Using telehealth to deliver speech treatment for Parkinson s into the home: Outcomes & satisfaction

Transcription

1 Using telehealth to deliver speech treatment for Parkinson s into the home: Outcomes & satisfaction Deborah Theodoros PhD Anne Hill PhD Trevor Russell PhD Telerehabilitation Research Unit Parkinson s Australia National Conference 2015

2 Speech Disorder in PD Hypokinetic dysarthria Prevalent in up to 90% of PWP Subtle changes in speech very early in disease May talk less - more passive in conversation Difficulty being heard on phone Asked to repeat more often

3 Speech Disorder in PD Reduced volume Monotonous speech Slurring of speech - imprecise articulation Breathy & harsh vocal quality Difficulty initiating speech Repetition of syllables, words, phrases Prolonged pauses Accelerated/short rushes of speech

4 Speech Disorder in PD Significant impact on PWP- affects capacity to communicate with family, friends & in community (Miller et al, 2006) Requires long-term management Drug & surgical treatments ineffective (Plowman-Prine et al, 2009) Behavioral therapy remains treatment of choice

5 Speech Treatment Lee Silverman Voice Treatment (LSVT LOUD) (Ramig et al, 2001, 2002) Intensive Tx 16 sessions 1 hr per day/ 4 days per week/ 4 weeks Focus on LOUD voice Increase in speech intelligibility

6 Barriers to Accessing Treatment Motor disturbances preclude/impede repeated attendance at clinic Expended effort & timing of medications Dependence on carers Geographical location

7 Solution Telehealth/Telerehabilitation Delivery of service across Internet Home-based treatment Enables intensive Treatment Optimizes timing & sequencing of intervention (Winters & Winters, 2004) Facilitates self-management in real-world

8 Evidence to Date Lab-based 61 PWP assessed simultaneously FTF & online Comparable agreement between online & FTF Ax for majority of perceptual & acoustic parameters 34 PWP treated LSVT LOUD FTF & online- RCT Improvements online comparable to FTF Tx Online Tx effectively delivered - mild & mod dysarthric speakers Constantinescu, Theodoros, Russell, Ward et al (2010, 2011)

9 Aims To determine the non-inferiority of an online home-based intensive speech Tx for PWP living in metropolitan area compared to conventional FTF intervention To determine if online treatment outcomes differ according to location

10 Methods Single, prospective, non-inferiority RCT 52 participants 31 Metro participants randomized to: Grp 1 FTF = 16 Grp 2 Metro Online = 15 Stratified according to speech severity 21 non-metro participants Grp 3 Outside Metro city boundary & within 5 hr drive

11 Protocol 2 x Baseline assessments 16 x 1 hr treatment sessions LSVT LOUD 2 x post-treatment assessments All assessments performed online assessors blinded Primary outcome measure Mean change in speech sound pressure level (SPL-dB) during monologue

12 Outcome Measures Secondary outcome measures SPL on speech tasks, max F 0 range Perceptual ratings Communication partner ratings Quality of life: Dysarthria Impact Profile (Walsh et al, 2009) Parkinson Disease Questionnaire (PDQ-39) (Jenkinson et al, 1997) Participant & clinician satisfaction

13 1 Technology Virtual clinic Secure on VPN Real-time videoconferencing Store & forward features Multi-media Images Written material Recording & play back audio and video files Acoustic measurement software Vocal sound pressure level & frequency Connectivity 3G mobile phone network or ADSL

14 Technology

15 Results Non-inferiority analyses (monologue SPL) Metro online & FTF Metro online treatment not inferior to FTF treatment - Upper 95% CI (3.16 db) of difference in change scores between groups within non-inferiority margin of db and 0 Metro Online & Non-Metro online Non-Metro online treatment not inferior to Metro online treatment -Upper 95% CI (2.97 db) within noninferiority margin of db and 0

16 Results LMM analyses Intention To Treat No significant difference between groups in mean pre-post change on any outcome measure i.e. No one group performed better or worse than the others Significant improvement pre-to post-treatment across groups

17 Outcome measure SPL Sustained phonation; reading; monologue <.001 Max F 0 range.021 Perceived loudness <.001 Communication Partner Ratings Easy to understand; Less repetition required; Overall rating <.001 Fixed effect for Time (p values) Initiate conversation with familiar persons.030 Dysarthria Impact Profile (DIP) Effect of speech on person.022 Acceptance <.001 Total DIP Score.004

18 Participant Satisfaction (N = 36)

19 What did they say? What they liked Convenience In comfort of own home Saved time & travel Less fatigue Suited lifestyle & work able to fit in with a busy lifestyle freedom to plan my day My life could continue around speech therapy didn t impact too heavily on my job What they did not like Connection problems

20 Clinician satisfaction (36 responses, 4 clinicians)

21 What did they say? Benefits Convenient for participants Allowed access to treatment Did not impact on participants lifestyle or work Issues/Considerations Connectivity Screening accuracy (cognition, vision, hearing) Environment Noise Location in home Seating Lighting

22 Discussion Online speech treatment not inferior to FTF treatment Able to achieve similar improvements in speech & quality of life online as FTF treatment Location of online treatment did not have an effect on outcome High satisfaction - PWP & speech pathologists

23 Conclusions Evidence to support delivery of intensive speech treatment via telehealth into the home for PWP What s next? Technology-enabled pathways for PWP to maintain speech & quality of life Translate research into service delivery

24 Acknowledgements National Health and Medical Research Council Project Grant No PWP and their families Dr Monique Waite, Dr Anna Rumbach, Stacie Park, Rachelle Pitt, Sarah Skerrett