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Deb Crislip, MA, CCC-SLP
Shepherd Center

Individuals with severe speech and language disabilities can benefit from the ever-increasing range of voice output technologies. However, many people have been unable to make full use of these systems because of inadequate supports (Glennen & DeCoste, 1997).

Learning to use Augmentative Alternative Communication (AAC) devices requires extensive training and support from a speech therapist and communication partners. AAC devices are often abandoned by users due to mismatches between skills, expectations, and device capabilities (Culp, Ambriosi, Berniger, & Mitchell, 1986).

Ideally, individuals receive services at a clinic which provides the clinical expertise needed to effectively evaluate communication needs, prescribe an appropriate system, and provide necessary training and support to the user and his or her communication partners. However, there are relatively few specialists who can provide these services, especially in rural communities. Distance, lack of funding, inadequate transportation, and the frequency of required training sessions could make it difficult or even impossible for clients to come to the clinic for these services. Telerehabilitation has the potential to bridge the gap in some cases.

Telerehabilitation is the use of telecommunication and electronic communication technologies to provide rehabilitation and long term support to people with disabilities, when they are at a distance. Telerehabilitation is proving to be a valuable and very desirable tool for extending our expertise into the community. Because availability of therapy support is such a priority for our population and most people have phone service, we focused on low-cost telephone-based technologies that permit our staff to interact with consumers in their own home.

Shepherd Center has done over 400 TeleRehab visits with more than 100 patients for a variety of rehab services such as post discharge medical follow-up, prevention and treatment of secondary complications, such as pressure ulcers, and support of assistive technology (AT). Our AT services include computer access, seating/mobility, environmental controls, adaptive driving, and home and work site accessibility. Shepherd Center recently began investigating the use of telerehabilitation to provide training and support to individuals learning to AAC devices. This approach can overcome major transportation problems, extend therapy into the home, provide support for the patient/family/caregivers, and provide support for local providers.

Telerehabilitation support for the training and use of AAC devices can provide the opportunity for therapy which the consumer would not have otherwise, due to lack of transportation, funding or local expertise. Our experiences to date have been enlightening with respect to both the potential benefits and problems associated with telerehabilitation, from both human factors as well as technological perspectives. During the development of the Telerehab AAC project, there have been many technical challenges. These problems can be classified into two major categories: technical challenges-visual problems with the display, audio problems with the sound quality, and telephone line problems; and human interface problems with the telecommunication technology.

One of the most serious areas of technical difficulty was the video photography. The therapist initially wished to see both the consumer's face and the AAC device. However, due to technical limitations, the therapist can only see one image at a time. A clinical decision must be made about which image is of primary importance. In most instances, it is the device. In order to train someone in the use of a device, such as the Delta Talker(tm), the therapist must "see" the speech the person formulates with the device. The Delta Talker(tm) works by scanning through a matrix of icons with LED's on the display, then selecting icons which represent words which are strung together to make phrases or sentences. To "see" this speech, the therapist must view the icon and it's placement on the keyboard. This was very difficult from a photography perspective. For some systems, a scan converter box was used to convert the digital signal from the AAC device into a signal that could be displayed on a video monitor for the therapist to view thus, negating the need for a camera.

However, other systems required a camera with specific parameters for lighting and positioning. In order to visualize the device and "see" the speech as formulated, the only reasonable choice of camera position may be over the shoulder or directly above the device. Both of these positions are easily compromised by random movement of the consumer's head or hands, directly related to their disability, making it difficult for the therapist to determine which word has been selected. Technical solutions to this problem required experimentation and perseverance. Minute adjustments may need to be made to the camera position. It is very important to have open communication between therapist and technical support person in order to find solutions.

Audio quality is of primary importance in any telerehabilitation application because without it, images lose their immediate context and viewers become frustrated. To maximize the audio portion of our TeleRehab training sessions, use of a good speakerphone was critical. Even so, extraneous noise in the home environment can be disruptive. Reducing ambient noise in the environment is critical and solutions may be simple. Televisions, and radios should be turned off or the doors closed. Children who are laughing, crying, or screaming should also be removed from the room, as should barking dogs, yowling cats and noisy birds. Also, medical equipment, such as a ventilator, which is critical for survival, may interrupt the audio. Simply adding a microphone close to the AAC device may improve the sound quality.

