Re-app-ilitation Smart use of Smart-Phones in Therapy

Colleen Kerr Optimal SP

Re-app-ilitation 2

Colleen Kerr

Emma Charters (RPA, Liverpool BIU)

Colleen Kerr

Re-app-ilitation 3

Part 1 – Evidence App-lenty (Emma) Part 2 – Practical Applications (Colleen)

Systematic review

• Efficacy of electronic portable assistive devices for people with acquired brain injury: a systematic review. 2015

– Dr. Grahame Simpson & Lauren Nguyen

• Evaluation:

– RCT: PEDRO

– Group: Downs & Black

– Single: SCED

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Other systematic reviews out there…

• de Joode et al., 2010

• focused on the usability of assistive technology for patients with cognitive and memory deficits

• Morris & Reinson, 2010

• focused on the usability of assistive technology for patients with memory deficits only

• Gillespie, Best, and O’Neil (2012)

• Assistive devices that were and were not portable

Missing Communication!!

Variable methodological quality rating systems

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Results • Participants: Mix of neurologically based brain injury

• Range of Devices

• Training:

• Range of clinicians

• Training time: 30-180 min

• Cueing method:

• Visual, auditory and/or tactile

• Errorless learning

• Measures:

• Participant

• Carer

• Clinician

• Outcomes:

Positive Neutral

PDAs

Neuropage

Smart phones

Voice memo

AAC

Mobile phone

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Results

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Study Device Goal

Bo a Mobile Phone ADL Recall

Bo a PDA Exercise & ADL Recall

Culley & E a s Mobile Phone Goal Recall

Dowds PDA ADL Recall

E a s Neuro-page ADL Recall

Fish Mobile Phone Phone Call Recall

Gentry PDA ADL Recall

Hart Voice organiser Goal Recall

Kirsch Pager Information Recall

Kirs h PDA Navigation

Laffont Speech Synthesizer AAC 9

Study Device Goal

Sohlberg PDA Navigation

“tapleto Mobile Phone ADL Recall

“ o oda & ‘i hards Smart Phone ADL Recall

“ o oda & ‘i hards Smart Phone ADL & Phone call Recall

Thone-Otto & Walther PDA + Mobile phone Information & ADL Recall

Van Den Broek Voice organiser Information & ADL Recall

Van Hulle & Hux, 2006 Wrist alarm + voice recorder ADL Recall

Wade & Troy, 2001 Mobile phone ADL Recall

Wilson et al., 1997 Neuro-page ADL Recall

Wilson et al., 2001 Neuro-page ADL Recall

Wright et al., 2001 Pocket computer ADL Recall

Yasuda et al., 2002 Voice message recorder Diary writing and ADL Recall 10

Barriers

• Devices • Motivation • Prior knowledge + acceptance • Motor and sensory impairments • Apps available • Distractions • Cost • Accidental setting changes • Internet connection • Privacy • Infection control

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For the future

• Statistical analysis

• Validated outcome measures

• Document the details

• Clinician’s background

• Teaching + cueing strategies

• Participant factors

• Goal/function

• Adverse events

• Larger participant numbers

• Control groups

• Randomisation + blinding strategies

• Independent assessors

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Themes

• Majority of recent research is focused on:

– App choice

• Rapid rate of app development

– Institution description of their methods

– Single or small group case descriptions

• Broadening the EPAD scope:

– Clinicians

– Clinical populations

– Types of devices

– Functions and goals

– Measurement tools

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EVIDENCE SINCE THE REVIEW…

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Our role

Rehab clinicians have a role in helping to select:

Appropriate smartphone/tablet/mobile tech

Apps and accessories

AAC (augmentative and alternative communication)

(Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association, 2013)

Evaluate appropriateness of app

(Wild, 2014)

Feature match Apps to the patient’s strength’s and needs

(Gosnell, 2011)

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SELECTION

• Consider:

– Length of time in marketplace

– Frequency of updates

– Functioning after updates

• (Wild, 2014)

