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

ABSTRACT

The delivery of Intensive Comprehensive Aphasia Programs (ICAPs) via telerehabilitation is a potential solution to the ongoing geographical, transport, and mobility barriers that people with aphasia (PWA) face in accessing this service model. To ensure the ICAP retains its evidence-based elements, configuration of the telerehabilitation system requires consideration of user and therapy task requirements. The human-centred design (HCD) process incorporates user and task considerations when developing technological systems. Therefore, the aim of this study was to use the HCD process to translate the Comprehensive High-dose Aphasia Therapy (CHAT) program for delivery via telerehabilitation (TeleCHAT).

Methods

The HCD translation process used consisted of five iterative stages. Relevant literature was reviewed, and speech-language pathologists (SLPs) experienced in delivering ICAPs were consulted to understand the therapy context. Researchers gathered therapy task and user requirements of PWA, support people (SP) and SLPs to engage in therapy. Technology that met user and therapy task requirements were identified and a preliminary technology configuration was tested in a simulated environment. The finalised system was tested in a pilot trial of TeleCHAT with a cohort of four PWA, two SPs, and two SLPs. Feedback and technical and user issues were collated from users and analysed to inform improvements to the TeleCHAT configuration and protocol.

Results

User and therapy task requirements to deliver TeleCHAT were identified with consideration of communication and participation supports for PWA. The configured technology system comprised of Zoom^© as the videoconferencing platform of choice, and additional critical technical functions including screen and audio sharing of therapy content, and multi-point interaction using remote control and annotation tools. Simulation testing and a pilot trial of the configuration confirmed system operability and identified modifications to optimise functioning.

Conclusion

The HCD framework was used to successfully configure an optimal technology system for the delivery of TeleCHAT. The HCD framework can be used by clinicians to identify patient needs and configure optimal telerehabilitation systems for delivery of complex interventions.

KEYWORDS:

• Aphasia
• telerehabilitation
• human-centred design
• intensive comprehensive aphasia program

Introduction

Aphasia is a highly prevalent acquired neurological impairment that affects approximately 38% of stroke survivors. When applying the World Health Organisation’s International Classification of Functioning, Disability and Health (WHO-ICF) model (World Health Organisation [WHO], 2002), the complex and multi-factorial impacts of aphasia become apparent (Simmons-Mackie & Kagan, 2007). Aphasia can impair multiple communication modalities, including spoken production, listening comprehension, reading comprehension, written production, and gesture, at varying levels of severity. These communication impairments make it difficult to perform everyday activities, such as talking on the phone, watching television, reading emails or filling out forms (Simmons-Mackie & Kagan, 2007). Having aphasia may also limit individuals’ social participation, with many reporting less involvement in social or leisure activities, and difficulty maintaining relationships with friends and family (Brown et al., 2012; Davidson et al., 2008; Parr, 2007). An array of different treatment approaches is required to target each of the WHO-ICF domains to provide holistic, patient-centred care.

First described by M. L. Rose et al. in 2013, intensive comprehensive aphasia programs (ICAPs) are a service delivery model that deliver an intensive dose of a variety of treatment approaches (e.g., impairment-based or functional-based therapy) targeting multiple ICF domains, to a cohort of people with aphasia (PWA) and their families within a set time frame (Monnelly et al., 2021; M. L. Rose et al., 2013, 2021). There is emerging evidence to support the efficacy of ICAPs, with some studies demonstrating significant positive language and communication outcomes for participants. For example, two ICAPs which delivered similar therapy doses to similar cohort sizes (Babbitt et al., 2015; n=74, 114 hours & Winans-Mitrik et al., 2014; n=73, 115 hours) reported significant overall improvement in aphasia severity, as measured on standardised aphasia tests (the Western Aphasia Battery-Revised; Kertesz & Raven, 2007, and the Comprehensive Aphasia Test; Swinburn et al., 2004, respectively). Psychosocial benefits of ICAPs, such as improvements in mood, communication confidence and quality of life, have also been reported in the literature (Babbitt et al., 2015; Escher et al., 2018; Griffin-Musick et al., 2020; Hoover et al., 2017; Off et al., 2019; Persad et al., 2013; Rodriguez et al., 2013). In addition to the many benefits for the participating PWA, ICAPs can also generate, through provision of education, communication training, psychosocial support and counselling, a significant and meaningful positive impact on family caregivers (Off et al., 2019).

The Comprehensive High-dose Aphasia Therapy (CHAT) program is an ICAP that was developed based on findings of the Aphasia LIFT trials (Dignam et al., 2015; Rodriguez et al., 2013). An exploratory study of Aphasia LIFT showed that the ICAP produced significant positive group-level changes across impairment, functional and communication-related quality of life measures (Rodriguez et al., 2013). On an individual level, seven out of eleven participants demonstrated at least two-point increases on post-treatment impairment-based measures using the Comprehensive Aphasia Test Naming Subtest (Swinburn et al., 2004) and/or the Boston Naming Test (Kaplan et al., 2001). Furthermore, family-reported functional communication also improved for all nine participants rated, at post treatment and again at follow-up. On the Quality of Communication Life Scale (Paul et al., 2005), seven out of ten participants showed improvements post-treatment (Rodriguez et al., 2013). The second study on Aphasia LIFT compared a 48-hour dose of therapy delivered in an intensive therapy schedule (16 hours per week for three weeks), to the same dose delivered across a distributed therapy schedule (six hours per week for eight weeks) (Dignam et al., 2015). The distributed therapy schedule yielded better acquisition and maintenance of naming, and comparable positive outcomes on functional communication, communication confidence and communication-related quality of life (Dignam et al., 2015). This high therapy dose was further supported by recent Level I evidence which has found that higher dose treatments (20-50 hours) yielded larger effect sizes and significantly more improvements in overall language as compared to low dose therapy (Brady et al., 2016; The REhabilitation and recovery of peopLE with Aphasia after StrokE (RELEASE) Collaborators et al., 2022). The CHAT program built on the Aphasia LIFT program and added two extra hours of group therapy so that this valuable therapy approach could be delivered in each week of the 8-week program. The current CHAT program delivers 14 hours each of impairment, functional and computer-based therapy and 8 hours of group therapy across 8 weeks (Dignam et al., 2023).

