Celia Woolf

Codesign for people with aphasia through tangible design languages

Codesign techniques encourage designers and end-users to work together in the creation of design solutions, but often make assumptions about the ways in which participants will be able to communicate. This can lead to the unwitting exclusion of people with communication impairments from the design of technologies that have the potential to transform their lives. This paper reports our research into codesign techniques for people whose communication skills are impaired. A variety of techniques were explored on two projects; some were adaptations of existing codesign techniques, others were created specially. In both cases, the emphasis was on creating tangible design languages. The results illustrate how people with communication impairments can be given a voice in design and demonstrate the benefits of doing so.

A comparison of remote therapy, face to face therapy and an attention control intervention for people with aphasia: a quasi-randomised controlled feasibility study

Objective: To test the feasibility of a randomised controlled trial comparing face to face and remotely delivered word finding therapy for people with aphasia. Design: A quasi-randomised controlled feasibility study comparing remote therapy delivered from a University lab, remote therapy delivered from a clinical site, face to face therapy and an attention control condition. Setting: A University lab and NHS outpatient service. Participants: Twenty-one people with aphasia following left hemisphere stroke. Interventions: Eight sessions of word finding therapy, delivered either face to face or remotely, were compared to an attention control condition comprising eight sessions of remotely delivered supported conversation. The remote conditions used mainstream video conferencing technology. Outcome measures: Feasibility was assessed by recruitment and attrition rates, participant observations and interviews, and treatment fidelity checking. Effects of therapy on word retrieval were assessed by tests of picture naming and naming in conversation. Results: Twenty-one participants were recruited over 17 months, with one lost at baseline. Compliance and satisfaction with the intervention was good. Treatment fidelity was high for both remote and face to face delivery (1251/1421 therapist behaviours were compliant with the protocol). Participants who received therapy improved on picture naming significantly more than controls (mean numerical gains: 20.2 (remote from University); 41 (remote from clinical site); 30.8 (face to face); 5.8 (attention control); P <.001). There were no significant differences between groups in the assessment of conversation. Conclusions: Word finding therapy can be delivered via mainstream internet video conferencing. Therapy improved picture naming, but not naming in conversation.

Using voice recognition software to improve communicative writing and social participation in an individual with severe acquired dysgraphia: an experimental single-case therapy study

Background: Two previous single-case studies have reported that voice recognition software (VRS) can be a powerful tool for circumventing impaired writing in aphasia. However, these studies report mixed results regarding transfer of skills to functional tasks, such as emailing. Method: A single-case therapy study was conducted with “Stephen”, a 63-year-old man with fluent aphasia and severe acquired dysgraphia and dyslexia limiting his social participation and ability to return to work. Treatment consisted of 16 one-hour sessions. Stephen was trained to use Dragon NaturallySpeakingRTM VRS to assist writing and Read+WriteGoldRTM text-to-speech software to assist reading, and to develop computer skills required to use email. Outcome measures evaluated writing efficiency and communicative effectiveness, the functional impact of the intervention, and changes in participation. Results: Training produced significant gains in the efficiency and communicative effectiveness of Stephen’s writing, despite his underlying writing impairment remaining unchanged. Gains generalised to everyday functional communication, leading to increased social participation with Stephen undertaking a wider range of social activities and increasing his social network following treatment. Gains were maintained at follow-up assessment. Discussion: Results indicate that a relatively short training period with assistive technologies achieved extensive generalisation to independent, functional communicative writing. Indeed, for this case, VRS training may have exceeded the degree of improvement in functional text writing that could have been achieved through impairment therapy, since gains were not limited to treated vocabulary. Some challenges were encountered in training Stephen to use VRS but, through adaptations to the training process, were largely overcome. Importantly, regaining independent writing skills resulted in profound and life-changing improvements to social participation. This may have resulted in Stephen reconnecting with important aspects of his pre-stroke identity, and improving his self-esteem. Conclusion: This case adds to a small evidence base indicating that training in the use of VRS, in combination with text-to-speech software, may be an effective way to address writing impairments in chronic aphasia for individuals with relatively well-preserved spoken output. Not only can these technologies improve the efficiency and communicative effectiveness of writing, they can also lead to significant gains in functional communication and social participation. Further research is needed trialling this approach with a larger group of people with aphasia.

Evaluating the Benefits of Aphasia Intervention Delivered in Virtual Reality: Results of a Quasi-Randomised Study.

Introduction This study evaluated an intervention for people with aphasia delivered in a novel virtual reality platform called EVA Park. EVA Park contains a number of functional and fantastic locations and allows for interactive communication between multiple users. Twenty people with aphasia had 5 weeks’ intervention, during which they received daily language stimulation sessions in EVA Park from a support worker. The study employed a quasi randomised design, which compared a group that received immediate intervention with a waitlist control group. Outcome measures explored the effects of intervention on communication and language skills, communicative confidence and feelings of social isolation. Compliance with the intervention was also explored through attrition and usage data. Results There was excellent compliance with the intervention, with no participants lost to follow up and most (18/20) receiving at least 88% of the intended treatment dose. Intervention brought about significant gains on a measure of functional communication. Gains were achieved by both groups of participants, once intervention was received, and were well maintained. Changes on the measures of communicative confidence and feelings of social isolation were not achieved. Results are discussed with reference to previous aphasia therapy findings.

