ArticlePDF AvailableLiterature Review


It is estimated that 10% of the world's population, approximately 650 million people, have some form of disability. Population growth, aging, and medical advances that preserve and prolong life have increased demands for health and rehabilitation services. Recent predictions indicate a shortage of speech-language pathologists and other rehabilitation specialists to provide care for individuals with disabilities. The application of telemedicine and telehealth technologies offers effective solutions to this challenge. An extensive literature review was conducted that included technical reports, websites, publications from the American Speech-Language-Hearing Association, and peer-reviewed journal articles of telehealth applications in speech-language pathology. Various applications of telehealth in speech-language pathology are described including types of technology, patient and clinician satisfaction, advantages of using telehealth, challenges and barriers to application, and future directions. This review provides a strong foundation for broader applications of telehealth technologies in this area of healthcare.
DOI: 10.1089/tmj.2008.0080 © MARY ANN LIEBERT, INC. • VOL. 14 NO. 10 • DECEMBER 2008 TELEMEDICINE and e-HEALTH 1101
Pauline A. Mashima, M.S.,1 and Charles R. Doarn, M.B.A.2
1Communication Sciences and Disorders, 2Advanced Center for
Telemedicine and Surgical Innovation, University of Cincinnati,
Cincinnati, Ohio.
It is estimated that 10% of the world’s population, approximately
650 million people, have some form of disability. Population growth,
aging, and medical advances that preserve and prolong life have
increased demands for health and rehabilitation services. Recent
predictions indicate a shortage of speech–language pathologists and
other rehabilitation specialists to provide care for individuals with
disabilities. The application of telemedicine and telehealth technolo-
gies offers effective solutions to this challenge. An extensive literature
review was conducted that included technical reports, websites, pub-
lications from the American Speech-Language-Hearing Association,
and peer-reviewed journal articles of telehealth applications in
speech–language pathology. Various applications of telehealth in
speech-language pathology are described including types of technol-
ogy, patient and clinician satisfaction, advantages of using telehealth,
challenges and barriers to application, and future directions. This
review provides a strong foundation for broader applications of tele-
health technologies in this area of healthcare.
Key words: telehealth, telepractice, telerehabilitation, speech–lan-
guage pathology, communication disorders, swallowing disorders,
dysphasia, speech therapy, language therapy
peech and language disorders affect one’s ability to talk,
understand, read, and write, and may range from a few
speech sound errors to a total loss of the ability to use speech
to communicate effectively. Dysphagia or a swallowing dis-
order is a serious health problem that can be life-threatening. Speech–
language pathologists (SLPs) evaluate, diagnose, and treat communica-
tion and swallowing disorders in individuals of all ages, from infants
to the elderly. The American Speech-Language-Hearing Association
(ASHA) is the professional, scientific, and credentialing association for
more than 130,000 SLPs, audiologists, and speech, language, and hear-
ing scientists in the United States and internationally.1
A significant problem in many geographical areas is a shortage of
SLPs. According to the U.S. Bureau of Labor Statistics, employment
of SLPs is expected to grow 11% from 2006 to 2016, about as fast
as the average for all occupations.2 A healthcare survey conducted
by ASHA in 2005 identified an increase in vacancies from 25% in
2002 to 40% in 2005 for SLP positions across all healthcare settings.
The largest increase in vacancies was in home health.3 A survey of
schools conducted by ASHA in 2006 identified school districts with
significant personnel shortages; 68% of respondents reported that job
openings were more numerous than job seekers.4
ASHA’s position is that telepractice or telehealth is an appropri-
ate model of service delivery for the profession of speech–language
pathology, and may be used to overcome barriers of access to services
caused by distance, unavailability of specialists and/or subspecialists,
and impaired mobility.5 Research and demonstration projects have
provided evidence that telehealth is a feasible, effective, and appro-
priate model for providing SLP services to a broad range of patients.
According to a review of the literature, clinicians in Australia,
Canada, Greece, Ireland, Japan, the United Kingdom, the United
States, and Sweden are exploring the possibility of using telehealth
to diagnose, assess, and provide treatment to individuals with com-
munication and swallowing disorders who otherwise may not have
access to these services. The objective of this paper is to provide an
overview of the literature.
Materials and Methods
An extensive literature search was conducted of current avail-
able resources including peer-reviewed journal articles, professional
Overview of Telehealth Activities in
Speech–Language Pathology
and lay articles, abstracts of presentations, and policy statements by
associations. The search included the following terms: telehealth,
telemedicine, telepractice, telerehabilitation, speech–language pathol-
ogy, communication disorders, speech therapy, language therapy,
swallowing disorders, and dysphagia.
This literature search resulted in 40 articles that are tabulated
in the Appendix. In addition to policy documents, the existing lit-
erature consists primarily of pilot studies and anecdotal accounts of
telehealth applications rather than large, well-controlled, random-
ized clinical trials. The following is a discussion of topics that were
gleaned from each source.
Patient Candidacy
Patient candidacy for the telehealth model of service delivery in SLP
is typically determined on a case-by-case basis utilizing careful selec-
tion criteria. While not exclusionary, the following factors are typically
considered: (1) ability to sit in front of a monitor and attend to the
clinician; (2) ability to see material on a computer monitor; (3) ability
to follow directions to operate the equipment; (4) ability to sit in front
of a camera and minimize extraneous movements to avoid compromis-
ing the image resolution; (5) manual dexterity to operate a keyboard if
needed; (6) hearing acuity; (7) cognitive ability; (8) speech intelligibil-
ity; (9) comfort level with technology; (10) willingness of patient or
family/caregiver to participate; (11) cultural/linguistic considerations
such as the availability of an interpreter if needed; and (12) access to
and availability of technical resources if needed.6
Investigators at the Mayo Clinic reported the following challenges
for SLP consults in their early experience with telemedicine: (1) the
inability to assess muscle strength and musculoskeletal tension and
to physically manipulate speech structures may result in omission of
important information in patients with motor speech disorders; (2) elic-
iting sensitive case history information at-a-distance may be difficult
when assessing patients with psychogenic speech disorders; and (3)
patients with significant language or cognitive impairment may have
difficulty grasping the interactive process over television monitors.7
Clinicians at the Rehabilitation Engineering Research Center on
Telerehabilitation at the National Rehabilitation Hospital (NRH)
reported that age, education, technology experience, and gender
did not significantly affect the difference between performance of
brain-injured patients on a standardized speech-language evaluation
conducted face-to-face versus via videoconference.8 Stroke-related
symptoms such as poor attention, severely impaired comprehension,
poor vision, and motor impairment may adversely affect a patient’s
ability to participate in a telehealth session. However, “in-home”
delivery of speech–language services may be most appropriate for
this population if family members, caregivers or paraprofessionals are
available and willing to provide assistance.9–11
A variety of venues are involved in the delivery of SLP services
via telehealth, including medical centers, rehabilitation hospitals,
specialty cancer care centers, satellite clinics, residential healthcare
facilities, rural community health centers, Veterans Affairs Medical
Centers, military medical facilities, universities, patient’s homes,
schools, and child care nurseries. The majority of applications are
aimed at reaching out to underserved populations in remote or rural
areas within a district, county, state, province, or country to evalu-
ate and/or treat speech, language, cognitive–communication, and
swallowing disorders (see Appendix for a summary of applications
including types of services and technologies used).
