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Improving Functional Communication Outcomes in Post-Stroke Aphasia via Telespeech: An Alternative Service Delivery Model for Underserved Populations

Portia Carr, Ph.D.,CCC-SLP

Have you provided teletherapy during

the pandemic?

1. Was the transition easier or harder than you thought it would be?

2. Did your client’s makeprogress?

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• Stroke is a leading cause of serious long-term adult disabilities

• According to the National Stroke Association, 800,000 people in the United States suffer from strokes each year

• 38% of stroke survivors are diagnosed with aphasia

Problem

• Many (PWA) have limited access to speech language treatment (SLT) due to:• lack of insurance reimbursement• speech-language pathologist (SLP) shortages• case-load capacities• geographical barriers • physical disabilities • transportation barriers • COVID-19

Problem

• Provisions to provide SLT during the COVID-19 pandemic have allowed for temporary expansion of telehealth services for speech-language pathologists

• It is important to provide ongoing empirical evidence to advocate for permanent telehealth coverage.

Problem

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Background

• Arkansas has significant healthcare accessibility challenges. Arkansas is a rural state in which 73 of 75 counties have underserved populations (Bouldon 2019).

• Approximately 6,000 residents in rural Arkansas suffer from strokes every year (Brown et al., 2019).

• One of the most concerning long term impacts of PWA is expressive language impairments in functional everyday life settings.

Literature Review

• Telespeech is a promising cost-effective alternative service delivery model for delivering speech-language rehabilitative services to underserved populations

• Several studies have found that telespeech services for (PWA) yields comparable outcomes to in-person SLT (Munsell, et al., 2019 ; Regina Molini-Avejonas et al., 2015; Hall et al., 2013; Lavoie et al., 2017; Zheng et al., 2016) • improved language scores on standardized tests• improvements on treatment-related data

• Expand the current literature by using • functional communication assessments to measure

the effectiveness of telespeech with PWA• evidence-based treatments corresponding with the

Life Participation Approach to Aphasia (LPAA)

• Expand the literature supporting the feasibility of telespeech to advocate for permanent reimbursement for telespeech.

Purpose/Rationale

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Aims:• 1) To determine if functional communication outcome scores improve

after telespeech intervention in PWA • 2) To determine the feasibility of telespeech as measured by a

telespeech satisfaction survey

Hypothesis:• 1) Telespeech will be an effective delivery model for assessment and

treatment. PWA will demonstrate improvements on language outcome measures and functional communication tasks.

• 2) Telespeech will be a feasible alternative delivery model for SLT with high participant satisfaction.

Aims and Hypothesis

10 participants were recruited through the UAMS Speech-Language and Hearing Clinic, local medical, residential, or community-based facilities, and email

Study Population

age range between 40 and 89

mild-moderate aphasia

native English speakers

6- months post-stroke

ParticipantsEligibility Criteria - INCLUSION

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uncorrectable hearing or vision

severe auditory comprehension deficits

less than 6-months post-stroke

ParticipantsEligibility Criteria - EXCLUSION

Participants

P a rtic ip a n t A ge G en d er H a n d ed n ess E d u ca tio n Y ea rs P o st-stro k e W A B -R A Q

1 60 F L 16 5 71 .8

2 43 F L 12 12 74 .3

3 47 F R 12 2 74 .4

4 64 F L 14 6 79 .2

5 51 F L 16 14 81 .4

6 67 M L 16 2 85 .7

7 60 M R 12 5 87 .2

8 46 M R 15 1 90 .6

9 53 M R 12 0 .75 90 .8

10 63 F R 14 1 92 .0

Method

• Three Phases• Pre-Test: 2-3 sessions; 60 minutes • Treatment: 8 sessions; 60 minutes• Post-Test: 2 sessions; 60 minutes

• Maximum of 1 hour of remote training for using the computer and Zoom before the first assessment session.

