Introduction
According to the National Institute on Deafness and other Communication Disorders, 7.7% of US children aged 3 to 17 had a disorder related to voice, speech, language, and swallowing within the past year. In adults, approximately 4% of the US population have experienced a voice issue during the last 12 months, with additional speech disorders including stuttering and acquired language disorders related to stroke or traumatic brain injury. Speech and language therapy is a critical intervention to promote language development and minimize potential gaps in skill development, including communication, social-emotional, cognition, and self-advocacy. Additionally, speech-language pathologists (SLPs) support those who may have difficulty chewing and swallowing, a disorder known as dysphagia, in their ability to manage food safely during mealtimes.
Telerehabilitation is one potential venue for providing speech and language therapy. Since 2006, the national accrediting board for SLPs, the American Speech Hearing and Language Association (ASHA), has supported remote service delivery as a viable option for those clients who could not access qualified providers. Telerehabilitation has provided a valuable service to children in remote areas where specialists are not readily available.
As the COVID-19 pandemic spread across the world in 2020, many medical institutions were forced to close and in-person therapy was no longer available. Many health care providers, including SLPs, suddenly had to rethink how to provide effective therapy and looked to telerehabilitation as a possible option. Most of this chapter will discuss the benefits and considerations specifically related to speech and language therapy in children in the United States, including those with developmental speech and language disorders and neurologically based disabilities. However, many of the interventions and considerations apply to pediatric and adult populations around the world.
Telerehabilitation in Speech and Language Therapy
The ability of clients to access teletherapy depends upon four main components: insurance and state regulations, accessibility to an appropriate learning environment, technology access, and client profile. Public and private insurers have specific policies regarding payment to providers and out-of-pocket costs to the family. During the COVID-19 crisis many insurers across the United States temporarily expanded coverage allowing more access to therapy than had been previously possible. However, many licensing restrictions remained in place. Licensure rules differ across states for speech-language pathology. In telerehabilitation for speech and language therapy, the onus lies upon the practicing clinician to abide by both the individual state regulations and those established by ASHA. This includes understanding the rules governing where the therapy takes place, and where the client is receiving services. For example, a therapist in Massachusetts providing therapy to a client in New Hampshire may be subject to the licensure and business regulations in both Massachusetts and New Hampshire.
Another consideration is technology use and access. According to the Pew Research Center an average of 58% of US school-aged children have internet at home to complete school work. This number is similar for adults aged 50 to 64 where 59% of this age group consistently have access to broadband services. Further, the National Center for Education Statistics conducted a survey indicating that 17% of children aged 3 to 18 do not have reliable access to a laptop or desktop computer. According to both sources, disproportionate access persists across socioeconomic class and race. This results in possible gaps in telerehabilitation across groups of clients who need prescribed speech and language therapy services.
Accessibility also includes navigating the physical computer or tablet and HIPAA-compliant telerehabilitation software platforms, to protect patient privacy. For younger children or individuals with severe disabilities, accessibility is reliant upon caregivers for technology setup, logging into the session, and navigating the use of the tablet, desktop, or laptop computer. Further considerations should be given to client and caregiver independence using a touchscreen, trackpad, or external mouse, as these features are often required for more interactive therapy activities.
Finally, the client’s profile should be carefully assessed for eligibility in telerehabilitation. ASHA notes that therapists should consider physical characteristics such as hearing and visual impairments, attention and behavioral issues, cultural considerations (including needing an interpreter), and caregiver support for access and troubleshooting. While none of these factors automatically disqualify a client from assessment or receiving teletherapy services, therapists should consider whether telerehabilitation is a viable and appropriate means of support. In many such cases, assessments and service delivery models may be adjusted to develop the most appropriate plan of care.
Service Delivery Models
Traditional speech therapy intervention includes physical face-to-face interactions. The client comes to the speech therapy room or the SLP provides intervention at the client’s home. Caregivers report positive experiences using telerehabilitation at home. Telerehabilitation therapy can be effective as a primary means of synchronous (real-time) online therapy, or in combination with other options as highlighted later.
Hybrid Therapy
Hybrid intervention may include a combination of in-person therapy, synchronous, and asynchronous online sessions. For example, the therapist may initially need to see a client in person to provide hands-on cueing for oral motor positioning to determine what may work for intervention during specific articulation or oral motor feeding tasks. Once this has been determined, the client can be followed using the same approach within an online venue. Additionally, the client may upload videos of their progress in between sessions to a secure online platform for the therapist to assess progress. In this way the client benefits from real-time feedback and the therapist can track progress over time.
