June 23, 2022 by Steve Kerschke, PT
Often led by a speech-language pathologist, the treatment of cognitive and communication deficits has traditionally been delivered face-to-face in a clinical setting. However, online speech-language therapy has emerged as a viable option for individuals suffering from cognitive and communication deficits after a catastrophic injury.
As the Director of Research at QLI, Dr. Karen Hux has the unique opportunity to tackle relevant clinical problems through a variety of research projects focused on rehabilitation and recovery from complex neurological injuries. In this interview, Karen discusses her treatment philosophy, the key aspects of service delivery related both to in-person and online treatment approaches and offers insights about the future of online therapy.
Karen began her career in rehabilitation at an acute rehabilitation center where she was primarily treating people with stroke and traumatic brain injury. By the time she left to go back to do her Ph.D. work, she was exclusively seeing people with traumatic brain injury, and that became a real specialty and passion. Karen completed her Ph.D. studies at Northwestern University and then went to the University of Nebraska-Lincoln. After spending 27 years at the University, she joined QLI to focus exclusively on research and expand her research areas beyond just speech-language pathology.
It’s been interesting. When I started as the Director of Research, I didn’t know what my role would be and how much of my own research I’d be doing versus organizing research for others. As it has played out, most of the research projects I’ve been involved in have ultimately come out of some sort of clinical need. For one reason or another, I end up consulting on a client with an atypical diagnosis or an unusual presentation, which then turns into a research project.
Traditionally, speech-language therapy for people with acquired communication disorders occurs through face-to-face interaction in a clinic, is very structured, and tends to be focused on drill and practice to rebuild and restore communication abilities with the hope of returning to the original level of functioning. That’s a wonderful goal, but we need to acknowledge that we can’t always get people back to their baseline level of function. Also, working solely from a restorative perspective doesn’t always address a person’s immediate challenges and needs.
As a result, my philosophy tends to be oriented towards addressing what needs to be done immediately while also working towards longer term goals that the client finds motivating. I want to give the person a way to communicate based on their current abilities. If and when recovery takes place, we can always adjust from there.
Correct. It should be a balance between the two. All too often, therapy programs are solely restoration oriented, and compensatory strategies and devices are only introduced at the last minute before a person is discharged from treatment. Introducing compensatory techniques at this stage is too late to allow for mastery and, hence, is usually unsuccessful.
Instead, I prefer to have a balance between compensation and restoration. We absolutely focus on getting as much function back as we possibly can, but we also deal with the here and now to help the person have a successful mode of communication regardless of the amount of eventual recovery.
I was skeptical. I would liken it to my thoughts about online education, which I have always and continue to be very skeptical about. With online education, I believe it’s very hard to know what a person is doing on the other side of the camera. I thought telerehab would be the same.
I also wasn’t convinced of its effectiveness. It was hard for me to see how it would be appropriate for a wide variety of clients and how certain deficits could be treated virtually. Similarly, it was difficult to envision how I would co-construct materials to support a person’s communication or how I would work simultaneously on shared materials to deliver effective speech-language services via telerehabilitation difficult.
Take someone with severe aphasia who has all sorts of communication problems, both with speech production as well as language comprehension and expression. I struggled to envision how I would use tools and strategies I’m familiar with to help them in therapy. For example, communication books are a standard tool we use. I had questions like, “How will I construct the book? How will I support their use of the book? How will I deliver it and update it?”
I had similar concerns about using high tech communication devices. For instance, I wondered, “How will I test out that device with the individual? How am I going to get the device to them so they can try it out? Will I be able to assess whether it is appropriate for them?”
Helping someone with communication deficits navigate unfamiliar situations can be challenging regardless of the treatment approach. With online therapy, clients may encounter these challenges regularly when logging into sessions and accessing various apps on their device. I was unsure how this would play out.
Doing an online assessment of spoken language may seem like it would be easy. After all, you are evaluating the person’s production of words and sentences and listening to a person speak does not require any special equipment. You must account for the fact that you don’t always see hand gestures and other aspects that go along with communication, however.
For the most part, this is not a huge barrier; however, with telerehab platforms, you lose some ability to interact simultaneously with materials the client has in front of him. Although you can share a video screen to jointly view the materials, it can also be difficult to see what a person is pointing to or the gestures a person makes to support their spoken output. These supplements can be critical to the success a person with aphasia experiences when trying to convey a message, but they may be missed when communicating via a video-conferencing interface. To overcome challenges like this, there is often a simple solution. For example, we use a wide-angle camera lens or incorporate an additional device to allow for multiple viewing angles.
