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Exploring Clinician Readiness for Interstate Telepractice
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig. 61.1 Telepractice, a fast-developing service-delivery model that employs telecommunications, typically conducted via synchronous
videoconferencing.
3. What aspects of RS’s professional credentials including licensure will be supportive of her telepractice?
a) RS is a member of ASHA’s Special Interest Group on Tele-
practice and is an active member of the group.
b) RS holds state licensure in Ohio, and is recognized as
qualified to practice in schools.
c) RS holds the requisite number of continuing education
(CE) credits to satisfy her Ohio licensure requirements.
d) RS intends to participate in CE opportunities specific to
telepractice within the next 3 months.
Answer: b is correct. RS holds state licensure in Ohio, and is recognized as qualified to practice in schools, which facilitates her
ability to gain licensure in other states where her potential clients are located.
a is incorrect. Though membership and participation in
ASHA’s Special Interest Group on Telepractice may be beneficial
for gaining knowledge about telepractice and networking, it is
not an aspect of professional credentialing.
c is incorrect. Although having the requisite CE credits to satisfy her Ohio licensure requirements is important, holding the
Ohio license and her Certificate of Clinical Competence facilitates her ability to gain licensure in other states where her prospective clients are located.
d is incorrect. Although it is advantageous for RS to participate in CE opportunities specific to telepractice, gaining licensure where her prospective clients are located is most critical to
support her telepractice.
4. What, if any, aspects of RS’s professional credentials includ-
ing licensure are not yet aligned with her intended telepractice?
a) All of RS’s professional credentials are aligned with her
intended telepractice.
b) RS must obtain a limited license for school-based SLPs in
the state of Michigan.
c) RS must obtain state licensure in Michigan and adhere to
the state’s requirements for professional practice, inclusive of telepractice.
d) RS must engage in CE opportunities from state-approved
CE providers in both Ohio and Michigan.
Answer: c is correct. RS does not yet hold state licensure in
Michigan, and is unfamiliar with the state’s requirements for
professional practice, inclusive of telepractice. RS can utilize
ASHA’s state-by-state advocacy resource to gain preliminary in-
formation and then check the currenc y and accuracy of the information by contacting the appropriate licensure board or regulatory agency.
a is incorrect. RS will need to obtain a state license to practice
speech therapy in Michigan, the state where her prospective clients are located and become familiar with the state’s requirements for professional practice, inclusive of telepractice.
b is incorrect. RS’s telepractice work will not be affiliated
with a school district or school-based services, rather she will
be providing private (solo) telepractice during the summer
months.
d is incorrect. Although it is advantageous for RS to participate in CE opportunities specific to telepractice, gaining licensure where her prospective clients are located is most critical to
support her telepractice. For license renewal purposes, RS
should review CE requirements of each state where she holds a
license, as activities that receive CE credit vary by state; also,
239
Exploring Clinician Readiness for Interstate Telepractice
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
some states require CE credits from state-approved CE
providers.
5. What act ion should RS take first to be fully prepared to
deliver telepractice during her upcoming vacations in New
Jersey and Maryland?
a) RS should become familiar with New Jersey and Mary-
land’s requirements for telepractice, including vacationrelated telepractice.
b) RS should utilize a password-protected service to access
the Internet while vacationing in New Jersey and Maryland.
c) RS should travel with the requisite assessment tools and
telepractice materials.
d) RS should coordinate schedules with her husband to
secure designated times to ut ilize the shared laptop
computer.
Answer: a is correct. RS should become familiar with New Jersey and Maryland’s requirements for telepractice, including
vacation-related telepractice. She should determine whether
the licensure boards claims jurisdiction if she is physically
located in the state (even if the client is not located/residing in
the state). Many state licensing boards do not claim jurisdiction
in this case and defer to the licensing board in the state where
the client is located. Some states have temporary practice provisions, which may allow RS to continue to work with her clients
while she or they are temporarily vacationing in the state.
b is incorrec t. Although it is true that RS should utilize password-protected services to access the Internet while vacationing in New Jersey and Maryland, it is not the first action she
should take. The first action should be determination of New
Jersey and Maryland’s requirements for telepractice, including
vacation-related telepractice.
c is incorrect. RS should have the necessary telepractice
materials with her while vacationing; however, it is not the first
action she should take.
d is incorrect. RS risks compromising protected health information (PHI) by sharing a computer with other family members
(i.e., her husband). RS should utilize available resources to
determine strategies to assure the privacy and security of PHI
when utilizing a shared computer. However, becoming familiar
with New Jersey and Maryland’s requirements for telepractice,
including vacation-related telepractice, is the first action she
should take to fully prepare to deliver telepractice during her
vacation.
61.5 Description of Readiness for
Telepractice and Recommended
Measures
RS has identified a clinical population with which to engage in
telepractice and is beginning to consider what is required.
Unfortunately, the time to prepare is very brief with less than a
month before the projected start of therapy. RS is not yet
licensed in Michigan and it is unlikely that she can successfully
apply for and gain her new license within 2 to 3 weeks. The
same constraints and expense could apply to practice in the
states in which she, and/or her clients, will be vacationing in,
and will require preparatory contact with the state licensure
boards of the vacation sites.
RS is similarly not prepared to begin telepractice via technologies and connectivity methods she intends to employ. Greater
attention must be given to practices that will uphold the privacy and security of the clinical session, as well as other electronic communication between the client and the clinician. RS
must also verify that any copyrighted diagnostic and therapeutic materials have been approved by their publishers for use
with telepractice. Finally, RS has but a brief time to become
more broadly trained in how to effectively engage in the conduct of telepractice sessions, as well as the research evidence
for such practice.
61.6 Outcome
Telepractice (i.e., telespeech and teleaudiology) is rapidly evolving within a complex and dynamic environment. This new service-delivery model is simultaneously subject to transformation
and constraint by numerous external influencers, including historical roots and current practices in telemedicine and telehealth; new and developing technologies; state licensure and
federal regulations; reimbursement and healthcare economics;
and professional association-based policies that dictate nomenclature, tele-ethics, and practice guidelines. RS read content
provided on the ASHA website (http://www.asha.org/PracticePortal/Professional-Issues/Telepractice/) and realized she was
not yet prepared to begin telepractice in 2 to 3 weeks as an
independent, sole provider with no identified mentor or prior
training in telepractice.
RS further relied upon ASHA’s Code of Ethics (http://www.
asha.org/Code-of-Ethics/) to guide her decision. While the
entirety of the Code applies to service delivery via telepractice,
two Rules of Ethics (in Principles of Ethics I) were especially relevant to RS’s decision making:
1. “Individuals who hold the Certificate of Clinical Competence
shall not provide clinical services solely by correspondence,
but may provide services via telepractice consistent with
professional standards and state and federal regulations.”
2. “Individuals shall protect the confidentiality of any profes-
sional or personal information about persons served professionally or participants involved in research and scholarly
activities and may disclose confidential information only
when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law.”
61.7 Key Points
●
Telepractice is a fast-developing service-delivery model that
employs telecommunication that is typically conducted via
synchronous videoconferencing. All technologies associated
with telepractice must be deployed in a manner that upholds
privacy and security.
●
An SLP must hold a valid state professional license in both the
state in which they are practicing and, if different, the state
where the client is present. If the client and/or the clinician
wishes to engage in telepractice from yet another state during
vacation, the clinician must abide by that state’s licensure
240
Exploring Clinician Readiness for Interstate Telepractice
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
requirements. (The requirement for multiple state licenses
does not apply to clinicians employed by the U.S. Department
of Veterans Affairs or the U.S. Department of Defense.)
Suggested Readings
[1] American Speech-Language-Hearing Association. ASHA state-by-state
requirements for state licensure. Available at: http://www.asha.org/advocacy/
state/. Last accessed April 30, 2016
[2] American Speech-Language-Hearing Association. Telepractice overview.
Available at: http://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/. Last accessed April 30, 2016
[3] Cason J, Brannon J. Telehealth regulatory and legal considerations: frequently
asked questions. Int J Telerehabil 2011; 3(20): 15–18. Available at: http://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6077.
[4] Cohn ER, Brannon JA, Cason J. Resolving barriers to licensure portability for
telerehabilitation professionals. Int J Telerehabil. 2011; 3(2):31–34
[5] Towey MP. Speech telepractice: installing a speech therapy upgrade for the
21st century. Int J Telerehabil. 2012; 4(2):73–78
[6] Watzlaf VJ, Moeini S, Firouzan P. VOIP for telerehabilitation: a risk analysis for
privacy, security, and HIPAA compliance. Int J Telerehabil. 2010; 2(2):3–14
References
[1] Cohn ER (2012). Tele-ethics in telepractice for communication disorders. Per-
spect Telepract 2012; 2(1): 3-15. Available at: http://sig18perspectives.pubs.
asha.org/article.aspx?articleid=1811135. Last accessed April 30, 2016
241
Paradoxical Vocal Fold Motion in a High-Level Athlete
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
62 Paradoxical Vocal Fold Motion in a High-Level Athlete
Karen Drake
62.1 Introduction
Paradoxical vocal fold motion (PVFM), also known as vocal cord
dysfunction or paradoxical vocal cord motion is a nonorganic
episodic breathing condition often mistaken for asthma. It
involves abnormal adduction of the true vocal folds during inspiration and/or exhalation resulting in narrowing of the upper
airway with perceived shortness of breath and/or stridor. It is
commonly seen in young, competitive athletes but can occur in
adults or in young nonathletes.