SLPs have used the telehealth model to provide services to patients
with aphasia, dysarthria, apraxia, cognitive–communication disor-
ders, and dementia resulting from cerebrovascular disease (CVA),
traumatic brain injury (TBI), Parkinson’s disease, cerebral palsy,
and multiple sclerosis. Telehealth offers the potential to extend the
continuum of care and improve clinical outcomes for these patients,
particularly in light of insurance reimbursement challenges and
shortened lengths of hospital stays.10
Early application of telecommunications technology in SLP
focused on diagnosis and treatment of neurogenic communication
disorders. In 1976, a “Tel-communicology” healthcare delivery sys-
tem for veterans was developed to meet expanding demands, upgrade
services, and overcome logistic problems. This system was designed
to enhance rather than replace traditional programs to treat patients
with communication disorders including aphasia and dysarthria.12
Beginning in 1987, investigators in Mayo Clinic facilities provided
SLP telemedicine consultations for patients with communication dis-
orders including dysarthria, apraxia, and cognitive–communication
impairment. They concluded that telemedicine provides an appro-
priate medium for speech–language consultations that is reliably
accurate in identifying various acquired neurogenic and psychogenic
speech disorders.7 In 1992, clinicians at the Veterans Affairs Medical
Center in Martinez, California conducted a simulation study to com-
pare face-to-face with “remote conditions” in the appraisal and diag-
nosis of aphasia, apraxia, dysarthria, and dementia. The agreement in
diagnosis among appraisal conditions was 93% to 94%. Results sug-
gested that either television or computer-controlled video laserdisc by
telephone could be substituted for face-to-face sessions.13
Since these early studies, many telehealth applications for neuro-
genic communication disorders have been reported. Investigators at
the Rehabilitation Engineering Research Center on Telerehabilitation
at the NRH have been at the forefront in technology innovations to
deliver services to patients with CVA and TBI.8,10,14,15 Clinicians in
Australia conducted a telerehabilitation pilot study with 19 partici-
pants with dysarthria. Results suggested that reliable assessment of
motor speech disorders over the Internet is possible in adults with
acquired neurological impairment with additional refinement of their
technology and assessment protocols.16 An investigator at the Center
for Health and Disabilities Research, National Rehabilitation Hospital,
reported that pilot study results with 24 poststroke patients suggested
that assessment of a patient’s functional communication using vid-
eoconferencing equipment at a transmission speed of 384 kilobits
per second (Kbps) was equivalent to a face-to-face encounter. A ran-
domized, double-crossover agreement design was used with carefully
devised criteria for a telemedicine equivalence trial. The investigator
outlined methodological improvements over previous telerehabilita-
tion studies and cited recommendations for future studies.17
In anecdotal reports, the Speech Therapy Department at St. Alexius
Medical Center in Bismarck, North Dakota, provided care through
their Tele-Care Network to patients in rural communities who suf-
fered a stroke and lacked access to local SLP services.18 A speech
pathologist in the Department of Veterans Affairs in Lexington,
Kentucky, reported treatment gains, good patient response, and cost
savings with the use of videophones to treat anomia.19 Clinicians in
Vasterbotten, Sweden, reported positive results and high patient sat-
isfaction with interactive and store-and-forward telehealth speech–
language rehabilitation for adults with aphasia.20
Telehealth is being used to address the problem of unfilled SLP posi-
tions in home healthcare agencies.11,21,22 One of the many important
responsibilities of SLPs in this setting is to evaluate and treat patients
recovering from speech, language, cognitive, and swallowing disorders
associated with CVA. Timely and regular rehabilitation services are
critical to maximize the potential for recovery of function or use of
compensatory strategies to enable the patient to be as independent as
possible including the possibility of returning to the workforce.
Telehealth is particularly advantageous in the treatment of fluency
disorders because there are few specialized centers for treating stuttering
and long-term follow-up for maintenance is frequently required. Early
stuttering should be treated efficaciously in the preschool years to pre-
vent progression to a long-term form. Although the Lidcombe Program
of Early Stuttering Intervention has been shown to be an effective treat-
ment, many children in Australia who live in rural and remote areas do
not have access to this program. Because it is implemented by parents
under guidance of an SLP, it is easily adaptable to telehealth delivery. A
series of research trials provided evidence that use of low-tech telehealth
technology (training videos, recorded speech samples, telephone, e-mail)
yielded satisfactory clinical outcomes; however, in one study, the results
were obtained with lengthier treatment times and at higher cost com-
pared to traditional clinic-based delivery.23,24
Researchers at the Australian Stuttering Research Centre at the
University of Sydney conducted a Phase 1 trial to investigate the via-
bility of telehealth delivery of the Camperdown Program with adults
who stutter. This behavioral treatment involving speech restructuring
was conducted remotely via telephone and e-mail contact between
clinician and patient. Preliminary data from 10 adults suggested that
the Camperdown telehealth program has potential to provide effica-
cious treatment for patients who do not have access to traditional
face-to-face treatment.25
A study was conducted with children and adolescents who stutter to
assess the feasibility and outcome of delivering services at-a-distance
between a Montreal pediatric tertiary care center and a primary care
center in a remote area in Northern Quebec, Canada. Results demon-
strated that interactive videoconferencing is a feasible and effective
model and resulted in improved fluency in all participants.26
Clinicians at the Institute for Stuttering Treatment and Research at
the University of Alberta in Canada used videoconferencing to pro-
vide services to adults in geographically remote areas following their
discharge from intensive treatment at the Institute. Clinical measures
of communicative performance, verbal reports from patients, and
clinician judgments indicated that treatment goals were met and
patients were satisfied with their telehealth treatment.27,28
Speech pathologists in Australia used an Internet-based (128 Kbps)
telerehabilitation application to deliver the Lee Silverman Voice
Treatment (LSVT) to 10 participants with Parkinson’s disease (PD).
Patient access to this treatment was limited because of distance, the
limited availability of certified LSVT clinicians in rural/remote areas
of Australia, and patient mobility challenges that preclude or impede
their travel to a healthcare facility in both urban or rural environ-
ments. Treatment outcomes data demonstrated that the online treat-
ment was feasible and effective.29 In an anecdotal report, telehealth
sessions combined with home visits enabled clinicians with the Visiting
Nurse Service of New York-Home Care to offer the LSVT program to
patients with PD. The intensive four-sessions-per-week schedule of
this evidence-based program often makes it unavailable to homebound
patients because of access difficulties or heavy caseload demands.21
Following a successful proof-of-concept study with 51 participants
in Hawaii, a vocal rehabilitation program was deployed from Tripler
Army Medical Center in Honolulu to treat patients diagnosed with
voice disorders in a U.S. Naval Hospital in Japan.30,31 The use of video
teleconferencing via Integrated Services Digital Network (ISDN) lines
(at 384 Kbps) provided patients with access to services not available
in their military medical facility. Preliminary data indicated that
clinical outcomes were comparable to providing therapy in-person.
Investigators in Australia validated an Internet-based telerehabili-
tation system designed to assess patients following surgical removal
of the larynx because of cancer. Greater than 80% agreement was
reported between online and face-to-face assessments of oromotor,
swallowing, and communication outcomes of 20 patients postlaryn-
gectomy; however, visualization of the stoma was reported to be
poor. Assessments were conducted at a bandwidth of 128 Kbps.32
An SLP in a specialty cancer care center in Manitoba used tele-
health technology to provide voice and speech therapy, tracheoe-
sophageal voice prosthesis management, psychosocial and peer sup-
port, and education for patients, family members and local healthcare
professionals. Telehealth addressed the challenge of providing post-
laryngectomy follow-up and rehabilitation for patients in rural or
remote communities in Manitoba where access to specialized head
and neck cancer expertise is often unavailable.33
Patients who are at risk for dysphagia should be thoroughly evalu-
ated because impaired swallowing can result in significant morbidity
and mortality. However, subspecialists in dysphagia may not be avail-
able in small rural communities or in remote areas. In addition to a
clinical evaluation, instrumental examination (e.g., videofluoroscopic,
fiberoptic endoscopic) is routinely used to identify underlying variables
and determine appropriate management strategies for the swallowing
problem. Investigators at the University of Illinois developed a program
using video transmission over a T1 line that permits real-time, remote,
interactive evaluation of oral/pharyngeal swallowing function. A custom
interface enabled an expert SLP at the controlling site to direct a modi-
fied barium swallow study remotely and view and interpret in real-time
the videofluoroscopic images captured in a hospital radiology suite.34
In anecdotal reports, an SLP at the University of Kansas Hospital men-
tored a colleague at a rural site in Kansas in performing modified barium
swallow studies utilizing a videofluoroscope that attached directly to a
Polycom F/X system. The cooperative venture provided an invaluable
diagnostic service to patients in an underserved rural area of Kansas
and eventually enabled the local clinician to complete the swallow stud-
ies independently.35 An SLP with the Visiting Nurse Association Health
Services in Port Huron, Michigan, monitored her patient through their
telehomecare program after discharging him from in-home dysphagia
therapy. The services, which were considered adjunct to the therapy
already provided, resulted in significant improvement in the patient’s
swallowing function. Without telehomecare, the follow-up services
would not have been possible since monitoring or maintenance is not
considered a skilled service that warrants in-home visits.11
There has been greater awareness of and increased emphasis on
the importance of early identification and diagnosis of speech and
language disorders. When the Individuals with Disabilities Education
Act (IDEA) was implemented in 1990 mandating special education
and related services to all eligible children with disabilities, rural
schools were faced with personnel shortages and problems with
recruitment and retention. In Oklahoma, a metropolitan rehabilitation
hospital, a rural hospital, and a rural school formed a partnership to
test the outcomes and acceptance of teletherapy in a public school.36
In North Dakota, the Center for Persons with Disabilities located at
Minot State University developed a program to provide speech–lan-
guage therapy through interactive videoconferencing in remote areas
of North Dakota where services were otherwise limited or nonexistent
because of SLP personnel shortages.37
Early intervention can reduce the negative effects of childhood
speech–language disorders such as academic difficulties. Children
with speech and language disorders in rural and remote areas may be
at a disadvantage because of poor access to SLP services. Results of
a pilot study in Australia suggest that an Internet-based assessment
protocol delivered via video teleconferencing through a 128 Kbps
link has potential to provide a clinically reliable method for assess-
ing pediatric speech disorders.38 In the United Kingdom, clinicians
are using videoconferencing technologies to deliver speech–language
therapy remotely to support services to children with communication
difficulties in mainstream schools.39 In Belfast, SLP services were pro-
vided to preschool children in a nursery and in their homes with an
interactive audiovisual interface, computers, and an ISDN 2 line (128
Kbps). “Televisits” allowed parents to participate more fully in their
child’s therapy program and gain a greater understanding of their
child’s communication development by observing them in the nurs-
ery setting. Clinicians were able to observe the child’s communication
environment in an unobtrusive manner and provide guidance to par-
ents.40 These projects demonstrate that telehealth is a viable treatment
option for children with special needs and can be used to support the
delivery of speech–language therapy services in the schools.
