in applying a “generic” software algorithm to

pathological speech may at times yield inaccurate

measurements. The need to use a good quality

microphone, to ensure samples are collected in a quiet

environment, and to standardise recording and analysis

protocols across time points cannot be overstated.

The measures and methods presented here provide the

clinician with a starting point for documenting treatment

effectiveness and accountability in a less subjective manner

than using perceptual measures alone. We hope that,

by documenting some of these methods with illustrative

cases, we may encourage and facilitate translation of these

techniques into clinical practice (Graham et al., 2006) and,

over time, stimulate development of large normative and

patient databases for comparison.

Acknowledgments

The initial stage of this work was conducted while the ﬁrst

two authors were employed as speech pathologists in the

Brain Injury Rehabilitation Service at the Royal Rehabilitation

Centre Sydney. We thank the three patients for their

participation in the study.

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www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 135

Christine Taylor is a lecturer and private practitioner with Cortex

Communication Partners and has over 19 years clinical

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Christine Taylor

Lecturer/Clinical Specialist

Masters of Speech, Language Pathology Program

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Technology

136 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 137

Sarah Maine

(top) and

Tanya Serry

This arTicle

has been

peer-

reviewed

Keywords

arTicUlaTion

TreaTmenT

cleFT palaTe

elecTro-

palaToGraphy

speech

disorders

visUal

FeedbacK

relate to unilateral or bilateral clefts with or without cleft lip

(Peterson-Falzone et al., 2010; Siren, 2004). Worldwide

clefts of the palate and/or lip occur in around 0.13 to 2.53

in 1000 live births every year, with substantial variation

across region of birth and gender (Marazita, 2004; Reid,

2004; Wyszynski, 2007). Primary surgical repair of cleft

palate is typically carried out between 12 and 18 months

of age (Clark, Milesi, Mishra, Ratanje, & Rezk, 2007).

Surgical intervention therefore interrupts the typical pattern

of speech development at a critical stage. Palatoplasty

describes the most common method of surgical repair

(Peterson-Falzone et al., 2010) and involves the re-

construction of the palate via plastic surgery, often resulting

in altered sensation to the palate.

Speech characteristics associated

with cleft palate

A cluster of deviant speech production features are commonly

associated with cleft palate (Lohmander, Henriksson, &

Havstam, 2010; Michi, Yamashita, Imai, Suzuki, & Yoshida,

1993; Pamplona, Ysunza, & Espinosa, 1999; Peterson-

Falzone et al., 2010). Compensatory articulation and

disordered resonance are reported as the most prominent

ﬁndings in the speech of the cleft palate population

(Lee et

al., 2009; Pamplona et al., 2005; Peterson-Falzone et al.,

2010). Various authors (Dalston, 1992; Hardin-Jones &

Jones, 2005; Peterson-Falzone, 1990) suggest that

prevalence of compensatory articulations in children with

repaired cleft palate ranges from 22% to 28% (as cited in

Lee, Gibbon, Crampin, Yuen, & McLennan, 2007).

Compensatory articulations are reported to result from

altered patterns of speech behaviour due to an inability

to obtain adequate intraoral pressure secondary to an

irregular oral cavity (Lee et al., 2009). They may also

occur as a response to limited sensory feedback from oral

structures. Some of the most prevalent misarticulations

include posteriorly articulated alveolar stops, palatalised

affricates, and palatalised sibilants (Gibbon et al., 2001;

Hardin-Jones & Chapman, 2008; Lohmander et al., 2010;

Michi et al., 1993; Pamplona et al., 1999; Pamplona et al.,

2005). Recent developments in technology have resulted in

research exploring the role of visual feedback in treatment

of articulation errors (Gibbon, Stewart, Hardcastle, &

Crampin, 1999).

Electropalatography

Electropalatography (EPG) is a procedure that uses visual

feedback to demonstrate lingual contact on the hard palate

Children born with cleft palate are at a high

risk for articulation disorders. Electropalato-

graphy (EPG) has emerged as a tool that

utilises visual feedback to treat persistent

articulation disorders in the cleft palate

population. The purpose of this paper is to

summarise the current research exploring the

use of EPG therapy for children with surgically

repaired cleft palate and inform clinicians on

the quality of evidence available to guide their

clinical practice. A search of the literature

identiﬁed six articles appropriate for inclusion

in the review. The review found that although

some evidence exists for the efﬁcacy of EPG

therapy, further research should be carried

out to form a more robust evidence base prior

to initiation of a randomised controlled trial.

Introduction

Children born with a cleft palate are at a higher risk of

speech problems than the general population (Hardin-

Jones & Chapman, 2008; Peterson-Falzone, Hardin-Jones,

& Karnell, 2010). Difﬁculties with resonance and articulation

are the most common areas of speech breakdown within

the heterogeneous cleft palate population (Peterson-

Falzone et al., 2010). Children with cleft palate are also at

an increased risk of developing negative attitudes toward

communication. In their study investigating communication

attitudes of 10-year-old children with cleft palate, Havstam,

Sandberg, and Lohmander (2011) found a statistically

signiﬁcant difference between mean Communication

Attitude Test (CAT-S) scores of children with cleft palate

compared to their typically developing peers.

Cleft palate

Cleft palate is a craniofacial structural disorder that occurs

during the seventh to twelfth week of embryonic

development (Lee, Law, & Gibbon, 2009; Siren, 2004). It

results from a lack of fusion of the two maxillary processes

during the growth period of these structures (Shprintzen,

1995). Clefts may result in a complete cavity of the palate,

creating a continuous passage between the oral and nasal

cavities (Shprintzen, 1995).

There are many documented variations of cleft palate.

The primary distinctions between types of cleft palate

Treatment of articulation

disorders in children

with cleft palate

Evidence for using electropalatography

Sarah Maine and Tanya Serry

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 137

of treating persistent articulation errors in children with cleft

palate when traditional methods fail (Gibbon et al., 2001).

However, no large-scale studies have been conducted to

support widespread clinical use of EPG with those who

have a repaired cleft palate.

This paper provides a narrative review of the evidence

to date that explores whether using EPG is an effective

method of treatment of persistent articulation errors in

children with surgically repaired cleft palate. It aims to: (a)

summarise and critique the current research surrounding

the most effective approaches to providing EPG therapy for

treating articulation disorders in the cleft palate population

and (b) inform clinicians on the quality of evidence available

to guide their clinical practice.

Method

The electronic databases Medline Ovid (1996–), EMBASE

(1998–), CINAHL, SpeechBITE, Cochrane Library, and

PsychInfo were searched for relevant articles. The search

terms cleft palate AND electropalatography OR EPG OR

biofeedback AND articulat* therapy OR speech intervention

OR speech treatment AND articulat* OR intelligibility OR

speech production produced a ﬁnal yield of 13 articles after

limiting results to English, excluding research on adults, and

eliminating duplicates. Six articles were identiﬁed that

evaluated the use of electropalatography as a speech

intervention technique for children with repaired cleft palate

and were therefore considered appropriate for inclusion in

the review. Table 1 provides further details about the articles

selected for review.

Results

Study design evaluation

Systematic searching of the literature revealed the majority

of studies conducted in the area of electropalatographic

treatment for disordered speech in the cleft palate

population are classiﬁed by the National Health and Medical

Research Council (NHMRC) as being low level evidence

(NHMRC, 2009). The NHMRC Evidence Hierarchy is a tool

used to identify the relative strength of a study according to

its design and the type of research question being posed

(NHMRC, 2009). The NHMRC Working Party acknowledges

using a dynamic, direct approach (Michi et al., 1993). The

technique of EPG has evolved into a highly established

research tool in the ﬁeld of speech intervention (Scobbie,

Wood, & Wrench, 2004). EPG therapy differs from

conventional articulation therapy by providing visual

feedback cues to the speaker as well as auditory feedback

in the form of voice and kinaesthetic feedback from the

articulators (Peterson-Falzone et al., 2010). The real-time

nature of EPG permits immediate information about tongue

placement and timing of articulatory movements (Gibbon et

al., 2001; Gibbon & Hardcastle, 1989; Michi et al., 1993).

Through identifying the speciﬁc placement of the tongue

and its position in reference to the hard palate, EPG allows

speakers to alter their linguo-palatal contact in order to

produce phonemes with increased accuracy (Gibbon et al.,

2001).

Electropalatography has also emerged as a viable tool

for the remediation of articulation problems exhibited by

the cleft palate population (Fujiwara, 2007; Gibbon &

Hardcastle, 1989; Lee et al., 2009). Peterson-Falzone et

al. (2010) suggest that the high imageability of the alveolar

region of the hard palate facilitates targeting sounds

that are incorrectly produced in a more backed position.

Moreover, its use in populations such as those with repaired

cleft palate, who may have decreased oral sensation, is

worthy of consideration due to the device’s lack of reliance

upon kinaesthetic biofeedback (Peterson-Falzone et al.,

2010).

Therapy for articulation disorders in children typically

involves using the speaker’s auditory feedback to guide

emergence of an altered pattern of articulation of any one

phoneme (Pamplona et al., 1999; Peterson-Falzone et al.,

2010). McAuliffe and Cornwell (2008) discussed the need

to implement principles of motor learning when altering

phoneme production patterns. In their research with a

single subject with an articulation disorder not related to

cleft palate, the authors found that incorporating EPG

with therapy guided by the principles of motor learning

and traditional articulation therapy resulted in positive

therapy outcomes when treating lateralised /s/ (McAuliffe &

Cornwell, 2008).

The limited research that has been conducted in the ﬁeld

of EPG has demonstrated its potential value as a method

Table 1. Articles included for review

Author/s Sample

size

Title Study design Level of

Evidence

Lohmander A., Henriksson C., &

Havstam C. (2010)

1 Electropalatography in home training of retracted

articulation in a Swedish child with cleft palate:

effect on articulation pattern and speech.

Single subject design IV

Fujiwara, Y. (2007) 5 Electropalatography home training using a portable

training unit for Japanese children with cleft palate.

Case series IV

Scobbie, J. M., Wood, S. E., &

Wrench, A.A. (2004)

1 Advances in EPG for treatment and research: an

illustrative case study.

Single subject design IV

Gibbon, F., Hardcastle, W. J.,

Crampin, L., Reynolds, B., Razell,

R., & Wilson, J. (2001)

12 Visual feedback therapy using electropalatography

(EPG) for articulation disorders associated with cleft

palate.

Randomised group study,

crossover design

Stokes, S. F., Whitehill, T. L., Yuen,

K. C. P., Tsui, A. & M. Y. (1996)

2 EPG treatment of sibilants in two Cantonese-

speaking children with cleft palate.

Case series IV

Michi K-I, Yamashita Y., Imai S.,

Suzuki N., & Yoshida H. (1993)

6 Role of visual feedback treatment for defective /s/

sounds in patients with cleft palate.

Randomised controlled trial IIa

Note:

According to NHMRC Evidence Hierarchy. The NHMRC Evidence Hierarchy is a tool used to identify the relative strength of a study according

to its design and the type of research question being posed (NHMRC, 2009).

138 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 139

Methods of therapy provision

Stokes, Whitehill, Tsui, and Yuen (1996) based their EPG

therapy on a combination of traditional methods for treating

sibilants outlined by Blache (1989, as cited in Stokes et al.,

1996) and conventional EPG therapy methods when

conducting therapy targeting /s/ with two children with

repaired cleft palate. Michi et al. (1993) utilised a similar

training schedule. Each of the studies found an

improvement in production of targeted phonemes using

visual comparison of EPG frames. These ﬁndings suggest

that EPG may play a successful role in treating persistent

articulation disorders when coupled with traditional

methods.

CleftNET Scotland argued that practical and ﬁnancial

difﬁculties are one of the primary factors limiting access to

EPG treatment (Gibbon et al., 1998). Jones and Hardcastle

(1995) developed the EPG-3, a portable training unit (PTU),

in order to improve access to EPG therapy. Fujiwara (2007)

found marked changes in the EPG patterns of four out of

ﬁve participants when using the EPG-4. Fujiwara (2007)

found delivering therapy through PTU to be especially

beneﬁcial for clients residing in remote locations.

Lohmander et al. (2010) also reported improvements

in their subject’s articulation of /t/ and /s/ in words and

sentences following therapy conducted in the home

environment using a PTU. Moreover, Lohmander et al.

reported improvements to their subject’s speech at word

level after just 8 hours of therapy, indicating that EPG via

PTU has the potential to produce rapid success.

In their randomised controlled trial, Michi et al. (1993)

found participants with excessive posterior tongue elevation

progressed more rapidly with EPG therapy, whereas

participants with less severe misarticulations at the onset of

that the hierarchy is “a broad indicator of likely bias and can

be used to roughly rank individual studies within a body of

evidence” (Merlin, Weston, & Tooher, 2009, p. 6). They

contend that ranking individual studies should be

undertaken as an initial step in appraising the evidence of

any given topic (Merlin et al., 2009).

The research presented in the six studies comprises

primarily small case series and single subject experimental

designs. Although single subject experimental designs

are considered relatively low-level evidence, they have

been acknowledged as an appropriate study design when

randomised controlled trials (RCT) are not suitable (Rose,

2010). According to Rose (2010), situations deemed

inappropriate for the use of a RCT include when research

is in the early stages of development, when the target

population contains too few individuals to form a robust

sample, and when the client group has a high degree

of variability. Hegde (1994, as cited in Lohmander et al.,

2010) concurs that single subject designs build strength

of evidence for treatment strategies when repeated across

different individuals. These reasons are likely explanations

for such designs that dominate the EPG literature under

review. Table 2 further demonstrates the variability across

the six studies.

Although the six studies included in this review provide

some important insights into the potential beneﬁts of EPG

to treat articulation disorders in those with a repaired cleft

palate, a number of limitations exist with the nature of

the studies. We contend, however, that there are some

viable explanations for what appears to be a relatively low

level evidence base. Further, it is valuable to examine the

available evidence as a means of advancing understanding

and progressing this potentially important area of clinical

practice.

Table 2. Study details

Author Cleft type/s Language Articulation

error/s present

Baseline data

collection

Treatment Primary outcome

measure

Follow-up

measures

Lohmander

et al.

(2010)

Isolated soft

& hard palate

cleft (n = 1)

Swedish Palatalised /s/

Palatalised /t/

3 pre-treatment

measures

Daily, approx.

