Cost analysis of home telerehabilitation for speech treatment in people with Parkinson's disease.

INTRODUCTION: Geographical barriers and impaired physical mobility among people with Parkinson's disease (PD) hinder their timely access to speech pathology services. We compared the costs of delivering a speech treatment via in-person consultation versus telerehabilitation. METHODS: We used data from a non-inferiority randomised controlled trial delivering the Lee Silverman Voice Treatment (LSVT LOUD®), where patients with dysarthria associated with PD were assigned to either the urban in-person group (N = 16) or the urban online group (N = 15), supplemented with a non-randomised group (regional online; N = 21). We compared costs over a one-month treatment period from a health-system perspective and a patient perspective. RESULTS: The mean treatment costs of both urban online ($1076) and regional ($1206) treatments tended to be slightly higher than urban in-person ($1020) from a health-system perspective. From a patient perspective, the mean treatment cost was $831 in the urban in-person group, $247 in the urban online group and $200 in the regional group. DISCUSSION: LSVT LOUD® may be delivered via telerehabilitation at a slightly higher cost than in-person delivery from a health-system perspective, but it is cost saving from a patient perspective. Telerehabilitation is an economically beneficial alternative for the delivery of the LSVT LOUD® programme in PD patients with speech disorders.

Clinical and Quality of Life Outcomes of Speech Treatment for Parkinson's Disease Delivered to the Home Via Telerehabilitation: A Noninferiority Randomized Controlled Trial.

PURPOSE: This study investigated the noninferiority and validity of an intensive speech treatment for people with Parkinson's disease (PD) delivered via telerehabilitation to the home. The effect of location on online delivery was also investigated. METHOD: In this single-blinded, randomized controlled noninferiority trial, 31 participants with dysarthria associated with PD from a metropolitan area were randomly assigned to either face-to-face or online Lee Silverman Voice Treatment (LSVT LOUD). A cohort of 21 participants from nonmetropolitan areas was also recruited and treated online. Outcomes were assessed using acoustic, perceptual, and quality of life measures. RESULTS: Noninferiority of online treatment was confirmed through comparable clinical and quality of life outcomes for the metropolitan online and face-to-face treatment groups. Significant improvements posttreatment were achieved for several acoustic, perceptual, and quality of life measures across the groups. No significant effect of online treatment location was identified. CONCLUSIONS: Clinical and quality of life outcomes supported the noninferiority and validity of online delivery of intensive speech treatment to people with PD in the home. Future research should address the implementation of online treatment in a clinical service, cost analyses, and potentially technology-enabled clinical pathways for people with PD in order to maintain optimal communication and quality of life.

Assessment and Treatment of Cognition and Communication Skills in Adults With Acquired Brain Injury via Telepractice: A Systematic Review.

PURPOSE: This is a systematic review of assessment and treatment of cognitive and communicative abilities of individuals with acquired brain injury via telepractice versus in person. The a priori clinical questions were informed by previous research that highlights the importance of considering any functional implications of outcomes, determining disorder- and setting-specific concerns, and measuring the potential impact of diagnostic accuracy and treatment efficacy data on interpretation of findings. METHOD: A literature search of multiple databases (e.g., PubMed) was conducted using key words and study inclusion criteria associated with the clinical questions. RESULTS: Ten group studies were accepted that addressed assessment of motor speech, language, and cognitive impairments; assessment of motor speech and language activity limitations/participation restrictions; and treatment of cognitive impairments and activity limitations/participation restrictions. In most cases, equivalence of outcomes was noted across service delivery methods. CONCLUSIONS: Limited findings, lack of diagnostic accuracy and treatment efficacy data, and heterogeneity of assessments and interventions precluded robust evaluation of clinical implications for telepractice equivalence and the broader area of telepractice efficacy. Future research is needed that will build upon current knowledge through replication. In addition, further evaluation at the impairment and activity limitation/participation restriction levels is needed.

Delivery of Intensive Voice Therapy for Vocal Fold Nodules Via Telepractice: A Pilot Feasibility and Efficacy Study.