• Received a troubleshooting cheat sheet to assist with navigating Zoom

• Each participant received a $25 gift card after the pre-testing phase and a $25 gift card after the treatment phase totaling $50

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https://docs.google.com/document/d/1e4sF7jGVq0mZqieo9r0h8am6-C0w15Di/edit#

MethodTroubleshooting Cheat Sheet

Pre-Test Qualifying Measures

1. Western Aphasia Battery - Revised (WAB-R; standard measure for classifying aphasia type, severity level, assessing linguistic skills: content, fluency, auditory comprehension, repetition and naming, reading, and writing, and assessing nonlinguistic skills: drawing, calculation, block design, and praxis)

Øscores rate severity as follows: Ø0-25 is very severeØ26-50 is severeØ 51-75 is moderateØ76–93.8 is mildØScores below 51 were excluded

2. Telespeech Hearing Screening – 3 questions about hearing-related medical history, 4 simple comprehension questions, 5 word repetitions

Method-Assessment

Pre- and Post-Testing for all participants (same tests administered twice)

1.Communication Activities of Daily Living – 3 (CADL-3); standard functional

measure for classifying severity level, assessing reading and writing, using

numbers, social interactions, contextual communication, non-verbal

communication, sequential relationships, humor, metaphor, absurdity, and

internet basics)

2.The Boston Naming Test Second Edition (BNT) - standard measure of

confrontational naming abilities

3.Communication Confidence Rating Scale for Aphasia (CCRSA) - self-reporting

measure of the PWA’s perception and confidence in communication skills

Method

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Teleassessment Modifications

https://docs.google.com/document/d/1MKsJ0lTrwfExSbGpOFo_bwax9ShxrqaO/edit

WAB-R

CADL-3https://docs.google.com/document/d/1nDN8tVjcphE77xAQDw41Dhu71x5JMIHv/edit

Additional Post-Test

• Telespeech Satisfaction Survey• measure of patient’s satisfaction with telespeech as a service delivery model• measure of satisfaction with the Zoom videoconferencing system

• Measured the feasibility of telehealth using a 5 point Likert scale to rate 6 factors • usefulness • ease of use and learnability• interface quality• interaction quality• reliability• satisfaction

Method

https://docs.google.com/document/d/152r0NADx_DXCaPoAegIZ9z9_DHvT3s8E/edit

Method Telespeech Satisfaction Survey

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• Four weeks of treatment consisting of 60-minute sessions twice weekly (2 days/week for 4 weeks=8 sessions)

• Synchronous real time telespeech sessions conducted with the Zoom videoconferencing platform

• SLT based on the Life Participation Approach to Aphasia (LPAA) which is a patient-driven service-delivery approach involving the PWA in decision making process for developing treatment goals for re-integration in life participation and society

1.Oral Reading for Language in Aphasia (ORLA) 2.Conversational Script Training (CST)

MethodSpeech-language treatment (SLT)

Sun Mon Tues Wed Thu Fri Sat

Week 1 Training(1 hour)

Testing(1 hour)

Testing(1 hour)

Testing(1 hour)

Week 2 Treatment(1 hour)

Treatment(1 hour)

Week 3 Treatment(1 hour)

Treatment(1 hour)

Week 4 Treatment(1 hour)

Treatment(1 hour)

Week 5 Treatment(1 hour)

Treatment(1 hour)

Week 6 Testing(1 hour)

Testing(1 hour)

Method-TreatmentSchedule

Oral Reading for Language in Aphasia (ORLA)

• Originally developed to target reading comprehension by providing practice through semantic and phonological pathways.

• PWA systematically reads paragraphs and sentences in unison with the clinician and then independently.

• Studies have found gains in other modalities including auditory comprehension, verbal expression, and written expression in fluent and non-fluent aphasia (Cherney, 1995; Cherney, 2004; Cherney et al., 1986).