10min/day, 5

days a week for 5

months via PTU

CoG values 3 times

within 3

months

Fujiwara, Y.

(2007)

UCLP

(n = 3),

BCLP

(n = 2)

Japanese Distorted /s/

Palatalised

affricates

Not reported Daily, approx.

30mins/day for

7–9 months via

PTU home training

CoG values,

qualitative analysis

of EPG frames

Not reported

Scobbie et

al. (2004)

Isolated cleft

of soft & hard

palate (n = 1)

English Distorted /s/

Distorted /t∫/

Not reported Ten 45min

sessions over 4

months

Perceptual analysis

of single words or

isolated phonemes

Not reported

Gibbon et

al. (2001)

UCLP (n = 7),

BCP (n = 2)

Soft palate

only (n = 3)

English Palatalised /s/

Palatalised /t/

Not reported Four 30 to 45min

sessions

CoG values,

qualitative analysis

of EPG frames

Completed

once (6

weeks post-

treatment)

Stokes et

al. (1996)

UCLP (n = 2) Cantonese Not reported 2 pre-treatment

measures

Seven weekly

1hour sessions

Perceptual analysis

& qualitative analysis

of EPG frames-

constriction of

tongue/location

4 months

post-therapy

(1 subject

only)

Michi et al.

(1993)

UCLP (n = 3)

and BCLP

(n = 3)

Japanese Palatalised /s/ 2–4 pre-

treatment

measures

Eight weekly 1

hour sessions

Visual analysis of

EPG frames

Not reported

Note: UCLP = unilateral cleft lip and palate, BCLP = bilateral cleft lip and palate, BCP = bilateral cleft palate, PTU = portable training unit,

CoG = centre of gravity

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 139

concentration of electrodes in the anterior-posterior

dimension” on the EPG frame (Hardcastle & Gibbon, 1997,

as cited in Fujiwara, 2007, p. 67). Lohmander et al. (2010)

and Gibbon et al. (2001) also used CoG measures to

quantitatively measure change over time.

It has been argued that the type of speech material used

in the assessment of speech intelligibility may impact the

reliability of results obtained (Klinto, Salameh, Svensson,

& Lohmander, 2010). Klinto et al. contended that word

naming is the most reliable method of assessing speech

intelligibility of children with cleft palate.

A standardised articulation test for Swedish speakers

(SVANTE) was implemented by Lohmander et al. (2010)

in order to assess articulatory accuracy before and after

treatment. Gibbon et al. (2001) also obtained speech

intelligibility ratings prior to treatment. The positive

relationships shown between listeners’ perceptual ratings

and standardised articulation test ﬁndings added strength

to the authors’ arguments about the validity of results

obtained (Gibbon et al., 2001; Lohmander et al., 2010).

Generalisability

Children with cleft palate are a heterogeneous population.

Different types of clefts, types of surgical intervention, age

of repair, severity of articulation disorder, and general

speech and language development all impact on the

resultant speech behaviour of a child with cleft palate

(Peterson-Falzone et al., 2010). Additionally, around 50% of

those with a cleft palate have co-occurring syndromes.

These introduce more complex factors for consideration

such as presence of further craniofacial abnormalities and

variable cognitive ability (Peterson-Falzone et al., 2010)

when reﬂecting on speech treatment outcomes. It is

important to note that the studies reviewed did not include

children with cleft palate as part of a syndrome in their

samples. As such, the combined results found are not

generalisable to the entire cleft palate population (Lee et al.,

2009).

Follow-up

The majority of studies investigating the use of EPG as a

treatment for cleft palate speech disorders did not provide

satisfactory follow-up measures for it to be deemed

successful as an enduring method of treatment for

articulation disorders. Without adequate follow-up, it is

difﬁcult to demonstrate that subjects will continue to show

improvements from the treatment or maintain its effects,

thus limiting the reliability of the study (Lee et al., 2009). For

example, Gibbon et al. (2001) provided only one follow-up

measure post-EPG treatment.

Special considerations

Stokes et al. (1996) provided some evidence that patterns

of emergence of fricatives and affricates differ across

languages. They referred to this as different “cross-linguistic

routes of development” (p. 276). For example, in Cantonese

there is evidence to demonstrate that children commonly

affricate /s/ to /ts/ as their phonetic system develops. This

is an uncommon occurrence in developing English, and

suggests that phonetic development in disordered speech

may be dependent on patterns of typical development in

individual languages (Stokes et al., 1996). Such variations

must be taken account of when considering the cleft palate

population. To demonstrate, retracted articulation of palatal

sounds is a universal ﬁnding among children with cleft

palate (Trost, 1981; Whitehill, Stokes & Yonnie, 1996, as

cited in Fujiwara, 2007). However, slight differences in

treatment demonstrated similar progress with EPG therapy

and non-EPG therapy. This ﬁnding strengthens previous

research suggesting EPG therapy is most advantageous

when treating articulation disorders that are not responsive

to traditional methods (Lohmander et al., 2010; Fujiwara,

2007).

Therapy frequency and intensity for motor-based

activities have been shown to impact treatment outcome

effects when using EPG to treat articulation disorders

not related to cleft palate (McAuliffe & Cornwell, 2008).

However to date, research has not examined ideal dosage

of EPG therapy with particular reference to targeting typical

cleft palate articulation errors. In their 2001 study, Gibbon

et al. reported that when compared with non-EPG therapy,

EPG therapy is “more efﬁcient in bringing about positive

change in articulation patterns” (p. 57) with only a few

therapy sessions. This preliminary evidence suggests that

EPG may be an efﬁcient method of delivering articulation

therapy to children with repaired cleft palate.

Discussion

This paper summarises the current research exploring the

use of EPG therapy for children with surgically repaired cleft

palate. Among the six studies reviewed, a signiﬁcant

amount of variability was found. By comparing and

contrasting the ﬁndings of each study, a limited evidence

base can be formed to guide clinical practice in this

growing area of speech pathology treatment. The remainder

of this section discusses each study’s methods, ﬁndings,

and conclusions in order to provide direction for future

research.

Sampling

Notable disparity between cleft types, speciﬁc articulatory

behaviours, and previous speech pathology intervention

were evident across the sample populations of the studies

being reviewed. Such variation is likely to be a consequence

of subject recruitment difﬁculties (Lee et al., 2009). Lohmander

et al. (2010) contend that the small number of children

considered eligible for EPG intervention makes it

challenging to obtain a signiﬁcant sample size in order to

conduct a study that would meet the criteria for a higher

level of evidence.

Baseline data

The majority of studies did not provide adequate baseline

measures of their subjects’ speech prior to EPG treatment

(Gibbon et al., 2001; Scobbie et al., 2004; Stokes et al.,

1996). For example, Gibbon et al. (2001) did not report a

pre-treatment measure of articulatory accuracy. Baseline

data provides stable pre-treatment production patterns in

order to provide a valid account of changes produced by

the treatment. Without an accurate impression of pre-

treatment articulatory performance, the results may have

shown fallacious improved outcomes (Portney & Watkins,

2009).

Outcome measures

The primary outcome measure for the majority of studies

conducted in this ﬁeld of research is correct articulation of

speech sounds targeted in therapy (Lee et al., 2009).

However, differences between how the researchers deﬁned

and measured correct articulation render the results

somewhat incomparable.

Fujiwara’s primary outcome (articulatory accuracy of

/t/) was assessed using the centre of gravity (CoG) value.

CoG values are obtained by calculating the “relative

140 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 141

about the factors that result in most effective treatment

outcomes for the cleft palate population prior to combining

these elements and conducting a large-scale randomised

controlled trial.

References

Clark, L., Milesi, R., Mishra, R., Ratanje, M., & Rezk, M.

(2007). Bridging the gap: Promoting speech in children with

cleft. La Trobe University, retrieved from http://www.latrobe.

edu.au/hcs/projects/Cleft_Palate/GeneralInformation.html

Dalston, R.M. (1992). Acoustic assessment of the

nasal airway. The Cleft Palate-Craniofacial Journal, 29(6),

520–526.

Fujiwara, Y. (2007). Electropalatography home training

using a portable training unit for Japanese children with

cleft palate. Advances in Speech-Language Pathology, 9(1),

65–72.

Gibbon, F., Crampin, L., Hardcastle, W., Nairn, M.,

Razzell, R., Harvey, L., & Reynolds, B. (1998). Cleftnet

Scotland: A network for the treatment of cleft palate

speech using EPG. International Journal of Language and

Communication Disorders, 33, 44–49.

Gibbon, F., & Hardcastle, W. (1989). Deviant articulation

in a cleft-palate child following late repair of the hard

palate: A description and remediation procedure using

electropalatography. Clinical Linguistics and Phonetics, 3,

93–110.

Gibbon, F., Hardcastle, W. J., Crampin, L., Reynolds,

B., Razell, R., & Wilson, J. (2001). Visual feedback therapy

using electropalatography (EPG) for articulation disorders

associated with cleft palate. Asia Paciﬁc Journal of Speech,

Language and Hearing, 6, 53–58.

Gibbon, F., & Paterson, L. (2006). A survey of speech

and language therapists’ views on electropalatography

therapy outcomes in Scotland. Child Language Teaching

and Therapy, 22, 275–292.

Gibbon, F., Stewart, F., Hardcastle, W., & Crampin, L.

(1999). Widening access to electropalatography for children

with persistent sound system disorders. American Journal

of Speech-Language Pathology, 8, 319-334.

Hardin-Jones, M., & Chapman, K. L. (2008). The impact

of early intervention on speech and lexical development for

toddlers with cleft palate: A retrospective look at outcome.

Language, Speech, and Hearing Services in Schools, 39,

89–96.

Hardin-Jones, M. A., & Jones, D. L. (2005). Speech

production of preschoolers with cleft palate. Cleft Palate-

Craniofacial Journal, 42(1), 7-13.

Havstam, C., Sandberg, A. D., & Lohmander, A. (2011).

Communication attitude and speech in 10-year-old children

with cleft (lip and) palate: An ICF perspective. International

Journal of Speech-Language Pathology, 13(2), 156–164.

Jones, W., & Hardcastle, W. J. (1995). New

developments in EPG3 software. European Journal of

Disorders of Communication, 30, 183–192.

Klinto, K., Salameh, E., Svensson, H., & Lohmander, A.

(2010). Research report: The impact of speech material

on speech judgement in children with and without

cleft palate. International Journal of Language and

Communication Disorders [early online article], 1–13. doi:

10.3109/13682822.2010.507615

Lee, A., Gibbon, F., Crampin, L., Yuen, I., & McLennan,

G. (2007). The national CLEFTNET project for individuals

with speech disorders associated with cleft palate.

Advances in Speech-Language Pathology, 9(1), 57–64.

production of palato-alveolar and alveolar phonemes exist

across languages and are important to acknowledge when

considering treatment using EPG (McLeod & Roberts,

2005, as cited in Fujiwara, 2007).

Lohmander et al. (2010) gathered EPG patterns of

typically developing adult Swedish speakers prior to

treatment in order to compare outcomes post-treatment to

the norm for the Swedish speaking population. Comparing

outcomes to native speakers’ norms of production was

found to be especially important when quantitative analysis

of results was performed, as subtle differences between

CoG values and timing of linguo-palatal placement were

not always identiﬁed by listeners’ perceptual ratings

(Lohmander et al., 2010).

Conclusions and future research

Although a limited set of research exists for the potential

beneﬁts of EPG to treat articulation disorders in those with

a repaired cleft palate, some promising albeit preliminary

ﬁndings have been made about the viability of using EPG to

signiﬁcantly enhance the speech intelligibility of children with

cleft palate (Fujiwara, 2007; Lee et al., 2009; Lohmander et

al., 2010; Michi et al., 1993; Stokes et al., 1996). In

particular, EPG therapy has been found to produce faster

improvements to articulation errors that are resistant to

conventional articulation therapy in the cleft palate

population (Fujiwara, 2007; Gibbon et al., 2001; Lee et al.,

2009).

The importance of collecting baseline data prior to the

treatment phase in single subject experimental designs has

been acknowledged (Rose, 2010). Further research should

obtain stabilised pre-treatment production patterns in order

to provide a valid account of changes produced by the

treatment. Additionally, follow-up measurements should be

obtained to ensure the changes are permanent (Lee et al.,

2009).

Future research in this area should focus on the factors

that may inﬂuence therapy outcomes, for example, therapy

environment, intensity and duration of sessions and method

of therapy provision. Prior to the initiation of a RCT, Gibbon

and Paterson (2006) state that controlled group studies

should be carried out to ascertain whether EPG therapy is

more beneﬁcial than the current methods of treatment for

improving longstanding articulation disorders associated

with cleft palate. Discovering the ideal conditions for EPG

therapy would potentially allow a suitably designed RCT to

be carried out in the future (Lee et al., 2009).

As different languages have slightly different norms of

production of certain phonemes, all research completed

should compare production patterns to that of the typically

speaking population. Generalisation to contexts outside the

clinic must occur in order for a meaningful improvement in

communication to be achieved (Gibbon & Paterson, 2006).

Further studies should assess intelligibility both at a spoken

word level (Klinto et al., 2010) and in conversational settings

to ensure carryover of the change in production pattern

(Gibbon & Paterson, 2006).

Current clinical guidelines in the United Kingdom suggest

EPG therapy is appropriate for treating articulation errors

in children with cleft palate who have had little success

when treated previously with conventional articulation

therapy methods (National Institute of Clinical Excellence,

2002). This review found there is limited evidence for

the widespread use of EPG for treatment of persistent

articulation disorders associated with cleft palate at this

stage. Future research should aim to increase knowledge

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 141

Sarah Maine recently completed her Master of Speech Pathology

at La Trobe University, Melbourne. Tanya Serry is a lecturer at La

Trobe University in Melbourne. Tanya teaches in the areas of

paediatric speech and language in the Department of Human

Communication Sciences. She is also engaged in research

projects exploring phonological awareness interventions and

collaborates on a project exploring school readiness.

Correspondence to:

Tanya Serry, PhD

Department of Human Communication Sciences

Faculty of Health Sciences

La Trobe University

Melbourne Campus, Bundoora, Australia 3086

phone: +61 (0)3 9479 1814

email: t.serry@latrobe.edu.au

Lee, A. S., Law, J., & Gibbon, F. E. (2009).

