Aphasiology

ISSN: 0268-7038 (Print) 1464-5041 (Online) Journal homepage: https://www.tandfonline.com/loi/paph20

Computer-based treatment of poststroke

language disorders: a non-inferiority study of
telerehabilitation compared to in-person service
delivery

Jed A. Meltzer, Allison J. Baird, Richard D. Steele & Stephanie J. Harvey

To cite this article: Jed A. Meltzer, Allison J. Baird, Richard D. Steele & Stephanie J. Harvey
(2018) Computer-based treatment of poststroke language disorders: a non-inferiority study of
telerehabilitation compared to in-person service delivery, Aphasiology, 32:3, 290-311, DOI:
10.1080/02687038.2017.1355440

To link to this article: https://doi.org/10.1080/02687038.2017.1355440

Published online: 20 Jul 2017.

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APHASIOLOGY, 2018
VOL. 32, NO. 3, 290–311
https://doi.org/10.1080/02687038.2017.1355440

Computer-based treatment of poststroke language

disorders: a non-inferiority study of telerehabilitation
compared to in-person service delivery
Jed A. Meltzera,b,c,d, Allison J. Bairde, Richard D. Steelef and Stephanie J. Harveye
a
Baycrest Health Sciences, Rotman Research Institute, Toronto, Canada; bPsychology, University of Toronto,
Toronto, Canada; cSpeech-Language Pathology, University of Toronto, Toronto, Canada; dCanadian
Partnership for Stroke Recovery, Ottawa, Canada; eSpeechworks, Inc., Winnipeg, Canada; fLingraphica, Inc.,
Princeton, NJ, USA

ABSTRACT ARTICLE HISTORY

Background: Telerehabilitation promises to greatly expand access Received 13 January 2017
of underserved populations to speech therapy, but concerns Accepted 5 July 2017
remain about the effectiveness of services delivered remotely KEYWORDS
compared to in-person treatment. Language; telerehabilitation;
Aims: To evaluate the effectiveness of telerehabilitation, we con- aphasia; tablet; cognitive-
ducted a randomized non-inferiority trial for chronic poststroke linguistic communication
communication disorders, testing whether equivalent gains can be disorder
expected from in-person vs. telerehabilitative clinical service deliv-
ery, with both groups completing homework exercises outside of
therapist contact time.
Methods & Procedures: We treated 44 participants with aphasia
or cognitive-linguistic communication disorder (CLCD). Treatment
comprised tablet-based homework exercises and realistic, custo-
mized treatment plans tailored to the needs of each individual
client. Clients had weekly 1-h sessions with the therapist over
10 weeks, with the interaction randomized to in-person and tele-
rehabilitation conditions. Objective gains were assessed with the
Western Aphasia Battery aphasia quotient (WAB-AQ) (for aphasia)
and Cognitive-Linguistic Quick Test (CLQT) (for CLCD) and subjec-
tive gains with the Communication Confidence Rating Scale for
Aphasia (CCRSA) (self-rating) and Communication Effectiveness
Index (CETI) (partner rating).
Outcomes & Results: Participants improved significantly on all of
these measures, with statistically equivalent gains between in-
person and telerehabilitation groups for WAB-AQ, CLQT, and
CETI. Only the CCRSA showed an advantage for the in-person
group. Gains on WAB-AQ were correlated with total time spent
on offline exercises.
Conclusions: Clinician-guided computer-based treatment is effec-
tive for producing widespread gains in language and communica-
tion skills in chronic stroke. Linguistic gains are equivalent whether
clinician services are provided via telerehabilitation equipment or
in person. Communicative confidence may still benefit from in-
person treatment, reinforcing the need for social engagement in
addition to deficit-focused linguistic treatment.

CONTACT Jed A. Meltzer jmeltzer@research.baycrest.org Baycrest Health Sciences, Rotman Research Institute,
Toronto, ON, Canada
© 2017 Informa UK Limited, trading as Taylor & Francis Group
 APHASIOLOGY 291

Introduction
Acquired communication disorders such as poststroke aphasia can be partially amelio-
rated through therapy provided by trained speech-language pathologists (SLPs).
Unfortunately, access to treatment by SLPs is severely limited by economic and geo-
graphic factors. Persons with aphasia (PWA) are often provided with therapy only in the
first few months post-onset, despite evidence that therapy can benefit them for years
(Brady, Kelly, Godwin, Enderby, & Campbell, 2016), and rural clients may have no access
at all. It is therefore critical to find ways to maximize the impact of SLP work hours using
modern technology.
Two technological approaches have recently shown promise in expanding the avail-
ability of speech therapy. First, computer-based exercises for language stimulation have
become commercially available. Such tools allow clients to complete extensive drills on
their own, allowing therapists to focus on higher-level activities such as evaluating
progress and assigning new exercises according to needs. This is sometimes referred
to as “asynchronous” telerehabilitation (TR), as the therapist is not interacting with the
client in real time. With asynchronous TR, a client can complete many more hours of
practice than would otherwise be possible, thus increasing the intensity of their treat-
ment. The idea that higher treatment intensity leads to better outcomes is one of the
least controversial tenets of intervention in aphasia (Barthel, Meinzer, Djundja, &
Rockstroh, 2008; Kempler & Goral, 2011). Thus, asynchronous TR technology has
achieved widespread acceptance, especially when monitored and supervised by a
professional SLP.
Second, two-way video communication is increasingly available, allowing a client
to consult a therapist without traveling, an approach known as “synchronous” TR.
Many speech pathologists now provide routine services via synchronous TR. However,
the effectiveness of remote clinical service delivery for poststroke communication
disorders remains uncertain, as there is currently little empirical evidence comparing
outcomes between TR and in-person (IP) speech-language therapy (Hall, Boisvert, &
Steele, 2013). Some potential users are concerned that TR may be a “second-rate”
treatment, slowing its adoption. Scientific evidence for TR effectiveness is therefore
greatly needed.
Asynchronous TR in aphasia already has a fairly solid evidence base (Palmer, 2015).
Reviewing trials of computer-based therapy programs, Zheng, Lynch, and Taylor (2016)
found that five out of six studies demonstrated efficacy compared to no treatment
(Cherney, 2010; Katz & Wertz, 1992; 1997; Palmer et al., 2012; Thompson, Choy, Holland,
& Cole, 2010; c.f. Doesborgh et al., 2004), and two studies that compared IP and TR in
separate groups found gains for both and no significant differences (Cherney, 2010;
Thompson et al., 2010). While these findings support the use of electronic homework,
they do not negate the necessity of a treating therapist. Zheng et al. (2016) found that
compliance with homework regimens strongly affected the success of treatment and
that ongoing clinical supervision is essential. Furthermore, these studies all tested very
specific treatments for narrowly defined deficits, whereas real-world SLP practice
requires a clinician to tailor a treatment program to the client’s needs.
The question remains of whether this essential clinical support can be effectively
provided remotely. For the many participants without easy access to an SLP in person,
292 J. A. MELTZER ET AL.

