VoiceEcological ValidityGeneralizationAcceptability

Brief VR voice therapy with clinician feedback elicited teaching-style prosody in pre-professional teachers - but also significantly increased reported vocal discomfort

Nudelman CJ, Bottalico P · 2026 · Journal of Voice · Quasi-experimental · n = 10 · Vocally healthy female undergraduate future teachers · DOI
Evidence certainty: Very low certainty
How this was rated

Single-session within-subjects pilot study with n=10 enrolled (9 analyzed due to one recording failure), all female undergraduate education students aged 18-19 from a single university (UIUC), all vocally healthy at baseline. **Fixed condition order** (control → teaching style → VR intervention) with no counterbalancing - the authors explicitly flag this as a potential order/practice/warm-up confound, and acknowledge differences in task duration across conditions (control was much shorter). All 10 participants were 'responders'. The authors explicitly state: 'statistical significance in this pilot study does not equate to clinical significance'. Multiple LMEs (13 total) were conducted without correction for multiple comparisons; the authors justify this on early-stage exploratory grounds. Relevant background: corresponding author Charles J. Nudelman is also the first author of the Nudelman, Niu, Hutz & Edwards (2026) scoping review of immersive VR in SLP already in this Evidence Hub. Funding source: Council of Academic Programs in Communication Sciences and Disorders (2024 PhD scholarship to CJN); Acoustical Society of America (2024 Raymond H. Stetson Scholarship in Phonetics and Speech Science to CJN); plus a Dr Edward Hashimoto gift supporting data collection. The paper was at Article-in-Press status at time of audit (published online; volume/issue/page not yet assigned).

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A single-session within-subjects pilot with 10 pre-professional teachers (9 analyzed). Both a teaching-style mock lesson and a clinician-controlled VR teaching intervention elicited teaching-style prosody vs a conversation control. CTT-style clinician feedback inside VR produced short-term modulations in SPL, fo, and Dt%. Critically, the VR condition also significantly increased self-reported vocal discomfort vs control (+20.5 VAS, p=.023) - a caveat that should travel with any clinical citation.

Clinical bottom line

A small single-session pilot study (n=10 enrolled, 9 analyzed, all female undergraduate education students) testing a brief VR teaching-and-voice intervention with Conversation Training Therapy-style clinician feedback. Both the teaching-style condition and the VR teaching intervention condition produced prosodic shifts consistent with teaching-style speech vs a conversational control. Clinician avatar feedback within VR produced short-term modulations in voice parameters (lower SPL, fo, Dt%; higher SPL_sd). BUT the VR condition itself significantly INCREASED self-reported vocal discomfort vs the control condition - a finding that should accompany any clinical interpretation. The authors are explicit: 'statistical significance in this pilot study does not equate to clinical significance' and 'These findings are preliminary'. Best understood as feasibility evidence for the VR + CTT delivery model and as hypothesis-generating signal for short-term phonatory modulation, NOT as evidence that VR voice therapy reduces voice-related disability or improves long-term outcomes.

