Research Watch Report: Telepractice in Aphasia

Introduction

The American Speech-Language-Hearing Association (ASHA) defines telepractice as “the application of telecommunications technology to the delivery of speech-language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation (ASHA, Telepractice). In light of the COVID-19 pandemic, telepractice has played a crucial role in the provision of clinical services. ASHA has a number of telepractice resources available to speech-language patholgists (SLPs), covering a variety of topics including policy, procedure, technical considerations, ethical considerations, and reimbursement. ASHA is also an excellent source for evidence-based practice resources on the subject of telepractice and many other topics (see ASHA’s Evidence Maps).

COVID-19 has created an increased need for telepractice services. While some SLPs and their clients are comfortable with the telepractice model, SLPs who provide services to adults with neurogenic language impairments, such as aphasia, might find engaging in telepractice more challenging for their clients for a variety of reasons.

One clear challenge of telepractice is the reality that some clients lack experience or familiarity with the required technology. A recent survey by the Kaiser Family Foundation found that 32% of adults age 65 and older reported not having a smartphone, tablet, or computer (Cubanski, 2020). Compare that to the 15% of adults ages 50-64 and the 5% of adults ages 30-49 who reported not having one of these devices. The results of this survey suggest that adults 65 and older might not own or regularly engage with the technology required for participation in telehealth services, which is relevant because many people with aphasia (PWA) are over 65.

Another concern related to the use of telepractice with PWA is that telepractice platforms may not provide the rich visual and auditory cues that are part of face to face interactions (Goldberg, Haley, & Jacks, 2012). Missing these kinds of faciliative cues could hinder clients’ progress. Hall, Boisvert, and Steele (2013) outlined other potential challenges, including clients’ privacy concerns, and issues related to audio-visual quality and connectivity, in their systematic review focused on speech-language services for PWA.

Despite these kinds of potential disadvantages, telepractice has many potential advantages. Hall et al. (2013) also listed some of these, including cost effectiveness, efficiency,  improved attendance, and access for those who might not otherwise have been able to access services. Indeed, the era of COVID-19 has highlighted the accessibility issue for those who are sheltering in place. In addition, some research suggests that PWA can not only be taught to use the required technology, but they can also improve their ability to use the technology over time (see Simic et al., 2016).

Given the advantages, disadvantages, and the increased use of telepractice due to COVID-19, what does research evidence say about the use of telepractice with PWA? Weidner and Lowman’s (2020) systematic review of telepractice for adult clients receiving services for various neurogenic disorders found 125 potentially relevant articles between 2014 and early 2019, 31 of which were ultimately selected for inclusion in the analysis. That review found evidence to support the use of telepractice in adult clients, but cited relatively weak research designs as a liability for the current state of this area of inquiry (Weidner & Lowman, 2020). 

This research watch will report on three current articles with relatively strong research designs to help guide SLPs’ telepractice specifically with PWA.

Article 1. Dekhtyar, M., Braun, E., Billot, A., Foo, L., and Kiran, S. (2020). Videoconference administration of the Western Aphasia Battery-Revised: Feasibility and validity. American Journal of Speech-Language Pathology, 29, 673-687.

Background: What was the rationale and/or clinical question guiding this study? The goal of this study was to examine whether the Western Aphasia Battery-Revised (WAB-R; Kertesz, 2007) can be used to assess telepractice clients. Recently, the WAB-R was named a “core outcome measure for aphasia rehabilitation per expert consensus” (p. 674), which provided the impetus for the current study. Specifically, the authors set out to answer three questions:

1. Does administration of the WAB-R via videoconference yield comparable results to administration in the traditional in-person format? 
2. Do PWA have a preference of formats (in-person versus videoconference)?
3. Does aphasia severity differentially affect WAB-R scores administered via video conference? 

The authors cite three previous studies (Hill et al., 2009; Palsbo, 2007; Theodoros et al., 2008) that validated the administration of the Boston Naming Test-Second Edition (Short Form; Kaplan et al., 2001) and the Boston Diagnostic Aphasia Examination-Third Edition (Short Form, Goodglass et al., 2001) via videoconference. The current study appears to be the first to attempt to validate the WAB-R for videoconference administration.

