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JCPSLP Volume 14, Number 3 2012 127
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
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
Citation 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
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) checklist1 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.
Summary 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)