Method-Treatment

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Method-Treatment

Oral Reading for Language in Aphasia (ORLA)

Level 1:

Simple 3- to 5-word sentences at a first-grade reading level

Level 2:

8 to 12 words that may be single sentences or two short sentences, at a third grade reading level

Level 3:

15 to 30 words, divided into two to three sentences, at a sixth grade reading level

Level 4:

50 to 100 words comprising a four- to six-sentence simple paragraph, also at a sixth grade reading level

Method-TreatmentOral Reading for Language in Aphasia (ORLA)

Sample ORLA Script – Level 4

93 Words

Imagine eating cold ice cream on a hot summer day. Many years ago, there were no modern freezers. So it used to take hours and hours to make ice cream. Nancy Johnson thought of a way to freeze ice cream much quicker. She put a lot of ice and salt in a wooden bucket. Then, she put ice cream mix in it. She would turn the handle to move the ice cream around. After only 30 minutes, the ice cream would freeze! Now, freezers make it easy to make and store ice cream!

***share screen 1. SLP reads stimulus aloud to patient 2. SLP read stimulus aloud to patient with SLP pointing to each word *** share mouse control 3. SLP and patient read aloud together, with patient pointing to each word

SLP adjusts rate and volume 4. Above step is repeated twice 5. For each line or sentence, SLP states word for patient to identify 6. For each line or sentence, SLP points to word for patient to read 7. Patient reads stimulus aloud

SLP reads aloud with patient as needed

Method-TreatmentOral Reading for Language in Aphasia Protocol (ORLA)

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Conversational Script Training (CST)

• Functional aphasia treatment in which the participant verbally produces a personally relevant script

• Hierarchy of repetition, choral reading, and independent production

• Scripts are used to guide and facilitate participants’ conversations and actions in social situations. (Holland et al., 2002; Youmans et al., 2005).

Method-Treatment

Method-Treatment

• a. Clinician models with typed cues • b. Clinician and client in unison/choral with typed cues • c. Clinician and client In unison/fading cues with typed cues • d. Client says alone with typed cues • e. Client says alone with no typed cues

1. Start with 1 phrase

2. When the client can repeat 20 times correctly, add the next phrase to the chain.

3. Continue chaining/adding the phrases until the whole script is complete.

Conversational Script Training Protocol

**share screen

Clinician: Hello this is Papa John’s, how can I help you? Participant: I would like to order a large sausage pizza with mushrooms. Clinician: Any other toppings? Participant: Pepperoni please. Clinician: Would you like anything else with your order? Participant: Yes, I would like a small cheese pizza. Clinician: Would you like to do the special where you get two larges for 15.99?Participant: Yes Clinician: Would you like any drinks with that? Participant: Yes, a Pepsi and a root-beer Clinician: Ok will that be for pickup or delivery? Participant: PickupClinician: Ok that will be ready in 15 minutes. You can park in the marked areas in the front. Participant: Thank you.

Method-TreatmentExample script for CST (Papa John’s Script)

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• Total words produced correctly in reading passages

Oral Reading for Language in Aphasia

• Total words produced correctly in scripts

Conversational Script Training

Method-Data Collection

Results-Generalization Communication MeasuresGroup Means for CCRSA Pre-Test and Post-Test Scores

Statistically significant improvements in the pre-and post-test CCRSA scores (T = 51.00, p = 0.01) and the effect size was large (r = 0.53). The mean pre-test CCRSA score was 69.02 (SD = 17.12) and the mean post-test CCRSA score was 76.24 (SD = 16.00)

Results-Generalization Communication Measures

Means for CCRSA Pre-Test and Post-Test Scores by Participant

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No statistically significant differences between pre-test and post-test CADL-3 scores (T = 19, p = 0.888) and the effect size was small (r=.03). The mean pre CADL-3 score was 90.8 (SD = 5.28) and the mean post CADL-3 score was 89.9 (SD = 7.20).

Results-Generalization Communication Measures

Group Means for CADL-3 Pre-Test and Post-Test Raw Scores

Results-Generalization Communication MeasuresMeans for CADL-3 Pre-Test and Post-Test Scores by Participant

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10

Pre- tes t Pos t-te st

Results-Generalization Communication MeasuresGroup Means for BNT Pre-Test and Post-Test Scores (spontaneous correct responses)

No statistically significant differences between pre-test and post-test BNT scores (T = 31.500, p = 0.282) and the effect size was small (r =.24). The mean pre BNT score was 43.30 (SD = 5.83) and the mean post BNT score was 45 (SD = 7.76).