Electropalatography for articulation disorders associated

with cleft palate (Review). The Cochrane Library, Issue 4.

Lohmander, A., Henriksson, C., & Havstam, C.

(2010). Electropalatography in home training of retracted

articulation in a Swedish child with cleft palate: Effect on

articulation pattern and speech. International Journal of

Speech-Language Pathology, 12(6), 483–496.

McAuliffe, M. J., & Cornwell, P. L. (2008). Intervention

for lateral /s/ using electropalatography biofeedback and

an intensive motor learning approach: A case report.

International Journal of Language and Communication

Disorders, 43, 219–229.

Marazita, M. L., & Mooney, M. P. (2004). Current

concepts in the embryology and genetics of cleft lip and

cleft palate. Clinics in Plastic Surgery, 31, 125–140.

Merlin, T., Weston, A., & Tooher, R. (2009). Extending an

evidence hierarchy to include topics other than treatment:

Revising the Australian “levels of evidence”. BMC Medical

Research Methodology, 9, 34.

Michi, K. I., Yamashita, Y., Imai, S., Suzuki, N., & Yoshida,

H. (1993). Role of visual feedback treatment for defective

/s/ sounds in patients with cleft palate. Journal of Speech

and Hearing Research, 36, 277–285.

National Health and Medical Research Council (NHMRC).

(2009). NHMRC Levels of evidence and grades for

recommendations for developers of guidelines. Adelaide:

Author.

National Institute for Clinical Excellence (NICE). (2002).

Interventional procedures overview of electropalatography.

London: Bazian.

Neumann, S., & Romonath, R. (2011). Effectiveness

of nasopharyngoscopic biofeedback in clients with

cleft palate speech: A systematic review. Logopedics

Phoniatrics Vocology [early online article], 1–12. doi:

10.3109/14015439.2011.638669

Pamplona, M. C., Ysunza, A., & Espinosa, J. (1999). A

comparative trial of two modalities of speech intervention

for compensatory articulation in cleft palate children,

phonologic approach versus articulatory approach.

International Journal of Pediatric Otorhinolaryngology, 49,

21–26.

Pamplona, C., Ysunza, A., Patino, C., Ramirez, E.,

Drucker, M., & Mazon, J. J. (2005). Speech summer camp

for treating articulation disorders in cleft palate patients.

International Journal of Paediatric Otorhinolaryngology, 69,

351–359.

Peterson-Falzone, S. J. (1990). A cross-sectional analysis

of speech results following palatal closure. In J. Bardach

& H. L. Morris (Eds.), Multidisciplinary management of

cleft lip and palate (pp. 750– 756), Philadelphia, PA: W. B.

Saunders.

Peterson-Falzone, S. J., Hardin-Jones, M. A., & Karnell,

M. P. (2010). Cleft palate speech (4th. ed.). St Louis, MI:

Mosby.

Portney, L. G., & Watkins, M. P. (2009). Foundations of

clinical research: Applications to practice (3rd.ed.). Upper

Saddle River, NJ: Pearson Education.

Reid, J. (2004). A review of feeding interventions for

infants with cleft palate. Cleft Palate-Craniofacial Journal,

41(3), 268–278.

Rose, M. (2009). Single subject experimental designs in

health research. In P. Liamputtong (Ed.), Research methods

in health: Foundations for evidence-based practice (pp.

199–240), South Melbourne: Oxford University Press.

Scobbie, J. M., Wood, S. E., & Wrench, A. A. (2004).

Advances in EPG for treatment and research: An illustrative

case study. Clinical Linguistics & Phonetics, 18(6–8),

373–389.

Shprintzen, R. J. (1995). A new perspective on clefting.

In R. J. Shprintzen & J. Bardach (Eds.), Cleft palate speech

management: A multidisciplinary approach (pp. 1–15). St

Louis, MI: Mosby-Year Book.

Siren, K. (2004). Cleft lip and palate. In L. Schoenbrodt

(Ed.), Childhood communication disorders: organic

bases (pp.187–225). Clifton Park, NY: Thompson Delmar

Learning.

Stokes, S. F., Whitehill, T. L., Tsui, A. M. Y., & Yuen, K.

C. P. (1996). EPG treatment of sibilants in two Cantonese

speaking children with cleft palate. Clinical Linguistics and

Phonetics, 10, 265–280.

Trost, J.E. (1981). Articulatory additions to the classical

description of the speech of persons with cleft palate. Cleft

Palate Journal, 18, 193-203.

Wyszynski, D. F. (2002). Cleft lip and palate: From origin

to treatment. New York: Oxford University Press.

1 Disordered resonance in cleft palate speech is not speciﬁcally

addressed in this review as it is not amenable to EPG

treatment. Please refer to Neumann and Romonath (2011) for

a systematic review on current research relating to the use

of nasopharyngoscopic biofeedback to treat velopharyngeal

insufﬁciency in cleft palate speech.

Technology

142 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 143

develop and diversify within the 21st century”. Speech

pathologists are currently using telepractice for various

individual clinical purposes, for example, to assess speech

and language in children (Waite, Theodoros, Russell, &

Cahill, 2010), stuttering intervention (O’Brian, Packman, &

Onslow, 2008), and parent education (Baharav & Reiser,

2010). Other professionals are also utilising telepractice

to connect families – for example, child health nurses

facilitating a new mothers’ support group (Nyström &

Öhrling, 2006). The telepractice solutions described in this

paper illustrate how telepractice can be used to deliver

parent education groups to families living distantly from one

another.

Technology: changing the service

delivery options

The Royal Institute for Deaf and Blind Children’s RIDBC

Teleschool is based in Sydney, NSW, and is a dedicated

team to support families with hearing and/or vision

impairment across Australia. RIDBC Teleschool offers

weekly telepractice sessions with a consultant via

videoconference to enrolled families. This is supported by

resources, lesson plans, phone calls, and emails as

required. In 2009 RIDBC Teleschool began using a

telepractice model to provide parent education groups to

rural and remote families.

The parent education groups were designed to create an

environment for remotely located families to support each

other while learning about communication. “It Takes Two to

Talk

: the Hanen program

for parents” (Conklin, Pepper,

Weitzman, & McDade, 2007) was chosen because it is a

family-focused early language intervention program with a

strong evidence base. The It Takes Two to Talk program is a

comprehensive package providing detailed instructions for

each group and individual session. It contains pre-prepared

PowerPoint slides, as well as various videos to share with

participants. Some group tasks suggest breaking the group

into pairs or fours to complete activities. Participants also

have individual sessions which are video-recorded so that

they can be replayed during the session to comment on

the interactions captured.There are two major issues to

consider when delivering It Takes Two to Talk to families

via telepractice: the availability of appropriate technology,

and adapting the It Takes Two to Talk program to suit

telepractice service delivery. Several options were trialled

with three different groups of parents, and are discussed

below.

Clinical insights

Adapting speech pathology practice: Delivering parent

education groups using technology

Corinne Loomes and Alice Montgomery

This paper discusses parent education

groups for families with children who have

sensory disabilities. Families living in rural

and remote areas participated in group

sessions via videoconference. The

technology required to provide parent groups

for families located across Australia is

discussed, with three different telepractice

methods reported. The parent groups used

The Hanen It Takes Two To Talk

program as

the structure of the parent groups, and the

adaptations required to use this existing

program in a telepractice format are

described.

any families with children who have disabilities

have limited or no access to support services

(Senate Committee, 2002). Metropolitan areas

offer some opportunities for these families to meet and

support one another, for example, playgroups for children

with disabilities, and parent education groups. Socialising

with other families provides support and can have a

powerful and positive impact (Crinc & Stormshak, 1997).

Families in similar situations can provide each other with

encouragement, understanding, and humour (Atkins,

2009). However, the reality for one-third of Australians is

that they live in rural and remote areas (Australian Bureau of

Statistics, 2009). Living outside of a metropolitan area can

mean that these families miss out on meeting with others to

share experiences.

Considering the fact that approximately 2 in 1000

children have signiﬁcant permanent hearing loss (Russ et

al., 2003), it is easy to see how a specialised service for

hearing impaired children in remote locations might be

difﬁcult to ﬁnd. Where services are available, some of the

established difﬁculties for professionals working in remote

locations include: large and generalist caseloads; vast

distances to cover; difﬁculties accessing some areas due

to weather conditions; and high staff turnover (McCarthy,

2010). Telepractice can offer specialised services to be

delivered from large metropolitan centres and accessed by

all Australians.

Developments in technology enable services to be

provided using telepractice solutions previously not

possible. Theodoros (2011) suggests speech pathologists

need “to engage and embrace this change in order to

Corinne Loomes

(top) and Alice

Montgomery

Keywords

early

inTervenTion

parenT

edUcaTion

parenT GroUps

TelepracTice

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 143

connecting with other families over videoconference. Some

parents commented that it was difﬁcult for them to attend

sessions at a local studio and would have preferred a

home-based service. They reported that it took some time

to feel conﬁdent using speciﬁc strategies for telepractice

communication, for example, introducing themselves to

engage the voice activated picture display, where the

person talking is the person seen by all participants,

and muting microphones to maintain the picture on the

speaker rather than have the picture display changed by

background noises.

2. Videoconferencing using

web-based software

Alterations to the telepractice model were made based on

parent feedback from the videoconferencing method

described above. This second parent group used web-

based conferencing. Many conferencing programs are

available, and for this group Sightspeed Business (2004–

2009) was chosen. Sightspeed Business provided the

capacity to connect multiple sites and share ﬁles and

computer desktops while connected. As the conferencing

program was web-based, all families could participate at

home, provided they had access to a computer and

adequate upload/download speed.

In this It Takes Two to Talk group four families enrolled at

RIDBC Teleschool combined with four metropolitan families.

The metropolitan families attended group sessions at the

RIDBC campus in Sydney. The remote families connected

to the group using Sightspeed Business. By sharing

the presenter’s desktop, PowerPoint slides and video

clips could be viewed simultaneously by all participants.

Three technology solutions for

telepractice service delivery

1. Videoconferencing using ISDN

The ﬁrst It Takes Two to Talk group made use of

videoconferencing facilities with an ISDN (Integrated

Services Digital Network) connection. Individual and group

sessions were held at local videoconferencing studios. For

the group sessions a virtual bridge, which is a private

network that is created to connect speciﬁc

videoconferencing sites, was used to connect the four

families and the presenter.

In order to share PowerPoint slides and videos with

the families during the group sessions the presenter used

a document camera. The document camera connects

simultaneously to the videoconferencing equipment and a

computer. It allows information presented on the computer

to be viewed by the group participants via the television

monitor at their conference site. A key component of the

It Takes Two to Talk program involves individual sessions,

where the parent is ﬁlmed interacting with their child. This

video is then played back to the parent during the session

to analyse the interactions. It was still possible to provide

immediate feedback in the individual session by recording

the session occurring at the parent’s site, and then

replaying it to the parent for discussion. In this method, the

individual session was captured using a VHS recorder.

At the end of the course parents were asked to complete

a questionnaire about their experience. Parents were

satisﬁed with the technology used and thought that it

provided very high-quality audio and video. Parents also

reported how much they enjoyed the group sessions and

Delivering the

It Takes Two to

Talk program by

telepractice

144 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 145

Two to Talk program outlines six minimum requirements for

an adapted program (summarised in Box 1). All

requirements for the program were maintained in each

method described and essentially telepractice changed only

the relative location of the presenter and participants.

Sightspeed Business did not provide the capacity to record

and play back video instantaneously. To counteract this

problem, families attended a local studio for individual

sessions (see videoconferencing using ISDN).

Parent feedback from the questionnaire was again

positive. All families reported how much they had enjoyed

connecting with other families with one participant in rural

Victoria commenting “it’s great to know there is someone

else out there!”. In using web-based conferencing, more

technology problems were encountered than in method 1.

Some predictable difﬁculties occurred since transmission

relied on the quality and speed of the families’ individual

internet connections. The biggest challenge, however,

was preventing signiﬁcant amounts of audio feedback and

echo. A number of solutions were trialled and use of an FM

transmitter with a Direct Audio Input (DAI) connected to

the clinician’s laptop allowed for clearer transmission of the

audio signal. Although this solution was found to improve

audio quality greatly, feedback reoccurred occasionally.

Two presenters were then used: one to present and one

to manage and troubleshoot the technology. This is in

contrast to other methods, where one presenter was able

to manage both the material and technology.

3. Combining videoconferencing

with on-site sessions

The telepractice service delivery model was altered in two

ways in the third method as a result of parent feedback.

First, a residential component was added, to further

facilitate social support opportunities. Second, the group

sessions delivered remotely used in-home

videoconferencing technology. Three families were

accommodated at the RIDBC campus in Sydney and

attended the ﬁrst three group sessions and an individual

session while on site.

All the participants had dedicated in-home

videoconference equipment supplied on loan by RIDBC

Teleschool. This equipment utilised the cellular network

for transmission of the signal. The remaining group

sessions used a multipoint connection that was created

by using RIDBC Teleschool’s videoconference camera with

specialist software installed. This camera and software

has the capacity to link sites using ISDN and/or cellular

connections. PowerPoint slides and videos were shared

with families as per method 1, and participants could now

see all participants and slides simultaneously. Individual

sessions were recorded using computer software. The

footage was reviewed during the session using the

document camera that transmitted directly from the

computer.

Using dedicated videoconferencing equipment ensured

a high-quality picture and audio for all group and individual

sessions which was conﬁrmed by all participants on the

questionnaire. Parents again highlighted how positive it had

been to meet and connect with other families in a similar

situation. They also reported that the residential component

had provided opportunities for them to socialise with the

other parents. Parents said they felt more conﬁdent and

open in sharing during later group sessions.

Delivering the It Takes Two to Talk

program by telepractice

Apart from mastering the technology required for successful

telepractice, it was also important to ensure that the

content of the course was maintained, while altering the

presentation to suit the service delivery mode. The It Takes

Box 1. Minimum requirements when adapting It

Takes Two to Talk: the Hanen Parent Program

1. Ensure a recent assessment of each child is available.

2. Conduct and record a pre-program consultation.

3. Develop individual goals for the children collaboratively with

parents.

4. Provide a minimum of 4 group sessions and a minimum of 10

group hours.

5. Use full teaching cycles as per the program.

6. Conduct one or more individual sessions involving coaching and

feedback.

