Telehealth or telepractice can alleviate shortages of speech-language pathologists, particularly in rural and underserved areas, where specialists in voice and swallowing disorders may not be available. In addition to improving access to services, telehealth offers the opportunity for patients to receive care in their natural environment, as in the case of home health care where treatment can include family members and caregivers. This article presents an overview of telehealth applications in the remote management of voice and swallowing disorders including historical background, current issues, and a brief review of clinical effectiveness studies.
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Shortages of speech-language pathologists (SLPs), particularly in rural and remote areas, make telehealth a desirable means of accessing SLPs with specialties in voice and swallowing.
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Peripheral devices that can be used to support speech and swallowing services provided via telehealth include digital audio and video recording, otoscopes, endoscopes, fluoroscopes, and document cameras.
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Remote assessment facilitates decision making about the need for a follow-up visit, advancing the vocal rehabilitation program, and readiness for discharge.
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Voice treatment programs delivered via telehealth have been demonstrated to be comparable with in-person services where the audio and visual signals are adequate for the clinical application.
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Remote videofluoroscopic swallowing assessments show good agreement with on-site assessments and treatment recommendations where the visual image is adequate.
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Major barriers for the expanded use of telehealth by SLPs are licensure requirements for interstate practice and ineligibility to bill for telehealth services under Medicare Part B. Recognition and reimbursement by state Medicaid programs and private insurance are progressing slowly.
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Additional research is needed to investigate clinical and operational aspects of remote management of voice and swallowing disorders. Outcome measures including clinical effectiveness and clinician and patient satisfaction have been positive in the limited studies available.
Speech-language pathologists (SLPs) are certified and licensed professionals who provide clinical services to optimize individuals’ ability to communicate and swallow with the objective of improving their function and quality of life. SLPs collaborate with otolaryngologists to evaluate and treat individuals with communication and swallowing disorders associated with conditions such as neurologic diseases, head and neck cancer, benign laryngeal lesions, craniofacial anomalies, and hearing loss.
Access to speech-language pathology services is a significant problem in many geographic areas, due to a shortage of SLPs. According to the US Bureau of Labor Statistics, the demand for SLPs is expected to grow by 19% from 2008 to 2018. A health care survey conducted by the American Speech-Language-Hearing Association (ASHA) in 2009 indicated that 25% of respondents had unfilled positions in their facility. The highest percentage of vacancies (36%) was in home health. Although the rate of reported vacancies of SLPs in health care has decreased from its high of 40% in 2005, these shortages are most likely to be felt in rural and underserved areas, which are also less likely to have SLPs specializing in voice and swallowing assessments and treatments.
The potential benefit of telehealth in speech-language pathology is significant in light of personnel shortages, decreasing technological costs, more widespread connectivity, an increasing demand for home health care, and changes in our nation’s demographics with an expanding geriatric population more susceptible to communication and swallowing problems. In addition to improving accessibility to and increasing availability of services, telehealth enables the delivery of care in the least restrictive environment, increases participation of family members in the clinical process, and increases efficiency in delivering services, particularly for itinerant clinicians.
Telehealth in speech-language pathology
SLPs have documented the use of telehealth since the 1970s. Early applications and investigations in the use of telecommunication technologies focused on diagnosing and supplementing in-person treatment of neurogenic communication disorders in Veterans’ Administration and Mayo Clinic facilities. More recently, significant research in the area of telehealth in speech-language pathology has been conducted in Australia, where distances and limited access to SLPs make telehealth a desirable alternative to face-to-face services.
ASHA, the professional, scientific, and credentialing association for more than 145,000 SLPs, audiologists, and speech, language, and hearing scientists, has supported the appropriate use of telehealth for over a decade. ASHA developed official policy documents on telepractice (note: telepractice is ASHA’s preferred term because it includes applications by SLPs in schools as well as in health care settings) in 2005 and 2010. ASHA’s position statement affirms that telepractice is an appropriate model of service delivery for the profession of speech-language pathology to “…overcome barriers of access to services caused by distance, unavailability of specialists and/or subspecialists, and impaired mobility.” The position statement further stipulates that “…the quality of services must be equivalent to face-to-face.” ASHA’s 2010 professional issues document describes additional factors contributing to the quality of service, including patient selection, matching appropriate technology to the service being provided, clinician training and competency, and use of patient outcomes and patient and clinician satisfaction measures. Further, the critical importance of having institution-wide training and support is emphasized. Other organizations recognizing the relevance of telepractice for speech-language pathology include professional SLP associations in Canada that have also developed official documents, and the American Telemedicine Association, which has a Special Interest Group for Telerehabilitation.
SLPs have used synchronous interactive video teleconferencing (VTC) to provide services for speech, language, cognitive-communication, voice, and swallowing disorders comparable with those provided in person. Asynchronous applications have been used as an adjunct to supplement services delivered in person, or to review and validate information observed and recorded during synchronous telepractice/telehealth encounters.
Developing telehealth applications for voice and swallowing disorders
It is estimated that voice disorders affect as much as 10% of the United States population and are more prevalent in professional voice users who depend on their voice for work, such as teachers. SLPs and otolaryngologists evaluate patients with voice complaints, and recommend treatment. Voice therapy provided by certified SLPs is effective in addressing behavioral issues contributing to hoarseness.