Rekindling the love of books – a pilot project exploring whether e-readers help people to read again after a stroke

Background: E-readers may facilitate reading in aphasia through “aphasia-friendly” features such as altering text size and formatting, and text-to-speech functions. However, no previous research has examined whether e-readers help people with aphasia to read. Aims: This project explored: whether people with aphasia can learn to use e-readers following a brief period of training, whether e-reader training improves reading comprehension, and whether e-readers increase participation in and enjoyment of reading activities Method and procedures: In phase one, available e-readers were compared using an expert evaluation against a set of criteria, to identify the model with optimum accessibility features and fewest potential barriers. The Kindle Keyboard 3GTM (Amazon) was selected for trialling in phase two. Four people with self-reported reading difficulties poststroke participated in phase two. All had mild or mild-moderate aphasia. Four 1-hr training sessions aimed to trial accessibility features, identify helpful features, and teach independent operation of these. A repeated measures design was used. Outcome measures assessed reading comprehension (Gray Oral Reading Tests (GORT-4)) and confidence and emotions associated with reading (Reading Confidence and Emotions Questionnaire (RCEQ)). Matched texts were used to compare reading comprehension using printed texts and the e-reader. Usability evaluations explored independence in e-reader use and acceptability of the technology. Participation in reading activities and reading enjoyment were explored using qualitative exit interviews. Outcomes and results: Participants’ reading comprehension on the Kindle, as measured by GORT-4, did not improve following training and did not exceed comprehension of printed texts. However, reading confidence improved significantly for three of the participants (RCEQ: p < .05, p < .01, and p < .005). Analysis of exit interviews and usability evaluations indicates that three out of four participants preferred reading on the Kindle to printed texts. These participants read more frequently on the Kindle than they had done before the training, and the technology enabled them to access more challenging texts (e.g., novels). They appreciated different features of the Kindle. Two participants experienced difficulties operating the technology, one of whom would have benefited from a longer training period. Conclusions: This pilot study suggests that a short block of e-reader training led to improvements in reading confidence, participation, and enjoyment. E-readers were not shown to enhance reading comprehension. Larger-scale investigations are warranted to further investigate whether and how e-readers facilitate reading for people with aphasia.

Therapy for auditory processing impairment in aphasia: An evaluation of two approaches

Aims: This study evaluated two forms of discrimination therapy for auditory processing impairment in aphasia. It aimed to determine whether therapy can improve speech perception and/or help participants use semantic information to compensate for their impairment. Changes in listening were also explored by recording the level of facilitation needed during therapy tasks. Finally the study examined the effect of therapy on an everyday listening activity: a telephone message task. Method: The study employed a repeated measures design. Eight participants received 12 sessions each of phonological and semantic–phonological therapy. Both programmes used minimal pair judgement tasks, but the latter embedded such tasks within a meaningful context, so encouraged the strategic use of semantic information (semantic bootstrapping). Experimental measures of auditory discrimination and comprehension were administered twice before therapy, once after each programme, and again six weeks later. The telephone message task was also administered at each time point. Test data were subjected to both group and individual analyses. Records of progress during therapy (i.e., changes in support needed to carry out therapy tasks) were completed during treatment and analysed across the group. Results: Group analyses showed no significant changes in tests of word and nonword discrimination as a result of therapy. One comprehension task improved following therapy, but two did not. There was also no indication that therapy improved the discrimination of treated words, as assessed by a priming task. The facilitation scores indicated that participants needed less support during tasks as therapy progressed, possibly as a result of improved listening. There was a significant effect of time on the telephone message task. Across all tasks there were few individual gains. Conclusions: The results offer little evidence that therapy improved participants’ discrimination or semantic bootstrapping skills. Some changes in listening may have occurred, as indicated by the facilitation scores. Reasons for the null findings are discussed.

Experiencing EVA Park, a Multi-User Virtual World for People with Aphasia

Virtual worlds are used in wide-ranging ways by many people with long-term health conditions, but their use by people with aphasia (PWA) has been limited. In contrast, this article reports the use of EVA Park, a multi-user virtual world designed for PWA to practice conversations, focusing on peoples emotional, social, and conversational experiences. An analysis of observation and interview data collected from 20 people with aphasia who participated in a 5-week therapy intervention revealed key themes related to user experience. The themes offer a rich insight into aspects of the virtual world experience for PWA that go beyond therapeutic outcomes. They are as follows: affect (positive and negative); types of conversation, miscommunication, and misunderstanding; immersion in the virtual world; social presence and initiative and flow. Overall, the study showed that participants experienced positive emotional and social outcomes. We argue that this was achieved as a consequence of EVA Park being not only accessible but also a varied and entertaining environment within which PWA experienced both the realistic and the quirky while engaging with others and having fun.

