Using assistive technology software to compensate for writing and reading impairments in aphasia

Background: Aphasia is a language impairment affecting approximately one third of people after stroke. It can disrupt speaking, comprehension, reading and writing. This thesis concerned people with aphasia (PWA) with spelling and writing impairments (some also had reading difficulties) but relatively preserved speech and comprehension. Aims: 1. Consider the evidence for writing treatment interventions with a systematic review of the literature; 2. Conduct a pilot study testing the acceptability of a compensatory narrative writing treatment intervention using assistive technology (AT) software; 3. Report an empirical study which designed, delivered and evaluated a program to train ten PWA to operate two mainstream AT packages (Dragon NaturallySpeaking™, a voice recognition software (VRS) to support writing via dictation, and ClaroRead™, supporting reading via auditory processing). The study tested whether: a) AT could be used to produce functional narrative writing, b) reading support promoted writing success c) the intervention could be customised to suit individual goals. Methods: 1. Systematic literature review Electronic databases were searched; 53 papers meeting inclusion criteria were identified. Data were extracted, papers were critically appraised and their findings described. 2. Pilot Ten week AT training with two PWA to test acceptability of the intervention, design training schedule and materials, and test quantitative assessments and qualitative data collection methods for the main study 3. Main study Design and setting: Small group study with mixed methods, repeated measures design. Assessments and AT training in participants’ homes or at City, University of London. Participants: Ten participants meeting eligibility criteria (over 18 years old, medically stable, no significant cognitive impairment, aphasia due to stroke, presenting with acquired dysgraphia) were recruited via convenience sampling. They were not receiving speech and language therapy, had no marked evidence of neuromuscular, structural or motor-speech impairments, nor self-reported history of developmental dyslexia. Measures and procedure. Participants received 7-10 one-hour individual training sessions. Screening (language, cognition) and diagnostic (single word writing, single word reading) assessments took place at T1 (first baseline). Outcome measures (narrative writing, reading comprehension, quality of life, mood) were taken at T1 and repeated at T2 (second baseline), T3 (end of intervention) and T4 (three month follow up). Participant observation occurred throughout training; qualitative semi-structured interviews, a social participation assessment and cognitive monitoring took place at T2, T3 and T4. Results: 1. Systematic literature review Writing treatments were effective but often focused on single word production and seldom tested functional generalisation. Most were single case or small case series studies with remediatory goals; few used qualitative methodologies or investigated the impact of reading deficits. All narrative writing therapies were delivered via technology. 2. Pilot The intervention was acceptable to participants. Training schedule and materials were created and refined; quantitative outcome measures were finalised; emphasis on participant observation was increased. 3. Main study: Keyboard narrative writing was significantly improved by AT (Friedman’s χ² (3) = 8.27, p = . 041), as was keyboard reading comprehension (Friedman’s χ² (3) = 21.07, p < . 001), indicating compensatory effects of both AT. There was no change over time in pen and paper assessments of writing or reading, indicating no remediatory effect. A wide range of written genres were produced. Social network size significantly increased. There were no significant changes in mood or quality of life. Individual success rates varied; diagnostic and observation data suggested contributing factors were attitude, creativity, preserved speech production skills, spectrum of other aphasic traits, therapeutic goals, and cognition. Conclusion: The compensatory customisable AT training was acceptable to eight of ten participants, and resulted in significantly improved narrative writing performance. Implications: Compensatory AT interventions serve as a useful adjunct to remediatory spelling interventions, and are particularly useful for supporting functional narrative writing.