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Telemedicine and the Diagnosis of Speech and Language Disorders ISSN: 0025‐6196 Accession: 00005625‐199712000‐00004 Duffy, Joseph R. PhD; Werven, Gerry W. MS; Aronson, Arnold E. PhD

Author(s): Issue: Publication Type: Publisher:

Volume 72(12), December 1997, pp 1116‐1122 [Articles] © 1997 Mayo Foundation for Medical Education and Research From the Division of Speech Pathology, Mayo Clinic Rochester, Rochester, Minnesota.

Institution(s): Address reprint requests to Dr. J. R. Duffy. Division of Speech Pathology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905. Abstract Objective: To summarize results of telemedicine evaluations of speech and language disorders in patients in a small, rural hospital and in large multidisciplinary medical practices.

Material and Methods: Eight patients underwent assessment as part of experiments with the National Aeronautics and Space Administration‐launched Advanced Communications Technology Satellite. A second clinician was on‐site with patients to assess the reliability of satellite observations. Twenty‐four previously videotaped samples of speech disorders were also transmitted to assess agreement with original face‐to‐face clinical diagnoses. In addition, results of 150 telemedicine evaluations among Mayo Clinic practices in Minnesota, Arizona, and Florida were examined retrospectively.

Results: Evaluations were reliable, and patient satisfaction was good. Diagnoses were consistent with lesion localization and medical diagnosis when they were known, and they frequently had implications for lesion localization and medical diagnosis and management when they were previously unknown. The frequency of

uncertain diagnosis (13%) for evaluation among the Mayo practices was only slightly higher than that encountered in face‐to‐face practice. Face‐to‐face evaluations were considered necessary for only 6 of the 150 patients (4%).

Conclusion: Telemedicine evaluations can be reliable, beneficial, and acceptable to patients with a variety of acquired speech and language disorders, both in rural settings and within large multidisciplinary medical settings.

(Mayo Clin Proc 1997;72:1116‐1122)

ACTS = Advanced Communications Technology Satellite; NASA = National Aeronautics and Space Administration; TMCs = telemedicine consultations

Disorders of speech or language can be the first or only apparent clinical evidence of disease. In such cases, their careful examination may provide valuable information about localization of lesions and may contribute to the medical diagnosis and management. Often the examination itself can be conducted rapidly, noninvasively, and without costly and time‐consuming instrumental analyses.

The diagnosis of speech and language disorders traditionally involves face‐to‐face verbal interaction between clinician and patient. Language use, auditory perceptual features of speech, and visible characteristics of speech movements are the most salient information on which such diagnoses are based. Because of these crucial "listen and look" traits, examination of at least some types of speech and language disorders should be possible on‐line "at a distance," as long as the auditory and visual transmission is of sufficient quality to allow adequate patient participation and reliable and valid interpretation of signs and symptoms. The limited study of speech and language examinations conducted at a distance suggests that such assessments can lead to clinical diagnoses that are consistent with those obtained during face‐to‐face interaction. [1,2] In a sense, the assessment of many speech and language disorders is ideally suited to clinical telemedicine.

The Mayo Clinic has taken advantage of the apparent compatibility between telemedicine and the practice of speech‐language pathology for several years. In 1987, speech pathology telemedicine consultations (TMCs) were among the first clinical TMCs provided among the Mayo Clinic facilities in Rochester, Minnesota, Scottsdale, Arizona, and Jacksonville, Florida. These consultations have been a valuable resource for difficult‐to‐diagnose cases, particularly when a speech or language disorder has been the only or the most prominent complaint and clinical finding. This value was appreciated during the planning of recent telemedicine experiments using a

National Aeronautics and Space Administration (NASA)‐launched Advanced Communications Technology Satellite (hereafter referred to as the ACTS project). One arm of this project included the provision of speech pathology consultation‐by‐satellite.

In this report, we summarize our speech pathology consultation‐by‐satellite experience, with emphasis on the methods used, information obtained, difficulties encountered and overcome, and types of speech and language problems that have been evaluated through this medium. We will address separately our experience during the ACTS project and our more "routine" experience among three Mayo Clinic sites (hereafter referred to as Mayo TMCs) because the technology, goals, and types of patients served differed between these two experiences.

