Advertisement

Voice therapy for older adults during the COVID-19 pandemic in Brazil

Published:October 16, 2022DOI:https://doi.org/10.1016/j.jvoice.2022.10.007

      ABSTRACT

      Objective

      To characterize the clinical practice of Brazilian speech-language-hearing therapists regarding voice therapy for older adults during the COVID-19 pandemic.

      Methods

      Cross-sectional survey conducted remotely. Data were collected through a form shared online with approximately 1.500 speech-language-hearing therapists. The form included voice therapy practice with older adults during the COVID-19 pandemic. It was responded by 155 voice experts.

      Results

      Most respondents were females with over 21 years’ experience in vocal health care, working with both in-person therapy and teletherapy. Obtaining acoustic parameters and using therapy strategies for breathing and body training were the most reported changes in remote therapy during the pandemic. The main difficulties involved wearing masks in in-person therapy and assessing the voice in teletherapy. Patient adherence and goals reached were deemed positive by most participants. Associations were found between place and format of service; between patient adherence and goals reached; and between difficulties in teletherapy and use of complementary therapeutic resources.

      Conclusion

      The COVID-19 pandemic led Brazilian speech-language-hearing therapists to change their clinical practice with older adults in both remote and in-person therapy. The main changes involved wearing masks in in-person therapy and assessing the voice in teletherapy. Remote therapy proved to be a safe and effective possibility.

      Keywords

      Introduction

      The new coronavirus disease appeared in 2019, thus being named COVID-19. The World Health Organization (WHO) declared it a pandemic following the alarming increase in the number of cases and deaths in various countries

      World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march-2020, 2020. Acesso em 12 july 2020.

      . People of all age groups suffered from the disease, whose main clinical symptoms are fever, cough, and respiratory discomfort
      • Li Y
      • XIA L
      Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management.
      • Lu Q
      • Shi Y.
      Coronavirus disease (COVID-19) and neonate: What neonatologist need to know.

      Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet. Infectious diseases,2020; 20(11), e276–e288. https://doi.org/10.1016/S1473-3099(20)30651-4.

      • Tenforde MW
      • Billig RE
      • Lindsell CJ
      • Shapiro NI
      • Files DC
      • Gibbs KW
      • et al.
      Characteristics of Adult Outpatients and Inpatients with COVID-19 - 11 Academic Medical Centers, United States, March-May 2020.
      . In this context, older adults were considered a risk group because of their immunosenescence and susceptibility to inflammatory changes
      • Perrotta F
      • Corbi G
      • Mazzeo G
      • Boccia M
      • Aronne L
      • D'Agnano V
      • et al.
      COVID-19 and the elderly: insights into pathogenesis and clinical decision-making.
      • Vellas C
      • Delobel P
      • Souto Barreto P
      • Izopet J
      COVID-19, Virology and Geroscience: A Perspective.
      .
      The number of older adults in Brazil has been steadily growing, which points to the need for measures and actions to ensure active, effective, and healthy aging

      Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil e das unidades da federação. https://www.ibge.gov.br/apps/populacao/projecao/, 2019.Acessed at 27 sept 2019.

      . In speech-language-hearing (SLH) therapy, attention to patients in the field of voice stands out in two modalities – in-person therapy and speech-language teletherapy –, selected according to the patients’ profile, the therapist's experience in handling the modalities, access possibilities, and/or geographical distance between patient and therapist
      • Dimer NA
      • Canto-Soares N
      • Santos-Teixeira L
      • Goulart BNG.
      Pandemia da Covid-19 e implementação de telefonoaudiologia para pacientes em domicílio: relato de experiência.
      • Cantarella G
      • Barillari MR
      • Lechien JR
      • Pignataro L.
      The challenge of virtual voice therapy during the COVID-19 Pandemic.
      • Fong R
      • Tsai CF
      • Yiu OY.
      The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.
      .
      SLH therapy format choice has been changing since 2020, due to the new coronavirus (COVID-19) pandemic. This worldwide emergency changed both in-person therapy and teletherapy. In-person care requires personal protective equipment and reinforced hand and environmental hygiene to avoid virus dissemination. Exercises also had to be carefully chosen to prevent aerosols produced by the patients. During this period, activities were conducted individually rather than in groups to meet health recommendations, avoid crowds, and keep distance between people
      • Cantarella G
      • Barillari MR
      • Lechien JR
      • Pignataro L.
      The challenge of virtual voice therapy during the COVID-19 Pandemic.
      ,

      Conselho Federal de Fonoaudiologia. CFFA recomenda cuidados com a doença causada pelo novo coronavírus.https://www.fonoaudiologia.org.br/cffa/index.php/2020/03/cffa-recomenda-cuidados-com-a-doenca-causada-pelo-novo-coronavirus/, 2020. Acessed at 16 Aug 2020.

      Conselho Federal de Fonoaudiologia. Resolução CFFA n° 577, de 19 de junho de 2020. Dispõe sobre os atendimentos em domicílio ou instituição de longa permanência na vigência dos riscos de contágio pelo coronavírus (SARS-CoV-2). https://www.fonoaudiologia.org.br/resolucoes/resolucoes_html/CFFa_N_577_20.htm, 2020. Acessed at:16 Aug 2020.

      CDC. Centers for Disease Control and Prevention (CDC). Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, 2020. Acessed at 29 Aug 2020.

      .
      Some barriers are faced in speech-language teletherapy, which was conceived as an alternative to maintain therapy without physical contact. Particularly, professionals lack training to carry out this modality, as many of them are used to working with in-person patients and have no experience with online care. Also, professionals must cope with the lack of equipment for virtual care, as well as the patients’ refusal or resistance, often due to scarce technological resources and help from others to manage online care

      Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet. Infectious diseases,2020; 20(11), e276–e288. https://doi.org/10.1016/S1473-3099(20)30651-4.

      • Tenforde MW
      • Billig RE
      • Lindsell CJ
      • Shapiro NI
      • Files DC
      • Gibbs KW
      • et al.
      Characteristics of Adult Outpatients and Inpatients with COVID-19 - 11 Academic Medical Centers, United States, March-May 2020.
      .
      Given the above, the format of voice therapy used by SLH therapists in Brazil is going through changes, particularly during the COVID-19 pandemic – which affected healthcare management and even human life worldwide. Addressing older people as a risk group, it is necessary to know clinical experiences in the different modalities of voice therapy to ensure both safety and therapeutic effectiveness. Hence, the objective of this study was to characterize the clinical practice of Brazilian SLH therapists providing voice therapy to older adults during the COVID-19 pandemic.