Receiving Aphasia Intervention in a Virtual Environment: The Participants’ Perspective

ABSTRACT Background: Digital technology is making an increasing contribution to aphasia therapy. However, applications of virtual reality are rare. EVA Park is a virtual island developed with and for people with aphasia. It is a multi-user environment, which enables people with aphasia to interact with support workers, therapists and each other. The first study to use EVA Park in aphasia rehabilitation demonstrated significant gains in functional communication. This article augments the findings of that study, by reporting results from qualitative interviews conducted with the 20 study participants. Aims: This study aimed to determine the views of participants about the intervention that they received in EVA Park, and the impacts of that intervention. Long-term retrospective views were also explored. Methods & Procedures: Participants took part in 1:1, semi-structured interviews two weeks before (entry) and two weeks after (exit) the intervention. Questions focussed on activities undertaken by participants, communication, changes since the stroke and uses of technology. Exit interviews additionally explored participants’ views and experiences of EVA Park and any perceived impacts of the intervention. A subset of five participants was interviewed at least one year later, to explore long-term recollections of the EVA Park intervention and any perceived long-term impacts. Interview data were transcribed and subject to framework analysis. Outcomes & Results: The thematic framework comprised 10 parent themes and 33 sub-themes. Following “affect”, the largest single theme related to EVA Park, with 636 coded references. Comments were overwhelmingly positive. EVA Park intervention was strongly associated with fun and enjoyment. Participants particularly valued their relationship with the support workers who delivered the intervention. The virtual locations and activities in EVA Park were also appreciated, together with the contact with other participants. Perceived impacts related to communication, activity, computer use and confidence. Most (4) participants in the long-term interviews described maintained impacts. Conclusions: These interview results indicate that the first intervention delivered in EVA Park was highly acceptable to participants and perceived as beneficial. They augment the findings of our experimental study and suggest that EVA Park could be a valuable addition to the resources available to practising clinicians.

Technology-enhanced writing therapy for people with aphasia: results of a quasi-randomized waitlist controlled study: Technology-enhanced writing therapy for people with aphasia

BACKGROUND Acquired writing impairment, or dysgraphia, is common in aphasia. It affects both handwriting and typing, and may recover less well than other aphasic symptoms. Dysgraphia is an increasing priority for intervention, particularly for those wishing to participate in online written communication. Effective dysgraphia treatment studies have been reported, but many did not target, or did not achieve, improvements in functional writing. Functional outcomes might be promoted by therapies that exploit digital technologies, such as voice recognition and word prediction software. AIMS This study evaluated the benefits of technology-enhanced writing therapy for people with acquired dysgraphia. It aimed to explore the impact of therapy on a functional writing activity, and to examine whether treatment remediated or compensated for the writing impairment. The primary question was: Does therapy improve performance on a functional assessment of writing; and, if so, do gains occur only when writing is assisted by technology? Secondary measures examined whether therapy improved unassisted written naming, functional communication, mood and quality of life. METHODS & PROCEDURES The study employed a quasi-randomized waitlist controlled design. A total of 21 people with dysgraphia received 12 h of writing therapy either immediately or after a 6-week delay. The primary outcome measure was a functional assessment of writing, which was administered in handwriting and on a computer with assistive technology enabled. Secondary measures were: The Boston Naming Test (written version), Communication Activities of Daily Living-2, Visual Analogue Mood Scales (Sad question), and the Assessment of Living with Aphasia. Analyses of variance (ANOVA) were used to examine change on the outcome measures over two time points, between which the immediate group had received therapy but the delayed group had not. Pre-therapy, post-therapy and follow-up scores on the measures were also examined for all participants. OUTCOMES & RESULTS Time × group interactions in the ANOVA analyses showed that therapy improved performance on the functional writing assessment. Further interactions with condition showed that gains occurred only when writing was assisted by technology. There were no significant interactions in the analyses of the secondary outcome measures. A treatment effect on these measures was therefore unconfirmed. CONCLUSIONS & IMPLICATIONS This study showed that 21 people with dysgraphia improved on a functional writing measure following therapy using assistive technology. The results suggest that treatment compensated for, rather than remediated, the impairment, given that unassisted writing did not change. Further studies of technology-enhanced writing therapy are warranted.

Assistive technology approaches to reading therapy for people with acquired dyslexia

Background: Reading is a fundamental skill required to participate fully in society. While reading difficulties are common in aphasia, the remediation of reading difficulties has been relatively under-researched with particularly few studies exploring text-level reading interventions and the use of technology to assist reading. Assistive reading technologies have potential to facilitate reading in aphasia through “aphasia-friendly” features such as altering text size and formatting (Worrall et al., 2005), and text-to-speech functions. A pilot study provided preliminary evidence that people with aphasia may benefit from the use of text-to-speech conversion for text-level reading (Caute et al., 2016). Aims: This study evaluated the effects of technology-enhanced reading therapy for people with acquired dyslexia. It explored whether using mainstream assistive reading technologies alongside reading strategies would lead to improve reading comprehension and confidence and emotions associated with reading. It addressed the following research questions: