Clare L. Burns

Assessing Swallowing Disorders Online: A Pilot Telerehabilitation Study

OBJECTIVE Dysphagia (a swallowing disorder) is known to occur in numerous clinical populations, but unfortunately because of issues accessing speech pathology services, not all patients are able to receive dysphagia intervention and rehabilitation services in a timely manner. Existing research supports the use of telehealth technology for providing various aspects of speech pathology service; however, to date there is limited evidence to support the utilization of telerehabilitation in the assessment and management of dysphagia. The aim of this research was to provide pilot information on the basic feasibility and validity of conducting dysphagia assessments via telerehabilitation. MATERIALS AND METHODS Ten simulated patients, actors portraying patients with a range of swallowing difficulties, were used rather than actual patients to minimize any potential patient risk from unidentified aspiration. Dysphagia was assessed simultaneously by a face-to-face (FTF) and telerehabilitation speech pathologist (T-SP). Each simulated patient was assessed using a Clinical Swallowing Examination (CSE) protocol that was modified to suit a telerehabilitation environment. The CSE was administered with the support of an assistant via an Internet-based videoconferencing telerehabilitation system using a bandwidth of 128 kilobits per second. RESULTS Results revealed high to excellent levels of agreement between the T-SP and the FTF-SP across all parameters of the CSE. Agreement for aspiration risk was excellent. CONCLUSION The pilot data indicate that the current model of administering a CSE via telerehabilitation has potential to be a feasible and valid method for the remote assessment of swallowing disorders.

Assessing dysphagia via telerehabilitation: Patient perceptions and satisfaction

Abstract To gain insight into factors which may influence future acceptance of dysphagia management via telerehabilitation, patients’ perceptions were examined before and after a telerehabilitation assessment session. Forty adult patients with dysphagia (M =66 years, SD =16.25) completed pre- and post-session questionnaires which consisted of 14 matched questions worded to suit pre- and post-conditions. Questions explored comfort with the use of telerehabilitation, satisfaction with audio and video quality, benefits of telerehabilitation assessments and patients’ preferred assessment modality. Questions were rated on a 5-point scale (1 = strongly disagree, 3 = unsure, 5 = strongly agree). Patients’ comfort with assessment via telerehabilitation was high in over 80% of the group both pre- and post-assessment. Pre-assessment, patients were unsure what to expect with the auditory and visual aspects of the videoconference, however there were significant positive changes reported post-experience. In relation to perceived benefits of telerehabilitation services in general, most patients believed in the value of telerehabilitation and post-assessment this increased to 90–100% agreement. Although 92% felt they would be comfortable receiving services via telerehabilitation, 45% of patients indicated ultimate preference for a traditional face-to-face assessment. The data highlight that patients are interested in and willing to receive services via telerehabilitation; however, any concerns should be addressed pre-assessment.

Impact of Dysphagia Severity on Clinical Decision Making via Telerehabilitation

OBJECTIVE Recent research supports the proposal that valid and reliable clinical swallow examinations (CSEs) can be conducted via telerehabilitation. However, no studies have explored whether dysphagia severity has an impact on the success of the session or its outcomes. The current study examined how dysphagia severity impacted on either (a) clinical decision making for safety of oral intake or (b) clinician perceptions of CSEs conducted via telerehabilitation. SUBJECTS AND METHODS One hundred patients (25 nondysphagics and 25 mild, 25 moderate, and 25 severe dysphagics) were assessed using a telehealth system and methodology reported in prior research. For each assessment, the online and face-to-face (FTF) clinicians simultaneously completed a structured CSE. On session completion, the online clinician indicated level of agreement with two statements regarding the level of rapport and ability to competently assess the patient. RESULTS In each of the four groups, acceptable levels of agreement were observed between raters for the three primary outcomes (decisions regarding oral/nonoral intake and safe food and fluids) as well as over 90% of the CSE items. Clinicians agreed they could develop good rapport with the majority of patients in all groups. However, for a small but significant (p<0.5) proportion of patents in the severe dysphagic group, clinicians disagreed they were able to satisfactorily and competently assess to the best of their abilities using the telerehabilitation system. CONCLUSIONS Clinical decisions made during and as an outcome of the total CSE were found to be comparable to those made in the FTF environment regardless of dysphagia severity. Clinicians noted some difficulty assessing patients with greater complexity, which occurred in greater numbers in the group with severe dysphagia.

A pilot trial of a speech pathology telehealth service for head and neck cancer patients

Summary We explored the feasibility of providing access to specialist speech pathology services via telehealth for patients with head and neck cancer. A weekly telehealth clinic was conducted between the speech pathology departments of a tertiary hospital and a regional hospital in Queensland. Over a 5-month period, 50 telehealth sessions were conducted for 18 patients. There were 38 patient consultations, nine case discussions between clinicians and three clinical training sessions relating to the skills needed for specific client management (e.g. voice prosthesis selection). Eight sessions had multidisciplinary involvement. All cases were successfully managed via telehealth. All patients agreed that they were comfortable using telehealth and would be happy to use it again in future. Both clinicians agreed that they could competently assess patients using the telehealth system. There appeared to be financial benefits for the patient, because by receiving specialist intervention at a local facility their travel expenses were lower. There was also the opportunity for workforce training and development through online case discussion and clinical consultation.

Patterns of dysphagia and acute toxicities in patients with head and neck cancer undergoing helical IMRT±concurrent chemotherapy.