The dynamic nature of communication, problem-solving, and
behavior modification often necessitates synchronous transmis-
sion for “real-time” interactive evaluation and treatment of com-
munication disorders. Studies have demonstrated that VTC is a
viable and effective method for providing SLP services at-a-dis-
tance.7,8,14,16,26,27,29,31,33,34,36,37,39,40 Auditory/verbal/visual interaction is
essential for most procedures or at least preferred over audio only
connections to enhance a sense of clinician “presence” and to facili-
tate rapport with patients.
Although the majority of SLP applications utilize VTC technology,
store-and-forward components have also been used as a primary or
adjunctive means of delivering services.12,16,20,23,25,29,32,34,38,41
An important consideration in equipment selection is the exis-
tence of the infrastructure or network across which they connect.
Equipment, connectivity mediums, and bandwidth specifications vary
according to the telehealth application and desired outcomes. Image
and sound quality must be adequate to support the clinical procedure.
Equipment used in SLP telehealth applications include telephones,
videophones, fax machines, VTC units, computers for e-mail and
video teleconferencing software and webcams, closed circuit televi-
sions, and image scanners.6 Technology used for telehealth SLP ses-
sions should not distort or interfere with communication, or must do
so only in a minimal and well-characterized way, since the quality
of signals must support assessment and treatment of communication
disorders.8 Adequate bandwidth connection is imperative to ensure
optimal audio and visual quality for clinical decision-making.
Intervention tools such as custom software are being developed
to interface with VTC equipment to provide a “virtual desktop” for
clinicians to administer therapy materials. For example, research
engineers at the NRH developed a remote interactive touch screen
which is highly intuitive and allows for fast and efficient control of a
computer for therapy tasks and is particularly useful for patients with
minimal computer experience or cognitive impairment.10
Investigators in Greece developed an innovative Web-based sys-
tem of technology-assisted speech and language therapy tools and
visual speech aids. The “Telelogos” system provides information,
tests, report templates, a database for storing patient records and
information, and e-learning applications.42 According to usabil-
ity studies, the system has potential to supplement the traditional
delivery of speech therapy services. Pierrakeas et al.41 discussed the
use of “online collaboration environments” for various telehealth
applications for speech therapy including: online group therapy for
articulation disorders, aphasia and stuttering; clinical consultation
with a multidisciplinary team; and online mentoring and continuing
education. Both of these systems provide exciting possibilities for the
global delivery of SLP services.
Response to Telehealth
In addition to positive clinical outcomes, telehealth applications
have yielded favorable patient feedback. With technological advance-
ments and the ubiquitous use of computers in our daily lives, telehealth
is assuming a desirable role in the delivery of healthcare, particularly
for patients with an interest in technology. In Brennan et al’s study,10 4
of 10 patients with left and right CVA reported that their comfort level
was better in the telerehab condition because they felt “less self-con-
scious” when the clinician was out of the room or was “less distracted
because the computer made it interesting.” In a subsequent study with
40 participants with recent CVA or TBI, 34 of 40 participants expressed
an interest in future use of VTC.43 In a case report by Kully,27 a patient
who stuttered perceived the VTC format as challenging but manage-
able, and less demanding on fluency control than the telephone format
which was the traditional medium for their long-distance maintenance
program. In a study that compared in-person with remote delivery
of a vocal rehabilitation protocol, both quantitative data on clinical
outcomes and qualitative feedback were positive from patients who
received therapy via the telehealth model (e.g., “The video sessions
were just as good [as in-person]. It made it more interesting to see tech-
nology playing a part in medical sessions”). In fact, 16 of 16 qualitative
patient comments on the telehealth model were positive.30
Clearly, clinician satisfaction with the telehealth model is critical
to its widespread acceptance and use. With positive patient responses,
most SLPs engaged in telehealth have embraced the use of technol-
ogy in their practice, despite admitting to initial skepticism. The lack
of tactile feedback and cues may require creative problem-solving or
even preclude the use of techniques that require “hands-on” delivery.
However, investigators have reported that the absence of a clini-
cian’s physical presence does not compromise the “human element”
or reduce the effectiveness of services provided via telehealth.30,44
Suboptimal clinician satisfaction has generally been reported with
telehealth systems that utilized low bandwidth transmission or
low-tech options for auditory perceptual ratings of speech charac-
teristics that are inherently challenging to judge such as nasality or
resonance, or visual perceptual ratings of oromotor movements or
anatomical structures.16,32
Advantages of Telehealth
Telehealth offers the potential to deliver services in underserved
and remote/rural geographic areas where they are not available, and
in areas with shortages of specialists or lack of subspecialists. In
several reports, telehealth also provided access to a university medi-
cal center. As a result, both patient and clinician benefited from the
knowledge and expertise of a host of medical specialists. This was
particularly advantageous for the clinician since practicing in a rural
environment afforded few opportunities to interact with colleagues
for professional growth and skill development.34,35,45
Telehealth not only increases the capacity to provide service in
a “no-service” area but reduces the potential delay of service.46 For
example, the development of a telehealth program in rural Kansas
eliminated wait time in scheduling modified barium swallow stud-
ies, decreased travel time, reduced patient fatigue, and improved
accuracy of results. Patient follow-up was enhanced through timely
discussion of results and recommendations.35
Telehealth can increase efficiency and cost effectiveness of delivering
SLP services. Furthermore, telehealth meets the care needs of home-
bound patients with impaired mobility and allows for closer monitor-
ing to determine when additional or follow-up services are needed.11,21
Individualized home exercise programs can be developed to facilitate
carryover of learned skills to the functional home environment.46 The
cost benefits associated with reducing staff time and minimizing travel
expenses are significant for home healthcare and itinerant school ser-
vices. Notably, personnel shortages are most critical in these settings.
Telehealth may increase the length of time SLPs can provide services
to post-stroke patients. Carpenedo21 reported that telehealth treatment
allows the SLP to increase patient care time to meet the needs of the
communicatively impaired homebound patient. Sub-acute patients
with restorative potential can benefit from daily intervention with the
use of telehealth services in addition to in-home visits. According to
Brady,11 a primary benefit in a home health agency has been the ability
to increase available services. In spite of SLP shortages in rural areas,
telehealth enables clinicians to cover a larger geographic area while
providing more therapeutic services to patients.
Telehealth allows clinicians to provide adjunct treatment service
to enhance clinical outcomes. Follow-up services, particularly after
discharge from intensive or inpatient services can have a significant
positive impact on functional outcomes.14,21 In-home telehealth ses-
sions also afford the opportunity to include family members and
caregivers in the treatment program by providing education and
training. Telehealth may provide a means that is cost effective for
both the clinician and patient in order to economically extend ser-
vices when insurance coverage ends.10,11
Challenges and Barriers to Telehealth
Applications in Speech–Language Pathology
Challenges and barriers to widespread adoption of telehealth ser-
vices are summarized in Table 1. In 2002, ASHA conducted a survey
of 1600 members to sample their activities and attitudes with respect
to telepractice (telehealth). Respondents were positive about the
potential of telehealth. However, the barriers they perceived included
cost, lack of professional standards, and lack of data on efficacy and
cost effectiveness.47
Start-up costs including equipment purchase and installation as
well as maintenance costs and connectivity charges can be prohibi-
tive. However, with technological advances, these costs are decreas-
ing. In addition, with the expansion of telehealth applications and
demonstrated positive cost-benefits ratio, telehealth systems are
becoming more widespread in hospitals, clinics, home healthcare
agencies, and schools.
