Abstract: In the case of aphasia and associated disturbances of written language, therapy can be described in terms of participation, activities and disabilities. Specific neurolinguistic impairments may be treated additionally with the help of specially designed computer-aided therapy programmes. The Integrated Therapy System ITS is a new approach in the area of computer aided neurological research and rehabilitation. Using an example from everyday life, this lecture presents the collecting of data, their interpretation and their role in generating and proving the hypotheses of the underlying mechanisms of a given language impairment. One reason for the development of the ITS was the need for precise descriptive data during therapy (e.g. reaction time, error type, problem solving strategies). This data (a) is used in planning the next steps in therapy and (b) serves as an objective database which reflects the improvement in therapy. As part of a quality management system, the ITS may be used to prove the efficacy of our intervention in the field of disabilities. The second part of the lecture gives a short overview of the Integrated Therapy System ITS. It will be shown that sophisticated concepts do not have to capitulate in the face of demands for economic efficiency. Our aim is to sufficiently supply the population with high-quality aphasia therapy. Possibilities and limits of computer aided aphasia therapy with the ITS can be discussed.

 

 

Usually, a therapist’s daily work requires him to possess specific knowledge, experience, patience, responsibility, curiosity, creativity and conviction. The first two features, knowledge and experience, are measurable dimensions and part of educational programmes for speech language therapists. The five latter are nonetheless important factors which contribute to the quality of intervention. They belong to a therapist’s personality. All dimensions should play their role in therapists’ activities.

But what if curiosity wins the battle against responsibility, and what if conviction beats knowledge? Especially conviction alone is an insufficient adviser. The nature of aphasia therapy makes therapists prone to such internal confrontations, particularly when deciding whether it was the applied intervention which led to progress in therapy or not. Therapists probably tend to believe in this, but they would certainly like to know it for certain.

Our contributions toward increasing knowledge and decreasing uncertainty are presented today. We will do that on the one hand from the viewpoint of quality management and on the other hand from the viewpoint of the ICIDH-2 classification. We will also show how to improve knowledge with the help of the Integrated Therapy System - an easy to use computer-based solution, which is embedded in the necessary infrastructure of neurological research and rehabilitation.

In the case of aphasia and associated disturbances of written language, changes in the course of therapy can be described in terms of the WHO classification ICIAP (WHO, 1980). Let us show to what extent we may place the Integrated Therapy System in the new classification ICDIAP (ICIDH-2, Gress-Heister personal communication) and where it has its place. Later, we will consider its role in quality management.

Participation or participation restriction (partly the former category ‘handicap’) means by definition the nature and extent of a person’s involvement in life situations in relation to impairments, activities, health conditions and contextual factors, e.g. exchange of information in a social context as interaction between a person’s health condition and contextual factors. In this category, the therapy service is clearly restricted to supportive and educational interventions aimed at assisting the patient or family in identifying key issues and problem solving around them. To our knowledge there exists no standardised procedure for assessing the category "participation" in terms of quality management, with the exception of questionnaires (satisfaction ratings) for patients and family members. The use of the Integrated Therapy System will have its indirect impact here, but its role will be limited.

Activities or activity limitation (partly the former category ‘handicap’) mean by definition the nature and extent of functioning at the level of the person, e.g. the ability to formulate messages and to interpret and understand received messages. Non-verbal means of communication such as facial expression and gestures are also included. The therapy service offers role-play simulating real-life interaction as it can be observed in the family, with friends, at the patient’s workplace, in a supermarket or at a shop. Verbal as well as non-verbal interaction is applied. The therapist’s personal presence in a face to face situation plays an important role in the therapy room or in group-settings. Only a few rating scales for assessing performance in aphasic patients’ communicative activities in daily living are available. Quality management may be done or applied with the Amsterdam Nijmegen Everyday Language Test (Blomert et al.,1994). Success in communicative verbal activities in daily living is partly based on retraining/therapy of basic skills. The use of the Integrated Therapy System will have a more direct impact here because it offers the opportunity to retrain in the underlying basic skills.

