Objective and Subjective Clinical Swallowing Outcomes via Telehealth: Reliability in Outpatient Clinical Practice

Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote: Test-Retest and Interrater Reliability of Candidate Items

PURPOSE

The primary aim of this study was to establish the reliability of candidate items as a step in the development of the Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote (ALS-BDI-Remote), a novel tool being developed for the detection and monitoring of bulbar signs and symptoms in remote settings.

METHOD

The set of candidate items included 40 items covering three domains: cranial nerve examination, auditory-perceptual evaluation, and functional assessment. Forty-eight participants diagnosed with ALS and exhibiting a range of bulbar disease severity were included. Data collection for each participant took place on Zoom over three sessions. During Session 1, the participants were instructed to adjust their Zoom settings and to optimize their recording environment (e.g., lighting, background noise). Their cognition and eating were screened to determine their ability to follow instructions and their eligibility to perform the swallowing and chewing tasks. During Session 2, two speech-language pathologists (SLPs) administered the tool consecutively to determine the items' interrater reliability. During Session 3, one of the SLPs readministered the tool within 2 weeks of Session 1 to assess test-retest reliability. The reliability of each item was estimated using weighted kappa and the percentage of agreement. To be considered reliable, the items had to reach a threshold of 0.5 weighted kappa or 80% percentage agreement (if skewed distribution of the scores) for both interrater and test-retest reliability.

RESULTS

In total, 33 of the 40 candidate items reached the reliability cutoff for both reliability analyses. All assessment domains included reliable items. Items requiring very good visualization of structures or movements were generally less reliable.

CONCLUSIONS

This study resulted in the selection of reliable items to be included in the next version of the ALS-BDI-Remote, which will undergo psychometric evaluation (reliability, validity, and responsiveness analyses). Additionally, the results contributed to our understanding of the remote administration of SLP assessments for telehealth applications.

The Timed Water Swallow Test (TWST): Normative data on swallowing capacity for healthy people aged 60 years and older

PURPOSE

To provide normative data on swallowing capacity (mL/s) in people older than 60 years using the Timed Water Swallow Test (TWST), stratified by sex. Intra- and inter-rater reliability for swallowing time in TWST was further investigated.

METHOD

A total of 165 participants, aged 60 years and above, were included in the study. The time taken to consume 150 mL of tap water and the swallowing capacity (mL/s) was observed in a clinical context using the TWST. Video recordings of the performances were collected for 118 of the 165 participants for inter-rater reliability testing, of which a random set of 25 performances were assessed for intra-rater reliability. Analysis of the agreement between TWST rated by an in-person clinician and rated from a video recording was further evaluated.

RESULT

There were significant age and sex effects observed for swallowing capacity. The average reduction in swallowing capacity in the investigated age range (60-92 years) was 8.8 and 7.3 mL/s, for women and men respectively. The results showed high inter-and intra-rater reliability and agreement between the clinical assessment and the video recording.

CONCLUSION

The presented measurements indicate a clear effect of age on swallowing capacity and that women may be expected to have lower capacity scores than men when tested using TWST. The provided norms can be used as reference points in the clinical identification of people at risk of dysphagia in the older population.

Chewing and Swallowing Abilities of Persons Living With Dementia: A Systematic Review of Psychometric Properties of Instruments

Background and Objectives

It is critical to use validated instruments to diagnose and manage chewing and swallowing problems of persons living with dementia. The study aimed to synthesize the characteristics and psychometric quality of instruments that assess the chewing and swallowing abilities of persons living with dementia.

Research Design and Methods

The systematic review was used to conduct this study. We searched 5 electric databases for records published from January 1, 1980, to July 8, 2022. Records were eligible if they included any instrument to assess chewing ability or swallowing ability in the dementia population. Eight characteristics of eligible instruments were extracted from the records: (1) development process, (2) operationalized concept/construct, (3) sample and setting, (4) administration method, (5) items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric assessment for self-report and observational tool was used to evaluate 12 psychometric properties of eligible instruments.

Results

In total, 11,074 records were reviewed. Thirty-five eligible instruments, including observational tools, self-report questionnaires, and physiological instruments, were identified from 60 records. All 8 instruments assessing chewing ability were evaluated as having low psychometric quality, and only 3 out of 27 instruments assessing swallowing ability were evaluated as having moderate psychometric quality. Fifteen instruments were tested for only 1 type of psychometric property, limiting the overall evaluation of psychometric evidence.

