Pocket CPocket C--Speak Aphasia:Speak Aphasia: Handheld AAC Program for Handheld AAC Program for

People with AphasiaPeople with Aphasia

Marjorie Nicholas, PhDMarjorie Nicholas, PhD KrystalKrystal Peralta, MSPeralta, MS

Goals of this seminarGoals of this seminar

1. Describe and demonstrate PCSA

2. Show videotapes of people with aphasia learning and using PCSA

3. Discuss factors relating to successful use of PCSA:

• Cognitive requirements- research results from CSA study

• Physical requirements/issues

• Social context issues

PCSA is based onPCSA is based on CC--Speak AphasiaSpeak Aphasia

• Nicholas and Elliott (1998)• CSA was created using Speaking

Dynamically Pro and Boardmaker software (Mayer-Johnson Co.)

• Available as a special set of boards; need SDP/BM software bundle CD to operate it

Features of CFeatures of C--Speak Aphasia Speak Aphasia and the pocket versionand the pocket version

• Direct picture selection method• Minimal reading/writing required• Purposefully agrammatic• Both single icon selection to create

novel, more complex messages and

• Pre-programmed phrases for specific communication situations

CC--Speak Aphasia Main ScreenSpeak Aphasia Main Screen

PocketPocket CC--Speak AphasiaSpeak Aphasia• Software program created with

PTP-Mobile program (Point-to- pictures mobile is available as a download from rjcooper.com)

• Works on several models of Pocket PCs (Dell, HP iPAQs, etc. that operate with Windows CE)

• Designed to be as close as possible to the laptop version of C-Speak Aphasia created with SDPro

PCSA MAIN ScreenPCSA MAIN Screen

Telephone

Autobiog.

People Actions Objects

Topics

Help

PCSA People ScreenPCSA People Screen

“Bill”

Bill added to message display area

cook

cook added to message display area

PCSA Actions ScreenPCSA Actions Screen

PCSA Object Subcategories ScreenPCSA Object Subcategories Screen

food

spaghetti

spaghetti added to message display area

PCSA Food ScreenPCSA Food Screen

Then, click on display area and device speaks the message

Questions about using Questions about using handheld AAC such as PCSAhandheld AAC such as PCSA

• Loudness of voice output- may need a set of mini-speakers (some come prepackaged with the device)

• Small size of buttons and text- may be an issue for some users- need a stylus- these get lost

• Cognitive requirements similar/identical to laptop version

• Is it really true that if it’s more portable, it will be more functional?

CC--Speak Aphasia TrainingSpeak Aphasia Training

• Requires months of training to become a good user

• At first, focuses on dictated Subject- Verb-Object messages

• Progresses to responses to open-ended questions/conversations

• 3 training modules:– Generative language– Telephoning– Assisted writing and e-mailing

Pocket CPocket C--Speak AphasiaSpeak Aphasia Training: Mr. MTraining: Mr. M

Hyperlink to PCSA training session EP.mpg

• Several years post onset Left MCA CVA

• Severe nonfluent aphasia; auditory comprehension fairly good; some deficits in cognitive testing of nonverbal executive functions

•Lives by himself in a retirement community with some services; family in the local area

•Training on PCSA for a few months (2x/weekly sessions)

•Note the contrast on the video- he does well with highly structured stimulus-response “scripted” task; then has difficulty in more real-life communicative context.

Who will become effective Who will become effective users of alternative users of alternative communication systems communication systems like this?like this?

We need more evidence to We need more evidence to show whether these show whether these approaches can be approaches can be

efficacious for people with efficacious for people with severe aphasiasevere aphasia

Using a computer to communicate: Effect of executive function impairments in people with severe aphasia.

Marjorie Nicholas, Michele P. Sinotte, Nancy Helm-Estabrooks, Aphasiology, 2005.

Goals of the StudyGoals of the Study

1. Investigate whether functional communication could be improved via training on an alternate commun- ication system (C-Speak Aphasia)

2. Find out who the good candidates are for such systems, by examining both cognitive and linguistic factors as they relate to response to training.

Hypotheses:Hypotheses:

1. Some patients will improve functional communication via use of C-Speak Aphasia

2.2. Executive functionExecutive function skills will be important to good response

3. Severity of aphasia and specifics of the language impairment will be less important

Overall Design of the Study: Single Subject, Overall Design of the Study: Single Subject,

Multiple Baseline, Repeated MeasuresMultiple Baseline, Repeated Measures

• Baseline testing of:- language and nonverbal cognitive skills- semantic categorical knowledge- functional communication probe tasks

– Off computer– On computer

• Treatment begins: Module 1- Generative language

• Retest functional communication probe tasks every 3-4 weeks, each time

– Off computer– On computer

• Treatment lasts approx. 6 to 12 months

Data from first 5 subjects have been Data from first 5 subjects have been analyzed and published *analyzed and published *

Currently 8 additional subjects also Currently 8 additional subjects also have been treated and data analysis have been treated and data analysis is in progress. is in progress.

3 of these subjects use PCSA3 of these subjects use PCSA

* Nicholas, M., Sinotte, M.P., & Helm-Estabrooks, N. (2005). Using a computer to communicate: Effect of executive function impairments in people with severe aphasia. Aphasiology, 19, (10/11), 1052-1065.