62.2 Clinical History and
Description
DR was in his early 20 s and a very high-level runner, regularly
competing in distance events at national and international
meets. At presentation, he reported a 7-month history of
breathing problems that began after a bad flu. He was initially
diagnosed with asthma and was taking Advair as well as two
puffs of Albuterol prior to exercise. This treatment protocol provided some relief of his dyspnea, but he still felt like his throat
“constricted” when running. When symptomatic, he reported
increased difficulty inspiring relative to expiring and he was
occasionally stridorous on inhalation. His symptoms affected
his ability to train as intensely as required and affected his running performance. He denied any limitations related to his
voice, but reported increased difficulty with voicing when
symptomatic.
62.3 Clinical Testing
Perceptual/observational assessment of voice and breathing was
completed. DR’s resting breathing was primarily thoracic. He
was neither short of breath nor stridorous at rest. His voice was
moderately tight and characterized by low pitch and nearly constant glottal fry. Flexible fiberoptic laryngoscopy was employed
to visualize laryngeal anatomy and function during both speaking and breathing. Normal laryngeal anatomy was observed with
normal vocal fold mobility. Significant supraglottic activity was
observed during connected speech primarily characterized by
severe anterior-posterior squeeze with the arytenoid cartilages
postured toward the epiglottis, which limited visualization of the
vocal folds during conversational speech. The vocal folds
remained abducted during rest breathing.
In addition, an exercise challenge was completed by having
DR run on a treadmill at a fast pace until he became symptomatic. Flexible f iberoptic laryngoscopy was then performed to
visualize the larynx while symptomatic. Some paradoxical
motion of the vocal folds toward midline during the breath
cycle was observed. Excess vertical motion of the larynx was
also observed during respiration with some “hooding” of the
airway with the arytenoid cartilages pulling anteriorly and
inward on inhalation. Stimulability was also determined during
the evaluation; DR was very stimulable for more efficient
breathing (▶ Fig. 62.1 and ▶ Fig. 62.2).
62.4 Questions and Answers for
the Reader
1. In what ways can PVFM be differentiated from asthma?
a) Asthma responds to a “rescue” inhaler and symptoms are
fairly immediately relieved.
b) Asthma typically causes more difficulty breathing out and
PVFM typically causes more difficulty breathing in.
c) Asthma may cause wheezing in the lungs and PVFM may
cause stridor at the level of the vocal folds.
d) All of the above.
Answer: d is correct. All of the above is the correct answer.
a is correct. Asthma typically responds to a rescue inhaler
(Albuterol) and symptoms improve fairly quickly. PVFM does
not respond to a rescue inhaler, though brief relief of symptoms
may be related to the deep inhalation associated with the
inhaler, which leads to increased vocal fold abduction.
b is correct. Both asthma and PVFM are associated with
shortness of breath or dyspnea. However, asthma is typically
associated with increased difficulty with exhalation. In contrast,
PVFM is typically associated with increased difficulty inspiring.
However, occasionally, patients may have difficulty with both
inspiration and expiration.
c is correct. With an asthma attack, wheezing is common and
can be heard via stethoscope to the lungs, or in severe cases,
without a stethoscope. During a significant PVFM attack, stridor
from the vocal folds is common and patients are typically aware
of tightness in their throat.
2. It is not uncommon for patients with PVFM to also have
laryngeal tension during phonation or laryngeal hyperfunction with voicing. Why do you think this might happen?
a) PVFM is a focal neurological disorder, which can cause
problems with breathing and voicing.
b) PVFM is caused by vocal cord edema, which can affect
breathing and voicing.
c) Tightness in the intrinsic and/or extrinsic muscles during
the breathing cycle contributes to PVFM. Tension in those
same muscles can contribute to laryngeal hyperfunction
while voicing.
d) Voice disorders cause PVFM.