Key findings

  • 10 participants enrolled, 9 analyzed (one recording failure); all female undergraduate education students ages 18-19 (M=18.5 SD=0.7), all vocally healthy at baseline (passed VHI-10, V-RQOL, VFI, stroboscopy, and pure-tone audiometry screens), from University of Illinois Urbana-Champaign College of Education
  • Fixed condition order (no counterbalancing): control (5 min conversational speech) → teaching style (20 min one-on-one mock lesson with research team member) → VR teaching intervention (20 min in VR with CTT-style clinician avatar feedback)
  • Across-condition findings vs control: SPL did NOT differ significantly. SPL_sd was higher in VR (+0.6 dB, p=.045). fo was higher in teaching-style condition (+9.7 Hz, p=.020) but NOT in VR (p=.120). fo_sd was higher in BOTH teaching-style (+8.4 Hz, p=.014) AND VR (+5.6 Hz, p=.007). Dt% was LOWER in VR (-5.5%, p<.001)
  • Within VR, clinician avatar feedback (raised hand triggered when SPL exceeded the participant's 85th-percentile baseline from the teaching-style condition; minimum 1 min between cues) produced significant short-term modulations: SPL -1.5 dB (p<.001), fo -5.6 Hz (p=.011), Dt% -4.7% (p=.001), SPL_sd +0.4 dB (p=.007). fo_sd showed no feedback effect
  • Self-reported vocal status (0-100 VAS) - teaching-style condition vs control: vocal effort +18 (p=.013), vocal fatigue +15 (p=.022), vocal discomfort +27.9 (p=.003). VR condition vs control: vocal effort +11.5 (NS, p=.095), vocal fatigue +4.2 (NS, p=.503), vocal DISCOMFORT +20.5 (p=.023)
  • Critical caveat NOT in current .md: the VR condition significantly INCREASED self-reported vocal discomfort vs control. Authors interpret this within the broader context of CTT-induced shifts but it should be flagged in any clinical citation
  • Modified Gatineau Presence Questionnaire (0-100): Presence M=75.0 (SD=24.6), Realistic M=65.5 (SD=29.1), Artificial M=46.0 (SD=31.3), Awareness of VR M=51.5 (SD=30.8), Voice Affected M=50.5 (SD=22.9). Comparable to Remacle et al. 2023's parallel measures with student teachers
  • Hardware/software: Meta Quest 2 VR headset running Ovation software; Sennheiser HD600 open-backed headphones; auralization in Reaper software simulating a classroom previously captured with a Head and Torso Simulator; NTi XL2 Sound Level Meter monitoring participant SPL in real time; Logi C270 HD webcam relaying SLM display to research team outside the Whisper Room; calibrated NTi Audio M2211 microphone for voice recording at 30 cm from participant; Tascam UH-7000 soundboard; Audacity 3.1.3 + Reaper recording; MATLAB R2023b + Praat 6.0.13 + R 4.2.0 for analysis; LMEs fitted by REML with participant random intercepts
  • Authors' explicit interpretive caveats: 'Statistical significance in this pilot study does not equate to clinical significance. Given the small sample and brief, single-session intervention, the magnitude of acoustic changes observed in the present results should not be assumed to translate to clinically meaningful vocal outcomes. Rather, these preliminary data provide an initial signal that warrants further examination in adequately powered studies designed to evaluate clinical impact.'

Background

Teachers are among the most common occupational voice users to develop voice disorders - approximately 57% of US teachers report voice problems, and 20-35% of pre-professional teachers already show voice-disorder symptoms before entering the workforce. Most voice-wellness programs are delivered in clinical settings that do not replicate the auditory and visual cues of a real classroom, which contributes to a long-standing carryover challenge in voice therapy. Nudelman and Bottalico set out to pilot a brief, preventative VR voice-therapy intervention with pre-professional teachers, combining elements of Conversation Training Therapy (CTT) with real-time clinician feedback delivered within an immersive VR classroom.

The intervention sits at the intersection of three prior strands: Remacle and colleagues’ demonstrations that VR classrooms can elicit teachers’ classroom-style voice characteristics (2021, 2023); the Gartner-Schmidt / Gillespie group’s development of CTT as a generalization-focused voice therapy (2016, 2019, 2021); and the broader motor-learning literature emphasizing contextual relevancy for skill transfer.

What the researchers did

Ten undergraduate education students from the UIUC College of Education were recruited via flyer and word-of-mouth. All passed voice screens (VHI-10, V-RQOL, VFI, stroboscopy) and a hearing screen (pure-tone audiometry 250-8000 Hz). All ten were female, ages 18-19 (M=18.5, SD=0.7). The experiment took place on a single day in a sound-attenuating double-walled Whisper Room (226 × 287 × 203 cm) at UIUC.

Three conditions in fixed order (no counterbalancing - the authors flag this as a limitation):

  1. Control condition (5 minutes): Participant seated one meter from a research-team member in the Whisper Room. Spoke about themselves and described a typical day. Designed to elicit conversational speech.

