Deborah Theodoros PhD Professor and Head Division of Speech Pathology The University of Queensland

Transcription

1 Deborah Theodoros PhD Professor and Head Division of Speech Pathology The University of Queensland

2 Ever-increasing cost & demand for health care Social & demographic changes Rapid developments in technology Advances in neuroscience

3 Ageing population In Europe median age predicted to increase 37.7yrs (2003) to 52.3yrs (2050) (Brookings Institute) 29% population 65yrs + over in 2050 By 2050, ratio of retirees to workers - 4:2 (Carone & Costello, 2006)

4 Baby boomer generation - born between 1946 and 1964 Leading edge reached 60 yrs in million worldwide (Morris et al, 2010) Live longer with chronic disabilities Costs of health care? Capacity to maintain levels of SLT services, let alone shortfall

5 Equitable access to FTF services difficult due to distance & climate Access difficult for disabled Effort required physical & cognitive state Require carer & specialised transport Children Competing needs of siblings Parent work schedules

6 Tomorrow s elders expectations for retirement likely to be different (Morris et al, 2010) Remain living in own homes transport issues as capacity to drive Need services to accommodate this change Extended time in employment (esp women) Changes in family structure Accessing FTF services problematic

7 Rapid in capacity to: Access information & services Be entertained Engage in social networking More people work from home than ever before Smartphones Internet connectivity now ubiquitous UK study - 98% children access Internet (UK Children Go Online, 2006)

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9 Expectation to access SLT services online will grow rapidly with successive generations Potential for providing SLT services not yet realised

10 Core of our therapeutic approach Enhanced understanding of brain function & new learning Neuroplasticity adaptive capacity of CNS (Kleim & Jones, 2008) ability of neurons & brain cells to alter structure & function in response to internal & external influences

11 Behavioural training - facilitator of change in neural function (Kleim & Jones, 2008) Principles of experience-dependent neuroplasticity critical factors that may drive new learning and recovery guide to clinicians in optimizing new learning & rehabilitation

12 1. Use it or lose it 2. Use it & improve it 3. Specificity 4. Repetition matters 5. Intensity matters 6. Time matters 7. Salience matters 8. Age matters 9. Transference 10. Interference

13 Use it or lose it Constraint-Induced Language Therapy (CILT) (Pulvermüller et al 2001; Maher et al 2003) Focus on verbal output, intensive Tx Intensity matters Bhogal et al (2003) Sig Tx effects - av 8.8 hrs/wk for 11.2 wks Nonsig Tx effects av 2hrs/wk for 22.9 wks

14 Intensity matters 1 hr/day, 4x /wk, for 4 wks Repetition matters Multiple repetition of tasks 15x each - /ah/, pitch glides 10 Functional phrases 5x each Salience matters P rewarded for being LOUD in daily communication able to be heard by others

15 Look beyond conventional practice to methods that will: Promote EDN Optimize rehabilitation or developmental process Be equitable, and time & cost-effective Will require innovation to be effective & sustainable

16 Not so much about what we do, but how we do it

17 SLT underpinned by technology Alternate modes of service delivery Revolutionize therapy tools Transform everyday practice

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19 Use of telecommunications technology to deliver professional services at a distance (ASHA, 2010) Telerehabilitation - Use of telecommunications & information technology to provide rehabilitation services at a distance (ATA Telerehabilitation SIG, 2010) Teletherapy, telespeech, telehealth

20 SLT - primarily audio-visual interaction Readily translatable into online or technologybased environment Need to be able to replicate & transmit auditory & visual signals at a distance

21 Equitable access Improved quality of care (McCue, Fairman, & Pramuka, 2010) Optimize timing, intensity, and sequencing of intervention Deliver Tx in natural environment generalization Longer periods of Tx - access to the client Monitoring Facilitate self-management

22 Adult neurogenic communication disorders Voice disorders Stuttering Dysphagia Laryngectomy Articulation, language, & literacy disorders in children

23 Development & validation of online Ax & Tx Aphasia Dysarthria Apraxia of Speech Dysphagia Laryngectomy Speech, Language & Literacy in children

24 Ax of neurogenic speech & language disorders Aphasia (Hill et al, 2009; Theodoros et al, 2008) 32 participants mild to severe aphasia BDAE Dysarthria (Constantinescu et al, 2010; Hill et al, 2006, 2009a) 61 participants with PD 40 participants CVA, TBI, PD Apraxia of speech (Hill et al, 2009b) 11 participants mild to severe apraxia Apraxia Battery for Adults

25 Good - very good strength of agreement between online & FTF assessors High inter- & intra-rater reliability across the majority of parameters measured oromotor performance test scores & ratings - standardized tests for aphasia (BDAE) & apraxia of speech (Dabul) acoustic measures perceptual speech ratings participant satisfaction high - >80%

26 Story-retelling task (Brennan, Georgeadis, Baron, & Barker, 2004; Georgeadis et al., 2004) 40 participants - stroke & TBI No sig differences in performance between FTF & online Functional communication (Palsbo, 2007) comparable levels of agreement between online & FTF assessment post-stroke

27 Connects to standard telephone line using analogue modem technology LSVT (Tindall et al, 2008) 24 participants SPL consistent with FTF Tx, except for loudness in conversation

28 Howell et al (2009) LSVT 3 participants 3 sessions/wk Skype 1 session FTF (to measure SPL) Consistent with FTF outcomes Limitations participant training, unable to measure SPL & freq accurately, computer requirements

29 Constantinescu et al (2010) RCT - 34 PWP treated LSVT FTF & online Improvements online comparable to FTF Tx SPL & pitch range gen. consistent previous FTF data Online Tx effectively delivered - mild & mod dysarthric speakers.

