Semin Speech Lang 2021; 42(01): 073-084
DOI: 10.1055/s-0040-1722754
Review Article

Phonogenic Voice Problems among Speech-Language Pathologists in Synchronous Telepractice: An Overview and Recommendations

Kristie Knickerbocker
1   A Tempo Voice Center, LLC
Cara Bryan
2   South Tampa Voice Therapy, LLC
Aaron Ziegler
3   The Wellness Group for Voice, Speech, and Swallowing, LLC
› Author Affiliations


Many speech-language pathologists (SLPs) recently adopted a live, synchronous online distribution of clinical services due to physical distancing measures aimed at bringing the coronavirus disease 2019 (COVID-19) outbreak under control. Few SLPs had received training in telepractice to prepare them for changes from an in-person service delivery model to synchronous telepractice. The new telepractice environment may alter vocal behaviors and communication interactions in such a way that negatively impacts voice production. Thus, delivering synchronous online clinical services may require that SLPs adopt novel prevention strategies for avoiding phonogenic voice problems. Guided by two complementary injury frameworks, the Haddon Matrix and the Haddon Countermeasures, this article provides an overview of potential factors associated with phonogenic voice problems among SLPs in telepractice and proposes possible prevention strategies to maintain optimal vocal health and function with synchronous modes of online clinical practice.

Financial Disclosure

K.K. is the owner of the A Tempo Voice Center and receives financial compensation. C.B. is the owner of the South Tampa Voice Therapy and receives financial compensation. A.Z. is the co-owner of The Wellness Group and PhoRTE, LLC and receives financial compensation from both companies. All the three authors are owners of the Confident Clinician Cooperative, LP and receive financial compensation.

