Telepractice in the Assessment and Treatment of Individuals with Aphasia: A Systematic Review

Telepractice involves the application of technology to deliver services over a geographical distance. Studies in which telepractice procedures were used in the assessment or treatment of individuals with aphasia were reviewed. Systematic searches identified 10 studies meeting inclusion criteria. These studies were evaluated in terms of the: (a) characteristics of the participants, (b) technology utilized (c), services delivered via telepractice, (d) research methodology, and (e) results and conclusions of the study. Telepractice was used by speech-language pathologists and allied health professionals to assist with the delivery of services to participants with aphasia by their caretakers or clinicians. The services delivered included appraisal, diagnostic assessments, interventions, and consultation. This review suggests that telepractice is a viable method of service delivery for individuals with aphasia, however further research is warranted. Guidelines for practitioners and potential directions for future research are discussed.


Introduction
Telerehabilitation has become a practical application of technology for the provision of a variety of professional and clinical practices. This evolution in service delivery is primarily due to advancements in technology and the mainstream use of computers, the Internet, and telecommunications. In the field of speech-language pathology, the implementation of telerehabilitation services -known as telepractice -requires careful consideration to ensure that best-practices are being implemented. The very nature of the services being delivered to individuals with communication challenges, such as an acquired aphasia, require audio and visual telecommunication technologies, as well as careful consideration of how to deliver speech and language services at a distance. Furthermore, clinicians must be trained on how best to assess disorders, arrive at diagnoses, develop treatment plans, provide intervention, supply therapeutic materials, instruct in their uses, monitor patient progress, manage required paperwork, and receive third-party reimbursement for services delivered. These factors, combined with state licensing and credentialing requirements, as well as ethical, privacy, and legal issues (Brown, 2011) have resulted in slow and often uneven advancement of telepractice within the field of speech-language pathology.
The first documented use of telepractice within the field of speech-language pathology was described using telepractice with individuals with aphasia. In these pioneering studies, the researchers used a telephone to present auditory stimuli paired with printed visual materials (Vaughn, 1976a(Vaughn, , 1976b(Vaughn, , 1977(Vaughn, , 1981. Since these seminal investigations there have been a number of studies examining the efficacy of telepractice with individuals diagnosed with acquired aphasia. In an effort to understand the evolution of telepractice with this population, this paper presents a review of the research on the use of telepractice with adults with acquired aphasia, with a focus on remote assessment and service delivery. Moreover, principles to help professionals understand the current state-of-practice will be identified to help further frame the clinical thinking about how to best implement evidence-based telepractice services for people diagnosed with aphasia.

Search Procedures
A systematic, five-step procedure used in other research of this kind (Boisvert, Lang, Andrianopoulos, & Boscardin, 2010) was employed to identify studies for inclusion in this review. The steps were as follows: (1) computer literature searches were conducted in five electronic databases covering the field of health and human service-Education Resources Information Center (ERIC), Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO -using the terms "Aphasia," "Dysphasia," "Anomia," "Adult Neurogenic Disorder," "Acquired Language Disorder," "Broca's Aphasia," "Wernicke's Aphasia," "Primary Progressive Aphasia," and "Global Aphasia," paired with "Telediagnostic," "Telemedicine," "Telepractice," "Teleconference," "Skype" ©, "iChat" ©, "Videoconferencing," "Distance Education," "Telehealth," "Teletherapy," and "Telerehabilitation" (e.g., Aphasia AND Videoconferencing); (2) abstracts of identified articles were reviewed to determine compliance with the inclusion criteria specified below; (3) reference lists of studies meeting these criteria were then reviewed to identify additional articles for inclusion; (4) the surname of the first author of each of the included studies was then searched to identify additional work by that author to be considered for inclusion; and (5) hand searches of the two most recent issues of the journals that had published at least one of the included studies were conducted in order to identify recent studies that were not yet listed in the aforementioned databases.