      Materials and Methods

      This cross-sectional survey was approved by the Research Ethics Committee under no. 4.478.408.
      The authors initially surveyed the literature to develop the first version of a research form, which was judged and improved by SLH therapists. These judges were professors specialized in voice, with at least 3 years’ clinical and teaching experience. They were indicated by administrators of public and private institutions from various regions of Brazil. Only six of them agreed to assess the form.
      The form items were analyzed based on the following criteria: relevance, clarity, objectivity, and content. The specialists could make considerations and suggestions regarding the items whenever they deemed necessary. Judges gave each item a score from 1 to 4 points (1 = completely disagree, 2 = partially disagree, 3 = completely agree, and 4 = partially agree) to calculate the content validity index (CVI)
      • Jesus EMS
      • et al.
      Development and validation of a hospital pharmaceutical services assessment tool.
      – whose formula was the number of responses 3 and 4 divided by the total number of responses
      • Alexandre NMC
      • Coluci MZO.
      Content validity in the development and adaptation processes of measurement instruments.
      . If the result was equal to or above 70%, the item was approved; if it was below 70%, it was reformulated
      • Alpirez LA.
      Desenvolvimento e validação de um instrumento de avaliação do recém-nascido na primeira semana de saúde integral.
      . After the judgment, the final version was developed in Google Forms (Appendix) and made available with a link.
      Participants were selected according to a sample calculation based on the number of voice specialists registered at the Federal SLH Council – the agency that regulates and inspects the activities of SLH therapists in Brazil. By January 2021, there were 1,138 such therapists; it was established that 75% of them attended older adults during the pandemic in Brazil. Considering a 20% loss, 50% frequency, 10% margin of error, and 95% confidence interval, the minimum sample size was 138 subjects. However, the final research sample was 155 responses from SLH therapists who met the legibility criteria and accessed the link to Google Forms.
      To be eligible as respondents in this research, SLH therapists had to be experts in voice – i.e., those who had been given the title of voice specialist by the Federal SLH Council or had at least finished a specialization course on voice. They also had to inform their experience (at least 3 years) caring for older people, providing voice therapy to them in in-person therapy or teletherapy.
      The website of the Federal SLH Council was searched to obtain the name of the voice specialists registered in Brazil. They were contacted via social networks (Facebook, Instagram), telephone, message application (WhatsApp), and e-mail addresses available on the Internet.
      Besides searching for the names of voice specialists, this research was also publicized and shared in WhatsApp groups including SLH therapists specializing in voice. As the forms were sent to the specialists, they were invited to help by sharing and publicizing it to their fellow SLH therapists who met the preestablished criteria. The researcher also sent this instrument to undergraduate and postgraduate professors of voice in SLH Sciences programs in Brazil to reach SLH therapists specializing in voice; it was also sent to SLH therapists in nursing homes, SLH clinics, voice laboratories, the Brazilian SLH Society, SLH syndicates, Regional SLH Councils in Brazil, specialization courses on the voice or whose faculty included voice specialists, otorhinolaryngologists and otorhinolaryngology institutions. These last ones were also invited to share it with acquainted SLH therapists. The form was available from March 24, 2021, to June 18, 2021.

      Statistical analysis

      Individual responses were initially analyzed in Google Forms. This platform shows descriptive results in graphs and charts, with absolute (n) and relative (%) frequencies for the categorical variables.
      Besides the descriptive data, an inferential analysis was made associating categorical variables, using the chi-square independence test in R software, considering the 95% confidence interval. Some alternatives were not checked by the respondents; therefore, their frequency was zero and was not considered in the association analysis.
      The following variables were tested: the place of service and therapy format; time since graduation and therapy format; educational attainment and therapy format; patient adherence and therapy format; patient adherence and goals reached; speech-language teletherapy before the pandemic and frequency of teletherapy during the pandemic; difficulties in teletherapy and complementary therapeutic resources.

