JCPSLP vol 14 no 3 2012

Table 1. Key research articles identified Author (date) Nature of telerehabilitation consultation Clinical population

Evaluation

Outcome

Level of evidence*

IV

Concluded it was possible to determine the nature and extent of the swallowing and language problems despite the challenges Concluded utility for telehealth in the management of patient with H&N cancer is promising

Single case post CVA

Case discussion and review of problems and solutions faced during assessment Limited case discussion of management provided via telerehabilitation for 3 cases Levels of agreement between diagnostic decisions from simultaneous FTF and online assessments

Lalor et al. (2000)

Assessment of language and swallowing via satellite connection

IV

2 total laryngectomy and 1 chemoradiotherapy patients

Myers (2005)

Case descriptions (n = 3) of providing (a) speech and psychological support, (b) support and therapy for voice and swallowing issues, and (c) voice prosthesis management via videoconferencing Performed CSE using a customised videoconferencing forward; free standing zoom capable web camera, lapel microphone) and including modifications incorporated into the CSE protocol to assist online assessment Assessment of alaryngeal speech and swallowing via a system providing videoconferencing and additional capabilities (store and forward) system with additional capabilities (store and units providing real-time videoconferencing with additional capabilities (store and forward; additional free standing zoom capable webcameras) Performed CSE using the customised videoconferencing system with additional capabilities plus the CSE modifications as detailed in Sharma et al. (2011) Assessment of alaryngeal speech and swallowing using custom built telerehabilitation

III-2

High levels of agreement found between online and FTF decisions across all aspects of the clinical swallow assessment: general orientation, alertness, and posture; oromotor and laryngeal assessment; and decisions and recommendations Found acceptable levels of agreement between online and FTF ratings for oromotor, speech, and swallowing clinical decisions, but issues with limited vision from fixed webcameras. Clinicians reported reduced satisfaction. Patient satisfaction was high With new system modifications since the Ward et al. (2007) paper this study found acceptable levels of agreement between online and FTF ratings for oromotor, speech, swallowing, and stoma status. Clinicians and patients reported high satisfaction Clinically acceptable levels of agreement found between online and FTF decisions across: oral, oromotor, and laryngeal function; food and fluid trials; aspiration risk; and clinical management decisions

10 standardised patients portraying 2 each of normal, mild, moderate,

Sharma et al. (2011)

and severe dysphagia

III-2

20 laryngectomy patients

Compared diagnostic decisions from simultaneous

Ward et al. (2007)

FTF and online assessments of communication, swallowing, and stoma status

III-2

10 laryngectomy patients

Compared diagnostic decisions from simultaneous

Ward et al. (2009)

FTF and online assessments of communication, swallowing, and stoma status

III-2

Levels of agreement between diagnostic decisions from simultaneous FTF and online assessments

40 patients from inpatient and outpatient caseload

Ward et al. (2012)

Note: * NHMRC (2009); FTF = face-to-face; CSE = clinical swallow examination; CVA = cerebrovascular accident

from cancer care patients. Although it is an assessment paper not research evidence for rehabilitation, the ability to assess and detect aspiration risk when dealing with a patient remotely is a primary safety issue addressed by this paper. Your critique is detailed in Table 2. Clinical bottom line There is currently Level III-2 evidence to support the assessment of dysphagia and weak Level IV evidence for the provision of ongoing dysphagia rehabilitation via telerehabilitation. Hence there is some positive evidence to support the use of telerehabilitation for this client, though you acknowledge that this recommendation is only at NHMRC level “C” – meaning that this recommendation

regarding the Grade of Recommendation (NHMRC, 2009) is a “C” meaning “Body of evidence provides some support for recommendation but care should be taken in its application”, largely because there is evidence for assessment but only very weak evidence for rehabilitation. Equally, the evidence base is still small, with limited numbers and patient diversity to date. One of the primary concerns of your line manager is the relative safety of managing dysphagia via the telehealth modality, so you decide to critique in more detail the paper presenting the strongest evidence. The paper by Ward, Sharma, Burns, Theodoros, and Russell (2012) has the largest cohort studied; it includes patients with actual aspiration risk; and you note that 45% of the cohort came

126

JCPSLP Volume 14, Number 3 2012

Journal of Clinical Practice in Speech-Language Pathology