Inclusion Criteria
To be included in this review, studies had to meet predetermined inclusion criteria. The inclusion criteria for this review was as follows: (1) the study had to include at least one participant with a diagnosis of aphasia (i.e., Broca's aphasia); (2) at least one dependent variable that involved the participant with aphasia and the results of an assessment and/or the fidelity of implementation of an intervention, assessment and/or consultation; and (3) use of telepractice to deliver one of the above services from a specialist or expert at one location to a participant with aphasia at a remote location (e.g., a speech-language pathologist could conduct a language evaluation from a university clinic to an adult with aphasia in his/her home setting). In an effort to understand the evolution of telepractice for individuals with acquired aphasia, the publication year was not restricted. However, the search was limited to studies written in the English language and published in peer-reviewed journals. This literature review was conducted over the months of November and December of 2012.

Data Extr action and Review Par ameters
Each study was reviewed to determine whether or not it met the inclusion criteria. Then, each study was read and summarized by the first two co-authors of this review. Both co-authors hold doctoral degrees in speech and hearing science and are certified and licensed speechlanguage pathologists. The co-authors used a coding sheet designed specifically for this systematic review (available upon request) to extract data describing: (a) the characteristics of the participants with aphasia, (b) the technology utilized to support telepractice, (c) the type of services delivered via telepractice, (d) the research design utilized, and (e) the results and conclusions of the study. Various procedural features were noted, including the settings of the telepractice services and any reported advantages and disadvantages to implementation.

Inter-coder Agreement
Each co-author independently completed the literature review. The accuracy of each summary was independently checked to ensure adherence to the above listed review parameters; specifically whether or not the summary included an accurate description of the participants, technology, services delivered, research design, results and conclusions. This helped guarantee accuracy of each of the study summaries and provided a measure of intercoder agreement on data extraction and analysis. The point-by-point inter-coder agreement was calculated by dividing the number of agreements by the total number of agreements and disagreements and multiplying by 100. Agreement for this literature review was 90%.

Results
To ensure the fidelity of the literature search each component of the above mentioned five-step procedure was completed independently by the co-authors. The first stage (the electronic database review of terminology combinations) yielded 26 studies. The abstracts of the 26 studies were reviewed to determine whether or not they met the inclusion criteria. Careful review of all 26 abstracts resulted in exclusion of 16 articles and therefore narrowed the selection to 10 articles. Inter-coder agreement as to whether a study should be included or excluded was 90% (i.e., agreement was obtained on 9 of the 10 studies). A study completed by Hoffman, Worrall, Eames, and Ryan (2010) was identified for inclusion by one co-author and not the other. After discussion, this study was included as service delivery via the telephone, and completion of outcome questionnaires, were considered relevant and a form of telepractice.     The 10 studies involved eight caregivers (Hoffman et al., 2010). A reported 77 (50%) of participants were males and 51 (33%) were females. The gender of the remaining 25 participants was not reported. Of the 10 studies, nine reported specific information regarding diagnoses of the participants (all but Palsbo, 2007) and yielded inclusion of 92 individuals (60%) with a diagnosis of aphasia. Of these 92 individuals with aphasia, 75 (81%) were diagnosed as having mild-severe aphasia, 13 (14%) as having nonfluent/Broca's aphasia, one (1%) as having expressive aphasia, one (1%) as having fluent aphasia, one (1%) as having conduction aphasia, and one (1%) participant as having a combined expressive and receptive aphasia. Furthermore, it was reported that 13 of the 92 individuals diagnosed with aphasia (14%) had a concomitant apraxia of speech.