Other technical problems that require creative problem solving are lighting and telephone line problems. Lighting in a home can be difficult. Ambient light in rooms can vary from one visit to the next and can be very difficult to control. Solutions can be as simple as asking the family to turn on another light in the room or to close the blinds. Each household is different and time must be allotted for experimentation to find appropriate photography, lighting and audio conditions to meet the needs of both the therapist and the client.

Telephone line problems can occur if the consumer has call waiting or answering machines. The telephone infrastructure in rural as well as urban areas can have out dated switching systems, which interfere with transmission from the home to the therapist. Sometimes, the solution may be having the consumer turn off call waiting and not pick up any extensions during the visit. Hanging up and calling back to get a better line can often, solve telephone infrastructure problems.

Human factors are at least as important as technological problems. A guiding principle of ours is that the patient and family must be central to our treatment team. Some of the most important members of our team are family members or group home employees who can set up the equipment and troubleshoot as necessary: They are your hands in the home. Team building among all these diverse people is necessary to create a treatment team to achieve mutually agreed upon client goals. Team members bring their unique expertise and experience to the team.

Many factors can decrease the effectiveness of the team and make it more difficult to achieve patient goals. Competition between team members, lack of trust and established patient goals, and unrealistic expectations are all barriers to effective teamwork. Successful treatment teams practice open communication, creative problem solving, constructive critiques, and humor. This allows everyone to practice effective conflict resolution and to have realistic expectations for the training sessions.

Clinicians and therapists can be "Technophobic", and are, initially, skeptical of their ability to treat clients using technology. Family and caregivers may have difficulty learning to set up the equipment and may fail to take ownership of their end of the video call. With repeated consults with the technical support person and careful instruction, technical and logistical barriers are lowered. When the team realizes that the client is less fatigued, able to retain more instruction from increased frequency and that the setting up of the equipment produces more positive interaction with communication partners, therapists, and client, they are "sold".

Although the telerehabilitation approach is not without its technical and human challenges, users actually make better progress with the support of telerehabilitation than they would using conventional speech therapy alone. This is due in large part to the increased frequency and greater efficiency of training (Jones, 1998; Burns, Crislip, Daviou, Temkin, Vesmarovich, Anschutz, Furbish, & Jones, 1998). Because less time and hassle is involved in transportation to and from the speech clinic and because training can be provided in the home setting, the client and his or her communication partners can devote more focused attention on learning to communicate.

In the words of one of our clients: "I'm 56 years old. I was born with Cerebral Palsy. My Delta Talker (tm) is a communication device that allows me to speak words for the first time in my life. Communication is one of the keys to a full, rich life. It allows us to connect with other human beings and share our thoughts and feelings. No one should fear the act of communicating in front of other people. The only fear should be the inability to share thought with others. I know because being able to communicate with words opens doors for me." (Franklin, 1998)


1. Glennen, S.L. & DeCoste, D.C. Handbook of Augmentative and Alternative Communication. Singular Publishing Group, Inc., 1997.

2. Culp, D. M., Ambriosi, D.M., Berniger, T.M. & Mitchell, J.O. (1986). Augmentative communication and use: A follow-up study. Augmentative and Alternative Communication, 2, 19-24

3. Jones, M.L. (1998). Telerehabilitation to overcome transportation barriers. Invited testimony at the NIDRR Public Meeting on Assistive Technology. Tallahassee, FL, April 2, 1998.

4. Burns, R.B., Crislip, D., Daviou, P., Temkin, A., Vesmarovich, S. H., Anshutz, J., Furbish, C. & Jones, M. L. (1998). "Using Telerehabilitation To Support Assistive Technology. Resna ,10 (2).

5. Franklin, Butch (1998). Personal Communication to Deb Crislip.