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Feasibility and outcome evaluation of a
telemedicine application in speech–language
pathology
Claude Sicotte* , Pascale Lehoux*, Julie Fortier-Blanc
{
and
Yves Leblanc*
*Department of Health Administrat ion, Faculty of Medicine, University of Montreal;
{
Department of Speech– Language
Pathology, Facult y of Medicine, Universit y of Montreal, Quebec, Canada
Summary
This evaluative study assessed the feasibility and outcome of delivering speech–language services from a
distance to child ren and adolescents who stutter. All six patients who formed the first cohort seen in the
telespeech programme were included in the study. The results demonstrated that interactive
videoconferencing can provide a feasible and effective care delivery model. Patient attendance was
maintained throughout the intervention. All participants showed improved fluency. Stuttering ranged from
13% to 36% before treatment and 2% to 26% after treatment. All participants maintained at least part of their
improved fluency during the six-month follow-up, when stuttering ranged from 4% to 32%. The study
demonstrates that full assessment and treatment of stuttering in children and adolescents can be
accomplished successfully via telemedicine.
Introduction
...............................................................................
Speech–language pathologists (SLPs) are a scarce
resource and their availability is especially limited in
remote areas. The ability to offer speech therapy from a
distance represents an opportunity to improve access
for those who migh t oth erwise be deprived of SLP
assessment or treatment. However, speech–language
therapy for patients who stutter may require num erous
sessions over an extended period
1
. Clinical efficacy
depends on the establishment of a close relationship
between the SLP an d patient
2–6
. Intervention from a
distance may be possible, but studies dealing with
speech–language pathology applications are rare
7,8
.
There appear to be only two evaluative studies,
although both suggest that speech–language services
given via vi deoconferencing can be reliable and
acceptable for adults and children who stutter
9,10
. One
of these studies concerned diagnostic services
9
, while
the other dealt with follow-up service s to patients who
had undergone intensive on-site treatment
10
.
The aim of the present study was to assess the
feasibility of telemedicine in speech–language
pathology in children and to measure treatment
outcome in terms of clinical improvement i n speech
fluency.
Methods
...............................................................................
Telemedicine feasibility was assessed from the point of
view of both the patient and the SLP. It was assessed at
the end of the intervention for the patients and
concurrently for the SLP. Telemedicine outcome was
measured both from the point of view of the patient
and by objective changes in speech behaviour. This
latter part was assessed with a reliable, quantitative
clinical indicator, the percentage of syllables stuttered,
in a pre–post-treatment comparison
4,11,12
. The study’s
main sources of information were: questionnaires,
observation, structured intervie ws, video-tape
analysis.
Original article
........ ....... .............................. ....... ..................................................................................................
"
Journal of Telemedicine and Telecare 2003; 9: 253–258
Accepted 25 May 2003
Correspondence: Claude Sicotte, Department of Health Administration,
University of Montreal, PO Box 6128, Station Downtown, Montreal,
Quebec H3C 3J7, Canada (Fax: +1 514 343 2448;
Email: Claude.Sicotte@umontreal.ca)
Patient selection
The patients ha d to meet the followi ng criteria in order
to be selected for the intervention: d emonstrated
difficulty with at least 5% of syllables spoken;
considered themselves (or were consid ered by their
families) as having a stuttering problem; used
appropriate speech and language for their age; had no
concomitant medical or behavioural problems; were
willing to participate. The sample comprised six
patients: four ch ildren, aged between 3 and 12 years,
and two adolescents, aged 17 and 19 years. The study
was approved by the relevant university review board
for human subject research.
Telemed icine application
The telemedicine intervention was organized between
a Montreal paediatric tertiary care centre and a local
primary care centre, in Matane, a remote area in
northern Quebec, Canada. The objective of the
telemedicine intervention was to offer asses sment and
treatment for persons who stuttered and were unable to
receive these ser vices within their community. A
certified SLP special izing in stuttering was re cruited to
develop and deliver telemedicine services.
The SLP, based in Montreal, delivered the service via
videoconferencing. In Matane (the remote site), one
parent was present in the room with the child, to assist
the SLP and help keep the child focused on the activity.
In order to overcome the lack of physical contact with
the child, a strategy based on verbal interaction and
directives was used. Since it is more difficult to direct
activities from a distance, special care was taken in
choosing the toys and games used during therapy.
Participants received 12 i ndividual, 1 h sessions, at
weekly intervals. Four of the six participants received
an additional eight sessions, to give a total of 20 h of
therapy. During a subsequent maintenance phase, five
1 h sessions were given at the second, fourth and
eighth week, and then at the third and sixth month.