Technology Used
The 10 included studies utilized a variety of technological supports ranging from telephones and widely available equipment to highly-customized and exclusive tools (please reference Appendix A  (Fitch, 1983).
Of those studies using videoconferencing, Georgeadis and colleagues (2004) reported using a high bandwidth (10 Mbps) Local Area Network connection to transmit audio and video information via the Internet. Palsbo

Research Designs
The most common research design used to evaluate the efficacy of assessment, intervention, and consultation services delivered via telepractice was a single-subject experimental design. This type of research design was implemented for 60% of the studies. Fitch (1983), Helm-Estabrooks and Ramsberger (1986), as well as Lasker and colleagues (2010) described using a singlesubject AB (i.e., pre-/post-treatment) case study to detail implementation of specific interventions for individuals with aphasia. Georgeadis Palsbo (2007) used this method to compare telepractice to traditional, in-person assessment procedures. The remaining study (10% of selected investigations) implemented informal observations to gather qualitative information regarding the telepractice services provided (Fitch, 1983). It is important to note that four of the studies included in this review used satisfaction surveys (Georgeadis et al., 2004;Hill et al., 2009;McGrath et al., 2008;Theodoros, 2008).

Outcomes
All ten of the investigations included in this review confirmed the feasibility of telepractice for the implementation of diagnostic, intervention, and consultative services for individuals with aphasia. Of those studies that examined the effectiveness of assessments conducted in-person and via telepractice (Georgeadis et al., 2004;Palsbo, 2007;Theodoros et al., 2008), all reported no significant differences between assessment scores and results obtained in each therapeutic environment. Hill and colleagues (2009) investigated assessments conducted via telepractice and in traditional settings, and focused on the effect of aphasia severity on clinicians' ability to administer language assessment protocols. This team concluded that the "severity of aphasia did not greatly influence the accuracy of telerehabilitation assessment…[but] severity of aphasia appeared to affect the ability to assess naming and paraphasias" (p. 627).
The studies that used the telephone and/or videoconferencing tools to provide intervention and consultation services found that services conducted via telepractice were feasible and equally as effective when compared to in-person interventions (as evidenced by dependent variable measures). Overall, the studies included in this review found that telepractice is an effective tool for service delivery for individuals with aphasia.

Discussion
The evidence gathered from the studies included in this review suggests that assessment, intervention, and consultative services conducted via telepractice are feasible, effective, and equivalent to in-person services for individuals with aphasia. Further review of the included studies yielded some advantages and disadvantages to telepractice services. Advantages discussed were as follows: (1) participants' improved attentiveness to stimuli and materials presented via computers (Fitch, 1983), (2) reduced cost of travel (Fitch, 1983 The authors of the studies discussed some limitations and challenges to telepractice services that are important to consider. Limitations and disadvantages were as follows: (1) difficulty sustaining telephone and/or Internet connections (Fitch, 1983), (2) challenges communicating over a distance due to connectivity and a resulting audio/ video delay (Georgeadis et  The disadvantages listed above are by no means insurmountable. Each of the above listed challenges was related to the technology used to support and deliver the services. The continuously evolving and advancing resource of widely available technology will help counteract challenges associated with connectivity, transmission speed, and audio/video quality. Hill and colleagues (2009) advise, "difficulties such as audio and video quality deterioration may be eliminated with the use of higher bandwidths" (p. 639). Upload/download Internet speeds (related to the broadband connectivity) greatly impact the overall quality of telepractice services that can be provided. In the studies that reported the actual bandwidth speed, Georgeadis  In addition to having access to an adequate Internet connection, other more advanced off-the-shelf technology equipment will ensure the integrity of telepractice services. For example, wired Internet connections established through standard Ethernet cables offer more reliable Internet connections. Hands-free echocancellation microphones (Georgeadis et al., 2004) and high definition, external webcams will improve the quality of audio and video data shared between different locations. In a recent publication, Boisvert, Hall, Andrianopoulos, and Chaclas (2012) describe the hardware, software, and Internet requirements needed to implement high quality, evidence-based telepractice services -all of which are widely available to the general public and are not restricted to clinical and/or university institutions.