synchronous TR promises to make speech therapy accessible and affordable, as long as

its effectiveness can be supported by evidence.
Although several studies have established the effectiveness of TR for remote assess-
ment of poststroke aphasia (Duffy, Werven, & Aronson, 1997; Hill, Theodoros, Russell,
Ward, & Wootton, 2009; Theodoros, Hill, Russell, Ward, & Wootton, 2008), evidence in
intervention is more limited. Most studies (reviewed in Hall et al., 2013) have been single
case studies (Lasker, Stierwalt, Spence, & Cavin-Root, 2010; McGrath, Dowds, & Goldstein,
2008), case series (Getz, Snider, Brennan, & Friedman, 2015; Goldberg, Haley, & Jacks,
2012), and group outcome studies (Steele, Baird, McCall, & Haynes, 2014), all lacking
control groups. Recent studies have employed a crossover design within small groups to
compare treatment effectiveness of TR and IP delivery of a specific interventional
exercise. Three studies found similar gains across IP and TR portions of crossover trials
treating picture naming (Agostini et al., 2014; Fridler et al., 2012; Woolf et al., 2016).
Within this background, there is still a need for a randomized non-inferiority trial to
test whether TR and IP treatments can result in equivalent gains in separate matched
groups of participants, especially when applied to a broader range of impairments. To
demonstrate non-inferiority, a large enough sample is needed to estimate confidence
intervals (CIs) and show that they are within a predetermined margin of each other
(Schumi & Wittes, 2011). Here we present such a randomized trial with 44 total partici-
pants. The study’s goal was to isolate the factor of IP contact with the supervising
clinician. Participants were randomized to weekly therapy sessions conducted either in
person or remotely, but the therapy provided to both groups relied heavily on asyn-
chronous TR in the form of tablet-based language exercises.
The approach is based on three principles derived from recent research and clinical
practice concerning the factors that maximize the effectiveness of a limited amount of
therapy. The first principle is intensity. Intensive therapy (>5 h per week) has been
shown to be more effective than slower programs with the same total number of hours
(Barthel et al., 2008; Cherney, Patterson, Raymer, Frymark, & Schooling, 2008; Kempler &
Goral, 2011; Pulvermüller et al., 2001). The heterogeneity of outcomes for aphasia
treatment may be attributable largely to differences in intensity (Bhogal, Teasell, &
Speechley, 2003), although patients are also more likely to withdraw from highly
intensive treatment programs (Brady, Kelly, Godwin, & Enderby, 2012; Brady, Kelly,
Godwin, Enderby, & Campbell, 2016). Our approach emphasizes asynchronous TR, i.e.
homework. Although individuals vary in their motivation, at-home exercises allow clients
to receive many more hours of treatment than could ever be realistically delivered in
person (Aftonomos, Steele, & Wertz, 1997; Des Roches, Balachandran, Ascenso, Tripodis,
& Kiran, 2014). The role of the SLP in asynchronous TR is to assess the client’s needs,
assign exercises, track progress, and maintain goal orientation.
The second principle is social engagement. Aphasia’s devastating impact on social life
can create a vicious circle, as increasing isolation results in a lack of language stimulation
(Davidson, Howe, Worrall, Hickson, & Togher, 2008; Parr, 2007). Several aphasia support
programs now emphasize social interaction (Kagan, Black, Duchan, Simmons-Mackie, &
Square, 2001; Simmons-Mackie, 1998) and have developed formal principles to train
friends and caregivers to communicate more effectively with PWA. Such training can
increase the quality of life for the PWA even without overt linguistic improvements, but
the increased communication effectiveness may also increase motivation for social
 APHASIOLOGY 293

interaction and drive objective gains. Therefore, training of a communication partner

was an important component of the present treatment program.
The third principle is customization. PWA differ in their linguistic impairments as well
as their goals for recovery. For some, reading is their highest priority, whereas for others,
listening or speaking may be more important. Treatment programs must accommodate
such client-oriented priorities (Aftonomos, Appelbaum, & Steele, 1999; Des Roches et al.,
2014; Steele, Aftonomos, & Koul, 2010). In contrast to previous studies investigating a
very specific treatment exercise delivered remotely, our goal in the present study was to
directly compare outcomes in IP and TR treatment that is customized for individual
needs, exactly as an SLP would normally provide. Although this may introduce
unwanted variability, we aimed to include a large enough sample to nonetheless
provide a direct statistical comparison of IP and TR practices as they would realistically
be used to serve a diverse client base.
The present study involved a realistic therapy program similar to that used by the
authors in private practice. The study consisted of an IP assessment before and after a
10-week treatment, with a heavy emphasis on homework exercises completed on a
tablet, with weekly therapist contact conducted either IP or TR. Communication partners
also received training and participated in the weekly contact sessions. To more fully test
the general applicability of the approach, the study was not limited to aphasia, but also
included clients with cognitive-linguistic communication disorder (CLCD). CLCD, a fre-
quent consequence of right-hemisphere stroke (but also other etiologies), can take a
major toll on social integration following stroke but is somewhat understudied and
underserved compared to aphasia (Tompkins, 2016). We therefore included clients with
CLCD in our study in both TR and IP arms, but we randomized and assessed them
separately from clients with aphasia due to their different symptom presentations.
We hypothesized that clients would show objective and subjective improvements in
language use no matter which modality of therapist contact was used. Furthermore, for
clients with aphasia (the larger clinical group), we used a non-inferiority trial design to
explicitly test the hypothesis that TR results in therapeutic gains that are within an
acceptable margin of those to be expected from IP treatment.

