JCPSLP vol 14 no 3 2012

Table 2. Critically appraised article Article purpose

Establishing the validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation Ward, E. C., Sharma, S., Burns, C., Theodoros, D., & Russell, T. (2012). Validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia . doi: 10.1007/s00455-011-9390-9

Citation

Design Non-inferiority cohort study Level of evidence NHMRC Level III-2 (for diagnostic studies)* Quality of evidence Only 14% of the 47 items in the “Recommended reporting elements” of the extended Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist 1 were not reported (40% not applicable). Average non-reporting rates across 60 published cohort studies has been found to be 23.6% 1 Participants 40 participants with mild (28%), moderate (55%), moderate-severe (7%), and severe (10%) dysphagia from inpatient and outpatient caseload of a large metropolitan hospital. Aetiology: 55% acquired or progressive neurological conditions and 45% cancer care patients. Patients with greater than mild cognitive impairment were excluded. Experimental group Telerehabilitation assessment of a clinical swallow assessment. Assessments conducted simultaneously by an online clinician and a FTF clinician (located in the room with the participant). Specific system modifications and modifications to the clinical swallow exam were detailed. Results Levels of agreement between the diagnostic decisions made online and FTF reached clinically acceptable levels of agreement (criteria: 80% exact agreement and/or Kappa >0.6): agreement for the oral, oro-motor, and laryngeal function tasks ranged from 75%–100% (Kappa 0.36–1.0); ratings of food and fluid trials ranged from 79%–100% (Kappas 0.61–1.0); and parameters related to aspiration risk and clinical management had exact agreement ratings between 79% and 100% (Kappas 0.49–1.0). High clinician ratings for: overall satisfaction, ease of use, ability to competently assess the patient, ability to generate rapport, and audio and visual quality. When using the described purpose-built telerehabilitation system with the described modifications to the CSE and the use of an assistant at the patient end, there is comparable clinical accuracy between diagnostic decisions on the CSE made online and FTF in patients with normal to mild cognitive impairments. Further research is needed to assess accuracy using other types of technology to perform dysphagia assessments and the use of these systems with more clinically diverse patient populations. Clinical bottom line Performing a CSE via telerehabilitation can achieve comparable clinical decisions to those made in the FTF clinical environment for individuals with normal to mild cognitive impairment. Note: FTF = face-to-face; CSE = clinical swallow examination * Classification for diagnostic studies, NHMRC, 2009 1 Poorolajal, Cheraghi, Irani, & Rezaeian (2011) Summary

administer and evaluate a MBS assessment (Perlman & Witthawaskul, 2002; Malandraki et al., 2011), unfortunately the rural service to which the patient is returning does not have MBS facilities. Although you can commence treatment based on the instrumental study performed at the metropolitan hospital prior to your client being discharged home, it is acknowledged that it may be necessary in the future for the client to return to the metropolitan setting for further instrumental review. Patient perceptions of this mode of service In your readings you noted that studies report positive patient perceptions regarding receiving speech pathology services via telerehabilitation. This gives you further confidence to try this mode of service delivery. In particular, the positive patient satisfaction data reported by Ward et al. (2007) and Ward et al. (2009) for laryngectomy patients following a telerehabilitation assessment of their communication and swallowing has most relevance to your current client. You do acknowledge that this data was based on perceptions of a single assessment session only, so you plan to monitor your client’s perceptions and concerns closely over the course of the sessions. Conclusion Although there is only weak evidence for the use of telehealth for dysphagia rehabilitation, the overall results of the review, and the evidence supporting telehealth

“must be applied carefully to individual and organisational circumstances and should be interpreted with care” (NHMRC, 2009, p. 8). Technology concerns From your review you realise that although many elements, such as the appropriate connection bandwidth, and use of modified utensils and throat markers during dysphagia assessments (see Ward et al., 2012) can be easily implemented in your own sessions, most research has used more advanced technology systems than are available to you. In particular, you can see the limitation of not having components such as store-and-forward capabilities (Ward et al., 2007; Ward et al., 2009; Ward et al., 2012), which record the session and allow playback for later clinical decision-making, or free-standing cameras with lighting for better oral cavity visualisation. However, you reflect that you do have a speech pathologist in the room with the patient who is simultaneously assessing the patient and can assist with clarification and verification of any missed information. Managing remote instrumental swallowing assessment Your primary concern is the rehabilitation of safe swallowing for this client. While the evidence supports the use of telerehabilitation for conducting clinical swallowing assessments, for ongoing rehabilitation you will want access to instrumental assessment data. Although there is preliminary evidence to support the use of technology to

127

JCPSLP Volume 14, Number 3 2012

www.speechpathologyaustralia.org.au