Discussion and Implications

The study findings inform the use and adaptation of appropriate instruments for practice and research. All existing instruments warrant further validation in larger samples to expand use in diverse care settings. This review described and evaluated current instruments measuring chewing and swallowing abilities and potential use in research and clinical practice to plan for and evaluate the effectiveness of mealtime and oral care practice and reduce health-related negative outcomes of persons living with dementia.

A Within-Subject Comparison of Face-to-Face and Telemedicine Screening Using the Timed Water Swallow Test (TWST) and the Test of Mastication and Swallowing of Solids (TOMASS)

The Timed Water Swallow Test (TWST) and the Test of Mastication of Solids (TOMASS) are dysphagia screening procedures that have been shown to be reliably assessed from video. The reliability of the procedures performed over telemedicine has not previously been assessed. TWST and TOMASS outcomes in two situations (both face-to-face and over telemedicine) were compared for 48 participants (aged 60-90; 27 with clinical conditions and 21 older persons). Both testing situation and test performed order were randomized, and all assessment procedures were performed within 3 h of each other. The results indicated a high level of agreement between face-to-face and telemedicine screening outcomes for TWST and TOMASS, respectively. The assessments indicated an 83% and 76% agreement in classifications of individual participants as within or outside normal limits for the TWST and TOMASS for the two test situations. The TWST showed a balanced distribution in differing classification in telemedicine (0.16-0.19 error rates). The TOMASS procedure classified more participants as outside normal limits over telemedicine compared to face-to-face administration. Agreement in the observed number of swallows was substantially lower than other outcome measures, which is attributed to increased difficulty in observing this property over video. Most participants (60%) reported that they would prefer telemedicine over face-to-face assessments, and 90% viewed the procedure as more accessible than expected. All participants were satisfied with the telemedicine procedures. The results suggest that clinical assessment of dysphagia over telemedicine using the TWST and TOMASS are viable alternatives to face-to-face administration of the procedures.

Reliability and Validity of Non-Instrumental Clinical Assessments for Adults with Oropharyngeal Dysphagia: A Systematic Review

This systematic review on non-instrumental clinical assessment in adult oropharyngeal dysphagia (OD) provides an overview of published measures with reported reliability and validity. In alignment with PRISMA, four databases (CINAHL, Embase, PsycINFO, and PubMed) were searched, resulting in a total of 16 measures and 32 psychometric studies included. The included measures assessed any aspect of swallowing, consisted of at least one specific subscale relating to swallowing, were developed by clinical observation, targeted adults, and were developed in English. The included psychometric studies focused on adults, reported on measures for OD-related conditions, described non-instrumental clinical assessments, reported on validity or reliability, and were published in English. Methodological quality was assessed using the standard quality assessment QualSyst. Most measures targeted only restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Across the 16 measures, hypothesis testing and reliability were the most reported psychometrics, whilst structural validity and content validity were the least reported. Overall, data on the reliability and validity of the included measures proved incomplete and frequently did not meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods.

Telehealth Management of Dysphagia in Adults: A Survey of Speech Language Pathologists' Experiences and Perceptions

The goal of this study was to explore telehealth use for dysphagia management in response to COVID-19 to understand variables associated with clinician confidence and perceived effectiveness of this service delivery model and determine clinician-perceived benefits and challenges of managing dysphagia via telehealth. Speech-language pathologists (SLPs, n = 235) completed a web-based survey, providing information on demographics, telehealth use during the pandemic, and perspectives on current and future tele-management of dysphagia. Analyses included descriptive statistics to examine usage patterns; logistic regression to determine which variables were associated with telehealth use, clinician confidence, and perceived-effectiveness; and conventional content analysis to analyze responses to open-ended questions. Results revealed a sharp increase in the tele-management of dysphagia during the pandemic. Years of experience with dysphagia management (p = .031) and pre-pandemic use of telehealth (p < .001) were significantly associated with current use patterns. Working in the outpatient setting was associated with greater clinician confidence (p = .003) and perceived effectiveness (p = .007), and use of guidelines (p = .042) was also associated with greater clinician confidence. Key challenges identified included inadequate technological infrastructure, inadequate patient digital literacy, and reimbursement restrictions. Key benefits were treatment continuity, improving access to care, and time savings. The majority (67%) of respondents reported that they would use telehealth in the future. These findings demonstrate SLPs' abilities and desire to expand their practice patterns to include telehealth for dysphagia management. Therefore, clinician training and more research on best practices for assessment and treatment of dysphagia via telehealth is warranted to refine models of care for dysphagia tele-management.

