Music, occupational, physical, and speech therapy interventions for patients in disorders of consciousness: An umbrella review.

BACKGROUND: Current clinical guidelines recommend that a multidisciplinary team inclusive of allied healthcare practitioners deliver assessment and intervention for disorders of consciousness. Allied health professionals include music, occupational, physical, and speech therapists. These allied health clinicians are challenged to select interventions due to a lack of evidence-based recommendations regarding rehabilitation interventions that support recovery of consciousness. This umbrella review synthesizes available systematic reviews (SRs) that describe occupational, speech and language, physical and/or musical therapeutic interventions for people with disorders of consciousness. OBJECTIVES: Identify and summarize evidence from systematic reviews (SRs) that examine allied healthcare interventions for patients with disorders of consciousness. Additionally, this umbrella review aims to evaluate the impact of allied health interventions on recovery of consciousness, methodological quality and risk of bias for the included systematic reviews. METHODS: An umbrella review was completed. The review was reported according to the Preferred Reporting Items for Overview of Reviews (PRIOR) guidance. Five academic databases (PubMed, CINAHL, PsycInfo, Web of Science, and the Cochrane Library) were searched for SRs and/or meta-analyses of allied health (i.e., music, occupational, physical, and speech therapy) interventions for disorders of consciousness. For included studies, data were extracted and quality of the SRs appraised using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 checklist. Data extracted from each SR identified the authors and years of primary studies, interventions, comparators, and outcomes related to recovery of consciousness (i.e., neurobehavioral/cognitive), functional status, physiological response pain, and adverse events. Rehabilitation interventions were categorized and described. RESULTS: Fifteen SRs were included and three of these reviews conducted meta-analyses. Identified rehabilitation interventions included: 1) sensory stimulation, 2) median nerve stimulation, 3) communication/environmental control through assistive technology, 4) mobilization, and 5) music-based therapy. SRs were published between 2002 and 2022 and included 2286 participants. Using the AMSTAR 2, the quality of reviews was critically low (k = 6), low (k = 3), moderate (k = 4), and high (k = 2). SRs within this umbrella review demonstrated significant heterogeneity in research methods and use of outcome measures to evaluate the recovery of consciousness within the primary studies. These factors influenced the ability to conduct meta-analyses. CONCLUSIONS: Sensory stimulation, median nerve stimulation, music therapy and mobilization are all interventions that demonstrate some level of benefit, but current SRs fail to prove benefit through high-level quality evidence. There is an indisputable need for continued rehabilitation research to expand options for treatment modalities and to ensure that the interventions being applied to DoC rehabilitation are evidence-based to improve consciousness and recovery.

Emergence from Disorders of Consciousness: Optimizing Self-Agency Through Communication.

Language and communication deficits are intrinsic to disorders of consciousness. This article will provide an overview of language and communication deficits that can significantly confound the accuracy of diagnostic assessment in these patients. Authors will also discuss interventions to promote early communication using assistive technology and augmentative communication rehabilitation strategies. Finally, this article will discuss the importance of family education as well as ethical considerations connected to the recovery of communication and adaptive strategies to support patient autonomy and enhance self-agency.

Evaluating Camera Mouse as a computer access system for augmentative and alternative communication in cerebral palsy: a case study.

Camera Mouse is a freely available software program that visually tracks the movement of facial features to allow individuals with motor impairments to control a computer mouse. The goal of this case study was to provide an evaluation of Camera Mouse as a computer access method as part of a multiple modality communication system for an individual with cerebral palsy. The participant was asked to reproduce sentences and respond to ethical dilemmas for language sampling. Tasks were completed using natural speech and an AAC solution consisting of Camera Mouse paired with an orthographic selection interface and speech synthesis. The participant completed a questionnaire for satisfaction with the introduced assistive technology. Camera Mouse resulted in higher intelligibility than natural speech, while natural speech had a higher rate. She used more complex language with her natural speech. The participant rated Camera Mouse as at least 3/5 on all measures, including 5/5 on weight and safety. The results of this case study suggest Camera Mouse is a promising computer access system for communication supported by the participant's satisfaction rating, expressive language, and synthesized speech production capabilities.