Methods
Participants
Inclusion criteria for the study were: (1) a history of unilateral stroke resulting in a
communication disorder, occurring at least six months in the past, (2) availability of a
communication partner to participate in the treatment program, (3) ability to travel to the
treatment site if not at home, and (4) ability to hear instructions and operate an iPad tablet
to perform homework exercises. Exclusion criteria included a history of dementing illness
or other neurological disorder. Participants were recruited by advertisements and word of
mouth. The study was approved by the Research Ethics Board of Baycrest Hospital.
Participants were classified according to three categories of etiology (left hemisphere
[LH] stroke, right hemisphere [RH] stroke, and other) and three categories of diagnosis
(aphasia, CLCD, and dysarthria). Classification was done according to self-report, medical
294 J. A. MELTZER ET AL.

records (when available), and the clinical impression of the evaluating SLP. Participants
within each diagnosis category were randomized to either IP or TR.
A total of 53 participants were recruited. Five dropped out in the early stages due to
medical or logistical issues. Of the remaining 48 participants, the largest clinical group,
with 33 participants, was people with aphasia, all but one of whom had the etiology of
LH stroke. Sixteen were assigned to IP treatment and 15 to TR. Eleven participants were
diagnosed with CLCD, resulting from a mix of etiologies, including RH stroke. Six were
assigned to IP treatment and 5 to TR. Four participants (2 LH stroke, 1 RH stroke, and 1
brainstem stroke) exhibited only dysarthria. Although they were treated in this study,
they were not included in the analyses due to insufficient power, leaving 44 total
participants analyzed. Demographic information is given in Table 1. The primary goal
of the study is a non-inferiority comparison between IP and TR treatment for objective
language impairments in PWA, as quantified by the Western Aphasia Battery aphasia
quotient (WAB-AQ). Secondary outcome measures included subjective assessments in
aphasia, and both objective and subjective assessments in the smaller CLCD group.

Treatment procedures
The study took place over 12 weeks for each participant, with an IP assessment in the
first and last weeks and therapy during the intervening 10 weeks. Each appointment was
generally conducted on the same day of the week at the same time, with a few
reschedulings by a day or two.
Participants had an initial 2-h IP meeting with the therapy team, which included
collection of medical history, informed consent, initial assessments, goal identification,
instruction on using the TalkPath software, and random assignment of the participant to
either IP or TR treatment. The study was limited to participants living within reasonable
driving distance of the IP treatment site in Winnipeg, MB, Canada, so that participants
could be randomly assigned to IP or TR treatments without bias.
For participants assigned to the TR group, remote therapy sessions were conducted
via teleconferencing equipment and software. Participants possessing adequate equip-
ment at home consulted the therapist using WebEx, a commercial teleconferencing
program, except for one participant who preferred to use VSee as they were already
familiar with it. Others visited a local site of MBTelehealth, a province-wide network for
the provision of health-care services through videoconferencing technology. A few

Table 1. Demographic characteristics of participants, with mean ± standard deviation for quantita-
tive measures.
Group N Age Sex Etiology WAB Pre WAB Post
Aphasia in person 16 62.9 ± 11.6 5 F, 11 M 15 LH stroke, 1 othera (n = 15) 64.1 ± 23.5
57.5 ± 23.6
Aphasia telerehab 17 66.8 ± 11.2 7 F, 10 M 17 LH stroke (n = 15) 57.7 ± 24.9
50.0 ± 24.4
Cog-Ling in person 6 63.2 ± 8.4 3 F, 3 M 3 LH stroke, 2 RH stroke, 1 otherb - -
Cog-Ling telerehab 5 60.8 ± 10.4 2 F, 3 M 3 RH stroke, 2 otherc - -
a
One client with LH stroke plus brainstem stroke.
b
One client with multiple strokes.
c
Two clients with brainstem strokes.
 APHASIOLOGY 295

participants came to the therapy site itself for TR treatment. For those participants, IP
contact with the treating therapist was strictly prevented during the visits, and they
interacted only with the receptionist to get setup for treatment in a separate room from
the therapist, using WebEx. This experience was essentially identical to visiting an
MBTelehealth site. Although this variability was not ideal, it was not feasible to require
home access to the necessary equipment for our study population. The randomized
design demanded that some participants be assigned to the TR group regardless of
what technological resources they had at home, as using that information to influence
group assignment could have introduced a systematic confound in the results. All
participants reported satisfactory audio–video quality for the treatment, regardless of
method. During the IP assessment, clients were loaned an iPad for the duration of the
study, pre-loaded with the required software. For clients using the TalkPath software
(see later), accounts were set up so that the software could be used on either the iPad or
a computer via the website, allowing progress to be synched between devices and
monitored by the therapy team.
In weeks 2–11, the treating therapist conducted a 1-h weekly treatment session, using
either the IP or TR modality. In three sessions (week 3, 6, and 9), 30 min of the session was
devoted exclusively to the communication partner, giving training on Supported
Conversation techniques and helping the partner keep the client on track with the treatment
program. In the other sessions, the degree of participation of the communication partner
varied according to individual preferences. In some cases, a brief telephone call was con-
ducted between therapy sessions to provide support and monitor progress, particularly when
there were concerns about homework compliance. For homework exercises, the majority of
the clients used the commercial software program TalkPath (Lingraphica Inc., Princeton, NJ,
USA; Steele et al., 2014), which comprises graded exercises in Speaking, Listening, Reading,
Writing, and paralinguistic cognitive skills including memory. The TalkPath software has been
continuously developed for over 25 years and emphasizes ease of use in the aphasic popula-
tion. All participants using the software were trained in its use during their initial meeting, and
none reported difficulty using it. This software was supplemented by other exercises as
needed, particularly for participants with less severe deficits. Other homework items included
modified script training (Cherney & Halper, 2008), sentence patterning, writing exercises (e.g.
responding to videos and readings), and preparing for specific activities including public
speaking events. Treatment sessions frequently included a structured conversational exercise
referred to as “type talking”, in which the therapist conducts a naturalistic conversation with
the client, most typically about the client’s activities during the previous week. The therapist
provides oral and written feedback on the client’s answers to shape them into more complete
and organized sentences. The therapist also presents typed support for their own commu-
nication, including key words for each sentence in written form. In week 12, participants
received their final assessments in person, along with recommendations for follow-up activ-
ities to maintain their improvements.

Assessments
Initial and final assessments were carried out in person by an experienced SLP practi-
tioner not involved in the treatment administration. For aphasia, the main objective
outcome measure was the Western Aphasia Battery-Revised, Part 1 (WAB-R; Kertesz,
296 J. A. MELTZER ET AL.