      Results

      A total of 264 responses were received from the SLH therapists who filled out the form. Of these, 155 gave voice therapy to older adults during the pandemic – 95 voice specialists registered in the Federal SLH Council and 60 SLH therapists with a postgraduate specialization in voice. Most respondents were women (57.1%), aged 41 to 50 years (20.1%), residents of the states of São Paulo and Rio de Janeiro (19.7%/8.3%), who had been working in SLH therapy for 21 or more years (31.5%), using both therapy formats for older adults (35.4%).
      The main general therapy data are described in Table 1. The places most used by SLH therapists were the home and private offices. Speech-language teletherapy was not a predominant practice before the pandemic, whereas its frequency increased among respondents during the pandemic. Biosafety measures were maintained in this period.
      Table 1Description of general voice therapy data given to older adults during the COVID-19 pandemic (n = 155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      General data
      Place of service
      Home19(51.4)18(64.3)38(41.8)55(60.4)
      Outpatient center5(13.5)1(3.6)26(28.6)10(11)
      Nursing home3(8.1)1(3.6)3(3.3)1(1.1)
      Private office25(67.6)6(21.4)62(68.1)56(61.5)
      Teaching clinic4(10.8)0(0)12(13.2)7(7.7)
      University or college health care center1(2.7)0(0)7(7.7)2(2)
      Others4(10.9)6(21.6)8(8.8)5(5.5)
      Freq. Teletherapy Pandemic
      Always0(0)18(64.3)0(0)18(19.8)
      Almost always0(0)8(28.6)0(0)27(29.7)
      Sometimes0(0)2(7.1)0(0)36(39.7)
      Rarely0(0)0(0)0(0)9(9.9)
      Never0(0)0(0)0(0)1(1.1)
      Teletherapy before pandemic
      Yes0(0)3(10.7)0(0)18(19.8)
      No0(0)25(89.3)0(0)73(80.2)
      Biosafety
      Washing hands before the session35(94.6)0(0)73(80.2)0(0)
      Washing hands after the session34(91.4)0(0)70(76.9)0(0)
      Washing hands after contact with secretions32(86.5)0(0)52(57.1)0(0)
      Mask35(94.6)0(0)82(90.1)0(0)
      Face shield27(73)0(0)64(70.3)0(0)
      Safety goggles12(32.4)0(0)30(33)0(0)
      Medical gloves34(91.4)0(0)65(71.4)0(0)
      Surgical gown19(51.4)0(0)31(34.1)0(0)
      White coat27(73)0(0)54(59.3)0(0)
      Medical cap18(48.6)0(0)37(40.7)0(0)
      Cleaning equipment with alcohol26(70.3)0(0)50(61.5)0(0)
      Acrylic shield barrier2(5.4)0(0)10(11)0(0)
      I continued using the same biosafety measures4(10.8)0(0)18(19.8)0(0)
      Legend: Freq. teletherapy pandemic = Frequency of speech-language teletherapy sessions during the pandemic; Teletherapy before pandemic = Whether had given speech-language teletherapy before the pandemic; Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Changes in therapy sessions, patient adherence, and goals reached are listed in Tables 2 to 7. The need for changing individual therapy and therapeutic strategies for the body and breathing stood out. The mask was pointed out as the main hindrance in in-person therapy, while voice assessment was the main barrier in speech-language teletherapy. Patient adherence and goals reached were reportedly positive for most respondents in either format.
      Table 2Description of changes in care regarding evaluative parameters, therapeutic strategies, and individual or group voice therapy for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Changes in care
      Evaluative parameters
      Self-assessment of voice1(2.7)1(3.6)4(4.4)10(11)
      APA1(2.7)2(7.1)4(4.4)16(17.6)
      Acoustic assessment4(10.8)15(53.6)15(16.5)36(39.6)
      MPT2(5.4)4(14.3)7(7.7)6(6.6)
      I continued using the same parameters31(83.8)11(39.3)71(78)50(54.9)
      Others0(0)0(0)2(2)2(2)
      Therapeutic strategies
      Body8(2.1)12(42.9)23(25.3)29(31.9)
      Speech/articulation11(29.7)8(28.6)27(29.7)18(19.8)
      Breathing16(43.2)8(28.6)40(44)25(27.5)
      Phonation exercises11(29.7)7(25)36(39.6)19(20.9)
      Prosody2(5.4)3(10.7)7(7.7)11(12.1)
      Resonance2(5.4)4(14.3)16(17.6)15(16.5)
      I continued using the same strategies14(37.8)12(42.9)40(44)46(50.5)
      Individual or group therapy
      Individual30(81.1)18(64.3)66(72.5)56(61.5)
      Group1(2.7)6(21.4)7(7.7)7(7.7)
      Individual care was not changed10(27)9(32.1)23(25.3)33(36.3)
      Group care was not changed0(0)0(0)0(0)3(3.3)
      Legend: APA = Auditory-perceptual assessment; MPT = maximum phonation time; Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Table 3Description of changes in care regarding voice therapy program or method for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Changes in care
      Voice program or method
      VTE0(0)0(0)0(0)0(0)
      VFE0(0)0(0)0(0)0(0)
      PhoRTE1(2.7)0(0)4(4.4)1(1.1)
      LSVT0(0)2(7.1)3(3.3)6(6.6)
      I continued using the same programs and methods during the pandemic32(86.5)23(82.1)77(84.6)77(84.6)
      I have never used these programs or methods4 (10.8)4 (14.3)7 (7.7)8 (8.8)
      Legend: VTE = Voice Therapy for the Elderly; VFE = Vocal Function Exercises; PhoRTE = Phonation Resistance Training Exercise; LSVT = Lee Silverman Voice Treatment; Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Table 4Description of changes in care regarding complementary resources in voice therapy for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Changes in care
      Complementary Therapeutic Resources
      Electrostimulation5(13.5)0(0)10(11)1(1.1)
      Flexible and/or hard tube6(16.2)5(17.9)16(17.9)13(14.3)
      Massager5(13.5)0(0)14(15.4)1(1.1)
      Incentive spirometer10(27)2(7.1)16(17.6)16(17.6)
      Shaker8(21.6)2(7.1)19(20.9)18(19.8)
      Power Breathe2(5.4)1(3.6)10(11)20(22)
      EMST-1502(5.4)0(0)11(12.1)16(17.6)
      I continued using the same therapeutic resources during the pandemic25(67.6)17(60.8)46(50.5)47(51.6)
      I have never used these resources0(0)2(7.1)0(0)4(4.4)
      Any instrument that made contagion easier was eliminated1(2.7)0(0)0(0)0(0)
      Other (laser)0(0)1(3.6)2(2.2)1(1.1)
      Other (I make adaptations)0(0)2(7.1)0(0)1(1.1)
      Other (nebulizer)0(0)0(0)2(2.2)0(0)
      Other (individual equipment)0(0)0(0)4(4.4)0(0)
      Other (I keep some distance during exercises)0(0)0(0)1(1.1)0(0)
      Other (acoustic analysis, voice recording, and articulation are impaired)0(0)0(0)0(0)1(1.1)
      Other (individual use)0(0)0(0)0(0)2(2.2)
      Other (laser therapy and cutaneous electrostimulation)0(0)0(0)0(0)1(1.1)
      Other (electrostimulation, tape, and laser)0(0)0(0)0(0)1(1.1)
      Legend: EMST-150 = Expiratory muscle strength trainer; Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Table 5Description of changes in care regarding the substitution of voice therapy exercises for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Changes in care
      Voice exercise substitution
      Patient's profile18(48.6)15(53.6)51(56)45(49.5)
      Difficulty understanding the exercise9(24.3)5(17.9)24(26.4)37(40.7)
      Difficulty doing the exercise10(27)12(42.9)29(31.9)43(47.3)
      Exercise done inadequately5(13.5)6(21.4)20(22)34(37.4)
      Not applicable9(24.3)6(21.4)22(24.2)22(24.2)
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Table 6Description of changes in care regarding in-person and remote voice therapy for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Changes in care
      In-person difficulties
      Wearing a mask and managing therapeutic resources27(73)0(0)61(67)0(0)
      Wearing a mask and doing the exercises20(54.1)0(0)61(67)0(0)
      Impossibility to remove the mask19(51.4)0(0)44(48.4)0(0)
      Small, closed environments5(13.5)0(0)14(15.4)0(0)
      Lack of AIIR2(5.4)0(0)9(9.9)0(0)
      Aerosol10(27)0(0)25(27.5)0(0)
      Distance13(35.1)0(0)31(34.1)0(0)
      I have no difficulties3(8.1)0(0)16(17.6)0(0)
      Others2(5.4)0(0)4(4.4)0(0)
      Teletherapy difficulties
      Change the degree of difficulty or resistance of the resource0(0)7(25)0(0)40(44)
      Voice assessment0(0)8(28.6)0(0)35(38.5)
      Voice recording0(0)12(42.9)0(0)67(73.9)
      Therapeutic dosage0(0)0(0)0(0)0(0)
      Therapeutic test0(0)1(3.6)0(0)28(30.8)
      Progress monitoring0(0)5(17.9)0(0)21(23.1)
      I have no difficulties0(0)1(3.6)0(0)1(1.1)
      Others0(0)4(16)0(0)2(2.2)
      Legend: AIIR = airborne infection isolation room; Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Table 7Description of patient adherence and goals reached in voice therapy for older adults during the COVID-19 pandemic (n=155)
      Format
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Patient adherence
      Yes32(86.5)28(100)83(91.2)83(91.2)
      No5(13.5)0(0)8(8.8)8(8.8)
      Goals reached
      Yes15(40.5)19(67.9)59(64.8)52(57.1)
      Partially22(59.5)9(32.1)32(35.2)38(41.8)
      No0(0)0(0)0(0)1(1.1)
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities.
      Association data are shown in Tables 8 to 14. Significant associations were found between the place of service and therapy format, between patient adherence and goals reached, and between difficulties in speech-language teletherapy and the use of complementary therapeutic resources, as shown in Tables 8, 12, and 14.
      Table 8Association between place of service and voice therapy format for older adults during the COVID-19 pandemic (n=155)
      FormatTotalp-value
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Place of service
      Home19(51.4)18(64.3)38(41.8)55(60.4)130
      Outpatient center5(13.5)1(3.6)26(28.6)10(11)420.0019*
      Nursing home3(8.1)1(3.6)3(3.3)1(1.1)8
      Private office25(67.6)6(21.4)62(68.1)56(61.5)149
      Teaching clinic4(10.8)0(0)12(13.2)7(7.7)23
      University or college health care center1(2.7)0(0)7(7.7)2(2.2)10
      Others4(10.8)6(21.6)8(8.8)5(5.5)23
      Total6132156136385
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities; * Chi-square test
      Table 9Association between time since graduation and voice therapy format for older adults during the COVID-19 pandemic (n=155)
      FormatTotalp-value
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Time since graduation
      3 to 6 years3(23.1)3(23.1)7(53.8)7(53.8)20
      7 to 10 years4(23.5)2(11.8)11(64.7)11(64.7)28
      11 to 20 years13(28.9)5(11.1)27(60)27(60)720.7329*
      21 or more years17(21.2)18(22.5)45(56.2)45(56.2)125
      Total37289090245
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities; * Chi-square test
      Table 10Association between educational attainment and voice therapy format for older adults during the COVID-19 pandemic (n=155)
      FormatTotalp-value
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Educational attainment
      Specialization22(28.9)14(18.4)40(52.6)40(52.6)116
      Master's degree11(24.4)6(13.3)28(62.2)28(62.2)730.1652*
      Doctoral degree2(6.7)8(26.7)20(66.7)20(66.7)50
      Postdoctoral degree2(50)0(0)2(50)2(50)6
      Total37289090245
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities; * Chi-square test
      Table 11Association between patient adherence and voice therapy format for older adults during the COVID-19 pandemic (n=155)
      FormatTotalp-value
      In-person

