Configuration of a telerehabilitation system to deliver a comprehensive aphasia therapy program via telerehabilitation (TeleCHAT): A human-centred design approach

Figures & data

Figure 1. The Human-Centred Design process (International Organization for Standardization, 2010) adapted for the development of the TeleCHAT telerehabilitation system configuration.

Table 1. Communication and Participation Supports: User Requirements and Technical Functions.

Impairment area	Communication/Participation support	SLP interaction	PWA interaction	Technical functions required to facilitate interaction
Auditory comprehension/ spoken production	Gesture	Gesture in view of camera	Gesture in view of camera	Record, transmit and receive clear live video
Spoken and written production	Modification of verbal communication	Speak and hear PWA’s speech	Speak and hear SLP’s speech	Record, transmit and receive live audio
Poor auditory comprehension (with intact reading comprehension)	Writing key words	Type/write and view written text on the screen	Type/write and view written text on the screen	Text annotation tool (+ chat box/captions/secondary camera)
Spoken and written production	Drawing	Draw and view drawing on shared screen	Draw and view drawing on shared screen	Drawing annotation tool
Auditory and reading comprehension	Show picture to communication partner	Display and view picture on shared screen	Display and view picture on shared screen	Record, transmit and receive clear live video and screen share
Reading aloud	Show text to communication partner	View text on shared screen	Display text on shared screen	Screen share
Reading comprehension	Displaying aphasia friendly text	Display text on shared screen	View text on shared screen	Screen share and text annotation tool
Limb weakness or other hand movement restrictions	Use of functional limb	Verbal or written direction/prompt	Use of other hand to control computer mouse or to type	Computer mouse, keyboard
Visual field	Repositioning of material	Verbal or written direction/prompt	Reposition device within visual field, add in visual reminders	Computer/device red tape
Hearing	Environmental – increase of volume	Verbal or written direction/prompt	Use of headphones	Headphones

Note. SLP = Speech-Language Pathologist; PWA = Person with Aphasia.

Table 2. Example Task Analysis considering user and therapy task requirements.

Therapy Approaches and Activities	SLP Interaction	PWA Interaction	Technical Function
IMPAIRMENT e.g., Semantic Feature Analysis, Verb Network Strengthening Treatment (VNeST)	Share therapy stimulus with PWA	View shared therapy stimulus	Share screen of SLP’s computer
	Share and hear audio from therapy stimulus	Hear audio that SLP shared	Share computer/device audio from SLP’s computer
	Allow PWA to point to/move/click/type on shared stimulus	Point to/Move/Click/Type on shared stimulus	Allow multi-point interaction (e.g., remote control and pointing, typing, and erasing annotation tools) on shared therapy stimulus from SLP and PWA ends
	Share therapy stimulus from a second device	View stimulus from a second device	Share screen from a second device on the SLP’s end.
	Share and view written text from a second camera	Share and view written text from a second camera	Share screen from a second device on the SLP or PWA’s end.
FUNCTIONAL e.g., Communication partner training, Script training	Share and view therapy stimulus	Share and view therapy stimulus	Share screen of SLP and PWA’s device(s)
	Share and view therapy stimulus from a second device	Share and view stimulus from a second device	Share screen from a second device/camera on the SLP or PWA’s end.
	Share and view written text from a second camera	Share and view written text from a second camera
	Share and hear audio from therapy stimulus	Share and hear audio of therapy stimulus from device	Share computer/device audio from SLP and PWA’s device(s)
	Point to/Move/Click/Type on shared stimulus	Point to/Move/Click/Type on shared stimulus	Allow multi-point interaction (e.g., remote control and pointing, typing, and erasing annotation tools) on shared therapy stimulus from SLP and PWA ends
	View all members of the group including support people (3+ people)	View all members of the group including support people (3+ people)	Gallery/grid view of 3+ users (and shared screen)
GROUPe.g., InterD-CAG program, ASK program, guest Speakers	Share and view therapy stimulus	Share and view therapy stimulus	Share screen of SLP and PWA’s device(s)
	Point to/Move/Click/Type on shared stimulus	Point to/Move/Click/Type on shared stimulus	Allow multi-point interaction (e.g., remote control and pointing, typing, and erasing annotation tools) on shared therapy stimulus from SLP and PWA ends
	Share and hear audio from therapy stimulus	Hear audio that SLP shared	Share computer/device audio
	View all members of the group (6+ people)	View all members of the group (6+ people)	Gallery/grid view of 6+ users (and shared screen)
COMPUTER e.g., Constant Therapy, eSALT, Step by Step, Tactus therapy	Share and view therapy app/computer program	Share and view therapy app/computer program	Share screen of SLP and PWA’s device(s)
	Share and view therapy stimulus from a second device	View stimulus from a second device	Share screen from a second device on the SLP or PWA’s end.
	Share and hear audio from therapy stimulus	Share and hear audio of therapy stimulus from device	Share computer/device audio from SLP and PWA’s device(s)
	Point to/Move/Click/Type on shared stimulus	Point to/Move/Click/Type on shared stimulus	Allow multi-point interaction (e.g., remote control and pointing, typing, and erasing annotation tools) on shared therapy stimulus from SLP and PWA ends

Note. SLP = Speech-Language Pathologist; PWA = Person with Aphasia.