Current opinion of presentation of dysphagia and dysphonia in patients with coronavirus disease 2019

PURPOSE OF REVIEW

Dysphagia and dysphonia are common presentations of both acute and long coronavirus disease 2019 (COVID-19). The majority of peer-reviewed publications in 2020 and early 2021 were expert guidance and consensus statements to support dysphagia management in multidisciplinary teams while protecting clinicians and patients from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. This review discusses dysphagia and dysphonia primary data published in 2021-2022, focusing on patient presentations, pathophysiology, and evidence for interventions.

RECENT FINDINGS

Clinicians and researchers amassed knowledge of the cross-system presentation of dysphagia and dysphonia in patients with COVID-19, from severe disease requiring ICU stays to those with mild-to-moderate disease presenting to outpatient clinics. Pre-COVID-19 health status, hospitalization experience, presence of neurological symptoms, and impact of the virus to the upper aerodigestive and respiratory system need consideration in patient management. Long-term dysphagia and dysphonia manifested from COVID-19 require otolaryngologist and speech-language pathologist input.

SUMMARY

Changes in immunity through population vaccination and variations in COVID-19 from SARS-CoV-2 mutations means prevalence data are challenging to interpret. However, there is no doubt of the presence of long-term dysphagia and dysphonia in our clinics. Long-term dysphagia and dysphonia are complex and a multidisciplinary team with a tailored approach for each patient is required.

An International Commentary on Dysphagia and Dysphonia During the COVID-19 Pandemic

COVID-19 has had an impact globally with millions infected, high mortality, significant economic ramifications, travel restrictions, national lockdowns, overloaded healthcare systems, effects on healthcare workers' health and well-being, and large amounts of funding diverted into rapid vaccine development and implementation. Patients with COVID-19, especially those who become severely ill, have frequently developed dysphagia and dysphonia. Health professionals working in the field have needed to learn about this new disease while managing these patients with enhanced personal protective equipment. Emerging research suggests differences in the clinical symptoms and journey to recovery for patients with COVID-19 in comparison to other intensive care populations. New insights from outpatient clinics also suggest distinct presentations of dysphagia and dysphonia in people after COVID-19 who were not hospitalized or severely ill. This international expert panel provides commentary on the impact of the pandemic on speech pathologists and our current understanding of dysphagia and dysphonia in patients with COVID-19, from acute illness to long-term recovery. This narrative review provides a unique, comprehensive critical appraisal of published peer-reviewed primary data as well as emerging previously unpublished, original primary data from across the globe, including clinical symptoms, trajectory, and prognosis. We conclude with our international expert opinion on what we have learnt and where we need to go next as this pandemic continues across the globe.

Rehabilitation of Airway Protection in Individuals With Movement Disorders: A Telehealth Feasibility Study

PURPOSE

Airway protective deficits (swallowing and cough) greatly reduce health and quality of life and are a pervasive consequence of neurodegenerative movement disorders. Expiratory muscle strength training (EMST) and cough skill training (CST) are two treatment approaches to improve airway protection; however, many patients are unable to access these treatments. Telehealth may improve access to care, but it remains unknown whether these treatments are feasible and efficacious via telehealth. This study aimed to determine the practical feasibility and preliminary treatment effect of EMST and CST via telehealth.

METHOD

Twenty participants with movement disorders completed 4 weeks of EMST and 2 weeks of CST, including two clinician-directed treatment sessions via telehealth and 3 days of home practice per week. Feasibility was calculated for each treatment. Practical feasibility was defined as completing treatment (EMST or CST) and obtaining the relevant outcome measures-a proxy of maximum expiratory pressure (pMEP) for EMST and peak expiratory flow rate (PEFR) for CST-within a 30-min session/period. Session factors that may have influenced feasibility were examined. Preliminary treatment effect was defined as changes in pMEP and PEFR.

RESULTS

Time taken to obtain pMEP and complete EMST was 17.48 min, and time taken to obtain PEFR and complete CST was 17.69 min. pMEP, single voluntary cough PEFR, and sequential voluntary cough PEFR increased from pre- to posttreatment.

CONCLUSIONS

Findings suggest that the delivery of EMST and CST is feasible via telehealth and yield improvements to pMEP and PEFR. This has important implications for expanding service delivery of airway protective interventions and reducing health care disparities in people with neurodegenerative movement disorders.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21357669.