Method: Who participated in the study and what did they do? Seven women and 13 men (a total of 20 participants) with chronic aphasia and a mean age of 55 years participated in the study. The participants reported varying levels of involvement in aphasia groups and individual SLP services within the six months prior to and at the time of the study.

Participants were encouraged to use their own devices in an effort to measure validity of the WAB-R in a “real-life” setting. They were also asked to use some basic items from their homes, such as white paper, a book, and a pen, for test administration. If participants did not have these items, the researchers provided them, along with other specialized manipulatives required for  WAB-R administration.

Before the WAB-R was administered, participants were asked to complete a survey consisting of open-ended questions about their current level of technology use. Participants’ caregivers were asked to provide technical assistance to the participants as needed.

Zoom and GoToMeeting videoconferencing platforms were utilized for the study. Portions of the WAB-R were adapted to allow for administration via videoconference. For example, stimuli were scanned and shared as .pdf files. Participants were allowed to indicate their responses by moving the mouse pointer to the selected item. All participants were given the WAB-R both via videoconference and in-person. The order of administration was counterbalanced to control for order effects. The researchers also took a number of measures to ensure that all test administrators were appropriately trained and their scores were calibrated to ensure reliability.

After they had completed both types of testing, participants were asked to complete a survey to comment on various aspects of their experiences, such as their level of satisfaction with both videoconference and in-person administration, as well as the likelihood they would be willing to participate in future videoconference assessments, and audio/video quality.

Results: What were the outcomes of the experimental measures? Statistics revealed high correlations between the videoconference and in-person administration of the WAB-R. In other words, the participants’ scores for the videoconference administration were very similar to their scores on the in-person administration. The researchers also reported high rates of interrater reliability for the clinicians administering the test. Most of the participants (n=17) indicated that they had no preference of one method over the other. One participant who preferred in-person administration had previously reported a lack of comfort with technology. Also, 16 of the participants indicated that they were satisfied with the videoconference administration, while three were neutral and one was not satisfied.

Clinical Application: What are the take-home messages for me as an SLP? The researchers set out to answer three clinically relevant questions in this study. They found that administration of the WAB-R via videoconference did indeed yield comparable results to administration in the traditional in-person format. They also noted that most of the participants did not indicate a preference for one format over the other, and that most of the participants were satisfied with videoconference assessment. 

The final question the authors attempted to answer was whether aphasia severity was related to score differences between formats. They did not find group differences between formats, but they found some inconsistencies between in-person and videoconference administration for a subset of participants. Their analyses of these inconsistencies indicated that they were related individual differences within participants, such as hearing acuity, and, possibly, slight differences in test administration.

Overall, this study provides support for the validity of videoconference administration of the WAB-R. Clinicians should be mindful that most of the participants in this study required some technical assistance from a caregiver, so this must be considered when undertaking telepractice assessment with adults with aphasia. Other client factors, such as visual or hearing impairment and mobility, must also be taken into account prior to the initiation of telepractice services.

Article 2. Ora, H., Kirmess, M., Brady, M., Partee, I., Hognestad, R., Johannessen, B., Thommessen, B., & Becker, F. (2020). The effect of augmented speech-language therapy delivered by telerehabilitation on poststroke aphasia - a pilot randomized controlled trial. Clinical Rehabilitation, 34, 369-381.

Background: What was the rationale and/or clinical question guiding this study? Research suggests that frequent, intensive intervention sessions are effective for recovering language function in post-stroke aphasia. However, achieving a high-dosage and high-intensity intervention schedule presents a number of challenges for clients and clinicians, and may not be appropriately reimbursed due to constraints on payment structures.

A possible alternative to high dosage in-person services is supplemental use of telepractice services. The authors designed this pilot study to compare client outcomes when PWA receive only in-person services to those who receive in-person services with supplemental telepractice services.

Method: Who participated in the study and what did they do? The study included individuals who had aphasia as documented by a percentile score of 70 or lower on the naming subtest of the Norwegian Basic Aphasia Assessment, a comprehensive aphasia assessment that includes subtests for naming, auditory comprehension, and repetition. Participants were randomly assigned to one of two groups. The control group, whose members would receive in-person services only, consisted of 22 males and 8 females with a mean age of 65 years. Participants in the experimental group, who were to receive both in-person services and telepractice services, included 19 males and 13 females with a mean age of 64.7 years. Participants’ number of months post-stroke ranged from fewer than 3 months to greater than 12 months across both groups. In addition, as this study was conducted in Norway, all participants spoke Norwegian as their preferred language.