BACKGROUND There is limited prospective data reporting the extent of treatment related toxicities associated with helical Intensity Modulated Radiotherapy (H-IMRT) for head and neck cancer (HNC). The study aim was to investigate severity, peak incidence and recovery patterns of dysphagia and related toxicities in patients undergoing H-IMRT±chemotherapy to examine when patients are experiencing symptoms requiring supportive clinical care. METHODS Prospective study of 212 patients undergoing H-IMRT. Dysphagia and associated acute toxicities were monitored weekly during treatment and at weeks 2, 4 and 12 post treatment using the CTCAE v4, Functional Oral Intake Score and National Dysphagia Diet Descriptors. RESULTS 75% experienced Grade 2-3 dysphagia. Over 70% had grade 2-3 dysguesia, xerostomia, and thick saliva, and >50% experienced grade 2-3 pharyngeal mucositis, oral mucositis, and nausea. 13% patients declined to NBM requiring complete enteral nutrition, 25% required enteral nutrition but maintained some form of oral intake. Symptoms peaked in final week of treatment, consistently improving thereafter, with the majority better than baseline by 12 weeks post-treatment. Concurrent chemotherapy at least doubles the odds of experiencing most symptoms excepting xerostomia, taste and fluid level. CONCLUSION Despite advancements in radiation techniques, results confirm a high proportion of HNC patients experience dysphagia and related toxicities requiring supportive care during H-IMRT. Patients receiving H-IMRT alone experience a lower incidence of symptoms compared with those receiving concurrent chemotherapy. The data confirms the ongoing need for active on treatment monitoring with implications for the timing and intensity of patient support services.

Training the allied health assistant for the telerehabilitation assessment of dysphagia

We examined the effect of knowledge and task specific training provided to an allied health assistant (AHA), prior to her involvement in facilitating assessments of dysphagia (swallowing disorders) via telerehabilitation. The AHA received four hours of training, which included basic theoretical information regarding dysphagia as well as hands-on training with simulated patients. A written test examining swallowing function and its evaluation was completed pre- and then immediately post-training, and then again after the 15th and 30th of 31 consecutive patient assessments. In addition, after each set of 5 clinical dysphagia assessments completed with patients following the training, two speech pathologists rated the AHAs competence in relation to performing the tasks and activities required of her during the telerehabilitation swallowing assessment. The AHA also self-rated the perceived level of confidence at these times. Before training, the assistants knowledge of dysphagia theory was at 40%. Following training, all tests were above the 80% level. The AHAs performance was rated as competent on each evaluation post-training. The AHA also expressed overall satisfaction with the initial training provided and reported feeling confident after the initial sessions with patients. Thus for an AHA with previous clinical experience, competence and perceived comfort in providing assistance in the sessions was achieved with only a few hours of task specific training.

Managing patient factors in the assessment of swallowing via telerehabilitation

Undoubtedly, the identification of patient suitability for a telerehabilitation assessment should be carried out on a case-by-case basis. However, at present there is minimal discussion of how telerehabilitation systems can accommodate and adapt to various patient factors, which may pose challenges to successful service delivery. The current study examines a subgroup of 10 patients who underwent an online assessment of their swallowing difficulties. Although all assessments were completed successfully; there were certain patient factors, which complicated the delivery of the online assessment session. The paper presents a discussion of the main patient factors observed in this cohort including the presence of speech and/or voice disorders, hearing impairment, dyskinesia, and behavioural and/or emotional issues and examines how the assessment session, the telerehabilitation system, and the staff involved were manipulated to accommodate these patient factors. In order for telerehabilitation systems to be more widely incorporated into routine clinical care, systems need to have the flexibility and design capabilities to adjust and accommodate for patients with varying levels of function and physical and psychological comorbidities.

Evaluation of a clinical service model for dysphagia assessment via telerehabilitation

Emerging research supports the feasibility and viability of conducting clinical swallow examinations (CSE) for patients with dysphagia via telerehabilitation. However, minimal data has been reported to date regarding the implementation of such services within the clinical setting or the user perceptions of this type of clinical service. A mixed methods study design was employed to examine the outcomes of a weekly dysphagia assessment clinic conducted via telerehabilitation and examine issues relating to service delivery and user perceptions. Data was collected across a total of 100 patient assessments. Information relating to primary patient outcomes, session statistics, patient perceptions, and clinician perceptions was examined. Results revealed that session durations averaged 45 minutes, there was minimal technical difficulty experienced, and clinical decisions made regarding primary patient outcomes were comparable between the online and face to face clinicians. Patient satisfaction was high and clinicians felt that they developed good rapport, found the system easy to use, and were satisfied with the service in over 90% of the assessments conducted. Key factors relating to screening patient suitability, having good general organization, and skilled staff were identified as facilitators for the service. This trial has highlighted important issues for consideration when planning or implementing a telerehabilitation service for dysphagia management.

Randomized controlled trial of a multisite speech pathology telepractice service providing swallowing and communication intervention to patients with head and neck cancer: evaluation of service outcomes

The purpose of this study was to present our evaluation of a new speech pathology telepractice service supporting the swallowing and communication management of patients with head and neck cancer.

Dysphagia and nutritional management i Australia and New Zealand head and neck cancer centers

Dysphagia Research Society Annual Meeting and Post-Graduate Course March 13–16, 2013 The Fairmont Olympic Hotel, Seattle, Washington Springer Science+Business Media New York 2013