      N(%)
      Teletherapy

      N(%)
      Both (in person)

      N(%)
      Both (teletherapy)

      N(%)
      Patient adherence
      Yes32(14.3)28(12.5)82(36.6)82(36.6)224
      No5(23.8)0(0)8(38.1)8(38.1)210.2837*
      Total37289090245
      Legend: Both (in person) = Responses regarding in-person therapy from speech-language-hearing therapists who conducted both care modalities; Both (teletherapy) = Responses regarding speech-language teletherapy from speech-language-hearing therapists who conducted both care modalities; * Chi-square test
      Table 12Association between patient adherence and goals reached in voice therapy for older adults during the COVID-19 pandemic (n=155)
      Patient adherenceGoals reachedTotalp-value
      Yes

      N(%)
      Partially

      N(%)
      No

      N(%)
      Yes141(97.9)83(83)0(0)224
      No3(2.1)17(17)1(100)210.0000*
      Total1441001245
      * Chi-square test
      Table 13Association between speech-language teletherapy before the pandemic and frequency of speech-language teletherapy during the pandemic in voice therapy for older adults during the COVID-19 pandemic (n=155)
      Teletherapy before the pandemicFrequency of speech-language teletherapy sessions during the COVID-19 pandemicTotalp-value
      Always

      N(%)
      Almost always

      N(%)
      Sometimes

      N(%)
      Rarely

      N(%)
      Never

      N(%)
      Yes5(25)8(40)7(35)0(0)0(0)20
      No30(30.6)27(27.6)31(31.6)9(9.2)1(1)980.5341*
      Total35353891118
      *Chi-square test
      Table 14Association between difficulties in speech-language teletherapy and complementary voice therapy resources for older adults during the COVID-19 pandemic (n=155)
      Difficulties

      teletherapy
      ResourcesTotalp-value
      Elect

      N(%)
      Tube

      N(%)
      Mass

      N(%)
      Spirom

      N(%)
      Shaker

      N(%)
      EMST

      N(%)
      Power

      N(%)
      Other

      N(%)
      Change degree0(0)7(14)0(0)10(20)11(22)10(20)12(24)0(0)50
      Assessment0(0)14(31.8)1(2.3)8(18.2)8(18.2)5(11.4)7(15.9)1(2.3)440.0254*
      Recording2(2.9)13(18.6)0(0)14(20)12(17.1)1(15.7)14(20)4(5.7)60
      Dosage0(0)0(0)0(0)0(0)0(0)0(0)0(0)0(0)0
      Test0(0)4(12.9)0(0)6(19.4)7(22.6)6(19.4)7(22.6)1(3.2)31
      Monitoring1(4.8)4(19)0(0)4(19)4(19)3(14.3)3(14.3)2(9.5)21
      Others1(25)1(25)0(0)0(0)0(0)0(0)0(0)2(50)4
      Total44314242254310210
      Legenda: Difficulties teletherapy = Difficulties in speech-language teletherapy; Change degree = change degree of difficulty in resources; Assessment = Voice assessment; Recording = Voice recording; Dosage = Therapeutic dosage; Test = Therapeutic test; Monitoring = Progress monitoring; Elect = Electrostimulation; Tube = flexible tube; Mass = Massager; Spirom = incentive spirometer; EMST = Expiratory Muscle Strength Trainer; Power = Power Breathe; * Chi-square test

      Discussion

      The COVID-19 outbreak led humanity to change the therapeutic process in both in-person and speech-language teletherapy formats, including assistance to older adults, who belong to the risk group for worse coronavirus sequelae. During the pandemic, changes in both therapy formats have been recorded, particularly regarding the use of masks in in-person therapy and voice assessment in the remote modality.
      Females are strikingly present in the field of health, as pointed out in previous studies
      • Fong R
      • Tsai CF
      • Yiu OY.
      The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.

