Assessing Swallowing Disorders Online: A Pilot Telerehabilitation Study

Abstract

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.

Introduction

Impairments of swallowing (dysphagia) may occur as a result of damage or dysfunction in the neurological control of swallowing, from obstructions or alterations to the swallowing pathway, or as a consequence of aging.^1

–5 Occurring in 10%–30% of individuals over the age of 65 years,⁶ dysphagia places patients at great risk for aspiration and malnutrition, which can lead to significant morbidity and mortality.⁷ Early assessment and rehabilitation of the dysphagia by specially trained speech pathologists (SPs) is therefore crucial to prevent further medical complications and should be a high priority of healthcare practices. Although many hospitals around the world have policies for early dysphagia screening and assessment,^8

–14 health-funding issues, caseload constraints, and a shortage of SPs lengthen the waitlists for speech pathology services. In particular, the global shortage of SPs poses a challenge for patients to receive early intervention and rehabilitation services in a timely manner in areas that are outside of the metropolis.¹⁵

Telehealth technology has the potential to ease patient burden and assist with the shortage of SPs by enabling the provision of specialist services across large geographical areas. Although there has been substantial research and development work regarding the successful use of telehealth for medical specialty services such as telepsychiatry,¹⁶ teledermatology,^17,18 and telecardiology,¹⁹ the evidence base supporting the use of telehealth for rehabilitation services, that is, telerehabilitation, is still evolving.^20

–25 Within the field of speech pathology, recent research has created an initial evidence base supporting the use of telerehabilitation in various aspects of speech pathology practice including the assessment and/or treatment of aphasia,^26,27 stuttering,^28

–31 motor-speech disorders,^{28,32

–36} voice,^37

–40 pediatric communication disorders,^41,42 and postdischarge review assessments following laryngectomy.^43,44 Although these emerging studies support the delivery of certain aspects of speech pathology practice via telerehabilitation, to date there remains minimal published research to support the assessment or management of dysphagia via telehealth services.^43

–46

The clinical assessment of dysphagia presents some specific challenges for a telerehabilitation model. The traditional clinical dysphagia assessment process involves three key stages: (1) evaluation of the case history and current patient medical status, including suitability for oral trials, (2) assessment of oromotor and laryngeal function, and (3) food and fluid trials to determine aspiration risk. Therefore, any telerehabilitation system developed to facilitate the administration of a clinical swallow examination process online must ensure all of these components can be administered effectively. Existing research suggests that the first component of the assessment process can be relatively easily achieved via telerehabilitation through the use of electronic transfer of important medical information to the online clinician^47

–51 and the use of real-time videoconferencing to enable observations and interaction with the patient.^{31,33,36,41,43,44,52,53} The only specific consideration for a dysphagia telerehabilitation system relates to portability, as any system developed for these assessments would need to be portable and small enough to be able to be brought to the patient and positioned bed-side or chair-side, to allow interaction with inpatients.

Stage 2 of the clinical swallow assessment, that is, conducting valid oromotor and laryngeal function assessments, has also been shown to be possible via telerehabilitation when specific modifications and additional equipment are incorporated into the system. These modifications are necessary to ensure adequate auditory and visual information is relayed to the online clinician. Studies exploring the use of telerehabilitation to assess oromotor function and vocal quality in patients with motor speech disorders have shown that most aspects of the oromotor function can be validly assessed online when systems incorporate additional cameras and enhanced voice recording tools.^{31,33,36,41,53} Using freestanding cameras with zoom capabilities, Ward et al.^43,44 demonstrated successful completion of oromotor assessment for both swallowing and communication review assessments with laryngectomy patients.

Stage 3 of the assessment, involving food and fluid trials and decision making about aspiration risk, however, presents the greatest challenge in the online environment. A traditional assessment involves the clinician feeding the patient various foods and fluids and manipulating the mode of delivery, size of mouthful, and consistency trialed to determine swallowing safety. During these trials, the clinician uses visual, auditory, and tactile feedback to accurately determine the patient's swallow safety and aspiration risk. Although auditory and visual information can be enhanced for the online clinician through additional cameras and microphones, neither tactile information nor direct patient contact is possible. Therefore, involving an “assistant” who is located at the patient end may be necessary to facilitate accurate assessment.⁴⁵ This person would be responsible for assisting the patient, conducting the actual delivery of food and fluid trials, and relaying information to the online clinician. In their single case study, Lalor et al.⁴⁵ explained how support personnel were used to feel and describe the movement of the larynx to overcome the lack of visual and tactile input in an online dysphagia assessment. Other studies have also utilized the assistant role. In a study of the use of telehealth technology in head and neck oncology, Myers⁵⁴ demonstrated it was possible for an untrained individual to take on the role of a facilitator during a telehealth session particularly to assist with more technical aspects and the clinical management of patients. Similarly, McConnochie et al.⁵⁵ reported the use of a telehealth assistant in a childcare setting for assisting the telehealth assessment of common acute problems in the children.