Although CHAT offers effective, evidence-based treatment for people with aphasia (PWA) (Dignam et al., 2015; Rodriguez et al., 2013), their participation may be restricted by several factors. The inequitable distribution of ICAPs along with factors such as geographical remoteness, a lack of family or carer availability, patient fatigue or comorbidities, other patient commitments and limited transport options all contribute to the few PWA being able to access this rehabilitation service (Monnelly et al., 2023; M. L. Rose et al., 2021; Shrubsole et al., 2019). Delivery of the CHAT program via telerehabilitation would provide the opportunity to overcome these barriers and extend equity of access to this evidence-based rehabilitation approach. Telerehabilitation is the remote delivery of rehabilitation services using information and communication technology (Richmond et al., 2017). The literature on aphasia therapies delivered via telerehabilitation has matured over the last decade, with the feasibility, usability and acceptability of individual types of aphasia rehabilitation, such as impairment-based therapy (Choi et al., 2016; Dechêne et al., 2011) and group therapy (Pitt et al., 2019a, 2019b). Outcomes from telerehabilitation delivery of therapy have been found to be comparable to in-person delivery across communication, and quality of life measures (Agostini et al., 2014; Cacciante et al., 2021; Cruice et al., 2020; Furnas & Edmonds, 2014; Meltzer et al., 2018; Øra, Kirmess, Brady, Partee, et al., 2020; Pitt et al., 2018; Woolf et al., 2016; Zhou et al., 2018). Thus, there is enough evidence to consider the delivery of an ICAP via telerehabilitation.

It has been posited that an ICAP may be complex to translate for telerehabilitation delivery, as systems are required to be adaptable for the various types of therapy and differing technological readiness of participants, while supporting PWA with different aphasia severities (M. L. Rose et al., 2021). This complexity and diversity within both the therapy approaches and therapy recipients does warrant careful consideration and a systematic process for the translation of an ICAP for telerehabilitation delivery. Therefore, in order to translate the CHAT program for telerehabilitation delivery, we chose a systematic process which would guide the translation of this complex intervention. The World Health Organisation’s‘Guide for Monitoring and Evaluating Digital Health Interventions’ recommends use of a structured framework, such as the Human-Centred Design process (HCD) (International Organization for Standardization, 2010), that focusses on the end-user’s needs, wants and limitations to develop usable technology systems (World Health Organization, 2016). They note that poor planning, development, and monitoring of telerehabilitation services may jeopardise the quality and fidelity of interventions, and lead to inadequate and/or unsustainable telerehabilitation services (Pramuka & Roosmalen, 2009; World Health Organization, 2016). Within speech pathology, HCD principles have been used to design a telerehabilitation system to deliver paediatric feeding assessments (Raatz et al., 2019), but the HCD process is yet to be used to design a telerehabilitation system for the delivery of aphasia therapy. As the heterogeneity of aphasia was a key design constraint, using a comprehensive framework such as the HCD process was needed to ensure accessibility, engagement, and acceptance of the technology by this specific user group (Hymes et al., 2021; Vaezipour et al., 2020).

The translation of CHAT into TeleCHAT is the first phase of a broader program of research that seeks to determine the usability, feasibility, and acceptability of TeleCHAT from the perspectives of all end-users. The usability, feasibility and acceptability results will be published subsequently. The aim of this study was to use the HCD framework (International Organization for Standardization, 2010) to configure a telerehabilitation system that would enable the in-person delivered CHAT program to be delivered via telerehabilitation (TeleCHAT).

Methods

Research Setting

This research was based at the Queensland Aphasia Research Centre (QARC), The University of Queensland, Brisbane, Australia, which was located in university spaces within a tertiary rehabilitation hospital. The study was conducted from April 2020 to June 2021, by four researchers (GV, AH, CB and JD). The translation process was led by GV, a qualified speech-language pathologist (SLP), in consultation with the co-authors (AH, CB, JD), who were qualified SLPs, with >21 years of clinical and research experience in the fields of aphasia rehabilitation and telerehabilitation. The TeleCHAT program was piloted with a cohort of four participants, in May-June 2021. Ethical approval was received from the relevant Human Research Ethics Committees (HREC/2020/QRBW/61636 and 2020/HE002118).

Description of the Human Centred Design (HCD) Process

The HCD framework for development of interactive systems aims to optimise the interaction between humans and the interactive system, through consideration of the users, tasks to be undertaken, the environment, and technology components (International Organization for Standardization, 2010). The original four-stage HCD process was adapted to be more specific to configuring a telerehabilitation system and consisted of the following stages (as presented in Figure 1): 1) understand and specify the context of use; 2) specify user and therapy task requirements; 3) configure technology solutions; 4) evaluate technology solutions against requirements; and 5) evaluate technology solutions with users. In terms of adaptations from the original process, we outline these here: The second stage was rephrased from ‘specify the user requirements’ to ‘specify user and therapy task requirements’, because it was necessary to understand key components of the therapy task to ensure fidelity of the evidence-based therapies when delivered via telerehabilitation. Additionally, the original fourth stage, ‘evaluating the design’, was separated into two stages to increase the rigour and feedback provided on the system configuration. Stage 4 evaluated the design against requirements in a simulated clinic, and Stage 5 evaluated the design with users in a pilot trial. The translation process was iterative, meaning that the technology configuration was continuously revised, with information collected throughout the HCD process used to refine the TeleCHAT system to meet user requirements.