Disabilities (the former categories ‘disabilities and impairment’) are by definition a loss or abnormality of body structure or of a physiological or psychological function, e.g. syndrome oriented definitions of disabilities and/or specific neurolinguistic and/or neuropsychological impairments such as agrammatic sentence production, phonemic and semantic paraphasias, paralexias, word finding difficulties, memory loss, reduced divided attention and others. The therapy service offers exercises on a broad scale, nowadays still mainly in face to face settings. One can assess the disabilities in terms of standard syndromes and in terms of the type and extent or severity of a syndrome as for instance with the AAT (Huber et al, 1980). Terms as "severe Broca’s Aphasia" or "mild Wernicke’s Aphasia", fluent or non-fluent aphasia are often used in the effort to quantify and qualify the nature of the disabilities. While these categories are still of some importance for clinicians in their daily work (they reflect frequently observed statistical patterns), they are of no help in understanding the impairments and their relation to each other (Hoffmann, 1987), and even less in their relation to communicative verbal activities as described above. In a world with increasing attention to aphasia and a huge amount of new scientific findings about the nature of aphasia, we are still far from understanding what is going on in a single case. In the course of conventional aphasia therapy in a face to face setting, the therapist is restricted to a certain degree, insofar as his attention and capacity are concerned: unexpected phenomena are neglected by the therapist and objective reaction times are not or rarely registered. Clinicians have learned from science to observe error types, but are unable to write down more than a few observed phenomena, not to mention the complex interplay of dozens of factors over a period of time. With the help of specially designed computer-based therapy programmes, this problem may be partly solved. The Integrated Therapy System comes into the frame particularly in the rehabilitation of impairments.

Fifteen years ago, beginning with the instruments "quality control" and then "quality assurance", industry focused on products alone. It was an expensive and static method which did not bring the expected improvement in the products. Some years later, the term "quality management" was invented together with a more efficient procedure. In order to apply quality management in the health services, one must consider

1. the organisation and infrastructure needed for therapy services
2. all measures taken throughout the therapeutic process and
3. quantity and quality of therapy outcome

One can characterise this new procedure, which is in contrast dynamic, as follows

1. repeatedly define the actual state and the required state
2. repeatedly define the difference between them
3. repeatedly define goal, progress and results in the effort to minimise the difference.

As part of a quality management system, the ITS may be used to control the efficiency of our intervention in the field of disabilities. In the light of the above mentioned points, the crucial questions which quality management and evidence based aphasiology should help to answer are:

1. Has the patient been able to profit in any measurable dimension in the category of impairments during therapy ?
2. Has the patient been able to regain / build up / transfer competence towards a better performance in daily communication ?
3. May the improvement in performance in daily communication be viewed as the result of therapeutic intervention ?

Question (a) is answered by the internal statistical protocol of the ITS, dependent on the type of exercise and its intention and additional testing procedures. Some examples will be given later.

Question (b) is up to the therapist, who must compare the results of question (a) to his evaluation of the remaining handicap (activities and participation).

Question (c) is up to aphasiology and it has an immense importance for the future. To answer this question with reasonable certainty, much work lies ahead.

One reason for the development of the ITS was the need for precise descriptive data during therapy (e.g. reaction time, error type, problem solving strategies). These data can be used to plan the next steps in therapy and serve as an objective database for the therapist which reflects improvement in therapy. Using an example from everyday life, we now present the collection of data, its interpretation and its role in generating and proving hypotheses about the underlying mechanisms of a given language impairment. This will be done bearing models of normal language processing in mind.

Case KP:

One can imagine a prototypical exercise with a written word and a target picture. Additionally, the exercise presents one to seven pictures as distractors, depending on the patient’s error rate. In case of a small amount of errors, the programme will automatically increase the number of distractors and vice versa.

The statistical protocol in the following example displays at least three different types of accumulated information: The green line indicates the correctness rate in percentage terms for each therapy session. The blue line indicates the average reaction-time in the case of correct reactions. The red line on the bottom indicates the changing "pure chance level" which varies according to the increasing number of distractors offered to the patient. This data is collected during therapy and displayed over a time period of 26 therapy sessions.

A totally different picture emerges in another exercise. Here, the patient is confronted only with pictures. His task is to search for two only two pairs of similar words presented together with distractors. No progress at all was observed in the time period except for a decreasing reaction time.

"Correctness-rate", "average reaction-time" and "pure chance level" are not the only data the ITS may provide. If the developer wishes to implement other analyses of any reaction pattern, he can easily do so.

The following chart for instance displays a portion of the results of an exercise known as "writing to dictation" over a time period of 19 therapy sessions. Analysed and compared are the relative distribution of different error types, as anticipation, perseveration and distractors. The results clearly indicate a higher percentage of anticipations compared to perseverations in this special case.

