Speech Therapy

Number: 0243

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses speech therapy.

1. Medical Necessity

   Aetna considers the following indications for speech therapy as medically necessary (unless otherwise specified):

   1. Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease when all of the following criteria are met:

      1. The member’s physician has determined that the member’s condition can improve significantly with speech therapy; and
      2. The speech therapy is expected to result in a significant improvement in the individual’s condition within a reasonable and generally predictable period of time; and
      3. Speech therapy services must be performed by a duly licensed and certified, if applicable, provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; and
      4. The speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws; and
      5. Speech therapy services must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations. The plan of care should be of sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment (see Appendix for documentation requirements);

   2. Speech therapy is considered not medically necessary in the following circumstances:

      1. Duplicate therapy when members receive both occupational, physical and speech therapy; the therapies should provide different treatments and not duplicate the same treatment. When multiple therapies are used, each must have separate written treatment plans and must provide significantly different treatments and not be seen as generally duplicating each other; or
      2. Maintenance programs such as drills, techniques, and exercises that are intended to preserve the member's present level of function or prevent regression of function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur. Specifically, these include continued activities for individuals who have achieved generally accepted levels of function and are at a plateau or have reached "normal" levels. A plateau is a period of four weeks or dependent on the specific condition and/or individual situation, a lesser period of time that is seen as generally accepted; or
      3. Treatments that do not require the skills of a qualified provider of speech therapy services, such as treatments that maintain function by using routine, repetitious, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors) or procedures that may be carried out effectively by the member, family, or caregivers at home on their own;
   3. Speech therapy is considered not medically necessary for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting;
   4. Speech therapy for idiopathic delays in speech development when both of the following criteria are met:
      
      
      1. The member is 18 months of age or older; and
      2. The member has been evaluated by a qualified speech-language therapist who has determined that a treatable communication problem exists.

      Speech therapy for idiopathic delays in speech development is considered experimental and investigational for infants and children younger than 18 months of age because idiopathic delays in speech development can not be reliably diagnosed or treated in the prelingual developmental stage.

   5. Home-based speech therapy in selected cases based upon the member's needs (i.e., the member must be homebound). This is usually used in the transition of the member from hospital to home and is an extension of case management services. Note: In Aetna HMO and QPOS plans, such short-term speech therapy accumulates towards the 60-day limit or other applicable rehabilitation benefit limits. Please check benefit plan descriptions for details.

2. Experimental and Investigational

   The following procedures / indications for speech therapy are considered experimental and investigational because the effectiveness of these approaches has not been established (not an all-inclusive list):

   1. Altered auditory feedback devices for stuttering and all other indications because of a lack of evidence in the peer-reviewed published medical literature on the effectiveness of these devices. Note: In addition, altered auditory feedback devices are communication aids that are not considered prosthetics for speech because they are not speech generating devices; thus, altered auditory feedback devices would be excluded from coverage under plans that exclude coverage of communication aids. Please check benefit plan descriptions. Brands of altered auditory feedback devices include the SpeechEasy (Janus Development Group, Greenville, NC), the Fluency Master (National Medical Equipment, Inc., New Hyde Park, NY), Pocket Speech Lab (Casa Futura Technologies, Boulder, CO), SmallTalk (Casa Futura Technologies, Boulder, CO), Telephone Fluency System (Casa Futura, Technologies, Boulder, CO), and the Fluency Enhancer (Casa Futura Technologies, Boulder, CO);
   2. Facilitated communication for all indications;
   3. Speech therapy as a treatment for chronic cough;
   4. Speech therapy for post-extubation dysphonia after hospitalization with COVID-19;
   5. Transcutaneous electrical nerve stimulation for use in speech therapy rehabilitation of voice and swallowing function.

3. Policy Limitations and Exclusions

   1. Speech therapy may be a limited benefit. Often, in Aetna commercial HMO-based plans, the benefit is limited to a 60-day treatment period.  The treatment period of 60 days applies to a specific condition.  Once the 60-day treatment period expires, no additional speech therapy benefits will be provided for that condition; however, it is possible for a member to receive more than one 60-day treatment course of speech therapy when the need is the result of a separate condition.  For example, a stroke or a surgical procedure causing the need for speech therapy is considered to be the initiation of a new or separate condition in a person who previously received this service for another reason, and so qualifies the member to receive coverage for an additional course of speech therapy as outlined above.  An exacerbation or flare-up of a chronic illness is not considered a new incident of illness.
   2. Coverage for speech therapy benefits under traditional plans range from a defined number of visits per year to unlimited benefits.  Benefit levels are determined by the particular benefit plan selected by the employer or contract holder.  Please check benefit plan descriptions for details.
   3. Most Aetna plans exclude coverage of educational training or services. Under these plans, speech therapy that is provided in an educational setting is excluded from coverage.  Please check benefit plan descriptions.

4. Related Policies

   • CPB 0034 - Aural Rehabilitation (includes auditory verbal therapy [AVT])
   • CPB 0284 - Melodic Intonation Therapy
   • CPB 0437 - Speech Generating Devices (includes criteria for augmentive and alternative communication devices)
   • CPB 0625 - Dysphagia Therapy
   • CPB 0646 - Voice Therapy
   • CPB 0648 - Autism Spectrum Disorders
   • CPB 0668 - Auditory Processing Disorder