Regular contact following the active phase of therapy is
important to help participants maintain their fluency
skills
2,4
. The type of therapy given consisted of
currently accepted and well used procedures docu-
mented by various author s
4,13–21
. The telemedicine
intervention under study was initiated at the end o f
December 1999. It was carried out each week for each
patient until June 2000. Th e maintenance phase was
completed in January 2001.
Equip ment
The two sites were equipped with the same type of
videoconferencing unit (ViewStation MP, Polycom).
Each site had one television monitor (74 cm). The
microphones were omnidirectional and had both an
AGC (automatic gain control) function and an ANS
(automatic noi se suppression) function. Reception
frequencies varied between 50 Hz and 7.0 kHz. The
audio protocol used during the videoconference was
G.722. Transmission took place at a maximum of
768 kbits/s via an intranet.
Measurem ents
Feasibility was assessed in terms of patient attendance
and barriers that could affect attendance. The patient’s
attendance was documented usin g an administrative
log, which listed each telemedicine telecommuni-
cation and the identity of the interlocutors.
Documentation of potential barr iers w as first
conducted w ith the SLP, who was asked to complete
a structured questionnaire after each patient
intervention. The unit of analysis in this case was th e
telemedicine session.
After each session, the SLP rated its quality on a
seven-item, five-point scale ( from 1ˆ highly dissatisfied
to 5ˆhighly satisfied). The scale was divided into two
sections, relating to technical and clinical quality:
technical quality of the teleme dicine unit was assesse d
in terms of the quality of the sound, delay in signal
reception (which results in a jerky image or clipped
voice) and image quality; clinical quality of the
intervention was assessed in terms of the quality of the
therapeutic relationship with the patient, degree of
control over the patient during treatment, attainment
of clinical goals, and degree of patient complianc e with
the instructions given by the therapist.
A structured questionnaire was administered once to
each patie nt or parent by telepho ne at the end of the
treatment sessions. The unit of analys is in this case was
the entire intervention. Patient satisfaction with
respect to the technical quality of th e telemedicine unit
(image and sound quality) and with respect to the
clinical quality of the intervention (quality of the
contact between the child and the SLP) was assessed,
on a three-point scale: highly satisfied, somewhat
satisfied, not at all satisfied.
The survey also included questions to help identify
potential barrie rs in terms of accessibility. Three factors
were measured: geographical accessibility (the distance
from the patient’s home to the telemedicine site),
temporal accessibility (potential scheduling conflicts
between daily activities such as school and work and
the intervention time), and financial accessibility (cost
for the patient to receive therapy). No additional fees
were requested to cover the use of the telecom-
munication system or p rofessional fees of the SLP, as is
the practice in the Canadian public health care system.
Patient expenses assessed in the survey related to car-,
C Sicotte et al. Telemedicine for speech–language pathology
254
Journal of Telemedicine and Telecare Volume 9 Number 5 2003
work- or home-related expenses enc ountered by the
participants when coming to treatment.
At the end of treatment, patients or their parents
were asked to rate, on a three-point scale (high, a little,
none), their perceived reduction in the frequency of
stuttering and the acquisition of better communication
skills. Furthermore, the frequency of stuttering
was assessed in various communicative activities
(conversation, picture description and readin g for older
subjects or the Stocker Probe Technique for younger
subjects
22,23
). This outcome measure was obtained by
determining the number of stutte red syllables over the
total number of syllables spoken, expressed as a
percentage. It was determined twice before therapy,
twice at the end of the treatment phase, and three
times during the maintenan ce phase
11
. A mean was
calculated for each of the treatmen t phases from the
repeated measures tak en during the pre- and post-
treatment and maintenance phases. This measure,
determined by analysing the speech recorded on video-
tape, is among the most widely used to determine
stuttering frequency, a prominent overt characteristic
of the problem
2–4,12
.
Results
...............................................................................
Patient attendance
All six patients were prese nt at each weekly therapeutic
session and at each follow-up session. All patients
completed the entire programme without missing any
sessions.
Therapis t’s opinion
There was a resp onse rate of 85% (101 completed
questionnaires out of 119 sessions). Technical quality
was judged by the SLP as being moderately good.
Overall, 50% of the session ratings were of 3 on the
five-point scale (Table 1) and 43% of the session ratings
were of 4 or more for the technical quality. Among the
three indices of technical quality, image quality was
judged the least successful, with 63% of the ratings in
the middle of the scale.