Answer: c is correct. Patients often present with co-occurring
tension of the extrinsic and/or intrinsic laryngeal muscles during voicing. Many of those same muscles have increased tension
when exercising or otherwise symptomatic.
a is incorrect. PVFM is not a focal neurological disorder. It is a
functional or nonorganic episodic breathing disorder improved
behaviorally, rather than with medication.
b is incorrect. Vocal cord edema does not cause PVFM. It can
contribute to dysphonia. If a patient has severe edema such as
242
Paradoxical Vocal Fold Motion in a High-Level Athlete
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig. 62.1 The larynx elevating, the vocal folds moving toward midline,
and the arytenoid cartilages partially hooding the airway on inhalation
just after triggering symptoms during exercise.
with polypoid corditis, shortness of breath may be related to
the vocal folds obstructing the airway, not PVFM .
d is incorrect. Voice disorders do not cause PVFM. The cause
of PVFM is unknown and thought to be multifactorial.
3. Treatment for PVFM in young athletes should include:
a) Botox injections to limit vocal fold adduction.
b) Behavioral treatment to train more efficient breathing
patterns at rest and during exercise.
c) Medication such as valium prior to exercise.
d) Discontinue athletics to avoid breathing problems.
e) All of the above.
Answer: b is correct. Behavioral treatment aimed at more effi-
cient breathing patterns at rest as well as specific breathing strategies to use during exercise has been shown to successfully reduce
or eliminate symptoms. These strategies and their application
may need to be modified to meet the demands of a specific sport.
a is incorrect. Botox injections are not typically indicated for
the treatment of PVFM. Botox to the vocal folds can also have
temporary negative side effects including difficulty swallowing
and breathy voice.
c is incorrect. Although many patients with PVFM have anxiety associated with their symptoms, which is understandable
given the degree of dyspnea, treating anxiety with a muscle
relaxant is not indicated, as it may negatively affect athletic performance.
d is incorrect. Quitting sports may temporarily decrease episodes of PVFM, but is not an optimal long-term solution. The
implications for limiting physical activity are significant.
e is incorrect. All of the above is not correct for reasons
already stated.
4. Evaluation of a patient with suspected PVFM should include:
a) Laryngoscopic evaluation to ensure that there is no vocal
fold pathology and no conditions such as subglottic stenosis that could result in dyspnea.
Fig. 62.2 Normal, abducted vocal cord position during inhalation and
exhalation in the same patient.
b) Educating the patient regarding normal laryngeal appear-
ance and physiology during both breathing and speech.
c) Visualizing the larynx when symptomatic to see laryngeal
motion/vocal fold motion when the patient is feeling
short of breath.
d) Initiating visual biofeedback. The laryngoscope can be
employed to show the patient the larynx and visualize
the vocal folds as they adduct. Strategies can be employed
to decrease adduction with concurrent visual feedback.
e) All of the above.
Answer: e is correct. All of the above is the correct answer.
a is correct. Laryngoscopy is a critical component of a PVFM
evaluation to rule out any condition or pathology that could
contribute to shortness of breath as well as to confirm paradoxical motion of the vocal folds. The larynx should be imaged
before beginning treatment and patients must be seen in collaboration with an otolaryngologist to make a medical diagnosis. If the speech pathologist is not part of a voice/PVFM team,
they should engage an otolaryngologist to obtain this information before initiating therapy. Occasionally, patients referred for
the evaluation of PVFM present with subglottic stenosis or
bilateral vocal fold paralysis. Treatment for these two conditions is quite different from PVFM treatment.
b is correct. The vast majority of patients and their families
are unaware of PVFM. Allowing patients to view their laryngeal
examination is extremely helpful to increase awareness of the
issues underlying their shortness of breath.
c is correct. It can be extremely helpful to trigger symptoms
of PVFM by an exercise or scent challenge (exposing them to
whatever scent triggers their symptoms) and then visualize the
larynx while symptomatic. This examination allows both the
clinician and patient to see what is happening during an attack.
PVFM can be “classic,” with the vocal folds adduc ting on inhala-
243
Paradoxical Vocal Fold Motion in a High-Level Athlete
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
tion and opening on exhalation, but several variants of PVFM
have been described. In some patients, the arytenoids pull forward, a condition referred to as “hooding” the larynx during
inhalation. In contrast, the vocal folds can remain fairly
abducted, but the larynx rises excessively in the neck. Some
patients maintain significant vocal tension during inhalation
and exhalation, while others maintain some vocal fold tension
during the breathing cycle, even during rest breathing.
d is correct. Visual biofeedback can be critical for patient education and “buy in” for therapy as well as self-efficacy or the
belief that he/she can control his/her symptoms. The clinician
can instruct the patient to imitate an attack if they are not
actually symptomatic and the patient can see abnormal vocal
fold motion and how this affects the airway. Patients can then
be instructed to release laryngeal tension by using a strategy
such as breathing in through the nose and out through the lips
and cheeks, which commonly allows the larynx to drop into a
more natural position in the neck and facilitates vocal fold
abduction.