Publication History

Article published online:
17 February 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Occupational Outlook Handbook. Speech-Language Pathologists. Bureau of Labor Statistics, US Department of Labor; . Updated April 10, 2020. Accessed July 14, 2020 at:
  • 2 American Speech-Language-Hearing Association. Survey of Telepractice Use among Audiologists and Speech-Language Pathologists. Rockville, MD: American Speech-Language-Hearing Association; 2002
  • 3 American Speech-Language-Hearing Association. 2014 SIG 18 Telepractice Services Survey Results. 2014 . Accessed December 21, 2020 at:
  • 4 American Speech-Language-Hearing Association. 2016 SIG 18 Telepractice Survey Results. 2016 . Accessed December 21, 2020 at:
  • 5 Grillo EU. Results of a survey offering clinical insights into speech-language pathology telepractice methods. Int J Telerehabil 2017; 9 (02) 25-30
  • 6 American Speech-Language-Hearing Association. ASHA COVID-19 Survey. Rockville, MD: 2020. . Accessed December 21, 2020 at:
  • 7 Castillo-Allendes A, Contreras-Ruston F, Cantor-Cutiva LC. et al. Voice therapy in the context of the COVID-19 pandemic: guidelines for clinical practice. J Voice 2020; ; (epub ahead of print) DOI: 10.1016/j.jvoice.2020.08.001.
  • 8 Zughni LA, Gillespie AI, Hatcher JL, Rubin AD, Giliberto JP. Telemedicine and the interdisciplinary clinic model: during the COVID-19 pandemic and beyond. Otolaryngol Head Neck Surg 2020; 163 (04) 673-675
  • 9 Mohan HS, Anjum A, Rao PKS. A survey of telepractice in speech-language pathology and audiology in India. Int J Telerehabil 2017; 9 (02) 69-80
  • 10 American Speech-Language-Hearing Association. Telepractice (Practice Portal). . Accessed December 21, 2020 at:
  • 11 Sprecher S. Initial interactions online-text, online-audio, online-video, or face-to-face: Effects of modality on liking, closeness, and other interpersonal outcomes. Comput Human Behav 2014; 31 (01) 190-197
  • 12 Jones K, Sigmon J, Hock L, Nelson E, Sullivan M, Ogren F. Prevalence and risk factors for voice problems among telemarketers. Arch Otolaryngol Head Neck Surg 2002; 128 (05) 571-577
  • 13 Hazlett DE, Duffy OM, Moorhead SA. Occupational voice demands and their impact on the call-centre industry. BMC Public Health 2009; 9: 108
  • 14 Koufman JA, Isaacson G. The spectrum of vocal dysfunction. Otolaryngol Clin North Am 1991; 24 (05) 985-988
  • 15 Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice 1997; 11 (03) 254-259
  • 16 Runyan CW. Introduction: back to the future--revisiting Haddon's conceptualization of injury epidemiology and prevention. Epidemiol Rev 2003; 25: 60-64
  • 17 Haddon Jr W. A logical framework for categorizing highway safety phenomena and activity. J Trauma 1972; 12 (03) 193-207
  • 18 Haddon Jr W. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep 1980; 95 (05) 411-421
  • 19 Runyan CW, Brown TL, Brooks-Russell A. Preventing the invisible plague of firearm suicide. Am J Orthopsychiatry 2015; 85 (03) 221-224
  • 20 Barnett DJ, Balicer RD, Blodgett D, Fews AL, Parker CL, Links JM. The application of the Haddon matrix to public health readiness and response planning. Environ Health Perspect 2005; 113 (05) 561-566
  • 21 Hutton A, Savage C, Ranse J, Finnell D, Kub J. The use of Haddon's Matrix to plan for injury and illness prevention at outdoor music festivals. Prehosp Disaster Med 2015; 30 (02) 175-183
  • 22 Hume PA, Lorimer AV, Griffiths PC, Carlson I, Lamont M. Recreational snow-sports injury risk factors and countermeasures: a meta-analysis review and Haddon Matrix evaluation. Sports Med 2015; 45 (08) 1175-1190
  • 23 Vriend I, Gouttebarge V, Finch CF, van Mechelen W, Verhagen EALM. Intervention strategies used in sport injury prevention studies: a systematic review identifying studies applying the Haddon Matrix. Sports Med 2017; 47 (10) 2027-2043
  • 24 Ziegler A. Injury prevention of a touring professional singer with phonotrauma. In: Branski R, Molfenter S. eds. Speech Pathology Casebook. Thieme Publishing, Inc.; 2020
