A 54-year-old right-handed Caucasian man of Sicilian ancestry was admitted at the Oasi Research Institute-IRCCS of Troina (Italy), where he worked as Information and Communications Technology (ICT) manager. Both patient and caregiver (i.e., his wife) received detailed information. An informed consent form accessible to people with aphasia was used, and a written consent was obtained from the patient.

Cardiovascular disease, stroke, and dementia were reported in his family history, whereas past medical history included hypertension and dyslipidaemia. He was on daily treatment with pantoprazole, irbesartan, and simvastatin. Approximately one year earlier (July 2019), he suddenly presented with confusional state, non-fluent aphasia, and motor deficit of the right limbs. At the Emergency Department, the brain computed tomography (CT) scan showed an intracerebral haemorrhage of the left nuclear-capsular and frontal region. Because of the clinical and neuroradiological worsening, with evidence of an initial midline shifting of the left lateral ventricle, the patient was transferred to the Intensive Care Unit. A few days after, he underwent a left frontal minicraniotomy, hematoma drainage, and refixing of the bone operculum. Post-operative CT showed improvement of the affected areas, along with clinical recovery.

At the neurological examination, he was collaborating and partially oriented, and showed: global mainly non-fluent aphasia, right facial nerve central palsy, right hemiparesis, brisk tendon reflexes and sensory deficit at the right limbs, and right spastic gait. Routine laboratory exams were normal, as well as thyroid hormones, coagulation, and Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) test. Electrocardiogram showed signs of hypertensive cardiopathy, whereas chest X-ray was unremarkable. Electroencephalogram revealed sub-continuous non-reactive theta-delta activity over the left frontal and temporal regions. After discharge, he underwent motor, speech, and cognitive rehabilitation. All data were obtained with the informed consent of the participant.

The patient started a conventional SLP therapy, which, however, was early stopped due to the pandemic. The baseline assessment through the standardized comprehensive test for Italian aphasic patients, called ENPA (“Esame Neuropsicologico per l’Afasia”, that is “Neuropsychological Exam for Aphasia”) [22], showed non-fluent aphasia, anomies, circumlocutions, phonemic paraphasia, and deficit of narration, morphosyntax, pragmatic skills, and working memory. He also showed an impairment of writing (even for dictated words), comprehension, and word generation. Finally, when asked to repeat, he was unable without significant difficulties and repeated attempts to self-correct himself (the so-called “conduites d’approche”).

Remote SLP therapy was initiated, by using the well-known free platform “Skype”, from the operators’ study laptop to the patient’s home laptop, which were used for all the sessions. The technical setup included an external speaker to improve sound quality and a wide-angle web camera to enable also review of body language and other gestures. Patient and caregiver were given a short training on the use of the software before starting the TRH programme. All sessions were provided through a stable broadband connection.

A senior SLP therapist (F.S.), expert in PSA, delivered the TRH, assisted by an undergraduate SLP therapist (L.C.). All the interventions were tailored to the patient’s impairment and needs, and used a comprehensive approach to assess and enhance all aspects of language. The goal was to facilitate the access to the lexical store, to improve oral and written understanding, to strengthen narrative skills and working memory, to widen sentence length, and to stimulate pragmatic and narrative skills. They also used collections of tasks comprising individual aphasia exercises, for instance, oral and written naming and reading sentences and text. Furthermore, maps, pictures, and other items were used as additional resources.

Timing and duration of each session were established by the SLP therapist and arranged with the patient and his caregiver, according to the Template for Intervention Description and Replication (TIDieR) checklist for patients with PSA [23]. An intervention based on a duration of two hours and a frequency of twice per week was delivered, resulting in an intensity of 4 hours of therapy per week and a total dosage therapy of 88 hours planned. In some cases, due to some technical inconvenience, need for more breaks, explicit request of the patient, or recovery of time lost for a previously skipped session (which, however, occurred only twice, not consecutively), a longer time (up to 2.5 hours) was delivered to adjust to the participant’s timetable and other planned activities, but only if he was able to withstand a longer session. Sessions were delivered over five consecutive months, from March to July 2020. Logistic and/or technical issues occurred very rarely (none of the sessions was stopped, slowed down, or disturbed due to low Internet connection), as well as no adverse event or medical complication during the above-mentioned period.