OBJECTIVES: This pilot study examined voice outcomes and patient perceptions after intensive voice therapy for vocal fold nodules via telepractice. STUDY DESIGN: Pilot, within-subjects experimental trial. METHODS: Participants included 10 women diagnosed with bilateral vocal fold nodules who received intensive voice treatment via a free videoconferencing platform Skype, (Microsoft Corp., Redmond, WA). All participants completed one vocal hygiene session in person, followed by eight sessions of therapy via telepractice over 3 weeks. Before and immediately after treatment, patients attended a clinic in person to complete perceptual, stroboscopic, acoustic, and physiological assessments of vocal function. Analyses were performed by a speech-language pathologist and an otolaryngologist independent to and blinded to the study. Participants also completed the Voice Handicap Index and a telepractice satisfaction questionnaire, or an anticipated satisfaction questionnaire, before and after the treatment. RESULTS: Significant improvements were found in perceptual, vocal fold function, acoustic, and physiological parameters as well as nodule sizes and patient perceptions of voice-related quality of life post-treatment. Participants were highly positive about their first experience with telepractice. Results were similar to those from a separate study investigating the effects of an intensive voice therapy delivered in conventional face-to-face (FTF) format. CONCLUSIONS: This study is consistent with possible benefits of telepractice in the delivery of intensive treatment for vocal fold nodules. Pending final verification with a FTF comparison group, telepractice could be recommended as an alternate treatment modality for patients with vocal fold nodules.

Development, construction, and content validation of a questionnaire to test mobile shower commode usability.

BACKGROUND: Usability is an emerging domain of outcomes measurement in assistive technology provision. Currently, no questionnaires exist to test the usability of mobile shower commodes (MSCs) used by adults with spinal cord injury (SCI). OBJECTIVE: To describe the development, construction, and initial content validation of an electronic questionnaire to test mobile shower commode usability for this population. METHODS: The questionnaire was constructed using a mixed-methods approach in 5 phases: determining user preferences for the questionnaire's format, developing an item bank of usability indicators from the literature and judgement of experts, constructing a preliminary questionnaire, assessing content validity with a panel of experts, and constructing the final questionnaire. RESULTS: The electronic Mobile Shower Commode Assessment Tool Version 1.0 (eMAST 1.0) questionnaire tests MSC features and performance during activities identified using a mixed-methods approach and in consultation with users. It confirms that usability is complex and multidimensional. The final questionnaire contains 25 questions in 3 sections. The eMAST 1.0 demonstrates excellent content validity as determined by a small sample of expert clinicians. CONCLUSION: The eMAST 1.0 tests usability of MSCs from the perspective of adults with SCI and may be used to solicit feedback during MSC design, assessment, prescription, and ongoing use. Further studies assessing the eMAST's psychometric properties, including studies with users of MSCs, are needed.

Intensive versus traditional voice therapy for vocal nodules: perceptual, physiological, acoustic and aerodynamic changes.

OBJECTIVES: To investigate the perceptual, physiological, acoustic, and aerodynamic outcomes of patients with vocal nodules following intensive voice treatment compared with traditional voice treatment. STUDY DESIGN: Pragmatic randomized clinical trial. METHODS: Fifty-three women diagnosed with bilateral vocal nodules participated in the study. Voice recordings, stroboscopic recordings, acoustic, and aerodynamic assessments were made before voice treatment, after vocal hygiene education, and immediately postvoice treatment. All participants completed one session of vocal hygiene and eight sessions of direct voice therapy, however the delivery of the treatment between the two groups differed in treatment intensity. RESULTS: Physiological improvements were observed after vocal hygiene alone, whereas physiological, perceptual, and acoustic parameters all improved to some degree in both treatment groups immediately posttreatment. There were no differences in the extent of change observed between the two groups at any point following treatment. CONCLUSIONS: The investigation provided initial evidence that individuals with vocal nodules are able to recover voice function, vocal health, and vocal communication through intensive voice treatment. The results suggest comparable positive perceptual, physiological, and acoustic outcomes from intensive voice therapy compared with traditional voice therapy. Further investigation is required to determine the long-term effects of intensive treatment.

Impact of dysphagia severity on clinical decision making via telerehabilitation.

