Digital Technology and Aphasia
A couple of weeks ago I had the pleasure of attending the British Aphasiology Society (BAS) update meeting in Newcastle University. This comprised a series of 20 minute talks from academics, clinicians and technology experts from around the UK; the meeting lasted all day.
I hope to be able to summarise for readers the researchers' key points in their (often) early stages of research. I aim to do this in a way which does justice to what really was an exciting and informative day for Speech and Language Therapy, Aphasia, Research, and Technology.
Lexi Johnson, supervised by Julie Morris & Fiona Menger, Newcastle University - Undergraduate dissertation: Facilitating the use of technology with people with aphasia: what are the challenges for speech and language therapists?
Background: Speech and Language Therapists (SLTs) may use technology with people with aphasia (PWA) in a variety of ways; including therapy software, as alternative and augmentative communication, or to support participation, e.g. email or word processing. Research has explored some of the benefits and barriers for PWA, but the views and experiences of SLTs have had little attention. The study also aims to update older studies on similar topics due to the p
Aims: The aims of this study are to explore:
1) How SLTs are using technology in their work with PWA
1) How SLTs are using technology in their work with PWA
2) What roles concerning technology SLTs feel they should undertake
3) The barriers that restrict use of technology with PWA
4) Whether personal interest in technology affects opinions on these topics
Methods & Procedures: This investigation had two phases. The first used semi-structured interviews (N=4) to explore practising SLT's opinions about technology from a purposive sample. This data was used alongside literature to inform a survey, which formed the second phase. The survey gathered information on technology use, roles and barriers. Data was collected from 115 participants, including students, academic staff and SLTs.
Outcomes& Results: Therapists use technology as therapy software and to increase intensity of therapy more than they use it as AAC, to give homework or to facilitate participation. Most participants feel SLTs have a role in using technology but that some technical roles are better suited to a specialist technology service. Client’s suitability to use technology was the biggest barrier but work environment barriers such as the cost of devices and availability of trial products also play a role. Those who dislike technology are more likely to rate therapist technology skills as a barrier.
Conclusions: Technology is being used in the profession in a variety of ways, and most SLTs see the use of technology as part of their role. How SLTs make decisions on suitability to use technology is unknown, and this is worthy of further exploration. A more robust evidence base is needed in the case of many technological interventions in order to prove their effectiveness and to ensure that each client receives appropriate intervention.
1) Fiona Menger & colleagues, Newcastle University - IDEA Project: Inclusion in the digital economy for people with aphasia
Menger's talk highlighted the difficulties for people with aphasia (PWA) in accessing technology, she noted that PWA may be the people who are most in need of the social benefits of technology, but potentially the least able to access it. The majority of PWA are people who have had a stroke, and so are often (though not always) of an older generation. This generation has not been brought up with the internet and have barriers of their own to internet use. Menger's research focuses on trying to tease out the barriers PWA have in using technology, including the internet, phones, and TV.
Pilot project: how do people with aphasia use the internet?
Comparing a small sample of 12 people with aphasia (PWA), Menger's research suggests PWA tend to use the internet in broadly the same way as the rest of the general public (GP), with the exception that PWA require more support. Email, email attachments and video calls were listed as the internet functions most used by both the GP and PWA's
One exception to this was that only 33% of PWA used the internet to look up health related things, compared with the retired general public (70%).
All 12 participants wanted to improve their internet skills and most considered their aphasia a barrier to using the internet.
Current project: do PWA use the internet differently from matched population with no language impairment?
Currently Menger is collecting data: 20 people with aphasia and 20 who have had stroke but don’t have aphasia (matched). She aims to address the following questions:
- What are barriers to internet use experienced by PWA who were internet users prior to stroke?
- How do carers and SLTs view their role in supporting people with aphasia to use the internet?
- Can intervention improve internet use for PWA?
2) Laoray Hunter & colleagues, NHS Tayside, Univeristy of Dundee - It’s not one thing: Interdisciplinary collaboration to promote digital technology use by people with aphasia
Hunter's talk discussed research on a multi-phase project supporting PWA to use digital technology, specifically, ipads. The participants were PWA who had previously received intervention from the trust and who had identified a need for support in using their iPads. All were members of the local speech-after-stroke group, Speakeasy. Hunter raised the important question of 'when do we fund the iPad as a communication aid?', though her talk does not address this.
Pilot projects: aimed to develop model for workshops for PWA to use iPads; create self-assessment tool for PWA to monitor their own progress and create a learning manual (workbook) so that the user can learn/use i-Pad independently
Service delivery model:
- Workshops for 10 weeks (4 weeks with a break followed by 6 weeks).
- 2 hour class with long break in the middle.
- Class focused on how to use the iPad.
- All workshops were done in university, which eliminated some of the Information Governance problems in accessing the internet; this highlighted the project design being far less feasible in an NHS setting.
By the end of the intervention people were using their iPads to
- Set calendar functions to remember appointments.