62.5 Recommended Treatment
DR had fairly classic PVFM with movement of the vocal folds
toward midline on inhalation during strenuous aerobic exercise. He had also had excess laryngeal elevation during the
breathing cycle and his arytenoid cartilages pulled forward during inhalation. He demonstrated an inefficient breathing pattern at rest and tended to hold his breath frequently throughout
the day as an unconscious habit. We recommended behavioral
treatment to train preventative breathing strategies, including
efficient breathing at rest and warm-up breathing exercises
aimed at releasing laryngeal tension during the breathing c ycle
as well as rescue breathing strategies or tasks to prevent symptoms while running and to immediately interrupt symptoms
when they occur. DR also demonstrated laryngeal hyperfunction during voicing and spoke with a low-pitch, throat-focused
resonance and poor airflow likely related to significant anterior-to-posterior compression. Voice treatment was also initiated, as he was tightening his extrinsic laryngeal muscles with
speaking as well as with breathing.
For athletes, it is critical to gain confidence with efficient
breathing during sport. In this case, we recommended frontfocused, open-throat breathing, which involved shifting the
focus of the breath from the throat to the front of the mouth as
if the air was going in and out through a large straw. Allowing
the air to be gently exhaled through the lips and cheeks opened
the vocal folds during exhalation, and focusing inhalation at the
lips instead of the throat maintained vocal fold abduction. He
began implementing this technique during a slow jog on the
treadmill working up to a sprint. Success was emphasized to
build self-efficacy and confidence that he could control his
symptoms. DR was highly motivated throughout treatment as
his running performance had suffered due to his PVFM.
DR was able to complete negative prac tice while running on
a treadmill by returning to his baseline breathing and then
switching to the new, more efficient breathing technique. He
could feel the difference between running with his habitual
throat-focused breathing and running with the more efficient,
front-focused breathing. As he became more aware of his
throat/laryngeal muscles and his breathing, he also became
more aware that he had constant tension in his throat likely
related to increased laryngeal tension while speaking and
breath holding. Although DR initially had no voice complaints,
he began to understand and feel how he was also tightening his
laryngeal muscles and stopping airflow while voicing. Optimal
vocal technique was implemented to address this issue. He was
given daily vocal warm-up exercises, and, during therapy sessions, improved breath support, coordination of breath and
sound, and front vocal resonance in conversation were targets.
62.6 Treatment Outcome
DR completed the initial evaluation and three treatment sessions (once per week for 3 weeks). His track coach was involved
and was motivated to assist with implementation of therapeutic techniques. Both DR and his coach were educated during the
initial evaluation. It was helpful for them to see what was happening at the level of the vocal folds via laryngoscopy at baseline, and also when symptomatic after running on a treadmill.
DR progressed rapidly through treatment as he was skilled at
differentiating between his habitual respiratory pattern and
more efficient front-focused breathing. By the end of the third
session, he reported significant improvements in his workouts.
Two weeks after the completion of treatment, he set a personal
record in his event. In follow-up, he reported excellent control
over his symptoms. His dyspnea index scale score
from 27 before treatment to 4 after treatment. He had no further symptoms, but occasionally had to think about controlling
his symptoms during especially hard workouts and races. He
also reported improved vocal function and decreased vocal fatigue. Further more, he reported that he felt much more confident with voicing when he had to do a running workshop or
give interviews.
1
improved
62.7 Key Points
●
PVFM is a functional or nonorganic episodic breathing disorder that responds very well to behavioral treatment with a
speech pathologist trained to work with this challenging population.
●
PVFM differs from asthma in which tightness is usually felt in
the upper chest and/or throat and the breathing limitation is
typically most obvious on inhalation. Rescue inhalers are not
associated with lasting relief of PVFM. Asthma is typically felt
more on the exhalation, though further into an attack,
patients can feel difficulty with both inhalation and exhalation. In addition, with asthma, tightness is typically reported
in the mid-chest area and rescue inhalers typically relieve
symptoms very quickly.
●
In PVFM treatment, breathing strategies used during resting
breathing will differ from breathing strategies used during
aerobic exercise, as the oxygen demands are greater and the
rate of breathing increases.