OBJECTIVE: Recent research supports the proposal that valid and reliable clinical swallow examinations (CSEs) can be conducted via telerehabilitation. However, no studies have explored whether dysphagia severity has an impact on the success of the session or its outcomes. The current study examined how dysphagia severity impacted on either (a) clinical decision making for safety of oral intake or (b) clinician perceptions of CSEs conducted via telerehabilitation. SUBJECTS AND METHODS: One hundred patients (25 nondysphagics and 25 mild, 25 moderate, and 25 severe dysphagics) were assessed using a telehealth system and methodology reported in prior research. For each assessment, the online and face-to-face (FTF) clinicians simultaneously completed a structured CSE. On session completion, the online clinician indicated level of agreement with two statements regarding the level of rapport and ability to competently assess the patient. RESULTS: In each of the four groups, acceptable levels of agreement were observed between raters for the three primary outcomes (decisions regarding oral/nonoral intake and safe food and fluids) as well as over 90% of the CSE items. Clinicians agreed they could develop good rapport with the majority of patients in all groups. However, for a small but significant (p<0.5) proportion of patents in the severe dysphagic group, clinicians disagreed they were able to satisfactorily and competently assess to the best of their abilities using the telerehabilitation system. CONCLUSIONS: Clinical decisions made during and as an outcome of the total CSE were found to be comparable to those made in the FTF environment regardless of dysphagia severity. Clinicians noted some difficulty assessing patients with greater complexity, which occurred in greater numbers in the group with severe dysphagia.

Assessment of student competency in a simulated speech-language pathology clinical placement.

Clinical education programs in speech-language pathology enable the transition of students' knowledge and skills from the classroom to the workplace. Simulated clinical learning experiences provide an opportunity to address the competency development of novice students. This study reports on the validation of an assessment tool designed to evaluate speech-language pathology students' performance in a simulated clinical placement. The Assessment of Foundation Clinical Skills (AFCS) was designed to link to concepts and content of COMPASS(®): Competency Assessment in Speech Pathology, a validated assessment of performance in the workplace. It incorporates units and elements of competency relevant to the placement. The validity of the AFCS was statistically investigated using Rasch analysis. Participants were 18 clinical educators and 130 speech-language pathology students undertaking the placement. Preliminary results support the validity of the AFCS as an assessment of foundation clinical skills of students in this simulated clinical placement. All units of competency and the majority of elements were relevant and representative of these skills. The use of a visual analogue scale which included a pre-Novice level to rate students' performance on units of competency was supported. This research provides guidance for development of quality assessments of performance in simulated placements.

The performance of standardized patients in portraying clinical scenarios in speech-language therapy.

BACKGROUND: Standardized patients (SPs) are frequently included in the clinical preparation of students in the health sciences. An acknowledged benefit of using SPs is the opportunity to provide a standardized method by which students can demonstrate and develop their competency. Relatively little is known, however, about the capacity of SPs to offer an accurate and standardized performance across a speech-language therapy student cohort. AIMS: To investigate the accuracy, reproducibility (consistent performance of each SP across student interviews) and replicability (consistent performance of a number of SPs across each scenario) of SPs portraying three scenarios, each as a parent of a child presenting with a speech disorder. METHODS & PROCEDURES: Forty-four speech-language therapy students interviewed four SPs to gain a case history. All interviews were videotaped. The accuracy of SP portrayal of key features of each scenario was scored by an expert rater and two other raters. Data were analysed to determine levels of accuracy, reproducibility and replicability, and inter-rater reliability was evaluated. OUTCOMES & RESULTS: SPs were found to have moderate to high levels of accuracy across the three scenarios. There were no significant differences in the performances of each individual SP across interviews or between all SPs on each scenario, indicating that reproducibility and replicability were achieved. Overall inter-rater reliability between raters across all scenarios was greater than 80%. CONCLUSIONS & IMPLICATIONS: The results would seem to indicate that SPs can present in a standardized manner within a speech-language therapy context, confirming the value of their inclusion in clinical education programmes. Suggestions for improving the training of SPs in order to maintain accuracy are highlighted.

Speech-language pathology students' perceptions of a standardised patient clinic.

UNLABELLED: This study aimed to investigate speech-language pathology students' perceptions of a foundation clinical skills simulation program incorporating standardised patients (SPs) by determining if experiences with SPs decreased students' anxiety about interaction with real clients and increased confidence in clinical skills. In addition, it aimed to identify students' overall perceptions of the SP experience. METHODS: The study used a pre-post design. Students who were enrolled in undergraduate and graduate speech-language pathology programs (n=175) completed a survey prior to and following the SP clinic. The survey asked questions related to levels of anxiety and confidence for clinical skills. The post-clinic survey also included questions about the use of SPs and program administration. RESULTS: All participants reported decreased anxiety levels following clinic, with those of the undergraduate students at a significant level. Participants also reported significantly increased confidence in a range of clinical skills and evaluated the program positively. CONCLUSIONS: The results of this study suggest that inclusion of SPs into a foundation clinical skills program is perceived by students to be valuable. Further investigation is required to determine the relationship between students' perceived increase in confidence and their clinical competencies. These results will inform future simulation program development.