Many telehealth applications in SLP have been demonstration proj-
ects or funded research protocols. The lack of reimbursement presents
Table 1. Challenges and Barriers to Telehealth Applications
in Speech-Language Pathology
Lack of funds for purchasing start-up equipment
Lack of infrastructure to support telehealth services
Lack of administrative, personnel, and/or technical support
Lack of reimbursement for telehealth services
Lack of professional and technical standards and guidelines to ensure
appropriate application that does not compromise the standard of care expected
for in-person clinical encounters
Lack of data on efficacy and cost-effectiveness of telehealth services
Licensure restrictions including the need to obtain multiple state licenses to
practice across state lines
Ethical issues including protecting and preserving patients’ privacy and
confidentiality and complying with HIPAA regulations
Legal issues including risk management (e.g., ensuring clinical and technical
competency; obtaining informed consent; using assistants and caregivers in
providing services)
a challenge to sustainment of programs beyond the initial stages of
research and development.44 The majority of clinicians (71%) surveyed
in 2002 reported that they were not being reimbursed for telehealth
services; 15% reported reimbursement by private pay, 10% by private
insurance, and 5% by Medicaid.47 Fortunately, federal funds are being
offered to support telehealth programs, particularly in rural health net-
works (e.g., grants from the Office for the Advancement of Telehealth).
Furthermore, a request to the Centers for Medicare & Medicaid Services
(CMS) was submitted by the American Telemedicine Association to add
speech pathology/therapy procedures to the approved list of telehealth
related CPT codes, and to approve SLPs as eligible telehealth providers
through the physician fee scheduling process.
Denton48 addressed legal and ethical issues associated with tele-
practice in SLP including state licensure, privacy and confidential-
ity, malpractice, competence, informed consent, and use of assis-
tants. Current licensure requirements present a barrier to telehealth;
obtaining multiple state licenses is required to practice across state
lines. Licensure typically includes initial application and subsequent
renewal fees as well as fulfilling examination and continuing edu-
cation requirements that differ across states. If telehealth is to be a
feasible means of providing services, the restrictive nature of inter-
state licensure requirements must be resolved. Potential solutions
include the establishment of national regulations, Congressional
action to regulate telemedicine licensure, reciprocity for the purposes
of telehealth, or cooperation among states for multi-state licensure
in telemedicine.48–50
A critical need that can be addressed through research is the
establishment of technical standards and guidelines to ensure
appropriate application that does not compromise the standard of
care expected in face-to-face or in-person clinical encounters (e.g.,
different bandwidths required for different tasks). While this may
paradoxically present access issues related to the need to travel to
telehealth sites with appropriate equipment and infrastructure, it is
important to maintain clinical standards. For example, the follow-
ing findings were reported in studies of SLP telehealth applications:
while the quality of sound and visual images permitted accurate
judgments about most aspects of patient’s speech performance, sub-
tle features like speech breathing were more difficult to assess; ade-
quate bandwidth and proper positioning of patients in front of the
camera are important in order to visualize structures for purposes
such as oromotor examinations or discriminating similar sounding
phonemes by observing articulatory placement; at times, compet-
ing Internet traffic compromised audio and video quality; although
a majority of participants receiving treatment remotely indicated
that online delivery was acceptable, some respondents indicated
that the audio and visual quality was less than adequate; occasional
problems associated with connectivity were resolved by preparing
patients and having a back up available such as a telephone in the
room; unlike other video-streaming applications that can tolerate
loss of video quality, the analysis of swallowing function requires
high-fidelity video with no loss in quality. These findings provide
valuable information for future telehealth applications.
Future Directions
A goal for the future is to integrate telehealth services seamlessly
into routine clinical and administrative functions. As communica-
tions technologies continue to develop and progress, advances in
infrastructure and software should eventually allow secure connec-
tions from patient’s home. Research is needed to define standards
for clinical protocols with equipment specifications (e.g., compres-
sion, resolution, and transmission quality) to support diagnostic and
therapeutic procedures and goals (Research Question 1: What are
minimum requirements for technology to ensure efficacious and cost-
effective telehealth services?).
When guidelines and standards are established, they can be used
to direct research questions and provide tools for designing research
protocols51 (Research Question 2: What assessment procedures and
tests yield accurate and reliable information when delivered via tele-
health to support diagnosis of communication disorders? Research
Question 3: What treatment protocols yield effective and efficacious
outcomes when delivered via telehealth?).
ASHA’s Working Group on Telepractice5,6,52 developed three docu-
ments that provide an excellent platform from which to embark on
future telehealth applications. Indeed, the proverbial “sky is the limit”
when venturing into the telehealth frontier with the vision of inter-
national collaboration to provide quality services to citizens in need.
With our global network across which to connect, the potential and
possibilities are virtually boundless.
An extensive review was conducted of the literature available on
the application of telemedicine and telehealth technologies in SLP.
While a significant amount of demonstrations and investigations
have been reported with favorable clinician and patient response,
evidence from clinical trials is needed to validate speech–language
pathology telehealth protocols including technical specifications,
clinical efficacy and outcomes, and economic analyses. The arma-
mentarium of technologies available to healthcare providers includ-
ing SLPs should be used to its fullest extent to enable better quality
care in environments that lack the physical presence of expertise.
The authors gratefully acknowledge the assistance of Dane K.
Disclosure Statement
No competing financial interests exist.
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Address reprint requests to:
Pauline A. Mashima, M.S.
Speech Pathology Clinic
1 Jarrett White Road
Honolulu, HI 96859-5000
Received: April 7, 2008
Accepted: June 10, 2008
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology
Brady (2007)11 experience of
a home health
Visiting Nurse
Health Services
in Port Huron,
telehomecare speech
therapy case report of patient
with dysphagia video and non-video
units for videoconfer-
ence (VC) sessions or to
monitor patients
speech therapy services
have proven to be the most
conducive to tele-homecare;
allows close monitoring and
helps to determine when
additional or follow-up ser-
vices are needed
Brennan, Georgeadis,
and Baron (2002)10;
Brennan, Georgeadis,
Baron, and Barker
(2004)8; Georgeadis,
Brennan, Barker, and
Baron (2004)43
number: 40
23 males
17 females
age: 18–70**
Center on
at the National
administered Story
Retelling Procedure
(SRP) to measure
language production
and comprehension
of spoken narratives
14 patients with
right cerebrovascu-
lar accident (CVA),
14 with left CVA; 12
with traumatic brain
injury (TBI)
computer-based video
(VTC) with full duplex
audio and video over
a high bandwidth of
10 megabits per sec-
ond (Mbps) Local Area
Network connection
no statistically significant
difference was found on SRP
performance between face-
to-face (FTF) and VTC set-
tings; 34/40 were interested
in future VTC use; 6/40 “no”
or “maybe” (all participants
with TBI)
Carpenedo (2006)21;
Brown and
Carpenedo (2006)46
more than
200 patients
treatment in
the speech
Visiting Nurse
Service of New
York Home Care
Brooklyn, Queens,
the Bronx)
combines service
delivery via teleprac-
tice as an adjunct
to in-home speech
treatment visits;
oral-motor, lan-
guage, voice (LSVT),
dysarthria, dysphagia
and cognitive-
speech disorders sec-
ondary to Parkinson’s
disease, communica-
tion disorders follow-
ing stroke, transient
ischemic attack (TIA),
neurogenic dysfunc-
tion, neuromuscular
dysfunction; aphasia,
videophones patient feedback was posi-
tive (4.2 to 4.8 on 5 point
Likkert scale) rating ease
of use, training received,
improved overall plan of
care, staff knowledge and
Clark, Dawson,
and Post (2002)22
case study of
female with
left CVA
rural Oklahoma
Jim Thorpe Rehab
interactive tel-
erehab (Physical
Therapy, Speech-
Language Pathology,
Vocational Rehab)
moderate to severe
nonfluent receptive
and expressive apha-
sia and moderate
apraxia of speech
secondary to left
desktop videophone
using plain old tele-