  2. Teaching-style condition (20 minutes): Same one-on-one seating arrangement. Participant taught a lesson to the research-team member as if in a real classroom. The participant’s vocal SPL was monitored via a calibrated NTi XL2 Sound Level Meter (1-second sampling). This was a clinical-style elicitation of teaching speech, NOT a full classroom simulation.

  3. VR teaching intervention condition (20 minutes): Participant in Meta Quest 2 headset running Ovation software, with Sennheiser HD600 open-backed headphones running Reaper auralization software (auralization captured from a real classroom using a Head and Torso Simulator). The participant’s view: a virtual classroom with multiple virtual student avatars. The clinician (Nudelman) controlled a virtual avatar in the scene; an NTi XL2 Sound Level Meter (live-streamed via Logi C270 HD webcam to a research-team member outside the Whisper Room) monitored the participant’s vocal SPL. When SPL exceeded the participant’s 85th-percentile baseline derived from the teaching-style condition, the monitoring researcher prompted the clinician avatar to raise its hand within the VR display, signaling the participant to bring awareness to voice production using CTT clear-speech cues. Minimum 1 minute between cues. Pre-intervention: stimulability trial for CTT clear-speech cues. The intervention itself was designed according to the Rehabilitation Treatment Specification System (RTSS) and reported per TIDieR checklist.

Outcome measures (post each condition):

Analysis. Linear mixed-effects (LME) models fitted by REML in R 4.2.0, with participant ID as random intercept. Within VR condition, presence-of-feedback was examined as a second fixed factor in separate LMEs. 30-second window post-each-feedback-event used as the analysis segment. Thirteen LMEs total. The authors explicitly did NOT apply multiple-comparison corrections, justifying this on early-stage pilot grounds.

What they found

Acceptability and presence. Modified GPQ ratings (0-100): Presence M=75.0 (SD=24.6), Realistic M=65.5 (SD=29.1), Artificial M=46.0 (SD=31.3), Awareness of VR M=51.5 (SD=30.8), Voice Affected M=50.5 (SD=22.9). These are descriptively comparable to Remacle et al. (2023)‘s parallel measures with student teachers, indicating broadly similar levels of immersion and realism.

Voice acoustic outcomes across conditions (vs control as reference). SPL did NOT differ significantly between any of the three conditions. SPL_sd was higher in VR (+0.6 dB, p=.045) - the authors interpret this as a more animated style, perceptually consistent with healthier voice patterns in occupational voice users. fo was higher in the teaching-style condition (+9.7 Hz, p=.020) but NOT in the VR condition (p=.120). fo_sd was higher in BOTH the teaching-style (+8.4 Hz, p=.014) AND VR (+5.6 Hz, p=.007) conditions - both elicited teaching-style prosody. Dt% was LOWER in VR (-5.5%, p<.001) than in the control condition; teaching-style did not differ from control on Dt%.

Voice acoustic outcomes within VR - feedback present vs absent. Following each clinician-avatar feedback episode (within the 30-second analysis window):

The authors interpret these as short-term modulations consistent with reduced vocal loading, and explicitly caution that the magnitudes are modest and may not generalize.

Self-reported vocal status (0-100 VAS). The teaching-style condition increased vocal effort (+18.0, p=.013), vocal fatigue (+15.4, p=.022), and vocal discomfort (+27.9, p=.003) vs control. The VR condition increased vocal discomfort (+20.5, p=.023) vs control, but did not significantly differ from control on vocal effort (+11.5, p=.095) or vocal fatigue (+4.2, p=.503). The vocal-discomfort increase in the VR condition is a finding that should accompany any clinical interpretation - VR was not ‘easier’ for participants than the control.

Why this matters

This pilot is one of the first studies to integrate Conversation Training Therapy-style clinician feedback with an immersive VR classroom for preventative voice work with pre-professional teachers. The acoustic findings - particularly the increased fo_sd in both teaching-style and VR conditions (indicating teaching-style prosody) and the short-term modulations in SPL, fo, and Dt% following clinician avatar feedback - support the feasibility of the delivery model and provide an initial signal that VR + CTT can produce measurable phonatory adjustments.