This may seem obvious, but it is also important to make sure the video quality is optimized. Internet speed, proper lighting, and positioning of the video device are all important aspects of this. Having a working knowledge of the platform and basic troubleshooting strategies allows us to address these issues quickly.
One easy way is to use standardized assessment tools we already have available. Many of them can be used virtually in the same we would use them in a clinic. Additionally, we can show pictures for naming or words or sentences for reading; we can ask questions through spoken or written language that the person has to answer. With some simple adaptations for eliciting responses—such as labeling response options with letters or numbers—we can come up with ways of working around reliance on spoken answers or pointing as a response mode. If a person cannot reliably say letters or numbers to indicate responses, we can be more creative and present response options on a color-coded grid; then, by holding up a card of the same color as the background, the person can indicate a desired response.
At the end of the day, the online experience must be smooth and easy to access for the clinician and the client. What I have learned after just providing a few months of telerehabilitation services is that many of my concerns and the challenges we face have relatively simple solutions. They are not insurmountable problems. In fact, overall, telerehabilitation as a service delivery model has some really strong advantages.
One of the most important is that you can see the person in their natural environment and often times with other people who they communicate with regularly. This gives you an insight into problems they are facing in their everyday life and helps clinicians better focus their treatment efforts.
Given that many individuals already access technology regularly during leisure and/or vocational time, the computer interface is an advantage for that purpose alone. The built-in assistive technology, like text-to-speech programs and word prediction functions offer relevant training opportunities, help support performance, and maximize efficiency.
Aside from this, many of the concerns I had going in are easily addressed simply by planning ahead, implementing new processes for onboarding, and using tools that are already built into the devices and apps we use. For example, we take an inventory of the client’s home or workspace to make recommendations on internet speed, lighting, etc.
As I alluded to earlier, sending the right device or equipment prior to starting any treatment is also an easy way to schedule pre-therapy training and initiate therapy sessions seamlessly. If there are additional things we need along the way, we send those too. Mounting devices can be used to change the viewpoint of the camera to allow us to see handwriting or hard-to-see areas in the client’s environment. We also use the screen sharing function within the video conferencing platform to see what the client sees and to share step-by-step directions to help with accessibility.
Convenience and access to expertise. Recently, I was working with an individual who suffered a stroke. Because of his injury and associated speech deficits, he required specialized care; however, he lived in a rural community. Telerehab afforded him the opportunity to have the appropriate therapy in a convenient way.
I also appreciate being part of an interdisciplinary team, which is not always the case with other outpatient programs. When working with individuals with complex neurological injuries, having input and access to other therapy disciplines is a big differentiator when comparing different providers. Being able to call upon psychology, occupational therapy, and/or physical therapy to compliment what I’m doing from a cognitive or speech perspective allows us to take a more holistic approach to care and address functional mobility, daily routines, sleep, and other important aspects of someone’s life in a collaborative way.
After a catastrophic injury, rehabilitation becomes the primary focus. As a result, one of the biggest issues we see is that our clients become so focused on formal therapy that it threatens to consume their entire life. This is especially the case with individuals who are highly motivated and driven. We end up spending a lot of time helping them envision what life looks like beyond doing therapy every day, and we help them understand that incorporating work, hobbies, and social opportunities helps to avoid burnout. It’s not surprising that we also see improved performance once we start layering meaningful activities together to promote a more balanced approach.
No doubt, skepticism remains about whether telerehab is going to survive long-term. Personally, I think it is here to stay, and it would be a shame to fall back into the routine of depending only on in-person therapy.
For one, we’ve found that many people prefer online therapy. Second, it offers an opportunity to work with a person in their natural environment. We don’t have to stick them in an office sitting across the table from a clinician, which is highly controlled and not typical of naturally occurring communicative interactions.
Telerehab offers an up-close and personal look at the person’s exact environment – barking dogs, loud lawnmowers, and all. This is a huge advantage because it shows exactly what the person encounters in the real world.
I also see opportunities for virtual group activities for this population. For example, I’ve got a series of research projects that I’ve been doing over the last couple of years with some colleagues where we’re hosting a virtual book club for people with aphasia. These are people from across the country who now have access to a community of individuals with similar interests and experiences without geographical limitations.
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