●
Many patients with PVFM experience tightness or laryngeal
tension during phonation as well laryngeal tension during
the breathing cycle.
244
Paradoxical Vocal Fold Motion in a High-Level Athlete
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
●
All patients with PVFM must see a physician to rule out laryngeal and/or upper airway pathology before initiating PVFM
treatment.
●
Imaging the larynx at baseline and when symptomatic, often
with an exercise challenge, is extremely beneficial to educate
the patient on normal and aberrant vocal fold anatomy and
physiology.
Suggested Readings
[1] Mathers-Schmidt D. Paradoxical vocal fold motion: a tutorial on a complex
disorder and the speech pathologist’s role. Am J Speech Lang Pathol. 2001;
10:111–125
[2] Murry T, Sapienza C. The role of voice therapy in the management of para-
doxical vocal fold motion, chronic cough, and laryngospasm. Otolaryngol Clin
North Am. 2010; 43(1):73–83, viii–ix
[3] Newman KB, Mason UG, III, Schmaling KB. Clinical features of vocal cord dys-
function. Am J Respir Crit Care Med. 1995; 152(4, Pt 1):1382–1386
[4] Sullivan MD, Heywood BM, Beukelman DR. A treatment for vocal cord dys-
function in female athletes: an outcome study. Laryngoscope. 2001; 111(10):
1751–1755
Reference
[1] Gartner-Schmidt JL, Shembel AC, Zullo TG, Rosen CA. Development and vali-
dation of the Dyspnea Index (DI): a severity index for upper airway-related
dyspnea. J Voice. 2014; 28(6):775–782
245
Accent Modification in a Thai-Speaking Graduate Student
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
63 Accent Modification in a Thai-Speaking Graduate
Student
Dana Rissler Fritz
63.1 Introduction
Persons seeking to modify accents typically have strong English
language skills in terms of comprehension and production, but
have increasing difficulty with details of the English language
that do not match with linguistic patterns of their first language, specifically with the use of phonemes, coarticulation,
and intonation patterns.
63.2 Clinical History and
Description
P was a 28-year-old woman originally from Thailand referred to
a university accent modification program. P was pursuing a
doctorate in chemical engineering and sought to improve her
research-presentation skills as well as her ability to be understood by her fellow students, professors, and friends. She
studied English for more than 10 years in Thailand with primary emphasis in reading and writing, but relatively limited
practice in listening and speaking. She began using English for
daily communication 2 years ago when she started her academic program. P presented as an outgoing person with a large
international cohort of friends.
63.3 Clinical Testing
The Proficiency in Oral English Communication (POEC)1was
administered to determine P’s strengths and weaknesses
related to American English pronunciation and intonation. The
POEC provides information regarding word-level intonation,
sentence-level intonation, use of contrastive stress, and
articulation of consonants and vowels, as well as auditory discrimination abilities with common minimal pairs. Words with
second-syllable stress (whether two or three syllables in length,
such as “aCROSS” and “conSIStent”) were particularly difficult
for P; she had a tendency to stress the first syllable irrespective
of appropriate stress placement. Pitch, volume, and duration
changes to syllables within sentences were observed dur ing
conversation and within the question–answer intonation task
of the POEC. However, these changes did not wholly conform to
what would be expected of American speakers. She had a tendency to raise pitch or use a monotone pitch at the end of
“WH” questions and statements; many utterances sounded as if
she were asking a helping verb question (“Do you…?”; “Will
we…?”) rather than employing falling pitch with high points
for important words, which is more typical of American speakers. Contrastive stress or the ability to highlight a particularly
important word to improve listener comprehension of utterances was an area of relative strength for P. During a brief conversation sample, very little linking or coarticulation between
words was observed.
With regard to phoneme production, P demonstrated commonly deleted word-final consonants and reduced consonant
clusters in initial, medial, and final positions. Consonant substitutions noted during the assessment were /d/ for /θ, ð/ and /w/
for /v/. Consonant sounds used interchangeably included /s/
and /z/, /ʃ/ and /tʃ/, /ʒ/ and /dʒ/. Auditory discrimination tasks
revealed difficulties distinguishing most voiced and voiceless
English consonants. Regarding vowels, P had difficulty consistently producing /ɪ/, /ɛ/, /e/, /ə/, /ɶ/, and /o/; she tended to overuse canonical vowels when lip rounding was not needed. She
also had a tendency to make errors related to orthography (e.g.,
always pronouncing words with the spelling pattern “ou” as /ɑ/
). Schwa insertion was commonly noticed, particularly when
three consonants were strung together (e.g., /str/).