Approximately 10 million Americans with swallowing difficulties are evaluated each year. SLPs perform clinical bedside and/or instrumental assessments such as videofluoroscopy or fiberoptic endoscopy, which are highly sensitive in analyzing the functional swallow and guiding appropriate management. Treatment approaches improve nutritional status and hydration, and reduce morbidity from pneumonia.
The telehealth model is suitable for treating voice disorders because of the frequency and intensity of follow-up, with multiple visits for patients who typically do not require acute medical care during the course of rehabilitation. The prevalence of swallowing disorders increases with age and poses particular problems in older patients, including the potential of compromising nutritional status or increasing the risk of aspiration pneumonia, and negatively affecting quality of life. The convenience of receiving specialty services in the home or local community is particularly relevant for the elderly population for whom complex health issues, transportation, or mobility may pose access challenges.
Peripheral devices to support speech-language pathology applications for voice and swallowing include digital audio and video recording devices for a wide range of functions; digital otoscopes for oral mechanism examination; digital fluoroscopes for modified barium swallow studies; fiberoptic video endoscopes to visualize the larynx for fiberoptic endoscopic evaluation of swallow, phonoscopic assessment, or biofeedback training; document cameras to present stimulus materials during evaluation and treatment; pan-tilt-zoom features on cameras for close-up assessment of features or finer movements (eg, check status of tracheoesophageal voice prosthesis, provide instruction on abdominal breath support for voice); and auxiliary video input equipment for computer interfacing.
Procedures that require direct physical contact with the patient are contraindicated for the remote management of voice and swallowing disorders via telehealth. For example, laryngeal palpation is not an option for assessing swallowing dysfunction, and digital laryngeal manipulation and manual circumlaryngeal techniques are not options for assessing musculoskeletal tension or treating muscle tension dysphonia. High bandwidth is typically required to ensure adequate audio and video quality to support clinical decision making during assessment, and for interactive clinical procedures that require immediate and accurate feedback such as to support the establishment of target behaviors during treatment.
Different models of service delivery may be used concomitantly and at different phases of intervention as required for appropriate management. For example, because the quality of video images is critical for visual-perceptual assessment of swallowing or phonoscopic evaluation of vocal function, peripheral devices can be used to capture higher-resolution video data for transmission in the store-and-forward mode to supplement information available during a synchronous consultation, or for review at a later time. Similarly, peripheral devices may be used to obtain higher-fidelity audio data, because the quality of audio samples is critical for auditory-perceptual assessment of voice disorders. During treatment, either in-person or synchronous interaction may be required to establish target behaviors while generalization and maintenance may be achieved with asynchronous follow-up. Audio and video samples may be recorded during real-time guided practice with the clinician, and used as models for home practice. The patient can then record subsequent practice sessions to forward to the clinician for review. Real-time therapy interactions may also be supplemented with electronic mail communication between sessions.
Holtel and Burgess conceptualized a remote Web-based monitoring system using software and peripheral devices including external microphones and headsets to record and assess performance on vocal exercises prescribed during in-person or VTC sessions. Through remote assessment of the patient’s status, the clinician can determine (1) the need for a follow-up visit to provide additional instruction or reinforcement, (2) indicators to advance the patient’s course of vocal rehabilitation, and (3) readiness for discharge from treatment. Compliance with a vocal health or vocal abuse reduction program could also be monitored remotely.
Developing telehealth applications for voice and swallowing disorders
It is estimated that voice disorders affect as much as 10% of the United States population and are more prevalent in professional voice users who depend on their voice for work, such as teachers. SLPs and otolaryngologists evaluate patients with voice complaints, and recommend treatment. Voice therapy provided by certified SLPs is effective in addressing behavioral issues contributing to hoarseness.
Approximately 10 million Americans with swallowing difficulties are evaluated each year. SLPs perform clinical bedside and/or instrumental assessments such as videofluoroscopy or fiberoptic endoscopy, which are highly sensitive in analyzing the functional swallow and guiding appropriate management. Treatment approaches improve nutritional status and hydration, and reduce morbidity from pneumonia.
The telehealth model is suitable for treating voice disorders because of the frequency and intensity of follow-up, with multiple visits for patients who typically do not require acute medical care during the course of rehabilitation. The prevalence of swallowing disorders increases with age and poses particular problems in older patients, including the potential of compromising nutritional status or increasing the risk of aspiration pneumonia, and negatively affecting quality of life. The convenience of receiving specialty services in the home or local community is particularly relevant for the elderly population for whom complex health issues, transportation, or mobility may pose access challenges.
Peripheral devices to support speech-language pathology applications for voice and swallowing include digital audio and video recording devices for a wide range of functions; digital otoscopes for oral mechanism examination; digital fluoroscopes for modified barium swallow studies; fiberoptic video endoscopes to visualize the larynx for fiberoptic endoscopic evaluation of swallow, phonoscopic assessment, or biofeedback training; document cameras to present stimulus materials during evaluation and treatment; pan-tilt-zoom features on cameras for close-up assessment of features or finer movements (eg, check status of tracheoesophageal voice prosthesis, provide instruction on abdominal breath support for voice); and auxiliary video input equipment for computer interfacing.