But three caveats are critical for clinical interpretation:

  1. The VR condition significantly INCREASED self-reported vocal discomfort vs control. This is not mentioned in the current Evidence Hub framing, which focuses on the positive acoustic findings. Any clinical citation should pair the acoustic shifts with the discomfort finding - participants did not experience VR as easier than the conversational baseline.

  2. The authors are explicit that statistical significance ≠ clinical significance. They write: ‘Statistical significance in this pilot study does not equate to clinical significance. Given the small sample and brief, single-session intervention, the magnitude of acoustic changes observed in the present results should not be assumed to translate to clinically meaningful vocal outcomes.’ This caveat should be carried forward when the study is cited.

  3. Fixed condition order, all-female sample, single university source, vocally healthy participants only. The 20-35% of pre-professional teachers who already have voice-disorder symptoms are not represented; the design cannot rule out order/practice/warm-up effects.

For Therapy withVR specifically: this study did NOT use, test, or evaluate Therapy withVR. The system was a Meta Quest 2 running Ovation software with custom auralization and a clinician-controlled avatar - different platform, different control model, different population focus. The paper is included in the Evidence Hub because it adds to the broader immersive-VR-for-voice evidence base and represents a methodologically interesting VR + CTT delivery model, not because it relates to Therapy withVR.

Limitations

The authors flag the following explicitly:

Implications for practice

For SLPs and voice-care clinicians considering VR-based delivery of preventative voice work with pre-professional teachers: this pilot provides feasibility evidence that a Conversation Training Therapy-style protocol can be delivered within an immersive VR classroom and that clinician avatar feedback within the VR can produce short-term modulations in SPL, fo, and Dt%. The pilot does NOT support claims of clinical effectiveness, durability of effect, or generalization to real classroom teaching. The increased self-reported vocal discomfort in the VR condition (vs control) is an important caveat - VR was not 'easier' for participants than the conversational baseline, and clinicians considering VR delivery should screen for tolerance and stagger doses accordingly. The authors recommend future trials with counterbalanced designs, longer follow-up, more representative samples (including male teachers and those with existing voice disorders), and interactive student avatars.

Implications for research

Future studies should counterbalance/randomize condition order, equalize task duration across conditions, include longer-term follow-up to assess persistence of vocal modulations, recruit a sample more representative of the broader pre-professional teacher population (including male participants and the substantial subset with existing voice disorders), and incorporate interactive student avatars to better approximate the vocal demands of a real classroom. The intervention combines CTT-style cueing + immersive VR; disentangling the contribution of each component would benefit from a dismantling design (CTT-without-VR vs VR-without-CTT vs both). The unexpected INCREASE in self-reported vocal discomfort in the VR condition - which the current pilot data cannot fully explain - warrants follow-up to determine whether this reflects novelty/cognitive-load effects (which may diminish with practice) or a more durable feature of immersive-VR voice work.

Editorial notes from withVR

Where this connects to Therapy withVR

The study above is independent research and does not endorse any product. The notes below are commentary from withVR on how the themes in this research relate to features of Therapy withVR. The research findings are not claims about Therapy withVR.

VR classroom environment for teacher voice work (editorial parallel only)

This study used a custom Meta Quest 2 + Ovation software setup with auralization captured from a real classroom via a Head and Torso Simulator. Therapy withVR provides VR classroom environments under clinician control within its own design space - the general concept (VR classroom for preventative voice work) is shared, but the specific platforms differ. Editorial parallel only - the studied tool is research software, not Therapy withVR.

Clinician avatar feedback during VR voice work (editorial parallel only)

The Nudelman & Bottalico study used a clinician avatar that raised its hand to signal participants to bring awareness to their voice production using Conversation Training Therapy-style clear-speech cues when SPL exceeded the participant's 85th-percentile baseline. Therapy withVR's clinician-controlled avatar features support analogous real-time clinician interventions within its own design. Editorial parallel only.

