Telepractice or telehealth involves the delivery of therapeutic care through the use of technologies that include videoconferencing (i.e., interactive audio and video conferencing), the internet, the telephone, text messaging, e-mail and other communications technology. Telepractice allows clients in remote or rural settings to access health care, including specialist services not available in their communities. It has been used for a range of conditions and therapeutic needs, from transatlantic surgery to the provision of speech and language therapy.

Canada, where ISTAR is located, is the second largest country in area in the world. Approximately 34 million people live in ten provinces and three territories encompassing over 9 million square kilometres. Our population density per square kilometre ranges from close to 0 in Nunavut and the Northwest Territories to 23.9 in Prince Edward Island. In the 2006 census, approximately 30% of Canadians lived in rural areas.

In 2008, Dr. Deborah Theodoros at the University of Queensland, Australia, reported that access to Speech-Language Pathology services in rural and remote areas is a problem throughout the world, and that the treatment of stuttering is well suited to an online environment. Telehealth methods have been used in Australia, like Canada a large country with a low population base, to successfully deliver stuttering treatment. Using a combination of telephone, voicemail recordings, e-mail contact and mailing of audio or video taped exemplars, the Camperdown Program has been delivered to adults in remote and local areas (O'Brian et al, 2008; Carey et al, 2010). The Lidcombe Program of Early Stuttering Intervention (Lidcombe Program; Onslow, Packman, & Harrison, 2003) also has been delivered to children (Lewis et al, 2008) using these same technologies with the addition of mailed in audio recordings of children's speech samples and parents delivering treatment.

In 2000, Deborah Kully described use of telehealth at ISTAR and provided a case report of a fluency maintenance program designed for a client in rural Alberta. In 2003, Claude Sicotte and colleagues based in Montreal used telemedicine to treat six children and adolescents who stuttered and lived in a remote, northern Quebec community. In both centres, videoconferencing was used to deliver the therapy.

ISTAR, based in Edmonton with a satellite office in Calgary, Alberta, is a self-funded Institute of the Faculty of Rehabilitation Medicine at the University of Alberta. Since 1985, ISTAR has provided evidence-based treatment to people of all ages who stutter from across Canada and around the world. Approximately 70% of the clients in our intensive programs come from outside the Edmonton area.

In 1998, we began using telepractices at ISTAR to provide assessment, therapy and maintenance services to our long distance clients. At that time, the primary mode of delivery of services was through the telephone with mailed-in video samples. The primary type of services delivered was maintenance, following in-clinic attendance at intensive therapy programs. Since then, the telepractice technologies used at ISTAR and the types of services delivered have evolved. Technologies include interactive videoconferencing, secure webconferencing via Adobe® Acrobat® Connect� Pro Meeting, transmission of audio/video samples via mail or electronically, and telephone calls or a combination of these. Services now include assessments of stuttering, delivery of treatment using a variety of approaches, and follow-up care. Treatment approaches used in telepractice include the Lidcombe Program, the Comprehensive Stuttering Program for school-aged children (Langevin, Kully, & Ross-Harold, 2007) and the Comprehensive Stuttering Program for adolescents and adults (Kully, Langevin, & Lomheim, 2007).

At present, we use videoconferencing, telephone and secure webconferencing for long distance assessments of school-aged children and adults (with additional audio/video samples, if needed, and attitude inventories sent by mail or e-mail). We also use these technologies for delivering maintenance programs for school-aged children, adolescents and adults who have attended individual or group intensive programs at ISTAR and for clients who have had combinations of intensive and extended therapy. In our school-aged intensive treatment programs, we have also used Skype to bring parents who have had to return home into the parent information meetings that are a part of our program. In these cases, one parent or another care-giver who stays with the child in Edmonton attends the "live" meeting.

For preschoolers, for whom we frequently recommend the Lidcombe Program of Early Stuttering Intervention, we often provide a short period of live intensive treatment (4-5 days) at one of our clinics, followed by telehealth sessions. These could take the form of video or secure webconferences, telephone calls supplemented with samples mailed or sent electronically, or video or webconferences alternated with telephone calls. We occasionally use telepractice methods for local clients who are unable to come to the clinic due to work/scheduling issues.

The following three composite cases illustrate some of our telepractice work.

Arturo was a 5 year old living in Southern Alberta, approximately four hours by car from ISTAR's nearest clinic in Calgary. Because of his young age, the length of the assessment (two hours) and the need to gather multiple samples, his stuttering was assessed "live" at our Calgary office. He had been stuttering for approximately one year and had received previous therapy for a mild-moderate language disorder. He demonstrated moderate stuttering with no avoidance behaviours. A month later, Arturo and his mother attended a live one week program (two hours a day, one in the morning and one in the afternoon) where she was taught how to make stuttering severity ratings and apply the Lidcombe Program. At the end of the week, Arturo and his mother returned to their community. Weekly sessions were conducted via videoconferncing. The clinician delivered the therapy from a nearby Calgary health centre that was equipped with videoconferencing equipment. Artruo and his mother went to their local community health centre that also was equipped with videoconferencing equipment. Videoconferencing allowed for the collection of necessary speech samples, observation of the parent delivered therapy, provision of feedback, and discussion with the parent. A technician was available by phone to help with occasional problems with audio/visual quality (typically a delay in the signals). Telephone sessions, with samples sent electronically, were occasionally used when the videoconference equipment wasn't available. Arturo has now completed stage 2 (maintenance) of the Lidcombe Program.

Zahra was an English and Arabic speaking University student living in the Middle East. Her speech was assessed via videoconferencing from her home City in the Middle East. Attitude inventories were sent and returned electronically. Zahra presented with severe overt stuttering, and avoided speaking in most situations except with close family members. She had not had any previous speech therapy, and therapy was not available in her city. Zahra attended a three week intensive therapy program at ISTAR's Edmonton clinic. After Zahra returned home, regular maintenance sessions were scheduled by telephone and/or secure webconferencing. These sessions included practice of fluency skills, discussion of practice/transfers and use of cognitive-behaviour skills such as self talk, and problem solving of difficult speaking situations. These sessions decreased in frequency as her stuttering stabilized at a low level, and she was able to problem solve well without our assistance. Five years later, Zahra has graduated from university and works as a professional. She continues to successfully manage her stuttering, and seek out communication opportunities and ways to educate others about stuttering.

Billy was a lively 8 year old boy who lived in a rural Northern community in Saskatchewan, Canada and stuttered severely. He did not avoid speaking. His classmates and teachers were very accepting of his stuttering, though there had been some teasing and bullying by older children at an adjacent junior high school. He had received bi-weekly school-based speech therapy, but, in the opinion of the referring S-LP, Billy needed more intensive treatment. He and his father attended a two week, 30 hour, individual intensive program at ISTAR to establish fluency skills. They returned home and completed six weeks of home practice, with mailed/emailed samples sent to the clinic. He returned to ISTAR six weeks later for another three days, where therapy focused on further stabilizing fluency, completing outside transfers, and problem solving of his home practice plan. This live session was followed by weekly telehealth (videoconference) maintenance sessions, which continued until Billy's stuttering severity was stable at severity ratings of 2 (very mild stuttering). Maintenance sessions were then gradually reduced to once every two weeks, then four weeks and so on. Two years after his initial therapy, he was maintaining fluency at severity ratings of 2-3 (on a 10 point scale where 1=no stuttering, 2=very mild stuttering and 10=severe stuttering).

There are some barriers to provision of telehealth, particularly via internet or videoconferencing, as these may not be available in some countries or areas, and the cost of long distance phone calls may be high. In Canada, delivery of government sponsored health care is a provincial or territorial responsibility. Regulations, codes of ethics, registration and licensing requirements for Speech-Language Pathologists vary across the country. The Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA) published a position paper on the use of telepractice in 2006. In 2009, the Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) issued preferred practice guidelines for the use of telehealth. Both documents discuss the importance of informed consent, practitioner knowledge of the equipment, the quality of audio/video signals, and the need to attempt to ensure the security of transmissions. Sometimes ISTAR's ability to provide telehealth options to clients who live in other parts of Canada is limited by provincial regulations. For example, one province currently only allows the provision of follow-up care by S-LPs who are registered in that province. Therefore, in order for ISTAR S-LPs to provide follow-up care (i.e., maintenance sessions) to clients living in that province, they would need to also be licensed there.

Despite licensing limitations, telepractice at ISTAR and the world over has allowed clients to access therapy that was, in the recent past, unavailable to them. The evidence-base for the effectiveness of telepractice in the assessment and delivery of stuttering therapy is growing and we look forward to publishing a report of case examples of clients treated at ISTAR in the near future.

References

Carey, B., O'Brian, S., Onlsow, M., Jones, M., Packman, A. 2010. Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: the Camperdown Program. International Journal of Language and Communication Disorders, 45, 108-120.

Kully, D. 2000. Telehealth in speech pathology: applications to the treatment of stuttering. Journal of Telemedicine and Telecare, 6, S2:39-41

Kully, D., Langevin M., & Lomheim, H. (2007). Intensive treatment of stuttering in adolescents and adults. In E. G. Conture and R. F. Curlee (eds.), Stuttering and related disorders of fluency, (3rd ed., pp. 213-232). New York: Thieme.

Langevin, M., Kully, D. A., & Ross-Harold, B. (2007). The Comprehensive Stuttering Program for School-age Children with strategies for managing teasing and bullying. In E. G. Conture and R. F. Curlee (eds.), Stuttering and related disorders of fluency (3rd ed., pp. 131-149), New York: Thieme,

Lewis, C., Packman, A., Onslow, M., Simpson, J., Jones, M. (2008). A Phase II trial of telehealth delivery of the Lidcombe program of early stuttering intervention. American Journal of Speech-Language Pathology, 17, 139-149.

O'Brian, S., Packman, A., Onslow, M. 2008. Telehealth delivery of the Camperdown Program for adults who stutter: a phase 1 trial. Journal of Speech, Language and Hearing Research, 51, 184-195.

Onslow, M., Packman, A., & Harrison, E. (Eds.). (2003). The Lidcombe Program of early stuttering intervention: A Clinician's guide. Austin, TX: Pro Ed.

Sicotte, C., Lehoux, P., Fortier-Blanc, J., Leblanc, Y. 2003. Feasibility and outcome evaluation of a telemedicine application. Journal of Telemedicine and Telecare, 9, 253-258.

Theodoros, D.G. 2008. Telerehabilitation for service delivery in speech-language pathology. Journal of Telemedicine and Telecare, 14, 221-224.

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