Table 3. Essential and preferred technical functions and productions.

Functionality Required for Delivery of TeleCHAT	Technological Product with functionality	Technical Considerations	Aphasia Friendly Use Considerations
Essential functions
Display 11+ participant videos as well as a shared screen	VC: ‘View’ tool	N/A	N/A
Side-by-side grid view of all TeleCHAT participants and SLP (2-6 users)	VC: ‘View’ tool with side by side, speaker, and grid view options	Must allow clear view of users as well as shared stimulus material	N/A
Record and transmit clear live video of self	Camera	N/A	Easier if SLP can control
Record and transmit live audio	Microphone	Headset is best (headphones with microphone) as it minimises the number of equipment PWA needs to connect	Easier if SLP can control
Receive clear audio	Headphones		N/A
Share screen of desktop/internet browser/application/secondary device/secondary camera.Screenshare must allow sharing of sound from the device	VC: ‘Screen Sharing’ Tool including ‘share sound’ Secondary devices (e.g., iPad, tablet, phone, laptop)	Must be able to connect iPad to VC (either as another user or through screen share of device)	If PWA able to screen share: VC easier as less steps involved to achieve screen share than with external software.
Remote control to enable multi-point interaction on shared content - Move/Click	VC: ‘Remote Control’ tool	Consider privacy issues – users should only be able to control what the user allows or shares. Sharer should be able to easily regain control.	Large cursor easier to see. If PWA is indicating - may need to use annotation on iPad as easier to indicate with finger than controlling mouse.VC easier as fewer steps involved to achieve remote control than with external software. Easier if SLP can enable/disable remote control for PWA.
Annotation tools: Point/Type/write and erase (+ whiteboard)	VC: ‘annotation’ tools	Some document editors allow annotation within the software.	Easier to draw/write using a stylus if on a tablet. Easier to erase with a rubber function that locks onto drawn content, than with a white pen. PWA can write on paper and hold up/use secondary camera
Sending messages and files to and from PWA	Text, email or cloud storage	N/A	Ensure aphasia-friendly text. May need SP to assist if PWA unfamiliar with technology or has comprehension/written output impairments.
Preferred Functions
Annotation tools: Highlight/underline/bolden	VC: ‘annotation’ tools / Microsoft Office/Adobe software	Access to this may look different dependent on device/VC software	Helpful to make text aphasia friendly
Reaction	VC: ‘reaction’ tools	N/A	Participants can gesture or hold up Yes/No card on their endHelpful to support non-verbal communication
Chat Box for sending files and messages	VC: ‘chat’ tools/Phone messenger/email	PWA/SLP can send files asynchronously, however VC easier as fewer applications involved to receive information from. SLP can text PWA using phone.	Ensure aphasia-friendly text. May need SP to assist if PWA unfamiliar with technology or has comprehension/written output impairments.
Typed/automated live captions	VC: ‘caption’ tools	SLP can type on document/use annotation tools instead	Helpful to support verbal communication for those with auditory comprehension difficulties

Table 4. Comparison of Videoconferencing Platforms against Essential and Preferred Functions.