Designing an app for alternative access assessments: using interviews to uncover and define user needs.

To support effective alternative access assessment and service delivery for people with motor impairments, we are developing an app called Access Navigator. This paper describes the first stage of the project: the interviews we conducted as part of a discovery process to improve our understanding of user needs. We individually interviewed 8 assistive technology practitioners and 3 clients who use alternative access methods, to learn what practitioners were currently doing in their access assessments, identify opportunities for improving current practice, and understand what the assessment process was like for clients. We extracted 236 relevant quotes from interview transcripts, and clustered the quotes using the affinity wall method, yielding 42 themes. Here we present the 21 highest priority themes, along with the app requirements that support those themes. Results confirmed the need for a tool to support more effective assessments, with emphasis on taking the worry out of access assessments and supporting early success. Results also revealed specific needs such as flexible workflow, personalized test-drive tasks, and a choice of metrics (including client preference). With a richer understanding of user needs, we are in a much better position to design software that can address those needs.

Ability-Based Methods for Personalized Keyboard Generation.

This study introduces an ability-based method for personalized keyboard generation, wherein an individual's own movement and human-computer interaction data are used to automatically compute a personalized virtual keyboard layout. Our approach integrates a multidirectional point-select task to characterize cursor control over time, distance, and direction. The characterization is automatically employed to develop a computationally efficient keyboard layout that prioritizes each user's movement abilities through capturing directional constraints and preferences. We evaluated our approach in a study involving 16 participants using inertial sensing and facial electromyography as an access method, resulting in significantly increased communication rates using the personalized keyboard (52.0 bits/min) when compared to a generically optimized keyboard (47.9 bits/min). Our results demonstrate the ability to effectively characterize an individual's movement abilities to design a personalized keyboard for improved communication. This work underscores the importance of integrating a user's motor abilities when designing virtual interfaces.

Ability-based Keyboards for Augmentative and Alternative Communication: Understanding How Individuals' Movement Patterns Translate to More Efficient Keyboards: Methods to Generate Keyboards Tailored to User-specific Motor Abilities.

This study presents the evaluation of ability-based methods extended to keyboard generation for alternative communication in people with dexterity impairments due to motor disabilities. Our approach characterizes user-specific cursor control abilities from a multidirectional point-select task to configure letters on a virtual keyboard based on estimated time, distance, and direction of movement. These methods were evaluated in three individuals with motor disabilities against a generically optimized keyboard and the ubiquitous QWERTY keyboard. We highlight key observations relating to the heterogeneity of the manifestation of motor disabilities, perceived importance of communication technology, and quantitative improvements in communication performance when characterizing an individual's movement abilities to design personalized AAC interfaces.

Lessons for the AAC field: a tribute to Dr. David Beukelman.

On February 5, 2022, the field of augmentative and alternative communication (AAC) lost a giant when Dr. David "Dave" Beukelman passed away. As the readership of this journal is aware, Dave was one of the principal founders of the AAC field and devoted his career to providing a voice to those without one. Before AAC became a field, people who could not talk were invisible or seldom noticed, unless they were in the way. For more than 40 years, he was a catalyst for change in AAC clinical practice, research, dissemination, teaching, and public policy development. This tribute aims to honor Dave's lifelong mission of serving others by sharing some of his most timeless and valued lessons. Each lesson begins with one of Dave's most enduring quotes that is then followed by a brief synopsis of the lesson Dave hoped to convey.

Preference and visual cognitive processing demands of alphabetic and QWERTY keyboards of individuals with and without brain injury.