- Access websites - by SLT adding widgets to homescreen, e.g. for radio.
- Some people used screen shots for communication.
- The user with smallest amount of speech started using voice messages.
- Everybody increased their online shopping (SLTs not involved with this).
- Everybody used more photographs for communication.
- Aim is to develop criteria that could possibly be used for commissioning: are some people more likely to respond to workshops/Ipads? e.g. it’s likely people will need a degree of executive functioning.
- Some questions around outcome measures in project to prove effectiveness of SLT intervention in helping people facilitate use of Ipad.
- Discussion on changing technologies.
3) Abi Roper, City University - Revealing effects of computer gesture therapy for users with severe aphasia: GEST
Previous research provides evidence that a higher dose of gesture therapy is more effective than low.
GEST is a computer gesture therapy tool designed for people with severe expressive aphasia.
Click here for a video showing how GEST works.
- To assess effects of GEST (for gestures, and naming)
- Do benefits transfer to interactive communication?
- Explore candidacy for computer therapy
- Explore user attitudes.
30 participants supported one hour a week by SLT, prognostic tests (Cognitive Linguistic Quick Test); expressive-receptive language (CAT) Limb praxis (not retested)
Repeated measures were taken on naming, gesture, in isolation and with familiar conversation partner, technology questionnaire (do you use this…) and confidence rating (how confident do you feel using this…)
Results (only 9 people tested so far)
Most people seemed to be using technology more often, time will tell significance.
Limb praxis not measured afterwards, audience member suggested that gesture therapy may be contributing to improved limb praxis, another volunteered that a different study had shown some improvement in limb praxis following gesture therapy but nothing significant (not cited).
4) Gennaro Imperatore, Strathclyde University - Developing an AAC mobile application for aphasic users
Described current AAC software as being too slow; he noted that in functional communication this can be frustrating for both the person communicating the sentence as well as the listener.
Imperatore’s aims were to use text entry techniques to improve AAC apps and specifically to reduce the amount of tasks for the user. The AAC system will do this in a similar way to the way in which search engines such as ‘Google’ work.
After originally attempting to download Wikipedia in its entirety to use as a corpora of data (!!); he limited subjects to four high frequency communication topics:
· Food and drink (70 articles)
· Music (70 articles)
· Sports (70 articles)
· Transport (70 articles)
Used ‘pointwise’ to determine relatedness of words depending on the frequency with which they occur in similar Wikipedia articles.
Word à[related word 1, related word 2, related word 3....... related word 50]
- MASK film script corpora using speech as different to text.
- Programme can’t learn from user at the moment; i.e. select likelihood of following word based on past selections by the user.
- Many people (not all) with aphasia have central semantic deficits and this would cause difficulty when faced with a screen of semantically related words.
- The above point could become a positive, should the AAC be designed as a therapy program for semantic impairment.
- There is a risk of ending up with the word you started off with (much like ‘synonyms’ in word document).
- Will add pictures to accompany text later on, also wants to deal with regular verb suffixes and irregular verbs.
5) Faustina Hwang & Christos Salis, Reading and Newcastle University - Computer Skills Assessment Protocol for people who have had a stroke
Question: How can you tell if client will respond well to computer based assessment?
Pilot study 2010
Assessing computer access skills for people with aphasia:
· Background assessment interview: how has aphasia affected willingness and ability to use the computer?
· Assessment of typing skills
· Assessment of internet skills (including functional internet search: turning computer on, accessing BBC Weather for specific place e.g. Reading, then changing location to ‘oxford’, accessing and searching Google, turning computer off.
4 people aged 44; 57; 73 and 66.
3 participants had mild aphasia and one had moderate aphasia, with one participant also experiencing mild cognitive impairment.
Results so far, earlier tasks were easier and later tasks were difficult.
Should there be step-ups/step-downs to the task so we can learn from task how best to support people with the internet following stroke; to answer question ‘what does person need in order to use that technology.
Difficult to disentangle skills needed for complex tasks such as 'using a computer'.
Recognised potential for software to be used as therapy resource, as well as AAC, e.g. for semantic therapy.
6) Rachel McCrindle, University of Reading - Use of technology to support people with aphasia
Discussed two projects with the potential to support people with aphasia
A system comprising near field communication (NFC) chips in sticker form, approx 1”x1”. Each microchip can be programmed with individual information, and will activate when swiped with an android phone. The tags can be placed anywhere; in the examples given they tended to be stuck to objects around the house. The user would then swipe the tag from within a 5cm distance and it will perform its intended action.
Possibilities for people with aphasia or other communication impairments include: swiping an object, e.g. a kettle, and the phone saying name of object e.g. as a target word to practise, whilst encouraging generalisation into the home environment; swiping an object and the phone listing instructions on how to use that object; storing favourite channels on the television or website pages; having a reminder while leaving the house to e.g. ‘turn the iron off’.
