The world’s population is increasing and aging due to medical advancements over disease and injury. However, the World Health Organisation (WHO, 2006) in its health report predicts that the loss of health and life in the future will be greater from non-communicable diseases and/or chronic impairments such as cerebrovascular disease (CVA) and cancers than from the better known infectious diseases. With greater numbers of individuals living with disabilities and immobility, healthcare systems as a result will be burdened to provide quality healthcare services. This will be further challenged by impending issues with workforce shortages and the distribution of populations across larger geographical areas. Hence healthcare providers are actively seeking alternate models for providing healthcare services in the future. One such approach is telehealth. Although there exist various definitions of the term “telehealth”, the term quite literally means “the delivery of healthcare services from a distance” (Darkins, & Cary, 2000). Traditionally, the face-to-face consultation is considered by many to be the “gold standard”. However, evidence-based research over the past decade has proven the quality and the benefits of many forms of telehealth service, which has in turn brought about an uptake and acceptance of telehealth in various fields, such as medicine.
Speech pathology, like other health professions is embracing the potential of telehealth to provide rehabilitation services via the Internet i.e. telerehabilitation. To this end, the past decade has seen a rapid expansion in research into the use of telerehabilitation across several areas of speech pathology practice such as assessing aphasia, assessing and managing stuttering, treating motor-speech disorders, voice assessment, assessment and therapy for paediatric communication disorders, voice treatment for Parkinson’s disease and post discharge management of patients with laryngectomy. Overall the growing evidence base has demonstrated very positive outcomes. However, at the time this thesis commenced, one aspect of speech pathology practice which had received little systematic investigation was the use of telerehabilitation to provide dysphagia management services. Dysphagia, a swallowing disorder, is a highly prevalent condition. Occurring as a result of abnormal deglutition, it can lead to consequences such as malnutrition, dehydration and aspiration pneumonia which can sometimes become fatal. While dysphagia can occur in any clinical population, detailed investigations have found that it is present in greater than 30% - 47% of individuals with CVAs (Eckberg, Olsson, & Hindfelt, 1998; Paciaroni, Mazzotta, & Corea, 2004; National Stroke Foundation, 2009), between 40% - 60% of individuals with head injuries (Terre, & Mearin, 2007) and in 10% - 30% of individuals over the age of 65 years (Barczi, 2000). Due to the high prevalence of dysphagia, it has been recognised that dysphagia management absorbs greater than 20% of staffing in acute care speech pathology (Petheram, & Enderby, 2001) and over 50% of clinical time of all SPs, regardless of practice setting or age of patients serviced (ASHA, 1999). The demands for speech pathology services for dysphagia management however cannot be met due to the critical shortage of speech pathologists globally. As such other avenues such as telerehabilitation may be needed to fill this gap between the demand and supply of speech pathology services.
Prior to implementation of a new form of telerehabilitation service, it is important to determine (1) the nature and type of telerehabilitation system required to provide the specific service, (2) staffing needs and training, (3) the safety and acceptability to patients and then (4) determine to what extent the telerehabilitation service is valid and reliable when compared to the traditional face-to-face (FTF) modality. The overall objective of the current thesis was to explore these issues through a systematic series of investigations into the use of a telerehabilitation system to evaluate the clinical dysphagia status in adults. The current thesis is therefore a series of five investigations that address the issues related to the assessment of dysphagia via a telerehabilitation protocol. The first investigation examined the feasibility of using a custom-built telerehabilitation system for the assessment of dysphagia (Chapter 2). The system had specific modifications to enhance its use for conducting a dysphagia protocol including the use of fixed and free standing webcameras remotely controlled by the T-SP, split screen displays, store-and-forward capabilities, a free-field combined echo cancelling microphone and web-conference speaker for general communication and, a lapel microphone to capture the participant’s voice quality. In this pilot study, ten standardised patients were assessed using a Clinical Swallowing Examination (CSE) protocol, delivery of which was also modified to suit the telerehabilitation environment. Results revealed high to excellent levels of agreement between the telerehabilitation speech pathologist (T-SP) and the face-to-face speech pathologist (FTF-SP) across all parameters of the CSE. Agreement for aspiration risk was excellent. The positive outcomes from that study lead then to the second investigation in Chapter 3 which systematically addressed issues relating to validity and reliability, and clinician satisfaction with the online modality in a large clinical trial. This clinical trial contained 40 patients of different ages, who presented varying dysphagia severities and aetiologies. The results found that the majority of the parameters assessed on the CSE yielded high levels of clinical agreement. Specifically, agreement between the T-SP and FTF-SP ratings for the oro-motor tasks revealed exact agreements ranging from 83% - 100% (Kappas 0.36 - 1.0) while the parameters relating to food and fluid trials revealed exact agreements ranging 75% - 100% (Kappas 0.36 - 1.0). Parameters related to aspiration risk and clinical management decisions revealed exact agreements of 75% - 100% (Kappas 0.49 - 1.0). Clinician satisfaction was also high.
As it is recognised that patient perceptions and satisfaction with a new service relates strongly to the acceptance and success of the service in the future, the satisfaction of the 40 participants with the online assessment of dysphagia was then examined in Chapter 4. Patients’ comfort with assessment via telerehabilitation was high in over 80% of the group both pre- and post-assessment. Although pre-assessment, patients reported some concern with audio and video aspects of the videoconference, significantly positive opinions were noted post-experience. Notably, 92% of the patients felt they would be comfortable receiving services via telerehabilitation and reported to be willing to attempt telerehabilitation for the management of their dysphagia again in the future. The subsequent investigation in Chapter 5 explored staff training, specifically the training provided for the role as an assistant in the telerehabilitation assessments of dysphagia, and the impact of this training on knowledge, competence in the role and perceived level of comfort performing the role. Overall it was revealed that providing four hours of theoretical and practical training was highly successful in improving knowledge of dysphagia, and preparing the assistant to perform her role in the telerehabilitation sessions competently and with a high level of perceived comfort. The final investigation in the thesis explored patient factors that were found to challenge the online clinician during the assessments conducted. Ten individuals who presented with complex conditions and characteristics that presented some challenges to the online assessment environment were identified from the clinical trial in Chapter 3. These challenges and the measures taken to overcome them by the online speech pathologist and the assistant are discussed in Chapter 6 of the thesis. While these characteristics and conditions proved to be challenging during the online dysphagia assessment sessions, they were not impossible to manage. The chapter highlights the importance and need to be prepared to manage patient factors in addition to technical factors when carrying out a telerehabilitation assessment.
The data from the current series of five investigations provides evidence that the assessment of dysphagia via telerehabilitation using a purpose-built system, with specific modifications and a trained assistant at the patient end, allows outcomes that are comparable to a traditional face-to-face assessment. Patients and clinicians were also highly satisfied providing services via this modality. The findings from the series of investigations highlight areas for future research in this field, particularly the validity and reliability of providing dysphagia services with different systems and exploring further possible patient factors (e.g. severe dementia) that may potentially limit the clinical applicability of telerehabilitation within the larger and more diverse clinical population. The current evidence provides a strong initial evidence base for supporting the use of telerehabilitation in the management of patients with dysphagia. This work will be integral in the process of establishing new models for dysphagia services, designed to enhance access to speech pathology services for more patients in the future.