Source: Conklin et al., 2007, p. 562.

Additional planning was required to deliver some of the

practical elements of the program, including facilitating

group discussions and modifying group activities. For

example the “icebreaker” task is usually done in groups of

four. However, telepractice does not allow for participants

to hold separate discussions using the same multipoint

connection. In each of the methods, all participants were

involved in the activity together (Conklin et al., 2007, p.

113). Some adaptation in the role play activities was also

required. For example, in method 1 presenters modelled

role-play activities, as only one site could be seen at a

time. In method 3 it was possible to have participants from

different locations work together on the role play activities.

In the “Birthday Game” (Conklin et al., 2007, p. 119)

participants are asked to form a line in the order of their

birthdays without talking. When conducting this activity by

telepractice, participants were still able to determine their

birth order without speaking. However, instead of forming

a line, they wrote a number on a piece of paper, and

displayed it to the group to indicate their place in the “line”.

This worked successfully in all three telepractice methods

described.

Discussion in pairs was possible. In method 1 two pairs

were formed by members of the same family at the same

location. The remaining 2 participants (in separate locations)

used the videoconference equipment for their discussion.

All other participants muted their microphone so their

discussion did not interrupt the videoconference pair. They

also turned the speaker volume down, so they weren’t

hearing the discussion of the videoconferencing pair. At

other times discussions were conducted as a whole group.

Other practical considerations include advanced

planning, for example, booking rooms for the telepractice

sessions, and sending out resources and handouts required

for each session well in advance. Reviewing the program

for each week ahead of time and making modiﬁcations

to activities was also very important. Often a backup plan

was required to enable the session to continue despite

technology problems, for instance, having videos available

in multiple formats in case of technology problems.

Another consideration is the number of participants. The

group numbers were smaller than typical for the It Takes

Two To Talk program. While this was mainly due to the

family availability and suitability for each course, the smaller

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 145

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Russ, S., Poulakis, Z., Barker, M., Rickards, F., Saunders,

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the CELF-4. Language, Speech, and Hearing Services in

Schools, 14, 445–458.

number allowed us to manage any technology problems.

This discussion highlights some key practical and

pedagogical considerations that are required to make the

telepractice model successful and illustrates modiﬁcations

that might be made in telepractice sessions on other topics

or within other areas of speech pathology.

Conclusion

Our aim of providing an It Takes Two to Talk program to

parents was to connect rural families and provide a

high-quality parent education program. For families enrolled

in RIDBC Teleschool, this required the use of technology to

deliver parent courses. When speech pathology services

can use technology to offer group sessions to support

communities of people from similar circumstances across

wide distances, then rural and remote families are truly

receiving services comparable to their metropolitan

counterparts. RIDBC Teleschool’s initial investigations in

using telepractice to deliver parent education groups have

been technology-based. Each telepractice method

described was trialled to establish which technologies can

be used to effectively deliver parent education groups.

Future research should investigate the effectiveness of

telepractice parent education groups as compared to those

delivered face to face. This should not only look at parent

satisfaction, but also examine the changes in the

communication skills of the children participating while

using different modes for delivering the parent education

groups.

References

Atkins, V. (2009). Family involvement and counselling in

serving children who possess impaired hearing. In R. Hull

(Ed.), Introduction to aural rehabilitation (pp. 89–106). San

Diego, CA: Plural Publishing.

Australian Bureau of Statistics. (2009) Australian social

trends: 2008. Retrieved from http://www.abs.gov.au/

AUSSTATS/abs@.nsf/Lookup/4102.0Chapter3002008

Baharav, E., & Reiser, C. (2010). Using telepractice in

parent training in early autism. Telemedicine and e-Health,

16, 727–731.

Conklin, C., Pepper, J., Weitzman, E., & McDade, A.

(2007). It Takes Two to Talk: The Hanen program for parents

(5th ed.). Toronto, Canada: Hanen Centre Publication.

Crinc, K., & Stormshak, E. (1997). The effectiveness of

providing social support for families of children at risk. In

M. J. Guralnick (Ed.), The effectiveness of early intervention

(pp. 209–226). Baltimore, MD: Paul H. Brookes Publishing.

McCarthy, M. (2010). Telehealth or tele-education?

Providing intensive, ongoing therapy to remote

Corinne Loomes is a senior speech pathologist who has worked

in the ﬁeld of disability since 1998. She is currently working with

hearing- and vision-impaired children across Australia with RIDBC

Teleschool. Alice Montgomery is a speech pathologist working at

RIDBC Teleschool. Alice works with children with a hearing

impairment who live in rural and remote Australia. Alice graduated

from City University in London in 2005 and moved to Australia in

2008.

Correspondence to:

Corinne Loomes

RIDBC Teleschool

Private Bag 29, Parramatta, NSW, 2124

phone: +61 (0)2 9872 0254

email: Corinne.loomes@ridbc.org.au

Technology

146 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 147

Shane Erickson

between and within countries due to economic, political

and in particular, geographical factors. Lifestyle factors also

present as a barrier for clients, with signiﬁcant direct costs

such as transportation and accommodation, and indirect

costs including time off work for clients and family members

or even childcare costs (Doolittle & Spaulding, 2006).

While the Lidcombe Program has gained widespread

acceptance among speech pathologists in Australia

(Onslow et al., 2003), this isn’t necessarily the case

around the world. The treatment has been introduced and

accepted by clinicians in the United Kingdom, South Africa,

Canada, New Zealand, and Germany. Additionally, there is

some uptake by clinicians in other European countries like

Denmark and the Netherlands. However, client access in

some countries (including the United States) has likely been

affected by a preoccupation with treatments inﬂuenced by

the diagnosogenic theory of stuttering (that it is caused by

parents inappropriately drawing attention to their child’s

dysﬂuencies) which directly opposes the principles of the

Lidcombe Program.

To combat access issues, speech pathology services

in other areas of the profession have been delivered via

telehealth for more than three decades. However, published

data regarding telehealth implementation in the ﬁeld of

stuttering is limited and only dates back to 1999. Harrison,

Wilson, and Onslow’s (1999) single case study successfully

adapted the Lidcombe Program to be delivered over the

telephone for a family isolated from treatment services.

The positive outcome has more recently been conﬁrmed

by phase I and phase II trials of telehealth delivery of the

Lidcombe Program (Lewis, Packman, Onslow, Simpson, &

Jones, 2008; Wilson, Onslow, & Lincoln, 2004). Presently, a

randomised controlled trial is underway comparing in-clinic

delivery of the Lidcombe Program with Internet delivery

using Skype.

In Melbourne, experienced speech pathologist Dr Brenda

Carey has delivered the Lidcombe Program via Skype when

families were unable to access in-clinic sessions. This has

resulted in clients from places like China, United States,

India, Singapore, Italy, and indeed rural Australia receiving

this treatment. One such client is Jenny (pseudonym) and

her son Tom (pseudonym) who live in South Africa. The

following are the perspectives of Dr Carey and Jenny about

their experiences of the Skype-delivered Lidcombe Program.

Establishing contact

Jenny (J): I read about the Lidcombe Program on the

Internet. It just sounded so child centred and positive. I

Given the barriers that inﬂuence many clients’

access to stuttering treatment, clinicians and

researchers are seeking effective alternative

treatment delivery models. Positive outcomes

from trials reporting the telehealth delivery of

stuttering treatment has meant clients can

avoid many of these access issues and

conveniently receive treatment. Despite little

reported evidence to support the use of

Skype, evidence for delivery methods such as

using a telephone would seem to indicate

that it is a viable alternative to face-to-face

treatment. This clinical insight reports the

perspectives of experienced stuttering

clinician Dr Brenda Carey and her client

about the use of Skype to deliver the

Lidcombe Program internationally.

hile data regarding the incidence and prevalence

of stuttering are limited, most studies have

suggested that around 1% of people stutter (e.g.,

Craig, Hancock, Tran, Craig, & Peters, 2002). Typically

developing before the age of four, stuttering has been

observed in all cultures, races, historical periods, and

languages (Ardila, 1994). The current consensus is that

ideally stuttering should be treated in the preschool years

(Jones et al., 2005). This is primarily based on the fact that

neural plasticity decreases with age and as such stuttering

becomes less tractable. Early, effective intervention appears

crucial in preventing the signiﬁcant impact of stuttering,

with the potential for it to become a chronic condition

by adulthood, signiﬁcantly disrupting life on a daily basis

(Onslow, 2000).

Presently, the Lidcombe Program (Onslow, Packman,

& Harrison, 2003) is the most efﬁcacious treatment for

children who stutter. Randomised controlled trials have

shown that this parent-delivered, behavioural treatment is

most effective with children younger than 6 years of age

(Jones et al., 2005). Traditional delivery requires parents to

travel weekly to clinics specialising in this treatment.

Access to treatment is a signiﬁcant issue for many clients

who stutter and their families. Doolittle and Spaulding’s

(2006) review of the importance of telemedicine health

care identiﬁed that many people do not have access to

appropriate services for their needs. Major disparities exist

Clinical insights

No boundaries: Perspectives of international Skype

delivery of the Lidcombe Program

Shane Erickson

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 147

Building a relationship

J: From the very start of treatment I felt Brenda was right

there in the trenches with us – not managing the issue in a

detached way. Of course the irony of it was that she was

actually thousands of miles away yet we had this sense of

real partnership with her. In fact, my husband even found

that he was no longer allowed to insult the Australian nation

during rugby matches on the TV – he had to qualify his

comments by adding “except Brenda of course” or get dirty

looks from Tom and me!

BC: I felt a constructive and supportive relationship was

quickly established that was not impeded by the delivery

model. Jenny was clearly engaged in her son’s treatment.

Parental motivation, creativity, persistency, and belief in the

treatment are always contributors to success and this

parent had all of these qualities in spades!

Delivering treatment via Skype

BC: While Tom was present at every consultation, he

usually only remained on camera for a short time. During

these times severity ratings were discussed and conﬁrmed

and I demonstrated aspects of therapy. To augment this,

Jenny recorded and emailed weekly speech samples of

Tom’s spontaneous and treatment conversations. Jenny’s

excellent compliance afforded me the opportunity to hear

his speech in a variety of commonly occurring situations.

J: I think telehealth has a huge amount to offer. I found it so

convenient and incredibly stress free. My son and I were in

our own home so there was none of the settling in period

that might occur when working in a therapist’s rooms. My

son is also terribly interested in technology so the idea that

he got to chat to an interested (and interesting!) adult via

Skype on a weekly basis was a huge treat for him.

emailed Professor Mark Onslow (of the Australian Stuttering

Research Centre) to ask him if he knew of Lidcombe

therapists in South Africa. He gave me a few ideas but also

said the option of telehealth was available.

Dr Brenda Carey (BC): As a specialist stuttering clinician

and member of the Lidcombe Program Trainers’

Consortium I have used the Lidcombe Program in clinic for

many years, and am aware of the outcomes from telehealth

trials. My doctoral and subsequent research has involved

the delivery of stuttering treatments using telehealth

models. When approached by this family experiencing

access barriers to the Lidcombe Program, I was willing to

provide this service. I had previously treated adults who

stutter using the Camperdown Program, over the phone,

and a few children living internationally who were unable to

access the Lidcombe Program.

Access to the Lidcombe Program in

South Africa

J: I chatted to two speech therapists in South Africa. The

ﬁrst one saw the Lidcombe Program as simply “good

speech therapy” rather than a distinct approach. I then

spoke to another therapist who didn’t seem speciﬁcally

trained in the Lidcombe Program either. I did try making

further enquiries but couldn’t ﬁnd anyone who described

themselves as a Lidcombe therapist.

BC: I know she had difﬁcult ﬁning a clinician who had

Lidcombe Program training, and when she did, the

program was offered as an adjunct to another treatment,

not as recommended by the “Clinician’s Guide to the

Lidcombe Program” (http://sydney.edu.au/health_sciences/

asrc/docs/lidcombe_program_guide_2011.pdf).

Advantages of Skype delivery

BC: For some clients telehealth may be the only service

delivery model available. It may also be the only opportunity

to access treatment that has randomised controlled trial

evidence (Jones et al., 2005). A telehealth service is also

timesaving as there is no need to drive to a clinic or wait in

the clinic waiting room. Finally, children and parents are

more likely to feel comfortable to receive treatment in their

own homes.

The clinician achieves greater insight into the child’s

world. The treatment is conducted in the child’s

environment, and it’s not unusual for the child to bring into

the session toys, family members, and pets. As a result, the

clinician also sees a larger and more representative sample

of the child’s speech.

J: Well, I think it allowed me direct access to someone like

Brenda (even though she was on the other side of the

world) who is obviously so highly skilled and respected in

delivering the Lidcombe Program.

Tom’s initial presentation

BC: Jenny described Tom (age 4;0 years) as a highly

communicative, creative, and imaginative child. She

expressed concern about Tom’s stuttering which had been

present for more than a year, and the possible impact it

may have on him in the future, should it become

“entrenched”. Jenny had read extensively about stuttering

and was well informed about the varied treatment

approaches. She did not feel that Tom was aware of his

stuttering, and in line with what she had read, had made

every attempt not to draw attention to it, fearing this might

make it worse. She described a close, supportive family

with a positive family history of stuttering.

Recordings of Tom conﬁrmed that his stuttering was

frequent and he displayed a range of repetitive stuttering

behaviours. His percentage of syllables stuttered in a

10-minute conversation with his father was 20 %SS,

Severity Rating (SR) of 7.

J: I ﬁrst noticed that Tom was struggling with certain words

when he was nearly three. Initially I hoped it would just go

away and certainly there were periods when it improved;

however, it never disappeared completely. Over a number

of years I read up as much as I could about stuttering, but

was fairly ambivalent about what therapy, if any, to embark

on. This was exacerbated by the fact that sometimes his

speech would improve, only to worsen a little later.

Dr. Brenda Carey

providing Skype

treatment to a

pre-school child

who stutters

148 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 149

I would suggest that clinicians ﬁrst exhaust all other

avenues to access the Lidcombe Program in-clinic.

Outcomes from an RCT of the Lidcombe Program delivered

over the phone (Lewis et al., 2008) show it is a less efﬁcient

delivery model, and takes on average three times longer

to reach stage 2. Until research outcomes are available

for the Lidcombe Program over Skype, we should be very

conservative in its use.

