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JCPSLP
Volume 14, Number 3 2012
Journal of Clinical Practice in Speech-Language Pathology
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
Table 1. Key research articles identified
Author
(date)
Nature of telerehabilitation
consultation
Clinical
population
Evaluation
Outcome
Level of
evidence*
Lalor et al.
(2000)
Assessment of language
and swallowing via satellite
connection
Single case post
CVA
Case discussion and
review of problems
and solutions faced
during assessment
Concluded it was possible to
determine the nature and extent
of the swallowing and language
problems despite the challenges
IV
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
2 total
laryngectomy and 1
chemoradiotherapy
patients
Limited case
discussion of
management
provided via
telerehabilitation for
3 cases
Concluded utility for telehealth in
the management of patient with
H&N cancer is promising
IV
Sharma et
al. (2011)
Performed CSE using a
customised videoconferencing
system with additional
capabilities (store and
forward; free standing zoom
capable web camera, lapel
microphone) and including
modifications incorporated
into the CSE protocol to assist
online assessment
10 standardised
patients portraying
2 each of normal,
mild, moderate,
and severe
dysphagia
Levels of agreement
between diagnostic
decisions from
simultaneous
FTF and online
assessments
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
III-2
Ward et al.
(2007)
Assessment of alaryngeal
speech and swallowing
via a system providing
videoconferencing and
additional capabilities (store
and forward)
20 laryngectomy
patients
Compared diagnostic
decisions from
simultaneous
FTF and online
assessments of
communication,
swallowing, and
stoma status
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
III-2
Ward et al.
(2009)
Assessment of alaryngeal
speech and swallowing using
custom built telerehabilitation
units providing real-time
videoconferencing with
additional capabilities (store
and forward; additional free
standing zoom capable
webcameras)
10 laryngectomy
patients
Compared diagnostic
decisions from
simultaneous
FTF and online
assessments of
communication,
swallowing, and
stoma status
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
III-2
Ward et al.
(2012)
Performed CSE using the
customised videoconferencing
system with additional
capabilities plus the CSE
modifications as detailed in
Sharma et al. (2011)
40 patients from
inpatient and
outpatient caseload
Levels of agreement
between diagnostic
decisions from
simultaneous
FTF and online
assessments
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
III-2
Note: * NHMRC (2009); FTF = face-to-face; CSE = clinical swallow examination; CVA = cerebrovascular accident