Consultative
This model provides a broader, more inclusive approach to intervention. In a caregiver survey conducted by Tenforde et al., families perceived consultation across providers to be helpful in establishing consistency of care between home, school, and outpatient therapy. Like in-person visits, a consultative approach may include the therapist implementing a virtual treatment session, while additional providers (i.e., other medical professionals, caregivers, or support staff) observe the session through a shared screen feature. If there are multiple team members present during the therapy session, it may be helpful to turn off the audio and video portion of other providers to minimize distracting the client. As part of the consultative model, the clinician can use a portion of the session to allow for comments and team feedback. This can be helpful in providing concrete strategies for intervention.
Multidisciplinary Model
A multidisciplinary model of intervention may be helpful when the client could benefit from the expertise of more than one professional at one time. For example, a child with feeding and swallowing issues may be best evaluated by both an SLP and an occupational therapist to address both oral motor and swallowing safety, but also fine motor, positioning, and self-feeding skills. This allows both disciplines to assess the client while minimizing the demands upon the client and family. Like the consultative model of intervention, this model allows the client to benefit from the perspectives of different disciplines simultaneously to provide a more comprehensive view of the client’s current skills and treatment needs.
Group therapy
Group therapy may be a viable option for some telehealth participants. Walker et al. found that telerehabilitation provided in a group format may reduce a sense of social isolation amongst participants diagnosed with aphasia. Research on the efficacy of telerehabilitation and group speech-language therapy continues to be an emerging area of need. Therapists choosing this option must continue to consider client privacy needs within a group setting.
Asynchronous Option
An asynchronous, or a “store and forward” option may be helpful for the clinician when evaluating how a specific intervention is working or being implemented. In this case, the client records a short video clip of a given activity and uploads the video to a secure portal for the clinician to review ahead of the live session. This allows the clinician to view how a goal is being addressed within a specific setting or with specific caregivers. Conversely, asynchronous exercises or home programs may be created by the clinician and sent to the client or client’s family in order to provide a model that can be reviewed as necessary. This option may be helpful when providing services within a consultative model.
Use in Assessment
In order to establish measurable therapy goals, the clinician must first perform a speech, language, or swallowing evaluation. A cursory intake of skills through a previsit form may help the clinician best prepare for assessment. This intake form may include the client’s medical history and current speech, language, and/or dysphagia needs. A wide variety of online standardized assessments are available through major testing publishing companies. Commonly used articulation, vocabulary, and language tests can be administered by the clinician sharing the screen to allow the examinee to view pictures from each standardized test. The examinee can respond verbally, or by using the mouse or touchscreen. In some cases, external devices such as document cameras can serve as another way the examinee can view the test items or materials. For checklist or parent survey assessment tools, the item can be scanned and emailed, or sent by a hyperlink for the parent to complete and return. If this proves too cumbersome, the clinician can review the items with the parent during the virtual session.
For less standardized measures or skills best captured through observation, clinicians can coordinate with caregivers to set up an environment conducive to gathering information. This may include appropriate seating and positioning (seated at a table or highchair) and having toys from home available to observe play skills. For a feeding or swallowing assessment, therapists may observe the client’s oral motor skills and interactions with food, including related items (cups, bottles, utensils, etc.). Therapists may experience issues when trying to assess some aspects related to swallowing or voice, so this may present as a challenge while supporting a client remotely. Caregiver interview is also a critical component of informal assessment procedures. As with all telerehabilitation visits, the client and family member should be set up in a relatively quiet, distraction-free environment. To ensure privacy compliance, all sessions should be completed in a private setting, not in a public place.
Use in Special Populations
While research remains scant specific to diagnosis, telerehabilitation has been notably successful in children with developmental delays and neurological disorders such as autism. Some positive findings have emerged in the research related to treatment of voice, aphasia, and traumatic brain injury, though the amount of research specific to such diagnosis remains limited to primarily case studies with small populations. Specific to speech disorders some positive results have been found in children with a diagnosis of stuttering and childhood apraxia of speech (CAS). In children receiving school-based intervention, results of treatment appear to be equally as effective in treating children with speech sound disorders in person compared to an online venue. As with face-to-face sessions, crafting an online session with children who have significant attention issues or those who are minimally verbal may require additional clinical accommodations. For children with significant attention issues, accommodations may include a combination of visual supports and movement breaks.