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

Stage 1 - Understand and Specify the Context of Use

The purpose of the first stage of the translation process was to understand the context in which TeleCHAT will be delivered. This involved understanding who the service users were, what the service environment is, and what the key components of the therapy program were. This understanding was achieved through review of literature, the CHAT protocol, discussions with researchers and clinicians involved in delivering the in-person program, and observations of the therapy being delivered. The information acquired was categorised and tabulated under user, therapy task and program-specific considerations. Literature was reviewed across three broad topics areas: 1) Service users - PWA, support people (SP), SLPs, 2) aphasia therapy approaches delivered in CHAT, and 3) aphasia therapy delivered via telerehabilitation. Separate searches on each of these three topics were conducted between May and December 2020, in the databases PubMed, CINAHL and EMBASE (refer to Supplementary Table 1 for the search terms used). In all literature reviews, articles were excluded if the participant population was under 18 years old or had acute aphasia (within 1-month post onset). Non-english articles, non-peer reviewed articles and incomplete texts were excluded from the reviews. Information extracted about the service users included their characteristics, impairments, and comorbidities, as well as their needs for and challenges faced when participating in aphasia rehabilitation.

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.

To further understand the clinical context of CHAT, researchers observed clinical planning for eight CHAT patients, across two four-hour clinical planning meetings. The researchers discussed typical patient care with the two SLPs employed to deliver the CHAT program at the tertiary rehabilitation hospital. The goal was to obtain information about typical patient presentations and therapy tasks delivered in CHAT. Additionally, CHAT clinical protocols and a total of eight videorecorded therapy sessions (one of each CHAT participant doing either impairment, functional, computer and group therapy), were reviewed to confirm the content and scope of therapy to be delivered in TeleCHAT. Data saturation was reached after these observations.

Stage 2 - Specify User and Therapy Task Requirements

The purpose of the second stage of translation was to specify what service users require to participate in aphasia therapy delivered via telerehabilitation. Using information gathered in Stage 1, the requirements of service users to engage in the TeleCHAT program were examined. Information extracted from Stage 1 included the common impairments experienced by PWA and supports required to aid communicative participation during in-person therapy. Potential physical supports required to participate in a telerehabilitation session (e.g., manual dexterity to be able to move a computer mouse or type) were mapped to each of the impairments or participation requirements. Additionally, supports required to assist SPs’ interaction with technology (when supporting the PWA) were matched to their varying range of technological skills and confidence. Finally, following discussions with CHAT clinicians, SLPs’ requirements to deliver the CHAT program, including workflow efficiency, and confidence and experience using technology, were considered and potential supports were noted.

The therapy activities delivered within the CHAT program were then examined using a task analysis (Pitt et al., 2019a; Pramuka & Roosmalen, 2009; Ward et al., 2022) to determine each tasks’ requirements for delivery via telerehabilitation. Firstly, the essential steps required to deliver the therapy as per its protocol were noted in a task analysis table. This included detailing the SLPs’ and PWA’s interactions, specifically, what each participant would need to see, hear, say, and do with the therapy stimulus to engage in the therapy task. Stimuli or resources required to deliver the therapy task and preparations needed to make the resource digitally accessible, were mapped to each therapy activity.

Stage 3 - Configure technology solutions

The aim of the third stage in the translation process was to map technology solutions to the user and therapy task requirements identified in Stage 2. Firstly, technical functions that could facilitate the user interactions and enable therapy task components (e.g., remote control of patient/clinician device to allow multi-point interaction) were mapped against each requirement. These functions were classified as either essential or preferred. An ‘essential’ function was defined as being critical for the delivery of the task, whereas a ‘preferred’ technical function was one that may increase the ease and efficiency of a task, but the task could be achieved via other methods (e.g., use of other software, devices, or procedures). Next, the research team searched for the range of technological products that could perform the required technical functions. Six videoconferencing platforms were chosen, based on their availability for free trials, or use within the affiliated universities and health service. Alternative technology options (e.g., smart devices instead of document cameras) and aphasia-friendly adaptions (e.g., use of large font) were also considered to optimise access to the technology used by PWA (Galliers & Wilson, 2013; Howe et al., 2004; Pitt et al., 2019a).

Finally, the research team tested the chosen technical products, incorporating a range of videoconferencing platforms and equipment. Testing was conducted at two locations where TeleCHAT users would most likely be situated; that is 1) a residential home (patient and SP’s location) and 2) the telerehabilitation suites at QARC (SLPs’ location). The videoconferencing platforms were evaluated against three criteria: 1) Platform meets requirement of technical function, 2) Technical function available on platform but with limitations to its use, or 3) Platform does not perform the technical function.

Stage 4 - Evaluate technology solutions against requirements

The purpose of this fourth stage was to evaluate the telerehabilitation configuration on whether it could deliver therapy tasks as detailed in Stage 2’s task analysis. Once ideal technical products were confirmed, they were configured to function as a preliminary telerehabilitation system. To evaluate this configuration against the therapy task requirements, a simulation telerehabilitation trial was conducted between the university’s telerehabilitation suites and a residential home. The trial consisted of four 1-hour therapy sessions where researchers took turns simulating the role of the SLP or the PWA. Specific therapy activities across the four therapy approaches, that involved different technical functions (e.g., Communication partner training which involves sharing computer audio, and Tactus Therapy which involves screensharing a second device), were trialled. The telerehabilitation system was evaluated against the user and therapy task requirements detailed in the task analysis. Multiple devices (e.g., computers and smart devices) were trialled to understand the varying format and functionality of the videoconferencing program at both the SLP and PWA ends. During the trial, considerations around the supports and training requirements to optimise the SLP’s and PWA/SP’s use of the telerehabilitation system were noted separately as field notes.

Stage 5 - Evaluate technology solutions with users

The aim of Stage 5 was to confirm that the telerehabilitation system met user requirements, and to make final modifications based on user feedback. To achieve this, the newly developed telerehabilitation system was tested in a pilot trial of the TeleCHAT program with PWA and their SP.

Participants

Four people with aphasia (PWA) were recruited from clinical and professional networks and social media. In addition to the CHAT program’s eligibility criteria (Dignam et al., 2023), participants were required to have access to videoconferencing compatible devices with internet connectivity (e.g., desktop computer, laptop, or tablet). Participants were able to invite support people (SPs) to participate in TeleCHAT with them. SPs were a family member or friend over 18 years old with basic English language proficiency. The TeleCHAT program was delivered by two speech-language pathologists (SLPs), the lead author (GV) and co-author (HW), a qualified SLP with graduate experience in delivering aphasia rehabilitation and telerehabilitation. However, neither SLP had delivered the CHAT program before delivering the TeleCHAT program.