At the end of the TRH, the patient was reassessed by means of the same tests used at baseline (ENPA) [22]. Given that the baseline evaluation was carried out in a “face-to-face” modality, also the post therapy assessment took place in person. This allowed a more reproducible comparison and made the writing parts of the test more reliable than an on-line remote examination. He improved in the following skills: repetition of non-words, writing of words, reading of sentences, oral naming of verbs, written naming of verbs and names, oral and visual comprehension of words; the generation of words list, which was severely affected at baseline, improved substantially. Conversely, other abilities (i.e., repetition of words and sentences, writing of non-words and sentences, reading of words and non-words, oral naming of names and colours, oral and visual comprehension of sentences) did not vary or did not further improve following the TRH. After the end of the lockdown period, the patient continued his rehabilitation program in a conventional “face-to-face” modality only. The choice to give TRH in addition to the usual care is still a debated issue, as it challenges the possibility to determine the effects of each rehabilitation modality.

Table 1 (Ref. [23]) summarizes all the participant’s and SLP intervention items and data, based on the TIDieR checklist [23].

The COVID-19 pandemic represented a challenge for adaptation on several fronts. Studies on teletherapy during the pandemic [24] have shown that COVID-19 is broadly impacting neurorehabilitation, including SLP services: referral patterns are less numerous and different, usual care has been disrupted and interventions have been modified, eventually affecting the impact on outcomes. However, the need for social distancing and the extreme care to reduce the spread of infection anticipated changes that were actually already possible, such as those regarding the use of telehealth. In particular, telemedicine and technology can be used to upgrade rehabilitative care, especially within the setting of shorter hospitalization stays, social distancing and confinement, and limited access and resources [25], as recently highlighted by the application of lexical retrieval training in tablet-based speech-language rehabilitation of aphasia [26]. For patients who received SLP therapy, it was found that the outcomes did not change significantly [24].

In this case, a TRH-based approach has proven to be a feasible tool to overcome the limits imposed by the lockdown, especially in terms of healthcare reorganization, and to support the role of technology and as a strong ally during the pandemic. Overall, treatment adherence based on the operator’s assessments was high, and incomplete adherence for technical problems occurred very rarely. Due to the motor deficit in his right side, the adherence to some writing tasks was not always optimal; however, he managed to perform the tasks requested and to show the results to the operators with the assistance of his caregiver. In line with the patient’s feedback, acceptability of the telespeech therapy was also positive, since he was constantly motivated during the sessions and the exercises performed autonomously, as confirmed by the SLP therapist and patient’s caregiver, respectively.

The implementation of telespeech therapy has recently been described [27]. The purpose is to guarantee the continuity of care services for patients who could worsen during the period of social distancing. Consultations, carried out through synchronous video calls by all participants (patients, caregivers, SLP therapists, and students), enabled a remote care with the same quality of “face-to-face” interventions. In this context, it cannot be excluded that telehealth technologies will be part of the professional reality in the near future, both to respond to the needs imposed by the pandemic and to expand the offer of speech therapy services worldwide [28].

Telepractice also facilitates healthcare services in exceptional settings and situations, being the ongoing pandemic one of these. A recent online survey [29] has shown that both patients and operators were satisfied because telepractice allowed them to receive and provide, respectively, clinical services in an exceptional scenario. The main reasons for client refusal or discontinuation were the lack of proper equipment, insufficient independence, and doubts on the effectiveness of such a modality [29]. This is in line with the fact that while COVID-19 has propelled the use of telemedicine to the forefront, many previous barriers to telemedicine implementation still exist. These include the actual efficacy of an “urgent telemedicine” (especially in terms of feasibility, patient satisfaction, and outcomes), payment and reimbursement policies, administrative regulations, cyber and ethical security, and technology education and utilization, among others [30].