Auralization of real classroom acoustics

The study's auralization captured a real classroom's acoustic signature using a Head and Torso Simulator and reproduced it via Sennheiser HD600 open-backed headphones running Reaper software during the VR condition - a level of acoustic realism (room reverberation, background noise floor) that is not standard in most VR voice studies. Therapy withVR uses environmental sounds within its design; the Nudelman & Bottalico acoustic-realism approach is editorial reference for the importance of room-acoustic fidelity in voice-VR work.

Learn more in the Therapy withVR documentation.

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Cite this study

If you reference this study in your work, the canonical citation formats are:

APA 7th
Nudelman, C. J., & Bottalico, P. (2026). Effects of a Virtual Reality Teaching Intervention on Voice Production in Pre Professional Teachers: A Pilot Study. Journal of Voice. https://doi.org/10.1016/j.jvoice.2026.03.007.
AMA 11th
Nudelman CJ, Bottalico P. Effects of a Virtual Reality Teaching Intervention on Voice Production in Pre Professional Teachers: A Pilot Study. Journal of Voice. 2026. doi:10.1016/j.jvoice.2026.03.007.
BibTeX
@article{nudelman2026,
  author = {Nudelman, C. J. and Bottalico, P.},
  title = {Effects of a Virtual Reality Teaching Intervention on Voice Production in Pre Professional Teachers: A Pilot Study},
  journal = {Journal of Voice},
  year = {2026},
  doi = {10.1016/j.jvoice.2026.03.007},
  url = {https://withvr.app/evidence/studies/nudelman-2026}
}
RIS
TY  - JOUR
AU  - Nudelman, C. J.
AU  - Bottalico, P.
TI  - Effects of a Virtual Reality Teaching Intervention on Voice Production in Pre Professional Teachers: A Pilot Study
JO  - Journal of Voice
PY  - 2026
DO  - 10.1016/j.jvoice.2026.03.007
UR  - https://withvr.app/evidence/studies/nudelman-2026
ER  -

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Funding & independence

From the paper's Declaration of Competing Interest: 'Charles J. Nudelman reports financial support was provided by Council of Academic Programs in Communication Sciences and Disorders. Charles J. Nudelman reports financial support was provided by Acoustical Society of America. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.' Specifically: '2024 Ph.D. scholarship from The Council of Academic Programs in Communication Sciences and Disorders (CAPCSD)' awarded to CJN, and '2024 Raymond H. Stetson Scholarship in Phonetics and Speech Science from the Acoustical Society of America (ASA)' awarded to CJN. Acknowledgements thank 'Dr. Edward Hashimoto for his generous gift that supported data collection' and Drs. Daniel Fogerty, Brian Monson, Mary Flaherty, and Eric Hunter for feedback, plus six research assistants (Asritha Tunuguntla, Naomi Ha, Isabella Rogala, Kaliyah House-Henry, Bella Lopez, Ricardo Perez-Gurrero). **Relevant background relationship:** corresponding author Charles J. Nudelman is also the first author of the Nudelman, Niu, Hutz & Edwards (2026) AJSLP scoping review of immersive VR in speech-language pathology already in this Evidence Hub. Author affiliations: Charles J. Nudelman (Department of Communication Sciences and Disorders, Syracuse University, Syracuse, NY); Pasquale Bottalico (Department of Speech and Hearing Science, University of Illinois Urbana-Champaign, Urbana, IL). Study approved by UIUC IRB (#23336). Data available at https://osf.io/98rqy/. The VR system used was a Meta Quest 2 running Ovation software + Sennheiser HD600 headphones + Reaper auralization software - **this is NOT Therapy withVR.** No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published paper (Article-in-Press status at time of audit, accepted March 10 2026).

Last reviewed: 2026-05-12 Next review due: 2027-05-12 Reviewed by: Gareth Walkom