      Conselho Federal de Fonoaudiologia. CFFA recomenda cuidados com a doença causada pelo novo coronavírus.https://www.fonoaudiologia.org.br/cffa/index.php/2020/03/cffa-recomenda-cuidados-com-a-doenca-causada-pelo-novo-coronavirus/, 2020. Acessed at 16 Aug 2020.

      Conselho Federal de Fonoaudiologia. Resolução CFFA n° 577, de 19 de junho de 2020. Dispõe sobre os atendimentos em domicílio ou instituição de longa permanência na vigência dos riscos de contágio pelo coronavírus (SARS-CoV-2). https://www.fonoaudiologia.org.br/resolucoes/resolucoes_html/CFFa_N_577_20.htm, 2020. Acessed at:16 Aug 2020.

      CDC. Centers for Disease Control and Prevention (CDC). Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, 2020. Acessed at 29 Aug 2020.

      . The predominance of this public originates in the beginnings of undergraduate SLH Sciences programs in Brazil and may be related to the role of caregiving
      • Jesus EMS
      • et al.
      Development and validation of a hospital pharmaceutical services assessment tool.
      . Another characteristic of the respondents was their age and time in the profession – the surveyed public had greater life and professional experience.
      The states in the Southeast Region of Brazil predominated, possibly because of its greater territory and socioeconomic importance, attracting more SLH therapists
      • Rech
      • et al.
      Speech-language therapy offer and primary health care in Brazil: an analysis based on socioeconomic development.
      . Rio de Janeiro and São Paulo may also have more SLH therapists active in social networks, which were widely used to collect responses in this research.
      The therapy formats appeared in the following order: both formats, in-person therapy, and speech-language teletherapy. This result may be related to the pandemic situation experienced by Brazilian SLH therapists at the time the questionnaires were answered, between March and June 2021. At the beginning of 2020, since little was known about the virus and the case and mortality rates were high, health professionals substituted in-person with virtual therapy as a prevention measure
      • Alpirez LA.
      Desenvolvimento e validação de um instrumento de avaliação do recém-nascido na primeira semana de saúde integral.
      • Nguyen LH
      • et al.
      Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study.
      . Then, as case, hospitalization, and mortality rates decreased in some parts of Brazil, everyday activities were partially normalized, following the health authorities’ instructions
      • Ortiz Z
      • et al.
      Preocupaciones y demandas frente a COVID-19. Encuesta al personal de salud [Concerns and demands regarding COVID-19. Survey of health personnel].
      • Lai X
      • et al.
      Coronavirus Disease 2019 (COVID-2019) Infection Among Health Care Workers and Implications for Prevention Measures in a Tertiary Hospital in Wuhan, China.
      . This new situation indicates that, during the COVID-19 pandemic in Brazil, speech-language teletherapy prevailed in the first months of 2020, whereas by the end of the first semester of 2020 some professionals returned from virtual to in-person therapy. This created three realities
      • Paladine HL
      • et al.
      The role of rural communities in the recruitment and retention of women physicians.
      that remained in 2021, namely: maintaining some virtual therapies to ensure a small number of patients; returning to in-person therapy, following the known safety measures; and using a hybrid format – both virtual and in-person therapy.
      Private offices predominated among participating professionals as the place of in-person service, as it meets the requirements of clinical voice treatment
      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      • Thijs Z
      • Knickerbocker K
      • Watts CR.
      Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic.
      • Watts CR
      • Knickerbocker K.
      Characteristics of a Treatment-seeking Population in a Private Practice Community Voice Clinic: An Epidemiologic Study.
      • Awad R
      • Shamil E
      • Gibbins N
      • Aymat A
      • Harris S.
      From Voice Clinic to Operating Room: Are We Out of Tune?.
      . On the other hand, the home stood out as the setting for speech-language teletherapy, given the need to continue rehabilitation while following social distancing recommendations during the COVID-19 pandemic
      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      ,
      • Mattei A
      • et al.
      Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.
      • Caetano R
      • et al.
      Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian contexto.
      . Remote voice therapy for older adults was already increasing before the pandemic, especially for Parkinson's disease patients, applying the Lee Silverman method
      • Thijs Z
      • Knickerbocker K
      • Watts CR.
      Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic.
      • Watts CR
      • Knickerbocker K.
      Characteristics of a Treatment-seeking Population in a Private Practice Community Voice Clinic: An Epidemiologic Study.
      – although this situation was not significantly present in this research.
      Regarding the frequency of speech-language teletherapy during the pandemic, SLH therapists who adhered to virtual care sought to continue therapy in this format to follow up their patients’ progress.
      Health professionals already practiced biosafety measures involving personal protective equipment use
      • Awad R
      • Shamil E
      • Gibbins N
      • Aymat A
      • Harris S.
      From Voice Clinic to Operating Room: Are We Out of Tune?.
      before the outbreak of the new coronavirus. Hence, their use was reinforced by the pandemic. The most reported resources were masks (indispensable mouth and nose protection accessories for all citizens) and face shields (additional equipment during the pandemic to protect the eyes from contact with secretion)

      Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil e das unidades da federação. https://www.ibge.gov.br/apps/populacao/projecao/, 2019.Acessed at 27 sept 2019.