Notwithstanding these issues, TRH for stroke survivors has emerged as a promising intervention for motor, speech, cognitive, occupational, and other therapies. A recent systematic review of 22 publications suggested that TRH has either better or equal effects on motor recovery, higher cortical deficits, and mood disorders compared with conventional “face-to-face” therapy [31]. However, current evidence in PSA is still preliminary, with only few videoconference trials [32]. A recent randomized controlled pilot study in 30 PSA patients showed that synchronous TRH was safe and acceptable, with tolerable technical issues and high satisfaction among both patients and operators [33]. However, complex TRH interventions require a higher degree of technical expertise and long-term effects are still unclear. In particular, there are still few trials exploring how TRH can be used to increase therapy time and the impact that such augmented intervention might have on the outcome measures [34, 35].

In the patient with PSA described here, although some skills did not improve, the most important goals could be considered achieved, leading to a global increase in his language abilities. The effects of treatment were subjectively evident already during the interventions and were confirmed at the end of the TRH, thus suggesting that this approach may have influenced the patient’s skills beyond a single speech ability [10]. It is also possible that tailoring the intervention to the baseline patient’s impairment might have endorsed a greater generalization of speech-related skills. These results are also in line with the overall effects shown by videoconference-based TRH in brain-injured subjects, including stroke, and have translational implications for further remote applications [36].

As known, the most powerful predictor of PSA recovery is the initial severity of aphasia, given that greater severity is associated with poorer improvement [37]. However, this report suggests that improvement may persist over time and depend on the usage time [6]. A previous study reported that also the number of hours per week of TRH correlated with recovery and that at least 4 hours per week (as carried out in the present case) or 24 hours in four weeks were required to show significant results [38]. Nevertheless, although PC, tablets, and other devices have great potential for personalized home practice to maintain and augment traditional aphasia rehabilitation, both attitude and motivation to use the technology, as well as an adequate training, seem to be even more important factors than age and aphasia type or severity [39]. As a former ICT manager, the patient reported here was already skilled with the use of the PC and the main telecommunication applications specialized in video chat and voice calls. As such, he did not have any difficulty in accessing Skype, even during training, and no specific therapy or protocol modification/adjustments were needed when translating from conventional to remote sessions.

Lastly, we confirmed the helpful guidance of caregivers (i.e., the patient’s wife in this report), since they usually assisted the patient in the management of technology and home exercises [40]. In the pandemic scenario, social distance provides more family time, and in some cases, better organization for carrying out the exercises prescribed, with a positive impact on the user prognosis [27]. In other words, as Volkers stated, “family members develop activities previously performed by therapists” [41].

The main contribution of this case is the use of a videoconference tool for TRH, including the description of the patient’s acceptance, compliance, and adherence with the method. Overall, this approach has shown positive results, probably due to the delivery of the therapy in a more comfortable environment and through a previously known communication platform.

Other strengths of TRH are the possibility to fully use the time available, to interact more with the caregiver, to provide therapy directly in the patient’s living environment, and to arrange the sessions easily. Home-based therapy for aphasic patients has proven to be as effective as in-clinic session, with the added advantage that patients can practice more and in a more comfortable way [42]. Increased autonomy and opportunity for practice with the remotely monitored therapy has also been acknowledged, but the supervision of a trained SLP therapist (as that engaged in the present report) remains crucial [43].

The main limitation of this report is that it is based on a single case, with pre- and post-language test performed by the same operator. Another caveat it that evidence of generalizability to other clinical contexts or individuals with other types of aphasia or speech disorders (such as progressive aphasia) cannot be provided.

Third, although we have found effects in some language abilities, but not all, these might have been due to the increase in the total therapy time received. On the other hand, it might also due to the fact that, to date, only few SLP therapists have received an adequate training for switching from an in-person service to a synchronous telepractice model. This new and unexpected environment shift may have altered vocal behaviours and communication interactions, thus negatively impacting some treatment outcomes [44]. A sudden change from in-person to online clinical services, such as that imposed by the COVID-19, requires novel strategies and specific support to address specific pandemic-related issues.

Lastly, other disadvantages of TRH are the same of telemedicine, i.e., the lack of a direct contact between patient and therapist; the preliminary adaptation of both user and therapist, often requiring additional consultation time and more session duration; less socialization, which is instead a relevant component of the in-hospital rehabilitation; the need that all patient’s rights are maintained by efficient and confidential service [45]; slow Internet connection and other technical issues (e.g., low quality of sound and/or video, etc.) [46].