The last word...

J: I think Skype has incredibly exciting potential in allowing

clients to access health care that simply wouldn’t be an

option otherwise. I am just so grateful that we were able to

ﬁnd the exact help that Tom needed.

BC: I think and hope that there will be an increasing range

of evidence-based treatment delivery alternatives for people

who stutter. I see the potential beneﬁts might be greatest if

webcam Internet treatments can be developed for

adolescents. Computers are such an integral part of their

lives, and viewed so favourably by them. We are working on

this at the Australian Stuttering Research Centre at present

and hope to have our phase I trial results published soon.

References

Ardila, A. (1994). An epidemiologic study of stuttering.

Journal of Communication Disorders, 27, 37–48.

Craig, A., Hancock, K., Tran, Y., Craig, M., & Peters, K.

(2002). Epidemiology of stuttering in the community across

the entire lifespan. Journal of Speech, Language, and

Hearing Research, 45, 1097–1105.

Doolittle, G. C., & Spaulding, R. J. (2006). Deﬁning the

needs of a telemedicine service. Journal of Telemedicine

and Telecare, 12, 276–284.

Harrison, E., Wilson, L., & Onslow, M. (1999). Distance

intervention for early stuttering with the Lidcombe

Programme. Advances in Speech Language Pathology,

1(1), 31–36.

Jones, M., Onslow, M., Packman, A., Williams, S.,

Ormond, T., Schwarz, L., & Gebski, V. (2005). Randomised

controlled trial of the Lidcombe programme of early

stuttering intervention. British Medical Journal, 331(7518),

659–667. doi: 10.1136/bmj.38520.451840.E0

Lewis, C., Packman, A., Onslow, M., Simpson, J. M.,

& Jones, M. (2008). A phase II trial of telehealth delivery

of the Lidcombe Program of Early Stuttering Intervention.

American Journal of Speech Language Pathology, 17(2),

139–149. doi: 10.1044/1058-0360(2008/014)

Onslow, M. (2000). Stuttering treatment for adults.

Current Therapeutics, 41(4), 73–76.

Onslow, M., Packman, A., & Harrison, E. (2003).

Lidcombe program of early stuttering intervention: A

clinician’s guide. Austin, Texas: Pro-Ed.

Wilson, L., Onslow, M., & Lincoln, M. (2004). Telehealth

adaptation of the Lidcombe Program of Early Stuttering

Intervention: Five case studies. American Journal of

Speech-Language Pathology, 13, 81–93.

I never really had any doubts – as soon as the process

of telehealth was explained to me, it seemed like such a

viable, sensible option. I had read a lot about Brenda via

the Internet and during an initial conversation felt that she

completely “got” our situation – she was so obviously highly

skilled and incredibly empathetic too.

Treatment delivery difficulties

J: We had a few times when technical difﬁculties arose.

Luckily my husband is very au fait with IT so we were

usually able to resolve any problems quickly. When we

started the therapy I hadn’t really used Skype before but

lots of people use it to stay in touch with friends and family.

Previously, I would have advised others considering

telehealth to make sure they have access to good technical

help; however, now that the technology is so mainstream I

think this is less important as so many people have access

to Skype at home and it seems less complex.

BC: Parents might ﬁnd it a little harder to learn Lidcombe

Program practices when demonstration is restricted. The

clinician needs to rely on effective verbal communication

even more. For example, during an in-clinic session a

clinician typically demonstrates with toys or books how to

provide the contingencies to the child. This is more difﬁcult

over Skype. Additionally, extra ﬂexibility in scheduling client

appointments may be required if treating clients in the

northern hemisphere, due to time differences. Finally, there

are technological issues, for example poor Internet

connection.

Tom’s progress

BC: Overall, Tom has reduced his stuttering markedly.

However, this has taken many weeks longer than the mean

from in-clinic outcome studies. While this is consistent with

Tom’s high pre-treatment severity, it is also possible that the

delivery model may have been a contributor. As can be

common to Lidcombe Program clients, there have been

small exacerbations along the way, and weeks during which

severity ratings (SR) have plateaued. Tom currently sits at a

SR 2 (0.7 %SS), and we continue to aim for SR 1 (no

stuttering).

J: His progress was really fast at ﬁrst. After that, we did

have a few plateaus which Brenda managed by changing

strategy or sometimes suggesting a short therapy holiday,

to give us more energy to tackle the issue later on.

Face-to-face versus telehealth

for Tom?

BC: Of course this is impossible to know. Children with high

severity typically take longer to complete the Lidcombe

Program, and Skype delivery might have extended this further.

J: I found the Skype-delivered treatment so convenient and

stress free that I think it’s superior! Had we embarked on

the treatment in South Africa, I would have needed to drive

at least an hour to access treatment. Engaging with a

therapist via Skype was new for me; however, I felt such a

sense of trust in Brenda, certainly on a professional level, as

it was clear that she was a highly esteemed and qualiﬁed

practitioner.

Required clinician skills

BC: Clinicians need a high degree of in-clinic experience

with the Lidcombe Program, and must be conﬁdent that

they have met the program’s clinical benchmarks for a large

number of clients. They also need to be conﬁdent with the

technology.

Correspondence to:

Dr Shane Erickson

Lecturer and Speech Pathologist

School of Human Communication Sciences

La Trobe University

Bundoora, VIC 3086

phone: +61 (0)3 9497 1838

email: s.erickson@latrobe.edu.au

Technology

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 149

Caroline Bowen

abbreviations: GIF, meg, net; memes; and computerese –

the Tech Speak of computer geeks: “You’ll love this! At the

end of ’88 I was still running the old IBM OS/2 SE 1.0 on an

AT/099 with an ST251-1. Hilarious or what?”

Third, online social networking – connecting with others

and sharing information via the Internet – in our ﬁeld is

increasing. At the same time, WC3’s semantic web

currently in development and frequently called Web 3.0,

is already changing life online. But it is not quite time for a

Web 2.0 (“social web”) retrospective.

The purpose of this feature-length Webwords is to

suggest ways that modestly net-savvy and computer

literate speech-language pathologists can utilise, enjoy, and

reap the beneﬁts of web technologies without spending a

fortune. It includes an explanation of Web 1.0 and Web 2.0

and a tour of the so-called Web 2.0 technologies with links

to more detailed information; the interesting ways our SLP/

SLT professional associations and colleagues use these

tools; and the lowdown on creating professionally oriented

blogs, wikis, Internet forums, and electronic mailing lists, or

websites.

Read/write web

The date 6 August 1991 marked the debut of the world

wide web as a publicly available service on the Internet.

“Web 1.0” or “Web”, refers to its ﬁrst stage, in which html

pages were connected with revolutionary hypertext links

(hyperlinks) and web-based email came into its own,

impacting the dissemination of knowledge within

and across settings. Tim Berners-Lee

, who

invented it, is serious about accessibility (Berners-

Lee, 2002; Bowen, 2012), and it is timely, in the

National Year of Reading

, to be reminded that

he wanted it to be the “Read/Write Web” where

anyone, anywhere could meet and read and write.

Connecting people

Digital doyenne Darcy DiNucci coined the

term “Web 2.0” in 1999. It persists despite

Berners-Lee’s criticism that, “nobody even

knows what it means”. When asked in 2006 if

he agreed that “Web 1.0 is about connecting

computers, while Web 2.0 is about connecting

people”, Berners-Lee replied, “Totally not. Web

1.0 was all about connecting people ... If Web

2.0 for you is blogs and wikis, then that is people

to people. But that was what the Web was

supposed to be all along”.

Years later, there remain two difﬁculties with the

notion of the Web 2.0 websites being qualitatively

different from the Web 1.0 websites. One, Web 2.0 is

still not different from Web 1.0, but rather continues as

an extension of the original plan, and two, the Web 2.0

websites are so dissimilar from each other in terms of

content that it is odd to classify them as belonging in a

single category.

evisiting the world of information and

communication technology (ICT) and the speech-

language pathologist (Bowen, 1999; 2003) in

2012, three main themes emerge. First, most of the useful

personal, recreational, business, and professional web

applications can be sourced for no cost or at a very low

cost and conquering their use is easy but potentially time-

consuming.

Second, despite fears that the language of the Internet

(Crystal, 2001) would destroy English and other languages,

the language that appears in our browsers is essentially the

same as it was in pre-Internet days with just a few changes

relating to an increase in stylistic range, ﬂexibility in the use

of punctuation and capitals, and a grammatical informality

not found in written English since the Middle Ages (Crystal,

2008). There are new written forms and novel word usages

associated with blogging, emailing, chatting, and texting,

and new expectations of how words might be interpreted.

How ever did Webwords anticipate that an image search

for “Middle Ages” might yield pictures of vibrant Threshold

Generation party animals living well, exercising regularly,

and getting a good chuckle out of scrapping their

retirement plans?

Webwords 44

Life online

Caroline Bowen

The Internet has boosted the lexicon by some 200–300

words. There are CamelCase words: eBay, PayPal, and

WikiLeaks; portmanteau words (Carroll, 1871): bit (binary

digit), malware (malicious software), modem (modulate

demodulate), and pixel (picture element); acronyms: FCOL;

150 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 151

or school, to connect with family, friends, colleagues, and

people with compatible interests. Many organisations have

a public presence on Facebook to connect all of their

employees or members, while some have found

advantages in using an internal, secure version of Facebook

for private collaboration. Five mutual recognition agreement

(MRA) signatories are on Facebook: ASHA, CASLPA, the

New Zealand Speech-language Therapists’ Association

(NZSTA), the Royal College of Speech and Language

Therapists (RCSLT), and Speech Pathology Australia (SPA);

but at last count, not the Irish Association of Speech &

Language Therapists (IASLT).

Twitter

All six MRA signatories tweet. Twitter is a free social

networking micro-blogging service in which users send and

read updates or “tweets” of no more than 140 characters.

Guidance (Twetiquette and more) is provided in Tanya

Coyle’s Twitter for SLPs

series and Jessica Hische’s

mom, this is how twitter works

is, as she says, not just

for moms. Potential professional uses include brainstorming

and efﬁcient provision of updates and announcements to

an “in” group. For example, Shareka Bentham and Tanya

Cole at SLPChat

cleverly unite the blogging tool

WordPress with Twitter for the purposes of SLP/SLT

discussion within a small (so far) following.

Blogs

A blog (web log) is a personal journal published on the web,

typically composed by a blogger working alone or with one

or a very small band of collaborators. Blog entries usually

appear in reverse chronological order so that the blogger,

blog visitor, or follower sees the most recent post ﬁrst and

has to scroll down for earlier entries. The better blogs, like

ASHAsphere

, are interactive and allow comments and

messages using graphical user interface (GUI) controls (also

called widgets) such as windows or text boxes. Bloggers of

interest to SLPs/SLTs, judging by their followings, are

Martin J Ball and Nicole Müller

and Judith Stone-

Goldman on WordPress, and Dorothy Bishop, Madalena

Cruz-Ferreira, David Crystal, Sharynne McLeod

, and

John Wells on Blogger. Their respective blog rolls provide

many leads to other professionally stimulating journals.

Some SLPs/SLTs have developed blogs as resource

sites. Heidi Hanks is Mommy (of four) Speech Therapy, Paul

Morris issues The Language Fix, Jenna Rayburn shares

her Speech Room creations, Mirla Raz reviews apps for

speech therapy, Sean Sweeny “looks at technology through

a language lens” and provides a collaborative document

at Google Docs called The SLP Apps List which anyone

can edit (note also the October 2011 ASHA Leader’s

Apps: An Emerging Tool for SLPs by Jessica Gosnell and

the Speaking of Apps message board on the Speaking

of Speech site), Rhiannon Walton has therapy ideas and

videos, and Pat Mervine uses Blog.com for her blog on

the Speaking of Speech site. All the sites mentioned in

the two preceding paragraphs, and those that follow are

hyperlinked in the web version of Webwords 44 at www.

speech-language-therapy.com

Wikis

The word “wiki” comes from the Hawaiian word for “quick”,

so Wikipedia is a portmanteau of quick/wiki and

encyclopaedia. A wiki is a website whose content is easily

editable within the wiki-editor’s browser. Usually there is an

“edit” button on every page of a wiki and it is conﬁgured to

Web content classification

Folksonomy is one webword you probably don’t like, and

you deﬁnitely don’t want to say it with a blocked nose. A

portmanteau of folks and taxonomy, it refers to a web

content classiﬁcation process called collaborative tagging

or social bookmarking. In it, producers-and-consumers or

professionals-and-consumers (“prosumers”, either way)

cooperate in the creation and management of tags in order

to annotate, group, and ﬁnd web content. Folksonomies

have been popular since 2004 on social websites like 43

Things

where over 3 million people “list their goals, share

their progress, and cheer each other on”. Folksonomies,

tagging, blogging, and social networking (e.g., via

Facebook, Linkedin, RSS feeds, Twitter, and You Tube) are

among the deﬁning characteristics of Web 2.0

and its

toolkit.

Toolkit

Podcasts

The American Speech-Language-Hearing Association

(ASHA) was the ﬁrst speech pathology professional

association to launch a website and lead the charge in

embracing Web 2.0 (Fisher, 2009). Its use of a blog, RSS

feeds, and informational podcasts

to promote and

publicise its activities, publications, and services is

extensive. Podcasting is a convenient means of

automatically downloading audio or video ﬁles to a

computer. The ﬁles can be played on the same computer or

transferred to a portable MP3 or video player. Podcasts can

be expensive and technically challenging for non-experts

but can be monetized

by advertisers or sponsors.

RSS feeds

A subscription to an RSS (really simple syndication) web

feed, such as the ASHA journals RSS

feeds, the

Canadian Association of Speech-Language Pathologists

and Audiologists (CASLPA) RSS

feeds, or the MedWorm

Speech Therapy RSS

feeds takes moments. Web

content is delivered or “pushed” to the subscriber’s free

reader (e.g., Google Reader, Yahoo, Microsoft Outlook, or

Live Bookmarks). It costs nothing for an organisation or

individual to generate the feed and if prominent news

aggregators (e.g., DecaPost, Drudge Report, Google News,

or the Hufﬁngton Post) pick it up, the message reaches an

extended readership.