Perhaps in light of the challenges that exist, no studies to date have described either a functional system or a valid and reliable process for conducting clinical dysphagia assessments via telerehabilitation. Although there are various challenges, prior research into the use of telerehabilitation systems with other clinical populations or conditions do suggest some potential solutions. The aim of the present study was to pilot a telerehabilitation assessment process, which incorporated modifications to the teleconferencing equipment, the actual dysphagia assessment process, and the personnel required. The overall objective was to determine the basic feasibility of this new system architecture to inform subsequent research and clinical trials regarding the validity of telerehabilitation assessment of dysphagia.

Materials and Methods

Assessment

Three personnel were involved in each online assessment: (1) the telerehabilitation SP (T-SP) at the remote site, (2) the face-to-face SP (FTF-SP), and (3) an assistant situated in the room with the patient (Fig. 1A, B). The two SPs were randomly assigned to serve as either the FTF-SP or T-SP. The T-SP led all Clinical Swallowing Examinations (CSEs). The FTF-SP was located in the room with the patient and assessed the patient simultaneously with the T-SP during the CSE to establish the concurrent feasibility of the telerehabilitation assessment compared with the standard clinical assessment environment. The FTF-SP had freedom of movement that allowed close-up views and the ability to touch the patient to assess oromotor muscle strength but was required to complete the CSE passively as an observer. Diagnostic and management decisions were not verbalized so as not to confound the T-SP's decisions.

Fig. 1.

(A) The system setup at the T-SP end with fixed Web camera and split-screen view. (B) The system setup at the patient end showing the notebook computer, free-standing Web camera, and split-screen view, while the assistant and patient wait for further instructions from the T-SP. Note the white tape on the patient's thyroid notch and the pulse oximeter on the patient's finger. T-SP, telerehabilitation speech pathologist.

An SP performed the role of the assistant for the CSE in this pilot study. In reality, this could be a layperson who, with the basic training in dysphagia assessment protocol, would be able to provide the relevant information when instructed by the T-SP. Real-time interaction enabled the T-SP and the assistant to confirm any information that may have been missed. Information that required tactile sensation, such as muscle strength assessments, was evaluated and relayed by the assistant.

Participants

Two clinicians with over 5 years of experience managing dysphagic patients acted as standardized patients with specific oromotor and swallowing problems. A standardized patient is a patient scenario that is acted out by a healthy individual in such as way as to realistically represent a real patient with specific symptoms or problems.⁵⁶ Standardized patients were used in this study to eliminate the risk of having undetected aspiration occur in a real patient during the trials. Each clinician was asked to portray 5 different standardized patients across a range of dysphagia severities, thus creating a total of 10 standardized patient case data available for analysis (2 normal, 2 mild, 2 moderate, 2 severe, and 2 profound). Prior to each assessment, details of the diagnosis, general medical state, oromotor function, aspiration risk of certain food and fluid consistencies, and overall dysphagia severity were provided to both standardized patient clinicians. Adequate time was allowed for them to prepare and familiarize themselves with each clinical case prior to the assessment. These case details were provided only to the clinicians portraying the standardized patients and no information other than age, sex, and a brief medical history was provided to the assessing telehealth clinicians. The second standardized patient clinician served as an observer in each assessment and, using their years of experience as an SP, determined that a realistic portrayal of the standardized patient case scenario had been portrayed to the assessing clinicians.

The Telerehabilitation System

The telerehabilitation system consisted of two notebook computers that were equipped with custom videoconferencing software that used high-quality audio and video compression technology for real-time videoconferencing between the sites. An ad-hoc 802.11g wireless network was used to connect the systems at a throttled bandwidth of 128 kilobits per second (Kbps). Past research has shown that this relatively low bandwidth allows for successful administration of an assessment via telerehabilitation.^{28,33,35,39,41,44,52}

The computer system for telerehabilitation at the patient end was designed to be stand-alone, portable and simple to use and required no intervention from the patient (Fig. 2). The system was originally designed and built by the Telerehabilitation Unit at The University of Queensland, Australia, though specific modifications were made to this existing system to enhance the visual and auditory information required for a CSE. These include the following points:

Fig. 2.

