A serious game for speech training in dysarthric speakers with Parkinson's disease: Exploring therapeutic efficacy and patient satisfaction.

BACKGROUND: The increasing need for speech therapy due to our ageing population raises the demand on therapeutical resources. To meet this demand, innovative delivery of speech training is required. eHealth applications may provide a solution, as intensified and prolonged training is only possible and affordable in patients' home environment. AIMS: This study explores the effects on speech intelligibility of game-based speech training that provides automatic feedback on loudness, pitch and pronunciation. Additionally, we investigate how satisfied patients are with the game-based speech training and how they experience the automatic feedback. Furthermore, patients' preferences for game-based speech training compared with face-to-face training are explored. METHODS AND PROCEDURES: Eight adult dysarthric speakers with Parkinson's disease (PD) completed a 4-week game-based speech training in their home environment. For each speaker, 24 speech utterances were audio recorded 4 weeks before (T1), immediately before (T2) and immediately after (T3) the training. All speech samples were rated on speech intelligibility by 10 untrained listeners, by comparing them with the corresponding utterances realized by a healthy speaker. Changes over time were analysed using a linear mixed-effects analysis. Patient satisfaction with the game and the automatic feedback was assessed using a questionnaire. The preferences of patients were collected using a paired comparisons procedure in which the patients were asked whether they would prefer game-based or face-to-face speech training in four hypothetical scenarios with different hypothesized levels of speech improvement. OUTCOMES AND RESULTS: While there was no significant difference in speech intelligibility ratings between T1 and T2, we did find one between T2 and T3. At T3, speech intelligibility was rated higher than at T2, indicating positive effects of the game-based speech training. Patients generally seemed satisfied with the game as average ratings were above 7 on a 10-point rating scale. Generally, patients agreed with the automatic feedback and could use it to positively change the way they spoke. Patients prefer the training that provides the highest hypothetical improvement, and thus do not prefer face-to-face above game-based therapy. CONCLUSIONS AND IMPLICATIONS: The results of this study suggest that dysarthric speakers due to PD see game-based speech therapy as a valid alternative for face-to-face therapy and that it leads to an average improvement in speech intelligibility. For an optimal effect and user satisfaction it should preferably not be used in isolation but in combination with face-to-face training. In this manner, the strengths of both therapeutic deliveries can be harnessed. WHAT THIS PAPER ADDS: What is already known on this subject Dysarthric speech in patients with PD is known to benefit from intensified and long-term speech therapy. The increasing need for speech therapy due to our ageing population raises the demand on therapeutical resources making highly frequent and long-term therapy difficult. eHealth provides the opportunity to intensify and prolong speech training in patients' home environment. A drill-and-practice method was employed and investigated in a web-based speech application, indicating positive effects on speech intelligibility. However, participants indicated a lack of variation in exercises making the training less enjoyable. Other research showed that serious games can increase enjoyment during training. What this paper adds to existing knowledge The results of this study show that it is possible to develop a serious game that can be successfully used for speech training by patients with dysarthria due to PD. Comparing speech intelligibility ratings before and after training, we observed significant improvements in speech intelligibility ratings. Patients generally agree with the automatic feedback and can use it to positively change the way they speak. Average ratings were above 7 on a 10-point scale, indicating that patients are satisfied with the game. Patients prefer the type of training (game based or face to face) that provides the highest hypothetical improvement. What are the potential or actual clinical implications of this work? The results of this study suggest that game-based speech training can improve speech intelligibility in patients. This indicates that it can be considered a suitable approach in the treatment of patients with dysarthria due to PD. Patients do not prefer game-based training above face-to-face training in all scenarios. For that reason, for every patient one should carefully consider how to optimally combine game-based and face-to-face training.

eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects.

BACKGROUND: The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on health care quality and to be a promising alternative to face-to-face health care contacts. Surprisingly little is known about possible adverse effects of eHealth apps. OBJECTIVE: We conducted a scoping review on empirical research into adverse effects of eHealth apps that aim to deliver health care at a distance. We investigated whether adverse effects were reported and the nature and quality of research into these possible adverse effects. METHODS: For this scoping review, we followed the five steps of Arksey and O'Malley's scoping review methodology. We searched specifically for studies into eHealth apps that replaced or complemented the face-to-face contact between a health professional and a patient in the context of treatment, health monitoring, or supporting self-management. Studies were included when eHealth and adverse effects were mentioned in the title or abstract and when empirical data on adverse effects were provided. All health conditions, with the exception of mental health conditions, all ages, and all sample sizes were included. We examined the literature published between December 2012 and August 2017 in the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and the Cochrane Library. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists. RESULTS: Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority were characterized by small research populations and low study quality. Adverse effects are rarely subject to systematic scientific research. So far, information on real adverse effects is mainly limited to incidental reporting or as a bycatch from qualitative pilot studies. Despite the shortage of solid research, we found some indications of possible negative impact on patient-centeredness and efficiency, such as less transparency in the relationship between health professionals and patients and time-consuming work routines. CONCLUSIONS: There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care. While the development of eHealth apps is ongoing, the knowledge with regard to possible adverse effects is limited. The available research often focuses on efficacy, added value, implementation issues, use, and satisfaction, whereas adverse effects are underexplored. A better understanding of possible adverse effects could be a starting point in improving the positive impact of eHealth-based health care delivery.