The Sentence Intelligibility Test (SIT),
semantically unpredictable, yet grammatically correct sentences of 5 to 15 words in length was administered. The testing
protocol involves recording these productions and these
recordings are then transcribed by three unfamiliar American
listeners. P was 80% intelligible.
2
which consists of 11
63.4 Questions and Answers for
the Reader
1. What is a likely language difference in the area of phonology
between English and Thai?
a) Fewer pitch changes are expected and utilized to impact
meaning in Thai.
b) Consonant clusters are more common in Thai than in
English.
c) Linguadental phonemes are more often used in English
than in Thai.
d) All of the above.
e) None of the above.
Answer: c is correct. Linguadental phonemes (voiced and
voiceless “th”) are uncommon in most Asian languages, and
not used in Thai.
a is incorrect. Pitch change in the Thai language is common
and expected by the listener.
b is incorrect. Within-word consonant clusters are more
common in English than in Thai.
d is incorrect. Not all of the above answers are correct.
e is incorrect. At least one of the above answers is correct.
2. P’s accent modification and pronunciation should primarily
focus on:
a) Improving correct production of consonants and vowels.
b) Word-level stress.
c) Sentence intonation and appropriate pitch variation.
d) All of the above.
e) None of the above.
Answer: d is correct. Although targets for pronunciation vary
among participants, all of the above should be employed in
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Accent Modification in a Thai-Speaking Graduate Student
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
this case—consonants, word stress, and sentence intonation.
Linking or coarticulation is also a common area of work in
accent modification. Once these foundational aspects of
pronunciation are addressed, therapy shifts toward applying
these skills to real-world communication needs.
a is incorrect. Phoneme practice is only one component of
therapy.
b is incorrect. Word-level stress is also only one part of
intervention.
c is incorrect. Therapy should focus not only on sentence
intonation and pitch variation but also on other areas.
e is incorrect. At least one of the above answers is correct.
3. P’sdifficulty in effectively producing syllable-stress
differences was mostly related to:
a) Volume.
b) Pitch.
c) Syllable duration.
d) Coarticulation.
e) Air support.
Answer: b is correct. P could produce differences in syllable
volume and duration—two of the three ways English speakers stress key syllables, but pitch was more difficult for her to
change consistently. Overall, her pitch was more monotone
in nature, as compared to her clinician’s target model analyzed on PRAAT (to be discussed in the following section).
a is incorrect. Although overall volume was sometimes aberrant, it was not an issue when P was using louder volume on
stressed syllables.
c is incorrect. P was able to increase the length of stressed
syllables with relative ease.
d is incorrect. Coarticulation does not directly relate to distinguishing stressed syllables at the word level.
e is incorrect. Air support was not a relevant clinical issue
related to syllable stress.
4. In terms of voiced and voiceless consonants, P had difficulty
differentiating between many fricative and affricate consonants. It could be assumed that:
a) P had a hear ing and/or speech disorder.
b) The use of fricatives and affricates in Thai is less common
than in English.
c) The importance of voicing distinctions in terms of listener
perception and comprehension is less in Thai than in Eng-
lish.
d) a and c are correct.
e) b and c are correct.
Answer: e is correct. In the Thai language, only three fricatives are used (/s/, /f/, and /h/) and no affricates are used.
Voiced/voiceless correlates common and frequently used in
the English language are infrequent in Thai, and only include
p/b and d/t.
a is incorrect. As an English-language learner, P’s main
concern was a difference in her ability to be understood by
American listeners, not problems related to a disorder in
speech or hearing.
b alone is incorrect. It is not the only aspect of auditory
discrimination that can be assumed.
c alone is incorrect. It is not the only aspect of auditory
discrimination that can be assumed.
d is incorrect because a is incorrec t; P’s issues are related to a
language difference, not disorder.
63.5 Description of Language
Difference and Recommended
Treatment
P’s intelligibility to American listeners fell within tier III in the
Missouri University Accent Modif ication and Pronunciation
program’s constructs (tier III describes listeners who are greater
than 75% intelligible to unfamiliar listeners; see ▶ Table 63.1).
This score likely indicated that she was asked to repeat herself
regularly in situations where she was meeting new people, in
noisy environments, or when the scientific jargon of engineering was challenging. Likely she was seldom misunderstood by
close friends and fellow students. P was active and involved on
campus, which involved significant communicative demands.
Similarly, she had many opportunities to practice. Generalizability of newly learned pronunciation skills is key to effective
accent modification work; her active social life was a favorable
prognostic indicator.