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Results-Generalization Communication MeasuresBNT Pre-Test and Post-Test Scores (spontaneous correct responses) by Participant

Results-Trained Communication Measures

Group Mean for Percentage of Total Words Correct on CST Script #1 at Baseline and Last Session

Statistically significant differences for CST script #1 (T = 55.00, P = 0.005) and the effect size was large (d= .627). The mean baseline percentage of words produced correctly for script #1 was 74.70 (SD = 15.25) and the mean percentage of words produced correctly during the last treatment session was 93.85 (SD = 6.99).

Results-Trained Communication MeasuresPercentage of Total Words Correct on CST Script #1 at Baseline and the Final Session by Participant

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Results-Trained Communication MeasuresGroup Mean for Percentage of Total Words Correct on CST Script #2 at Baseline and Last Session

Statistically significant improvements for CST script #2 (T = 15.00, P = 0.043) and the effect size was medium (r = .452). The mean baseline percentage of words produced correctly for script #2 was 84.83 (SD = 10.53) and the mean percentage of words produced correctly during the last treatment session was 95.2 (SD = 2.82).

Results-Trained Communication MeasuresPercentage of Total Words Correct on CST Script #2 at Baseline and Last Session by Participant

Results-Trained Communication MeasuresGroup Mean for Percentage of Total Words Correct on ORLA Passage #1 at Baseline and Last Session

Statistically significant improvements for reading passages #1. The findings were significant (T = 55.00, P = 0.005) and the effect size was large (r=.63). The mean baseline percentage of words produced correctly for passage #1 was 74.70 (SD = 15.25) and the mean percentage of words produced during the last treatment session was 93.85 (SD = 7.59)

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Results-Trained Communication MeasuresPercentage of Total Words Correct on ORLA Passage #1 at Baseline and Last Session by Participant

Results-Trained Communication Measures

Group Mean Percentage of Total Words Correct on ORLA Passage #2 at Baseline and Last Session

Statistically significant improvements for ORLA reading passage #2 (T = 27.00, P = 0.028) and the effect size was medium (r = .49). The mean baseline percentage of words produced correctly for passage #2 was 83.60 (SD = 14.73) and the mean percentage of words produced correctly during the last session was 92.05 (SD = 7.59).

Results-Trained Communication MeasuresPercentage of Total Words Correct on ORLA Passage #2 at Baseline and Last Session by Participant

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Mean Satisfaction Score for all Components Combined

95

Usefulness

100%

Ease of use and

learnability90%

Interface quality

80%

Interaction quality

100%

Reliability

70%

Satisfaction and Future Use

100%

Results-FeasibilityTelespeech Satisfaction Survey

• Effectiveness of telespeech as an alternative service delivery model

• Feasibility of telespeech for all stakeholders

• Provides clinicians with specific telespeech assessment modifications for the WAB-R and CADL-3

• Provides clinicians with specific telespeech treatment modifications for the ORLA and CST treatment protocols

Clinical Implications

Limitations and Future Directions

• Larger sample size with various aphasia severity levels

Small Sample Size

• Utilize generalization follow-up measures and investigate the effects of telespeech treatment in various situational contexts

No explicit generalization measures

• Randomized control trial (RCT) design to directly compare the outcomes of telespeech and in-person delivery approaches

Within-subjects pre-and post-test design

• Include a pre-and post-test telespeech satisfaction survey to allow the researcher to compare the perceived feasibility of telespeech pre-treatment to the perceived feasibility post-treatment

Only used a post-satisfaction survey

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Aliza Brown, Renee Joiner, Sanjeeva Onteddu, personal com m unication, February 20, 2019.