Evaluation of a Clinical Service Model for Dysphagia Assessment via Telerehabilitation.

Emerging research supports the feasibility and viability of conducting clinical swallow examinations (CSE) for patients with dysphagia via telerehabilitation. However, minimal data has been reported to date regarding the implementation of such services within the clinical setting or the user perceptions of this type of clinical service. A mixed methods study design was employed to examine the outcomes of a weekly dysphagia assessment clinic conducted via telerehabilitation and examine issues relating to service delivery and user perceptions. Data was collected across a total of 100 patient assessments. Information relating to primary patient outcomes, session statistics, patient perceptions, and clinician perceptions was examined. Results revealed that session durations averaged 45 minutes, there was minimal technical difficulty experienced, and clinical decisions made regarding primary patient outcomes were comparable between the online and face to face clinicians. Patient satisfaction was high and clinicians felt that they developed good rapport, found the system easy to use, and were satisfied with the service in over 90% of the assessments conducted. Key factors relating to screening patient suitability, having good general organization, and skilled staff were identified as facilitators for the service. This trial has highlighted important issues for consideration when planning or implementing a telerehabilitation service for dysphagia management.

Reflections on clinical learning in novice speech-language therapy students.

BACKGROUND: Reflective practice is reported to enhance clinical reasoning and therefore to maximize client outcomes. The inclusion of targeted reflective practice in academic programmes in speech-language therapy has not been consistent, although providing opportunities for speech-language therapy students to reflect during their clinical practice has been reported. Indeed, there has been limited investigation of the nature of speech-language therapy students' reflections. AIMS: (1) To describe the breadth and depth of reflection skills of novice speech-language therapy students by utilizing structured reflective learning journals. (2) To evaluate the use of a coding system to determine its reliability and relevance in identifying reflection skills. METHODS & PROCEDURES: Participants were 52 students in their second year of a 4-year undergraduate speech-language therapy programme. Mean participant age was 20.5 years; all students were female. Participants completed guided written reflections following three interviews with a standardized patient (an actor portraying a parent of a child with delayed speech development). Reflections were coded by two raters. Nine participants' reflections were recoded by raters A and B to establish intra-rater reliability. Inter-rater reliability between these two raters was calculated and a third rater completed coding of 20% of students' reflections to further establish inter-rater reliability. OUTCOMES & RESULTS: Results indicated that the majority of students were categorized as 'reflectors'. All students demonstrated at least one element of reflection. Their reflective writing primarily focused on a discussion of the content of and strategies used within the interviews, and reflection on and for action. Results also indicated that the coding system used within the study was reliable in determining both the breadth and depth of student reflections. CONCLUSIONS & IMPLICATIONS: This study found that novice speech-language therapy students can reflect on their clinical learning experiences within a structured clinical environment involving standardized patients. Only a small number of novice students were found to be critical reflectors who were able to analyse the content of clinical interviews, view the interaction from the perspective of the patient, and record changes to their own perspective which occurred as a result. The coding system was established as reliable and thus relevant for use in furthering research on reflective practice within speech-language therapy and other disciplines. Further investigation of reflective skills within other clinical environments and with additional clinical experience is recommended.

Assessing children's speech intelligibility and oral structures, and functions via an Internet-based telehealth system.

We examined the validity and reliability of an Internet-based telehealth system for screening speech intelligibility and oro-motor structure, and function in children with speech disorders. Twenty children aged 4-9 years were assessed by a clinician in the conventional, face-to-face (FTF) manner; simultaneously, they were assessed by a second clinician via the videoconferencing system using a 128-kbit/s Internet connection. Speech intelligibility in conversation was rated and an informal assessment of oro-motor structure and function was conducted. There was a high level of agreement between the online and FTF speech intelligibility ratings, with 70% exact agreement and 100% close agreement (within ± point on a 5-point scale). The weighted kappa statistic revealed very good agreement between raters (kappa = 0.86). Data for online and FTF ratings of oro-motor function revealed overall exact agreement of 73%, close agreement of 96%, moderate or good strength of agreement for six variables (kappa = 0.48-0.74), and poor to fair agreement for six variables (kappa = 0.12-0.36). Intra- and inter-rater reliability measures (ICCs) were similar between the online and FTF assessments. Low levels of agreement for some oro-motor variables highlighted the subjectivity of this assessment. However, the overall results support the validity and reliability of Internet-based screening of speech intelligibility and oro-motor function in children with speech disorders.