phone system (POTS)
at clinician site; set-
top communication
device using existing
telephone for audio
and television for video
in patient’s home; 18
frames per second;
maximum data rate of
33.69 kilobits per sec-
ond (Kbps)
after 62 SLP teletherapy
sessions, patient expressed
basic needs independently;
FIM scores on cognitive
& communication items
improved; cost savings for
travel; productivity savings
for caregiver
County Council of
Vasterbotten (n.d.)20
in delivering
speech therapy
in Vasterbotten,
Lycksele Hospital
to cottage
hospitals with
video technology
located through-
out Vasterbotten
County; plan
to expand to
schools in rural
interactive speech-
language rehabilita-
tion; plan to expand
to pediatric and ado-
lescent rehabilitation
aphasia; plan to
extend services to
vocal problems and
problems or dyslexia
and “stammering”
“video technology;”
described interactive
and store-and-forward
positive results; high patient
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Duffy, Werven, and
Aronson (1997)7
number: 150
46 males
104 females
age: 20–90
number: 8
age: 35–87
Mayo Clinic
facilities in
Arizona, Florida
project compar-
ing FTF with
remote delivery
of services from
Mayo Clinic
in Rochester
to rural com-
munity hospital
in Wabasha,
pathology consulta-
evaluation including
examination of oral
mechanism, motor
speech and language
dysarthria, apraxia,
aphasia, dysphonia,
cation impairment,
laryngectomy, stut-
cerebral palsy,
stroke, basilar artery
aneurysm repair, TBI,
multiple sclerosis
non-compressed sat-
ellite transmissions,
broadcast quality, ana-
logue, visual equivalent
of 108 Mbps
digitized low-data rate
satellite transmission;
1.5 Mbps
telemedicine provides
medium for speech-language
consultations that is reliably
accurate in identifying vari-
ous acquired neurogenic and
psychogenic speech disorders
Forducey (2006)36 number:
11,000 speech
age: school-
Teletherapy pro-
gram, Oklahoma
screenings; group
and individual
therapy; standardized
testing; IEP meetings
via TC
autism, fluency dis-
order, hearing loss
real-time, two-way
interactive TC-point-
to-point Internet
Protocol (IP); VC
endpoints with T1 or
greater connections to
the state technology
network infrastructure
provided much-needed clini-
cal services to students who
otherwise would have mini-
mal or no access to speech
Georgeadis and
Brennan (2003)14;
Brennan (2006)44
[Baron, Hatfield, and
Georgeadis (2005)15]
[case study]
Center on
at the National
Hospital in
Washington, DC
adult speech-lan-
guage rehabilitation
[treatment of neuro-
genic communication
speech-language and
cognitive communi-
cation disorders sec-
ondary to neurologic
[moderate nonfluent
aphasia and moder-
ate-severe apraxia of
custom software pack-
age REmote SPEech-
language Cognitive-
Treatment (RESPECT)
combines live VTC
features with “Virtual
Desktop” via custom-
ized graphical user
interface to enable
clinician to administer
therapy materials
[patient exhibited marked
improvement with reading
comprehension scores and
spontaneous verbal output;
patient’s family noted a sig-
nificant difference in com-
munication skills]
Georges, Potter, and
Belz (2006)35
University of
Kansas Hospital
and a rural site
in Kansas
remote, interactive
modified barium
swallow studies;
dysphagia video fluoroscope
attached to a Polycom
F/X system at the
remote site
clinicians at both sites were
comfortable with the tech-
nology and studies indicated
good acceptance by patients;
allowed mentoring clinicians
at rural site which resulted
in professional growth and
skill development
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Glykas and Chytas
20 speech-lan-
guage thera-
pists delivering
services to
children and
system set up
and implemented
in a clinical
center in Athens,
Greece and
accessed by users
from Greece
and the United
usability study
evaluating user
acceptance including
usefulness in therapy
sessions, user friend-
liness, accuracy of
feedback, range of
uses, portability of
the system, afford-
hearing impairment,
voice disorders, dis-
fluency, learning dis-
abilities, cleft palate,
physical disabilities,
delay and disorder,
neurological disorder,
web-based system of
therapy tools and
visual speech aids
including information,
tests, report templates,
database for storing
patient records and
information, e-learning
applications; active
server pages (ASP)
“Telelogos” provides poten-
tial to supplement tradition-
al delivery of speech therapy
services; enhances access to
information and resources,
empowers patients to make
informed healthcare deci-
sions, streamlines orga-
nizational processes and
transactions, and improves
quality, value, and patient
Hill, Theodoros,
Russell, Cahill, Ward,
and Clark (2006)16
number: 19
age: 18–78 university and
hospital labora-
tory in Australia
repeated measures
design comparing
perceptual assess-
ments of motor
speech disorders
administered FTF and
in an online environ-
dysarthria associated
with an acquired
neurological impair-
real-time VTC
Internet 128 Kbps IP
connection; store-
and-forward video and
audio data
online assessment of motor
speech disorders using
Internet-based system is
feasible; more reliable
assessment is possible with
additional refinement of
technology and assessment
protocols; measurements
of severity of dysarthria, %
intelligibility in sentences,
and most perceptual ratings
fell within clinically accept-
able criteria; several online
ratings on the Frenchay
Dysarthria Assessment were
not comparable to FTF
Houn and Trottier
number: 20 Speech Therapy
at St. Alexius
Medical Center in
Bismarck, North
Dakota and 7
medical centers
and 1 school
pathology services stroke reported as
example full-motion video
consultation with
spontaneous audio
and video interaction;
written material faxed
or mailed in advance;
Elmo overhead projec-
tor stand
clinicians reported “a very
positive experience and
appears to be beneficial for
everyone involved”; pro-
vided opportunity to reach
patients who would other-
wise not receive services
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Kully (2000)27;
[Kully (2002)28]case report of
[n = 80 ses-
age = 3–38]
(aim was to
gather prelimi-
nary experience
to determine
feasibility and
clinical practice
Centre at the
University of
Alberta’s Faculty
of Rehabilitation
Medicine and
rural telehealth
center in Two
Hills, Alberta,
follow-up sessions
after completing
intensive 3-week
treatment program
at the Institute for
Stuttering Treatment
and Research in
Edmonton; involved
practice of specific
speech skills/strate-
gies and discussion
aimed at facilitating
and problem-solving
[combination of in-
clinic and telehealth
stuttering (VC system employed a
digital line with a data
rate of 770 Kbps; docu-
ment camera relayed
graphic images)
[primarily through ISDN
lines with bandwidth
from 128 to 384 Kbps]
verbal reports of both
patient and clinician were
positive; patient reported
satisfaction with structure
of session and effective-
ness of feedback; clinician
evaluated session outcomes
as satisfactory; high-quality
of sound and visual images
permitted accurate judg-
ments about most aspects of
patient’s speech performance
Lewis (2006)23 15 children Australia Lidcombe Program
of Early Stuttering
stuttering “low-tech telehealth
adaptation” including
training videos, record-
ed speech samples,
telephone consulta-
tions, e-mail
telehealth delivery required
more lengthy treatment
times and higher cost than
clinic-based delivery; how-
ever it is a viable, effective
and acceptable option to
improve access to services
McCullough (2001)40 4 preschool
children with
Down syn-
drome and 1
preschool child
with Cornelia
de Lange syn-
nursery/clinic and
home in Belfast 27 teletherapy ses-
sions focused on
parent training (20
to 35 minutes per
disorders in children
with special needs
home: TV/video record-
er, motion media Setop
box/PTZ camera clinic:
PC, PTZ camera, VCON
system connected via
ISDN2 line (128 Kbps)
user friendly and reliable for
both parents and therapists;
telemedicine judged to be a
viable and effective treat-
ment option for children
with special needs; “children
related to the system in a
natural and spontaneous
Madsen and Rollings
50 students in
9 schools North Dakota
Center for
Persons with
Disabilities at
Minot State
University and
rural schools in
North Dakota
speech and language
therapy interactive VC:
Windows XP with
Pentium III processors
and 256 MB of mem-
ory; T1 Internet access
analysis of data collected
during online speech-lan-
guage therapy indicated
telehealth as effective model
for providing articulation
and language therapy
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Mashima, Birkmire-
Peters, Holtel,
and Syms (1999)9;
Mashima, Birkmire-
Peters, Syms, Holtel,
Burgess, and Peters
[Mashima and Holtel
number: 51
age: 18–85
video camera
and monitor in
adjacent rooms
compared with
[military medi-
cal facilities
in Hawaii and
treatment of voice
[deployment of
remote units to treat
voice disorders]
vocal nodules, vocal
fold edema, vocal
fold paralysis, vocal
hyperfunction with-
out pathology
real-time interaction
via video camera and
monitor sharing voice
analysis software via
[VTC with Tandberg
880 via ISDN lines at
384 Kbps bandwidth]
no difference in treatment
outcomes between tele-
health and face-to-face
Myers (2005)33 number: 3 case
age: 55, 45, 76
specialty cancer
care center and
local health
care facilities in