The portable notebook computer on a mobile platform can be wheeled to the patient's bedside or chair as needed. The freestanding Web camera is placed behind the notebook screen but can be positioned as required.

1. Visual information: Visual information was optimized through the use of both fixed and freestanding cameras, split-screen displays, and store-and-forward capabilities. A fixed Web camera (Sphere Camera MP AF; Logitech) at the remote site allowed the patient end to view the T-SP at all times during the videoconference session. A second Web camera with similar specifications was used at the patient end and allowed the T-SP to see the patient. This Web camera was freestanding and positioned on an adjustable mobile platform that allowed the assistant to adjust the camera position and height for each patient. The T-SP could also move the camera dynamically using the remote control and zoom functions. Three different views and zoom settings were utilized to enhance the image captured: (1) A standard view that allowed the view of the patient's full face, neck, and upper torso for the first section of the CSE, (2) a close-up view of the oral cavity that allowed the assessment of tongue function for the second section of the oromotor and laryngeal function examination, and (3) a lateral view that showed a close-up lateral view of the patient's mouth (to note bolus delivery to the mouth and any deficits such as anterior spillage) and neck (to monitor laryngeal excursion) during the food and fluid trials.

2. Auditory information: General communication between the patient site and the T-SP used a free-field combined echo cancelling microphone and Web conference speaker (Duet Executive; Phoenix), whereas a lapel microphone (CK55L; AKG) clipped to the patient's shirt/blouse collar captured and recorded the patient's voice quality.

3. Other: A Finger Pulse Oximeter (MD300C; GE) measured oxygen saturation in the patient throughout the assessment session. Information from the pulse oximeter is used to monitor any immediate change in oxygen desaturation post-swallow, which may be indicative of an aspiration event,^58,59 and for any gradual desaturation over time throughout the assessment to determine patient's capability in managing ongoing repeated breath/swallow coordination demands. Although an aspiration event would have been unlikely in this study, the pulse oximeter was used to validate the process of obtaining the data remotely and assess the feasibility of gaining the data from the assistant.

The Clinical Swallow Examination

A set proforma was used to ensure a structured and consistent delivery of the CSE. The proforma included four sections: (a) assessment of the patient's general orientation, alertness, and posture, (b) assessment of oral hygiene, dental status, and oromotor and laryngeal function, (c) food and fluid trials, and (d) clinical decisions, including diet recommendation, need for oral care, need for instrumental evaluation, and need for follow-up speech pathology review. In each section, parameters of interest were recorded using either (a) nominal scales (e.g., present/absent), (b) five level severity scales (1=normal functional limits; 5=severe impairment), or (c) multiple-choice checklists.

All food and fluid consistencies used in the CSE were consistent with the National Dysphagia Diet descriptors.⁶⁰ Colored food dye was added to the water trials to better enable the T-SP to observe the amount of water taken by the patient in a single sip and the visualization of anterior spillage, if any. Other modifications included the use of clear plastic feeding utensils and cups to maximize the T-SP's view of the patient's performance during the food and fluid trials. The clear utensils and cups enhanced the visualization of the bolus size and permitted the T-SP to make judgments about the timing of the delivery of the bolus and rate of intake. A strip of white surgical tape was also positioned at the level of the patient's thyroid notch to enhance visualization of laryngeal elevation during the swallow.

The Assessment Procedure

The CSE sessions were carried out in a laboratory setting within two separate rooms at The University of Queensland. The patient, FTF-SP, and the assistant were located in one room and the T-SP was in another room within the same building. The assistant's role was to position the patient directly in front of the portable telerehabilitation computer system and then fasten the pulse oximeter (MD300C; GE), lapel microphone, and surgical tape over the patient's thyroid. During the assessment, the assistant aided the T-SP with the oromotor and laryngeal function examination and food and fluid trials and also repositioned the camera. The T-SP's role was to initiate the session with the patient and commence store-and-forward recording of the session once the videoconferencing session began. The T-SP was responsible to lead and direct the CSE with the patient and made clinical judgments based on the assessment. The T-SPs were provided with a guideline script but had the freedom to ask questions depending on each patient's response similar to that in a real-life situation. The FTF-SP who was in the room with the patient observed the CSE and simultaneously completed the CSE assessment proforma independent of the T-SP.