Bouldon, B. (2019). UAM S Arkansas Geriatric Education Collaborative Awarded $3.7 M illion by Health Resources and Services Adm inistration. Retrieved from https://news.uam s.edu/2019/07/16/uam s-arkansas-geriatric-education-collaborative-awarded-3-7-m illion-by-health-resources-and-services-adm inistration/.

tice for speech-language pathologists [Professional Issues Statem ent]. According to the APA (7th Ed.), you don’t need to cite personal com m unication in the References because your readers cannot recover the source. You

only need to cite it in-text (APA, 2020, p. 260).

Cherney, L.R., M erbitz, C.T., & Grip, J.C. (1986). Efficacy of oral reading in aphasia treatm ent outcom e . Rehabilitation Literature, 47(5-6), 112-118.

Cherney L. R. (1995). Efficacy of oral reading in the treatm ent of two patients with chronic Broca's aphasia. Topics in Stroke Rehabilitation , 2(1), 57-67.

Cherney L. R. (2004). Aphasia, alexia, and oral reading. Topics in Stroke Rehabilitation . 11(1), 22-36.

Cherney, L. R., Kaye, R. C., Lee, J. B., & Vuuren, S. V. (2015). Im pact of Personal Relevance on Acquisition and Generalization of Script Training for Aphasia: A Prelim inary Analysis. Am erican Journal of Speech-Language Pathology, 24(4). doi:10.1044/2015_ajslp-14-0162

Hall, N., Boisvert, M ., & Steele, R. (2013). Telepractice in the assessm ent and treatm ent of individuals w ith aphasia: A system atic review. International Journal of Telerehabilitation , 5(1). https://doi.org /10.5195/ijt.2013.6119

Holland, A., M ilm an, L., M uñoz, M ., & Bays, G. (2002). Scripts in the m anagem ent of aphasia. Paper presented at the World Federation of Neurology, Aphasia and Cognitive Disorders Section M eeting, Villefranche, France.

References

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M unsell, M ., Oliveira, E. D., Saxena, S., Godlove, J., & Kiran, S. (2019). Closing the Digital Divide in Speech, Language, and Cognitive Therapy: Cohort Study of the Factors Associated W ith Technology Usage for Rehabilitation (Preprint). doi: 10.2196/preprints.16286

Regina M olini-Avejonas, D., Rondon-M elo, S., De La Higuera Am ato, C. A., & Sam elli, A. G. (2015). A system atic review of the use of Telehealth in speech, language and hearing sciences. Journal of Telem edicine and Telecare, 21(7), 367-376. https://doi.org /10.1177/1357633x15583215

Sim ic, T., Leonard, C., Laird, L., Cupit, J., Hobler, F., Rocchon, E. (2016). A Usability Study of Internet-Based Therapy for Nam ing Deficits in Aphasia. Am erican 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. Telem edicine and e-

Health , 14(6), 552-559. https://doi.org /10.1089/tm j.2007.0091

Youm ans, G., Youm ans, S. R., & Hancock, A. B. (2011). Script training treatm ent for adults w ith apraxia of speech. Am erican Journal of Speech-Language Pathology, 20(1), 23–37.

Zheng, C., Lynch, L., & Taylor, N. (2016). Effect of com puter therapy in aphasia: a system atic review. Aphasiology, 1–34. doi: 10.1080/02687038.2014.996521Weidner, K. Lowm an, J. (2020). Telepractice for Adult-Speech Language Pathology Services: A System atic Review. Perspectives of the ASHA Special Interest Groups, 5, 326-338.

References

Acknowledgments

Special thanks to all who made this study possible especially:

• Dana Moser, Ph.D., CCC-SLP – UAMS Associate Professor; Speech-Language Pathology Program Director

• UAMS College of Health Professions Seed Grant

• Shana Williamson, M.S., CCC-SLP – UAMS Assistant Professor; Speech Language Pathology Clinical Education Director

• Dissertation Committee – Dana Moser Ph.D., CCC-SLP; Betholyn Gentry, PhD. CCC-SLP; Barbara Jones M.S.,CCC-SLP; Stephen Kintz Ph.D.; Gregory Robinson Ph.D., CCC-SLP

• 2nd Year UAMS CSD Graduate Students

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Any questions?

Thanks!