Finally, for those clients who do not attend well to a screen, or seem too young to benefit, a short period of intervention may be appropriate in the form of parent coaching and education. This may include setting up items ahead of time, and then the therapist coaching how to use specific toys or items to facilitate language and play skills. The therapist serves as a guide to support the client’s needs by direct caregiver instruction.
Use in Practice
Like a traditional therapy session, client engagement is imperative for desired outcomes within a virtual treatment session. For a clinician whose experience lies primarily in traditional therapy delivery, the transition to teletherapy can pose challenges in lesson planning and execution. Fortunately, through the assistance of features built into telerehabilitation platforms and both subscription-based and free online resources, clinicians have the tools to effectively target a variety of speech, language, and feeding/swallowing goal areas.
Leveraging Functions and Features of Online Platforms
Screen Share
Many HIPAA-compliant telehealth platforms have built-in features to create an interactive session. The most important interactive feature is the “screen share” tool, which allows both the clinician and the client to simultaneously view what is on the clinician’s computer screen. The clinician is given the option to share their entire screen, or share only a specific application, so that other browsers and applications on a clinician’s computer may remain private. This is often recommended in order to remain HIPAA compliant. When sharing the entire screen, a client may be accidentally exposed to private health information found on a medical documentation system, clinician therapy schedule, or an email application. However, the entire screen share feature may be useful when a lesson requires the clinician to toggle between two applications. In this case, care should be taken to minimize or close all browsers intended to remain out of view of the client.
One screen share option includes an interactive whiteboard feature. An intended blank slate—therapists can utilize this feature as they see fit. Common options include written or visual schedules, Venn diagrams, and to replicate language programs like the Expanding Expressions Tool by Sara L. Smith or the Story Grammar Marker by MindWing Concepts. Other sharing options to facilitate interaction include sharing computer audio and sharing mouse control. Sharing computer audio allows both the client and clinician to hear audio playing on the clinician’s computer. Sharing mouse or trackpad control allows the client to interact with the clinician’s shared screen. This feature is necessary for student participation in standardized assessments, but it also increases engagement with the variety of online treatment materials that require turn taking and direct selections. Control settings can be manipulated quickly for those clients who may be unable, or unwilling, to relinquish control of the mouse or trackpad.
While in screen share mode, clinicians will have access to a toolbar for text and annotation. Options include line drawing, highlighting, free text, shapes, stamps, and a laser pointer feature. These tools give clinicians the ability to quickly provide scaffolding for individual learner needs. The stamp feature can be utilized to represent a token reinforcement schedule like a star chart for earning a preferred object or desired activity. This toolbar can also be utilized by the client when accessing the mouse-share feature, which can be helpful for marking choices during receptive language testing and treatment. The client may place a stamp or hover the laser pointer over their answer selection. This helps to reduce expressive language demands like labeling the stimulus number. This may also help reduce the reliance upon a caregiver to report the child’s answer.
View, Background, and Special Features
Telerehabilitation platforms provide numerous options regarding how the clinician and client can view each other and themselves. Typically, when in screen share mode, the video image of each participant is reduced in size in order to focus the view on the clinician’s screen. This should be considered during the treatment of certain diagnoses where visual models of the clinician are necessary. For example, when treating clients with speech sound disorders, there is evidence to support providing visual models of the sound in conjunction with specific gesture cues. Therapists may need to remove screen share mode in these instances. The client’s ability to see themselves may serve as a source of visual feedback, which can improve direct imitation of an articulatory target. However, there are options to hide the view of the client for individuals who may be distracted by their own image.
The virtual waiting room feature allows clients to be admitted into the teletherapy session at the clinician’s discretion. This feature helps support patient privacy laws and ensures that individuals cannot enter the platform during another client’s session. Clients can be easily moved into and out of the virtual waiting room, which is particularly useful during multidisciplinary evaluations or co-treatment sessions. This gives providers the opportunity to discuss evaluation results and develop a service delivery plan before presenting this information directly to the client.
Some videoconferencing and telerehabilitation platforms offer the option to record sessions for later review. This feature is used most often for asynchronous service delivery models but may also be a useful tool for multidisciplinary collaboration and caregiver education. Clinicians may record portions of a session to demonstrate the use of a specific technique to another provider or to elaborate on treatment plan recommendations for a parent. Therapists should exercise caution when using the screen recording feature to ensure they are remaining HIPAA compliant and within accordance of state law regarding audio and video recordings. Clinicians must receive the appropriate consent to distribute any recorded video or audio containing private health information.