Tags may be different colours, contain pictures and/or text. They can be bought very cheaply; for less than a pound; and in bulk approx. 20p. More than one function can be assigned to each chip and the chip will respond differently according to its function depending on the phone which is swiped. This means that many users can use the same chip; for example in a residential home a chip may be placed outside a dining hall and residents can scan their phone as they enter the room to be reminded what they ordered for food that morning.
This technology hasn’t been used on patients yet and is being designed on an android platform for ease of development; however developers would also look to develop it for the iPhone. This interesting blog gives more information on the technology.
Royal Berkshire hospital OTs are currently using Xbox Kinect in therapy and are in the process of developing software to help people perform simple exercises with games. The Kinect, McCrindle explained, has great potential to be used in the speech and language therapy world e.g. using articulograms to guide real-life production of mouth positioning for a client with apraxia of speech: in addition the technology could then be used collect and track individual’s data to monitor progress, as well as collect many different people’s data to calculate specific norms. McCrindle also spoke of the technology’s potential for using speech recognition software; using words as targets for therapy.
7) Laura McCaine, Newcastle University - Computerised therapy for short term memory in Aphasia
Literature studies reveal that difficulty in comprehension of spoken sentences can stem from a deficit in a linguistic deficit and/or a short term memory deficit.
McCaine and colleagues are working on the hypothesis that treating auditory short term memory will improve understanding of spoken sentences.
Computerised delivery of therapy can reduce SLT variation of productions e.g. timing, and intonation and reduce the effect of human influence, e.g. lipreading.
Researchers at Newcastle University are developing an application, ‘MEMO’, which aims to improve short-term memory via a serial word recognition task presented in auditory form only. People with aphasia will be presented with lists of words and have to judge whether the sentences are the same or different; similar to PALPA 13.
E.g. the user will need to select either ‘same’ or ‘different’ after hearing the following set of words:
1a) Bee mug car
1b) Bee mug car
If they correctly identify ‘same’ then this will take them to the next dyad, if they get it incorrect then they have one more chance to try again.
2a) Bee mug car
2b) Bee car mug
Clinicians and users have worked together on the production of ‘MEMO’ from the start. The application can be used on a touch screen.
This app will allow for manipulations of:
- Number of exercises
- Number of words per list
- Order of words
- Speed of word presentation
Stimuli and feedback are also customisable
Feedback shows the client in written and visual form (depicted by the character, Memo, climbing a mountain), the percentage of items they got correct, as well as the percentage they got correct on the first attempt.
8) Jane Marshall & colleagues, City University - Evaluating the effects of a virtual communication environment for people with aphasia (EVA)
I've tried to be objective up until this point, but I have to say at this point that this study blew me away.
Before you go any further, please take a minute to look at this webiste which will explain the EVA project far better than I ever could.
The project uses a virtual world (EVA park) in which people with aphasia can visit (virtually using a personal avatar) and meet up with others with aphasia. In addition, each PWA has a support worker who works with them 1:1; these support workers can embody other avatars and so assume different roles depending on what the person's goal is.
Will access to a virtual communication environment:
- Improve communication skills?
- Improve people's confidence?
- Reduce social isolation?
- Will effects be maintained?
- What are participant's thoughts on the project?
20 people with aphasia have unlimited access to EVA park for a five week period. During which there will be four 'live' periods: where a group of participants comes together and interact together virtually. In addition, each person will have daily sessions 'at' EVA with their support workers (during which time, other participants may also happen to be having sessions or be 'in' EVA park, offering further opportunities to communicate). Each individual will have personal goals and will be assessed pre and post therapy.
The participants in the study were on average slightly younger than an average person with stroke-acquired aphasia and tended to be fairly well educated.
The following assessments will be used:
- Word retrieval (fluency test: 50-50 words found in EVA park and words not found in EVA park).
- Narrative Assessment
- Word retrieval in conversation (POWERS analysis)
- Functional (Communication Activities of Daily Living)
- The Friendship Scale
The following experimental design was used to allow for comparison of PWA at stages 1 and 2
EVA provided a lot of opportunities for Role Play. Conversations that occured between participants were sometimes about things happening in EVA park (e.g. scandels related to current elections) as well as conversations about real life.
To recruit volunteers with aphasia to participate in for the program click here
The PWA met up with each other and support members once before the project started to design their avatars; this offered the opportunity for people to put a face to the avatar!
Thoughts need to go into how it can be rolled out on a bigger scale
Only have time logs at the minute for individuals in EVA park during the 1:1 sessions and 'live' periods. It would be interesting to find out the quality of exchange in peer interactions (when the support worker is not there and participants meet each other on a stroll in EVA park).
I hope this whistle-stop tour provided some insight into the wonderful research that is currently being conducted in and around technology use for people with Aphasia. It's an exciting time and I would like to thank all of the speakers and organisers for such a fantastic event. I for one cannot wait for the next BAS update meeting.
Any comments/suggests/amendments welcome :)