Amount of kinematic feedback affects learning of speech motor skills.

Knowledge of Performance (KP) feedback, such as biofeedback or kinematic feedback, is used to provide information on the nature and quality of movement responses for the purpose of guiding active learning or rehabilitation of motor skills. It has been proposed that KP feedback may interfere with long-term learning when provided throughout training. Here, twelve healthy English-speaking adults were trained to produce a trilled Russian [r] in words with KP kinematic feedback using electropalatography (EPG) and without KP (noKP). Five one-hour training sessions were provided over one week with testing pretraining and one day and one week posttraining. No group differences were found at pretraining or one day post training for production accuracy. A group by time interaction supported the hypothesis that providing kinematic feedback continually during skill acquisition interferes with retention.

Assessment of children's literacy via an Internet-based telehealth system.

OBJECTIVE: Interactive telehealth applications have potential for the assessment of reading disability in school-aged children. However, there is currently a lack of research on the validity of such applications. The aim of this study was to investigate the validity and reliability of an Internet-based videoconferencing system for the assessment of children's literacy on a battery of standardized assessments. MATERIALS AND METHODS: Twenty children aged 8-13 years were simultaneously assessed in real-time both face-to-face and over a 128-Kbps Internet link. The assessments included eight subtests of the Queensland University Inventory of Literacy (QUIL), the South Australian Spelling Test, and the Neale Analysis of Reading Ability, 3rd edition (Neale-3). RESULTS: The limits of agreement for the majority of raw scores fell within predetermined clinical criteria, with the exception of the QUIL nonword reading and nonword spelling measures and the rate score of the Neale-3. Weighted kappa analyses on the tests' scaled scores indicated very good agreement for all parameters (kappa 0.92-1.00). Percentage levels of agreement were adequate (above 80%) for most measures except for the nonword reading raw score of the QUIL and the reading error classification component of the Neale-3. Very good intra- and interrater reliability was determined for all online parameters (intraclass correlation coefficient 0.98-1.00). CONCLUSIONS: As issues with audio latency, break-up, and echo were observed, some modifications to the technology may improve system effectiveness and usability. However, the overall positive results of this study support the validity and reliability of the assessment of children's literacy skills via telehealth.

Changes to articulation following LSVT(R) and traditional dysarthria therapy in non-progressive dysarthria.

The present study aimed to evaluate the effects of the Lee Silverman Voice Treatment (LSVT(R)) on acoustic and perceptual measures of articulation in non-progressive dysarthria in comparison to traditional dysarthria therapy. The study involved 26 individuals with non-progressive dysarthria who were randomly allocated to receive either LSVT(R) or traditional dysarthria therapy (TRAD), both of which were administered for 16 hourly sessions over 4 weeks. Participants' speech samples were collected over a total of six testing sessions during three assessment phases: (1) prior to treatment, (2) immediately post-treatment, and (3) 6 months post-treatment (FU). Speech samples were analysed perceptually to determine articulatory precision and intelligibility as well as acoustically using vowel space (and vowel formant measures) and first moment differences. Results revealed short and long-term significant increases in vowel space area following LSVT(R). Significantly increased intelligibility was also found at FU in the LSVT(R) group. No significant differences between groups for any variables were found. The study reveals that LSVT(R) may be a suitable treatment option for improving vowel articulation and subsequent intelligibility in some individuals with non-progressive dysarthria.

A review of standardized patients in clinical education: Implications for speech-language pathology programs.