alaryngeal speech
and swallowing ther-
apy, management of
voice prosthesis,
psychosocial support,
education of patient/
family/ healthcare
aphonia, dysphonia,
dysphagia secondary
to head and neck
VC; technology require-
ments for patients with
head and neck cancer
include availability of
close-up; high-reso-
lution video and still
images; adequate light-
ing for accurate assess-
ment of stomas, pros-
thesis status, and skin
and mucosal properties;
room with acceptable
acoustics to assess
speech intelligibility
utility of telehealth in
management of individuals
with head and neck cancer
appears promising; recom-
mend research to evaluate
clinical effectiveness of
speech-language pathol-
ogy services for this patient
population as well as other
clinical populations
O’Brian, Packman,
and Onslow (2008)25
number: 10
8 males
2 females
age: 22–48
Research Centre
and participants’
naturalistic set-
tings (e.g., home,
work, university)
Phase I trial to inves-
tigate the viability of
telehealth delivery
of the Camperdown
Program for adults
who stutter
stuttering telephone and e-mail participants showed an
82% reduction in stutter-
ing frequency immediately
after treatment and a 74%
reduction 6 months after
treatment; preliminary data
suggest that telehealth
Camperdown has potential
to provide efficacious treat-
ment for clients who do not
have access to traditional
FTF treatment
Palsbo (2007)17 24 adults;
18 males
6 females
age: 25–81
Hospital in
Jim Thorpe
Hospital in
Oklahoma City
randomized, double-
crossover agreement
design using pairs of
FTF and remote SLP
post-stroke (time
since stroke ranged
from 2 months to
15 years; median =
1 year)
VTC at 384 Kbps results suggested that
assessment of a patient’s
functional communication
using VTC is equivalent to a
FTF encounter
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Perlman and
project to
design a
program to
conduct modi-
fied barium
swallow studies
of Illinois
at Urbana-
Champaign and a
fluoroscopy suite
in a hospital
real-time, remote,
interactive evalu-
ation of oral/
pharyngeal swal-
lowing function via
an Internet system;
video recording with
back-up store-and-
swallowing disorder PCs at remote and
controlling sites con-
nected via broadband
Internet (IP); T1 with
maximum throughput
at 1.5 Mbps (hospital);
10 Mbps Ethernet LAN
(university lab)
preliminary work has pro-
ceeded well; system will
eventually permit creation
of a dysphagia portal and
databank for secured, world-
wide access for research and
education, and serve as a
virtual workspace for experts
to collaborate
Georgopoulos, and
Malandraki (2005)41
application of
online collab-
orative envi-
ronments for
speech therapy
Greece group therapy; men-
toring; continuing
education; clinical
consulting in multi-
disciplinary teams
articulation disor-
ders, aphasia, stut-
real-time interactive
and store-and-forward
components; real-
time multipoint VC
with connections as
low as 28.8 Kbps; PC
with video and audio
capabilities and dial-
up connection; online
collaboration environ-
telemedicine provides
patients in rural and remote
areas with access to quality
rehabilitation services that
are sufficient, accessible,
and user-friendly leading
to new possibilities in com-
prehensive and long-term,
cost-effective diagnosis and
Rose, Furner, Hall,
Katsavras, and
Clarke (2000)39
18 school-aged
children nursery in
Salisbury, 4 pri-
mary schools in
Wiltshire, UK
therapy support
services for children
entering mainstream
“communication dif-
ficulties” real-time interactive
VTC via 3 x ISDN2 lines VC technology can be used
to support the delivery of
speech and language therapy
services into schools
Savard, Borstad,
Lauderdale, and
Conroy (2003)50
number: 75
age: 9
(not all
received SLP
1 case study
of pediatric
consult includ-
ing speech-
Sister Kenny
Institute in
MN; National
Hospital in
D.C.; LBJ Tropical
Medical Center in
American Samoa
tion consultations
included physiatrists,
physical therapists,
occupational thera-
pists, speech-lan-
guage pathologists,
recreation specialists,
equipment special-
ists, orthotists
neurologic diagno-
ses including CVA,
Parkinson’s disease,
spinal cord injury,
cerebral palsy, trau-
matic brain injury,
amyotrophic lateral
sclerosis, multiple
sclerosis, muscular
Polycom ViewStation;
ISDN (128-384 Kbps),
IP (128-768 Kbps);
“SLP rated the clinical effec-
tiveness of the encounter as
good; limitations identified
were lack of evaluation and
follow-up tools validated for
care delivery via VTC”
Sicotte, Lehoux,
Fortier-Blanc, and
Leblanc (2003)26
number: 6
age: 3–19 Montreal pedi-
atric tertiary
care center and
a local primary
care centre in
a remote area
Quebec, Canada
assessment and
treatment for per-
sons who stuttered
and were unable
to receive services
within their com-
stuttering VC unit, reception
frequencies varied
between 50 Hz and 7.0
kHz; transmission took
place at a maximum
of 768 Kbps via an
patient and clinician sat-
isfaction were high, par-
ticipants considered the
intervention to be effective;
patients’ perceptions regard-
ing a decrease in stuttering
were favorable
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Russell, Ward,
Wilson, and
Wootton (2006)29
number: 10
8 males
2 females
age: mean =
73, SD = 10
clinician in one
room and partici-
pant in another
room connected
via VC link
Lee Silverman Voice
Treatment (LSVT)
for speech disorder
associated with
Parkinson’s disease
mild to moderate-
severe hypokinetic
dysarthria secondary
to idiopathic PD
VC via a 128 Kbps
Internet link; store-
and-forward, text
results demonstrated the
feasibility of an Internet-
based application to deliver
the LSVT; further research
needed involving larger
numbers of participants
Tindall and Wright
number: 1
age: 57 Veterans Affairs
Medical Center
in Lexington,
Kentucky and
patient’s home
treatment for anomia Broca’s aphasia; left
CVA videophones patient responded well to
therapy delivered via vid-
eophones; no assistance
needed to operate the vid-
eophone; positive feedback
from spouse
Vaughn (1976)12 adults Veterans Affairs
Hospital in
supplementary and
reinforcement ser-
vices on an outreach
basis for veterans
with communication
voice disorders, ala-
ryngeal speech, artic-
ulation disorders,
stuttering, aphasia,
dysarthria, auditory
system utilized tel-
ephonic systems, pro-
grammed materials and
educational media
eliminated travel time,
reduced travel costs, and
increased frequency of
therapy contacts
Waite, Cahill,
Theodoros, Busuttin,
and Russell (2006)38
number: 6
age: 4:3–6:8
(mean = 5.3)
University of
Queensland; pilot
study comparing
FTF assessment
vs. “online” clini-
cian in another
room within the
same building
assessment of single-
word articulation,
speech intelligibility
in conversation, and
oromotor structure
and function
mild to moderately
severe speech dis-
VTC through a 128
Kbps Internet link;
transfer of pre-record-
ed video and audio
data to the online
high level of agreement
between online and FTF
assessment; results provided
preliminary evidence for the
feasibility of an Internet-
based assessment of child-
hood speech disorders
Ward, White,
Russell, Theodoros,
Kuhl, Nelson, and
Peters (2007)32
number: 20
17 males
3 females
age: 41–70;
mean = 61
separate rooms
within same hos-
pital in Australia
comparison of simul-
taneous online and
FTF assessments of
oromotor, swallow-
ing, and communica-
tion in patients post
laryngectomy to vali-
date Internet-based
surgical removal of
larynx due to cancer assessments conducted
at bandwidth of 128
Kbps; specialized VC
software allowed real-
time objective evalu-
ation, captured high-
quality video and audio
recordings independent
of VC tools, data shar-
ing, and Web camera
patients were 100% satis-
fied with usability of system
and quality of services
they received; there was
greater than 80% agree-
ment between online and
FTF clinician for all variables
relating to oromotor func-
tion, swallowing status,
and communication ability;
however, visualization of the
stoma was poor; clinician
satisfaction with the func-
tionality of the system was
low, although their ratings
were high for ease of use
and potential for telerehab
as service delivery method
APPENDIX. Summary of Telehealth Applications in Speech–Language Pathology continued
Wertz, Dronkers,
Ellis, Sterling,
Shubitowski, Elman,
Shenaut, Knight, and
Deal (1992)13
number: 72
age: adults simulation study
FTF vs. remote
Veterans Affairs
Medical Center
in Martinez,
appraisal and diag-
nosis of neurogenic
communication dis-
aphasia, apraxia,
dysarthria, dementia,
TBI, confusion, right
closed circuit televi-
sion; computer-con-
trolled video laserdisc
over the telephone
agreement in diagnosis
among appraisal conditions
(93% to 94%) and close
approximation of patient
performance on appraisal
measures among conditions
suggest that either televi-
sion or computer-controlled
video laserdisc by telephone
could be substituted for FTF
appraisal and diagnosis
Wilson, Onslow, and
Lincoln (2004)24
number: 5
age: 3 yrs, 5
mos to 5 yrs,
7 mos
Australia; low-
tech telehealth
adaptation of
the Lidcombe
Program of
Early Stuttering
therapy for childhood
stuttering stuttering telephone calls; record-
ings of speech samples
mailed to clinician
telehealth adaptation of the
Lidcombe Program may be
clinically viable and able to
produce satisfactory clinical
outcomes; delivery via VTC
should be investigated
*As reported by investigators.