Data Analysis

Levels of agreement between the T-SP and FTF-SP were determined using percentage exact agreement (PEA) and percentage clinical agreement (PCA) as per prior research.^{27,33,35,42
–44} The PCA is taken as ±1 scale level difference. For the present study, agreement greater than 80% on the PCA for data on a five-point rating scale was considered as having high agreement.^61
–63

Results

General Orientation, Alertness, and Posture

Both PEA and PCA between the telerehabilitation and FTF environments for general orientation, alertness, and the patient's posture were 100%.

Oral Cavity and Oromotor and Laryngeal Function Examination

Decisions by the T-SP and FTF-SP regarding nature and status of dentition revealed both PEA and PCA of 100%. The need for oral hygiene care also revealed 100% agreement. The percentage agreement values for the online and FTF ratings for the oromotor and laryngeal function examination are presented in Table 1. The mean overall agreement between the T-SP and FTF-SP's ratings was 96.3% PEA (range=87%–100%) and 100% PCA.

Table 1.

Agreement Between the Telerehabilitation and Face-to-Face Ratings for the Oromotor and Laryngeal Function Examination of the 10 Cases

PARAMETER ASSESSED	PEA	PCA
Cranial Nerve V (Averaged)	100	100
Symmetry and opening/closing jaw strength	100	100
Cranial Nerve VII (Averaged)	100	100
Squeeze eyes closed	100	100
Raise eyebrows	100	100
Open/close mouth	100	100
Open/close mouth against resistance	100	100
Smile wide	100	100
Pucker	100	100
Smile wide-Pucker with speed	100	100
Cranial Nerve IX & X (Averaged)	98	100
“Ahh” (nasality)	100	100
“Ahh” (breath support)	80	100
“Nei-Pei” (nasality)	100	100
Counting 1–5 (nasality)	100	100
Counting 1–5 (voice quality)	100	100
Laryngeal elevation (dry swallow)	100	100
Cough on cue	100	100
Clearing of throat on cue	100	100
Soft palate function	100	100
Cranial Nerve XII (Averaged)	87	100
Tongue protrusion/retraction	80	100
Tongue protrusion/retraction with speed	80	100
Tongue tip up/down	80	100
Tongue tip up/down with speed	80	100
Tongue tip to corners of lips	100	100
Tongue tip to corners of lips with speed	80	100
Licking lips	90	100
Licking lips with speed	90	100
Tongue in cheek (strength)	100	100

PEA, percentage exact agreement; PCA, percentage clinical agreement (PCA is taken as ±1 scale level difference).

Decisions and Recommendations

All diet decisions for fluids and food showed excellent levels of agreement (Table 2). Agreement between the two assessment environments for safe food texture decisions were 90% PEA and 100% PCA levels, whereas PEA and PCA for safe fluid decision were both 100%. The two clinicians also agreed on the need to refer the patient to another professional for further management revealing PEA of 100%. The PEA for the need for further instrumental evaluation was also at 100%.

Table 2.

Ratings for Fluid and Food Decisions Given by the Face-to-Face-Speech Pathologist and Telerehabilitation Speech Pathologist in the Telerehabilitation Assessment of Swallowing

PATIENT	FLUID DECISION (FTF-SP)	FLUID DECISION (T-SP)	FOOD DECISION (FTF-SP)	FOOD DECISION (T-SP)
A	1	1	2	2
B	2	2	2	2
C	1	1	5	4
D	1	1	5	5
E	1	1	2	2
F	6	6	6	6
G	3	3	2	2
H	1	1	5	5
I	3	3	1	1
J	6	6	6	6
PEA	Fluids: 100%		Food: 90%
PCA	Fluids: 100%		Food: 100%

Fluid 1=water/thin; Fluid 2=mildly thick; Fluid 3=moderately thick; Fluid 4=extremely thick/puree; Fluid 6=Nil per Oral (NPO).

Food 1=puree; Food 2=minced and moist; Food 3=soft (no crust); Food 4=soft (with crust); Food 5=normal diet; Food 6=Nil per Oral (NPO).

FTF-SP, face-to-face speech pathologist; T-SP, telerehabilitation speech pathologist; PEA, percentage exact agreement; PCA, percentage clinical agreement (PCA is taken as ±1 scale level difference).