Function	Zoom^© (Commercial VC platform)	QLD Health Telehealth Portal (Telepractice platform)	Microsoft Teams^© (Commercial VC platform)	Neorehab^© (Telepractice Platform)	Coviu^© (Telepractice Platform)	Theraplatform^© (Telepractice Platform)
Access to platform	Web app/ desktop app/ mobile app	Web app	Web app/ desktop app/ mobile app	Web app	Web app	Web app
Essential Functions
Security	End to end encryption, HIPAA compliant, waiting room	High encryption, waiting room external to platform	High encryption, waiting room	Waiting room	Peer to peer encryption, waiting room	HIPAA Compliant, waiting room
Record and transmit clear live video of self	Clear resolution, low latency	High latency, often pixelated resolution	Clear resolution, low latency	Increased latency with increased users	Increased latency and pixelation with increased users	Increased latency and pixelation with increased users
Record and transmit live audio Produce and receive clear audio	Clear audio, low latency	High latency, often distorted audio especially with increased users	Clear audio, low latency	Increased latency with increased users	Increased latency and audio distortion with increased users	Increased latency and audio distortion
Display 11 or more participant videos + shared content	Yes	No, only 2 users displayed clearly	Yes - display of SLP is small	Yes	Yes	Yes - but with >3 users, display is small
Side-by-side grid view of all participants	Yes	No	No	Yes	Yes	Yes – but must scroll to see >3 users
Share screen of desktop/internet browser/application/secondary device + sound from the device	Yes	No – cannot share sound, cannot share from secondary device, low resolution when screensharing	Yes, but does not allow full functionality with iOs devices	No	Yes – but there are limitations on what can be shared. Low resolution when screensharing	Yes - with add-ons, but there are limitations on what can be shared. Low resolution and increased latency when screensharing
Remote control to enable multi-point interaction on shared content - Move/Click	Yes - however unable to control a tablet/iPad from a desktop.	No	Not enabled	No	No	Yes - however unable to control a tablet/iPad from a desktop.
Annotation tools: Point/Type/write and erase (+ whiteboard)	Yes	No	Yes	Yes	Yes	No
Preferred Functions
Annotation tools: Highlight/underline/bolden*	Yes	No	No	No	Yes	No
Reaction*	Yes - but appears small	No	No	No	No	No
Chat Box for sending files*	Yes	No	No	No	No	No
Typed/automated live captions*	Yes	No	Yes	No	No	No
Chat box for sending messages*	Yes	Yes - but disabled	Yes	Yes - but it covers the video	Yes	Yes - but it covers the video

Note. Meets requirements | Meets requirement but not ideal | Does not meet requirement | *= Preferred functions | SLP = Speech-Language Pathologist | PWA = Person with Aphasia | VC = videoconferencing software | HIPAA = Health Insurance Portability and Accountability Act |This evaluation was last updated in May 2021, and platforms’ functionalities may have changed since then.

Table 5. Participant Demographics.

	PWA 1	PWA 2	PWA 3	PWA 4
Basic Demographics
Sex	M	M	F	M
Age (Years)	64	54	24	73
Highest ISCED	6	3	4	4
Handedness	Right	Right	Right	Right
Time post onset of aphasia (Years; Months)	3;5	2;0	1;9	0;7
No. Strokes	1	1	1	2
Lesion Hemisphere of stroke	Left	Left	Left	Left
Comorbidities	Nil	Apraxia of speech	Right upper limb weakness	Visual deficit
Location^#	Rural	Metropolitan	Metropolitan	Metropolitan
Aphasia Profile
Aphasia severity^+	47.67	55.67	54.17	46
Auditory Comprehension (>56)	39	57^^	52	49
Reading Comp (>59)	41	56^	53	49
Repetition (>59)	48	52	53	45
Naming (>62)	50	60	58	46
Reading Aloud (>60)	57	51	54	44
Writing (>57)	51	58	55	43
Technology
Confidence using technology*	3.5	3	5	2
No. sessions SP attended (% of sessions delivered)	46 (92%)	4 (8%)	5 (10%)	12 (24%)
Tech help provided by SP?	Yes (consistent)	No	No	Yes (partial)

Note. ISCED = International Standard Classification of Education | SP = Support Person | + = Mean T-score across six modalities in the language battery of the Comprehensive Aphasia Test (Swinburn et al., 2004) | ^ = T-Score is above cut-off | *rating on 5-point scale with 1= Definitely no – 5 = Definitely, yes | # = According to Rural, Remote and Metropolitan Area (RRMA) classification.

Table 6. TeleCHAT pilot study: Therapy dose, technology used, and issues experienced.

	PWA 1	PWA 2	PWA 3	PWA 4
Devices used	Mac Laptop, iphone	Windows laptop, ipad, android phone	Windows laptop, ipad, iphone	iPad, iPhone
Technology modifications to support user participation	SLP used document camera to display phone content to teach PWA to use their iPhone for therapy tasks	Use of headset	Use of mouse and keyboard	PWA screenshared iPad to SLP, to teach PWA to use iPad accessibility tools
Example therapy tasks	AAC app, RISP, Tactus Naming therapy app	Aphasia Scripts^©, Role Play, Tactus Advanced Reading therapy app	VNeST, Functional written discourse, Constant Therapy	SFA/PCA, PACE, Functional reading, Step by Step comprehension therapy
Example Zoom^© functions used to deliver therapy tasks	Screenshare iPhone as second device, Screenshare therapy app	Screenshare computer audio, Screenshare from iPad as second device	Remote control to type and move textboxes; Screenshare therapy app	Remote control to select answers.
Total dose received (hh:mm) (% of intended dose)	51:57 (104%)	52:10 (104%)	48:34 (97%)	49:35 (99%)
Total issue duration (hh:mm)	0:54	0:34	0:08	3:12
Total number of technical issues	16	12	3	23
Poor Internet Connection	13	8	0	19
Hardware	2	2	1	2
Computer therapy software	0	2	1	0
Zoom^© Software	1	0	1	1
Impact of location/environment	0	0	0	1
Total number of user issues	1	4	0	19
Difficulty using Zoom^© functions	1	3	0	15
Difficulty using hardware	0	1	0	3
Difficulty using iphone/ipad apps	0	0	0	1