METHODS Environment and Examination Protocol (ACTS Project and Mayo TMCs). The teleconference environment during the ACTS project and the Mayo TMCs enabled patients to see the clinician‐ usually from the waist up‐on a television monitor. The loudness could be adjusted to a comfortable listening level. An overhead camera allowed projection of pictures and printed materials on the monitor, and size and focus were adjustable by the clinician or technical assistant.

The camera could be adjusted to provide anything from a full‐body view of the seated patient to a close‐up focus on the lips, tongue, and palate. The patient usually wore or was near a microphone, and the loudness could be adjusted on request by the clinician.

The following paragraphs summarize the range of tasks beyond elicitation of the history and recording of complaints that were most often used. For most cases, only those tasks necessary to establish the nature and general severity of the primary problem were used. For example, if the only complaint or evident problem was a motor speech disorder, formal assessment of language was not pursued.

Oral Mechanism Examination. With use of close‐up views, the size, symmetry, and range of motion of the jaw, face, tongue, and palate could be observed at rest or during movements on command or imitation (for example, tongue protrusion, smiling, palatal movement during vowel prolongation, and coughing). Oral reflexes and responses to strength testing of the jaw, tongue, and face conducted by an on‐site assistant could be observed. This examination was most often used when a neurologic speech disorder was suspected.

Motor Speech Examination.

For a motor speech examination, the following tasks were performed: reading a paragraph, conversational speech, prolongation of the vowel "ah," rapid alternating motion rates (for example, rapid and steady repetition of "puhpuhpuhpuh ..."), sequential motion rates (for example, "puhtuhkuhpuhtuhkuh ..."), cough and glottal attack, and repetition of simple words and multisyllabic words and sentences. Additional tasks were devised on‐line, as is common during face‐to‐face assessment. This examination was most often used when a neurologic motor speech disorder (that is, dysarthria or apraxia of speech), organic dysphonia, or psychogenic voice or speech disturbance was suspected.

Language Examination. Most often, the following tasks were included in language examination: following simple and complex verbal commands, picture identification, picture naming, sentence repetition, word definitions, proverb explanations, narrative description of a depicted scene, oral spelling, reading aloud, and answering questions about text material that had been read. In some cases, a sample of writing was obtained and projected for review. This examination was most frequently used when aphasia or cognitive disturbances affecting communication ability were suspected.

After the examination, the clinician summarized impressions and recommendations for the patient and family member or caregiver. After the patient left, discussion with the referring clinician was pursued, either on the air or later by telephone. In all cases, a written report for the medical record was sent to the referring clinician. The satellite time for examination, counseling, and discussion generally was 20 to 45 minutes.

ACTS Project. In 1993, the space shuttle Discovery launched a communications satellite (ACTS). Projects using the technology of this satellite were funded by the Advanced Research Project Agency, a government agency that supports technologic development. Involvement by the Mayo Clinic was part of investigations of new methods for sending medical images and other information across long distances, both at high and low data rates of digital transmission. Speech pathology consultation was one component of the Mayo involvement in the ACTS experiments. The specific project provided services to St. Elizabeth's Hospital, a small rural community hospital in Wabasha, Minnesota. The purpose was to demonstrate and evaluate the capacity of speech and language assessment to identify the nature of acquired speech and language disorders and to formulate appropriate recommendations. Signals from the ACTS for speech pathology consultations were transmitted digitally at a low data rate (1.5 megabits per second).

For the purposes of the project, eight adults with medical conditions affecting their ability to communicate were recruited by St. Elizabeth's Hospital staff. Patients were residents in nursing homes or residential facilities or were

living at home in the nearby area. Their problems were deemed appropriate for the demonstration purposes of the project, and the evaluation was thought to have potential benefit for them or their caregivers.