Future Research
The studies included in this literature review highlight the sheer paucity of investigations in the use of telepractice with individuals with aphasia. It is critically important that researchers continue to examine the effectiveness of services for individuals with aphasia using more robust research designs such as randomized investigations and use of control groups. Implementation of better-controlled designs would enable researchers to compare performance and outcome data of services rendered via telepractice as compared to in-person services.
Replication of the assessments, interventions, and procedures cited in this review is necessary to further generalize the use and application of telepractice for this population. In addition, a greater range of assessment and intervention services (i.e., functional gains therapy) delivered via telepractice should be examined. Further exploration is warranted to determine the amount of support needed and rate of learning demonstrated with a range of technology, equipment, and software by individuals with aphasia. This information is critical to identifying the specific intervention and training needs of this population in order to adequately implement a telepractice service delivery model. Furthermore, researchers should continue to explore issues of reimbursement (including Medicare and private insurance companies), HIPAA and privacy, procedures and policies (i.e., encryption, firewalls, passwords, etc.), as well as the ethical considerations necessary to better serve individuals with aphasia.

Conclusion
The outcome of this review suggests that telepractice is an effective way to deliver services to individuals with aphasia. The findings indicated that telepractice is a viable form of service delivery that can enhance the quality of services by making assessments, interventions and consultation available to individuals in geographically remote areas, reducing scheduling conflicts and travel time, and maximizing the utility of material resources.
Given the advancements of technology and the growing need for speech and language services, it is anticipated that telepractice will be an accepted form of service delivery in the future. Telepractice has the potential to extend clinical outreach and provide services to patients and clients diagnosed with aphasia who may have physical mobility limitations. As hardware, software, and other associated technology for clinical purposes become more widely used, the integration of this methodology will support clinical telepractice services for individuals with aphasia.
This systematic review clearly depicts the range of telepractice services and the advancement of these services for individuals with aphasia. The investigations completed by researchers and teams included in this review provide foundational evidence that can help refine the quality of services for individuals with aphasia. This information, in combination with the advancements in technology, supplementary equipment, and infrastructure of the Internet will ultimately enhance the quality, quantity, and accessibility of services for individuals with aphasia. Refers to the bit-rate and is an indication of the maximum amount of data transfer, within a given period, over the Internet.
Is a measurement of how fast information is processed and transferred over a communication link, like the Internet. It is measured in bits per second (bit/s), kilobits per second (kbit/s), megabits per second (Mbit/s), gigabits per second (Gbit/s), and terabits per second (Tbits/s) Refers to the transmission of video camera signals to a specific and defined location (rather than an open transmission). This is often found in video surveillance systems.
A wired system for connecting a number of computers to a local area network (LAN).
A hardware-based or software-based network barrier designed to filter material and keep a network safe.
A light-weight electronic visual display, also known as a flat screen, with a flat front surface.
Two-way audio that can be recorded and reproduced at the same time.
A unit of computer memory/data/storage that is equal to approximately 1,000 bits.
A computer network that connects and links computer devices within a given area (i.e., building or group of buildings).
A PDP-11 minicomputer that has a large-scale integration processor.
A unit of computer memory/data/storage that is equal to approximately 1,000,000 bits.
Part of a series of 16-bit general purpose minicomputers sold by Digital Equipment Corporation in the late 1990's.
A miniature area of illumination on an electronic visual display. In the display, individual pixels form an image.
A computer used as part of the REMATE project at the Veteran's Administration Medical Center in Birmingham, Alabama. The computer "responds to the frequency of the tone generated when the patient presses a key (button) on the Touchtone telephone" (Fitch, 1983, p. 47) with a maximum of 12 different possible responses correlating with the 12 keys of a Touchtone key pad.
The number of distinct pixels that are displayed in each dimension on an electronic visual display.
A software application that allows individuals to make voice and video calls over the Internet.
A system that uses a telephone to present auditory stimuli paired with printed visual materials, and a range of patient response recording techniques.
A device that combines features of a computer, television, and telephone and is able to receive and transmit audio and visual information via the Internet.
A telephone with a number/letter keypad.
The delivery of professional services over a geographical distance using telecommunications technologies.
A telephone within which calls are made by touching keys/buttons on the device that transmits varying tones/pitches.
The process of using a set of telecommunication technologies that support two-way audio and visual communication across two or more locations.
A video camera that transmits video images via the Internet. * Information for the definitions was collected from Google and Wikipedia.