Video sharing

YouTube is a video-sharing website where users can

upload, view, and share clips. Unregistered users are able

to watch the videos, while registered users can upload an

unlimited number of videos. CASLPA has its own CASLPA

YouTube Channel, a low-budget, less technically

demanding alterative to podcasting that has been active

since March 2010. YouTube competes with many other free

or low-cost video hosting sites such as Animoto, Flickr,

Screencast, Slideshare, and Vimeo, and videos can also be

uploaded to personal and work websites. Speechwoman

smiled on Firm Foundations

, also in Canada, for an

excellent example of videos made by teachers and

uploaded to a section of a school district website, to

demonstrate phonological awareness training and other

early literacy skills.

Facebook

Facebook is a free social networking service. Facebook

users can join networks organised by location, workplace,

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 151

metered (“rented”) service. Microsoft offers a cloud-based

collaboration and communication suite, Ofﬁce 365 for cents

per day, competing with Google Apps for Business and

IBM Lotus. Most of the suite vendors offer free trials, and

some users opt for and stay with free secure suites such as

free Google Apps and R360. Cloud computing is often

presented as a form of green computing, but to date there

is no empirical support for this claim.

Bookmarking and sharing

Cloud-powered online bookmarking and sharing tools like

Diigo and Firefox Sync enable subscribers to organise,

annotate, and group bookmarks with ease. A toolbar is

used to seamlessly add and annotate a link, then return to

the site of interest; tag sites with multiple category names

rather than the single category folders for favourites or

bookmarks provided by browsers (e.g., Explorer, Firefox,

Safari, Opera, and Chrome). Users can view their

bookmarks in a web-based account from any browser or

computer; and ﬁnd more sites by searching within the

network or by tag.

Open source

Many of the software programs,

including content management

systems like Drupal, Joomla,

WordPress, and Tiki Wiki, that people

use to create blogs, wikis and

websites are classiﬁed as “open

source”, as deﬁned by the Open

Source Initiative

, and are published under creative

commons25 licences.

Australians who are new to online publishing will ﬁnd

helpful information about legal sharing, remixing and

reusing content, and on protecting and disseminating

their own intellectual property, on the Creative Commons

Australia site and the Copyright Agency Limited

site.

Constructing any category of Creative Commons License

is as simple as ﬁlling out an online form. It lets the licensee

retain copyright and allows people to copy and distribute

the work as speciﬁed by the copyright holder. Once the

form has been completed the licensee is given the HTML

needed in order to add the license information to the

relevant website site and information on how to select a

license on one of several free hosting services that have

incorporated Creative Commons.

Websites

Small, professionally managed sites

For SLPs/SLTs who want a web presence in the form of a

small website there are advantages in hiring and brieﬁng a

designer to get the job done professionally. The main

recurring costs are for DNS registration and re-registration,

hosting, and the designers’ fees. A well-chosen web

designer is able to offer a range of services that may

include an inexpensive, attractive, navigable, secure,

custom-made site uniquely designed and built to the

client’s speciﬁcations, website hosting including arranging

DNS registration (e.g., with TPP Internet who provide

pricing information for Australian .au, New Zealand .nz, and

Global.com, .net, .org, .biz, and .info domain names),

eCommerce tools, database development, custom and

web promotions. Examples of such paid-for sites, some by

professional developers and others by experienced

let anyone with or without a password (as in the case of

Wikipedia), or only people with passwords, to edit any

page, including other people’s posts, as in Wikispaces,

Wikidot and Tiki Wiki CMS Groupware.

The Wikispaces service from Tangient LLC houses the

resource rich Universal Design Technology Toolkit

maintained by Joyce Valenza and Karen Janowski. Michał

Fra˛ckowiak’s Wikidot is the third largest wiki host, or wiki

farm to date. On Wikidot, all education sites, such as

The Special Ed Wiki, are provided at no cost, modestly

priced

paid-for sites are available, and there is a no-

obligation sandbox where people can try their hand. Tiki

Wiki is a community-managed, open development project,

with an ofﬁcial Tiki Software Community Association as the

legal steward. A nice feature of Tiki Wiki is its beginners’

guide called, “Tiki for Dummies

Smarties” by Rick Sapir,

featuring – last time Webwords looked – 468 pages,

from 168 contributors, read by 7,965,240 smarties, in 6

languages!

Internet forums, message boards,

and electronic mailing lists

An Internet forum, or message board, like the open source

phpBB

®21

, and the paid-for or free Boardhost and free Zeta

Boards (no learning curve, no boundaries, no stress, and

no languages other than English!), is a website that allows

people to engage in discussion in the form of posted

messages (“posts”). Unlike chat rooms, messages are at

least temporarily archived, and depending on the setup

messages may need to be approved by a moderator before

becoming visible to forum members and visitors.

The primary difference between forums and mailing

lists, such as LISTSERV

, is that mailing lists automatically

deliver new messages to subscribers, while forums require

subscribers to visit the forum’s website to view new posts.

LISTSERV

Lite Free Edition

is a freeware version of

LISTSERV Lite, limited to a maximum of 10 mailing lists with

up to 500 subscribers each. It is available for users who

want to run hobby or interest-based email lists and do not

derive a proﬁt, directly or indirectly, from using the software.

Software is available that conveniently combines forum and

mailing list features allowing participants to post and read

by email or in a browser, depending which they prefer. Both

Google Groups used by Info-CHILDES and Stutt-L, and

Yahoo! Groups, home of a-p-d and phonological therapy

use this formula.

Cloud computing

Like the progression from Web

1.0 to Web 2.0 to Web 3.0,

the advent of cloud computing

has been more of an evolution

than a revolution and users of

Amazon, Facebook, G-mail,

Google docs, iTunes, and

Twitter, for example, have

already experienced it.

Crikey

explains that cloud

computing is the provision of computing (using and

improving computer hardware and software) as a service

rather than as a product. Shared resources, software, and

information are provided to computers and other devices as

a utility over a network, typically the Internet. Utility

computing is the packaging of computational resources,

such as computation, storage, and services, as a low-cost

152 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 153

Bowen, C. (2003). Harnessing the net: A challenge for

speech language pathologists. The 2003 Elizabeth Usher

Memorial Lecture. In C. Williams & S. Leitao (Eds), Nature,

nurture, knowledge: Proceedings of the Speech Pathology

Australia National Conference, Hobart, 9–20.

Bowen, C. (2012). Webwords 43: Alternative and

augmentative communication. Journal of Clinical Practice in

Speech-Language Pathology, 14(2), 93–94.

Carroll, L. (1871). Through the looking glass (and what

Alice found there). London: Hepburn.

Crystal, D. (2001). Language and the Internet.

Cambridge: Cambridge University Press.

Crystal, D. (2008). Txtng: the Gr8 Db8. Oxford: Oxford

University Press.

DiNucci, D. (1999). Fragmented future. Print, 53(4), 32.

Fisher, W. (2009). Forging a new trail with a Web 2.0

Compass. Lawrence, Kansas: Allen Press. Retrieved

from https://www.facebook.com/note.php?note_

id=109700939472

Links

1. http://www.w3.org/2001/sw

2. http://www.w3.org/People/Berners-Lee

3. http://www.love2read.org.au

4. http://www.43things.com

5. http://en.wikipedia.org/wiki/Web_2.0

6. http://asha.peachnewmedia.com/ashapodcast

7. http://www.websitemagazine.com/content/blogs/

posts/pages/create-and-monetize-podcasts-on-any-

budget.aspx

8. http://www.asha.org/sitehelp/rss

9. http://www.speechandhearing.ca/en/component/bca-

rss-syndicator/?feed_id=2

10. http://www.medworm.com/rss/medicalfeeds/therapies/

Speech-Therapy.xml

11. http://www.nvsd44.bc.ca/Firmfoundations/main.html

12. http://lexicallinguist.wordpress.com/2011/02/21/

nomenclature-and-basic-functions-of-twitter

13. http://www.jhische.com/twitter

14. http://slpchat.wordpress.com

15. http://blog.asha.org

16. http://clinicallinguistics.wordpress.com/author/

clinicallinguistics

17. http://speakingmylanguages.blogspot.com.au

18. http://www.speech-language-therapy.com

19. http://udltechtoolkit.wikispaces.com

20. http://www.wikidot.com/plans

21. http://www.phpbb.com

22. http://www.lsoft.com/download/listservfree.asp

23. http://www.crikey.com.au/2010/07/13/crikey-clariﬁer-

what-is-cloud-computing/

24. http://opensource.org/

25. http://creativecommons.org/

26. http://www.copyright.com.au

27. http://commons.wikimedia.org/wiki/Category:Images

28. https://www.jumpchart.com

29. http://drupal.org

30. http://www.joomla.org

31. http://mambo-foundation.org

Like all Webwords columns, this one is available on-line

at www.speech-language-therapy.com with featured and

additional links.

amateurs, in Australia include Speech Moves made in

Drupal by Bea Pate, and Melvin Speech Pathology made in

Joomla by Meehan Design.

Free, self-managed sites

Rather than a fully paid-for small site, SLPs/SLTs can build

a web presence with a free editor such as Weebly (e.g.,

Voice Energetics by Sarah Wilmot), PageBreeze (e.g.,

Corella Speech Pathology by Benjamin Jardine and Sally

Hodson), WordPress (e.g., Jigsaw Speech, Language and

Literacy by Bethany Stapleton), or Google Sites (e.g.,

Belinda Neimann Speech Pathologist by Belinda Neimann).

They can be enhanced with royalty-free images from

sources that include Wikimedia Commons Pictures and

Media

and Microsoft Ofﬁce Images. An account with

Jumpstart

provides an opportunity to plan the

architecture of a website and practice browser-based

project website construction, alone or with one other

collaborator. The natty thing about Jumpstart is that once

you have everything looking just right, the whole site can be

exported straight into a free editor such as WordPress. The

owner can choose whether to locate their site on a free

hosting site, with or without advertising, or to buy a plan

with a web hosting provider such as Digital Paciﬁc, iiNet, or

Melbourne IT in Australia, just as long as the bandwidth that

comes with the plan is adequate.

Larger sites

Bandwidth is a signiﬁcant determinant of hosting plan

prices, and most hosting plans have bandwidth

requirements measured in months. The high price of

bandwidth in Australia drives many site owners overseas.

For example, Lycos provides 300GB per month for under

US$9.00 ($108.00 per annum) and 500GB per month for

under US$12.00 ($144.00 per annum) to anyone

worldwide. Compare this with a “reasonably priced”

Australian host charging an annual fee of A$286.00 for 1GB

data trafﬁc per month (plus an establishment fee in the ﬁrst

year), A$815.00 for 30GB per month and A$1,000.00 for

70GB per month. Add to these charges design and

development, setting up a content management system

(CMS) such Drupal

, Joomla!

or Mambo

, CMS

training, technical support, search engine optimisation,

social marketing, and additional applications such as

tracking, messaging, and making a site mobile friendly, and

the costs are substantial.

By sharing the load with the host, developer, and

designer a site owner who wants to keep their business

in Australia can establish a site with a budget of A$3,500

to A$4,000 for the ﬁrst year and expect to pay about

A$1,000.00 in subsequent years provided that monthly

bandwidth does not exceed 70KB. The host would design

the site and the owner would populate it, saving him or

herself some A$4,000.00 in copy writing for a site of about

100 HTML pages. Potentially, costs can be defrayed by

accepting paid advertising, seeking donations, or charging

for downloads.

References

Berners-Lee, T. (2002). The world wide web – past present

and future: Exploring universality. Japan Prize

Commemorative Lecture.

Bowen, C. (1999, February). Webwords 1: Getting

to know the Internet. ACQuiring Knowledge in Speech,

Language and Hearing, 1, 29–30.

Technology

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 153

2 Teleconferencing and

videoconferencing

The SPAD team (organising committee) often use

teleconference to meet and discuss plans for SPAD

meetings. This often saves a lot of travelling time! During

interest group meetings we can also have members join via

phone. Although these people may miss out on the full

interaction of the session, teleconferencing allows them to

hear the information ﬁrst hand and ask questions.

Videoconferencing sites across the state mean that SPAD

members can join meetings, interact, and present across

large distances. Our evaluations have shown that while

there can be hiccups with technology, both rural and

metropolitan members ﬁnd that it is worth the effort to use

teleconferencing and videoconferencing for meetings.

3 Twitter

Twitter is not just a social tool. The health industry is rapidly

discovering that sites such as Twitter can provide a new

avenue for professional networking and learning. Speech

Pathology Australia has developed a Social Media Guide for

Speech Pathologists which is a valuable resource for those

exploring the beneﬁts of social media for

professional networking: http://www.

speechpathologyaustralia.org.au/

my-spa/social-media

You can follow SPAD on Twitter:

@SPADite

PAD is a support network and special interest

group for those with an interest in communication

and/or dysphagia for adults with intellectual and/

or physical disabilities. SPAD provides a forum for

speech pathologists to share ideas and resources about

communication and dysphagia. Current members of SPAD

include people working for Ageing Disability & Home Care

(NSW Government), health settings including acute and

rehabilitation, the Northcott Society, the Cerebral Palsy

Alliance, private practitioners, and students. We have four

meetings each year and the dates are advertised on our

wiki (see link below) and on the Speech Pathology Australia

website.

We would like to thank Yvonne Pearce, Bettina Bacall-

Arenstein, and Margaret Trzcinka for sharing their top

resources.

SPAD (Speech Pathologists

in Adult Disability) Top 10

SPAD members love bits of technology that help

us connect SPAD members across large

distances (even internationally!)

1 Websites and wikis

SPAD has used a website to share meeting agendas and

minutes in the past and now uses a wiki site: http://

spadgroup.wikispaces.com. What is a wiki and why do we

use it? Visit the site to ﬁnd out! Or you can watch the video

on YouTube called “Wiki’s in Plain English” from www.

commoncraft.com

SPAD members love useful things that help

create materials and support augmentative and

alternative communication (AAC).

4 Boardmaker Plus!

Boardmaker Plus! starts at $499 from Spectronics. This

program is probably on the list of every speech pathologist

who works in the area of AAC so we couldn’t leave it off

ours. There are also a number of other programs that can

help you create

materials for

communication

supports, such as

SoftPics ($190 from

Spectronics) or Picture

This... Pro Photo

Library ($152.90 from

Spectronics). http://

www.spectronicsinoz.

com/

154 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 155

• Resources from Scope Victoria: Easy English Writing

Style Guide and Images for Easy English http://www.

scopevic.org.au/index.php/site/resources

• Government of South Australia: The Plain English

Good Practice Guide http://www.saes.sa.gov.au/index.

php?option=com_content&view=article&id=20&Itemid=5

SPAD members love books and videos too! These

are some of our favourites.