Procedures that require direct physical contact with the patient are contraindicated for the remote management of voice and swallowing disorders via telehealth. For example, laryngeal palpation is not an option for assessing swallowing dysfunction, and digital laryngeal manipulation and manual circumlaryngeal techniques are not options for assessing musculoskeletal tension or treating muscle tension dysphonia. High bandwidth is typically required to ensure adequate audio and video quality to support clinical decision making during assessment, and for interactive clinical procedures that require immediate and accurate feedback such as to support the establishment of target behaviors during treatment.
Different models of service delivery may be used concomitantly and at different phases of intervention as required for appropriate management. For example, because the quality of video images is critical for visual-perceptual assessment of swallowing or phonoscopic evaluation of vocal function, peripheral devices can be used to capture higher-resolution video data for transmission in the store-and-forward mode to supplement information available during a synchronous consultation, or for review at a later time. Similarly, peripheral devices may be used to obtain higher-fidelity audio data, because the quality of audio samples is critical for auditory-perceptual assessment of voice disorders. During treatment, either in-person or synchronous interaction may be required to establish target behaviors while generalization and maintenance may be achieved with asynchronous follow-up. Audio and video samples may be recorded during real-time guided practice with the clinician, and used as models for home practice. The patient can then record subsequent practice sessions to forward to the clinician for review. Real-time therapy interactions may also be supplemented with electronic mail communication between sessions.
Holtel and Burgess conceptualized a remote Web-based monitoring system using software and peripheral devices including external microphones and headsets to record and assess performance on vocal exercises prescribed during in-person or VTC sessions. Through remote assessment of the patient’s status, the clinician can determine (1) the need for a follow-up visit to provide additional instruction or reinforcement, (2) indicators to advance the patient’s course of vocal rehabilitation, and (3) readiness for discharge from treatment. Compliance with a vocal health or vocal abuse reduction program could also be monitored remotely.
Remote management of voice disorders
Empirical studies by SLPs support the use of telehealth to diagnose and treat voice disorders remotely. Duffy and colleagues conducted telemedicine consultations at Mayo Clinic facilities between 1987 and 1994. In a review of 150 consultations, 82 patients were diagnosed with voice disorders including spasmodic dysphonia, voice tremor, psychogenic dysphonia, and musculoskeletal tension dysphonia. Otolaryngologic intervention was recommended for 50 patients. The investigators concluded that telemedicine represents a viable alternative to face-to-face consultation when distance precludes timely and cost-effective service, or when specialists are unavailable for speech and language problems that are difficult to diagnose or manage.
Spurred by the aging of the population, extensive rural areas, and difficulty accessing SLPs in Australia, Theodoros and colleagues at the University of Queensland have conducted numerous studies and case reports examining the efficacy and effectiveness of assessment and treatment via telehealth. Their results demonstrate comparable outcomes between in-person and telehealth services for dysarthria, postlaryngectomy, and voice disorders.
Constantinescu and colleagues investigated the validity and reliability of a telerehabilitation application for assessing the speech and voice disorder associated with Parkinson disease (PD). In simultaneous online and face-to-face environments, 61 participants with PD and hypokinetic dysarthria were evaluated on perceptual measures of voice and oromotor function, articulatory precision, speech intelligibility, and acoustic measures of vocal sound pressure level, phonation time, and pitch range. A personal computer-based videoconferencing system with store-and forward capabilities was used to conduct the online assessments over a 128-Kbps Internet connection. The investigators reported comparable levels of agreement between the two environments for the majority of parameters, and concluded that online assessment of speech and voice in PD appears to be valid and reliable.
In 2003, Mashima and colleagues at Tripler Army Medical Center, Hawaii followed a stepwise process described by research team members Burgess and colleagues in developing and deploying a telehealth vocal rehabilitation protocol as part of a comprehensive telemedicine otolaryngology-head and neck surgery service including audiology and speech pathology. An in-house proof-of-concept study with 51 participants demonstrated no significant differences in auditory-perceptual, acoustic, patient satisfaction, and fiberoptic laryngoscopy outcome ratings between the control (in-person delivery) and experimental (telehealth delivery) groups. Participants in both groups showed positive changes on all 4 outcome measures after completing the vocal rehabilitation protocol. Preliminary data from deployment of remote VTC units to a satellite clinic in rural Oahu and a military hospital in Japan support telehealth as a viable and effective method of service delivery with positive outcomes, including clinician satisfaction with technology used to perform clinical procedures and patient reports of comfort with the technology. Tandberg 880 VTC systems connected via Integrated Services Digital Network (ISDN) lines with 384 Kbps bandwidth were used. Software interfaced with the VTC system and a desktop computer at each site provided the capability to record and analyze voice samples. Laryngeal examinations were performed with a digital videostroboscopy system. Data files of voice samples and laryngeal images were captured, saved, stored, downloaded, and viewed remotely ( Fig. 1 ).