Following a severe brain injury (BI), some literate individuals who require augmentative and alternative communication (AAC) strategies to support communication may benefit from the use of onscreen keyboards to generate text. A range of layouts are available to these individuals within specialized communication software. However, a paucity of information is available to describe user preferences, user perceptions, as well as the visual-cognitive processing demands of such layouts. Such information is critical to guide clinical decision-making for keyboard selection and to provide patient-centered services. This study: (a) described the preferences and perceptions of two onscreen keyboard layouts (QWERTY and alphabetic) and (b) used eye-tracking analysis to investigate the visual-cognitive processing demands between these onscreen keyboards for individuals with and without BI. Results indicated participants in both groups held a strong preference for QWERTY keyboard interfaces and had extensive prior experience using the QWERTY keyboard layout on mobile devices. Eye-tracking analysis revealed less visual-cognitive processing demands using a QWERTY keyboard layout for both groups but were only statistically significant for those without BI. Results suggest that use of a keyboard layout that aligns with client preferences and prior experiences (i.e., the QWERTY keyboard for these participants) may lead to increased satisfaction with the communication experience and increased communication efficiency.

Personalization of Patient-Provider Communication Across the Lifespan.

People with disabilities are more likely to be hospitalized and use healthcare services relative to people without disabilities. They also report experiencing negative experiences interacting with health care providers during these encounters placing them at risk for preventable adverse medical events, poor quality of life, and dependence on others. Fortunately, providers and people with communication disabilities can take steps to improve these interactions by personalizing and implementing communication supports to empower people with communication disabilities to actively participate in these interactions and improve outcomes. The purpose of this article is to describe strategies that health care providers can use to develop and implement personalized communication supports for children and adults with communication disorders during health care interactions. Additional strategies are provided to guide people with disabilities as well as their community/school providers and families to prepare for health care interactions. Case examples are provided to illustrate use of these strategies in acute care, inpatient rehabilitation, and outpatient settings. The use of emerging training tools (e.g., video visual scene displays) and AAC partner training formats (e.g., just-in-time training) are also presented as future directions to expedite learning and implementation of communication supports in fast-paced and time-limited health care interactions.

Personalization of Visual Scene Displays: Preliminary Investigations of Adults with Aphasia, Typical Females across the Age-Span, and Young Adult Males and Females.

Visual scene displays (VSDs) are becoming an increasingly popular method of message representation within augmentative and alternative communication (AAC) supports; however, design factors can influence the effectiveness of these images as communication supports. One issue that has come to light in recent years is the fact that selecting personalized VSDs, which depict the person with complex communication needs or an individual with whom they are familiar, are preferred over generic VSDs, which depict unfamiliar individuals. Although personalization is likely an important factor in the usability of VSDs, these images may be difficult for clinicians to obtain. As such, compromises must be identified. The purpose of this study was to explore the effects of controlling personal relevance factors (i.e., age and gender of the people depicted in generic VSDs) on the image preference patterns of adults with and without aphasia. Results from three very preliminary study summaries indicate that gender and age are both mitigating factors in image preference, as males tended to indicate preference for VSDs containing males over those containing females. In addition, females tended to indicate preference for females of a similar age depicted in VSDs.

Perceived importance of AAC messages to support communication in rehabilitation settings.

PURPOSE: Permanent or temporary speech loss can occur due to a variety of medical conditions and often requires individuals to use augmentative and alternative communication (AAC) strategies and technologies to support communication. The use of AAC in medical and rehabilitation settings is critical to ensure the health, safety and psychological well-being of communicatively vulnerable individuals. METHOD: This study surveyed the perceived importance of communication messages within five categories (Basic Needs, Patient-Provider Specific Communication, Social, Feelings, and Messages for Young Children) by individuals with disability who have undergone recent medical care as well as by rehabilitation care providers. RESULTS: Results indicated that, with only a few exceptions, participants with disability more frequently selected all of the messages listed under the Patient-Provider Specific, Social, and Feelings categories compared to rehabilitation care providers' responses. Additionally, the individuals with disabilities selected messages that were more personalised to their specific care needs under Basic Needs. Both participant groups were asked to also suggest other messages that they perceived as important under each category. The other suggested messages demonstrated the potential need to provide personalisation to AAC displays to best meet the communication needs of individuals with disability.Implications for RehabilitationThere is a critical need for individuals who find themselves in medical settings (ICU, acute care hospital, rehabilitation hospital, etc.) to be able to communicate. This study provides preliminary information on the breadth of communication content that is perceived as relevant by individuals with disability and rehabilitation care providers. The need to provide personalized as well as a wide range of communication content options was of particular importance to individuals with disability. This information may provide specific guidance on how to best develop augmentative and alternative communication options for individuals in medical settings.