Pre-TeleCHAT preparation

1. SLP training. Each SLP participated in a four-hour CHAT training session, which provided an overview of the CHAT program and its therapy components, including clinical case examples. The lead author GV then delivered 6 hours of technology training on the delivery of TeleCHAT, to the other SLP. This multimodal training, developed by the authors based on learnings from the HCD process, included theoretical, lecture-style presentations, hands-on workshops, and practical simulations. SLPs self-evaluated their independence and competency across skills needed to deliver the TeleCHAT program, using an observation of technological skills checklist, adapted from Hill and Breslin (2016).

2. Assessment, goal setting and training for PWA. As per the CHAT protocol, two SLP researchers conducted baseline language assessments, and collaborative goal setting with participants (Dignam et al., 2023). During these home visits, the SLPs also set up technology (i.e., the participants’ devices and the videoconferencing software), trained participants in the use of the telerehabilitation system, and provided aphasia-friendly quick-reference guides on using the videoconferencing software and troubleshooting potential technical difficulties. Following training, the SLPs completed an observation of technological skills checklist (Hill & Breslin, 2016), which confirmed whether the PWA could perform the basic skills required to access and use the technology. The checklist was also used to guide tailoring of the therapy activity to accommodate the participants’ physical/language impairments (e.g., not using chat-box for those with writing impairments), and/or identify if further support or training was required.

3. Clinical Planning. After the home visits, and informed by assessment and training results, the SLPs, along with the broader research team, completed 2 hours of clinical planning for each PWA. As per the CHAT protocol, this clinical planning involved developing evidence-based treatment plans that matched the participants’ goals. Planning also identified how technology would be optimised, and how digital therapy resources could be personalised, to enable PWAs’ full participation in their treatment.

TeleCHAT delivery

Each participant completed eight weeks of TeleCHAT therapy, delivered completely via the videoconferencing platform. The SLPs delivered the therapy sessions from the university telerehabilitation suites, to the PWA and SP at their homes. As per the CHAT protocol (Dignam et al., 2023) and based on Dignam et al. (2015) a total of 50 one-hour sessions of impairment (14 hours), functional (14 hours), computer (14 hours) and group (8 hours) therapy were scheduled per participant. Any cancelled sessions were rescheduled where possible. At the beginning of sessions, SLPs completed a ‘Therapy Checklist’, adapted from Ora et al. (2020), which prompted them to confirm that the PWA was prepared and motivated for the session, and identify and address any patient-related issues. The SLPs conducted weekly debrief sessions to discuss and resolve patient, service or technology-related issues, and met with the research team monthly to discuss patient progress and troubleshoot any additional issues.

Data Collection and Analysis

To evaluate the telerehabilitation system to deliver TeleCHAT, the following data was collected.

1. PWAs’ demographics, and technological confidence were collected using an aphasia-friendly survey completed during an interview with the SLPs, and PWAs’ stroke related information were collected from medical discharge summaries;

2. The PWAs’ language profile as per the Comprehensive Aphasia Test (CAT) (Swinburn et al., 2004);

3. Technical devices used by the participants, including modifications made to enhance participant engagement, were reported from therapy plans and progress notes;

4. The SLPs recorded participant (PWA and SP) attendance/non-attendance in progress notes, along with session details including therapy activities completed and therapy dose. The occurrence and duration of any technical and user issues were collected within sessions using the issue registration form. Technical issues were issues that were caused by a hardware or software malfunction, whereas User issues were caused by the SLP or PWA, improperly using the system due to failing to remember, or not knowing how; and

5. User satisfaction with the TeleCHAT system configuration was collected from PWAs, SPs and SLPs during a post-TeleCHAT interview with a member of the research team not involved in the delivery of therapy (AH or CB). Participants rated their agreement with the statement ‘I am confident using technology like computers, tablets, iPads, phones’ on a 5-point Likert scale (1 = Definitely no, to 5 = Definitely yes). SLPs also provided an overall rating of whether the experienced issues affected planned therapy sessions, using a 5-point Likert scale (1 = Definitely affected the planned session, to 5 = Definitely did not affect the planned session). Data was analysed using descriptive statistics.

Using the results, the researchers made modifications to the technical configuration, and the procedural delivery of TeleCHAT. These modifications were reported against the technical and user issues within the issue registration form or noted during meetings between SLPs and the research team.

Results

Stage 1 - Understand and Specify the Context of Use

Understanding the CHAT program

From discussions with researchers involved in the development and delivery of the CHAT program, and a review of the Aphasia LIFT studies (Dignam et al., 2015; Rodriguez et al., 2013), which the CHAT program was based on, it was established that the program delivers 50 hours of individual and evidence-based impairment, functional, and computer therapy as well as psychosocial group therapy (Dignam et al.,). Impairment therapy aims to remediate the underlying linguistic deficit and involves the use of verbal, written and physical stimuli to support language function (Rodriguez et al., 2013). Functional therapy targets use of communication skills in personally relevant, context-specific tasks, which may include training the use of assistive technology, and education of communication partners (Rodriguez et al., 2013). Computer therapy uses therapy software on computers or smart devices to promote independent practice and prepare participants for self-directed practice post-therapy (Rodriguez et al., 2013). The psychosocial group therapy delivered in CHAT incorporates multi-modal resources (e.g., PowerPoint presentations, videos, smart device applications) and guest speakers discussing topics related to living with aphasia. The active participation of support people, who may be family, friends, or carers, in therapy was encouraged (Rodriguez et al., 2013), which aligns with ICAP criterion on the provision of patient and family education (M. L. Rose et al., 2013). Importantly, all therapy was centred around the participant’s goals (Rodriguez et al., 2013) and therefore needs to be salient to the PWA. Translation of CHAT to TeleCHAT required analysis of all therapy types to ensure the maintenance of therapy fidelity and alignment with targeted and personalised participant goals.