In-person treatment was provided by SLPs working in community clinics and hospitals. Three SLPs received specific training related to telepractice services. Those three SLPs then provided telepractice services to the members of the experimental group. The nature of the in-person speech-language intervention services (i.e., tasks, activities, stimuli, etc.) was not dictated by the study, but was to target verbal expression through naming and conversational tasks. The telepractice intervention was structured similarly across participants, using the same materials. Participants’ goals, however, were tailored to their deficits. The telepractice intervention was designed with treatment fidelity and replicability in mind. The treating SLPs maintained documentation of type of services (in-person or telepractice) and length of each session.

Because all participants were receiving in-person services in their own communities, which were not necessarily near the location of the researchers conducting the study, the total amount of hours of in-person services they received was dependent upon what was available to them locally. Participants in the experimental group received an additional five hours per week of teleservices via videoconference over four weeks. These participants were required to participate in at least 16 sessions of teletherapy via videoconference over 32 days.

The videoconferencing platform used in this study was Cisco Jabber/Acano from Norwegian Health Net. The SLPs engaging in telepractice also used LogMeIn software to remotely control the participants’ computers during sessions. All participants in the experimental group had external speakers and webcams to be used with their computers during sessions. They also received 30-60 minutes of instruction on the use of the necessary hardware and software.

Dependent measures included the Norwegian Basic Aphasia Assessment; the Verb and Sentence Test, used to assess participants’ syntactic skill; and, the Communicative Effectiveness Index (CEI), a family/caregiver checklist used to evaluate functional communication skills. The Norwegian Basic Aphasia Assessement and the Verb and Sentence Test were administered at the beginning of the intervention, immediately following completion of the intervention, and four months post-intervention. The CEI was administered immediately following completion of the intervention and four months post-intervention.

Results: What were the outcomes of the experimental measures? Analyses revealed that, on average, participants in the control group received a greater number of hours of in-person intervention than did those in the experimental group, but the participants in the experimental group received more hours of treatment time overall.

Visual inspection of the data shows that scores improved from baseline to the post-intervention time frame. However, statistical results for the dependent language measures were mixed. The experimental group performed significantly better than the control group on the repetition subtest of the Norwegian Basic Aphasia Assessment and on the Verb and Sentence Test at four months post-intervention. No other significant differences were revealed for language measures. CEI scores improved over time for both groups, but these changes were not statistically significant.

Clinical Application: What are the take-home messages for me as an SLP? The authors of this study intended it to be a first step toward the potential validation of the use of telepractice with PWA to augment in-person SLP services in order to increase treatment dosage and improve client outcomes. Their analyses indicated that a future study would need to include 226-230 participants in order to have enough statistical power to reliably determine the presence of differences between the control and experimental groups.

These acknowledgements by the researchers, however, do not negate our ability to carefully apply their findings to clinical practice. Their findings suggest that PWA who receive telepractice services in addition to in-person services may present with some additional benefits over PWA who receive only in-person services. From a slightly different perspective, their results also suggest that providing telepractice to supplement in-person services does not appear to have a negative effect on language outcomes in PWA, as scores on all measures trended up even though these trends could not be statistically confirmed in this study.

Article 3 Pitt, R., Theodoros, D., Hill, A., & Russell, T. (2019). The development and feasibility of an online aphasia group intervention and networking program - TeleGAIN. International Journal of Speech-Language Pathology, 21, 23-36.

Background: What was the rationale and/or clinical question guiding this study? The World Health Organization’s International Classification of Functioning, Disability, and Health (WHO ICF; WHO, 2001) is a biopsychosocial model that emphasizes the role of life participation in health. For a number of years, SLPs have recognized the potential for improved life participation for PWA through aphasia groups. Studies have found evidence that involvement in aphasia groups may improve linguistic abilities and functional communication skills while also providing a vehicle for emotional support (see Elman, 2007).

Although aphasia groups are widely believed to be beneficial, the authors cite studies that have found group services may not be available to many PWA due to funding issues, mobility limitations, and lack of transportation. In order to address the need for expanded aphasia group services to increase life participation amid the chronicity of aphasia, the authors set out to develop and test the feasibility of a telepractice aphasia group.

