Telerehabilitation for service delivery in speech-language pathology

Introduction

Communication disorders have been estimated to occur in 5–10% of the population ¹ and can have a significant effect on the quality of life of individuals and their families. ^2,3 Speech-language pathologists (SLPs) provide services to this clinical population in the form of assessment and treatment for a range of speech, language, voice, fluency and associated swallowing disorders. In adults, communication disorders such as aphasia, dysarthria, apraxia of speech and cognitive-linguistic disorders commonly occur as a result of stroke, traumatic brain injury, Parkinson's disease (PD) and multiple sclerosis. ⁴ Similar disorders of speech, language, voice, fluency and swallowing occur in children. ⁵ In children, the most common cause of communication disorder is developmental delay, which occurs in up to 19% of paediatric populations. ⁶

Challenges of service delivery

For SLPs, the provision of services to people with communication and swallowing disorders is difficult with respect to equity of access and in the delivery of high quality management protocols. These challenges will be exacerbated in the future by an increasingly aged population. In Australia, for example, people aged 65 years and over will represent 26–28% of the population by 2051. ⁷ A consequence of this social trend will be an increase in the prevalence of neurological conditions and acquired neurogenic communication disorders.

Access to SLP services is most difficult in rural and remote communities where recruitment and retention of SLPs remains a problem worldwide. ⁸ Equally problematic, and frequently underestimated, is the difficulty encountered by those who have significant mobility difficulties (e.g. PD, stroke). For many adults with a communication impairment and associated physical dysfunction, travelling to and from a treatment facility regularly is a daunting task, if not impossible. Similarly, for single-parent and double-income families, accessing SLP services for their children can be onerous due to work and child care schedules, financial concerns, transport and distance.

Compounding the access problem is the fact that many communication and swallowing disorders require periods of intensive treatment followed by long-term management spanning several years. High intensity treatment protocols have been found to be effective, for example, in improving speech in PD, ⁹ and language function in persons with aphasia. ¹⁰ However, such programmes are difficult to deliver to all those requiring treatment owing to access problems and caseload numbers. Thus the need for long-term management of many adult and childhood communication disorders highlights the importance of service delivery models that are flexible, responsive to individual needs and sustainable.

Although face-to-face treatment has always been considered the ‘gold standard’ of care, SLPs need to consider alternative modes of service delivery to address the communication needs of a changing community and to ensure that the most effective treatment programmes are delivered. One possible solution to these service issues is the use of telemedicine to supplement or, in some situations, replace traditional face-to-face interventions.

Telerehabilitation and speech-language pathology

Telerehabilitation, in which rehabilitation services are provided at a distance, ¹¹ has the potential to lessen the access and treatment problems facing SLPs. As consultations mainly involve audio-visual interactions between the client and the clinician, the process lends itself to telemedicine. Thus the majority of telerehabilitation applications which have been developed involve videoconferencing. There has been less activity, however, in the development of interactive computer-based programs and environments to enable clients to engage in independent therapy activity.

Such technologies allow clients to be assessed and treated in their own home, or at the very least, in their local community. The quality of care for persons with communication and swallowing disorders may also be enhanced by this service model. Winters and Winters ¹² suggested that telerehabilitation has the potential to optimize the timing, intensity and sequencing of interventions that are likely to produce the greatest functional outcome for the patient. This is particularly relevant to the management of chronic communication and swallowing disorders where the inherent flexibility of telerehabilitation enables the clinician to more readily design short- and long-term management programmes that meet specific treatment goals, as well as client and family needs. An online service delivery platform also provides the clinician with the capacity to regularly monitor progress and intervene in a timely manner. ¹³ For patients with chronic and progressive neurological disorders (e.g. PD), periodic monitoring of communication and swallowing is important in order to assist them in maintaining these functions. An additional advantage of telerehabilitation in SLP is the potential to facilitate generalization of treatment to the individual's everyday existence. Treatment conducted within the person's social, educational and vocational environment can lead to improved functional outcomes and enhanced family and community integration. ¹⁴