8 Cichero, J., & Murdoch, B. E. (Eds.)

(2006). Dysphagia: Foundation, theory

and practice. West Sussex, UK: John

Wiley & Sons. ISBN-13: 978-1861565051.

This well-known text has valuable information about

assessment and intervention strategies for adults with

dysphagia.

9 Dossetor, D., White, D., & Whatson, L.

(Eds.) (2011). Mental health of children

and adolescents with intellectual

and developmental disabilities: A

framework for professional practice.

Hawthorn East, Vic.: IP

Communications.

Available from http://www.

ipcommunications.com.au

“This is a book by clinicians, for

clinicians” (back cover). This book

presents a framework for clinicians

on the important topic of the mental

health of people with intellectual

disabilities.

10. Listening to those rarely heard. A video

package developed by Jo Watson and

Rhonda Joseph from Scope Victoria.

A$100 from Scope, Victoria. http://www.scopevic.org.au/

index.php/site/resources/listeningtothoserarelyheard

5 Google Images

While we always need to be aware of copyright for images

sourced from Google Images, this can be an invaluable tool

to ﬁnd an image in a hurry. Google street view can be a

valuable time saver when you need a photo of a building

(such as a day program, doctor’s building, or shops). http://

images.google.com/

Correspondence to:

Harmony Turnbull

Level 6, 93 George St, Parramatta NSW 2150

phone: +61 (0) 2 9841 9149

email: Harmony.turnbull@facs.nsw.gov.au

6 Australian Sign Language (Auslan)

Signbank

The Auslan Signbank is a language resources site for

Auslan, the language of the Deaf community in Australia.

SPAD members ﬁnd it helpful using Auslan signs in

conjunction with resources from Key Word Sign Australia in

an AAC system.

In the Auslan Signbank you can search for a sign using

an English keyword or browse keywords alphabetically.

This site is great to be able to see how signs are produced

when still photos or line drawings are not adequate. The

Signbank is useful when preparing for a Key Word Sign

workshop and to keep our key word sign repertoire up to

date!

You can gain free access to the Signbank video clips at

www.auslan.org.au

SPAD members love plain English, easy English,

and accessible stuff!

7 Plain English and accessible

information resources

SPAD is committed to promoting the beneﬁts of plain

English, easy English, and accessible information. Here are

some of our favourite resources and where to ﬁnd them

(free):

• NSW Council for Intellectual Disability: Health

Information Fact Sheets in Easy English http://www.

nswcid.org.au/health/ee-health-pages/easy-fact-sheets.

html

Would you like to contact more

than 5,000 speech pathologists?

Advertising in JCPSLP and Speak Out is a great way to spread your message to speech

pathologists in Australia and overseas. We have different size advertising space

available.

If you book in every issue for the whole year you’ll receive a discount.

See www.speechpathologyaustralia.org.au for further information about advertising.

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 155

Libby Smith

(a bundle of nerve ﬁbres that carries messages from one

part of the brain to another) in the left hemisphere differs in

people who stutter compared to ﬂuent speakers (Chang,

Erickson, Ambrose, Hasegawa-Johnson, & Ludlow, 2008;

Cykowski et al., 2010; Sommer et al., 2002; Watkins et al.,

2008). Researchers are not yet sure what causes tracts to

differ in these images, but it may be due to abnormalities

in the protective sheath (myelin) that helps nerve ﬁbres

carry messages (Cykowski et al., 2010). This leads to the

intriguing conclusion that stuttering might be caused by

a problem with the formation of the myelin sheath during

brain development (myelogenesis) (Cykowski et al., 2010).

Unlike much of the brain that develops before birth, the

particular ﬁbre tract implicated in these studies undergoes

myelination during the ﬁrst two years of life (Yakovlev

& Lecours, 1967). It connects brain areas important

for speech which integrate auditory and speech motor

information (Cykowski et al., 2010). Impaired myelination

would interrupt the normal functioning of this connection.

Despite stuttering being a developmental disorder,

neuroimaging research has so far predominantly involved

adults who stutter and they participate many years after

stuttering onset. There remains a possibility that the brain

differences reported in neuroimaging studies involving

adults may be a consequence of stuttering behaviour of

the individuals over time, rather than a result of abnormal

development in the early post-natal period. By including

euroimaging studies conducted over the last

decade have consistently found differences in

brain anatomy and brain activation patterns during

speech between people who stutter and ﬂuent speakers

(Beal, Gracco, Lafaille, & De Nil, 2007; Cykowski, Fox,

Ingham, Ingham, & Robin, 2010; Foundas, Bollich, Corey,

Hurley, & Heilman, 2001; Fox et al., 1996; Neumann et

al., 2003; Sommer, Koch, Paulus, Weiller, & Buchel, 2002;

Watkins, Smith, Davis, & Howell, 2008). It is likely that a

complex interaction of genetic and environmental factors

inﬂuence the development of brain structure and function in

children who stutter, altering the normal functioning motor

speech networks in the brain (Watkins, Gadian, & Vargha-

Khadem, 1999).

Brain activation studies (using positron emission

tomography [PET] or functional magnetic resonance

imaging [MRI]) reveal that people who stutter use the

speech motor areas in the left side of their brain less than

ﬂuent speakers and use their right side more than ﬂuent

speakers (Brown, Ingham, Ingham, Laird, & Fox, 2005;

Watkins et al., 2008). These ﬁndings suggest that people

who stutter may use a compensatory network for speech

due to inadequate function in the normal speech areas

in the left hemisphere of the brain (Preibisch et al., 2003;

Sommer et al., 2002).

Recent research using diffusion tensor imaging (a type

of MRI) has found that a particular white matter ﬁbre tract

Developmental stuttering

A paediatric neuroimaging study

Libby Smith

Research update

Libby and a research participant prepare for a magnetic resonance imaging (MRI) scan

156 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 157

Acknowledgements

We want to extend our thanks to all the speech

pathologists who referred their clients to the study – we

couldn’t have done it without you!

References

Beal, D. S., Gracco, V. L., Lafaille, S. J., & De Nil, L. F.

(2007). Voxel-based morphometry of auditory and

speech-related cortex in stutterers. Neuroreport, 18(12),

1257–1260.

Brown, S., Ingham, R. J., Ingham, J. C., Laird, A. R., &

Fox, P. T. (2005). Stuttered and ﬂuent speech production:

An ALE meta-analysis of functional neuroimaging studies.

Human Brain Mapping, 25(1), 105–117.

Chang, S. E., Erickson, K. I., Ambrose, N. G.,

Hasegawa-Johnson, M. A., & Ludlow, C. L. (2008). Brain

anatomy differences in childhood stuttering. NeuroImage,

39(3), 1333–1344.

Cykowski, M. D., Fox, P. T., Ingham, R. J., Ingham, J.

C., & Robin, D. A. (2010). A study of the reproducibility and

etiology of diffusion anisotropy differences in developmental

stuttering: A potential role for impaired myelination.

NeuroImage, 52(4), 1495–1504.

Foundas, A. L., Bollich, A. M., Corey, D. M., Hurley, M.,

& Heilman, K. M. (2001). Anomalous anatomy of speech-

language areas in adults with persistent developmental

stuttering. Neurology, 57(2), 207–215.

Fox, P. T., Ingham, R. J., Ingham, J. C., Hirsch, T. B.,

Downs, J. H., Martin, C., … Lancaster, J. L. (1996). A

PET study of the neural systems of stuttering. Nature,

382(6587), 158–162.

Neumann, K., Euler, H. A., von Gudenberg, A. W.,

Giraud, A. L., Lanfermann, H., Gall, V., & Preibisch, C.

(2003). The nature and treatment of stuttering as revealed

by fMRI: A within- and between-group comparison. Journal

of Fluency Disorders, 28(4), 381–410.

Preibisch, C., Neumann, K., Raab, P., Euler, H. A., von

Gudenberg, A. W., Lanfermann, H., & Giraud, A. L. (2003).

Evidence for compensation for stuttering by the right frontal

operculum. NeuroImage, 20(2), 1356–1364.

Sommer, M., Koch, M. A., Paulus, W., Weiller, C., &

Buchel, C. (2002). Disconnection of speech-relevant brain

areas in persistent developmental stuttering. Lancet,

360(9330), 380–383.

Watkins, K., Gadian, D. G., & Vargha-Khadem, F. (1999).

Functional and structural brain abnormalities associated

with a genetic disorder of speech and language. American

Journal of Human Genetics, 65(5), 1215–1221.

Watkins, K., Smith, S. M., Davis, S., & Howell, P. (2008).

Structural and functional abnormalities of the motor system

in developmental stuttering. Brain, 131, 50–59.

Yakovlev, P., & Lecours, A. (1967). The myelogenetic

cycles of regional maturation of the brain. In A. Minkowski:

(Ed.), Regional development of the brain in early life (pp.

3–70). Oxford: Blackwell.

children as young as possible in our current project, we

hope to gain a better understanding of the neurological

markers of stuttering present in the early years.

Our research

During the last three years Libby Smith (PhD student) has

been working with Professor Sheena Reilly and Dr Angela

Morgan from the Murdoch Childrens Research Institute at

the Royal Children’s Hospital in Melbourne and Dr Alan

Connelly from the Brain Research Institute to investigate

brain activation and brain structure in children who stutter.

The speciﬁc aims of this project are to describe

differences between children who stutter and typical

speakers in three areas:

• brain activation during speech

• brain anatomy of the speech areas

• white matter ﬁbre pathways that connect different

regions involved in speech motor processing.

The data collection phase of this project is now complete.

Participants (15 children who stutter and a control group of

18 children with typical speech) attended two appoint-

ments. The ﬁrst involved speech, language, and IQ

screening to accurately determine the presence or absence

of stuttering and ensure the children had no concomitant

speech, language, or cognitive issues. The second

appointment was the MRI scanning session where a series

of functional and structural MRI images were acquired.

Strengths and challenges

We found that most children enjoyed having a brain scan

because they could keep some pictures of their brain to take

home and show their friends and they were able to bring a

DVD to watch while most of the pictures were being taken.

Nonetheless, scanning young children has presented

us with signiﬁcant challenges. It is important to make

sure the children understand the task they are required

to perform during the functional imaging scan. For this

study, children were required to listen to short sentences

through earphones, and then either listen only, or repeat

the sentence out loud, according to the instructions. The

children rehearsed the task using practice items outside the

scanner before the session. Each picture took somewhere

between 2 minutes and 8 minutes to acquire. During this

time the children needed to keep their head extremely still,

otherwise the images would be “blurred”. They could “have

a wriggle” between pictures, but the whole session could

take up to 1 hour. These factors placed limitations on the

age of children who could participate. While it would have

been interesting to include children from the age of 3 or 4

when they ﬁrst begin to stutter, most children this young

would not be able to cope with the demands of the task

or to stay still for the required amount of time. In this study

we included children aged between 5 and 10 years. Most

children ﬁnd it easier to keep still when they are watching

a DVD; however, some children will have difﬁculty lying still

regardless. Up to 25% of our data was discarded in the end

due to excessive movement.

What’s next

We are now in the process of analysing the data and are

looking forward to seeing the results. While this is a small

study in neuroimaging terms, it signiﬁes an exciting step in

the quest to unlock the mysteries of the stuttering brain. We

also hope the results will contribute to advancing the

long-term goal of developing treatments that consider the

underlying mechanisms of developmental stuttering rather

than simply addressing the symptoms.

Libby Smith is a PhD student in the Childhood Communication

Research Unit at the Murdoch Childrens Research Institute and

The University of Melbourne. She has a Bachelor of Arts/Bachelor

of Science and a Master of Arts (Neurolinguistics).

Correspondence to:

Libby Smith

phone: +61 (0)3 9936 6588

email: libby.smith@mcri.edu.au

Technology

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 157

One important ﬁnding was that the primary measures of

language and auditory processing improved signiﬁcantly

across all groups at all data points. However, without a

no-treatment control group, we cannot assess the extent

to which intervention or alternatively natural change

over time contributed to improvements observed. In

short, there is no additional beneﬁt of FFW-L compared

with another computerised intervention or intervention

delivered by a SLP or a general intervention focusing on

academic enrichment. Even though these results did not

support the temporal auditory processing hypothesis,

the authors emphasised that this does not mean that

auditory processing skills are not important for language

development and a necessary part of listening to speech

(Gillam et al., 2008).

SpeechBITE ratings

Eligibility speciﬁed: Y

Random allocation: Y

Concealed allocation: Y

Baseline comparability: Y

Blind subjects: N

Blind therapists: N

Blind assessors: Y

Adequate follow-up: Y

Intention-to-treat analysis: Y

Between-group comparisons: Y

Point estimates and variability: Y

References

Cohen, W., Hodson, A., O’Hare, A., Boyle, J., Durrani, T.,

McCartney, E., … Watson, J. (2005). Effects of computer-

based intervention through acoustically modiﬁed speech

(Fast ForWord) in severe mixed receptive-expressive

language impairment: Outcomes from a randomized

controlled trial. Journal of Speech, Language, and Hearing

Research, 48, 715–729.

Pokorni, J. L, Worthington, C .K., & Jamison, P. J. (2004).

Phonological awareness intervention: Comparison of

Fast ForWord, Earobics, and LiPS. Journal of Educational

Research, 97, 147–157.

Tallal, P. (2004). Improving language and literacy is a

matter of time. Nature Reviews: Neuroscience, 5, 721–728.

Online treatment of speech and voice in people

with Parkinson’s disease

Constantinescu, G., Theodoros, D., Russell, T., Ward, E.,

Wilson, S., & Wootton, R. (2011). Treating disordered speech

and voice in Parkinson’s disease online: A randomized

controlled non-inferiority trial. International Journal of

Language & Communication Disorders, 46(1), 1–16.