2007). The WAB-R is a widely used standardized assessment of aphasia severity covering
several domains of impairment, including spontaneous speech, auditory verbal compre-
hension, repetition, and naming, which are combined to form an overall “aphasia
quotient” (AQ). It has been extensively characterized psychometrically and is the main
outcome measure of choice in many studies of aphasia treatment in English-speaking
countries.
For participants with CLCD, the primary outcome measure was the Cognitive-
Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001). The CLQT provides a broad sam-
pling of cognitive abilities commonly affected in neurological disorders (Parashos,
Johnson, Erickson-Davis, & Wielinski, 2009). It consists of 10 subtasks administered
over 15–30 min, which are combined in weighted averages to yield scores in five distinct
cognitive domains: attention, memory, language, executive function, and visuospatial
skills. As impairments in all of these domains have been observed in RH stroke, and are
thought to contribute to communication deficits (Blake, Duffy, Myers, & Tompkins, 2002),
the CLQT may be a sensitive indicator of the effectiveness of interventions intended to
improve cognition in this population.
We also probed the subjective opinions of the participants and their communication
partners regarding their communication abilities. To assess subjective communication
confidence in the participants themselves, we administered the Communication
Confidence Rating Scale for Aphasia (CCRSA), a 10-item questionnaire that elicits con-
fidence ratings from 0 to 100 on a visual analog scale, about participant’s abilities to
carry out everyday activities such as talking on the telephone and following movies.
Evaluative studies of the CCRSA demonstrated high reliability and sensitivity to change
in response to computer-based treatment (Babbitt, Heinemann, Semik, & Cherney, 2011;
Cherney, Babbitt, Semik, & Heinemann, 2011).
To evaluate the functional competence of participants from a subjective but
external perspective, we used the Communication Effectiveness Index (CETI; Lomas
et al., 1989), a 16-item questionnaire asking the communication partner to evaluate a
stroke patient’s communicative abilities in a variety of situations on an unlabeled
visual analog scale ranging from “not at all” to “as able as before stroke.” To score the
CETI, the marks are measured on a scale of 0–100 with a ruler over the 100 mm
analog scale, and the total score is derived out of 100 by averaging across the 16
questions. Although the content of the situations addressed in the CCRSA and CETI
are largely similar, the CCRSA was specifically designed and normed for self-rating,
while the CETI was developed for a partner to provide the rating. The CETI also shows
good reliability and sensitivity to change, as a norming study showed essentially no
change in either WAB or CETI among chronic stroke survivors with stable symptoms
of aphasia, whereas a group of subacute patients undergoing intensive therapy
exhibited correlated gains on both measures (7.2/100 on WAB, 11/100 on CETI;
Lomas et al., 1989).
The WAB-R (Part 1), CLQT, CCRSA, and CETI constituted the formal outcome measures
for the present study. Some additional assessments were conducted on an individual
basis as needed, as part of the routine clinical practice of tailoring treatment to an
individual’s needs. These tests included: The WAB-R Part 2 (covering written language
and extralinguistic abilities), Boston Naming Test (BNT; Kaplan, Goodglass, Weintraub,
Segal, & van Loon-Vervoorn, 2001), the Apraxia Battery for Adults (Dabul, 2001), Reading
 APHASIOLOGY 297

Comprehension Battery for Aphasia (LaPointe & Horner, 1998), and the Frenchay
Dysarthria Assessment (Enderby & Palmer, 2008).

Comparisons and non-inferiority testing

We focused on two questions: (1) Is the overall treatment approach effective at reducing
poststroke linguistic impairments and improving communicative effectiveness? and (2) Is
TR-based treatment equally effective as IP treatment for this approach? The statistical
approach to question 1 is straightforward: we compared scores before and after treat-
ment in the same individuals using a paired t-test. Question 2 is slightly more compli-
cated, as we are seeking to demonstrate the equivalence of two treatments rather than
their differences. Simply showing a lack of a statistically significant difference between
them is not enough, as the study could have been underpowered to reveal differences.
Instead, the data must be analyzed from the framework of a non-inferiority study
(Schumi & Wittes, 2011). In this framework, one first specifies a margin, Δ, describing
the maximum acceptable loss of effect for an alternative treatment relative to an
established one. One then calculates a CI for the difference in effect size between the
two treatments (90% CI is conventional for non-inferiority testing). For example, if one
established treatment is known to elicit an average gain of 10 points on a standardized
test, but a clinician would be satisfied with a gain of 7 because of other compensating
advantages for an alternative treatment, then Δ could be set at 3. If Δ falls outside the
calculated CI for the difference between effect sizes, then the alternative treatment can
be declared non-inferior within the specified margin. The choice of margin is subjective,
but it is typically set to half the effect size of the established treatment or less.
Given that only the aphasia group had a large sample size, we only attempted a
formal non-inferiority comparison within that group, on the WAB-R AQ score. Because
our overall treatment approach had not previously been the subject of a large trial, we
looked at other studies that tested behavioral treatments in chronic aphasia with the
WAB as the outcome measure. A small sample of studies employing various treatment
approaches suggested that gains in the range of 4–7 points are typical (Cherney et al.,
2008; Elman & Bernstein-Ellis, 1999; Katz & Wertz, 1997; Maher et al., 2006; Shewan &
Kertesz, 1984), with the upper end of 7–12 being seen in studies of very intensive
residential programs (Babbitt, Worrall, & Cherney, 2015; Persad, Wozniak, &
Kostopoulos, 2013). Therefore, we chose a margin of 3 points for the non-inferiority
test, aiming to show that the average gains associated with TR are within 3 points of
those associated with IP treatment.
For comparisons on other tests, and within the smaller CLCD group, we tested for
differences in treatment gains between the TR and IP conditions using a two-sample
t-test on the individual differences in scores, posttreatment minus pretreatment. We
comment on significant differences where found, but lack of significant differences does
not formally establish non-inferiority, as we did not have a prespecified margin for these
tests. Note that we did not use a full factorial ANOVA (e.g. Group × Time) to analyze the
data, as treatment group was randomly assigned, and group differences prior to treat-
ment were not of experimental interest. The use of parametric tests was necessary for
computing CIs for non-inferiority testing. Because the small sample size in the CLCD
group raised concerns about the validity of parametric tests, we also computed the
298 J. A. MELTZER ET AL.

equivalent nonparametric tests (Wilcoxon signed-rank instead of paired t-test, Mann–

Whitney U test instead of two-sample t-test) for all comparisons shown in this paper. In
all cases but one, which will be indicated, the results were nearly identical between the
two approaches, in terms of which tests showed a significant difference and which
did not.