Clinical quality was judged more positively by the
therapist: 81% of the ratings were on the positive side
of the scale (the SLP was satisfied 53% of the time and
highly satisfied 28% of the time). A few drawbacks were
observed with regard to the quality of the interaction
between the child and SLP. This was mainly attributed
to the child’s behaviour. Fro m a distance, it is very
difficult for a cl inician to interact adequately with
agitated children who move constantly. It is also
particularly difficult to comprehend shy children who
speak softly.
Overall, the telemedicine unit was judged as ade-
quate by the SLP to delive r a satisfactory intervention.
Patients’ opinions
The response rate to the questionnai re was 100%. The
perceptions of the six patients were very positive, at
both the technical and clinical levels (Table 2).
Technical quality was scored at the highest level by all
but one of the patients. The quality of contact between
the child or adolescent and therapist was also scored at
the highest level except for one score. All patients or
parents had confidence in the quality of the care th ey
received, despite the fact that it was delivered from a
distance.
Accessibi lity
Geographical accessibility was not considered a
problem. Five of the six patients had to travel less than
30 km on a return trip (i.e. to the telemedicine facility
and back home). The sixth patient ha d to travel a far
greater distance (190 km). However, this distance was
not perceived as a major barrier given the scarcity of
resources in the region and the unique opportunity to
access this care.
Temporal accessibility was not considered a real
obstacle either. Even though the sessions were given in
the middle of the week, during regular office hours,
parents and patients arranged their schedules
accordingly.
C Sicotte et al. Telemedicine for speech–language pathology
Journal of Telemedicine and Telecare Volume 9 Number 5 2003
255
Table 1 Speech–language pathologist’s ratings of the
telemedicine sessions
a
(percentage of sessions receiving a rating of
1–5
b
)
1 2 3 4 5
Technical quality
Sound quality 0 9 43 47 1
Delay in signal reception 3 3 45 49 0
Image quality 0 2 63 33 2
Mean 1 5 50 43 1
Clinical quality
Quality of the therapeutic
relationship with the patient
0 1 18 44 37
Degree of control over the patient
during treatment
0 0 14 53 33
Attainment of clinical goals 0 1 17 63 19
Degree of patient’s compliance
with the instructions given by the
speech–language pathologist
1 2 23 51 23
Mean 0.25 1 18 53 28
a
The response rate was 85% : questionnaires were completed for 101 out o f a total of
119 telemedicine sessions.
b
A rating of 1 i ndicated ‘Highly dissatised’ and of 5 indicated ‘Highly satised’.
Finally, economic accessibility was also not a
problem, since the highest cost, that of the professional
fees for SLP services, was covered by the Quebec Public
Health Insurance System. The highest personal expense
was C$20 per session, which the parents considered
reasonable (C$1 is US$0.66, 0.59).
Thus, none of these factors was perceived as an
obstacle to the receipt of care. The opportunity to
access a scarce resource was appreciated by both the
patients and parents.
Outcome s
On the thre e-point self-rated scale, fi ve of the six
participants gave the highest score for the reduction in
the frequency of stuttering, while the sixth
participant’s e valuation was positive but to a lesser
degree, and four gave the highest score for their
communication skills, while a fifth participant
indicated the middle of the scale and a sixth indicated
the lowest level of the scale (Table 3). These last two
scores concerne d the youngest patients and may be
attributed to the fact that it is more difficult for parents
of young children to assess the acquisition of social
communication skills.
Changes in speech fluency were measured by
determining the frequency of stuttering expressed as a
proportion of syllables stuttered. All participants
showed improved fluency (Table 4). Stuttering ranged
from 13% to 36% across participants before treatment
and from 2% to 26% after treatment. All participants
maintained at least part of their improved fluency at
the e nd of follow-up, when stuttering ranged from 4%
to 32%.
Two subjects (B and C), among the youngest
children, d emonstrated a decrease in stuttering after
treatment and continued to improve their speech
during the maintenance period. Participants A and E
showed a decre ase in stuttering after treatment and
maintained their gains during follow-up. Two
participants (D and F) showed a decrease in stuttering
after treatment and an increase in stuttering during the
follow-up period. Participant D regressed during the
maintenance phase but regained partial fluency at the
end of this period.
Discussion
...............................................................................