With the appropriate infrastructure sophisticated concepts do not have to be abandoned in the face of demands for economic efficiency. Our aim is to supply the population with sufficient high quality aphasia therapy: Information technology should become accepted by all participants if the needs of professionals and patients are met concerning quality and if the technology is affordable. These two factors will contribute to and determine the success of a new treatment or a new technology in future. In the best case we will create a less costly and more effective treatment as it is shown in the following cost-effectiveness plan (adapted from Briggs et al 1999)

In order to reach this goal we had to consider the following demands:

5.1 Therapists should develop their own concepts – tailored for the individual needs of the patient, or use ready-made therapy modules and save time in planning and preparing therapies for individual patients.

5.2 All ready-made therapy modules should be based on the same basis, namely a flexible, open and easy to use system minimising costs of development.

5.3 Ready-made therapy modules should make the knowledge of experts from various fields available to all therapists.

These and many more demands have emerged out of the research for a computer-based technology. The result – the Integrated Therapy System – consists mainly of three parts: First of all multimedia databases with collections of digitised therapy materials as e.g. written and spoken words and sentences, drawings etc. The second part of the system consists of the development system, and a visual environment with a specially designed programming language, which can be easily learned within hours. The third part represents the therapy environment for conducting exercises or tests and evaluating the statistical results. The system contains therapy materials and some ready-made exercises, but the therapist is still able to change or replace material for his or her own needs in developing new exercises, as it can be expected from an open and flexible system. Unlike other approaches, the ITS does not limit you to any predefined structures or methods.

Furthermore, the system is embedded into the necessary infrastructure. This infrastructure consists of research partners at universities, consultants from various fields such as neurolinguistics, neuropsychology, neurology, special education, sociology and psychology. Also included are therapists and scientists who develop and publish new exercises and methods, a quality board responsible for the quality management of newly developed therapy modules or methods, partners who evaluate therapy modules in daily practice, an infrastructure for distribution and corporate partners in medical engineering industries.

Until now, computer aided intervention has always implicated the mental image of a patient struggling with a mouse and a keyboard - and the programme itself.

These problems have become obsolete since all ergonomic factors have been considered. New designs of user interfaces in combination with technologies such as touchscreens allow patients to concentrate on the exercises alone – without having to learn how to use a computer. All the patient has to do is work on the exercise. Because exercises can be designed to be adaptive within certain limits, we can also think about remote therapy.

Computer-aided speech therapy is certainly not restricted to a working room at the hospital and the therapist’s actual presence. A portion of the aphasic population without severe accompanying neuropsychological impairments is able to handle their rehabilitation without the presence of a therapist. This kind of therapy is well known. Remember the patient who takes paper and pencil exercises to his room in the hospital or at home. With the Integrated Therapy System, he now has "a sheet of paper" which speaks and reacts intelligently to his actions. Even more important, this "sheet of paper" can be returned with a complete reaction protocol to the therapist. This increases not only the quality, but also makes much more therapy available to the patient. Of course, this kind of therapy should only be offered on prescription in order to guarantee that a supervising specialist, a speech language therapist, decides about the content and combination of the exercises.

Advancing technology makes it even possible to offer remote therapy to immobile patients who are confined to their homes with severe motor handicaps. With an additional channel like video conferencing, great distances do not preclude the availability of cognitive therapy.

We hope you have been able to gain insight into the possibilities and the limits of computer aided aphasia therapy as has now become possible with the Integrated Therapy System. Before we finish, let me guide your attention to the exhibition outside. The ITS is on exhibit there, ready to prove what we have presented to you today.

Briggs, A.H., Gray, A.M., (1999) Handling uncertainty when performing economic evaluation of healthcare interventions. Health Technology Assessment 1999, Vol.3, No. 2

Hofmann, E. (1987) Der Aachener Aphasie Test als therapierelevantes Abklärungsverfahren? Ein Beitrag zu seiner kritischen Anwendung Neurolinguistik, (1), 27 - 39

Huber, W; Weniger, D; Poeck, K; Willmes, K., (1980) Der Aachener Aphasie Test Aufbau und Uberprufung der Konstruktion. Nervenarzt. 51(8)

WHO, (1980) International classification of impairments, disabilities, and handicaps (ICDIDH) Geneva : World Health Organization 1980