Understanding the users and their environments

Research from online aphasia group therapy suggested three to five PWA was an optimal size for group interventions delivered via telerehabilitation (Pitt et al., 2019a). Therefore, the TeleCHAT program was designed to be delivered by SLPs to groups of four PWA, each of whom may have a SP. A review of the literature on linguistic impairments and co-existing conditions of PWA (Chohan et al., 2019; Sand et al., 2013; Singh et al., 2018), as well as clinician discussions, provided information on patient and environmental factors that may impact delivery of TeleCHAT. PWA have differing types and severity of language impairments, necessitating the use of tailored communication support strategies and aphasia-friendly environments (Howe et al., 2004; T. Rose et al., 2003). The use of communication supports within a telerehabilitation context, based on Pitt et al. (2019a) findings were considered. Commonly reported physical (e.g., limb weakness); sensory (vision, hearing) and speech impairments (e.g., apraxia and dysarthria) may impact access to and interaction with technology (Chohan et al., 2019; Sand et al., 2013). Also, varying mood, cognition, and fatigue levels, may require modification of therapy schedules to allow the PWA to take breaks during sessions and/or attend a preferred appointment time (Chohan et al., 2019; Singh et al., 2018).

As per the CHAT program, SPs would also be encouraged to participate in therapy with the PWA during TeleCHAT. It was also thought that the SPs could potentially assist the PWA to use the telerehabilitation technology in addition to participation in therapeutic tasks. However, it was acknowledged that SPs may not live in the same household as the PWA; have varying skills/confidence and/or access to technology; and/or have mood, cognition, and other impairments impacting their capabilities (Gbiri et al., 2015; Zhao et al., 2021; Zorowitz et al., 2013). Given that online delivery offers flexible access, it was important to separately consider the PWA and SP’s access to appropriate technology/network speed, their skills/confidence in using technology, and the SP’s capacity to participate in therapy and provide technical support to the PWA if needed.

It was highlighted that SLPs delivering the treatment may have a range of experience, skill, and confidence in delivering aphasia therapy and using technology. SLPs delivering the CHAT program were required to see three to four patients a day, switching between delivering different types of therapy (e.g., functional therapy to computer therapy) for different patients. Additionally, they were required to perform indirect clinical duties such as documentation, planning, and resource preparation for sessions. Although CHAT was delivered from the tertiary hospital site, it was discussed that SLPs may be required to deliver TeleCHAT from alternative locations (e.g., work from home during COVID-19 restrictions). The university provided SLPs with access to physical infrastructure (e.g., telerehabilitation suites and high-quality technology) and technical assistance. University policies, governed by state privacy laws (Information Privacy Act, 2009), required a high level of security and data protection to be maintained during the delivery of telerehabilitation.

Stage 2 – Specify User and Therapy Task Requirements

Analysis of the context of use and participant characteristics revealed both user and therapy requirements necessary to deliver the TeleCHAT program.

User requirements

The PWAs required communication and participation supports for each area of language impairment, which incorporated the different modes of communication (i.e., gesture, verbal communication, written words, pictures, and drawings). These supports were categorised and tabulated in Table 1. Given that PWAs and SPs may have varying levels of experience and/or confidence in using technology, training in use of a new technology system was deemed necessary.

Regarding the SLPs, as they would deliver therapy sessions to multiple users, they required a system that would interact easily with all participants and offer them flexibility to provide technological assistance and/or facilitate PWA’s communication as needed. Hence, the capability to remotely control the PWA’s screen and offer interactive functions was viewed as an important technical inclusion. Also, as the SLPs would conduct multiple appointments per day, a technology system that was intuitive, flexible between therapy tasks, and interoperable between devices was required to enable efficient workflow. Finally, given the complexity of the behavioural intervention and the needs of the participants, the SLP would require training on, the delivery of the program, provision of support to PWA and SP to use the technology, and troubleshooting of technical issues.

Requirements of the Therapy Program

The therapy activities in the CHAT program commonly used paper-based resources, incorporated movement of word or text tiles, media presentations (videos, PowerPoint presentations, images), and/or other technology (e.g., phones, iPad/tablet apps). While digitising paper-based resources was a simple process, translating the SLP and PWA interaction with all therapy resources during a telerehabilitation session, required more detailed planning and consideration.

The task analysis revealed how each therapy task could be delivered and described differences between the SLP and the PWA interactions. An example of the task analysis conducted, for each therapy type, is presented in Table 2. In most therapy tasks, the SLP screenshares the therapy resources with the PWA, and the PWA interacts with the stimulus by pointing to or moving the stimulus on the SLP’s screen. Analysis of communication and participation supports, and therapy tasks revealed that certain user and task requirements appeared consistently across therapy activities. This information was used in Stage 3 to determine essential technology functions and is detailed further below.

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.

Stage 3 – Configure technology solutions

The research team considered technical functions and searched for technical products that could facilitate the user and therapy task requirements.

Technical functions required for the delivery of TeleCHAT

Technical functions that supported PWA’s communication and participation requirements were mapped onto Table 1. These technical functions were considered essential to the TeleCHAT delivery as they enabled people with different types and severity of language impairments to participate in the therapy tasks. For example, an SLP could support an individual with impaired auditory comprehension by writing or typing keywords on the PWA’s screen. Accessibility features that may be required to support SPs' communication needs (e.g., closed captions to support those participants with hearing impairment) were also considered (Table 1).

Secondly, technical functions that facilitated user interactions for each therapy type were considered and mapped accordingly (Table 2). Technical functions were then categorised into essential and preferred functions, and mapped to technical products, such as videoconferencing features, that could perform the function (Table 3). Most functions were deemed essential, which was expected, as they derived from the key therapy components. However, some functions, such as ‘highlighting text’ were classified as ‘preferred’, as they would enable more efficient delivery of the task but were not critical to the therapy activity and could be achieved through other means (e.g., use of a document editor). A key consideration when mapping technology functions to the participants’ interactions, was ‘technology burden.’ To reduce system complexity for the PWA and enable the SLP to resolve technical issues if they arose, it was intended that the SLP would take on more of the technological burden, transferring complex tasks (e.g., initiating sessions, navigating to the annotate button) from the PWA to the SLP. It was hypothesised that reducing the technical burden for the PWA would simplify the interaction, which could potentially increase accessibility and usability of the system. Overall, the essential technical functions and products required to deliver TeleCHAT were summarised as follows:

1. Record, display and transmit clear audio and video of 11+ users and shared content across different devices. Enabled using cameras, microphones, remote display, and screen sharing functions, this function ensured all users were able to see and hear each other, as well as the shared therapy stimulus. Interoperability of the videoconferencing platform across devices enabled multi-user interaction in group therapy, and simultaneous vision of participants and shared therapy activities. Screensharing of multiple sources of content (e.g., video, documents, computer therapy software, internet browsers) allowed SLPs flexibility to deliver therapy activities that were not available to the participant on their personal device.

2. Multi-point interaction on the same content. This included remote control of another user’s screen (e.g., moving and clicking ability) and the use of annotation features by multiple users (e.g., drawing, typing, pointing tools). This allowed users to interact with the therapy stimulus in a manner similar to an in-person session.

3. Ability to send information and multimedia resources between the SLP and PWA. This was enabled through email, messaging systems and/or cloud storage. This function was critical for ensuring that personalised, tailored therapy resources could be shared (e.g., PWA’s photos), modified, or monitored before, during and after therapy sessions.

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

Assessment of videoconferencing platforms against technical requirements

Six common videoconferencing platforms were tested and critiqued against the essential and preferred technical functions (Table 4). It was found that Zoom^© was the only platform that supported and enabled all technical functions essential for the delivery of TeleCHAT. It also had a wide range of preferred accessibility functions that made the delivery of TeleCHAT aphasia-friendly, such as the ability to increase font size on a whiteboard, and the ability to remotely unmute participants. Zoom^© was HIPAA (Health Insurance Portability and Accountability Act) compliant and offered a waiting room feature, which replicated in-person practice and supported privacy and security. Hence, Zoom^© was the platform selected to support the delivery of TeleCHAT.

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.

Stage 4 – Evaluate technology solutions against requirements

Simulation testing confirmed that the configured telerehabilitation system was able to achieve all essential technical functions and was suitable for the delivery of TeleCHAT. It established that a computer with two monitors, a microphone, speakers, a tablet/iPad and a secondary camera was necessary for the SLP. This multi-screen configuration allowed for the enlargement of the participant video and shared resource to be displayed on one screen, while therapy notes, or unshared pre-prepared therapy resources, could be displayed on the second screen. Furthermore, when screensharing PowerPoint presentations, the secondary screen was useful for displaying presenter notes. For the PWA, a computer/laptop, and/or tablet/iPad could be used; however, the tablet/iPad had some technical limitations, in that the SLP could not remotely control the devices’ screen. The simulation trial also identified procedures to decrease the technical complexity for PWA, such as video-calling the participant instead of sending them a joining link, and identified procedures for potentially complex processes, for example, connecting multiple users’ devices to the telerehabilitation session. Through the simulation trial, researchers identified technical features, procedures, and potential technical issues to be included in the program resources and training to support TeleCHAT users.

Stage 5 – Evaluate technology solutions with users

Participant Demographics

In total, three male and one female PWA were recruited and consented to participate in the TeleCHAT pilot trial (Table 5). They were aged between 24 to 73 years (M = 53.7) and lived in rural (1), and metropolitan (3) locations. According to the CAT modality mean score (Swinburn et al., 2004), participants presented with an average aphasia severity of 50.9 (SD = 4.8, range = 46-55.7). Three participants had physical comorbidities (apraxia of speech, limb paresis, visual impairment) that required consideration when tailoring the technology configuration for their therapy. Participants had not participated in CHAT previously. Overall, as measured on a 5-point Likert scale (1 = definitely no, to 5 = definitely yes), participants were moderately confident in using technology prior to training (M = 3.4, SD = 1.3, range = 2 - 5). Two SPs consented to participating in TeleCHAT, however, only one SP provided ongoing technical support, and completed the post-TeleCHAT interview. Two qualified speech pathologists with one to three years of clinical experience in aphasia and telerehabilitation, delivered the TeleCHAT program.

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.

Range of Technology Used

All participants were able to use their own personal devices to participate in the TeleCHAT program. Details of how the telerehabilitation system was adapted to accommodate for participants’ language impairments and physical comorbidities are provided in Table 6. For example, PWA2 was given a headset to transmit clearer audio to assist his apraxia of speech, while PWA3 used a wireless mouse and typed with her non-dominant hand.

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.

Completion of TeleCHAT as Intended

All participants completed the program, receiving at least 97% of the intended 50 hours of therapy (M = 50 hr 34 min, SD = 1 hr 46 min, range = 48 hr 34 min – 52 hr 57 min) (Table 6). Out of all the therapy sessions delivered (total = 200 sessions), participants experienced a total of 54 technical issues and 24 user issues, spanning across 63 sessions (31.5% of sessions). The mean duration of each issue was minimal at three minutes and consequently did not detract from PWA receiving the intended dose. Technical issues (total = 54 issues) occurred more frequently than user issues (total = 24 issues). These technical issues were primarily caused by poor internet connection (41 instances). The majority of user issues were caused by PWA having difficulty operating the Zoom^© software (19 instances). PWA4 experienced the greatest number of user and technical issues, which were predominantly caused by a poor and unstable internet connection, technical limitations of the device used (e.g., SLP was unable to remote control into an iPad), and the PWA’s difficulty using Zoom^© functions. In terms of SLP use of the telerehabilitation configuration, the SLPs experienced five user issues across therapy delivery to all four PWA. These issues occurred during the use of Zoom^© functions (four instances), and computer software (one instance). One SP had difficulty with using iPhone/iPad apps to transfer therapy resources. Overall, technical and user issues had a minimal impact on the therapy delivered. This conclusion was supported by SLPs, who reported that technical problems did not affect the planned therapy session (Table 7).

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).

User Satisfaction

Overall, PWA, their SP and SLPs were satisfied with the telerehabilitation system (Table 7). Three out of four participants were definitely satisfied with the telerehabilitation system used to deliver TeleCHAT, and half of participants found it definitely easy to use. One SLP found it definitely easy to provide tailored communication supports to the PWA as needed. One SLP and three PWAs reported that they thought it was definitely easy to fix technical issues on their ends. However, one SLP found it slightly harder to fix technical problems on the patient’s end, rating their satisfaction as neutral for that question.

Modifications to the TeleCHAT System Configuration

As user satisfaction levels were high, the functionality of the system was relied upon to drive improvements to the telerehabilitation configuration and TeleCHAT protocol. The adaptions and modifications were collated and are described in Table 8. Most modifications were made to the training delivered to participants, to enhance memorability of use of the system, and specificity of training to the participants’ individual therapy plans. In some cases, options for the resolution of issues were provided at different technical complexity levels dependent on the users’ technological skills. Furthermore, internet testing was included during PWA training, to test their internet’s capacity to support tasks that require a higher bandwidth (e.g., screensharing a computer therapy program or video). A stable internet connection with a high upload speed was recommended as a requirement of participation in the TeleCHAT program.

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.

During the pilot trial, the SLPs identified challenges with Zoom^©, including the variation in the display of information between devices, and the enabling of technical features on the SLP (host) and PWA (guest) screens. This presented as a challenge for SLPs when training or guiding PWAs through technical difficulties. Therefore, functions allowing SLPs to remotely control the participant’s screen, unmute the participant, and start the participant’s video, were considered helpful in assisting the participant overcome technical difficulties. However, some technical tasks, could only be completed at the PWA’s end (e.g., joining a meeting or sharing screen) and for these tasks, an SP assisted the PWA, with verbal guidance from the SLP, where necessary.

Discussion

This study has documented the successful translation of the CHAT program into TeleCHAT. By prioritising user needs and therapy requirements, the HCD process facilitated the configuration of a system that was optimised to cater to diverse user groups while preserving the fundamental elements of a comprehensive aphasia intervention and the integrity of the evidence-based therapies delivered. The system’s functionality was verified during simulation testing, followed by a pilot trial that confirmed its ability to deliver TeleCHAT as intended with high user satisfaction. These findings support the potential to deliver an ICAP via telerehabilitation, and in doing so, optimise access to evidence-based aphasia therapy.

Focus on user needs

Building technology around user needs not only optimises engagement (International Organization for Standardization, 2010; Kearns et al., 2019), but also aligns with person-centred care recommendations for aphasia rehabilitation (Forsgren et al., 2022; Lawrence & Kinn, 2012; Plowman et al., 2012; Worrall et al., 2011). While the use of aphasia-friendly technology designs has been reported in some studies on telerehabilitation delivery (Cherney et al., 2011; Getz et al., 2016; Hill, 2008; Hill & Breslin, 2016; Simic et al., 2016), few have provided detail on how the technology was chosen and configured specifically for PWA. By following the HCD process, the TeleCHAT system was deliberately configured to support the needs of PWA. Acknowledging common comorbidities experienced by PWA during the system design process (e.g., weakness of dominant upper limb), allowed for system modifications to be made so that delivery of the TeleCHAT program during the pilot trial was tailored to everyone (e.g., PWA3 required use of a wireless mouse, and typing functionalities as handwriting was difficult). While other studies have suggested that a lack of technical support from a SP may be a barrier to use and acceptance of technology by the PWA (Kearns et al., 2019), our consideration of the needs of a SP in TeleCHAT meant that SPs were appropriately trained in the technology for their level of involvement in TeleCHAT, whether they provided technical assistance or not. Despite three of our participants receiving minimal to no technical support from a SP in the pilot study, all PWAs felt that the telerehabilitation system was easy to use, and that problems could be fixed on their end. The deliberate shift of the technology burden to the SLPs, potentially facilitated PWA’s access to the technology configuration. Thus, focusing on the user needs in the HCD process enabled PWA to access the technology configuration regardless of whether a SP was available.

Furthermore, prioritising a videoconferencing platform with flexible access (i.e., ZOOM^© meant that a range of consumer grade devices (e.g., desktop, laptop, tablets) could be used for therapy. Enabling use of familiar, personal devices likely supported users’ comfort and confidence when learning the telerehabilitation system and participating in therapy. Finally, embedding technical functionalities that allowed users to maintain therapy participation despite their communication disability and/or technology confidence was a key advantage of the TeleCHAT system. For example, the ‘remote-control’ function was initiated by the SLP to troubleshoot difficulties for PWA who could not follow complex directions and/or were inexperienced with technology. When initiated by the PWA, the remote-control function also facilitated PWA’s interaction with therapy activities on the SLP’s shared screen. Prior research studies have identified the usefulness of the ‘remote-control’ function (Getz et al., 2016; Øra, et al., 2020), however, this has been primarily used to support resolution of technical issues. In our study, by expanding the use of the ‘remote-control’ function to enable interaction in therapy tasks, the PWA’s participation in TeleCHAT was optimised.

Clinicians require telerehabilitation systems that support efficient workflow, while minimising technical complexity (Messamer et al., 2015). Given that technical literacy of both clinicians and patients was cited as one of the most common barriers to adoption of telehealth post-COVID (Kruse & Heinemann, 2022), a technology solution that integrates essential functionalities (e.g. screensharing, remote control, annotation) within a single videoconferencing platform streamlined procedures and decreased the learning demand of new technology. Hence, a single platform, Zoom^© was chosen over a configuration of multiple external software, as has been reported in previous telerehabilitation studies (Getz et al., 2016; Øra, Kirmess, Brady, Sørli, et al., 2020). Feedback during the pilot trial revealed that clinicians felt that using the configuration, they were able to provide communication support to PWA, resolve technical issues on both SLP and PWA ends and that technical and user issues did not affect planned therapy sessions. This feedback suggests that SLPs had received adequate training to feel confident to modify and utilise the system’s functionality to best support PWA’s needs.

Focus on therapy task requirements

The HCD process prompted the detailing of technical requirements required to maintain the fidelity of evidence-based therapies across the four different therapy approaches. Given the variability across user interactions, and resources required to deliver each therapy task, it was necessary for technical features to offer adequate flexibility to maintain the fidelity of each therapy task. The identified essential technical features, including clear audio-visual quality, screensharing, annotation tools and remote-control capability, have been recommended in prior aphasia telerehabilitation configurations (Getz et al., 2016; Jacobs et al., 2021; Øra, Kirmess, Brady, Partee, et al., 2020; Pitt et al., 2019a; Simic et al., 2016). However, the TeleCHAT translation process stipulated additional requirements such as, the need to ‘screenshare visual and audio of multimodal resources from a range of different devices’ instead of just ‘screenshare’. By doing so, it revealed nuanced differences in the capability of each technical feature, which allowed the research team to choose the best product for delivery of TeleCHAT. During the pilot trial, technical functions were used to support a variety of therapy tasks for different PWA. For example, PWA 2 screenshared the Tactus Therapy^(c) Advanced Reading app from his iPad (joined into the session as a second device), while PWA 3 screenshared her written script from her laptop. Although both PWA used the ‘screenshare’ function, they shared different content (i.e., app vs document), from different devices (i.e., iPad vs laptop), for different purposes. The flexibility of the ‘screenshare’ function enabled PWA to fully engage with the therapy materials, and complete therapy activities tailored to their goals. The flexibility of technical functions also allowed SLPs to deliver the intended therapy activities, regardless of whether it was available on the PWA’s device. For example, PWA 2 was able to receive therapy using Aphasia Scripts^© even though this software was not available on his laptop. These examples demonstrate that the configured system for TeleCHAT had the optimal flexibility required to deliver therapy to a range of people without compromising on participant engagement, or the integrity of the therapy activity.

Importance of simulation and pilot testing

During the first three stages of the HCD process, theoretical knowledge and observation of the users and therapy task requirements informed the technology system configuration. However, not until the whole system was tested could it be evaluated with respect to its ability to meet users’ needs and deliver the intended therapy within the users’ environment (World Health Organization, 2016). While six videoconferencing platforms were trialled, only one met the requirements to deliver TeleCHAT. This finding reiterates the value of the HCD process in selecting appropriate technology to optimise user access and therapy task fidelity. Simulation testing revealed system flaws that were not identified in the configuration stage (Stage 3), and gave researchers the opportunity to make iterative changes to improve the system’s quality and interoperability (Demiris et al., 2010). Furthermore, simulating the role of both the clinician and patient allowed researchers to identify those technology features that required additional instruction (e.g., SLP explaining to the PWA how to annotate on the screen) (Demiris et al., 2010) and/or development of quick-reference/troubleshooting guides. Additionally, taking on the role of the patient provided insight into potential technology challenges at the PWA’s end and allowed the SLP-researchers to practice providing technical support, in preparation to support participants during the pilot trial (Demiris et al., 2010). Pilot testing the technical configuration enabled determination of the ability of the system to deliver the TeleCHAT program under clinical conditions, revealing everyday challenges with technological variability that needed to be addressed. For example, some participants had poorer internet bandwidth which occasionally affected the audio-visual display of therapy materials and users. This issue prompted a re-working of screening and training protocols so that internet connection issues could be identified and resolved prior to therapy commencement. Nevertheless, user feedback confirmed the system supported variable user needs, and clinicians were able to deliver the therapy program as intended.

Limitations

Several limitations were identified in this study. Firstly, participants self-nominated their interest in participating in the TeleCHAT program, therefore selection bias may have occurred. Secondly, the eligibility criteria included access to videoconferencing compatible devices and internet connectivity. However, this criterion was not a concern in this study as participants who expressed interest had the required technology available and three participants were lent technology (e.g., headset, stylus, laptop) to enhance their participation in TeleCHAT. Further, while physical supports to assist user participation were considered, it is acknowledged that the research team did not have occupational or physiotherapy training. While no adverse events occurred, future studies should consult occupational and/or physiotherapists to provide optimal physical support to participants with physical disabilities. A potential limitation of the assessment of six videoconferencing platforms in Stage 3 was that internet speeds were variable as they were not tested in a controlled environment. This may have impacted the platform’s functionality and thus inclusion in the technology configuration. However, as TeleCHAT was intended to be delivered in a non-controlled environment (i.e., directly to participants’ homes), it was appropriate to test platforms in a similar setting. Furthermore, the assessment of videoconferencing platforms was limited to those with free trials, or those that were currently available and used within the university and/or tertiary health facility. Consequently, the technology tested was not exhaustive and other technology may be suitable for the TeleCHAT program. Additionally, it is acknowledged that the first author (GV) was involved in the translation of the TeleCHAT program, the delivery and evaluation of the pilot trial, as well as the data collection and analysis. The author’s involvement across all stages of this study introduces potential confirmation bias. A larger group study exploring the perspectives of other SLPs and PWAs on the feasibility, usability, or acceptability of TeleCHAT, will address this bias by providing more objective evaluations. However, the successful translation does provide promising results for the effectiveness of this system configuration for a larger trial.

Conclusion

The translation of TeleCHAT is the first study to apply a HCD process to systematically translate an ICAP for delivery via telerehabilitation. We highlighted the importance of utilising a systematic translation process to configure technology that is fit for purpose and for all users. We recommend that clinicians use our study as an example of how to use the HCD process to evaluate their own telerehabilitation systems or select and configure a new telerehabilitation system for their service. Omission of this detailed translation process risks either the selection of inappropriate technology to deliver the intervention, or invalid modifications of the therapy program to suit the selected technology, which risks program fidelity.

Declaration of interest

The authors report there are no competing interests to declare.

Acknowledgements

The authors would like to thank Dr Jessica Campbell and Ms Katherine O’Brien for their support and input into clinical planning for the TeleCHAT pilot trial. We would also like to thank our research participants for their valuable time invested in participating in TeleCHAT.

Disclosure statement

No potential conflicts of interest are reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/02687038.2024.2314328.

Additional information

Funding

This research has been carried out as part of a PhD scholarship by the first author, funded by the Queensland Aphasia Research Centre, The University of Queensland. The TeleCHAT program was funded by the Queensland Aphasia Research Centre. The Queensland Aphasia Research Centre was funded through philanthropic gifts and The University of Queensland strategic funding.