Results
Aphasia group
Among participants with aphasia, the IP group and TR group did not differ significantly
in age, t(30.7) = .96, p = .344, nor did they differ in pretreatment aphasia severity as
assessed by the WAB-AQ, t(28.0) = −.85, p = .40, although the IP group had an average
score that was slightly higher than the TR group, 57.5 vs. 50.0.
Participants with poststroke aphasia exhibited large improvements on both objective
and subjective measures. A total of 30 participants completed the WAB before and after
treatment. Among these participants pooled together, there was a significant increase in
WAB-AQ score after treatment (Figure 1(a)), t(29) = 7.82, p < 10–7, corresponding to a
very high effect size, η2 = .68. The mean gain was 7.13 points out of 100 (SD = 5.00),
above the 5-point criterion conventionally considered to mark “clinically significant
improvement” (Elman & Bernstein-Ellis, 1999; Katz & Wertz, 1997). Out of the 30 parti-
cipants, 18 individuals achieved gains over the 5-point mark, and only 1 participant
failed to show any improvement.
There was no significant difference in the degree of improvement seen in the TR
group (n = 15, mean gain = 7.68, SD = 5.96) and the IP group (n = 15, mean gain = 6.58,
SD = 3.94), t(24.25) = .60, p = .55, η2 = .01. Results of the formal non-inferiority
comparison are shown in Figure 1(b). The average difference for TR gain minus IP gain
was 1.1 points in favor of TR, with a 90% CI of [−2.05, +4.26]. The chosen −Δ level of −3
points falls outside of this CI. This means that we can conclude with reasonable
confidence that TR is non-inferior to IP treatment, in that it can be expected to produce
gains that are no smaller than 3 points below that expected from IP treatment. In the
present study, the gains achieved under TR were actually numerically higher than those
achieved by the IP group, but because the CI for the difference crosses zero, we cannot
conclude that TR is superior. They are statistically indistinguishable by the chosen
margin Δ = 3.
Besides an overall AQ score, the WAB generates specific subscores in four domains:
(1) spontaneous speech, (2) auditory–verbal comprehension, (3) repetition, and (4)
naming and word finding. To examine whether the current treatment approach was
more effective at improving some aspects of language abilities more than others, we
scaled each subscore as a percentage of the maximum possible, rendering each one into
a comparable percentage scale, and then conducted repeated-measures ANOVA with
language domain as a within-subjects factor. There was no significant effect, F
(3,112) = .443, p = .72, suggesting that the treatment was equally effective at improving
all four domains of language. Gains on each individual subscore were significant as
assessed with a paired t-test, except for repetition, which showed a nonsignificant trend
towards improvement (spontaneous speech: t(29) = 5.11, p < 10–4; auditory–verbal
 APHASIOLOGY 299

Figure 1. a, c, d: Scores pre- (black) and post- (gray) treatment for participants with aphasia, on the
WAB, CCRSA, and CETI tests. Error bars represent one-sided 95% confidence intervals adjusted for
repeated measures using the method of Morey (2008). For all bar graphs, the y-axis represents
points on the test. b: The average difference in WAB-AQ gains for telerehabilitation minus in-person
treatment, with the 90% confidence interval. Vertical lines indicate 0 (no difference) and the pre-
chosen margin for non-inferiority testing, -Δ = −3.

Table 2. Mean ± standard deviation for the four subscores of the Western Aphasia Battery, for the
two treatment groups (IP: in person; TR: telerehabilitation) and time points (pre- and posttreatment).
Max
WAB subscore score IP pre IP post TR pre TR post
Spontaneous speech 20 11.0 ± 4.4 12.6 ± 4.4 9.8 ± 6.2 11.6 ± 6.2
Auditory–verbal 200 143 ± 52 153 ± 53 126 ± 54 138 ± 47
comprehension
Repetition 100 46 ± 29 51 ± 30 47 ± 29 58 ± 30
Naming and word finding 100 59 ± 32 66 ± 31 42 ± 29 51 ± 28

comprehension: t(29) = 3.57, p < .002; repetition: t(29) = 1.77, p = .087; naming and word
finding: t(29) = 4.94, p < 10–4). The mean and standard deviation of each of these four
subscores are shown in Table 2, for the two treatment groups (IP and TR) and time
points (pre- and posttreatment).
300 J. A. MELTZER ET AL.

Besides the overall measure of severity reflected by the AQ, the WAB provides a diagnostic
category for each participant based on their pattern of subscores, and this category some-
times changes following treatment. In the IP group, there were six participants diagnosed
before treatment with Broca’s aphasia (one changed to conduction aphasia), one with
conduction changed to anomic aphasia, three with anomic aphasia (one changed to
Wernicke’s), two with global aphasia (one changed to Broca’s), two with Wernicke’s aphasia
(one changed to Broca’s), and one with mixed transcortical aphasia that changed to Broca’s. In
the TR group, there were four participants with Broca’s aphasia (two changed to conduction),
six with conduction aphasia (one changed to Broca’s), two with global aphasia (one changed
to Broca’s), and three with anomic aphasia (one changed to conduction). Given this hetero-
geneity, it is not possible to make strong conclusions about whether some types of aphasia
are better suited to the TR approaches used in this study. The fact that participants on average
improved in all four domains of the WAB suggests that the treatment is generally applicable
with the caveat that the participants varied in the type and severity of their aphasia, and the
types of exercises assigned to each participant depended on their impairment.
Subjective improvements were evaluated by having participants rate their own
degree of communication confidence with the CCRSA and by having the communica-
tion partners rate the communication effectiveness of the participant with the CETI.
Twenty-eight participants completed this test at both time points. The two groups did
not differ in pretest scores (TR: 26.46, IP: 25.43), t(26.0) = .46, p = .65. In the group overall,
highly significant improvements averaging 3.48 points out of 40 (SD = 3.12; Figure 1(c))
were seen for the CCRSA, t(27) = 5.91, p < 10–5, η2 = .56. On this self-rating measure,
however, the gains were significantly higher for the IP group than for the TR group (TR:
n = 14, mean gain = 2.18, SD = 1.64; IP: n = 14, mean gain = 4.79, SD = 3.72), t
(17.8) = −2.40, p = .028, η2 = .18. Thus, although participants in both groups improved
equally on the WAB-AQ, an objective measure of aphasia severity, participants receiving
IP treatment experienced larger gains in their self-rated confidence.
For the partner-rated CETI, ratings were obtained from 27 participants before and
after treatment (Figure 1(d)). The two groups did not differ in pretest scores (TR: 47.24,
IP: 50.34), t(23.7) = −.44, p = .66. Across the whole group, there was a highly significant
gain averaging 11.6 points out of 100 (SD = 7.74), t(26) = 7.77, p < 10–7, η2 = .70. The
gains achieved by the TR group (n = 13, mean gain = 11.2, SD = 6.70) and the IP group
(n = 14, mean gain = 11.9, SD = 8.84) did not differ significantly, t(24.1) = −.22, p = .83,
η2 = .00. Thus, the subjective degree of improvement as judged by the communication
partner was virtually identical in both conditions.