      . Two recurrent practices also stood out – firstly, 70% alcohol was used to disinfect equipment, therapeutic resources, and surfaces
      • Mattei A
      • et al.
      Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.
      . Secondly, hands were washed more rigorously after having contact with secretions or body fluids, to ensure it was clean from such direct contact
      • Mattei A
      • et al.
      Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.
      .
      As for evaluative parameters, these professionals may have started assessing with adapted resources – e.g., recording voices with the smartphone instead of using acoustic analysis software and visually analyzing body structure instead of using muscle palpation. However, some participants changed the evaluative process; in speech-language teletherapy, the resources used to obtain acoustic measures stood out, probably due to unfeasible remote assessment for the lack of a microphone and speech processor 31.
      Regarding strategies used in in-person care, SLH therapists asked patients to temporarily remove their masks to assess and work out respiration and phonation. In speech-language teletherapy, not all procedures (for instance, body assessment) could be carried out without physical contact.
      Moreover, attention is called to changes in breathing intervention in in-person therapy, probably because of aerosols produced by patients and their difficulties breathing while wearing the mask 11. Another modified strategy was the use of body methods since virtual care does not enable physical contact between therapists and patients
      • Fong R
      • Tsai CF
      • Yiu OY.
      The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.
      .
      Regarding individual and group activities, all professionals who used individual therapy kept a 1.8-meter distance from subjects
      • Alpirez LA.
      Desenvolvimento e validação de um instrumento de avaliação do recém-nascido na primeira semana de saúde integral.
      and wore personal protective equipment

      Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet. Infectious diseases,2020; 20(11), e276–e288. https://doi.org/10.1016/S1473-3099(20)30651-4.

      . The predominance of individual sessions in teletherapy was possibly due to the need for individual monitoring in the remote format.
      Most participants reported the patients’ profile as the main factor for changes in voice therapy exercises. This information reinforces the importance of therapeutic planning based on the patients’ needs in specific contexts
      • Sackley CM
      • et al.
      Lee Silverman Voice Treatment versus standard speech and language therapy versus control in Parkinson's disease: a pilot randomised controlled trial (PD COMM pilot).
      • Godoy JF
      • Silverio KCA
      • Andrade EC
      • Brasolotto AG.
      Intensive voice therapy for the elderly.
      .
      Most respondents did not indicate changes in the use of therapeutic resources, programs, or methods in either format. It is inferred that professionals tried to maintain the clinical practices and equipment they were previously using, while following the recommendations to avoid contamination. For instance, professionals could choose not to use breathing activities in specific methods and programs, though using other components in voice training.
      Even though it was necessary, wearing a mask hindered in-person therapeutic management
      • Cantarella G
      • Barillari MR
      • Lechien JR
      • Pignataro L.
      The challenge of virtual voice therapy during the COVID-19 Pandemic.
      ,
      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      . Some professionals even recommended temporarily removing it for assessment and rehabilitation – which is contrary to public health recommendations, posing a risk of infection by the new coronavirus.
      One of the difficulties presented in speech-language teletherapy was voice recording, in which there was no control over environmental noise
      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      ,
      • Maryn Y
      • Ysenbaert F
      • Zarowski A
      • Vanspauwen R.
      Mobile Communication Devices, Ambient Noise, and Acoustic Voice Measures.

      Schaeffler F, Jannetts S, Beck JM. Reliability of clinical voice parameters captured with smartphones – measurements of added noise and spectral tilt. In: Proceedings of the 20th Annual Conference of the International Speech Communication Association INTERSPEECH, Graz, Austria, 15-19 September 2019 . Proc. Interspeech 2019, 2523-2527, 10.21437/Interspeech.2019-2910.

      . Thus, a comprehensive voice assessment could not be made, as it was impossible to multidimensionally analyze the voice regarding body and acoustic aspects in this specific pandemic period
      • Fong R
      • Tsai CF
      • Yiu OY.
      The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.
      ,
      • Patterson JM
      • Govender R
      • Roe J
      • Clunie G
      • Murphy J
      • Brady G
      • Haines J
      • White A
      • Carding P.
      COVID-19 and ENT SLT services, workforce and research in the UK: A discussion paper.
      .
      Another relevant point in therapy was adherence. Despite the therapeutic adversities, patients were careful to follow the therapists’ recommendations to ensure greater satisfaction with their voice. Most volunteers reported reaching the goals of therapy, although in exclusively in-person therapy they were partially reached. This probably reflects previously mentioned difficulties in in-person care, which prevented such successful therapy.
      As for the relationship between study variables, the place of service was associated with the therapy format, probably because COVID-19 changed the work setting. Professionals sought the therapy modality that made it possible to continue the rehabilitation process
      • Dimer NA
      • Canto-Soares N
      • Santos-Teixeira L
      • Goulart BNG.
      Pandemia da Covid-19 e implementação de telefonoaudiologia para pacientes em domicílio: relato de experiência.
      • Cantarella G
      • Barillari MR
      • Lechien JR
      • Pignataro L.
      The challenge of virtual voice therapy during the COVID-19 Pandemic.
      ,

      Conselho Federal de Fonoaudiologia. Resolução CFFA n° 577, de 19 de junho de 2020. Dispõe sobre os atendimentos em domicílio ou instituição de longa permanência na vigência dos riscos de contágio pelo coronavírus (SARS-CoV-2). https://www.fonoaudiologia.org.br/resolucoes/resolucoes_html/CFFa_N_577_20.htm, 2020. Acessed at:16 Aug 2020.

      CDC. Centers for Disease Control and Prevention (CDC). Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, 2020. Acessed at 29 Aug 2020.

      ,

      Conselho Regional de Fonoaudiologia 2ª região. Crefono 2 conversa com fonoaudiólogas e infectologista sobre cuidados necessários em caso de retomada do atendimento presencial.https://www.fonosp.org.br/noticias/1560-crefono-2-conversa-com-fonoaudiologas-e-infectologista-sobre-cuidados-necessarios-em-caso-de-retomada-do-atendimento-presencial, 2020. Acessed at 14 july 2021

      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      .
      Patient adherence associated with goals reached may be related to the recommendations followed by the patients, leading them to perceive voice quality improvements 40. On the other hand, changes in the usability of therapeutic resources were also associated with difficulties in speech-language teletherapy. This result may be explained by the characteristic absence of physical contact in remote therapy
      • Fong R
      • Tsai CF
      • Yiu OY.
      The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.
      ,
      Conselho Federal de Fonoaudiologia. Resolução 580 de 20 de agosto de
      Dispõe sobre a regulamentação da telefonoaudiologia e dá outras providências.
      and the impossibility of assessing patients comprehensively in a virtual setting
      • Castillo-Allendes A
      • Contreras-Ruston F
      • Cantor-Cutiva LC
      • et al.
      Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
      ,
      • Patterson JM
      • Govender R
      • Roe J
      • Clunie G
      • Murphy J
      • Brady G
      • Haines J
      • White A
      • Carding P.
      COVID-19 and ENT SLT services, workforce and research in the UK: A discussion paper.
      .
      Limitations of the study particularly include the non-heterogeneous sample distribution, as SLH therapists were mostly from the Southeast Region of Brazil. There was also a risk of type I error in association analyses due to the multiple comparisons between variables with more than two categories. This restriction resulted from the type of survey used for data collection.
      Concerning future recommendations, further research on speech-language teletherapy should include all age groups to find how remote voice therapy is used in different life cycles. Moreover, since assessment is essential to voice rehabilitation, other studies should use assessment in teletherapy to find new ways to evaluate patients and thus potentialize this stage in the virtual mode and compare pre- and post-therapy data.
      This research shows that SLH therapists used the teletherapy format more often, according to the professionals’/patients’ preferences and the clinical case analysis. Thus, voice therapy for older adults may be indefinitely maintained. This practice was strengthened as a vestige of the world health context and will possibly lead professionals to broaden their therapy possibilities for older adults, maintaining positive therapy results.