One of us (G.W.W.) was present at St. Elizabeth's Hospital to assist with the evaluation, if necessary, but primarily to assess the reliability of observations made by satellite. Before examination of the patient, the on‐satellite clinician (J.R.D. in all cases) was informed only about the patient's age, living environment, and the general cause of the communication disorder (for example, stroke or multiple sclerosis); he was not given information about localization of any neurologic lesion.

For all patients who participated in the ACTS project, we intentionally provided only minimal on‐site orientation of the patient to the television monitor and information about how the evaluation would proceed, and the on‐ satellite clinician was responsible for performing the assessment. In all cases, congruence of the satellite and on‐ site observations was discussed during or after the assessment. Congruence of the speech‐language diagnosis with the patient's history and medical data was examined after the evaluation. Patients or family members or caregivers were interviewed by telephone several weeks later to assess their satisfaction with the evaluation.

In addition to the previously described real‐time evaluations, 24 previously recorded 10‐ to 30‐second videotaped samples were transmitted from the hospital site for on‐satellite diagnosis. The samples represented various neurologic speech disorders that were consistent with the localization of the causal neuropathologic condition. The tape had been developed for teaching purposes by a colleague not involved in the ACTS project (A.E.A.), and the on‐satellite clinician was blinded to the original speech and neurologic diagnoses. The videotape assessments served as an indirect means of evaluating the quality of the low‐data‐rate satellite transmission for diagnostic reliability as well as the possibility of using satellite‐transmitted taped samples as an alternative method for assessment when patients are unavailable during satellite transmission time or cannot travel to the transmission facility.

Mayo TMCs. Between 1987 and mid‐1994, 150 speech pathology consultations were conducted by Rochester‐based speech‐ language pathologists (primarily by J.R.D. and A.E.A.) for patients in Scottsdale, Arizona, or Jacksonville, Florida. In contrast to the digitized low‐data‐rate transmission for the ACTS project, the signal for these satellite transmissions was noncompressed, of broadcast quality, analogue, and with a visual equivalent of 108 megabits per second. The purpose of these consultations was to diagnose and provide management recommendations for patients with speech, voice, or language problems, many of which were the only or the primary complaint of the patient. In many instances, the primary purpose of the consultation referral was to obtain assistance in the localization and diagnosis of the underlying disease. The written reports generated from these consultations, and a

review of patient medical records to assess outcome for illustrative cases, served as the database for the results reported in this article.

RESULTS ACTS Project. The characteristics of the eight patients who underwent assessment for the ACTS project are summarized in Table 1. Seven patients had a history of central nervous system disease and had signs and symptoms beyond those reflected in their speech and language. The duration of their disorders ranged from several months to 18 years. One patient had a long history of an unexplained voice problem. Five of the eight patients had hearing loss, visual impairment, or cognitive impairment; in no case did these problems obviously preclude evaluation.

Table 1. Characteristics of Patients Assessed During the ACTS Project*

Various communication disorders were identified. They included apraxia of speech, aphasia, nonaphasic cognitive deficits that affected communication, adductor spasmodic dysphonia, and several different types of dysarthria. In all patients for whom medical data were available for comparison, the speech‐language diagnosis was compatible with neurologic localization and diagnosis. In all cases, the speech pathologist's diagnosis was made with sufficient confidence to have been of assistance in the localization of the neurologic disease, if that had been relevant. In no case did the on‐site clinician disagree with the observations, diagnosis, or recommendations made by satellite.

Some basic counseling was possible for most patients. A recommendation for formal speech‐language therapy was made for one patient, modification of communication strategies for another, and laryngeal injection of botulinum

toxin for another. Specific recommendations were not made for five patients, but strategies for maximizing communication that were already in place were reinforced.

Informal follow‐up interviews were possible for five patients. All were satisfied with the satellite interaction, all thought that the information provided to them was useful, and all reported that the problems that were evident during the evaluation adequately reflected their communication abilities and disabilities. One caregiver said the evaluation demonstrated speech skills he never knew the patient had. One caregiver for a patient with hearing and visual difficulties said a larger television monitor would have been helpful.