CLCD group
Participants with CLCD were evaluated before and after treatment with the CLQT,
scoring performance on five separate cognitive domains. Because the treatment pro-
gram focused on verbal communication, we hypothesized that participants would
improve on the language domain in the CLQT, but we also report the changes from
the other domains. Participants were also evaluated on subjective improvements using
the CCRSA and CETI. Because the sample size for the CLCD group was much lower than
for the aphasia group, the two randomized groups were not always perfectly matched
on pretest scores of all outcome variables, with the TR group appearing somewhat less
 APHASIOLOGY 301

impaired on several measures, and there was insufficient statistical power to conduct
formal non-inferiority testing. Nonetheless, the results in the CLCD group strongly
resemble those obtained in aphasia, and we present them as a preliminary exploratory
study into the effectiveness of TR in CLCD.
In the language domain (Figure 2(a)), the 11 participants diagnosed with CLCD
exhibited highly significant gains averaging 3.55 points out of 37 (SD = 3.42), t
(10) = 3.44, p = .006, η2 = .54. There was no significant difference in the gains exhibited
by participants in the TR group (n = 5, mean gain = 3.00, SD = 2.12) and the IP group
(n = 6, mean gain = 4.00, SD = 4.38), t(7.47) = −.49, p = .64, η2 = .03. The participants in

Figure 2. Scores pre- (black) and post- (gray) treatment for participants with cognitive-linguistic
communication disorder, on the five domains of the Cognitive Linguistic Quick Test (CLQT):
Attention, Executive, Memory, Visuospatial, and on the CCRSA and CETI. Error bars represent one-
sided 95% confidence intervals adjusted for repeated measures using the method of Morey (2008).
For all bar graphs, the y-axis represents points on the test.
302 J. A. MELTZER ET AL.

the two treatment groups did not differ in pretest scores for language (TR: 30.2, IP: 26.7),
t(5.92) = 1.07, p = .33.
In the memory domain (Figure 2(b)), there was also a significant overall gain aver-
aging 18.3 points out of 185 (SD = 17.65), t(10) = 3.43, p = .006, η2 = .54 and no
significant difference between treatment groups (TR: mean gain = 17.0, SD = 11.04; IP:
mean gain = 19.3, SD = 22.86), t(7.46) = −.221, p = .83, η2 = .00. The participants in the
two treatment groups did not differ in pretest scores for memory (TR: 148, IP: 127), t
(5.94) = 1.10, p = .31.
Statistically marginal gains were observed for the executive function (Figure 2(c)) and
attention (Figure 2(d)) domains, although there were small pretest differences in the two
groups for these scores. For executive function, the mean gain was 1.82 points out of 40
(SD = 2.79), t(10) = 2.16, p = .056, η2 = .31, with no difference between treatment groups
(TR: mean gain = 1.40, SD = 3.85; IP: mean gain = 2.90, SD = 1.83), t(5.5) = −.41, p = .70,
η2 = .02. The TR group had higher pretest scores for executive function (TR: 27.6, IP:
18.8), t(7.2) = 2.50, p = .04.
For attention, the mean gain was 15 points out of 215 (SD = 35.47), t(10) = 1.95,
p = .079, η2 = .27, with no significant difference between treatment groups but
numerically greater gains for the IP group (TR: mean gain = 2.40, SD = 17.40; IP: mean
gain = 25.50, SD = 27.65), t(8.49) = −1.69, p = .13, η2 = .24. The TR group had higher
pretest scores for attention (TR: 191, IP: 116), t(5.14) = 2.97, p = .03.
In the visuospatial domain (Figure 2(e)), there were numerical gains with treatment,
5.8 points out of 105 on average (SD = 11.67), but the improvement was not significant, t
(10) = 1.65, p = .13, η2 = .21. The TR group had higher pretest scores for visuospatial
cognition (TR: 89.2, IP: 58.2), t(6.4) = 3.40, p = .013.
Like the aphasia group, the CLCD group also exhibited highly significant improve-
ments in subjective communication confidence based on the self-rated CCRSA (Figure 2
(f)), with a mean gain of 5.18 points out of 40 (SD = 2.48), t(10) = 6.93, p < 10–4, η2 = .83.
Also, like the aphasia group, within the CLCD participants, the CCRSA gains were slightly
higher for the IP group than for the TR group (TR: mean gain = 3.60, SD = 1.14; IP: mean
gain = 6.50, SD = 2.59), t(7.1) = −2.47, p = .042, η2 = .40. For this comparison, the
nonparametric Mann–Whitney U test did not quite reach significance, p = .064, making
this effect somewhat borderline. For the CCRSA, the TR group had slightly higher pretest
scores (TR: 33.8, IP: 26.0), t(7.4) = 2.47, p = .04.
Finally, for nine participants for whom partner-rated CETI scores were available before
and after treatment, significant improvements averaging 6.87 points out of 100
(SD = 7.54; Figure 2(g)) were observed, t(8) = 2.73, p = .026, η2 = .48. No significant
differences were seen on CETI improvements between the two treatment groups (TR:
n = 4, mean gain = 6.38, SD = 5.76; IP: n = 5, mean gain = 7.26, SD = 9.40), t(6.7) = −.17,
p = .87, η2 = .00. For the CETI, there were no differences on pretest scores between the
two treatment groups (TR: 47.2, IP: 50.4), t(23.7) = −.44, p = .66.
In summary, the results for the CLCD group patterned identically to those for the
aphasia group. Significant improvements were seen for objective language mea-
sures, subjective communication confidence by self-rating, and subjective commu-
nication effectiveness by partner rating. Of these measures, only scores on the self-
rating scale differed between the TR and IP groups, with stronger gains for IP
treatment.
 APHASIOLOGY 303

Relationship with homework

As the treatment varied across participants according to their needs, it was not possible to
objectively assess the amount of homework performed by all participants. However, out of
the 30 participants with aphasia, 19 were assigned exercises on the iPad using the TalkPath
software and were assessed with the WAB before and after treatment. For these partici-
pants, the TalkPath exercises constituted the majority of their treatment program, and their
use was logged by the software. We used this information to test the hypothesis that more
time spent on homework would translate into larger objective gains on the WAB. Total
logged homework time for these participants ranged from 5.3 to 64.7 h, and gains on the
WAB ranged from 1.1 to 17.8 points. A positive correlation was confirmed, r(17) = .51,
p = .027: more hours of homework were linked to larger objective gains (Figure 3). Among
these 19 participants, there was a slight tendency for IP participants to do more hours of
homework (TR: 21.1 h; IP: 28.9 h), but this difference was not significant, t(16.9) = −1.06,
p = .31. Likewise, among the participants with tracked homework hours, there was no
significant difference in WAB-AQ gains between the two groups (TR: 7.83, IP: 6.87), t
(15.5) = .44, p = .67. The overall correlation of r = .51 indicate that the amount of homework
completed by the participants accounted for 26% (r2) of the variance in gains on the WAB.
To test whether the strength of this relationship differed according to the type of treatment,
we compared the correlation coefficients for the relationship between WAB gains and
homework hours between the TR and IP groups. The strength of the correlation was
numerically higher in the TR group, n = 9, r = .79, p = .01, than in the IP group, in which
the correlation did not reach significance, n = 10, r = .35, p = .32. However, direct statistical
comparison between the two correlation coefficients with Fisher’s Z-test did not reach
significance, p = .21. Thus, the results suggest that homework hours may have had a greater
impact on performance within the TR group, but the study is unlikely to have had sufficient

Figure 3. Scatterplot illustrating the positive correlation between hours of homework completed on
the TalkPath software and objective gains in language performance, as quantified by WAB-AQ in
participants with aphasia. Filled and open circles indicate participants in the telerehabilitation and
in-person conditions, respectively.
304 J. A. MELTZER ET AL.

power to demonstrate such a difference, given the heterogeneity of treatment exercises

assigned to individuals based on their needs. No significant correlations were found
between homework hours and subjective improvements on the CCRSA, r(16) = .31,
p = .21, or CETI, r(18) = .15, p = .53.