SpeechBITE rating: 6/10

speechBITE review – Vivian Kan and Tricia McCabe

A signiﬁcant proportion of the Parkinson’s disease (PD)

population experiences hypokinetic dysarthria (Ramig, Fox,

& Sapir, 2004) which negatively affects patients’ quality of

Around the journals

Fast ForWord Language intervention in

school-age children

Gillam, R. B., Loeb, D. F., Hoffman, L. M., Bohman, T.,

Champlin, C. A., Thibodeau, L., Widen, J., Brandel, J., &

Friel-Patti, S. (2008). The efﬁcacy of Fast ForWord

Language intervention in school-age children with language

impairment: A randomized controlled trial. Journal of

Speech, Language, and Hearing Research, 51(1), 97–119.

SpeechBITE rating: 8/10

speechBITE review – Katherine Salmon

and Tricia McCabe

Do language impairments reﬂect a deﬁcit in auditory temporal

processing skills? Fast ForWord Language (FFW-L;

Scientiﬁc Learning Corporation, 1998) operates on the

hypothesis that they do. FFW-L is an approach to language

intervention designed to improve auditory temporal

processing skills in school-age children with language

impairments. Until now, few studies have compared FFW-L

to alternate interventions. Furthermore, the utility of using

acoustically modiﬁed speech to remediate language

impairments has been questioned (e.g., Cohen et al., 2005;

Pokorni, Worthington, & Jamison, 2004).

This study compared the efﬁcacy of Fast ForWord

Language (FFW-L) to three other interventions – academic

enrichment (AE), computer-assisted language intervention

(CALI), and individualised language intervention (ILI) – to

determine whether FFW-L was more effective than the

other interventions for improving language and auditory

processing skills.

The current research attempted to address the limitations

of previous research, in particular, the fact that none of the

previous trials evaluating FFW-L directly measured changes

in temporal auditory processing.

This study also included a larger group of participants

(216 children diagnosed with language impairment) than

previously reported. Participants were followed for 6

months following completion of the treatment phase and

the study compared FFW-L to a variety of alternative

interventions. The selection of 3 comparison interventions

and FFW-L, all presented 5 days per week for 6 weeks

for 80 minutes per day, allowed comparisons to be made

between (a) computer-delivered versus human-delivered

services, (b) modiﬁed speech versus unmodiﬁed speech,

and (c) speciﬁc versus nonspeciﬁc intervention goals. Gillam

and colleagues hypothesised that based on the temporal

processing deﬁcit hypothesis (Tallal, 2004) children

assigned to the FFW-L intervention would have better

outcomes than children in the other three interventions.

The results of the study showed no difference across

the four groups on receptive and expressive language

and auditory processing. That is, the children in all four

interventions made similar improvements on the language

and auditory processing measures. However, children

in the FFW-L and CALI interventions did make greater

improvements on a measure of phonological awareness

than children randomised to the ILI and AE interventions at

the six-month follow-up.

158 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 159

measure looking at intelligibility and communication

efﬁciency.

Treatment gains made in the online LSVT environment

were comparable to gains made by administering LSVT

face-to-face. This study conﬁrms that online delivery of

LSVT is equivalent to face-to-face delivery. Additionally,

participants in the online treatment reported the treatment

to be “very good” and that they were “more than satisﬁed”.

The paper’s robust study design provides conﬁdence in

the online delivery of LSVT for people with PD. However,

as online treatment was administered using a speciﬁcally

designed videoconferencing application, the results cannot

be easily transferred to clinical practice. Technological

development is necessary before clinicians will have the

opportunity to deliver LSVT in an online environment similar

to that of the present study. Similarly, development of

technology is needed to design studies that yield signiﬁcant

results while using easily accessible forms of technology.

Further research is also required to explore online treatment

for people at more advanced stages of PD and with

moderate to severe hypokinetic dysarthria.

SpeechBITE ratings

Eligibility speciﬁed: Y

Random allocation: Y

Concealed allocation: N

Baseline comparability: N

Blind subjects: N

Blind therapists: N

Blind assessors: Y

Adequate follow-up: Y

Intention-to-treat analysis: Y

Between-group comparisons: Y

Point estimates and variability: Y

References

Ramig, L., Fox, C., & Sapir, S. (2004). Parkinson’s disease:

Speech and voice disorders and their treatment with the

Lee Silverman Voice Treatment. Seminars in Speech and

Language, 25, 169–180.

Wenke, R. J., Cornwell, P. & Theodoros, D. G. (2010)

Changes to articulation following LSVT(R) and traditional

dysarthria therapy in non-progressive dysarthria. International

Journal of Speech Language Pathology, 12, 203–20.

Yorkston, K. M., & Beukelman, D. R. (1981). Assessment

of intelligibility of dysarthric speech. Austin, TX: Pro-Ed.

life. The Lee Silverman Voice Treatment (LSVT

) has been

proven to be an effective treatment for hypokinetic dysarthria

in people with PD (Wenke, Cornwell, & Theodoros, 2010).

However, the relatively low number of LSVT qualiﬁed

speech-language pathologists (SLPs), low caseload priority

for people with PD, and the physical difﬁculties people with

PD experience in travelling to services are all barriers that

hinder the delivery of speech pathology services to this

population. Telehealth presents a promising mode of

service delivery that could increase access to services and

support gains in speech and quality of life.

The present study was designed to investigate the

validity and reliability of online delivery of LSVT for speech

and voice disorders associated with PD. Constantinescu

and colleagues employed a single-blinded, randomised

controlled trial to compare online and face-to-face

treatment of LSVT. Thirty-four participants who had been

diagnosed with PD were included: 18 participants had mild

hypokinetic dysarthria while 16 had moderate dysarthria.

The participants were stratiﬁed and randomly assigned to a

treatment group, resulting in 17 participants in each group

(9 participants with mild dysarthria and 8 with moderate

dysarthria in each group). Four SLPs were randomised

to both treatment environments. No patients were

assessed by their treating clinician during post-treatment

assessments which allowed for blinding of the SLPs to the

participants’ treatment group.

Therapy for both groups adhered to the LSVT program.

A PC-based videoconferencing application was developed

for the online environment. The system allowed for:

videoconferencing in real time; presentation of phrases and

reading material during session tasks; the ability to adjust the

remote web cameras to maximise the viewing; high-quality

audio and video recordings; and calibrated average measures

of sound pressure level (SPL), and fundamental frequency

(Hz) and duration (sec) through the use of an acoustic

speech processor. LSVT was administered following

standard practice in the face-to-face treatment environment.

The key outcome measures for the two LSVT

service delivery models were: SPL in a monologue,

acoustic measures from the LSVT evaluation protocol,

and perceptual speech and voice judgements by two

independent SLPs using direct magnitude estimation. The

Assessment of Intelligibility of Dysarthric Speech (Yorkston

& Beukelman, 1981) was used also as a secondary

www.speechpathologyaustralia.org.au JCPSLP Volume 14, Number 3 2012 159

Resource reviews

barriers to EBP are made apparent, they are dealt with in a

proactive way, providing clinicians with practical evidence

that while EBP isn’t always easy, it is possible. The book is

divided into six sections that ﬂow cohesively and take the

clinician on a journey through all stages of the EBP cycle.

The ﬁrst three sections set the scene, providing the

deﬁnitions and foundation knowledge required for using EBP

in practice. The barriers that clinicians face are addressed,

while facilitators and practical ways of creating a supportive

culture and environment for EBP in any workplace are

identiﬁed. In sections four and ﬁve, the focus moves beyond

EBP knowledge to more practical aspects of translation

and application of evidence to meet clinical challenges. The

examples in this section are creative and innovative, show-

casing a range of “individual and organisational strategies

for embedding EBP” (p. 7). The ﬁnal section ties the

preceding discussion together and presents a clear and

achievable vision for the future. Overall, the book provides

an excellent platform for clinicians to critically reﬂect on their

own use of EBP and will inspire many to plan, undertake, or

disseminate the results of their own implementation projects.

As a clinician and academic with a keen interest in

EBP and its translation to everyday practice I feel that

this book has made an extremely valuable contribution

to the ﬁeld, showcasing how far the profession has

come. It has practical and professional relevance to both

practicing and student clinicians, as well as academics and

researchers, reminding us of why evidence is so important

for professional practice and how the EBP mantra can be

achieved. The collective and reﬂective nature of the book

makes it an enjoyable and informative read for us all.

Roddam, H., & Skeat, J. (Eds.) (2010). Embedding

evidence-based practice in speech and language

therapy: International examples. West Sussex, UK:

John Wiley & Sons. ISBN 978 0 470 74329 4; pp. 246;

A$59.95; http://au.wiley.com

Jade Cartwright

This book makes a timely and practical contribution to the

growing evidence based practice (EBP) literature in the

speech pathology ﬁeld. Its target audience is practising

speech pathologists who are committed to embedding EBP

into their routine clinical decision-making and who would

like to share in diverse exemplars of EBP innovations and

successes from around the world.

The book highlights and addresses the reality that EBP is

a necessity in routine clinical practice and that clinicians

require knowledge, skills, and practical support to embed EBP

into their clinical roles. It is clear that the editors, Dr Hazel

Roddam and Dr Jemma Skeat have selected contributions to

the book with care, providing a broad mix of EBP perspectives

and experiences from clinicians, researchers, and managers.

Real-life EBP scenarios are presented from diverse contexts

and across the range of speech pathology practice,

including adult and paediatric settings; from a number of

clinical areas such as voice, ﬂuency, speech, dysphagia,

and alternative and augmentative communication (AAC).

Furthermore, examples addressing more professional

aspects of EBP implementation concerning university

education, clinical supervision, and leadership are included.

Overall, the tone of the book is positive, celebratory,

and encouraging. While the well- known challenges and

Speech pathology resources

A phone solution for people

who are deaf or have a

hearing or speech impairment

1/12 12105

“ The phone is such a lifeline ...

The National Relay Service makes

it easier for people with complex

communication needs to retain

their networks and independence

– to phone a friend, contact the

bank or book a taxi.

Learning to use the NRS is

straightforward. Training is free and

can be done in your client’s home.

Ask for our free DVD and

other resources.

• 1800 555 660

• helpdesk

relayservice.com.au

• www.relayservice.com.au

... I advise many of my clients with speech or

hearing impairments to use the NRS.”

Technology

160 JCPSLP Volume 14, Number 3 2012 Journal of Clinical Practice in Speech-Language Pathology

Introducing the JCPSLP

Committee 2013–2014

Editors

Jane McCormack

Jane McCormack is a lecturer in the speech

pathology program at Charles Sturt

University. She is interested in speech and

language development in children, inter-

professional practice, rural and regional

service delivery, clinical education, and

application of the International Classiﬁcation

of Functioning, Disability and Health to speech pathology

practice. Jane has acted as a reviewer for national and

international speech pathology journals and recently

co-edited the conference proceedings special issue of the

International Journal of Speech-Language Pathology with

Anna O’Callaghan. Jane is looking forward to working with

the JCPSLP editorial committee in 2013–14.

Anna O’Callaghan

Anna O’Callaghan is a lecturer in the division

of speech pathology at The University of

Queensland. She is interested in speech

and language disorders in adults,

speciﬁcally adults with traumatic brain injury,

innovations in service delivery, clinical care

guidelines, and professional issues related

to speech pathology practice. Anna has acted as a

reviewer for national and international journals and recently

co-edited the conference proceedings of the International

Journal of Speech-Language Pathology with Dr Jane

McCormack. Anna is looking forward to continuing to

create exciting and innovative JCPSLP editions alongside

Jane and the JCPSLP editorial team.

Committee members

Jade Cartwright

Jade Cartwright is a lecturer at Curtin

University, with clinical, teaching, and

research interests in the areas of dementia,

progressive neurological disorders, aphasia,

and quality of life. She is currently completing

her doctorate part-time in the area of

primary progressive aphasia. Jade has been

actively involved with Speech Pathology Australia since

graduating from Curtin in 2000 and is the current Vice

President of the WA branch. This is her second year on the

JCPSLP editorial committee.

Natalie Ciccone

Natalie holds a PhD in speech pathology

and has worked clinically in hospital and

rehabilitation settings. She is currently

employed as a lecturer within the speech

pathology program at Edith Cowan

University. Natalie’s main area of research

interest lies in working with adults with

neurogenic communication disorders, and is particularly

focused on issues of treatment effectiveness and service

delivery and applying theoretical knowledge to improve

treatment outcomes.

Deborah Hersh

Deborah, PhD, has over 20 years of clinical

and research experience in speech pathology

in the UK and Australia. She has presented

and published in the areas of discharge

practice, professional client relationships,

clinical ethics, group work for chronic aphasia,

and goal setting in therapy. Deborah started the Talkback

Group Program for Aphasia in 1995 and established the

Talkback Association for Aphasia Inc. in 1999. She is a

Fellow of Speech Pathology Australia and a senior lecturer

in speech pathology at Edith Cowan University in Perth.

Elizabeth Lea

Elizabeth holds a Masters degree in Speech

Pathology from La Trobe University and

Bachelor degrees in Arts and Science (Monash

University). She is passionate about

augmentative and alternative communication

and has worked in schools, the disability

sector, and private practice. Elizabeth works at The

Communication Toolbox, a private practice she established

that specialises in the use of technology for communication.

Carl Parsons

Dr Carl Parsons has published more than

100 articles on communication disorders in

international refereed journals. Carl was

awarded the Elinor Wray Award by Speech

Pathology Australia in 1987. He is a patron

and life member of the Down Syndrome

Association of Victoria, the director of the Centre for

Advanced Assessment and Therapy Services, the director

of National Programs for the Andrew Fildes Foundation for

Language-Learning Disabilities (now called SHINE), and the

director of Integrated Services at Port Phillip Specialist School.

David Trembath

David is a postdoctoral research fellow at

the Olga Tennison Autism Research Centre,

School of Psychological Science, La Trobe

University. He has worked as a speech

pathologist, clinical educator, lecturer, and

consultant in the ﬁeld of disability, and has a

particular interest in the provision of augmentative and

alternative communication supports. David’s current

research is focused on the development and evaluation of

evidence-based communication interventions and supports

for children, adolescents, and adults with autism and other

developmental disabilities, as well as projects aimed at

supporting the integration of research and practice.

Samantha Turner

Samantha is currently completing a PhD at

The University of Melbourne, and her project

is focused on large families with speech and

language disorders. She has worked with

children presenting with a range of

neurodevelopmental disorders both as a

speech pathologist and clinical researcher. She is interested

in understanding the causes of these disorders and

providing early intervention for young children.