Applications in speech-language pathology

Telerehabilitation applications have been developed in the areas of adult neurogenic speech and language disorders, stuttering, voice disorders, laryngectomy, swallowing dysfunction, and speech and language disorders in children. Several studies have focused on the assessment of acquired neurogenic disorders using standardized and non-standardized assessment tools. A series of investigations conducted at the University of Queensland have focused on the reliability and validity of online assessment of dysarthria, aphasia, apraxia of speech and the online treatment of dysarthria associated with PD. A customized PC-based videoconferencing system incorporating dedicated software tools and connected to the Internet (128kbit/s) was designed to allow administration of standardized and informal assessments of speech and language function, and provide a platform for online dysarthria treatment. Similar online and face-to-face assessments of dysarthria speakers ¹⁵ and people with aphasia ¹⁶ have been achieved using this system. Another study has demonstrated significant improvements in the speech of people with PD when treated online with the Lee Silverman Voice Treatment (LSVT) that were similar to face-to-face delivery. ^17,18 Similarly, investigators using an Internet-based videoconferencing application called RESPECT (Remote SPEech-language Cognitive-communication Treatment) have reported reliable and valid assessment of verbal expression in adults with acquired brain injury using a standardized story telling procedure. ^19,20

Positive treatment effects similar to face-to-face treatment have been shown for people with voice disorders treated online, ²¹ while satisfactory clinical assessments of swallowing have been accomplished following stroke ²² and in patients following laryngectomy. ²³ Online assessment of swallowing involving real-time videofluoroscopic examination via the Internet has been reported to be feasible although not confirmed in a large sample. ²⁴ Videoconferencing has also been used to provide speech rehabilitation and psychosocial support to patients and families following laryngectomy and head and neck surgery. ²⁵

The management of stuttering in children and adults is well suited to the online environment due to the specific treatment and maintenance strategies involved. Studies reporting positive outcomes have included adaptations of the Lidcombe programme for stuttering in children using the telephone, ²⁶ and the management of stuttering in children and adolescents ²⁷ and adults ²⁸ via videoconferencing.

There have been few reports of telerehabilitation applications involving the management of speech and language disorders in children. The assessment of speech disorders in young children ²⁹ via videoconferencing has been reported to result in relatively high levels of agreement between face-to-face and online assessors regarding speech intelligibility, oromotor function, and the type of articulation disorder. McCullough ³⁰ reported on the delivery of therapy to five preschool children with special needs in their home via a 128 kbit/s videoconferencing link. Substantial improvements in communication in the children were noted by parents and clinicians following a course of teletherapy.

Interactive computer-based therapies

The majority of telerehabilitation applications have been designed to enable clinician–client interaction via videoconferencing. There is a need for the development of interactive computer programs and virtual reality environments to provide independent therapeutic activities for adults and children. While development in this area has been slow due to the expense involved, some applications for speech disorders and stuttering are now starting to emerge. In order to increase patient access to the intensive LSVT, ⁹ researchers have programmed a personal digital assistant (PDA), called the LSVT Companion (LSVTC), to collect speech data and provide feedback to clients as they work through the treatment at home. The device has been used to deliver the LSVT effectively in a combination of nine clinic sessions and seven LSVTC sessions. ³¹ An evolution of the LSVTC has been the development of a prototype LSVT virtual therapist (LSVTVT), an animated agent, which interacts with a client in the delivery of the programme. ³¹ Palmer et al. ³² have developed an interactive computer program based on speech recognition technology which has been shown to improve articulation accuracy in speakers with chronic dysarthria. In stuttering, Brundage et al. have developed a virtual reality environment (a job interview) to facilitate treatment practice and generalization. ³³ Results from this study highlighted the potential of virtual reality applications to meet these communication goals.

The future

With continuing advances in technology, it is possible to envisage SLP practice where a clinician conducts face-to-face consultations, an online assessment of person with aphasia in the home, monitors communication and swallowing function in a client with multiple sclerosis across the Internet, discusses voice production strategies with a teacher at a school online, and introduces a child and parent to an interactive computer-based therapy programme to be conducted in the home. For this type of practice to be implemented, research will be required to develop additional assessment and treatment applications and interactive computer programs, conduct cost-benefit and cost-effectiveness analyses of telerehabilitation applications and inform professional training. If successful, the implementation of telerehabilitation methods in SLP practice will assist in meeting the increasing demands of individuals with communication disorders while maintaining the quality and integrity of services.