• Pre-injury familiarity with devices

– Although they may not have been using them in a way that will help them post injury

• (Wild, 2014)

• Consider limitations of a device i.e. trouble shooting if battery runs out

• (Gentry, 2014)

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Study Device + Apps Outcome

Szabo &

Dittelman

2014

iPad, small talk aphasia, pictello and

story creator for script development,

photo editor, language therappy, dragon

dictation, awesome memory

iPad used in group context for people who pre-stroke had little exposure

to mobile technology

mobile and tablet devices can be used by people with aphasia as a daily

communication and organisational tool

Ramsberger

& Messamer

2014

iPad, dragon dictation, little story maker,

notepad pro

Incorporate smart phone and tablet technology in a step-wise fashion

incorporating client’s strengths/weaknesses and goals, considering the device, app and accessibility

Wong et al

2014

Smart phone Difficulty learning new technology (stroke), forgetting how to use

smartphone (TBI + stroke)

- entertainments apps associated with less anxiety

- therapy apps associated with more productivity

- communication apps associated with better productivity, social

integration and verbal learning

Kurland,

Wilkins &

Stokes 2014

iPad, iBooks + GoToMeeting iPads are a promising tool to maintain and progress treatment goals

attained in intensive aphasia therapy regardless of aphasia type and

familiarity with tablet technology.

Mehta et al

(2012)

Smart phone Monitors fundamental frequency, sound pressure level and model-based

glottal airflow. Piloted an ambulatory biofeedback tool which has the ability

to aid skill acquisition in voice therapy.

Hoover &

Carney 2014

iPad, proloquo2go, pictello, notes,

maps, calendar, camera, small talk &

skype

Preliminary evidence to support use of tablet technology in a range of

client centered goals with scope for generalisation across environments

Gurol-

Urganci et al

(2013)

Mobile phones Low-moderate quality evidence shows that SMS and MMS reminders do

improve attendance compared to no reminder or a postal reminder. 17

Study Clinical factors to consider in device and app selection

Ramsberger

& Messamer

(2014)

Assess then develop client centred goals

Assess motor, cognitive + sensory requirements of the device and apps under consideration

Assess the device + apps accessibility for the client

DeCurtis +

Ferrerr

(2011)

Participants: age and developmental appropriateness

Parameters: cost and environment

Purpose: what is the advertised purpose of the app

Positioning: ability to hold, position and use the device

Playtime (ADLs/leisure): how is the device incorporated into usual activities

Potential: how can it be used in more everyday activities

Dunham

(2011)

Apps can serve the same purpose as books, toys, games, stimulus cards and worksheets.

Smartphone and App technology can aid generalisation of treatment goals to more natural

environments

Care needs to be taken that treatment approach should not be dictated by the smartphone or app

Gosnell

(2011)

- Identify the person’s strengths + weaknesses and device access

- Clinician should be knowledgeable about apps and devices

- Clinician matches, compares and selects appropriate apps

- Functional assessment of appropriateness

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Part 2 - Practical Considerations Objectives: 1. Offer thoughts on staying current in a

changing app landscape 2. Outline a case where app-based therapy

appears to have been integral to intervention. 3. Consider factors that may be important in

smartphone/technology uptake.

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SLPs Talk Apps APPropriate Apps – SPA Member Group Tactus Therapy Solutions Jane Farral Consulting (AAC) iPhone, iPad, iTouch for Speech Therapy The Appy Ladies iTeach – Apps for the Classroom Appy therapy American OT Associaton (app repository – members)

Closer to home.... http://www.tbistafftraining.info/SmartPhones/SmartPhones1.html

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For Patients TAVISTOCK Aphasia Software finder http://www.aphasiasoftwarefinder.org National Aphasia Association Aphasia Hope But definite potential for too much information.....