Discussion
This study compared TR-based with IP treatment, incorporating a real-world approach of
treatment customized to the needs of individuals. The study successfully demonstrated non-
inferiority of TR, in that participants in both TR and IP conditions achieved objective gains that
were statistically and clinically significant and statistically indistinguishable from each other.
However, one study manipulating a single variable cannot conclusively establish a set of best
practices. In the sections below, we consider the findings and limitations of the present study
in light of existing literature, highlighting the lessons learned from this study for SLPs who
wish to take advantage of the treatment opportunities now made possible by communica-
tions technology.

Practice and placebo effects

Although we found that both the TR and IP versions of our treatment were effective,
neither treatment was directly compared to non-intervention or to an active/attentional
control. Therefore, we must consider whether the observed improvements can be
attributed to a therapeutic effect instead of a practice or placebo effect.
The considerable gains seen on the WAB-AQ are unlikely to be attributable to practice
effects alone. The WAB has been extensively normed (Kertesz, 2007), with test–retest
assessments showing a very high correlation within individuals and minimal gains on
repeated testing. Given the relatively large gains in WAB-AQ observed here (7/100
points), we are confident that they are not simply a practice effect.
Regarding a placebo effect, one might consider that the observed gains could be
attributable to the process of interacting with the therapist and the communication
partner, rather than the linguistic content of the intervention. However the degree of
objective gains in this study (WAB-AQ) was correlated with the amount of homework
completed, and the homework was done by the participant alone without interaction.
Thus, the objective gains are most likely attributable to the content of the therapy,
rather than simply interaction with the therapist.

Objective vs. subjective gains

The present study had as its primary outcome measure an objective test of language
skills for PWA (the WAB-AQ) and a test of more general cognitive abilities for CLCD (the
CLQT). On both measures, clients in both the TR and IP groups exhibited highly
significant improvements, which did not differ significantly between groups. In the
aphasia group, we conducted a formal non-inferiority trial, finding that the TR treatment
was in fact non-inferior to the IP treatment. The TR group actually exhibited slightly
larger gains (though not significantly), and the CI for the population mean difference in
treatment effects was within the chosen margin for non-inferiority.
 APHASIOLOGY 305

Although both TR and IP groups exhibited significant and equivalent gains on objective
language and cognitive skills, within both the aphasia and CLCD clinical groups, they did
differ on improvements in their subjective confidence. For both clinical groups, aphasia and
CLCD, there were significant improvements in general on the CCRSA scale, a self-rating of
communication confidence, but the gains were significantly higher in the IP group.
Interestingly, this subjective advantage for IP treatment did not extend to the ratings
given by the communication partners. Partners assessed clients before and after treatment
using the CETI scale. For this measure, there were significant improvements for all categories
of participants, and these gains did not differ between treatment arms.
These findings suggest that TR and IP treatment are equally effective at eliciting real
gains in language and communication ability, as assessed by objective skill tests and
partner rating, but are not quite equivalent in the degree of subjective communication
confidence improvement for the clients themselves. This is an important consideration,
as communication confidence plays a key role in a client’s motivation to seek out social
engagement opportunities, and therefore, low confidence can lead to continued isola-
tion. Thus, even if language deficits can be successfully mitigated by remote therapy, IP
interaction is still critical to the recovery process, and clients should be encouraged to
cultivate opportunities for social engagement beyond therapy.

Comparison to other treatment methods

The only factor differing between the two treatment arms of this study was whether the
weekly meetings with the treating therapist were conducted in the therapist’s office or
over a video link. The main aspects of the treatment were optimized for at-home use,
with the emphasis on tablet-based exercises. Thus, one cannot claim from this study
alone that TR is fully equivalent to “conventional” SLP treatment.
Nonetheless, the approaches used in the present study are in line with contemporary
trends in aphasia treatment. Granted, the most traditional approach involves one-on-one
interaction, with the therapist administering repetitive drill-like exercises to the client. It has
long been recognized that this is not the best use of a highly trained therapist’s time, given
that demand for such treatment far outweighs supply. Current trends have changed the role
of the SLP to a supervisory one, guiding treatment exercises to match goals and monitoring
progress to keep the treatment on track. First, it has been demonstrated that volunteers with a
small amount of training are equally effective as professional SLPs in the day-to-day admin-
istration of chosen treatment exercises, under the supervision of an SLP (Kelly, Brady, &
Enderby, 2010; Marshall et al., 1989; Wertz et al., 1986). Second, computer-based and tablet-
based applications have been extensively developed and validated for the administration of
routine language drills (Alloni et al., 2015; Lavoie, Routhier, Legare, & Macoir, 2016; Woolf et al.,
2016), freeing the SLP from the time-consuming task of running exercises and allowing them
to focus their time on supervising the treatment plan. Third, the importance of partner
training has increasingly been recognized as improving quality of life for PWA and increasing
social engagement.
Given these trends, our study’s approach reflects the emerging standards of con-
temporary treatment of poststroke communication disorders. The SLP plays a critical role
in evaluating deficits, devising a treatment plan, training the client and communication
partner to follow the plan, and adjusting the treatment plan as needed (including
306 J. A. MELTZER ET AL.