Method: Who participated in the study and what did they do? Stage 1: Development. First, the researchers developed the telepractice program, which they called Telerehabilitation Group Aphasia Intervention and Networking (TeleGAIN). Their process involved reviewing relevant literature and consulting experienced clinicians to create the intervention framework, including goals, materials, and procedures.

The goals for the TeleGAIN program were focused on providing the participants with opportunities for successful communication, to share their personal histories, and to offer social-emotional support within the group. Participants had individual intervention goals as well, which addressed their own communication deficits and participation restrictions.

Materials and activities were developed based on 12 different topics that PWA might find challenging, such as travel, ordering in restaurants, and sharing stories. Participants received a list of the topics to be discussed prior to the group meeting to allow them to prepare and to gather items such as pictures to be used during the session.

Because TeleGAIN was expected to include participants across a range of severity levels, a variety of communication aids were encouraged. These included items such as choice boards, photos, and rating scales. The program consisted of a total of 18 hours of group therapy, 1.5 hours weekly for 12 weeks. The program was developed to accommodate a maximum of four participants per group. Groups are intended to be populated with participants who are similar to each other in age, as well as in their interests and goals. These intentional groupings are considered foundational for relationship development within the groups.

The researchers selected Adobe Connect as the videoconferencing platform because they felt its functionality was best for TeleGAIN. All participants were provided with a webcam and headset with microphone to be used during TeleGAIN sessions.

Stage 2: Piloting.  Participants in the pilot study included four individuals with chronic moderate-severe non-fluent aphasia, two males and two females. All participants were at least 12 months post-onset and they ranged in age from 41-78 years. Three of the participants reported that they had experience with computers prior to and after having their strokes. One participant reported using a computer on a weekly basis with assistance from a family member.

The researchers arranged in-person meetings with each participant to help with the hardware and software set up, and to provide instruction for using Adobe Connect. Participants received aphasia-friendly instructional guides. The researchers also encouraged participants to include a family member or caregiver in the training so they could have assistance with technical issues if they arose during the TeleGAIN sessions.

Dependent measures included the Comprehensive Aphasia Test (CAT), which was used to assess expressive and receptive language function for spoken and written modalities; the Assessment of Life with Aphasia (ALA), which assesses functions associated with day to day life as a PWA; and, an aphasia friendly satisfaction questionnaire. The CAT and ALA was administered before and after the intervention. The satisfaction questionnaire was administered after intervention only.

Results: What were the outcomes of the experimental measures? The authors reported that the hardware and software performed appropriately, although all participants experienced poor connectivity and related issues at least once during the course of the study.

Three of the participants improved significantly on the CAT when compared to their pre-intervention scores. Two of the participants improved significantly on the ALA when compared to their pre-intervention scores. In addition, participants reported a high level of satisfaction with TeleGAIN, the skills they developed, and the technology used for the program.

The authors provided some context about the one participant who did not improve on the CAT. They described the participant as having more significant communication difficulties than the other three participants, and less ability to engage with the other participants during group sessions. They also stated that the participant was more than 15 years older than the other participants, and had needed, but had not consistently had, a caregiver available to provide technical assistance during group sessions.

Clinical Application: What are the take-home messages for me as an SLP? This study, like the one described in Article 2, is a first step toward the validation of a telepractice aphasia group. While it provides support for the development of a telepractice aphasia group, the authors also clearly state that larger trials are needed to fully explore the efficacy of TeleGAIN.  Their results may also indicate that, in considering the development of a telepractice aphasia group, SLPs should carefully consider aphasia severity, age, and availability of a caregiver who can provide technical support, as these aspects can affect participation and outcomes.

Final Thoughts

This article has reviewed three different investigations of telepractice applications for PWA. In short, these studies provide support for the use of telepractice for assessment, aphasia groups, and telepractice as a supplement to individual in-person SLP services, to varying degrees. They also reveal some additional considerations for telepractice implementation, which are discussed below.