Optimized and Predictive Phonemic Interfaces for Augmentative and Alternative Communication.

Purpose We empirically assessed the results of computational optimization and prediction in communication interfaces that were designed to allow individuals with severe motor speech disorders to select phonemes and generate speech output. Method Interface layouts were either random or optimized, in which phoneme targets that were likely to be selected together were located in proximity. Target sizes were either static or predictive, such that likely targets were dynamically enlarged following each selection. Communication interfaces were evaluated by 36 users without motor impairments using an alternate access method. Each user was assigned to 1 of 4 interfaces varying in layout and whether prediction was implemented (random/static, random/predictive, optimized/static, optimized/predictive) and participated in 12 sessions over a 3-week period. Six participants with severe motor impairments used both the optimized/static and optimized/predictive interfaces in 1-2 sessions. Results In individuals without motor impairments, prediction provided significantly faster communication rates during training (Sessions 1-9), as users were learning the interface target locations and the novel access method. After training, optimization acted to significantly increase communication rates. The optimization likely became relevant only after training when participants knew the target locations and moved directly to the targets. Participants with motor impairments could use the interfaces with alternate access methods and generally rated the interface with prediction as preferred. Conclusions Optimization and prediction led to increases in communication rates in users without motor impairments. Predictive interfaces were preferred by users with motor impairments. Future research is needed to translate these results into clinical practice. Supplemental Material https://doi.org/10.23641/asha.8636948.

Designing effective AAC displays for individuals with developmental or acquired disabilities: State of the science and future research directions.

This paper reviews research on the impact of AAC display variables on visual attention and performance of children with developmental disabilities and adults with acquired conditions, and considers implications for designing effective visual scene displays (VSDs) or grids. When using VSDs with children with developmental disabilities or adults with acquired conditions, research supports the use of personalized photo VSDs that include familiar people engaged in meaningful activities, with navigation bars with thumbnail VSDs, located adjacent to the main VSD. Adults with acquired conditions seem to benefit from the inclusion of text boxes adjacent to the scene. Emerging evidence supports the use of motion to capture visual attention to VSDs (video VSDs) or to specific elements in VSDs. When using grid displays with children with developmental disabilities, research supports the use of spatial cues and clustering based on internal symbol colour to facilitate visual searching and selection. Background colour does not seem to facilitate searching for symbols on smaller displays, and may actually distract children from processing the meaningful components of symbols. Preliminary research suggests that the organization of onscreen keyboards and the number, types, and pairings of symbols in grids may impact performance of adults with acquired conditions. Directions for future research are discussed.

Challenges and opportunities in augmentative and alternative communication: Research and technology development to enhance communication and participation for individuals with complex communication needs.

The field of augmentative and alternative communication (AAC) has witnessed significant changes since its inception. AAC services are now considered for a much greater number of individuals with complex communication needs and there are many more AAC options available as communication supports, including a proliferation of technologies. The scope and options for communication within society have increased substantially to include a wide array of digital and social media. Individuals with complex communication needs have increased expectations for participation and engagement across a full range of environments-education, employment, family, healthcare, and community living. Despite these advances, there remain critical challenges that must be addressed. This paper discusses key advances in the AAC field, delineates challenges, and discusses future directions to address these challenges, specifically as they relate to research and development to enhance AAC interventions and technologies for individuals with complex communication needs and their families.

New and emerging access technologies for adults with complex communication needs and severe motor impairments: State of the science.

Individuals with complex communication needs often use alternative access technologies to control their augmentative and alternative communication (AAC) devices, their computers, and mobile technologies. While a range of access devices is available, many challenges continue to exist, particularly for those with severe motor-control limitations. For some, access options may not be readily available or access itself may be inaccurate and frustrating. For others, access may be available but only under optimal conditions and support. There is an urgent need to develop new options for individuals with severe motor impairments and to leverage existing technology to improve efficiency, increase accuracy, and decrease fatigue of access. This paper describes person-centred research and development activities related to new and emerging access technologies, with a particular focus on adults with acquired neurological conditions.

