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Technology
124
JCPSLP
Volume 14, Number 3 2012
Journal of Clinical Practice in Speech-Language Pathology
Keywords
dysphagia
head and neck
cancer
telehealth
tele
rehabilitation
This article
has been
peer-
reviewed
Elizabeth C.
Ward (top) and
Clare Burns
What’s the evidence?
Use of telerehabilitation to provide specialist
dysphagia services
Elizabeth C. Ward and Clare Burns
In this edition of “What’s the evidence?” the
scenario explores the challenge of providing
specialist rehabilitation services for a rural
patient on their return home from a metro
politan centre following head and neck (H&N)
cancer management. Within Queensland, two
hospitals located in the capital city provide
the majority of the state-wide specialist care
services for patients with H&N cancers. Hence
many non-metropolitan patients are required
to travel significant distances to access these
specialist services during and post treatment.
As part of their role, the specialist clinicians
at the metropolitan centres provide outreach
and clinical support to non-metropolitan
clinicians who support the patients on their
return home. This scenario explores the
potential of using telerehabilitation as a
service delivery model for a patient located
outside the metropolitan centre. It also
highlights the use of telehealth to provide
mentoring and support for the local clinician.
Clinical scenario
Mr Jones (58) manages a large cattle property in western
Queensland. He presented to his general practitioner with a
4-month history of dysphagia, weight loss, and
odynophagia (pain on swallowing). He was subsequently
referred to the combined head and neck (H&N) clinic of a
large metropolitan hospital (1,400 km away) for specialist
services where he was diagnosed with a tumour of the left
pyriform fossa with nodal involvement (T2 N1 SCC) and
underwent chemoradiotherapy.
On completion of treatment Mr Jones continues to
experience moderate dysphagia. A modified barium
swallow (MBS) assessment establishes he is safe for
small amounts of puree diet and moderately thick fluids;
however, he requires nasogastric tube (NGT) feeds to meet
his hydration and nutritional requirements. Due to financial
difficulties and work commitments he is desperate to
go home and the team support this, providing adequate
speech pathology follow-up can be arranged. Mr Jones
requires intensive swallowing intervention to enable
transition to full oral intake and removal of the NGT. You are
aware that the speech pathologist working in Mr Jones’
local health service is a recent graduate who has no clinical
experience in managing patients with H&N cancer. You
contact her and she expresses concern with independent
management of this case and requests support. In your
role as the specialist clinician in the metropolitan cancer
service, you provide mentoring and clinical support to
colleagues within your cancer service district. Support is
typically provided via email and telephone. However, given
(a) the severity of Mr Jones’ dysphagia, and (b) the novice
clinician’s request for mentoring, you feel that more direct
assistance with his ongoing rehabilitation is needed. To
help address these issues, you consider the possibility
of a specialist consultation service via telerehabilitation to
provide some shared clinical sessions with this patient and
his local clinician on his return home.
Response to this scenario
Addressing the difficulties encountered by patients
accessing health care demands the adoption of different
modes of service delivery (Bashshur, 1997; Yellowlees &
Brooks, 1999). Telehealth, the delivery of health care
services using technology, is one mode of health care
service delivery that allows patients to access specialist
services by alleviating the barriers of distance, immobility,
travel time, and cost (Kuo, Delvecchio, Babayan, &
Preminger, 2001; Mun & Turner, 1999). Furthermore, it has
been suggested that this mode has the potential to help
clinicians optimise the timing, intensity, and sequencing of
therapy services to help facilitate patient outcomes (Winters
& Winters, 2004). This case scenario provides an
opportunity to explore telehealth/telerehabilitation services
and address questions including: “Is telerehabilitation
suitable for this patient?”, “Do I have access to technology
to provide the service?”, and then “What’s the evidence?”
Recent guidelines note that “the candidacy and
appropriateness for telerehabilitation should be determined
on a case by case basis with selections firmly based on
clinical judgement, client’s informed choice and professional
standards of care” (Brennan et al., 2011, p. 664). You
consider your patient and his situation, his pressing
need for ongoing swallowing rehabilitation, his age and
motivation, and the concerns of the remote new graduate
clinician and determine that there are multiple factors
favouring the use of telerehabilitation. You then consider
the issue of equipment availability. You are aware there is
general videoconferencing as well as specialist technology
available in your metropolitan hospital setting. You contact
the local coordinating service and establish that there is