determining when further treatment is inappropriate). The present study addresses the
question of whether this role can be fruitfully fulfilled through telepractice, thus bring-
ing services to a much wider range of clients with limited access to treatment centers
due to medical or geographic factors. Our findings indicate that such SLP services can be
provided effectively, but still point to a critical role for IP social engagement to enhance
subjective communication confidence.
To compare our approach with more traditional forms of therapy, one must refer to the
literature. Judging from other studies that have also used the WAB as the primary outcome
measure, the observed average gain of 7 points is rather high. A “gold standard” for effective
behavioral treatment of chronic aphasia would be an intensive residential program in which
participants receive several hours of focused individual and group therapy every day for
several weeks. Babbitt et al. (2015) report aggregate results from 74 clients involved in such a
program, finding an average increase of 7.3 points on the WAB-R AQ, from 51.3 to 58.6. These
numbers are very similar to our cohort. Persad et al. (2013) reported outcomes from two
intensive residential programs, finding an average gain of 11.4 points on the WAB in one
program, and reporting outcomes from the other program in a binary fashion as “clinically
significant improvement” or not, setting a threshold of 5 points improvement on the WAB-R
AQ and 12 points on the CETI. In that study, 64% of participants met that criterion on the
WAB-R AQ, and 51% met it on the CETI (12 points or more). In our study, the average gain
across all participants with aphasia was well above that threshold for clinical significance on
the WAB (7.13 points) and just below it for the CETI (11.16 points). On an individual basis, 18/
30 clients (60%) gained over 5 points on the WAB-R AQ, and 12/27 (44%) met the criteria of 12
points gained on the CETI. We are not aware of a generally accepted threshold for clinical
significance for the CCRSA, but the original norming study for that test, involving computer-
ized script training (Cherney et al., 2011), reported gains of 9.25% in recovering patients
(rescaled here), whereas our study achieved an average gain of 8.7%. Thus, the gains seen in
the present study compare well to those seen in intensive residential aphasia programs and
other treatment regimens.
The impressive gains seen in intensive residential programs are most likely attributable to
their high intensity, as numerous studies and meta-analyses have demonstrated an advan-
tage for intensive treatment (Kelly et al., 2010; Salter, Teasell, Bhogal, Zettler, & Foley, 2012),
and indeed, we observed in our own data that participants who completed more homework
hours achieved higher objective gains. However, the downside of high-intensity treatment
programs is that the dropout rate is higher, and presumably, the proportion of clients able
to participate in them is lower, especially for residential programs that require considerable
independent financial resources from the clients. Ideally, the intensity offered to any
individual client would be as high as they can handle, but not higher.
TR, both synchronous and asynchronous, offers an ideal solution to the intensity dilemma.
Participating in a treatment program need not be all or nothing, and the level of engagement
can be titrated to an individual client’s needs and ability to tolerate the treatment.

Generalizability and future extension

The present study included clients with both poststroke aphasia and CLCD. The nature
of the cognitive impairments in CLCD, especially following right-hemisphere damage, is
still poorly understood, and treatment options for CLCD are far less advanced and
 APHASIOLOGY 307

standardized than those for aphasia. Nevertheless, clients with CLCD achieved encoura-
ging gains on the CLQT, especially in the language and memory subscales. As in the
aphasia group, the extent of these objective improvements did not differ significantly
between TR and IP treatments, although the group was too small for formal non-
inferiority testing. Subjective improvements in communication confidence also occurred
in CLCD, with significant gains on both the CCRSA and CETI, of very similar magnitude to
those seen in the aphasia group. Again similar to the aphasia group, there was a
significant advantage of IP over TR treatment for self-rated confidence (CCRSA), but in
all other measures, the two treatment arms were statistically indistinguishable.
The small sample size of the CLCD group, along with the pretest differences in some
measures for the TR and IP subgroups, does not permit us to conclude with the same
certainty as for the aphasia group that TR produces equivalent gains as IP treatment
within the context of a homework-intensive program, but all outcomes in the CLCD
group resemble those seen for aphasia, suggesting that this is an effective approach
suitable for a variety of communication disorders.
The fact that we observed very similar outcomes for two clinical groups with very
different symptoms is encouraging for the further development and generalization of
remote treatment for communication disorders. TR is still relatively new and uncommon,
and in particular, regulatory and licensing issues remain to be worked out before it can
become a routine part of professional SLP practice (Cherney & van Vuuren, 2012). The
emergence of larger trials such as the present study and the UK-based Big CACTUS study
(Palmer et al., 2015) should help to increase enthusiasm for fully remote delivery of
treatment, particularly for patients in the later stages of recovery whose access to
treatment has traditionally been very limited due to insurance limitations.
Another factor slowing the adaptation of TR is the limited availability of the appro-
priate technology in clients’ homes, although this situation is gradually improving. Some
of our participants had to travel a short distance to receive the TR treatment, which may
have reduced the quality of their experience compared to those who could participate
from home. This is a limitation of the present study, but the fact that results were largely
equivalent between the IP and the TR groups suggests that the need to travel in some
cases does not negate the benefits of the TR treatment.
Our finding that IP treatment improves subjective communication confidence more
than TR suggests further room for improvement in TR-based therapy. As group activities
have become increasingly important in the treatment of aphasia, we suggest that these
kinds of activities may ultimately become available to a wider range of participants
through the use of videoconferencing technology. Although IP social gatherings are
probably more pleasant than teleconferences, the fact remains that many clients in need
of group therapy and support groups lack access to such services because of geographic
or mobility issues and would therefore benefit from the establishment of electronic
alternatives conducted in real time.
Future TR studies should also characterize factors that account for the variability in
response, such as age, pretreatment severity, type of impairments, years of education,
caregiver support, and cognitive deficits outside the language domain. We observed
that homework time accounted for considerable variance (r2 = .26) in WAB improve-
ment. The causality of this relationship is uncertain: perhaps some participants were
more motivated to practice, and therefore achieved higher gains, but another
308 J. A. MELTZER ET AL.

explanation is that participants experiencing improvements were more inclined to

persevere. The education level of participants, unfortunately not characterized system-
atically in this study, may also influence outcomes. Although no participants reported
any trouble using the software, a history of premorbid academic achievement may
position some PWA to succeed more in treatments requiring self-motivated practice
sessions.

Conclusion
We conducted a randomized non-inferiority trial comparing TR and IP treatment for
poststroke communication disorders. The treatment was highly effective, producing objec-
tive and subjective gains that are comparable with intensive residential programs. Similar
results were obtained for both aphasia and CLCD. These findings suggest that it is not
necessary for an SLP to be in the same room with the client in order to provide effective
supervision of self-paced treatment and that TR offers to bring first-rate treatment options
to currently underserved populations. The one shortcoming of TR observed in this study
was that participants receiving IP treatment achieved greater improvements in self-rated
communication confidence. This finding underscores the need for IP social engagement
during the recovery process, even if the primary means of therapy is delivered remotely.

Acknowledgments
We thank Mara Manzato for assistance with the study administration, and we also thank the
participating clients and their families.

Disclosure statement
Dr. Steele is the Chief Scientist at Lingraphica, which provided the TalkPath software used for
treatment in this study.

Funding
This project was supported by a “Telerehabilitation for Stroke” grant from the Heart and Stroke
Foundation Canadian Partnership for Stroke Recovery. Matching funds were generously provided
by the Manitoba Patient Access Network (MPAN).

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