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Case Study 2 – Kay – 21yo Motor vehicle accident 2010. GCS of 4 and required intubation at the scene of the accident. Traumatic brain injury characterised by left frontotemporal subdural haemorrhage with mass effect and intraventricular extension, bilateral frontal contusions, traumatic subarachnoid haemorrhage, left temporal contusions and midbrain haemorrhage. Bifrontal craniectomy, evacuation of the subdural haemorrhage and frontal haematoma and an extraventricular drain. Multiple left facial fractures, fracture of the right skull and a midclavicular fracture. PEG . History of depression and assault. Kay does not show functional communication skills for daily tasks.

She is unable to express her needs using talking/speech or gestures or to comprehend what is said to her. Kay’s daily needs are determined by her routine and what she is doing. Kay demonstrates ability to tolerate small amounts of puree however at this stage she

remains nil by mouth.

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Observed Behaviours 12.12.11

Looks towards unseen speaker Looks outside in response to question about rain (novel response not repeated in other contexts) Selective (ie preferential) focus on TV channels objects/people on command No gaze response to questions about bedroom, toys, Xmas tree.

Raises head and smiles when asked for photo (but response repeated at other times) Lowers head/leans forward to disengage Looks up to her name (not others)

Indiscriminate reaching/pulling of objects in room. Intermittent response to offered hand – shakes gently (without grabbing) Allows cleaning of clothes/hands by unfamiliar

Indiscriminate reaching/grabbing for carers but not for directional purposes Leans body in chair to express interest about unseen speaker

Indiscriminate ripping of paper/fabric Carers report sustained interest in bubble wrap and shredding (and passing) tinsel Throws spoon in agitation Throws toy in agitation Holds lifter belt in place with verbal and context cue. Tucks blanket under legs. Attempts to self propel in wheelchair.

Removes and rips paper/pictures but no meaningful response possible due to behaviour

Perseverative no-no-no (not meaningful) Head nod/shake used in response to basic needs but no consistency for biographical or immediate environment Discernible “Yup” when asked about food (novel response not replicated)

‘would you like some yoghurt’ lifts head and looks at food on bench (novel response not replicated)

X Let’s go into your room (no gaze) X Let’s watch the TV (no gaze) X I can see you are ready for Xmas with the Xmas tree (no gaze) Can you get the belt for me – looks down and holds

belt

No verbal responses to questions. Carers report occasional obscenities. Responding to hand shake but not initiating Not able to assess use of remote/light switches/phone due to behaviour (throwing)

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Pre-requisite cognitive skills

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Eating – shaping Matching pictures, photos (VAT) Sorting socks Matching dinner plates Picture cards or object cues to accompany directions Increasing periods of shared activity

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Dyspraxia hierarchy

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3.5 years post onset Echolalic and some obsessive behaviours. Some response to questions and cued naming just emerging prior to interstate transfer I Get It - Social stories trialled for continence training but not successful – had to remove iPad for a time Facebook – picture selection, news from outings Those Days Skype to group home residents/family interstate Clinical handover provided by video on iPad and Story Creator (stories about me) Ongoing improvement ??

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Why did apps make a difference?

•High degree of carer interest/engagement – young ACWs •All carers using smart-phones themselves and modelling to client •Pre-injury behaviour of client •Acceptability even on low level matching tasks •Used in conjunction with real life activities and other therapy modalities •Flexibility for upgrade as client needs changed – combination of apps and in-built features of device

•In this case no prospect of independent use so structured clinical apps were not used

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Practice Directions Technology in Supported Accomodaton Sloan Monash University (2015 ASSBI in press)

• 138 supported accommodation residents - house manager surveys • majority urban, ABI, tablet, often self-prescribed or self-provided • primary use social, recreation, communication, education

“build successful integration of technology into daily lives of people with focus on independence, autonomy, social connection and skill development” “deliver effective training, ongoing support structures and evaulation of technology over time to avoid abandonment”

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colleenk.optimalsp@gmail.com Emma.Charters@sswahs.nsw.gov.au

References

(Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association, 2013)

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