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part II): Reliability and Validity in Healthy Elderly Individuals and Oral Cancer Patients

In our prior published study, we extracted evaluation items suitable for remote administration, and made a relatively simple Remote Examination of Deglutition (RED). This study aimed at verifying the reliability and validity of RED. The participants were 21 healthy elderly individuals and 72 postoperative oral cancer (OC) patients. OC patients underwent videofluoroscopic dysphagia examination, and severity was judged on the dysphagia severity scale (DSS). Reliability and validity of RED were examined in all participants under face-to-face conditions, in comparison with the Mann Assessment of Swallowing Ability (MASA). Reliability and validity of remote administration of RED were examined in 40 participants. ROC curves were used to find cut-off RED scores to predict aspiration and deglutition disorders. The Cronbach's alpha coefficient for the items was 0.882. There was a high correlation between the total score of RED and MASA in the face-to-face condition. When RED score was compared among different severity groups (DSS1-4, DSS5-6, and DSS7), the total and oral preparatory stage scores revealed significant group differences. The area under the curve (AUC) for aspiration based on the ROC curve was 0.913, with a sensitivity/specificity of 0.80/0.98. The AUC for deglutition disorders was 0.819, with a sensitivity/specificity of 0.74/0.67. In both face-to-face and remote conditions, the reliability of RED was good.The reliability and validity of RED were confirmed. RED has shown the potential to assess the likelihood of aspiration and deglutition disorders in OC patients remotely as an initial assessment tool.

Attitudes Toward Telehealth Services Among People Living With Parkinson's Disease: A Survey Study

Background

Telehealth has been widely adopted in providing Parkinson's disease care during the coronavirus disease 2019 pandemic.

Objective

The aim of this study was to survey people living with Parkinson's disease (PwPD) about their attitudes toward and utilization of telehealth services.

Methods

A survey was administered to PwPD via Parkinson's Foundation and Columbia University mailing lists.

Results

Of 1,163 responses, 944 complete responses were analyzed. Telehealth awareness was 90.2% (850/942), and utilization was 82.8% (780/942). More than 40% of PwPD were equally or more satisfied with telehealth compared with in‐person visits in all types of services used. The highest satisfaction was observed in speech‐language pathology appointments (78.8%, 52/66) followed by mental health services (69.2%, 95/137).

Conclusions

In selected circumstances and indications, such as speech‐language pathology and mental health services, telehealth may be a useful tool in the care of PwPD beyond the coronavirus disease 2019 pandemic. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson Movement Disorder Society.

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

Establishing Clinical Swallowing Assessment Services via Telepractice: A Multisite Implementation Evaluation

Purpose While research has confirmed the feasibility and validity of delivering clinical swallowing evaluations (CSEs) via telepractice, challenges exist for clinical implementation. Using an implementation framework, strategies that supported implementation of CSE services via telepractice within 18 regional/rural sites across five health services were examined. Method A coordinated implementation strategy involving remote training and support was provided to 18 sites across five health services (five hub and spoke services) that had identified a need to implement CSEs via telepractice. Experiences of all 10 speech-language pathologists involved at the hub sites were examined via interviews 1 year post implementation. Interview content was coded using the Consolidated Framework for Implementation Research (CFIR) and constructs were rated for strength and direction of influence, using published CFIR coding conventions. Results Services were established and are ongoing at all sites. Although there were site-specific differences, 10 CFIR constructs were positive influencing factors at all five sites. The telepractice model was perceived to provide clear advantages for the service, and clinicians were motivated by positive patient response. Strategies used to support implementation, including having a well-organized implementation resource and an external facilitator who worked closely with the local champions, were highly valued. Two CFIR constructs, Structural Characteristics and Available Resources, were challenges for all sites. Conclusions A complex interplay of factors influenced service implementation at each site. A strong local commitment to improving patient care, and the assistance of targeted strategies to support local implementation were viewed as central to enabling implementation.