**Age reported in years unless otherwise indicated.
... Bu çalışmalarda tele-terapi hizmeti alan danışanlar ve/veya tele-terapi hizmeti veren terapistlerin kullanılan yöntemden memnuniyetlerine ve görüşlerine yönelik araştırmalar gerçekleştirilmiştir (Selman, 2021;Türkan & Koçak, 2021). Buna ek olarak, demans, kekemelik, afazi veya konuşma sesi bozuklukları gibi farklı alanlarda tele-terapi yönteminin etkili kullanıldığı görülmektedir (Cangi & Toğram, 2020;Dunkley ve ark., 2010;Fairweather & Lincoln, 2016;Fridler ve ark., 2012;Grogan-Johnson ve ark., 2010;Johrami & Ahmadian, 2018;Mashima & Doarn, 2008;Morgan ve ark., 2014;Sicotte ve ark., 2003). ...
... Öte yandan, tele-terapi hizmeti veren terapist adaylarına bakıldığında ise bu hizmetten memnun olduklarını bildirenlerin oranı %75, çevrimiçi ortamda yapılan terapilerin yeterli olduğunu düşünenlerin oranı ise %42.6'dır. Alanyazındaki araştırmalara göre tele-terapi deneyimi olmayan klinisyenler tele-terapi etkililiğine tereddütlü yaklaşabilmektedir (Alpüran-Kocabıyık & Demirci, 2021; Mashima & Doarn, 2008;Tucker, 2012). Cangi (2015), bu gibi tereddütlerin önüne geçilebilmesi için danışanlarla hizmet öncesinde denemeler yapılmasını önermektedir; örneğin, Hill ve Miller (2012) tele-sağlık uygulamalarının güçlendirilebilmesi için terapistlerin tele-terapi hakkında mesleki eğitimlere ve uygulama gösterimlerine ihtiyaç duyduklarını ortaya koymuştur. ...
... Dolayısıyla teknoloji kullanımında karşılaşılan sorunlar DKT adaylarının tele-terapi memnuniyet düzeyini düşürmüş ve tele-terapinin dil ve konuşma terapisine uygunluğu hakkında daha olumsuz düşünmelerine neden olmuş olabilir. Tele-terapide memnuniyeti ele alan çalışmalarda ses, görüntü ve internet bağlantısı tele-terapinin dezavantajları arasında sayılmaktadır (Fairweather ve ark., 2016;Johrami & Ahmadian, 2018;Mashima & Doarn, 2008). Hill ve Miller (2012), tele-sağlık uygulamalarının kullanımının önündeki en büyük bariyerlerden birinin teknolojiden kaynaklanan problemler olduğunu ileri sürmüştür. ...
... Telehealth uses Information and Communication Technologies for the exchange of information for the diagnosis and treatment of diseases and injuries, research, and evaluation, and for the continuing education of health professionals.'' 1 Telehealth has several advantages, including increased access to care, reduced delay of service delivery, and lower costs; it can also lead to better health outcomes, improved quality of life, and increased client satisfaction. [2][3][4][5][6][7] In speech-language pathology and audiology, telehealth is the use of telecommunication technology to link clinicians to clients, caregivers, or other professionals to provide assessment, intervention, consultation, or supervision services from a distance. [8][9][10][11] Generally, speech-language pathology services are delivered to clients through auditory and/or visual communication without the need for sophisticated equipment; hence, most speech-language pathology services could be conducted via telehealth while the client is at home or any other location. ...
... 12 Whereas audiology services generally require the use of equipment, thus most telehealth audiology services require the client to go to a local clinical site that is equipped and has a trained local facilitator to help set up the client for the audiological service. 13 Telehealth in speech-language pathology and audiology has been available from before the global pandemic caused by the novel coronavirus disease 2019 (COVID-19), [3][4][5][6][7] and it has been shown to be an effective mode of service delivery across many speech, language, and hearing disorders (e.g., speech sound disorders, aphasia, stuttering, dysphagia, hearing screening, tinnitus). [14][15][16][17][18][19][20][21][22] Further, the American Speech-Language and Hearing Association deemed telehealth suitable for the delivery of speech-language pathology and audiology services since 2005. ...
Full-text available
Introduction: The objective of this work was to investigate Speech-Language Pathologists' (SLPs) and audiologists' telehealth awareness, experience, and perception in terms of applicability, effectiveness, barriers, facilitators, and the influence of the coronavirus disease 2019 (COVID-19) pandemic on telehealth practice. Methods: A questionnaire was developed and validated based on relevant literature, authors' clinical expertise, and a published survey. Sample size was determined through power analysis, and participants were recruited using a snowball-sampling technique. Results: Ninety-five (n = 95) clinicians completed a survey. A majority (87.4%) reported awareness of and 68.4% reported experience with telehealth. The SLPs (86.4%) had more experience than audiologists (38.9%). Overall, 78.5% first used telehealth during the COVID-19 pandemic, with no significant difference in telehealth use during versus after the pandemic lockdown; 63.8% reported telehealth being less effective than in-person. However, there were differences in perceived telehealth effectiveness: Telehealth was significantly more effective for consultations and counseling, with adults aged 18-40 years; and clients with fluency and speech sound disorders. The highest significant barrier to telehealth delivery was network issues, and available workplace resources was the highest facilitator although this was not significant. Conclusions: Most clinicians were aware of telehealth, had a positive attitude toward it, and had experience using telehealth. More SLPs than audiologists used telehealth. The COVID-19 pandemic had a positive influence on telehealth service provision with an increase in use that was maintained after in-person services were re-initiated. Perceived effectiveness of telehealth services varied depending on the type of clinical service, the client's age, and diagnosis. These factors must be considered while planning telehealth services in Speech-Language Pathology and Audiology.
... Moreover, the prevalent rating, that videoconferencing does not affect the therapy success and even provides the possibility of a better and faster therapy success, gives a first clue for the effectiveness of videoconferencing in Germany. This finding corroborates research findings of international studies (e.g., Mashima & Doarn, 2008;Weidner & Lowman, 2020). ...
... 636 (78) 137 (17) 43 (5) therapists and patients that were mentioned by therapists correspond with those in the international literature. For example, increased efficiency, cost savings, and reduced travel times are among the benefits most indicated internationally (Coleman et al., 2015;Mashima & Doarn, 2008;McGill et al., 2019;Sutherland et al., 2018). Consistent with the findings of the systematic review by Hall et al. (2013), therapists most frequently reported difficulty during videoconferencing due to technology use, e.g. ...
Full-text available
During the COVID-19 pandemic, videoconferencing as a synchronous form of telepractice service delivery models received a boost. In Germany, online-only sessions are not a standardised means of healthcare provision, while telepractice is already well established internationally. This study examines videoconferencing in outpatient speech and language therapy during the first period of the COVID-19 pandemic in Germany. The experiences of therapists are reported in this study. For this quantitative study, data were collected by an online survey. Speech and language therapists in Germany were surveyed (n = 816). Data were analysed using descriptive statistics. The results demonstrated that 87% of participants used videoconferencing in the early days of the COVID-19 pandemic. Videoconferencing was conducted with patients of different ages and disorder indications. In their use of videoconferencing, 78% of therapists described benefits. The mentioned benefits and limitations are similar to international findings, showing the potential for synchronous speech and language therapy via videoconferencing. German therapists display a general acceptance of the sustainable use of videoconferencing, and the majority of therapists can imagine transferring videoconferencing to standard healthcare.
Introduction This article systematically reviews the reliability and validity of balance and gait outcome measures obtained by teleassessment in older adults. Methods Two reviewers searched electronic databases for articles published from 2010 to 2022. Included studies were appraised for quality. Results Six articles were reviewed. Reliability was found to be low to good, and validity was acceptable, with some concerns with bias during testing. Discussion There is evidence to support the use of certain balance and gait outcome measures in teleassessment of the older adult population if the individuals have appropriate electronic devices for telecommunication, good Internet connectivity, and adequate technological knowledge.