The last built-in feature to discuss includes the use of green screen and preset backgrounds. A user has the option to create virtually any background from a digital photograph or internet image. This feature may be utilized for the purposes of increasing professionalism when having to provide teletherapy from home, or as a creative measure to improve engagement with specific clients. Therapy sessions can suddenly be transported to a playground, outer space, or to a specific ecosystem to reinforce a curriculum-based vocabulary unit.
Using External Accessories and Tools
Until now, we have only described features provided directly by the telerehabilitation platform. While these features help provide accessibility to a variety of computer-based resources for therapy, there are several other avenues clinicians can use to adapt their traditional therapy materials for virtual use.
A lightweight, portable, documentation camera that is inserted into the universal serial bus (USB) port of a computer provides an additional camera source that is projected on the computer monitor during screen sharing. Documentation cameras, or “DocCams,” can be utilized to project therapy materials a clinician physically has on hand. This can include worksheets, flashcards, handmade materials, crafts, board games, or toys. A documentation camera is particularly helpful during interventions targeting dysphagia and feeding disorders. The DocCam can easily visualize cooking demonstrations and food play while the desktop or laptop remains in a stable position. The DocCam can be used to demonstrate therapeutic techniques to caregivers that are not easily visualized with a traditional webcam. Examples include thickening liquids according to a specific dysphagia diet or demonstrating physical prompts on a mannequin for breastfeeding, bottle feeding, cup drinking, or spoon feeding.
Many computer platforms provide compatibility with mobile technology devices allowing for a screen share option. The screen share feature allows clinicians to use interactive applications on their mobile device, eliminating the need for a direct internet connection. Using this screen share option, clinicians can display a technology-based augmentative alternative communication (AAC) system in order to provide a visual model to the client or caregiver for a navigational sequence. This can help the clinician teach caregivers how to make changes to a specific button or feature on the AAC system, or model technology use in real time.
For clients working on voice therapy and vocal intensity, additional accessories may be needed. In a pilot study of older patients participating in voice therapy, Quinn et al. noted the benefits of accessories to help with feedback and audio clarity. The authors included the use of an external microphone such as a headset or monitoring systems such as a sound pressure level meter to provide feedback to both the clinician and client. Clinicians must continually explore external accessories and web-based resources to maximize treatment outcomes.
Web-Based Resources
While teletherapy has existed since the early 2000s, this service delivery was brought into the spotlight during the COVID-19 global pandemic beginning in 2020. During this time, clinicians and educators across the world were faced with a sudden shift to virtual services. Several companies that had previously catered to providing analog therapy materials adapted, while new companies catering to digital resources flourished. As teletherapy continues to gain traction as an effective alternative to in-person services, the market for assessment and treatment resources will continue to grow and improve. In the interest of remaining relevant through the expansion of teletherapy resources, the following section will not focus on listing specific websites or online subscriptions. Instead, this text will aim to provide the reader with the necessary skill set for selecting appropriate materials for a variety of speech, language, and swallowing goals.
When planning for a teletherapy session, a clinician must first decide on the purpose of the material itself. For play breaks and reinforcement, the internet can provide an endless number of free videos and websites customizable to a client’s interest while addressing goals. Similarly, websites offering virtual dice, spinners, or adapted versions of classic games like Connect 4 and Chutes and Ladders may be an engaging complement to drill-based treatment like articulation or syntax targets. In many instances, utilizing a “DocCam” or screen sharing PDF files may be enough for a successful session.
FIVES Model for Choosing Resources
For other clients, it is necessary to find an interactive resource that contains the speech or language targets built into the activity. Evaluating materials using the “FIVES Criteria” developed by Sean Sweeney MS, MEd, CCC-SLP can help guide clinical decision-making when purchasing online products and subscriptions. The FIVES Criteria (which stands for F airly priced, I nteractive, V isual, E ducationally relevant, and S pecific) was created as a model to help professionals decide what electronic and mobile app resources were adaptable for use in intervention.
Fairly Priced
Determining whether a web-based material is fairly priced is most dependent upon its ability to be utilized across a variety of sessions and a variety of clients. A monthly subscription-based service that provides materials for a variety of ages and a variety of speech and language targets may be worthwhile for a clinician with a varied but primarily virtual caseload. This same service is likely not a great value for a clinician who has only a few teletherapy clients, or who is providing teletherapy services in a primarily consultative or parent coaching model. Currently, there are many online resources that are free or provided at low cost to clinicians, making teletherapy resources just as accessible as traditional therapy resources.