Evaluating the Use of Telepractice for Bottle-Feeding Assessments

There is currently limited evidence supporting the use of telepractice to conduct bottle-feeding assessments. This study aimed to investigate the inter-rater reliability of bottle-feeding assessments conducted via synchronous telepractice (real-time videoconferencing). Secondary aims were to investigate parent and clinician satisfaction. Bottle-feeding skills of 30 children (aged 1 month-2 years) were simultaneously assessed by a telepractice SP (T-SP) at a remote location and an in-person SP (IP-SP) at the family home. A purpose-designed assessment form was used to evaluate: (1) developmental level (screen only), (2) state, color, and respiration, (3) oral motor skills, (4), infant oral reflexes, (5) tongue tie (screen only), (6) non-nutritive suck, (7) bottle-feeding, (8) overall feeding skills and (9) recommendations. Results of the T-SP and IP-SP assessments were compared using agreement statistics. Parents reported perceptions of telepractice pre and post session, and also rated post-session satisfaction. The telepractice SP completed a satisfaction questionnaire post-appointment. The majority of assessment components (45/53, 85%) met the agreement criteria (≥80% exact agreement). Difficulties were noted for the assessment of palate integrity, gagging during non-nutritive suck assessment, and 6 components of the tongue tie screen. Parent and clinician satisfaction was high; SPs reported that they would offer telepractice services to 93% of families again in the future. Overall, the results demonstrated that most components of a bottle-feeding assessment could be reliably completed via synchronous telepractice in family homes. However, further research is required to improve the reliability of some intra-oral assessment components.

Proactive changes in clinical practice as a result of the COVID-19 pandemic: Survey on use of telepractice by Quebec speech-language pathologists

BACKGROUND

The coronavirus disease2019 (COVID-19) pandemic has led to important challenges in health and education service delivery.

AIMS

The present study aimed to document: (i) changes in the use of telepractice by speech-language pathology (SLP) professionals in Quebec since the start of the COVID-19 outbreak; (ii) perceptions of the feasibility of telepractice by SLPs; (iii) barriers to the use of telepractice; and (iv) the perceptions of SLP professionals regarding the main issues of telepractice.

METHODS & PROCEDURES

An online survey with closed and open, Likert scale and demographic questions was completed by 83 SLPs in Quebec in June and July 2020.

OUTCOMES & RESULTS

The survey responses showed that within the cohort responding, telepractice use has increased significantly as a response to the COVID-19 pandemic. Most respondents planned to continue using telepractice after the pandemic ends. In addition, the respondents considered telepractice to be adequate for many clinical practices but less so for others (e.g., swallowing disorders, hearing impairment). Most of the reported barriers to the use of telepractice concerned technological problems and a lack of clinical materials for online use. Confidentiality and privacy issues were also raised.

CONCLUSIONS & IMPLICATIONS

SLP professionals rapidly took advantage of existing technologies in their clinical settings to cope with the pandemic's effects on service delivery. The discrepancy between their perceptions and the evidence in the literature for some practices and populations strengthens the need for more information and education on telepractice.

WHAT THIS PAPER ADDS

What is already known on the subject The proportion of speech-language pathologists (SLPs) in Canada who use telepractice for clinical activities is unknown. Knowing this information became crucial in the context of the coronavirus disease 2019 (COVID-19) pandemic because non-essential activities were interrupted to halt the spread of the disease. What this paper adds to existing knowledge The findings from this survey study confirmed that the use of telepractice in SLP in Quebec increased significantly during the COVID-19 pandemic. Moreover, the majority of the respondents began using telepractice because of the pandemic, and most planned to continue doing so after it ends. This demonstrates how SLP professionals rapidly took advantage of existing technologies in their clinical settings to cope with the pandemic's effects on service delivery. What are the potential or actual clinical implications of this work? Although the SLPs expressed an overall positive perception of telepractice, they also highlighted barriers to its optimal use. The findings of this study should help employers and regulatory bodies in Quebec to bring down those barriers and make telepractice in SLP a durable, effective and efficient service delivery model.

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part I): Selection of Examination Items

In order to ensure appropriateness and feasibility of examination items for remote evaluation for deglutition disorders, a questionnaire based on the Delphi method was administered to 122 speech–language–hearing therapists (STs), and a set of examination items was selected. The participants were instructed to view a video recording of a remote assessment situation and answer a 30-item questionnaire. Of 19 items ensuring the appropriateness for deglutition disorders detection, 13 items ultimately met the consensus criteria for remote feasibility. Factor analysis extracted three factors: ‘oral observation,’ ‘overall evaluation,’ and ‘perceptual voice judgment.’ In free-text responses, “quality and stability of the voice that may be heard through the device” were the most common concerns, followed by “the need to correct of the camera angle, magnification, and targets that should be projected,” “concerns about the technical aspects of the assistants and their role in relation with the examiner/ST,” and “the need for palpation as well as visual confirmation.” The proposed 13-item examination is considered to capture the characteristics of deglutition disorders, while items that appeared difficult to implement remotely were excluded. The fact that some items could be influenced by the video calling experience when judging the feasibility of remote implementation, the acceptability of such items, is likely to increase in the future.