Hardware and Software

            All of these studies used different videoconferencing platforms. Each platform was selected because of its specific functionality relative to the telepractice activities being investigated. In addition, researchers ensured that participants had Internet access, as well as items like headphones and speakers. SLPs engaging in telepractice might not have a choice on the specific platform being utilized, but if they do, the functionality of different platforms relative to their clients’ needs should be carefully considered. SLPs might also have to take steps to ensure that their clients have reliable Internet access, an appropriate device, and the accessories necessary to deliver audio/visual signals that meet clients’ needs.

Technical Support

The researchers in these studies provided instruction to the clients and caregivers prior to the initiation of telepractice services. They also suggested that a capable caregiver be present during sessions to assist with technical support. In addition to providing training and ensuring that a caregiver is available during sessions, SLPs need to anticipate and have contingency plans for situations such as the lack of a caregiver to assist with technical issues, poor connectivity, necessary software updates, and unexpected platform downtime, and communicate these plans clearly to the client and/or caregiver.

Individual Differences

Clients present with a variety of individual differences that must be accounted for in order for them to be able to engage successfully in telepractice. SLPs engaging in telepractice must be proactive in determining if such differences might impede service delivery and what steps can be taken to mitigate these issues.

Some of these individual differences include:

1. Communicative function, including severity of impairment and linguistic variation (English proficiency, dialect status)
2. Visual impairment
3. Hearing impairment
4. Mobility limitations
5. Familiarity and comfort level with technology
6. Need for communication aids
7. Need for cues and type of cues needed
8. Home environment and whether it is conducive to telepractice

Ultimately, the take-home message from these studies offers a cautiously optimistic view of telepractice with PWA, with the caveats that (1) SLPs must be proactive in considering all of the factors involved in successful service delivery in this modality, and (2) larger, well-designed studies are needed in order to develop the literature base for telepractice with PWA.

References

American Speech-Language-Hearing Association. (n.d.). Telepractice. (Practice Portal). Available from https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/.

Cubanski, J. (2020, April 13). Possibilities and limits of telehealth for older adults during the COVID-19 emergency. Retrieved August 31, 2020, from https://www.kff.org/policy-watch/possibilities-and-limits-of-telehealth-for-older-adults-during-the-covid-19-emergency/.

Elman, R. (2007). The importance of aphasia group treatment for rebuilding community and health. Topics in Language Disorders, 27, 300-308.

Goldberg S., Haley K., & Jacks A. (2012). Script training and generalization for people with aphasia. American Journal of Speech-Language Pathology, 21, 222–238.

Hall, N., Boisvert, M., & Steele, R. (2013). Telepractice in the assessment and treatment of individuals with aphasia: a systematic review. International Journal of Telerehabilitation, 5(1), 27–38. https://doi.org/10.5195/ijt.2013.6119

Goodglass, H., Kaplan, E., & Barresi, B. (2001). BDAE-3: Boston Diagnostic Aphasia Examination-Third Edition. Lippincott, Williams, & Wilkins.

Hill, A., Theodoros, D., Russell, T., Ward, E., & Wootton, R. (2009). The effects of aphasia severity on the ability to assess language disorders via telerehabilitation. Aphasiology, 23, 627-642.

Kaplan, E., Goodglass, H, & Weintraub, S. (2001). Boston Naming Test-Second Edition. Lippincott, Williams, & Wilkins.

Kertesz, A. (2007). The Western Aphasia Battery-Revised (WAB-R). Pearson.

Palsbo, S. (2007). Equivalence of functional communication assessment in speech pathology using videoconferencing. Journal of Telemedicine and Telecare, 12, 40-43.

Weidner, K., & Lowman, J. (2020) Telepractice for adult speech-language pathology services: a systematic review. Perspectives of the ASHA Special Interest Groups - SIG 18, 5, 326-338. https://pubs.asha.org/doi/10.1044/2019_PERSP-19-00146

Simic, T., Leonard, C., Laird, L., Cupit, J., Hobler, F., & Rochon, E. (2016). A usability study of internet-based therapy for naming deficits in aphasia. American Journal of Speech-Language Pathology, 25, 642-653.

Theodoros, D., Hill, A., Russell, T., Ward, E., & Wootton, R. (2008). Assessing acquired language disorders in adults via the internet. Telemedicine and e-Health, 14, 552-559.

World Health Organization. (‎2001)‎. International classification of functioning, disability and health: ICF. World Health Organization.