      Conclusion

      SLH therapists predominantly provided voice therapy for older adults during the COVID-19 pandemic in Brazil in both formats. In in-person therapy, mask use hindered rehabilitation. In speech-language teletherapy, voice assessment difficulties stood out. Adherence to the therapy was reportedly positive in both formats, despite the adversities. Speech-language teletherapy may be a feasible and safe option, with older adults participating actively in the therapeutic process.

      Uncited References

      • Oliveira F.
      Por uma terapêutica fonoaudiológica: os efeitos do discurso medico e do discurso pedagógico na constituição do discurso fonoaudiológico. Rio Grande do Sul (Porto Alegre). Dissertação [Mestrado em Estudos da Linguagem].
      ,
      • Quinn R
      • Park S
      • Theodoros D
      • Hill AJ.
      Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study.
      ,
      • Griffin M
      • Bentley J
      • Shanks J
      • Wood C.
      The effectiveness of Lee Silverman Voice Treatment therapy issued interactively through an iPad device: A non-inferiority study.
      ,

      Conselho Federal de Fonoaudiologia. Manual de biossegurança. 2ª ed. https://www.fonoaudiologia.org.br/comunicacao/manual-de-biosseguranca/, 2020. Accessed at 02 July 2021.

      ,
      • White JT
      • Donahue EN.
      Patients' Perceptions of and Attitudes Toward Voice Therapy: A Pilot Study.

      ACKNOWLEDGMENT

      Gratitude is extended to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) for the grant provided – Finance Code 001 and to the Dean's Office for Master's Studies at the Federal University of Pernambuco (PROPG/UFPE) – Announcement PROPG no. 06/2022.

      References

      1. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march-2020, 2020. Acesso em 12 july 2020.

        • Li Y
        • XIA L
        Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management.
        AJR Am J Roentgenol. 2020; 214: 1280-1286https://doi.org/10.2214/AJR.20.22954
        • Lu Q
        • Shi Y.
        Coronavirus disease (COVID-19) and neonate: What neonatologist need to know.
        J Med Virology. 2020; 92: 564-567https://doi.org/10.1002/jmv.25740
      2. Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet. Infectious diseases,2020; 20(11), e276–e288. https://doi.org/10.1016/S1473-3099(20)30651-4.

        • Tenforde MW
        • Billig RE
        • Lindsell CJ
        • Shapiro NI
        • Files DC
        • Gibbs KW
        • et al.
        Characteristics of Adult Outpatients and Inpatients with COVID-19 - 11 Academic Medical Centers, United States, March-May 2020.
        MMWR. Morbidity and mortality weekly report. 2020; 69: 841-846https://doi.org/10.15585/mmwr.mm6926e3
        • Perrotta F
        • Corbi G
        • Mazzeo G
        • Boccia M
        • Aronne L
        • D'Agnano V
        • et al.
        COVID-19 and the elderly: insights into pathogenesis and clinical decision-making.
        Aging clinical and experimental research. 2020; 32: 1599-1608https://doi.org/10.1007/s40520-020-01631-y
        • Vellas C
        • Delobel P
        • Souto Barreto P
        • Izopet J
        COVID-19, Virology and Geroscience: A Perspective.
        The journal of nutrition, health & aging. 2020; 24: 685-691https://doi.org/10.1007/s12603-020-1416-2
      3. Instituto Brasileiro de Geografia e Estatística. Projeção da população do Brasil e das unidades da federação. https://www.ibge.gov.br/apps/populacao/projecao/, 2019.Acessed at 27 sept 2019.

        • World Health Organization
        Ageing and health.
        2018 (Acessed at 15 june 2019)
        • Dimer NA
        • Canto-Soares N
        • Santos-Teixeira L
        • Goulart BNG.
        Pandemia da Covid-19 e implementação de telefonoaudiologia para pacientes em domicílio: relato de experiência.
        CoDAS. 2020; 32e20200144
        • Cantarella G
        • Barillari MR
        • Lechien JR
        • Pignataro L.
        The challenge of virtual voice therapy during the COVID-19 Pandemic.
        J voice. 2020; https://doi.org/10.1016/j.jvoice.2020.06.015
        • Fong R
        • Tsai CF
        • Yiu OY.
        The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic.
        Telemed J E Health. 2021; 27 (Jan): 30-38https://doi.org/10.1089/tmj.2020.0223
      4. Conselho Federal de Fonoaudiologia. CFFA recomenda cuidados com a doença causada pelo novo coronavírus.https://www.fonoaudiologia.org.br/cffa/index.php/2020/03/cffa-recomenda-cuidados-com-a-doenca-causada-pelo-novo-coronavirus/, 2020. Acessed at 16 Aug 2020.

      5. Conselho Federal de Fonoaudiologia. Resolução CFFA n° 577, de 19 de junho de 2020. Dispõe sobre os atendimentos em domicílio ou instituição de longa permanência na vigência dos riscos de contágio pelo coronavírus (SARS-CoV-2). https://www.fonoaudiologia.org.br/resolucoes/resolucoes_html/CFFa_N_577_20.htm, 2020. Acessed at:16 Aug 2020.

      6. CDC. Centers for Disease Control and Prevention (CDC). Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, 2020. Acessed at 29 Aug 2020.