30 Constantinescu et al (2010) - Pilot Remote in home Improvements SPL all speech tasks overall speech intelligibility breathiness & vocal roughness

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32 Mashima et al (2003) 23 participants with voice disorder Secure Internet-based VC system Integrated speech analysis software Outcomes comparable to FTF Tx Ax pre- & post-tx - conducted FTF

33 Australian Stuttering Research Center Telephone-based applications Lidcombe program (Wilson et al, 2004) - 5 children (3-5 yrs) - < 2.0% SS 4/5 children Camperdown program (Carey et al, 2010) RCT 20 participants treated via telephone, 20 treated FTF No sig diff between groups % SS post, 6, or 12 ms Av 221 min less clinician contact time than FTF

34 Waite et al, (2006, 2010) Online & FTF Ax speech - 20 children (4-9 yrs) High level of agreement (68%-100%) FTF & online Single-word artic, speech intelligibility, oromotor function, phonological processes, phonetic transcription accuracy, diagnosis, speech severity ratings Waite et al., (2010) 20 children (8-13 yrs) Online & FTF Ax - Literacy, spelling & reading tests % levels of agreement > 80% most measures Intra- & inter-rater reliability - v. good all online parameters

35 Waite et al., (2010) Online & FTF Ax language - CELF children (5-9 yrs) No sig diff between online & FTF total raw scores & scaled scores Very good agreement - individual items, total raw scores, scaled scores, core language score, & severity level Intra- & inter-rater reliability online ratings v. good all measures

36 Ward et al (2007) 20 laryngectomy patients - Ax online & FTF > 80% agreement between online & FTF assessors oromotor, swallowing, communication Ward et al (2009) 10 patients Assessed remotely 1700km away Swallowing, stoma, & communication status Excellent levels of agreement achieved High patient & clinician satisfaction

37 Sharma et al (2011) 10 simulated patients - range of dysphagia severity levels Simultaneously Ax online & FTF Clinical Swallowing Examination with support of assistant High - excellent levels of agreement between online & FTF Aspiration risk agreement excellent

38 Ward et al (2011) 40 patients with dysphagia neurological & structural High levels of exact agreement between the online & FTF assessors: Oromotor ratings (83% to 100%) Food & fluid trials (75% to 100%) Diagnosis & recommendations for future management (75% - 100%)

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40 Need to consider a range of technologies Synchronous Real-time interaction between client & clinician Asynchronous Review information at later time Store & forward technology audio & video recordings

41 Technology may vary at different stages of management Assessment phase S Initial treatment phase S Maintenance phase AS Follow-up S / AS S synchronous AS - asynchronous

42 Digital audio & video recording - SmartPhone , SMS Videoconferencing Dedicated videoconferencing networks Free Internet services Skype, oovoo Integrated multi-media videoconferencing systems Interactive web-based applications

43 Integrated multi-media Videoconferencing systems Integrated software Multi-media functions Ease of set-up & operation ehab TM VYSTER (Versatile & Integrated System for Telerehabilitation) - Parmanto et al (2010), University of Pittsburgh

44 Financial interest in ehab TM through NeoRehab TM, UniQuest, University of Queensland, Brisbane

45 V 2 V 3

46 Completely controlled remotely Patient does not require any technical expertise High quality videoconferencing Remotely moveable / optical zoom camera Echo cancelling microphone Store & forward features 46

47 Specific assessment tools Informal motor speech Ax Informal language assessment Media tools display images, written materials, videos, playback 47

48 Measurement tools SPL & Frequency

49 Interactive web-based applications Webcam VC with clinician Interactive web-based therapy activities TinyEYE ( Web X, Adobe Connect Glogster, Popplet Powerpoint Sean Sweeney

50 Will transform how SLTs deliver daily therapy ipads, tablets, Smartphones Therapy transformed from pencil & paper based activities smart, engaging, & flexible therapy options

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52 Parkinson s Disease

53 Teacher with voice disorder To teacher Clinician videos voice technique To clinician

54 Technology is a tool Clinical reasoning must be used to identify appropriate use

55 Technology is a train: you will either be on it or under it (Author unknown)

56 Paradigm shift required FTF interaction in clinical setting - gold standard Is it? Diversify & adopt new modes of service delivery

57 Need to review perceptions about capacity of clients, old & young (& families) to engage in new management protocols & technology

58 Preparing future SLTs curriculum focus on technology-enabled practice Clinical experience in use of technology Reimbursement Availability of technology to meet clinical & client requirements Connectivity

59 demands on health care services Changing societal expectations Advances in technology & neuroscience Demand a proactive approach to more relevant & effective SLT services to meet needs of all individuals with communication & swallowing disorders

60 A/Prof Trevor Russell Prof Liz Ward Dr Anne Hill Dr Monique Waite Dr Gabriella Constantinescu NHMRC Project Grants , , ,