Proglašenje COVID-19 pandemije u ožujku 2020. godine rezultiralo je privremenom obustavom pružanja logopedske terapije u standardnom obliku i znatnim povećanjem korištenja usluga logopedske teleterapije u sustavu zdravstva. Budući da je mišljenje i zadovoljstvo korisnika i njihovih roditelja/skrbnika provedenom teleterapijom značajan čimbenik koji može utjecati na učinkovitost terapije i budućnost teleterapije u logopediji, cilj je bio ispitati mišljenje korisnika i/ ili njihovih roditelja/ skrbnika o provedenoj teleterapiji, otkriti što korisnici vide kao prednosti, a što kao nedostatke ovakvog načina rada i doznati njihovo mišljenje o provođenju iste izvan okvira COVID-19 pandemije. Za potrebe ovog istraživanja oblikovan je anonimni upitnik s 19 pitanja pod nazivom „Logopedska terapija na daljinu - stavovi korisnika“, sastavljen pomoću platforme Survey Monkey. Upitnik je ispunilo 252 sudionika, koji su tijekom COVID-19 pandemije sudjelovali u nekom od oblika teleterapije. U istraživanju su sudjelovali korisnici stariji od 16 godina koji su mogli samostalno ispuniti anketu i roditelji/skrbnici djece mlađe od 16 godina, te roditelji/skrbnici odraslih osoba koji nisu mogli samostalno ispuniti anketu, a bili su uključeni u neki od oblika logopedske terapije na daljinu u sustavu zdravstva. Od ukupnog broja sudionika, njih 79,2 %, izjasnilo se zadovoljnim pruženom uslugom. Kao najznačajniju prednost teleterapije vide dostupnost logopedske terapije tijekom izolacije i/ ili bolesti, te kontinuitet u radu. Od 252 sudionika, njih 137 (54,46 %) smatra da bi terapija na daljinu trebala postati jedan od uobičajenih oblika logopedskog rada i nakon COVID-19 pandemije. Rezultati koji su dobiveni analizom odgovora sudionika o zadovoljstvu, kao i navedenim prednostima logopedske teleterapije, potiču na razmišljanje o mogućnosti uređenja terapije na daljinu u sustavu zdravstva Republike Hrvatske kao dijela redovite ponude u načinima provođenja logopedske usluge.
Purpose There is a clear need for speech-language pathologists, audiologists, and related health care professionals to understand the barriers to hearing health care, so that we may propose possible solutions. Through interview, collaboration, and analysis, the objective was to identify opportunities to enhance support provided for these children. Method The authors conducted a review of available literature related to hearing health care disparities. Dr. Matthew Bush, an expert in hearing health care disparities and advocacy, was interviewed on October 12, 2022. Data were extracted and compiled from available literature and the interview including demographics, themes, and available interventions. Results The section “Entry Barriers” describes findings in the main categories of Steps, Proximity, Health Care Literacy, and Systemic Inequalities. The “Opportunities for Change” section describes topics from the interview for ongoing discussion in the field. Conclusions Ultimately, having this conversation led exactly in a direction that it should—toward further professional development, awareness, and a call to action. To facilitate meaningful change, we are tasked with active discussion, questioning, probing, and improvement. Only through evolution of existing systemic bias and harmful structures can we make meaningful change.
Objectives: This study aims to examine the validity of two types of remote language screening tests (indirect questionnaire type vs direct observational type), and differences in performance of children as well as satisfaction of their mothers between these two types of remote language screening test. Methods: In total 40 children without any language deficits aged 3 to 6 and their mothers participated in this study. For statistical analysis, a Pearson correlation was conducted between the remote language screening tests (indirect questionnaire type and direct observation type); a PRES (Preschool Receptive-Expressive Language Scale) to find out the concurrent validity, and a paired t-test was conducted to find out if there are significant differences in the performance of the children and satisfaction of their mothers between the two types of screening tests. Additionally as a qualitative analysis, mothers’ preference among two types of the test was asked using an open ended survey. Results: The two types of tests (indirect, direct) showed strong positive correlation with one another. Regarding concurrent validity, both test types showed strong positive correlation with a standardized language test as well. There was no significant difference between the two types in both the performance of the children and the satisfaction of mothers as well. However, 85% percent of mothers preferred the direct observation type citing better accuracy as their reasoning. Conclusion: It is hoped that remote language screening tests can contribute to the implementation of non-face-to-face screening in clinical settings since it is highly validated. Furthermore both two types of tests can be used and complement each other.
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Objective: To assess awareness level, practices, attitudes and barriers regarding telehealth among healthcare providers (HCPs) in Saudi Arabia. Methods: This cross-sectional study was approved by institutional review board (IRB) at King Fahad Medical City, Riyadh, Saudi Arabia, from June 28 to September 18, 2022, and comprised HCPs at different hospitals across the country. Data was collected using an online questionnaire exploring the awareness level, practices, attitudes and barriers regarding telehealth. Data was analysed using Statistical Analysis System 9.4. Results: Of the 607 HCPs, 525(86.5%) were Saudi HCPs; 301(57.33%) males and 224(42.66%) females, with the largest age group being 31-40 years 218(41.52%). The remaining 82(13.5%) HCPs were non-Saudi HCPs; 43(52.43%) males and 39(47.56%) females, with the largest age group being 31-40 years 35(42.68%). Overall, there were 305(50.24%) health practitioners and most of the HCPs belonged to the Riyadh region 194(31.96%). 549(90.44%) of HCPs were aware of telehealth, while 360(59.30%) were actually practicing it. Also, 488(80.39%) of HCPs believed that telehealth is a valid technology, while 443(72.98%) believed telehealth is a reliable technology. Conclusion: Awareness regarding telehealth was high among HCPs meaning telehealth are progressively growing and spreading among HCPs and medical facilities in Saudi Arabia, who also found it valid and reliable.
Full-text available
Objectives: The research aims to identify the public's use of communication technology for the provision of remote medical services and its relationship to the quality of healthcare. Methods: The two researchers used the field survey method and a comparative approach to identify similarities and differences in the study sample. The study was conducted with a sample of 400 individuals from the Egyptian public. The survey newspaper tool was employed, and various statistical techniques were utilized, including the Pearson correlation coefficient and the t-test. Results: The findings of the study indicate a statistically significant correlation between the public's use of communication technology for providing remote medical services and the quality of healthcare. Additionally, a statistically significant correlational relationship exists between the role of communication technology in providing telemedical services and the development of public usage, along with its contribution to generating interest in these services. Conclusions: It is crucial to emphasize the public's use of communication technology for providing telemedicine services in order to achieve the Sustainable Development Goals (SDGs) and the global commitment to attaining universal health coverage by 2030.
Background: Voice therapy provides patients with valuable exercises and techniques to optimize vocal behaviors and improve their ability to communicate effectively and efficiently. These sessions were typically held by speech-language pathologists (SLPs) in clinic. During the COVID-19 pandemic, SLPs were provisionally able to provide billable voice therapy services in telehealth format. There is a lack of existing research studies comparing outcomes based on the format of voice therapy. Methods: A retrospective chart review was performed on 101 patients who underwent voice therapy at a large academic institution in order to compare outcomes between clinic, telehealth, and mixed voice therapy formats. Demographics, dysphonia etiology, duration of symptoms, number of therapy sessions, and pre- and postvoice therapy scores using reflux symptom index (RSI), voice handicap index (VHI-10), consensus auditory-perceptual evaluation of voice (CAPE-V), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scoring were collected. Statistical comparisons were performed using Fisher's exact test and analysis of covariance. Results: There were no statistically significant differences in pre- to postvoice therapy RSI, VHI-10, CAPE-V, or GRBAS scores based on format of voice therapy, after adjustment for number of therapy sessions received. There were no differences in these outcomes when comparing voice therapy by etiology of dysphonia. Conclusions: Overall, these data support the effectiveness of the telehealth voice therapy format. It is a promising platform for greater patient access to therapy. All formats of voice therapy were effective in improving key measures of voice perception.
The subject of audiologists providing services over a distance via telepractice is attracting the attention of the profession. The new service delivery model will challenge us to exploit its potential without violating legal constraints or compromising our affirmative ethical responsibilities. This article provides an overview of the implications of current state licensure laws on telepractice and a look at the issues of competence, standard of care, privacy, informed consent, and the use of support personnel. Several principles are offered to guide the practitioner and additional resources are suggested.
Telehealth increasingly used to provide healthcare services to people living remote locations. This article describes the use of telehealth technology to provide speech-language pathology services to people living with head and neck cancer.
Recent advances in videoconferencing technology have resulted in a substantial increase in the use of live videoconferencing-referred to here as telepractice-to diagnose and treat speech, language, and hearing disorders. There is growing support from professional organizations for use of this service delivery model, as videoconferencing technology can alleviate the effects of distance on access to care. As telepractice becomes a standard mode of conducting diagnostic and treatment services in speech, language, and hearing disorders, it is essential to assure that research supports its application in the field. Search criteria were established to identify publications, primarily in peer-reviewed journals, from 1995 to 2011. These studies generally validate the delivery of diagnostic and therapeutic services through telepractice when compared to traditional services delivered in a face-to-face clinical setting. Most studies examined adults and school-age children. The search was then expanded to identify diagnostic and treatment services for infants, toddlers, and young children. The existing literature compels professionals to conduct more research related specifically to the effectiveness and efficacy of telepractice.