CSA Outcome Measures:CSA Outcome Measures: Five Probe TasksFive Probe Tasks

1.1. Autobiographical questionsAutobiographical questions: answering 7 questions: e.g. “What is your address?”

2.2. Picture descriptionsPicture descriptions: describe 5 simple photos, e.g. a man drinking coffee

3.3. Video event retellingVideo event retelling: describe a video of a kitchen scene with mother, 2 kids, and cat

4.4. Telephone callsTelephone calls: making two short calls with specified information to be exchanged

5.5. Writing tasksWriting tasks: a birthday card and a grocery list, with some specified information

Example of data for scoring of Example of data for scoring of video description taskvideo description task

Off-computer:“Um”, gestures cutting,“um”, gestures falling, “two”, gestures flathand to represent 2 children, gestures drinking, “too dee”, gestures drinkingand eating, “too dee”

On-computer:C: Marjorie cook knife eat cucumber lettuce. Girl eat grapes. Girl fall a little bit. Marjorie eat cookies milk girl. Girl go cat. Boy eat cookies milk.

RESPONSE TO RESPONSE TO TRAININGTRAINING

Response to Training: Response to Training: Sample novel storySample novel story

Performance on Probe Tasks: Performance on Probe Tasks: Answering Autobiographical QuestionsAnswering Autobiographical Questions

•Able to communicate quite a lot at baseline

•On-computer scores only slightly higher

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Baseline Treatment

Performance on Probe TasksPerformance on Probe Tasks Picture DescriptionsPicture Descriptions

•On-computer scores much higher on this task thanoff-computer scores

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Off-Computer

Baseline Treatment

Performance on Probe TasksPerformance on Probe Tasks Telephone callsTelephone calls

Again, on-computer scores are much higher than off-computer

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Off-Computer

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Summary score differences (Across all 5 tasks)Mean probe score minus mean baseline score for the

off-computer and on-computer probes.

Off- computer

On- computer

Subject 1 -.03 39.7

Subject 2 2.8 27.7

Subject 3 3.2 13.1

Subject 4 13.8 13.4

Subject 5 7.2 16.8

RESULTS SUMMARYRESULTS SUMMARYDespite similar aphasia profiles, subjects

responded quite differently to C-Speak training.Subject 1, with the most “normal” nonverbal

CLQT scores has shown best response (Graphs) Subject 2, with good Symbol Cancellation and

Design Generation scores on CLQT also has shown improvements on many probe tasks

Subject 3, with the worst CLQT scores overall has NOT shown improvements on most probe tasks.

Subject 4, with poor CLQT scores overall has NOT shown much improvement on probe tasks.

Subject 5, at normal cut-off on 2 CLQT subtests (but not Design Generation) - performance variable; some benefits of using the computer started to emerge

Conclusions From the CSA Conclusions From the CSA research studyresearch study

• Nonverbal cognitive measures, particularly executive function (EF) measures of “creativity” or cognitive flexibility such as Design Generation, may be able to predict who will respond favorably to training on systems like C- Speak Aphasia

• Recommend evaluations of EF be included as part of all assessments for treatment candidacy

Back to Pocket CSABack to Pocket CSAVideo sample: Mr. T• Several years post onset L MCA CVA• Severe nonfluent aphasia- no real words, only

syllable stereotypy; relative preservation of auditory comprehension; relative preservation of nonverbal executive function skills

• Lives with wife• Independent in most life activities• Has been learning PCSA for several months• Video shows combination of treatment tasks and

conversation

Hyperlink to PCSABO.mpg

Back to Pocket CSABack to Pocket CSAVideo sample: Mr. R• Several years post onset L MCA CVA• Severe nonfluent aphasia- stereotypy plus a

developing corpus of words; moderate impairment of auditory comprehension; relative preservation of nonverbal executive function skills

• Lives with wife• Independent in most life activities• Video shows how PCSA augments conversation for

some situations only• Since repetition is relatively preserved, he can use

the computer’s output as a model for natural speech also.

Hyperlink to PCSAconv.EG.mpg

Limitations specific to Limitations specific to Pocket CPocket C--Speak Aphasia and other similar Speak Aphasia and other similar

handheld AAC systems for aphasiahandheld AAC systems for aphasia

• Cognitive issues related to flexibility, switching• Assistant required to personalize boards- must

learn how to do the editing• Semantic issues related to knowledge of

semantic categorization (how the boards are designed)

• Physical limitations of the device-– battery/power limitations – sound – need for assistant who can link to desktop computer

for downloads/back-ups of boards

Social Limitations specific to Social Limitations specific to Pocket CPocket C--Speak Aphasia and other similar Speak Aphasia and other similar

handheld AAC systems for aphasiahandheld AAC systems for aphasia

• User and partner are looking at the device rather than at each other

• AS with any AAC device, using it tends to interfere with the feeling of a spontaneous, naturalistic, give and take interaction.

• This may be particularly true when there is some residual natural language capacity (as in the last sample)

Thank you!Thank you!

Questions?