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Speech Therapy other than with cochlear implants or hearing aids:
CPT codes covered if selection criteria are met:
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	group, two or more individuals
Other CPT codes related to the CPB:
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing dysfunction and/or oral function for feeding
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended) [transcutaneous electrical nerve stimulation]
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes [transcutaneous electrical nerve stimulation]
97535	Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes
HCPCS codes covered if selection criteria are met:
G0153	Services performed by a qualified speech and language pathologist in the home health or hospice setting, each 15 minutes
G0161	Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes
S9128	Speech therapy, in the home, per diem
Other HCPCS codes related to the CPB:
E0720	Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation
E0730	Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation
E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
G0129	Occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
S9152	Speech therapy, re-evaluation
S9129	Occupational therapy, in the home, per diem
ICD-10 codes covered if selection criteria are met (not all inclusive):
C00.0 - C00.9	Malignant neoplasm of lip
C01 - C02.9	Malignant neoplasm of tongue
C03.0 - C03.9	Malignant neoplasm of gum
C04.0 - C04.9	Malignant neoplasm of floor of mouth
C05.0 - C05.9	Malignant neoplasm of palate
C06.0 - C06.9	Malignant neoplasm of other and unspecified parts of the mouth
C08.0 - C08.9	Malignant neoplasm of salivary glands
C10.0 - C10.9	Malignant neoplasm of oropharynx
C11.0 - C11.9	Malignant neoplasm of nasopharynx
C13.0 - C13.9	Malignant neoplasm of hypopharynx
C14.0 - C14.8	Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
C32.0 - C32.9	Malignant neoplasm of larynx
C71.0 - C71.9	Malignant neoplasm of brain
D02.0	Carcinoma in situ of larynx
D14.1	Benign neoplasm of larynx
E74.02	Pompe Disease
F44.4	Conversion disorder with motor symptom or deficit [functional dysphonia]
G45.0 - G45.9	Transient cerebral ischemic attacks and related syndromes
G46.0 - G46.8	Vascular syndrome of brain in cerebrovascular diseases
G25.2	Other specified forms of tremor [voice]
I60.00 - I69.898	Cerebrovascular disease
I69.920 - I69.928	Speech and language deficits following unspecified cerebrovascular disease
I69.951 - I69.959	Late effects of cerebrovascular disease, hemiplegia/hemiparesis
I69.990	Apraxia following unspecified cerebrovascular disease
I69.991	Dysphagia following unspecified cerebrovascular disease
J38.00 - J38.02	Paralysis of vocal cords and larynx
J38.2	Nodules of vocal cords
Q31.0 - Q31.9	Congenital malformations of larynx
Q31.8, Q32.1, Q32.4	Other congenital malformations of larynx, trachea, and bronchus
Q32.0	Congenital tracheomalacia
Q32.2	Congenital bronchomalacia
Q32.3	Congenital stenosis of bronchus
Q35.1- Q37.9	Cleft palate and cleft lip
R13.10 - R13.19	Dysphagia
R49.0	Dysphonia [post extubation]
S01.501A - S01.552S	Open wound of lip and oral cavity
S02.0xx+ - S02.19x+	Fracture of skull
S02.0xxS - S02.92xS	Fracture of skull and face bones, sequela
S04.011S - S04.899S	Injury to cranial nerve, sequela
S06.0X0+ - S06.9X9+	Intracranial Injury
S11.011+ - S11.029+	Open wound of larynx and trachea
Z85.21	Personal history of malignant neoplasm of larynx
Z85.810	Personal history of malignant neoplasm of tongue
Z85.818 - Z85.819	Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx
Z96.20	Presence of otological and audiological implant, unspecified
Z96.21	Presence of cochlear implant status
Z96.3	Presence of artificial larynx
ICD-10 codes not covered for indications listed in the CPB :
F80.0 - F80.9	Specific developmental disorders of speech and language
H93.25	Central auditory processing disorder
R05	Cough
Speech Therapy with cochlear implants and hearing aids:
CPT codes covered is selection criteria are met:
92630	Auditory rehabilitation; pre-lingual hearing loss
92633	post-lingual hearing loss
CPT codes not covered for indications listed in the CPB:
Facilitated Communication, Altered Auditory Feedback Devices – no specific code:
ICD-10 codes not covered for indications listed in the CPB:
F98.5	Adult onset fluency disorder [stuttering]
J38.5	Laryngeal spasm
J38.7	Other diseases of larynx
R47.81 - R47.9	Other speech disturbance

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Background

Facilitated Communication

There is inadequate evidence of the effectiveness of facilitated communication.  The American Psychological Association (2004) has determined that "facilitated communication is a controversial and unproved communicative procedure with no scientifically demonstrated support for its efficacy."  Other national professional organizations adopting formal positions opposing facilitated communication as a valid mode of enhancing expression for people with disabilities include the American Academy of Pediatrics, the American Association on Intellectual and Developmental Disabilities, the American Academy of Child & Adolescent Psychiatry and the American Speech-Language-Hearing Association.

In a review on autism, Levy and colleagues (2009) stated that popular biologically based treatments include anti-infectives, chelation medications, gastrointestinal medications, hyperbaric oxygen therapy, and intravenous immunoglobulins.  Non-biologically based treatments include auditory integration therapy, chiropractic therapy, cranio-sacral manipulation, facilitated communication, interactive metronome, and transcranial stimulation.  However, few studies have addressed the safety and effectiveness of most of these treatments.

Flippin and colleagues (2010) stated that the Picture Exchange Communication System (PECS) is a popular communication-training program for young children with autism spectrum disorders (ASD).  This meta-analysis reviewed the current empirical evidence for PECS in affecting communication and speech outcomes for children with ASD.  A systematic review of the literature on PECS written between 1994 and June 2009 was conducted.  Quality of scientific rigor was assessed and used as an inclusion criterion in computation of effect sizes.  Effect sizes were aggregated separately for single-subject and group studies for communication and speech outcomes.  A total of 8 single-subject experiments (18 participants) and 3 group studies (95 PECS participants, 65 in other intervention/control) were included.  Results indicated that PECS is a promising but not yet established evidence-based intervention for facilitating communication in children with ASD aged 1 to 11 years.  Small to moderate gains in communication were demonstrated following training.  However, gains in speech were small to negative.

Altered Auditory Feedback Devices

The SpeechEasy Anti-Stuttering Device uses delayed auditory feedback and frequency altered feedback to create the illusion of another person speaking in unison with the user.  By emulating this "choral speech" pattern, the SpeechEasy device is intended to increase fluency of persons who stutter.  The Fluency Enhancer Anti-Stuttering Device also uses digital delayed auditory feedback and frequency altered feedback that is designed for temporary use in a protocol developed by the National Center for Stuttering.  However, there is a lack of evidence in the peer-reviewed published medical literature on the effectiveness of the SpeechEasy or Fluency Enhancer Anti-Stuttering Devices.  Ingham and Ingham (2003) commented that "[t]here is not a single peer-reviewed, published clinical research study demonstrating that this device produces sustained and satisfactory improvements in fluency – and for what percentage and age range of people who stutter – let alone that it produces benefits that are retained following extended use."

The Fluency Master Anti-Stuttering Device is a miniature, wearable, electronic stuttering control device that looks like a hearing aid.  It works on an auditory feedback principle.  The Fluency Master modifies vocal tone with the help of a miniature microphone positioned near the user's mastoid area.  The microphone picks up vibrations conducted through bone from the user's larynx.  The Fluency Master then amplifies this "bone conduction" vibration, so the user hears his voice differently than he normally does.  There is a lack of clinical evidence in the peer-reviewed published medical literature on the effectiveness and durability of results of the Fluency Master in persons who stutter.

Altered auditory feedback devices are also being investigated for use in treatment of rate and rhythm dysarthria associated with Parkinson disease, transient spasmodic dysphonia, and laryngeal spasms.  However, there is a lack of scientific evidence to support the effectiveness of altered auditory feedback devices for these indications.

A report on the SpeechEasy by the National Horizon Scanning Centre (2007) noted that a non-systematic review of peer-reviewed journal papers published from 1995-2005 (citing Lincoln et al, 2006) that investigated the effect of altered auditory feedback concluded that there is some experimental and limited phase I evidence of benefit, but that knowledge about the effect of altered auditory feedback during conversational speech and everyday situations is missing.  There is evidence that altered auditory feedback impacts positively on reading aloud (40 to 85 % reduction in stuttering).  The report found that there is only limited evidence of efficacy, and debate about possible risks to normal speech development of altered auditory feedback in children.