The present study used a battery of qualitative and
quantitative measures to assess feasibility and outco me
of telemedicine in speech–language pathology. Both
patient and clinician satisfaction were high, and
participants conside red the intervention to be effective,
despite the physical absence of the clinician. The
patients’ perceptions regarding a decrease in stuttering
were very favourable. In addition, the appeal of this
form of care in remote regions was so high that there
C Sicotte et al. Telemedicine for speech–language pathology
256
Journal of Telemedicine and Telecare Volume 9 Number 5 2003
Table 2 Patients’ or parents’ perceptions of telemedicine
Patient Age (years) Duration of therapy
(weeks)
Technical
performance
a
Therapeutic contact
b
Concerned about
treatment from a distance
c
A 4 20 Highly Highly Not at all
B 5 20 Highly Somewhat Not at all
C 7 12 Highly Highly Not at all
D 12 12 Highly Highly Not at all
E 17 20 Somewhat Highly Not at all
F 19 20 Highly Highly Not at all
a
‘A re you satised with the technica l performance (image and sound quality)?’, rated on a three-point scale: hig hly satised, somewhat satised, not at all satised.
b
‘ Are you satised that the c ontact between the patient and speech–language pathologist was good despite the distance?’, rated on a three-point scale: highly satised,
somewhat satised, not at all satised.
c
‘A re you concerned that you were (or your child was) treated from a distance by a speech–language pathologist?’, rated on a three-point scale: highly concerned, som ewhat
concerned, not a t all concerned.
Table 3 Patients’ or parents’ perceptions of outcome
a
Patient Reduction in frequency
of stuttering
Acquisition of better
communication skills
A High A little
B High None
C A little High
D High High
E High High
F High High
a
Rated on a three-point scale: high, a little, none.
Table 4 Frequency (%) of syllables stuttered
Patient Before
intervention
After
intervention
At end of
follow-up
A 16.7 8.6 9.5
B 15.0 8.5 5.6
C 23.7 15.2 6.1
D 17.2 2.3 8.6
E 13.4 2.1 4.0
F 35.5 26.3 31.5
were few barriers to limit patient attendance. Howeve r,
telemedicine also has its drawbacks. Clearly, this type
of intervention is more dem anding for the clinician,
particularly when it comes to dealing with young
children, and for parents, who must take an active role
during treatment. Although this presents an additional
burden for parents, it was not perceived as a constraint
and was offset by the opportunity to access SLP
services.
Quantitative results with regard to increased speech
fluency w ere also positive but still need to be compared
with traditional, face-to-face methods of intervention.
Unfortunately, few studies have dealt with tre atment
effectiveness in stuttering and most have investigated
intensive forms of intervention. Culatta and Goldberg
considered a 50% success rate with stutterers to be
laudable
24
. Bloodstein conclud ed that substantial
improvement occurs in 60–80% of stutterers
25
.
Pellowski
et al.
stated that 65% of preschool stutterers
make significant gains in therapy
26
.
Our findings showed a mean 52% decrease in the
frequency of stuttering. Furthermore, treatment
effectiveness in terms of post-treatment frequency of
stuttering has been reported as 1–4%, with slightly
higher frequencies, up to 6%, found 6–12 months after
treatment
27–33
. Our data showed a higher frequency of
stuttering following intervention. However, the
subjects, especially adults, often benefited fr om longer
periods of therapy than did stutterers in the present
study. The mean number of therapy hours reported for
the therapeutic and maintenance phases of inter-
vention have been 19–31 hours in preschool
children
20,29,34
and 24–70 hours in school-aged
children
3,30,35
. In adults, over 100 contact hours were
often needed to make significant and long-lasting
progress in fluency
33,36,37
. The treatment time received
by participants in th e present study was at the lower
end of the range and a greater reduction in stuttering
would probably have been possible with more contact
hours.
Initial (pre-treatment) frequenc y of stuttering is
another factor to consider when interpreting results.
The frequency in the present study was greater than
has been reported in other studies and may partly
explain th e poorer post-treatment scores
28,31– 33,38
. In
addition to these measures, it is now considered that
self-evaluation regarding speech behaviour and the
subjective views of the child and parents are critical
components of treatment outcome evaluation
39–41
, a
dimension assessed in our study.
The results thus add new evi dence about tele-
medicine in speech–language patho logy. The present
study goes beyond findings that telemedicine is a
feasible means of providing follow-up services to
stutterers after an initial on-site intervention
10
. This
research demonstrates that full assessment and
treatment of stuttering in children and adolescents can
be accomplished successfully via telemedicine. It
appears to be an important supplement to existing care
delivery models in the field of speech–language
pathology. It is applicable to areas where SLPs are rare.
It is an effective and well appreci ated service and, as
such, can contribute to the quality of care offered in
remote areas.
Acknowledgements:
This research was funded by an
operating grant from the Canadian Institute of Health
Research (MOP-36370).
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