        • Jesus EMS
        • et al.
        Development and validation of a hospital pharmaceutical services assessment tool.
        Rev Bras Farm Hosp Serv Saude Sao Paulo. 2015; 6: 6-11
        • Alexandre NMC
        • Coluci MZO.
        Content validity in the development and adaptation processes of measurement instruments.
        Cienc Saude Coletiva. 2011; 16: 3061-3068https://doi.org/10.1590/S1413-81232011000800006
        • Alpirez LA.
        Desenvolvimento e validação de um instrumento de avaliação do recém-nascido na primeira semana de saúde integral.
        Amazonas. Dissertação (Mestrado em Enfermagem) –– Universidade Federal do Amazonas. 2014;
        • Nguyen LH
        • et al.
        Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study.
        Lancet Public Health. 2020 Sep; 5: e475-e483https://doi.org/10.1016/S2468-2667(20)30164-X
        • Ortiz Z
        • et al.
        Preocupaciones y demandas frente a COVID-19. Encuesta al personal de salud [Concerns and demands regarding COVID-19. Survey of health personnel].
        Medicina (B Aires). 2020; 80 (Suppl): 16-24
        • Lai X
        • et al.
        Coronavirus Disease 2019 (COVID-2019) Infection Among Health Care Workers and Implications for Prevention Measures in a Tertiary Hospital in Wuhan, China.
        JAMA Netw Open. 2020 May; 1 (5)e209666https://doi.org/10.1001/jamanetworkopen.2020.9666
        • Paladine HL
        • et al.
        The role of rural communities in the recruitment and retention of women physicians.
        Women Health. 2020 Jan; 60: 113-122https://doi.org/10.1080/03630242.2019.1607801
        • Oliveira F.
        Por uma terapêutica fonoaudiológica: os efeitos do discurso medico e do discurso pedagógico na constituição do discurso fonoaudiológico. Rio Grande do Sul (Porto Alegre). Dissertação [Mestrado em Estudos da Linguagem].
        Universidade Federal do Rio Grande do Sul, 2002
        • Rech
        • et al.
        Speech-language therapy offer and primary health care in Brazil: an analysis based on socioeconomic development.
        CoDAS. 2019; 31e20180083https://doi.org/10.1590/2317-1782/20182018083
      7. Conselho Regional de Fonoaudiologia 2ª região. Crefono 2 conversa com fonoaudiólogas e infectologista sobre cuidados necessários em caso de retomada do atendimento presencial.https://www.fonosp.org.br/noticias/1560-crefono-2-conversa-com-fonoaudiologas-e-infectologista-sobre-cuidados-necessarios-em-caso-de-retomada-do-atendimento-presencial, 2020. Acessed at 14 july 2021

        • Castillo-Allendes A
        • Contreras-Ruston F
        • Cantor-Cutiva LC
        • et al.
        Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice.
        J Voice. 2021 Aug; 35; : 717-727https://doi.org/10.1016/j.jvoice.2020.08.001
        • Thijs Z
        • Knickerbocker K
        • Watts CR.
        Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic.
        J Voice, 2020https://doi.org/10.1016/j.jvoice.2020.06.025 (In Press)
        • Watts CR
        • Knickerbocker K.
        Characteristics of a Treatment-seeking Population in a Private Practice Community Voice Clinic: An Epidemiologic Study.
        J Voice. 2019 Jul; 33: 429-434https://doi.org/10.1016/j.jvoice.2017.11.019
        • Awad R
        • Shamil E
        • Gibbins N
        • Aymat A
        • Harris S.
        From Voice Clinic to Operating Room: Are We Out of Tune?.
        J Voice. 2020 Jul; 34: 604-608https://doi.org/10.1016/j.jvoice.2018.12.016
        • Mattei A
        • et al.
        Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.
        Eur Ann Otorhinolaryngol Head Neck Dis. 2020 May; 137: 173-175https://doi.org/10.1016/j.anorl.2020.04.011
        • Caetano R
        • et al.
        Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian contexto.
        Cad. Saúde Pública. 2020; 36e00088920
        • Quinn R
        • Park S
        • Theodoros D
        • Hill AJ.
        Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study.
        Int J Speech Lang Pathol. 2019; 21: 385-394https://doi.org/10.1080/17549507.2018.1476918
        • Griffin M
        • Bentley J
        • Shanks J
        • Wood C.
        The effectiveness of Lee Silverman Voice Treatment therapy issued interactively through an iPad device: A non-inferiority study.
        J Telemed Telecare. 2018 Apr; 24: 209-215https://doi.org/10.1177/1357633X17691865
      8. Conselho Federal de Fonoaudiologia. Manual de biossegurança. 2ª ed. https://www.fonoaudiologia.org.br/comunicacao/manual-de-biosseguranca/, 2020. Accessed at 02 July 2021.

        • Patterson JM
        • Govender R
        • Roe J
        • Clunie G
        • Murphy J
        • Brady G
        • Haines J
        • White A
        • Carding P.
        COVID-19 and ENT SLT services, workforce and research in the UK: A discussion paper.
        Int J Lang Commun Disord. 2020 Sep; 55: 806-817https://doi.org/10.1111/1460-6984.12565
        • Sackley CM
        • et al.
        Lee Silverman Voice Treatment versus standard speech and language therapy versus control in Parkinson's disease: a pilot randomised controlled trial (PD COMM pilot).
        Pilot Feasibility Stud. 2018 Jan 10; 4: 30https://doi.org/10.1186/s40814-017-0222-z
        • Godoy JF
        • Silverio KCA
        • Andrade EC
        • Brasolotto AG.
        Intensive voice therapy for the elderly.
        Audiol Commun Res. 2020; 25: e2098
        • Maryn Y
        • Ysenbaert F
        • Zarowski A
        • Vanspauwen R.
        Mobile Communication Devices, Ambient Noise, and Acoustic Voice Measures.
        J Voice. 2017 Mar; 31 (248.e11-248.e23)https://doi.org/10.1016/j.jvoice.2016.07.023
      9. Schaeffler F, Jannetts S, Beck JM. Reliability of clinical voice parameters captured with smartphones – measurements of added noise and spectral tilt. In: Proceedings of the 20th Annual Conference of the International Speech Communication Association INTERSPEECH, Graz, Austria, 15-19 September 2019 . Proc. Interspeech 2019, 2523-2527, 10.21437/Interspeech.2019-2910.

        • White JT
        • Donahue EN.
        Patients' Perceptions of and Attitudes Toward Voice Therapy: A Pilot Study.
        J Voice. 2019 Nov; 33: 860-865https://doi.org/10.1016/j.jvoice.2018.05.004
        • Conselho Federal de Fonoaudiologia. Resolução 580 de 20 de agosto de
        Dispõe sobre a regulamentação da telefonoaudiologia e dá outras providências.
        Access on Sept 3. 2020; (2020)