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JCPSLP Volume 14, Number 3 2012 125
videoconferencing equipment (with standard single fixed
adjustable zoom camera) available to use and that similar
equipment is available at the regional setting.
With the answers to your initial questions largely positive,
you now seek the evidence for providing telerehabilitation.
You need evidence for two reasons. First, you need
evidence to justify this alternate mode of service delivery
to your line manager. Second, you are seeking information
from the literature to inform how best to deliver the service.
Developing an answerable
clinical question
You begin by using the PICO framework to develop your
clinical question (Sackett, Richardson, Rosenberg, &
Haynes, 1997). This involves considering the Patient or
Problem, the Intervention, any Comparison intervention,
and specific Outcomes you are seeking (Asking a good
Question PICO:
PICO.htm). Studies have found a trend for higher
percentages of relevant citations found when searching
using PICO formatted questions (Schardt, Adams, Owens,
Keitz, & Fontelo, 2007).
Patient or problem
Your actual specific “patient/problem” group is H&N
patients with dysphagia following chemoradiotherapy.
However, you are aware that telerehabilitation is a relatively
new area of service delivery for speech pathology and the
chances of finding data on this particular subset of patients
are remote. Hence you feel it is more beneficial to further
widen your “patient/problem” group to patients with
dysphagia to ensure you access all relevant literature, then
narrow this down further to the H&N clinical subgroup if
evidence is available.
Intervention
In this situation, you are not necessarily examining an
intervention but rather a model of care, hence your
“intervention” in this case is telerehabilitation. In this
emerging field of technology, many terms are used to
describe the provision of health services through a remote
manner. Although telerehabilitation is the specific term used
to deliver rehabilitation services via technology, not all
studies use this term. For instance in policy documents of
the American Speech Hearing Association (ASHA) the term
“telepractice” is the adopted terminology (Brown, 2011). As
such, it will be important to search all main terms used in
this field such as: telehealth, telemedicine, telepractice,
telecare, and telerehabilitation.
Comparison intervention
The comparison intervention is traditional face-to-face (FTF)
practice.
Outcomes
The standard for evaluating a tele-service is to ensure that
the quality of the services delivered via this modality are
comparable with those delivered via traditional FTF services
(American Speech-Language-Hearing Association, 2005).
Hence, the outcome you are seeking in your evidence
search is whether or not dysphagia services can be
delivered via telerehabilitation, and to standards comparable
to traditional clinical practice.
Clinical question
In light of the considerations above, your clinical question
for this scenario is “Can telerehabilitation be used to provide
management services for an individual with dysphagia
following chemoradiotherapy?”
Searching for the evidence
You don’t have access to database searches via your office
desktop so the hospital librarian assists you to run searches
through PubMed, CINAHL, PsychINFO, the Cochrane
library, and SpeechBITE TM. In your search terms you use *
to truncate terms, – e.g., swallow* (note: some databases
use $ instead of * to truncate words eg., swallow$) – to
indicate to the search engine to find words with those first
letter strings (e.g., swallow, swallows, swallowing). When
you try using tele* to cover all possible telehealth terms you
find over 600 hits with the majority not relevant due to
unrelated words, e.g., telephone. Hence you proceed using
all telehealth terms you know linked by or (NHMRC, 2000).
Your final search term looks like this: ( dysphagia OR
swallow*) AND (telecare OR telemedicine OR telehealth OR
telerehabilitation OR telepractice ). You limit you search to
English papers only.
Your searching provides the following results: PubMed
= 17, CINAHL = 9, PsychINFO = 4, Cochrane = 0, and
SpeechBITE TM = 0. After removing duplicates, erroneous
hits, and excluding papers determined as unsuitable, you
find you have a list of 13 possible papers. On return to
your office you run a final search in Google Scholar from
your work desktop using the advanced search builder. This
produces 589 hits. All 13 papers found in the databases
were located on the first few pages of Google Scholar
search, and a further 7 possible articles were located. A
further 10 pages (at 10 hits per page) were scanned. When
no further new scientific literature was identified the search
was terminated.
After reading the 20 publications you found, 7 were
subsequently excluded as they either (a) were general
discussion papers, (b) covered aspects of telehealth
practice other than speech pathology, (c) discussed
the use of technology for remote assessments for other
scientific purposes, not telerehabilitation, (d) did not involve
adult patients, or (e) neither the publication source nor
year of publication could be verified (Internet document).
This left 6 general review papers and 7 scientific papers.
Cross searching of the reference lists of these papers
revealed one further paper for consideration. As the review
papers were general discussions of the literature, were
not systematic reviews, and contained all articles you had
found, these were ultimately excluded, bringing your total
set of papers for review to 8. Of these, there were 3 papers
specifically related to studies using telehealth to assess
and manage H&N cancer populations. A further 5 papers
were specific to swallowing management via telehealth for
other clinical populations; however, only 3 of these were
relevant. The others related to the equipment (Perlman &
Witthawaskul, 2002) and then the application of remote
MBS assessments of swallowing (Malandraki, McCollough,
He, McWeeney, & Perlman, 2011). As performing
remote MBS is beyond the nature of the service you are
considering right now, these 2 papers were not included
in your review . Table 1 lists the 6 papers relevant to this
review.
Using the NHMRC matrix for evaluating a body of
evidence (NHMRC, 2009) you classify the body of evidence
in Table 1 in relation to your clinical question as follows:
Evidence base – good; Consistency – good; Clinical
impact – satisfactory; Generalisability – satisfactory; and
Applicability – good. Furthermore, your overall decision