For the previously recorded videotaped samples that were evaluated by satellite, agreement about the speech diagnosis between the satellite observer and the original clinician was 96%. In each case, the speech diagnosis would have had specific implications for the localization of the underlying neurologic disease.

The nature of the evaluations and their outcomes are illustrated by the following two brief case summaries from the ACTS project.

Case 2. An 85‐year‐old woman had had a left hemisphere stroke 15 months before the current assessment. She had been examined directly by one of us (G.W.W.) at 7 months after occurrence of the stroke, at which time she exhibited severe aphasia and apraxia of speech. She was unresponsive to strategies that might have helped to improve communication, and therapy was not recommended at that time.

Although the patient was alert and attentive to the monitor, she initially was unresponsive to any request or statement from the on‐satellite clinician. After she failed to respond to simple items on the language examination, the on‐site clinician conducted a basic examination, to which she was responsive. The on‐site clinician then explicitly oriented her to the clinician on the monitor and prompted her to respond. Within a few minutes, she grasped the nature of the interaction. The on‐satellite clinician then was able to replicate the on‐site assessment; the patient's performance during the replication was slightly inferior to that during the on‐site assessment, but the nature and general severity of her deficits were unchanged. Because her performance clearly had improved since evaluation at 7 months and because she was responsive to efforts to cue better language performance, initiation of therapy on a trial basis was recommended.

This case illustrates some of the problems that may be encountered on interactive television with patients who have major language or other cognitive impairments. It also establishes that such obstacles can be overcome in at least some cases through careful orientation of patients to the interactive nature of the transmission.

Case 3. A 35‐year‐old woman had complications‐including motor, visual, hearing, and cognitive deficits as well as dysarthria‐after surgical treatment of a basilar artery aneurysm at age 17 years. The caregivers in her group home were interested in learning about her capacity for functional verbal communication and the degree to which she should be using nonverbal, augmentative communication strategies. Examination established the spastic nature of her dysarthria and her basic verbal and reading comprehension abilities. It determined that the intelligibility of her speech improved with some minor modifications in the rate of speech. It also established a simple strategy of using an alphabet board to point to the first letter of a poorly understood word to facilitate the intelligibility and efficiency of her speech. Her caregiver, who was able to observe these techniques, noted that they enabled her to communicate verbally more adequately than had previously been expected.

Mayo TMCs. The 150 Mayo TMCs were for 104 women and 46 men who ranged in age from 20 to 90 years (mean age, 56). The distribution of referral sources among subspecialties included 106 patients (71%) from otorhinolaryngology, 28 (19%) from neurology, 11 (7%) from speech pathology, and the other 5 from psychiatry or internal medicine. The primary medical complaint was confined to speech or language in 128 patients (85%), speech or language plus swallowing difficulty in 3 (2%), and speech or language plus a variety of other problems in 19 (13%). The duration of the problems for which consultation was sought ranged from less than 6 months to more than 5 years; 68% of the patients had had difficulty for more than a year.

The broad categories of speech pathology diagnoses made during Mayo TMCs are summarized in Table 2. Organic dysphonias were diagnosed in 82 patients, 57 of whom had some type of spasmodic dysphonia. Most of the spasmodic dysphonias were judged to be neurologic in origin, some were judged to be psychogenic, and several were idiopathic. Most of the remaining dysphonias were cases of organic voice tremor, psychogenic dysphonia, or musculoskeletal tension dysphonia, or they were consistent with already diagnosed vocal cord paralysis. Some diagnoses were less certain‐for example, three patients had dysphonias that were considered organic but that could not be specified further.

Table 2. Broad Categories of Speech Pathology Diagnoses for 150 Mayo Telemedicine Consultations

Forty‐six patients had a neurologic motor speech disorder or aphasia. All major types of dysarthria, including mixed types, were represented. Several patients had apraxia of speech, either as an isolated problem or in combination with aphasia or dysarthria. A few patients had nonaphasic cognitive deficits. All these diagnoses had implications for the localization of lesions to regions, structures, or pathways, including specific cranial nerves, the cerebellum, basal ganglia, unilateral or bilateral upper motor neuron pathways, the right or left cerebral hemisphere, or multifocal or diffuse involvement.

In addition, one patient stuttered, and one had undergone a laryngectomy. In 19 patients (13%), the diagnosis was indefinite‐dysphonias of uncertain cause in 15, an undetermined type of dysarthria in 2, a psychogenic speech disorder versus an ataxic dysarthria in 1, and a history of episodic speech difficulty but normal speech performance during the consultation in 1.

We do not know how many of the diagnostic uncertainties would have been resolved by direct examination, but direct examination in Rochester was recommended for six patients, a suggestion that at least some of the uncertainties were related to perceived limitations of the satellite interaction. In general, the percentage of the 150 patients for whom diagnosis was uncertain is probably slightly higher than that encountered with similar general categories of disorders during direct assessment of outpatients in the Mayo Rochester speech pathology

practice. For example, in the Rochester practice, about 12% of dysphonias (with normal laryngeal findings on otorhinolaryngologic examination) are of uncertain cause, and 3% of the dysarthrias are of uncertain type.

Recommendations made to patients and their referring physicians are summarized in Table 3. Otorhinolaryngologic intervention, most often botulinum toxin injection for adductor spasmodic dysphonia, was recommended for 50 patients. Behavioral speech or language therapy was recommended for 35 patients. For 44 patients, consultations with other medical subspecialties was recommended‐most frequently for neurologic evaluation because the speech examination suggested the presence of neurologic disease. Some patients were counseled about their problem or were reassured about the management they had been receiving. In some cases, no recommendations were made beyond the diagnosis.

Table 3. Recommendations Deriving From 150 Mayo Telemedicine Consultations

The Mayo TMC patients have not routinely undergone follow‐up for assessment of outcome. Several consultations, however, contributed to medical localization and diagnosis of disease, and many patients were successfully managed medically with treatment suggested by the TMC (especially those with spasmodic dysphonias who had laryngeal injections of botulinum toxin). Most, if not all, patients were comfortable with the satellite interaction, and we have received no complaints from patients about the television mode of interaction.

The following brief case summaries illustrate the types of problems and the outcomes associated with Mayo TMC evaluations.

Case 1. A 73‐year‐old woman was examined by a neurologist because of an isolated complaint of progressive, undiagnosed speech difficulty and dysphagia. Examination identified upper extremity weakness and exaggerated reflexes. A TMC opinion from speech pathology concluded that she had a mixed flaccid‐spastic dysarthria indicative of motor neuron disease or any other disease associated with a bilateral upper and lower motor neuron pathologic condition. After the complete neurologic work‐up, motor neuron disease was diagnosed.

Case 2. A 50‐year‐old man was referred for otorhinolaryngologic examination because of an 8‐ to 9‐year history of undiagnosed voice difficulty. Voice therapy had yielded no benefit. Laryngeal examination showed normal findings. TMC examination revealed a subtle voice tremor, dystonic facial movements during speech, and a family history of similar voice difficulty and torticollis. Although no obvious causal psychologic factors were detected, the patient did report having depression because of the voice disorder. Neurogenic adductor spasmodic dysphonia was diagnosed, and laryngeal injection of botulinum toxin was recommended; the patient benefited from the initial and five subsequent injections. He commented in a letter that his depression had been relieved and that he was having less trouble with his voice than he had experienced in years.

The disorders seen during Mayo TMCs differed some‐what from those seen for the ACTS project (for example, the participants in the ACTS project generally had more chronic conditions and clearly established neurologic diagnoses). These differences may reflect the demonstration nature and active recruitment of patients for the ACTS project versus the immediate clinical concerns associated with the Mayo TMCs. They may also reflect variations in problems likely to be encountered in rural areas versus large, multidisciplinary settings in which physicians encounter a higher proportion of undiagnosed or unusual problems requiring subspecialty expertise.

DISCUSSION Our experiences with telemedicine have been positive for participating clinicians, referring health‐care providers, and patients and their caregivers. They demonstrate that speech pathology consultation‐by‐satellite to both rural areas and large multidisciplinary medical settings can contribute to medical diagnosis and management of numerous communication disorders. The contributions range from evaluation and management recommendations for disorders commonly dealt with by speech‐language pathologists to difficult‐to‐diagnose or rare problems for which greater than average experience or expertise is required. Although diagnostic uncertainty occurs during satellite consultation, it has been relatively infrequent and not grossly disproportionate to the frequency of uncertainty that occurs within our routine direct practice.

Our telemedicine experience does suggest that some patients with language or cognitive problems may have difficulty grasping the nature of the interactive process over television monitors (as in our ACTS project case 2). These difficulties may be overcome with explicit efforts to orient such patients. We also have learned that assessment of some patients with psychogenic speech disorders can present special challenges for eliciting the history about personally turbulent issues and that the current inability to assess muscle strength and musculoskeletal tension, and to manipulate speech structures physically, may omit important information in some cases.

We have had little or no telemedicine experience with a wide range of speech and language disorders, some of which lend themselves to the telemedicine format and others of which may present challenges. For example, using telemedicine to assess children with suspected developmental delay, specific speech or language disability, or cleft lip and palate could be particularly useful in remote geographic areas where diagnostic assessment and recommendations about the need for further medical work‐up or surgical, prosthodontic, or behavioral management are not readily available. Although formal assessment of children may be difficult because of immaturity, behavior disorders, or the need for extended or multiple periods of observation, such difficulties can probably be overcome by remote control of cameras and reduced cost, which would allow extended observations. Transmission of taped or on‐line nasendoscopy and videofluoroscopy during speech and swallowing is feasible and could contribute to the diagnosis and management of speech and swallowing disorders.

Telemedicine also offers a mechanism for providing behavioral intervention for people who do not have access to services locally. A few studies have demonstrated the feasibility of providing at‐a‐distance evaluation and therapy services by telephone or closed‐circuit television to adults with acquired neurologic speech and language disorders. [1‐3] This mode of providing therapy will almost certainly receive more attention in the future, especially when in‐ home transmission becomes possible and affordable.

CONCLUSION Our experience supports the conclusion that telemedicine is an appropriate medium for providing speech‐language pathology consultation that is reliably accurate in identifying various acquired neurogenic and psychogenic speech disorders, with implications for lesion localization and, sometimes, specific medical diagnosis. Such evaluation may also identify a need for additional medical assessment or may help formulate appropriate medical or behavioral management strategies. Telemedicine represents a viable alternative to face‐to‐face consultation when distance precludes timely and cost‐effective service or when specialized expertise is unavailable for problems of speech and language that are difficult to diagnose or manage.

ACKNOWLEDGMENT

We thank the many members of the Mayo Foundation Video Communications staff who contributed to the ACTS project and to our Mayo TMCs. We appreciated the technical and administrative support and encouragement of Bijoy K. Khandheria, M.D., Marvin P. Mitchell, Abdul R. Bengali, Michael B. Wood, M.D., and Barry K. Gilbert, Ph.D., during the NASA project. We also thank the staff at St. Elizabeth's Hospital in Wabasha, Minnesota, for assistance in identifying and facilitating the assessment of patients for the ACTS project and Brian W. Edwards for help in obtaining follow‐up data for some of our Mayo Clinic Scottsdale TMC patients. Finally, we thank NASA for donation of satellite transmission time and the staff at the NASA Lewis Research Center for technical and scheduling assistance.

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2. Wertz RT, Dronkers NF, Bernstein‐Ellis E, Sterling LK, Shubitowski Y, Elman R, et al. Potential of telephonic and television technology for appraising and diagnosing neurogenic communication disorders in remote settings. Aphasiology 1992;6:195‐202 ExternalResolverBasic [Context Link]

3. Vaughn GR. Tel‐communicology: health‐care delivery system for persons with communicative disorders. ASHA 1976;18:13‐17 ExternalResolverBasic Bibliographic Links [Context Link]

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