Note. PWA = Person with Aphasia | SLP = Speech-Language Pathologist | AAC = Augmentative and alternative communication | VNeST = Verb Network Strengthening Treatment | RISP = Repeated, Increasingly Speeded Production therapy | SFA/PCA = Semantic Feature Analysis and Phonological Components Analysis | PACE = Promoting Aphasics’ Communicative Effectiveness therapy.

Table 7. User satisfaction ratings.

Question	Participant Group	Definitely no or I don’t think so n (%)	Neutral n (%)	I think so n (%)	Definitely yes n (%)
I was satisfied with the telerehabilitation system used to deliver TeleCHAT	PWA	-	-	1 (25%)	3 (75%)
	SP	-	-	-	1 (100%)
	SLP	-	-	-	2 (100%)
The telerehabilitation system was easy to use for group therapy	PWA	-	-	2 (50%)	2 (50%)
	SLP	-	-	1	1
The telerehabilitation system was easy to use for 1:1 therapy.	PWA	-	-	2 (50%)	2 (50%)
	SLP	-	-	2 (100%)	-
It was easy to fix technical problems on my end, in 1:1 therapy.	PWA (n=3)	-	-	-	3 (100%)
	SLP	-	-	1 (50%)	1 (50%)
It was easy to fix technical problems on the PWA’s end, in 1:1 therapy.	SLP	-	1 (50%)	1 (50%)	-
It was easy to provide communication supports to the PWA as needed	SLP	-	-	1 (50%)	1 (50%)
Technical problems did not affect the planned therapy session	SLP	-	-	2 (100%)	-

Note. PWA = Person with aphasia (n = 4) | SP = Support Person (n = 1) | SLP = Speech-Language Pathologist (n = 2).

Table 8. Adaptions and modifications implemented to resolve or mitigate issues.

Issue Types	Modifications to TeleCHAT protocol
Technical (examples)
Computer Therapy Software Voice recording/voice recognition functions did not work.	Used separate voice recorder and playback to PWA, SLP provide feedback. Difficulties with voice recognition software escalated to software developers.
Hardware Participant’s devices not charged or updated	In the training and the ‘Therapy Checklist’, participants encouraged to charge devices prior to, during and after therapy sessions.
Poor Internet Connection Video/audio lag/freeze/disconnect, especially when screensharing	Conduct internet speed test during PWA training and increase data plan if upload speed cannot support screensharing. SLPs screenshared resources/apps where possible.
Zoom^© Software Zoom^© call diverts to participant’s second device. Glitches preventing joining/stopping connection of Zoom^© call.	PWA instructed to open the Zoom^© software on their main device (likely computer) and ensure they are logged into their account before the therapy session.
Impact of Location/Environment Wind affected volume of participant’s microphone.	PWA instructed to set up in a private, quiet, and closed room.
User (examples)
Difficulty Operating Hardware (PWA) Difficulty logging onto laptop and connecting internet.	Ensure all participants have a strong Wi-Fi connection or lend participants a Wi-Fi-modem.
Difficulty Operating iPhone/iPad apps Saving photos from text message or sending video from phone to laptop, or to SLP.	SLP instructed the SP to complete these tasks as they were related to transfer of therapy materials rather than therapeutic activity.
Difficulty Operating Computer Software (SLP) SLP deleted a participant program off Step by Step	Regular back-up of participant data to the secure university cloud drive was mandated.
Difficulty Operating Zoom^© Software Screenshare function (desktop screen, iPad app, computer sound) Joining/ending a videoconferencing session on iPad. Finding the annotation and remote-control functions. Using the remote-control function on an iPad. Using the assistive reading button on their iPad. Connecting headphones to Zoom^© audio. Audio lag/disturbance created when the participant joined the videoconference call on two devices.	Increased time spent during training for PWA to practice screensharing functions. a-f) Added to quick-reference guides on using Zoom^© and device accessibility functions. g) Option 1: Participants can turn down the volume and mute themselves on one device. Option 2: If able to follow complex instructions/participant has a SP, they are instructed to ‘Leave audio’ on their primary device before joining audio on their secondary device. Option 3: If the participant could Share Screen from Zoom^© app, this was preferred over joining as a second user, as screensharing does not create audio feedback. Training moved to the week before therapy commencement to enhance memorability and specificity of training to the participant’s therapy plan.

Note. SLP = Speech-Language pathologist | PWA = Person with aphasia | SP = Support person.

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