Interactive and Visual
When adapting the FIVES model to teletherapy, the interactive and visual components are of greatest importance. A survey of SLPs following the COVID-19 pandemic revealed that a majority of SLPs reported increased workload and decreased confidence in their ability to provide quality intervention when compared with an in-person service delivery. In addition to a multitude of logistical obstacles, creating interactive treatment sessions was a concern for many clinicians. Therapists should consider the time and resources spent on web-based versus physical materials used with a documentation camera. In many cases, web-based materials may be more accessible and less time-consuming for treatment planning and preparation. For example, online streaming services and e-books can replace physical picture books. Applications that simulate situations like doll house play, a tea party, or a hair salon provide the opportunity to target vocabulary and concept development, comprehension for question forms and directions, and pragmatic elements of language during pretend-play schemas.
Educationally Relevant and Specific
Finding materials that are educationally relevant and specific to therapy objectives can be particularly important for school-based clinicians, who must focus on how the child’s disability impacts their educational performance. Collaboration with school and medically based SLPs can help clinicians target therapy goals while simultaneously accessing curriculum content. Currently, several online marketplace sites exist as a means for educators and therapists to create, buy, and sell digital resources with therapy objectives or curriculum units in mind.
Considerations Across the Lifespan
Many of the strategies mentioned in this chapter may also be applicable to an older population who present with disorders such as Parkinson’s disease, amyotrophic lateral sclerosis, and cerebral vascular accidents (CVAs). For those requiring voice intervention, research supports efficacy of treatment in patients with Parkinson’s disease. The role of the SLP in supporting clients with ALS may including supporting use of AAC devices and monitoring the progression of the disease and understanding how this may affect communication and swallowing intervention. Further telerehabilitation may be used to support patients as a means of social connection in those with cognitive-communicative disorders or aphasia as a result of CVA.
Therapists should consider physical limitations that may accompany these disorders and affect access. This may include assessing mouse, trackpad, or touchscreen features, and understanding the patient’s comfort using technology. As in pediatric patients, caregiver support may be indicated for setting up and managing the telerehabilitation session.
Outcomes and Recommendations for Future Research
In summary, telerehabilitation has some evidence for use in a wide range of speech and language disorders including aphasia, articulation disorders, autism, dysarthria, dysphagia, fluency disorders, language and cognitive disorders, and voice disorders. Many of these speech and language disorders result as a sequela of larger developmental or neurological conditions (e.g., traumatic brain injury, CVA, progressive neurological diseases, autism, and genetic syndromes). Therefore use of telerehabilitation may prove effective across the lifespan.
The efficacy of telerehabilitation across settings and specific populations requires further research. Schools are currently the most common setting in which telerehabilitation services are delivered, and there is a strong body of evidence to support this as a service delivery model. Research supports that school-aged children receiving speech telerehabilitation were at least equivalent in effectiveness and efficiency as traditional onsite speech therapy as assessed using functional communication measures established by ASHA. Similarly, telerehabilitation for adolescents and adults appears to be promising, though research in this area remains emerging.
Further research is needed comparing service delivery models for specific diagnoses, particularly those that have evidence for hands-on techniques that are not feasible for the therapist to provide through a virtual platform. For example, further research is needed for motor speech disorders such as apraxia and dysarthria. Some research exists for the efficacy of telerehabilitation and the use of the Lee Silverman Program for Voice Disorders. However, research is needed for other evidence-based methods for motor planning disorders, for example, tactile facilitation methods such as the Dynamic Temporal and Tactile Cueing and Prompts for Restructuring Oral Muscular Phonetic Targets treatment programs for CAS. Knowing this, studies comparing outcome measures for clients with apraxia who receive in-person or teletherapy are needed in order to further define the scope of teletherapy for the inclusion or exclusion of certain populations. Additionally, further research may be indicated to determine the efficacy of these techniques when provided by caregivers with clinician oversight.
Finally, research should also aim to analyze outcome measures across the previously mentioned telerehabilitation service delivery models of consultative, hybrid, group, multidisciplinary, and asynchronous. The evidence of these models remains relatively nascent for use in pediatric therapy and adults. This will help clinicians create evidence-based treatment plans and potentially increase stakeholder support and acceptance of teletherapy as a consistent treatment option. Currently in the United States, many private and public insurance policies do not provide consistent reimbursement for teletherapy services, making these services less accessible across socioeconomic populations. Further research that supports the efficacy for teletherapy will be crucial for obtaining reimbursement from a variety of payer sources, allowing for greater accessibility of speech and language therapy to the broader population.