  • 25 Joseph BE, Joseph AM, Jacob TM. Vocal fatigue---Do young speech-language pathologists practice what they preach?. J Voice 2020; 34 (04) 647.e1-647.e5
  • 26 Van Lierde KM, D'haeseleer E, Wuyts FL. et al. The objective vocal quality, vocal risk factors, vocal complaints, and corporal pain in Dutch female students training to be speech-language pathologists during the 4 years of study. J Voice 2010; 24 (05) 592-598
  • 27 D'haeseleer E, De Ley S, Cosyns M. et al. Speech characteristics in female students training to be speech-language pathologists. Folia Phoniatr Logop 2016; 68 (04) 167-174
  • 28 Warhurst S, Madill C, McCabe P, Heard R, Yiu E. The vocal clarity of female speech-language pathology students: an exploratory study. J Voice 2012; 26 (01) 63-68
  • 29 Gottliebson RO, Lee L, Weinrich B, Sanders J. Voice problems of future speech-language pathologists. J Voice 2007; 21 (06) 699-704
  • 30 Searl J, Dargin TC. Voice and lifestyle behaviors of speech-language pathology students: impact of history gathering method on self-reported data. J Voice 2019; ; (epub ahead of print) DOI: 10.1016/j.jvoice.2019.08.014.
  • 31 Tafiadis D, Chronopoulos SK, Siafaka V. et al. Comparison of voice handicap index scores between female students of speech therapy and other health professions. J Voice 2017; 31 (05) 583-588
  • 32 Lieberman R, Raisor-Becker L, Sotto C, Redle E. Investigation of graduate student stress in speech language pathology. Teach Learn Commun Sci Disord 2018; 2 (02) 1-14
  • 33 Couch S, Zieba D, Van der Linde J, Van der Merwe A. Vocal effectiveness of speech-language pathology students: before and after voice use during service delivery. S Afr J Commun Disord 2015; 62 (01) E1-E7
  • 34 Franca MC, Boyer VE. The impact of cumulative vocal demands on vocal performance of student clinicians in speech-language pathology. Perspect ASHA Spec Interest Groups 2017; 2 (03) 119-131
  • 35 Mesallam TA. Ambulatory phonation monitor indicator of voice use profile in a group of speech-language pathologists. JAMMR 2015; 7 (12) 999-1005
  • 36 Mozzanica F, Selvaggio A, Ginocchio D, Pizzorni N, Scarponi L, Schindler A. Speech and language pathologists' voice use in working environments: a field study using ambulatory phonation monitoring. Folia Phoniatr Logop 2016; 68 (06) 268-273
  • 37 Titze IR. Physiologic and acoustic differences between male and female voices. J Acoust Soc Am 1989; 85 (04) 1699-1707
  • 38 Titze IR, Švec JG, Popolo PS. Vocal dose measures: quantifying accumulated vibration exposure in vocal fold tissues. J Speech Lang Hear Res 2003; 46 (04) 919-932
  • 39 Ward PD, Thibeault SL, Gray SD. Hyaluronic acid: its role in voice. J Voice 2002; 16 (03) 303-309
  • 40 Butler JE, Hammond TH, Gray SD. Gender-related differences of hyaluronic acid distribution in the human vocal fold. Laryngoscope 2001; 111 (05) 907-911
  • 41 Hunter EJ, Tanner K, Smith ME. Gender differences affecting vocal health of women in vocally demanding careers. Logoped Phoniatr Vocol 2011; 36 (03) 128-136
  • 42 Hunter EJ, Cantor-Cutiva LC, van Leer E. et al. Toward a consensus description of vocal effort, vocal load, vocal loading, and vocal fatigue. J Speech Lang Hear Res 2020; 63 (02) 509-532
  • 43 Titze IR. Mechanical stress in phonation. J Voice 1994; 8 (02) 99-105
  • 44 Verdolini K, Hess MM, Titze IR, Bierhals W, Gross M. Investigation of vocal fold impact stress in human subjects. J Voice 1999; 13 (02) 184-202
  • 45 Branski RC, Verdolini K, Sandulache V, Rosen CA, Hebda PA. Vocal fold wound healing: a review for clinicians. J Voice 2006; 20 (03) 432-442
  • 46 Jiang JJ, Titze IR. Measurement of vocal fold intraglottal pressure and impact stress. J Voice 1994; 8 (02) 132-144
  • 47 Titze IR, Hunter EJ. Comparison of vocal vibration-dose measures for potential-damage risk criteria. J Speech Lang Hear Res 2015; 58 (05) 1425-1439
  • 48 Summers WV, Pisoni DB, Bernacki RH, Pedlow RI, Stokes MA. Effects of noise on speech production: acoustic and perceptual analyses. J Acoust Soc Am 1988; 84 (03) 917-928
  • 49 Weidner K, Lowman J. Telepractice for adult speech-language pathology services: a systematic review. Perspect ASHA Spec Interest Groups 2020; 5 (01) 326-338