Armson and Kiefte (2008) examined the effects of SpeechEasy on stuttering frequency, stuttering severity self-ratings, speech rate, and speech naturalness for 31 adults who stutter.  Speech measures were compared for samples obtained with and without the device in place in a dispensing setting.  Mean stuttering frequencies were reduced by 79 % and 61 % for the device compared to the control conditions on reading and monologue tasks, respectively.  Mean severity self-ratings decreased by 3.5 points for oral reading and 2.7 for monolog on a 9-point scale.  Despite dramatic reductions in stuttering frequency, mean global speech rates in the device condition increased by only 8 % in the reading task and 15 % for the monolog task, and were well below normal.  Further, complete elimination of stuttering was not associated with normalized speech rates.  Nevertheless, mean ratings of speech naturalness improved markedly in the device compared to the control condition and, at 3.3 and 3.2 for reading and monolog, respectively, were only slightly outside the normal range.  These results showed that SpeechEasy produced improved speech outcomes in an assessment setting.  However, findings raise the issue of a possible contribution of slowed speech rate to the stuttering reduction effect, especially given participants' instructions to speak chorally with the delayed signal as part of the active listening instructions of the device protocol.  Study of device effects in situations of daily living over the long-term is needed to fully explore its treatment potential, especially with respect to long-term stability.

O'Donnell et al (2008) examined the effects of SpeechEasy on stuttering frequency in the laboratory and in longitudinal samples of speech produced in situations of daily living (SDL).  A total of 7 adults who stutter participated, all of whom had exhibited at least 30 % reduction in stuttering frequency while using SpeechEasy during previous laboratory assessments.  For each participant, speech samples recorded in the laboratory and SDL during device use were compared to samples obtained in those settings without the device.  In SDL, stuttering frequencies were recorded weekly for 9 to 16 weeks during face-to-face and phone conversations.  Participants also provided data regarding device tolerance and perceived benefits.  Laboratory assessments were conducted at the beginning and the end of the longitudinal data collection in SDL.  All 7 participants exhibited reduced stuttering in self-formulated speech in the device compared to no-device condition during the 1st laboratory assessment.  In the 2nd laboratory assessment, 4 participants exhibited less stuttering and 3 exhibited more stuttering with the device than without.  In SDL, 5 of 7 participants exhibited some instances of reduced stuttering when wearing the device and 3 of these exhibited relatively stable amounts of stuttering reduction during long-term use.  Five participants reported positive changes in speaking-related attitudes and perceptions of stuttering.  The authors concluded that further investigation into the short-term and long-term effectiveness of SpeechEasy in SDL is warranted.

Pollard et al (2009) examined the effects of the SpeechEasy when used under extra-clinical conditions over several months.  Primary purposes were to help establish phase I level information about the therapeutic utility of the SpeechEasy and to compare those results with previous findings obtained in laboratory and clinical settings.  A total of 11 adults who stutter participated.  A non-randomized ABA group design was utilized.  Speech samples were collected every 2 weeks in extra-clinical environments.  Qualitative data were collected through weekly written logs and an exit questionnaire.  Group analyses revealed a statistically significant effect of the SpeechEasy immediately post-fitting but no treatment effect across 4 months' time.  Individual responses varied greatly with regard to stuttering frequency and subjective impressions.  Relatively more stuttering reduction occurred during oral reading than during formulated speech.  The authors concluded that based on this protocol, phase II trials are not indicated.  However, positive individual responses and self-reports suggest some clinical utility for the SpeechEasy.  The use of more challenging sampling procedures strengthened external validity and captured more modest altered auditory feedback effects compared with those previously reported in laboratory settings.  Device use coincided more so with positive subjective impressions than with measurable fluency improvement, highlighting challenges facing clinicians when implementing principles of evidence-based practice, including client-based preferences.

Andrade and Juste (2011) performed a systematic review of studies related to the effects of delayed auditory feedback on speech fluency in individuals who stutter.  Concepts of the Cochrane Handbook were followed: formulation of initial question (theme to be reviewed), location and selection of studies (PubMed database) and compatibilization among researchers (aiming to minimize possible citation losses).  The following were excluded: citations in languages other than English, citations that did not allow access to full text, repeated citations due to the overlap of keywords, studies developed exclusively with fluent individuals, case reports, reviews of the literature, letters to the editor, and texts that were not directly related to the theme.  Hence, texts that were related to treatment with delayed auditory feedback (DAF) and frequency-altered feedback (FAF) were analyzed.  Data were analyzed according to research indicators and according to study quality markers.  The results indicated that the use of altered auditory feedback devices for the reduction of stuttering events still do not have robust support for their applicability.  Methodological variability does not allow a consistent answer, or a trend about the effectiveness of the device, to be drawn.  The authors concluded that although the limitations in the studies prevent generalizations about the effectiveness of the device for the reduction of stuttering, these same limitations are important resources for future research planning.

Gallop and Runyan (2012) stated that the SpeechEasy has been found to be an effective device for reduction of stuttering frequency for many people who stutter (PWS); published studies typically have compared stuttering reduction at initial fitting of the device to results achieved up to 1 year later.  This study examined long-term effectiveness by examining whether effects of the SpeechEasy were maintained for longer periods, from 13 to 59 months.  Results indicated no significant change for 7 device users from post-fitting to the time of the study (t = -0.074, p = 0.943); however, findings varied greatly on a case-by-case basis.  Most notably, when stuttering frequency for 11 users and former users, prior to device fitting, was compared to current stuttering frequency while not wearing the device, the change over time was found to be statistically significant (t = 2.851, p = 0.017), suggesting a carry-over effect of the device.  There was no significant difference in stuttering frequency when users were wearing versus not wearing the device currently (t = 1.949, p = 0.92).  

Maruta et al (2014) noted that the pathophysiology of non-fluent variant of primary progressive aphasia (nfvPPA) remains poorly understood.  These researchers compared quantitatively speech parameters in patients with nfvPPA versus healthy older individuals under altered auditory feedback, which has been shown to modulate normal speech output.  Patients (n = 15) and healthy volunteers (n = 17) were recorded while reading aloud under delayed auditory feedback [DAF] with latency 0, 50 or 200 ms and under DAF at 200 ms plus 0.5 octave upward pitch shift.  Delayed auditory feedback in healthy older individuals was associated with reduced speech rate and emergence of speech sound errors, particularly at latency 200 ms.  Up to 1/3 of the healthy older group under DAF showed speech slowing and frequency of speech sound errors within the range of the nfvPPA cohort.  The authors concluded that these findings suggested that (in addition to any anterior, primary language output disorder) these key features of nfvPPA may reflect distorted speech input signal processing, as simulated by DAF.  They stated that DAF may constitute a novel candidate pathophysiological model of posterior dorsal cortical language pathway dysfunction in nfvPPA.

Speech and Language Therapy

Smith et al (2012) examined the evidence behind treatment options available to clinicians working with dysphagia and Parkinson's disease (PD) and drew conclusions regarding if compensatory or rehabilitative approaches are likely to provide the best outcomes for PD patients.  A critical literature review of compensatory and rehabilitative interventions for dysphagia in PD was undertaken.  Relevant studies were analyzed for their robustness and potential clinical applications.  General conclusions were drawn based on the evidence base identified in this review.  This review outlined the lack of evidence supporting both compensatory and rehabilitative methods of treating dysphagia in PD.  It directs clinicians and researchers towards areas that require further investigation.  The authors concluded that to-date, compensatory methods of treating dysphagia in PD have received more research attention than rehabilitative methods and yet neither approach has a strong evidence base.  They stated that this review argues that rehabilitative methods could possibly have greater potential to increase swallowing safety and improve quality of life in the long-term than compensatory methods alone.  However, at present there is a lack of research in this area.

In a Cochrane review, Herd and colleagues (2012a) compared the effectiveness of speech and language therapy (SLT) versus placebo or no intervention for speech and voice problems in patients with PD.  Relevant trials were identified by electronic searches of numerous literature databases including MEDLINE, EMBASE, and CINAHL, as well as hand-searching of relevant conference abstracts and examination of reference lists in identified studies and other reviews.  The literature search included trials published prior to April 11, 2011.  Only randomized controlled trials (RCT) of SLT versus placebo or no intervention were included.  A total of 3 RCTs (63 participants) were found comparing SLT with placebo for speech disorders in PD.  Data were available from 41 participants in 2 trials.  Vocal loudness for reading a passage increased by 6.3 dB (p = 0.0007) in 1 trial, and 11.0 dB (p = 0.0002) in another trial.  An increase was also seen in both of these trials for monologue speaking of 5.4 dB (p = 0.002) and 11.0 dB (p = 0.0002), respectively.  It is likely that these are clinically significant improvements.  After 6 months, patients from the first trial were still showing a statistically significant increase of 4.5 dB (p = 0.0007) for reading and 3.5 dB for monologue speaking.  Some measures of speech monotonicity and articulation were investigated; however, all these results were non-significant.  The authors concluded that although improvements in speech impairments were noted in these studies, due to the small number of patients examined, methodological flaws, and the possibility of publication bias, there is insufficient evidence to conclusively support or refute the effectiveness of SLT for speech problems in PD.  They stated that a large well-designed placebo-controlled RCT is needed to demonstrate SLT's effectiveness in PD.  The trial should conform to CONSORT guidelines.  Outcome measures with particular relevance to patients with PD should be chosen and patients followed for at least 6 months to determine the duration of any improvement.

In a Cochrane review, Herd et al (2012b) compared the efficacy and effectiveness of novel SLT techniques versus a standard SLT approach to treat Parkinsonian speech problems.  These investigators identified relevant, published prior to April 11, 2011, by electronic searches of numerous literature databases including CENTRAL, MEDLINE and CINAHL, as well as hand-searching relevant conference abstracts and examining reference lists in identified studies and other reviews.  Only RCTs of one type of speech and language therapy versus another were included.  Two review authors independently extracted data and resolved differences by discussion.  A total of 6 trials (159 patients) satisfied the inclusion criteria.  Data could not be analyzed from 1 trial due to changes in patient numbers and from a second because the data provided were not in a usable format.  All trials reported intelligibility measures but a statistically significant result was only reported for the diagnostic rhyme test used in the study of Lee Silverman Voice Treatment -LOUD (LSVT-LOUD) versus a modified version of this therapy (LSVT-ARTIC).  In this case a difference of 12.5 points (95 % confidence interval [CI]: -22.2 to -2.8; p = 0.01) between the mean changes in favor of the LSVT-LOUD group was reported for a speech sample overlaid with Babble noise; this difference was not reproduced for the 2 additional noise conditions under which the speech samples were assessed. LSVT-LOUD also outperformed LSVT-ARTIC and Respiration therapy (RT) in improving loudness, with a difference in reading a sample text of 5.0 dB (95 % CI: -8.3 to -1.7; p = 0.003) and 5.5 dB (95 % CI: 3.4 to 7.7; p < 0.00001) respectively, and a difference in monologue speech of 2.9 dB (95 % CI: 0.6 to 5.2; p = 0.01) versus RT.  The authors concluded that considering the small patient numbers in these trials, there is insufficient evidence to support or refute the efficacy of any form of SLT over another to treat speech problems in patients with PD.

In a RCT, Bowen et al (2012) evaluated the effectiveness of enhanced communication therapy in the first 4 months after stroke compared with an attention control (unstructured social contact).  A total of 170 adults (mean age of 70 years) randomized within 2 weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers were included in this study.  Interventions included enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants' needs for up to 4 months, with continuity from hospital to community.  Comparison was with similarly resourced social contact (without communication therapy) from employed visitors.  Primary outcome was blinded, functional communicative ability at 6 months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (un-blinded, 6 months): participants' perceptions on the Communication Outcomes After Stroke scale (COAST); carers' perceptions of participants from part of the Carer COAST; carers' well-being on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events.  Therapist and visitor contact both had good uptake from service users.  An average 22 contacts (intervention or control) over 13 weeks were accepted by users.  Impairment focused therapy was the approach most often used by the speech and language therapists.  Visitors most often provided general conversation.  In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure.  Both groups improved on the TOM activity subscale.  The estimated 6 months group difference was not statistically significant, with 0.25 (95 % CI: -0.19 to 0.69) points in favor of therapy.  Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference.  Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care.  There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95 % CI: 0.16 to 1.1)).  The authors concluded that communication therapy had no added benefit beyond that from everyday communication in the first 4 months after stroke.  They stated that future research should evaluate re-organized services that support functional communication practice early in the stroke pathway.

In a Cochrane review, Brady et al (2012) evaluated the effectiveness of SLT for aphasia following stroke.  These investigators searched the Cochrane Stroke Group Trials Register (last searched June 2011), MEDLINE (1966 to July 2011) and CINAHL (1982 to July 2011).  In an effort to identify further published, unpublished and ongoing trials, these researchers hand-searched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles and contacted academic institutions and other researchers.  There were no language restrictions.  Randomized controlled trials comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) with

1. no SLT;
2. social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions);and
3. another SLT intervention (which differed in duration, intensity, frequency, intervention methodology or theoretical approach). 

These investigators independently extracted the data and assessed the quality of included trials.  They also sought missing data from investigators.  These researchers included 39 RCTs (51 randomized comparisons) involving 2,518 participants in this review; 19 randomized comparisons (1,414 participants) compared SLT with no SLT where SLT resulted in significant benefits to patients' functional communication (standardized mean difference (SMD) 0.30, 95 % CI: 0.08 to 0.52, p = 0.008), receptive and expressive language; 7 randomized comparisons (432 participants) compared SLT with social support and stimulation but found no evidence of a difference in functional communication; 25 randomized comparisons (910 participants) compared 2 approaches to SLT.  There was no indication of a difference in functional communication.  Generally, the trials randomized small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes.  Suitable statistical data were unavailable for several measures.  The authors concluded that this review provided some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language.  However, some trials were poorly reported.  The potential benefits of intensive SLT over conventional SLT were confounded by a significantly higher dropout from intensive SLT.  More participants also withdrew from social support than SLT interventions.  They stated that there was insufficient evidence to draw any conclusion regarding the effectiveness of any one specific SLT approach over another.

Speech Therapy for Children with Early (Before 3 Years of Age) Acquired Dysarthria

In a Cochrane review, Pennington and colleagues (2016)

1. examined if any speech and language therapy intervention aimed at improving the speech of children with dysarthria is more effective in increasing children's speech intelligibility or communicative participation than no intervention at all , and
2. compared the effectiveness of individual types of speech language therapy in improving the speech intelligibility or communicative participation of children with dysarthria.

These investigators searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 , Issue 7 ), Medline, Embase, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to July 2015, hand-searched relevant journals published between 1980 and July 2015, and searched proceedings of relevant conferences between 1996 to 2015.  They placed no restrictions on the language or setting of the studies.  A previous version of this review considered studies published up to April 2009.  In this update, these investigators searched for studies published from April 2009 to July 2015.  They considered RCTs and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.  One author conducted searches of all databases, journals and conference reports.  All searches included a reliability check in which a second author independently checked a random sample comprising 15 % of all identified reports.  These researchers planned that 2 review authors would independently assess the quality and extract data from eligible studies.  No RCTs or group studies were identified.  The authors concluded that this review found no evidence from randomized trials of the effectiveness of speech and language therapy interventions to improve the speech of children with early acquired dysarthria.  They stated that rigorous, fully powered RCTs are needed to examine if the positive changes in children's speech observed in phase I and phase II studies are generalizable to the population of children with early acquired dysarthria served by speech and language therapy services.  They noted that research should examine change in children's speech production and intelligibility; and it must also investigate children's participation in social and educational activities, and their quality of life, as well as the cost and acceptability of interventions.

Management of Difficult-To-Treat Chronic Cough

Dąbrowska and colleagues (2018) state that the efficacy of management of chronic cough in adults is limited.  Speech therapy is one of the few therapeutic methods that appeared to be useful in patients with persistent chronic cough.  These researchers evaluated the efficacy of speech therapy in the management of patients with difficult-to-treat chronic cough.  Patients, who were diagnosed and managed due to difficult-to-treat chronic cough, were enrolled into the study.  Speech therapy was developed on the basis of the technique described by Vertigan.  The entire therapy consisted of 8 weekly sessions, each lasting 45 mins.  Before and after speech therapy, cough severity and its impact on the quality of life (QOL) was assessed by the visual analog scale (VAS) and Leicester Cough Questionnaire (LCQ).  Additionally, cough challenge test with capsaicin was performed.  A total of 18 women were enrolled into the study, 15 of them (83 %) attended all treatment sessions (median age of 66 years, median duration of cough 60 months).  There was a significant decrease in cough severity measured by VAS (46 versus 28 mm, p = 0.016) after completion of speech therapy.  A significant improvement in patients' QOL measured by LCQ (10.7 versus 14.6 points, p = 0.004) and an increase in the threshold of cough reflex measured by capsaicin challenge were also demonstrated.  The authors concluded that speech therapy resulted in a decrease in cough severity and improvement of QOL of women with refractory chronic cough.  They stated that these findings supported the use of speech therapy as add-on treatment in women with difficult-to-treat cough.  Moreover, they stated that these preliminary results need to be confirmed in a larger study. The authors stated that this study had several drawbacks.  First this study had a small sample size (n = 18).  Second, this study included only women, and this could be considered a selection bias that could have influenced the results.  These investigators noted that  this method certainly needs to be evaluated in men with difficult-to-treat cough.  Third, this study was a single-arm, observational study without control group or randomization, so the results could not be compared with other interventions and control patients.  Fourth, the effect of speech therapy was measured only once, just after the end of the intervention.  Thus, there is no evidence that these favorable results are long-term.  Finally, these researchers did not use cough monitors to assess the frequency of chronic cough.  There is no doubt that cough monitors are useful for objective measurement of cough frequency that significantly increase the reliability of studies on cough.  However, the authors have implied all other accessible tools to evaluate the impact of speech therapy on cough intensity.Furthermore, an UpToDate review on "Treatment of subacute and chronic cough in adults" (Weinberger and Silvestri, 2018) states that "Modalities such as speech therapy, breathing exercises, cough suppression techniques, and patient counseling have been tried in the management of chronic cough.  A systematic review reported that studies of such interventions showed improved cough severity and frequency, but few of them used validated cough measurement tools.  Thus, the robustness of these studies’ findings is limited".

Slinger and colleagues (2019) stated that cough both protects and clears the airway. Cough has 3 phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on QOL. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considered the evidence from RCTs evaluating the effectiveness of SLT in this context. In a Cochrane review, these investigators examined the effectiveness of SLT for treatment of individuals with UCC. They searched the Cochrane Airways Trials Register, CENTRAL, Medline, Embase, CINAHL, trials registries, and reference lists of included studies; the most recent search was February 8, 2019. These researchers included RCTs in which subjects had a diagnosis of UCC having undergone a full diagnostic work-up to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included SLT techniques for UCC. Two review authors independently screened the titles and abstracts of 94 records; 2 clinical trials, represented in 10 study reports, met the pre-defined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. They analyzed dichotomous data as odds ratios (ORs), and continuous data as MDs or geometric MDs. They used standard methods recommended by Cochrane. The primary outcomes were health-related QOL (HRQOL) and serious adverse events (SAEs). These researchers found 2 studies involving 162 adults that met the inclusion criteria. Neither of the 2 studies included children. The duration of treatment and length of sessions varied between studies from 4 sessions delivered weekly, to 4 sessions over 2 months. Similarly, length of sessions varied slightly from 1 60-min session and 3 45-min sessions to 4 30-min sessions. The control interventions were healthy lifestyle advice in both studies. One study contributed HRQOL data, using the Leicester Cough Questionnaire (LCQ), and these researchers judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to 4 weeks (MD 1.53, 95 % CI: 0.21 to 2.85; subjects = 71), revealing a statistically significant benefit for individuals receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week 4 and 3 months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach these investigators judged the quality of evidence for this outcome to be low. Data were also available for the pre-specified secondary outcomes. In each case data were provided by only 1 study, thus, there were no opportunities for aggregation; these researchers judged the quality of this evidence to be low for each outcome. A significant difference favoring therapy was demonstrated for: objective cough counts (ratio for mean coughs/hour on treatment was 59 % (95 % CI: 37 % to 95 %) relative to control; subjects = 71); symptom score (MD 9.80, 95 % CI: 4.50 to 15.10; subjects = 87); and clinical improvement as defined by trialists (OR 48.13, 95 % CI: 13.53 to 171.25; subjects = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on VAS of cough severity: -9.72, 95 % CI: -20.80 to 1.36; subjects = 71) and cough reflex sensitivity (capsaicin concentration to induce 5 coughs: 1.11 (95 % CI: 0.80 to 1.54; subjects = 49) times higher on treatment than on control). One study reported data on AEs, and there were no AEs reported in either the therapy or control arms of the study. The authors concluded that the paucity of data in this review highlighted the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, these researchers could include only 2 studies in the review. Furthermore, this review highlighted that end-points varied between published studies. The improvements in HRQOL (LCQ) and reduction in 24-hour cough frequency observed with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to 4 weeks only. These investigators stated that further studies are needed to validate these findings and to examine the effects of SLT interventions over time. They stated that it is clear that SLT interventions varied between studies; further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQOL. It is also important for future studies to report information on AEs. Because of the paucity of data, the authors could draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in UCC. This review identified the need for further high-quality research, with comparable end-points to inform robust conclusions.

Speech Therapy for the Treatment of Hypokinetic Dysarthria in Parkinson’s Disease

In a systematic review and meta-analysis, Munoz-Vigueras and colleagues (2021) examined the effect of speech and language therapy (SLT) on hypokinetic dysarthria (HD) in patients with Parkinson's disease (PD).  These researchers carried out a literature search of RCTs using PubMed, Web of Science, Science Direct and Cochrane database (last search October 2020).  Quality assessment and risk of bias were evaluated using the Downs and Black scale and the Cochrane tool.  Data were pooled and a meta-analysis was conducted for sound pressure levels, perceptual intelligibility and inflection of voice fundamental frequency.  They selected 15 high-to-moderate quality studies, which included 619 patients with PD.  After pooling the data, 7 studies, which compared different SLTs to no treatment, control groups and 3 of their variables, (sound pressure level, semitone standard deviation and perceptual intelligibility) were included in the analysis.  Results showed significant differences in favor of SLT for sound pressure level sustained phonation tasks (SMD = 1.79; 95 % CI: 0.86 to 2.72; p ⩽ 0.0001).  Significant results were also observed for sound pressure level and semitone standard deviation in reading tasks (SMD = 1.32; 95 % CI: 1.03 to 1.61; p ⩽ 0.0001).  Furthermore, sound pressure levels in monologue tasks showed similar results when SLT was compared to other treatments (SMD = 0.87; 95 % CI: 0.46 to 1.28; p ⩽ 0.0001).  The authors concluded that the findings of this meta-analysis suggested a beneficial effect of SLT for reducing hypokinetic dysarthria in patients with PD, improving perceptual intelligibility, sound pressure level and semitone standard deviation.  These preliminary findings need to be validated by well-designed studies.

An UpToDate review on “Hoarseness in adults” (Bruch and Kamani, 2021) states that “Approximately 70 to 90 % of patients with Parkinson disease exhibit laryngeal findings.  The voice is typically hypophonic with a soft breathy and monotone quality.  Resting vocal fold tremor occurs in about 55 % of patients.  The speech abnormalities associated with Parkinson disease are collectively termed hypokinetic dysarthria and are caused by 3 important underlying factors: aerodynamic deficits, inefficient vibratory function, and weak muscle activity”. 

International guidelines on speech language therapy in Parkinson disease (Kalf et al, 2011) recommended speech therapy for PD patients with hypokinetic dysarthria treatment if the voice quality – loudness, clarity and pitch – can be sufficiently stimulated; the patient has enough intrinsic motivation to practice intensively, based on the severity of the problem and the expectations of the communicative performance; the patient is (cognitively) able enough to learn a new technique; and the patient has enough energy to practice intensively.

Speech Therapy for Open Bite Associated with Atypical Swallowing

Cenzato and colleagues (2021) stated that the cause-effect relationship between anterior open bite and atypical swallowing, 2 frequently associated conditions, is currently not completely understood.  These conditions are often accompanied by speech disorders and represent a problem for both young patients and untreated adult patients.  Treatment of these complex cases may be orthodontic, logopedic therapy or both.  In a systematic review, these researchers compared the various types of treatment to determine their effectiveness in improving skeletal condition, normalization of muscle activity, as well as temporal stability.  This review was carried out following the Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) guidelines.  In order to find the most appropriate articles for inclusion, an electronic and manual search was carried out using PubMed and the Cochrane Library on May 23, 2021.  No language restrictions or time limits were applied.  Only human studies describing cases of patients in the developmental stage of dentition, i.e., deciduous dentition or mixed dentition with an anterior open bite related to a type of swallowing with tongue interposition between the arches, undergoing 3 different types of treatment (orthodontic only, myofunctional/logopedic only, combined) were included.  The authors concluded that the most effective treatment in cases of anterior open bite associated with atypical swallowing is a combination of the traditional orthodontic therapy and myofunctional therapy.  Moreover, these researchers stated that further studies are needed to devise an effective and universal logopedic protocol to be followed in these cases.

In an earlier evidence review of atypical swallowing (Maspero, et al., 2014) reached similar conclusions: "The biunique causal relation between atypical swallowing and malocclusion suggests a multidisciplinary therapeutic approach, orthodontic and myofunctional, to temporarily solve both problems. An early diagnosis and a prompt intervention have a significantly positive influence on the therapy outcome."

Speech Therapy for Post-Extubation Dysphonia after Hospitalization with COVID-19

In an observational, cohort study, Archer et al (2021) examined the outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia.  Subjects included all adult inpatients hospitalized with COVID-19 (n = 164) who were referred to speech and language therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020.  Interventions included SLT assessment, advice, and therapy for dysphonia and dysphagia.  Evidence of delirium, neurologic presentation, intubation, tracheostomy, as well as prone positioning history were collected, along with type of SLT provided and discharge outcomes.  Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain (GRBAS) scale for voice.  Patients (n = 164; 104 men) age of 56.8 ± 16.7 years were included.  Half (52.4 %) had a tracheostomy, 78.7 % had been intubated (mean of 15 ± 6.6 days), 13.4 % had new neurologic impairment, and 69.5 % were delirious.  Individualized compensatory strategies were trialed in all and direct exercises with 11 %.  Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (p < 0.0001).  On average, patients started some oral intake 2 days following initial SLT assessment (inter-quartile range [IQR], 0 to 8) and were eating and drinking normally on discharge; however, 29.3 % (n = 29) of those with dysphagia and 56.1 % (n = 37) of those with dysphonia remained impaired at hospital discharge.  A total of 70.9 % tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16 to 27).  Among the 164 patients, 37.3 % completed SLT input while inpatients, 23.5 % were transferred to another hospital, 17.1 % had voice, and 7.8 % required community follow-up for dysphagia.  The authors concluded that inpatients with COVID-19 presented with significant impairments of voice and swallowing, justifying responsive SLT.  Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations.  Patients typically improved with assessment that enabled treatment with individualized compensatory strategies.  Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.

The authors stated that this study had several drawbacks.  First, this study focused only on inpatients presenting to the hospital and, as the hospital Trust has a large critical care capacity, the sample was skewed toward the more severe end of the COVID-19 population.  However, given that only a small proportion had ongoing needs upon leaving the hospital despite being from this more severe sample, these findings were encouraging.  Second, only patients referred to SLT were included in this study; thus, prevalence data for the impairments described in the COVID-19 population as a whole was not represented.  It was possible that dysphonia or milder deficits could have been overlooked by patients and ward staff.  However, robust systems of screening and referral were in place, with high physical presence on the wards to facilitate referrals as needed; 25 % of patients were transferred to other inpatient facilities with ongoing SLT needs and 13 % died, leading to missing outcome data.  Following-up patients at other institutions was beyond the scope of this study; however, it was considered that the numbers on which outcome measures were obtained were reasonable to further understanding of patient trajectory.  Third, in the absence of readily available instrumental assessment, outcomes were based on clinical assessment rather than “criterion standard” examinations.  Furthermore, due to priorities dictated by the pandemic and the need for infection risk management, measurements were taken by the treating therapists, leading to a risk of observer bias.  However, validated measures were used to increase reliability and all therapists were highly trained and experienced in their use.  Fourth, the original objective was to collect the number and duration of prone positioning episodes. However, this level of detail was not consistently documented in the medical record, reflecting the rapid introduction of this treatment.  Similarly, grade of intubation was normally recorded very reliably, but intubations were frequently occurring on the medical wards or before patients were transferred to the Trust, so this information was not included.  A more challenging intubation could lead to increased effect on swallowing and voice, and this should be considered in future work.  Fifth, this study did not collect patient-related outcome measures, which would have been invaluable for determining individuals’ perceptions of their outcomes.  This was again due to the rapidly developing clinical context and enforced priorities among which the study was set up, and also the high incidence of delirium.  It was also beyond the scope of this study to capture longer-term outcomes and further work is needed, especially considering the high rate of intubation and any long-term effect this may have on the airway.

In a prospective, observational, multi-center study, Regan et al (2021) examined post-extubation dysphagia and dysphonia among adults intubated with COVID-19 and referred to SLT in acute hospitals across the Republic of Ireland (ROI) between March and June 2020.  These researchers also identified variables predictive of post-extubation oral intake status and dysphonia; and established SLT rehabilitation needs/services provided to this cohort.  This trial included a total of 100 adults with confirmed COVID-19 who were intubated across 11 acute hospital sites in ROI and who were referred to SLT services between March and June 2020.  Main outcome measures included oral intake status, level of diet modification and perceptual voice quality.  Based on initial SLT assessment, 90 % required altered oral intake and 59 % required tube feeding with 36 % not allowed oral intake.  Age (OR 1.064; 95 % CI: 1.018 to 1.112), prone positioning (OR 3.671; 95 % CI: 1.128 to 11.943) and pre-existing respiratory disease (OR 5.863; 95 % CI: 1.521 to 11.599) were predictors of oral intake status post-extubation.  Two-thirds (66 %) presented with dysphonia post-extubation.  Intubation injury (OR 10.471; 95 % CI: 1.060 to 103.466) and pre-existing respiratory disease (OR 24.196; 95 % CI: 1.609 to 363.78) were predictors of post-extubation voice quality; 37 % required dysphagia intervention post-extubation, whereas 20 % needed intervention for voice.  Dysphagia and dysphonia persisted in 27 % and 37 % cases, respectively, at hospital discharge.  The authors concluded that post-extubation dysphagia and dysphonia were prevalent among adults with COVID-19 across the ROI.  Predictors included iatrogenic factors and underlying respiratory disease.  These investigators stated that prompt dysphagia and dysphonia evaluation and management is needed to minimize clinical and QOL complications.

The authors stated that drawbacks to this study included missing data on oral health, delirium, grade of intubation and endotracheal tube size.  Missing data were especially difficult to access from intensive care records due to transmission risk.  Patient‐reported outcomes would have been beneficial but not feasible post‐extubation given how medically unwell this cohort were.  Validated scales to measure frailty and sarcopenia among adults intubated may have been useful, but again this was not feasible in the context of this study.  Fiberoptic endoscopic evaluation of swallowing (FEES) was not available in the intensive care unit (ICU) settings during the 1st wave of the pandemic due to international guidelines regarding transmission risk.  FEES provides physiological data on secretions, pharyngeal sensation and aspiration or residue.  While the validated outcomes used in this study were often used in dysphagia research, they are not direct measures of swallow function.  They instead capture the speech and language therapist's confidence in swallow function based on observed factors at the bedside including the acute status of the patient.  It could be argued that oral intake is a more meaningful outcome compared to physiological swallow measures from the patient perspective.  Nevertheless, endoscopic assessment of swallowing and intubation injury would be valuable to directly examine swallowing and to accurately examine the presence and nature of laryngeal injuries.  These researchers stated that post‐extubation dysphonia and dysphagia research is needed from future pandemic waves to establish the impact of evolving intensive care management and mutating virus variants on voice and swallowing outcomes.  They stated that post‐discharge time-points to capture longer-term voice and swallowing difficulties would guide multi-disciplinary service delivery in the community.

In a prospective, observational cohort study, Regan et al (2022) examined the presence, degree, predictors, and trajectory of dysphagia, dysphonia, and dysarthria among adults hospitalized with COVID-19 across the ROI during the 1st wave of the pandemic.  Adults with confirmed COVID-19 who were admitted into 14 participating acute hospitals across ROI and referred to SLT between March 1 and June 30, 2020 were recruited.  Outcomes obtained at initial SLT evaluation and at discharge were oral intake status (Functional Oral Intake Scale), perceptual voice quality (GRBAS), and global dysarthria rating (Dysarthria Severity Scale).  Data from 315 adults were analyzed.  At initial SLT assessment, 84 % required modified oral diets, and 31 % required tube feeding.  There were high rates of dysphonia (42 %) and dysarthria (23 %).  History of intubation (OR 19.959, 95 % CI: 6.272 to 63.513; p = 0.000), COVID-19 neurological manifestations (OR 3.592, 95 % CI: 1.733 to 7.445; p = 0.001), and age (OR 1.034; 95 % CI: 1.002 to 1.066; p = 0.036) were predictive of oral intake status.  History of intubation was predictive of voice quality (OR 4.250, 95 % CI: 1.838 to 9.827; p = 0.001) and COVID-19 neurological manifestations were predictive of dysarthria (OR 2.275; 95 % CI: 1.162 to 4.456; p = 0.017).  At discharge, there were significant improvements in oral intake (Z = -7.971; p = 0.000), voice quality (Z = -5.971; p = 0.000), and dysarthria severity (Z = -2.619; p = 0.009), although need for modified oral intake (59 %), dysphonia (23 %), and dysarthria (14 %) persisted.  The authors concluded that dysphagia, dysphonia, and dysarthria were widespread among adults hospitalized with COVID-19 and they persisted for many patients at discharge.  Prompt SLT evaluation and management are needed to minimize clinical and QOL complications both within the acute care setting and post‐discharge in the community.  Level of Evidence = III.

The authors stated that drawbacks of this study included lack of instrumental dysphagia and communication evaluations; FEES and stroboscopy were not available in the early stages of the pandemic due to concerns regarding transmission risk.  It could be argued that oral intake status is influenced by medical status.  Nevertheless, these investigators suggested that oral intake status may be a more meaningful swallowing outcome measure from the patient perspective.  Patient‐reported outcomes would have been beneficial but were not feasible given how medically unwell this cohort was.  Furthermore, data on swallowing and communication difficulties post‐discharge would inform outpatient service delivery.  Data collection from 2nd and 3rd wave is ongoing across the ROI to determine differences in clinical presentations across waves due to factors, including new variant and evolving multi-disciplinary management.

In a retrospective study, Shah et al (2022) examined the prevalence, characteristics, QOL assessments, and long-term effects of interventions for laryngeal dysfunction following recovery from COVID-19 infection.  This trial included a total of 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021.  Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included.  Patient demographics, co-morbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected.  Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI).  A total of 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation.  Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025).  Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients.  Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution.  VHI scores decreased for patients who reported symptom improvement; 7 (70 %) patients with LTS required more than 1 procedural intervention before symptom improvement.  Improvement across QOL indices was observed in patients with LTS.  The authors concluded that laryngeal dysfunction commonly presented and was persistent for months following recovery from COVID-19 in non-hospitalized and non-intubated patients.  These researchers stated that voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.  Moreover, these researchers stated that future studies are needed to continue examining speech and swallow disorders with larger cohort sizes and over extended timelines, with an emphasis on post-intervention outcomes and more objective assessments of these outcomes.

The authors stated that this trial had several drawbacks.  First, although a comprehensive chart review was carried out for all patients in this cohort, the dataset was limited by missing data for certain key points including QOL indices and clinician-reported voice evaluations, among others.  Second, even if fully represented among the datasets, the subjective nature of QOL surveys completed by patients may influence the reliability of these metrics in understanding patient symptom severity and improvement.  Third, while these researchers systematically identified patients through their institution's established longitudinal COVID clinic, their dataset was limited by its moderate sample size and retrospective nature, which were partly explained by the recency of the COVID-19 pandemic.  As a consequence, this trial was not powered to detect statistical differences in QOL scores, stroboscopy findings, and interventions between distinct laryngological diagnoses or through stratification by critical hospitalization-related features such as presence of intubation, tracheostomy, or prone positioning. 

Transcutaneous Electrical Nerve Stimulation in Speech Therapy Rehabilitation of Voice and Swallowing Function

da Silva and Mangilli (2021) stated that in recent years, several studies have been published comparing transcutaneous electrical nerve stimulation (TENS) and traditional speech therapy treatment of voice and swallowing functions; however, results have been conflicting.  In a systematic review, these investigators evaluated the methodological quality of studies and examined if TENS is an efficient therapeutic strategy for speech therapy treatment of healthy adults or those with dysphonia and/or dysphagia.  The databases used were Medline, Biblioteca Virtual em Saude (BVS), Cochrane Library and Web of Science (ISI Web of Knowledge).  The study was carried out between May 2018 and January 2019, in line with Cochrane Handbook guidelines, and included studies on the use of TENS in healthy adults or those with compromised voice and/or swallowing function.  After the search and extraction of studies, the following were identified: TENS + VOICE: 7 articles; TENS + SWALLOWING: 5 articles.  The studies exhibited medium quality and were heterogeneous, making it difficult to ascertain their effectiveness and the parameters to be used in future research.  There were no statistically significant differences between the use of TENS alone or associated with another therapeutic technique for voice.  For swallowing function, 1 study proved better results in cases of associated techniques - TENS + traditional therapy.  The authors concluded that researchers in the field of speech therapy should increase the number of studies published and improve their methodological quality, re-assessing methodological criteria.  Current clinical practice of using TENS in speech therapy rehabilitation of voice and swallowing function is not grounded in evidence-based science.  These investigators stated that the studies analyzed exhibited medium methodological quality; there were variations in the time, number and periodicity of the therapeutic sessions for TENS; there were no statistically significant differences between the use of TENS alone or associated with another therapeutic technique in voice; there were statistically significant differences between the use of TENS associated with traditional therapeutic in swallowing function.  These researchers stated that more studies are needed to determine standardized application methods and levels of effectiveness.

These investigators stated that although these findings were encouraging, many aspects still require further investigation.  The evidence presented is insufficient to establish TENS as an effective therapeutic approach for speech therapy in cases of voice and swallowing function rehabilitation/habilitation in patients without other associated disorders.  It was also not possible to identify technique application patterns, especially in cases of swallowing function.  The following were the most limiting factors regarding the level of evidence: the number of study participants; lack of information for randomization; lack of standardized tests for outcomes; and lack of stimulation parameters.

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Appendix

Documentation Requirements

Speech therapy should be provided in accordance with an ongoing, written plan of care.  The purpose of the written plan of care is to assist in determining medical necessity.  The following care plan documentation is required to justify the medical necessity of speech therapy:

1. The plan of care should include sufficient information to determine the medical necessity of treatment.  The plan of care should be specific to the diagnosis, presenting symptoms, and findings of the speech therapy evaluation.
2. The plan of care must be signed by the member's attending physician and speech therapist.
3. The plan of care should include: 
   
   
   1. The date of onset or exacerbation of the disorder/diagnosis;
   2. The speech therapy evaluation;
   3. Specific statements of long-term and short-term goals that are specific, quantifiable (measurable) and objective;
   4. A reasonable estimate of when the goals will be reached;
   5. The specific treatment techniques and/or exercises to be used in treatment; and
   6. The frequency and duration of treatment, which must be medically necessary and consistent with generally accepted standards of practice for speech therapy.

4. The plan of care should be ongoing (i.e., updated as the member's condition changes) and treatment should demonstrate reasonable expectation of improvement (as defined below):

   1. Speech therapy services are considered medically necessary only if there is a reasonable expectation that speech therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.
   2. The member should be re-evaluated regularly (i.e., monthly) and the results of these evaluations recorded in a standard format,
   3. There should be documentation of progress made toward the goals of speech therapy, and if needed, changes made in the treatment program as a result of the evaluations.
   4. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that speech therapy services are contributing to such improvement.

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References