"Augmentative and Alternative Communication (AAC) Will Give You a Voice": Key Practices in AAC Assessment and Intervention as Described by Persons with Amyotrophic Lateral Sclerosis.

The purpose of this study was to describe the perceptions of persons with amyotrophic lateral sclerosis (pALS) who use augmentative and alternative communication (AAC) with the AAC assessment and intervention process. Twenty-one pALS with complex communication needs participated in a multipart survey (and follow-up e-mails) to provide information on their experiences with AAC assessment and intervention. A majority of the participants agreed with the importance of three key AAC intervention principles: appropriate staging of the timing of assessment and intervention activities, inclusion of communication partners, and the use of multiple modalities and strategies as communication supports. Most participants reported that their assessment and intervention experiences included at least some aspect of these three key practices. The results of this study suggest that the identified best practices in AAC should be reviewed and implemented on an individualized basis for pALS with complex communication needs.

Integrating end-user feedback in the concept stage of development of a novel sensor access system for environmental control.

PURPOSE: This article illustrates user-centred design of a novel sensor access system for environmental control in the concept stage of development. METHODS: Focus groups of individuals with disabilities and rehabilitation healthcare professionals were provided with video illustration of the technology and asked to provide quantitative and qualitative feedback through a semistructured interview process. Qualitative methods were employed to analyse transcribed comments to develop themes supporting ongoing development of the technology. RESULTS: Both end-user streams rated the original design features of the sensor access system (alternative interface to assistive technologies, having wireless capabilities and not requiring batteries) as having high potential value. Both groups identified a need for the future design of the sensor technology to be able to capture minimal/reduced movements for those with severe physical impairments. Themes included (1) the sensor technology could be individualized/customized to accommodate the user, (2) minimal positioning and set-up requirement and (3) technology that alleviated problems encountered with touch-based solutions. CONCLUSIONS: Inclusion of end-user feedback provided the research team with valuable information that supported the initial conceptualization of the design features of the technology and provided valuable data to support development of a new prototype that can capture more reduced/minimal movements. Implication for Rehabilitation User-centered design of assistive technology is essential to the development of technology that can meet the unique needs of those with the most severe physical impairments. New sensor technology may alleviate some of the access challenges faced by individuals with severe physical impairments. Collaboration between all key stakeholders (individuals with disabilities, rehabilitation professionals, researchers, and developers) is an essential component in the iterative assistive technology design process.

Surface electromyographic control of a novel phonemic interface for speech synthesis.

Many individuals with minimal movement capabilities use AAC to communicate. These individuals require both an interface with which to construct a message (e.g., a grid of letters) and an input modality with which to select targets. This study evaluated the interaction of two such systems: (a) an input modality using surface electromyography (sEMG) of spared facial musculature, and (b) an onscreen interface from which users select phonemic targets. These systems were evaluated in two experiments: (a) participants without motor impairments used the systems during a series of eight training sessions, and (b) one individual who uses AAC used the systems for two sessions. Both the phonemic interface and the electromyographic cursor show promise for future AAC applications.

Speech Recognition for Environmental Control: Effect of Microphone Type, Dysarthria, and Severity on Recognition Results.

This study examines the use of commercially available automatic speech recognition (ASR) across microphone options as access to environmental control for individuals with and without dysarthria. A study of two groups of speakers (typical speech and dysarthria), was conducted to understand their performance using ASR and various microphones for environmental control. Specifically, dependent variables examined included attempts per command, recognition accuracy, frequency of error type, and perceived workload. A further sub-analysis of the group of participants with dysarthria examined the impact of severity. Results indicated a significantly larger number of attempts were required (P = 0.007), and significantly lower recognition accuracies were achieved by the dysarthric participants (P = 0.010). A sub-analysis examining severity demonstrated no significant differences between the typical speakers and participants with mild dysarthria. However, significant differences were evident (P = 0.007, P = 0.008) between mild and moderate-severe dysarthric participants. No significant differences existed across microphones. A higher frequency of threshold errors occurred for typical participants and no response errors for moderate-severe dysarthrics. There were no significant differences on the NASA Task Load Index.