The use of standardized patients has been reported as a viable addition to traditional models of professional practice education in medicine, nursing and allied health programs. Educational programs rely on the inclusion of work-integrated learning components in order to graduate competent practitioners. Allied health programs world-wide have reported increasing difficulty in attaining sufficient traditional placements for students within the workplace. In response to this, allied health professionals are challenged to be innovative and problem-solving in the development and maintenance of clinical education placements and to consider potential alternative learning opportunities for students. Whilst there is a bank of literature describing the use of standardized patients in medicine and nursing, reports of its use in speech-language pathology clinical education are limited. Therefore, this paper aims to (1) provide a review of literature reporting on the use of standardized patients within medical and allied health professions with particular reference to use in speech-language pathology, (2) discuss methodological and practical issues involved in establishing and maintaining a standardized patient program and (3) identify future directions for research and clinical programs using standardized patients to build foundation clinical skills such as communication, interpersonal interaction and interviewing.

Internet-based telehealth assessment of language using the CELF-4.

PURPOSE: Telehealth has the potential to improve children's access to speech-language pathology services. Validation of telehealth applications, including the assessment of childhood language disorders, is necessary for telehealth to become an accepted alternative mode of service provision. The aim of this study was to validate an Internet-based telehealth system for assessing childhood language disorders. METHOD: Twenty-five children ages 5 to 9 years were assessed using the core language subtests of the Clinical Evaluation of Language Fundamentals--4th Edition (CELF-4; Semel, Wiig, & Secord, 2003). Each participant was simultaneously assessed online and face-to-face (FTF). Assessments were administered by either an online or an FTF speech-language pathologist (SLP), but were simultaneously rated by both SLPs. RESULTS: No significant difference was found between the online and FTF total raw scores and scaled scores for each subtest. Weighted kappas revealed very good agreement on the individual items, total raw scores, scaled scores, core language score, and severity level. Intra- and interrater reliability were determined for a sample of online ratings, with intraclass correlation analysis revealing very good agreement on all measures. CONCLUSION: The results of this study support the validity and reliability of scoring the core language subtests of the CELF-4 via telehealth.

Home-based speech treatment for Parkinson's disease delivered remotely: a case report.

We investigated the validity and feasibility of online delivery of the Lee Silverman Voice Treatment (LSVT) for the treatment of the speech disorder of a patient with idiopathic Parkinson's disease. The treatment was delivered in 16 sessions to the participant's home, 90 km from the speech language pathologist. A PC-based videoconferencing system was used, operating at 128 kbit/s over the public telecommunications network. The patient achieved substantial improvements in vocal sound pressure levels during sustained vowel phonation (6.13 dB), reading (12.28 dB) and conversational monologue (11.32 dB). There were improvements in the duration of sustained vowel phonation (4 s). Improvements were also perceived in the degree of breathiness and roughness in the voice, and in overall speech intelligibility in conversation. The patient was very satisfied with the audio and video quality of the conferencing, and with the online treatment overall. He reported a preference for online sessions for the future management of his condition, rather than face-to-face treatment. Remote LSVT delivery was found to be feasible and effective.

The redesign and re-evaluation of an internet-based telerehabilitation system for the assessment of dysarthria in adults.

A previous study revealed that reliable assessment of dysarthria was feasible. However, that study also revealed a number of system limitations and suggested that technological enhancements and improvements in study design and clinical assessment protocols were needed before validity and reliability of assessment of dysarthria via telerehabilitation could be confirmed. In the current study, improvements in technology, study design, and clinical assessment protocols were implemented in order to re-examine the validity and reliability of assessing and diagnosing dysarthria via the telerehabilitation medium. The aim of this study was to explore the validity and reliability of assessing dysarthria using both formal standardized and informal assessments via a purpose-built telerehabilitation system. Twenty-four participants with an acquired dysarthria were assessed simultaneously via telerehabilitation and face-to-face (FTF) on a battery of assessments. A custom-built telerehabilitation system enabled real-time telerehabilitation assessment over a 128 Kbps Internet connection. Data analysis included an analysis of strength of agreement between the two methods using percentage agreement and weighted ? statistics. Inter-rater and intrarater reliability were also examined for both the FTF and telerehabilitation-led assessments. Good strength of agreement was found between the FTF and telerehabilitation assessment methods. High intrarater and inter-rater reliability within both the FTF and telerehabilitation assessment methods supported these findings. Participants reported high overall satisfaction in the telerehabilitatin environment. This study describes the improvements made to the telerehabilitation system reported previously and confirms that valid and reliable assessment of dysarthria using both standardized and informal assessments over the Internet is possible using this system.