  • 50 Molini-Avejonas DR, Rondon-Melo S, Amato CA, Samelli AG. A systematic review of the use of telehealth in speech, language and hearing sciences. J Telemed Telecare 2015; 21 (07) 367-376
  • 51 Theodoros DG. Telepractice in speech-language pathology: the evidence, the challenges, and the future. Perspect Telepractice 2011; 1 (01) 10-21
  • 52 Jarvis-Selinger S, Chan E, Payne R, Plohman K, Ho K. Clinical telehealth across the disciplines: lessons learned. Telemed J E Health 2008; 14 (07) 720-725
  • 53 Mashima PA, Doarn CR. Overview of telehealth activities in speech-language pathology. Telemed J E Health 2008; 14 (10) 1101-1117
  • 54 Cantarella G, Barillari MR, Lechien JR, Pignataro L. The challenge of virtual voice therapy during the COVID-19 pandemic. J Voice 2020; ; (epub ahead of print) DOI: 10.1016/j.jvoice.2020.06.015.
  • 55 Freckmann A, Hines M, Lincoln M. Clinicians' perspectives of therapeutic alliance in face-to-face and telepractice speech-language pathology sessions. Int J Speech Lang Pathol 2017; 19 (03) 287-296
  • 56 Hines M, Lincoln M, Ramsden R, Martinovich J, Fairweather C. Speech pathologists' perspectives on transitioning to telepractice: What factors promote acceptance?. J Telemed Telecare 2015; 21 (08) 469-473
  • 57 Haddon Jr W. Energy damage and the ten countermeasure strategies. J Trauma 1973; 13 (04) 321-331
  • 58 Haddon Jr W. Options for the prevention of motor vehicle crash injury. Isr J Med Sci 1980; 16 (01) 45-65
  • 59 Timmermans B, De Bodt M, Wuyts F, Van de Heyning P. Voice quality change in future professional voice users after 9 months of voice training. Eur Arch Otorhinolaryngol 2004; 261 (01) 1-5
  • 60 Van Lierde KM, d'Haeseleer E, Deley S. et al. The impact of a voice counseling procedure to select students with normal vocal characteristics for starting a master program in speech language pathology: a pilot study. J Voice 2012; 26 (05) 623-628
  • 61 Meerschman I, D'haeseleer E, De Cock E, Neyens H, Claeys S, Van Lierde K. Effectiveness of chewing technique on the phonation of female speech-language pathology students: a pilot study. J Voice 2016; 30 (05) 574-578
  • 62 Meerschman I, Bettens K, Dejagere S. et al. Effect of two isolated vocal-facilitating techniques chant talk and pitch inflections on the phonation of female speech-language pathology students: a pilot study. J Voice 2016; 30 (06) 771.e17-771.e25
  • 63 Meerschman I, D'haeseleer E, Catry T, Ruigrok B, Claeys S, Van Lierde K. Effect of two isolated vocal facilitating techniques glottal fry and yawn-sigh on the phonation of female speech-language pathology students: a pilot study. J Commun Disord 2017; 66: 40-50
  • 64 Meerschman I, Van Lierde K, Peeters K, Meersman E, Claeys S, D'haeseleer E. Short-term effect of two semi-occluded vocal tract training programs on the vocal quality of future occupational voice users: resonant voice training using nasal consonants versus straw phonation. J Speech Lang Hear Res 2017; 60 (09) 2519-2536
  • 65 Van Lierde KM, D'haeseleer E, Baudonck N, Claeys S, De Bodt M, Behlau M. The impact of vocal warm-up exercises on the objective vocal quality in female students training to be speech language pathologists. J Voice 2011; 25 (03) e115-e121
  • 66 Santos AC, Borrego MC, Behlau M. Effect of direct and indirect voice training in speech-language pathology and audiology students. CoDAS 2015; 27 (04) 384-391
  • 67 Peek-Asa C, Zwerling C. Role of environmental interventions in injury control and prevention. Epidemiol Rev 2003; 25: 77-89
  • 68 Verdolini Abbott K, Li NYK, Branski RC. et al. Vocal exercise may attenuate acute vocal fold inflammation. J Voice 2012; 26 (06) 814.e1-814.e13
  • 69 Schneider-Stickler B, Knell C, Aichstill B, Jocher W. Biofeedback on voice use in call center agents in order to prevent occupational voice disorders. J Voice 2012; 26 (01) 51-62
  • 70 Gray SE, Finch CF. The causes of injuries sustained at fitness facilities presenting to Victorian emergency departments - identifying the main culprits. Inj Epidemiol 2015; 2 (01) 6