Intrarater Reliability

Intrarater reliability was determined for each SP for the oral motor parameter and diet decisions only. Each T-SP reviewed the store-and-forward recordings of their online sessions (n=5) after a 4-week interval. Rater 1 and Rater 2 were found to have PEA and PCA results above 80% for all parameters except for three parameters of the oromotor and laryngeal function examination. Rater 1 had 60% PEA for three tasks including tongue protrusion–retraction, tongue protrusion–retraction with speed, and licking lips with speed. PCAs for these were 80%, 100%, and 80%, respectively. Rater 2 had 60% PEA (80% PCA) for the tongue protrusion–retraction task, 20% PEA (80% PCA) for tongue protrusion–retraction with speed task, and 80% PEA (80% PCA) for licking lips with speed task.

Discussion

The telerehabilitation system was designed to incorporate certain key elements from prior research such as automatic store-and-forward recording function^27,35 and the use of remotely controlled adjustable Web cameras,^43,44 certain delivery modifications, including the use of an assistant at the patient end,^45,54,55 and changes to aspects of the food and fluid trials, to optimize its functionality. Results revealed that the present system architecture allowed for the clinical assessment of swallowing to be conducted in a manner not too dissimilar to a traditional FTF swallowing assessment, with high clinical agreement observed between the online and traditional FTF assessors. Overall, the trial supports that telerehabilitation assessment of dysphagia is clinically feasible using the current system design elements.

This pilot trial revealed that the T-SP was able to successfully carry out and complete all components of a standard CSE protocol remotely with input from the assistant at the patient end. In the present system trials, the assistant was found to play a critical role in facilitating the assessment process and, as a consequence, should be considered integral for successful delivery of online dysphagia assessments. As per prior research,^45,54,55 in this system, the assistant played a critical role in assisting the online clinician, supporting the patient, and addressing the technical aspects of the assessment.

With respect to clinical agreement between the online and FTF assessors, the PEA for the clinical observation and oromotor assessment components of the CSE ranged between 87% and 100% and indicated that the telerehabilitation assessment of oromotor strength and function using this system was comparable to an FTF assessment environment. This finding is in line with previous research that also found high levels of agreement for ratings of oral cavity and dentition status^43,44 and oromotor function online.^27,35,42

Although the oromotor component of the CSE assessment is an important element of the assessment, ultimately, the primary purpose of a CSE is to identify aspiration risk and determine what food and fluid consistencies the patient can safely consume. Thus, it was encouraging to find that the PEA and PCA were at 100% for safe fluid decisions and 90% PEA and 100% PCA for food, validating that the assessment environment did not impact the ability to assess aspiration risk or influence diet decisions. Although no prior telehealth studies have compared the clinical and online assessment results of patients with dysphagia and at risk of aspiration, preliminary data collected by Ward et al.^43,44 for patients following laryngectomy also reported high levels of clinical agreement for clinical decision regarding food and fluid intake.

Despite the relatively low bandwidth, safe clinical decisions regarding swallowing function and aspiration were able to be made because of the availability of the store-and-forward function. At such low bandwidths, occasional variability in video quality and occasional delays between the audio and video images during the videoconference did occur, as reported in previous research using this bandwidth.^{33
–35,39,41,42,44,52,57} However, in these instances, the stored-and-forwarded video recordings were reviewed and rated once again by the T-SP to make a clinical decision. As many rural areas of Australia are limited by the availability of high-speed Internet connection, it is important to ensure system functionality can be fully achieved at such low bandwidths. However, it is acknowledged that in instances where Internet connectivity greater than 128 Kbps is available, the clarity of the audio and video of the session would be enhanced and clinicians may require less reliance on the store-and-forward application for clinical decision making.

Conclusion

This research was conducted as a pilot study to examine the potential of a telerehabilitation system for the assessment of swallowing disorders online. The data were positive, with high levels of agreement observed between the T-SP and the FTF-SP on all parameters of interest. This pilot study provides preliminary evidence for the feasibility of remote dysphagia assessment. Future research is now needed to extend this evidence and increase the generalizability of the results by performing trials of the system with a large cohort of patients, across all types of dysphagia etiology and severity. In addition, system functionality needs to be further examined through actual trials over distance, rather than simulated distance as in the present study. Finally, future data collection needs to explore patient and clinician satisfaction with the telerehabilitation environment. Although the present findings are still preliminary, the data contribute to the growing evidence base supporting the delivery of speech pathology services via telerehabilitation.

Footnotes

Acknowledgments

The authors thank Anna Rumbach for her assistance in the assessment sessions and gratefully acknowledge funding received from the Royal Brisbane and Women's Hospital Research Foundation.

Disclosure Statement

No competing financial interests exist.

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