Based on these issues, it was determined that P would likely
benefit from an individualized “American phonetics” class with
an intense focus on the specific phonemes and phonological
rules that were challenging for her. An approach focusing on
classes of sounds with significant direct practice and multimodal feedback (visual, auditory, and tactile) was determined to
be ideal. Using information gained from the POEC, treatment
focused on vowels and consonants in error, contrasting them
with phonemes that were generally produced correctly and
subsequent discussion regarding their similarities and differences. Explicitly teaching common word stress patterns would be
helpful as well to ensure that increased volume and increased
duration and increased pitch are required for syllable stress.
Focusing on the language of origin of English words is helpful in
predicting stress patterns (e.g., Latin words tend to have first
syllable stress or penultimate syllable stress; Germanic words
tend to have first syllable stress, etc.). In considering overall
sentence-level intonation, the freeware program PRAAT
an effective tool for visual feedback of pitch lines and word-toword linking (▶ Fig. 63.1 and ▶ Fig. 63.2). Determining P’s fundamental frequency using a yawn-sigh technique or a piano
keyboard would be helpful in determining what four notes she
would most likely shift among in American English. In English,
most speakers generally move among four notes as they speak,
Table 63.1 Intelligibility improvement as related to beginning
performance levels
MU AMP tier Average SIT
Tier I: < 50% at
baseline
Tier II: 50%–
75% at baseline
Tier III: > 75% at
baseline
Notes: To quantify progress and effectiveness of the Missouri University
Accent Modification and Pronunciation program (MU AMP), baseline
and endline data using the sentence intelligibility test (SIT) with
unfamiliar American listener transcribers has been gathered since the
program’s inception in 2006. This table documents our results to date.
a
p < 0.001.
baseline
43% 73.67% 30.67%
65.85% 80.51% 14.66%
86.37% 91.75% 5.38%
Average SIT
endline
3
can be
Average
improvement
a
a
a
247
Accent Modification in a Thai-Speaking Graduate Student
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig. 63.1 In this PRAAT sound file, you can see
changes in speaker volume on the intensity bar as
well as on the spectrogram (yellow line). You can
also observe pitch changes by examining the blue
line on the spectrogram as P says, “ Why would
you do that?” Although she is changing volume
of stressed syllables in a somewhat appropriate
fashion, you can see very little pitch change in
this question utterance, ranging from 137 to
187 Hz. You can also see very little coarticulation
between the syllables, as if she is saying each
word on its own. Coarticulation or linking
improves intelligibility overall.
Fig. 63.2 In this PRAAT sound file, P’s accent
modification and pronunciation clinician is saying
the same question as in ▶ Fig. 63.1: “Why would
you do that?” In this example, you can observe a
greater range in volume overall (intensity bar and
yellow line on the spectrogram), but in terms of
pitch (blue line on the spectrogram), the difference is dramatic. P’s clinician shows the typical
WH-question intonation, with peak pitch change
near the end of the question and a steep drop in
pitch after that. Her pitch range is from 124 to
314 Hz, which is more typical of American
speakers and approximately 72% more pitch
variation than in P’s example. You can also see
more coarticulation between syllables with the
only real spaces in voicing because of stopgap
consonants.
with their lowest note near their fundamental frequency and
the three notes above serving as contrast points for stress variation and to show emotional differences (e.g., higher pitches
used for excitement or to indicate a helping-verb question have
been asked such as “Can we talk later?”).
approach was initiated where P brought in research presentations, stories from the radio related to her educational interests,
and even a restaurant menu that she wanted to practice as she
felt frequently misunderstood when ordering. All pronunciation
skills directly targeted during the first part of the semester
were then critiqued as the focus shifted to more relevant com-
63.6 Outcome
P attended twenty-four, 50-minute sessions and was an active,
involved participant. Initially, treatment was clinician directed
with specific phoneme and intonation targets, and as improvements were observed at the syllable and word level, treatment
shifted to pronunciation skills in phrases and sentences. Since
accents are not disorders, rapid progression to more difficult
targets is common; “real-world” communication activities typically accelerate this process. By mid-semester, a more client-led
munication tasks. VoiceThread, a cloud-based educational
application, was employed for P to record herself along with
her presentation slides. Commentary and feedback were provided directly within the recorded presentation. This software
was a motivating, yet asynchronous, homework tool employed
to ensure generalization of clinic-based practice to everyday
communication.
At discharge, the SIT was readminis tered and distributed
again to three unfamiliar American listeners. P’s overall sentence-level intelligibility improved to 91%. P reported that she
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