Considerations on Effective Feedback in Computerized Speech Training for Dysarthric Speakers.

Introduction: In this article, we consider the role of feedback in computerized speech training for patients with dysarthric speech due to acquired neurological disorders such as Parkinson's disease and stroke. Methods: Based on literature from different fields, we review several issues that play a role when designing feedback for computerized speech training, including serious games. Results: Which speech dimensions (e.g., articulation, loudness) to target in computerized speech feedback, and at what level of detail to provide the feedback, depend on the focus of the specific speech therapy and the technical feasibility of providing reliable speech feedback. Furthermore, feedback that provides knowledge of results generally appears equally effective as knowledge of performance feedback, and is more easily provided in computerized speech training systems. Implicit feedback can be more motivating than explicit feedback (e.g., in serious games), but may be harder to understand. Multimodal feedback is preferred over unimodal feedback to ensure that the feedback message is optimally perceived. Mild negative task-oriented feedback can enhance effort but should be balanced with positive feedback, such as feedback referring to patients' progress. Finally, a balance should be found between the motivational advantages of high-frequency immediate feedback (e.g., in serious games) and the advantages of low-frequency and delayed feedback in preventing patients from becoming dependent on augmented feedback. Conclusions: Several aspects play a role in designing feedback for computerized speech training for dysarthric speakers. Decisions on these aspects should be made carefully, accounting for the specific characteristics of the patient group that is targeted, the focus of the specific speech therapy, and the technological possibilities that are available.

Intuitive visualizations of pitch and loudness in speech.

Visualizing acoustic features of speech has proven helpful in speech therapy; however, it is as yet unclear how to create intuitive and fitting visualizations. To better understand the mappings from speech sound aspects to visual space, a large web-based experiment (n = 249) was performed to evaluate spatial parameters that may optimally represent pitch and loudness of speech. To this end, five novel animated visualizations were developed and presented in pairwise comparisons, together with a static visualization. Pitch and loudness of speech were each mapped onto either the vertical (y-axis) or the size (z-axis) dimension, or combined (with size indicating loudness and vertical position indicating pitch height) and visualized as an animation along the horizontal dimension (x-axis) over time. The results indicated that firstly, there is a general preference towards the use of the y-axis for both pitch and loudness, with pitch ranking higher than loudness in terms of fit. Secondly, the data suggest that representing both pitch and loudness combined in a single visualization is preferred over visualization in only one dimension. Finally, the z-axis, although not preferred, was evaluated as corresponding better to loudness than to pitch. This relation between sound and visual space has not been reported previously for speech sounds, and elaborates earlier findings on musical material. In addition to elucidating more general mappings between auditory and visual modalities, the findings provide us with a method of visualizing speech that may be helpful in clinical applications such as computerized speech therapy, or other feedback-based learning paradigms.

Evaluating the feasibility and the potential efficacy of e-learning-based speech therapy (EST) as a web application for speech training in dysarthric patients with Parkinson's disease: a case study.

OBJECTIVE: As a Web application for speech training, e-learning-based speech therapy (EST) is assumed to have potential for neurological patients who aim at independent speech training in their home environment. This article reports a case study of a patient with dysarthric speech due to Parkinson's disease (PD) who enrolled in a 4-week intensive speech training through EST. The primary goal was to investigate the feasibility and the potential efficacy of EST as a Web application for speech training in dysarthric patients with PD. MATERIALS AND METHODS: The participant used EST, following a speech training program containing parts of the pitch limiting voice treatment for patients with PD. The feasibility of EST for independent speech training in the home environment was verified through a questionnaire. The questionnaire addressed the participant's individual experiences with EST as well as the extent of satisfaction with technological features of EST, the content of the speech training, and the suitability of the home training environment. The potential efficacy of EST as a device to improve speech intelligibility was investigated using a repeated measures with randomized blocks design. The proportion of correct orthographic transcriptions of semantically unpredictable sentences as well as ratings of perceived intelligibility on a 10-point scale were used as measures for speech intelligibility. RESULTS: Outcomes of the questionnaire resulted in recommendations to enhance EST feasibility. Speech intelligibility, as measured by transcription scores, improved significantly after EST training. This improvement was maintained for 2 weeks after completing the EST training, whereas considerably lower scores were observed after 11 weeks without training. Subjective ratings of intelligibility did not show significant differences across time. CONCLUSIONS: The results of this case study confirm the potential of EST for patients with PD.

E-learning-based speech therapy: a web application for speech training.

Abstract In The Netherlands, a web application for speech training, E-learning-based speech therapy (EST), has been developed for patients with dysarthria, a speech disorder resulting from acquired neurological impairments such as stroke or Parkinson's disease. In this report, the EST infrastructure and its potentials for both therapists and patients are elucidated. EST provides patients with dysarthria the opportunity to engage in intensive speech training in their own environment, in addition to undergoing the traditional face-to-face therapy. Moreover, patients with chronic dysarthria can use EST to independently maintain the quality of their speech once the face-to-face sessions with their speech therapist have been completed. This telerehabilitation application allows therapists to remotely compose speech training programs tailored to suit each individual patient. Moreover, therapists can remotely monitor and evaluate changes in the patient's speech. In addition to its value as a device for composing, monitoring, and carrying out web-based speech training, the EST system compiles a database of dysarthric speech. This database is vital for further scientific research in this area.