EXTENDING THE ASSESSMENT OF TECHNOLOGY-AIDED PROGRAMS TO SUPPORT LEISURE AND COMMUNICATION IN PEOPLE WITH ACQUIRED BRAIN INJURY AND EXTENSIVE MULTIPLE DISABILITIES.

Intervention programs for people with acquired brain injury and extensive motor and communication impairment need to be diversified according to their characteristics and environment. These two studies assessed two technology-aided programs for supporting leisure (i.e., access to songs and videos) and communication (i.e., expressing needs and feelings and making requests) in six of those people. The three people participating in Study 1 did not possess speech but were able to understand spoken and written sentences. Their program presented leisure and communication options through written phrases appearing on the computer screen. The three people participating in Study 2 did not possess any speech and were unable to understand spoken or written language. Their program presented leisure and communication options through pictorial images. All participants relied on a simple microswitch response to enter the options and activate songs, videos, and communication messages. The data showed that the participants of both studies learned to use the program available to them and to engage in leisure and communication independently. The importance of using programs adapted to the participants and their environment was discussed.

Helping people in a minimally conscious state develop responding and stimulation control through a microswitch-aided program.

BACKGROUND: Postcoma persons in a minimally conscious state (MCS) and with extensive motor impairment cannot independently access and control environmental stimulation. AIM: Assessing the effects of a microswitch-aided program aimed at helping MCS persons develop responding and stimulation control and conducting a social validation/evaluation of the program. DESIGN: A single-subject ABAB design was used for each participant to determine the impact of the program on his or her responding. Staff interviews were used for the social validation/evaluation of the program. SETTING: Rehabilitation and care facilities that the participants attended. POPULATION: Eleven MCS persons with extensive motor impairment and lack of speech or any other functional communication. METHODS: For each participant, baseline (A) phases were alternated with intervention (B) phases during which the program was used. The program relied on microswitches to monitor participants' specific responses (e.g., prolonged eyelid closures) and on a computer system to enable those responses to control stimulation. In practice, the participants could use a simple response such as prolonged eyelid closure to generate a new stimulation input. Sixty-six staff people took part in the social validation of the program. They were to compare the program to basic and elaborate forms of externally controlled stimulation, scoring each of them on a six-item questionnaire. RESULTS: All participants showed increased response frequencies (and thus higher levels of independent stimulation input/control) during the B phases of the study. Their frequencies for each intervention phase more than doubled their frequencies for the preceding baseline phase with the difference between the two being clearly significant (P<0.01). Staff involved in the social validation procedure provided significantly higher scoring (P<0.01) for the program on five of the six questionnaire items. CONCLUSIONS: A microswitch-aided program can be an effective and socially acceptable tool in the work with MCS persons. CLINICAL REHABILITATION IMPACT: The participants and staff's data can be taken as an encouragement for the use of a microswitch-aided program within care and rehabilitation settings for MCS persons.

Assistive technology to help persons in a minimally conscious state develop responding and stimulation control: Performance assessment and social rating.

BACKGROUND: Post-coma persons in a minimally conscious state (MCS) and with extensive motor impairment and lack of speech tend to be passive and isolated. OBJECTIVE: This study aimed to (a) further assess a technology-aided approach for fostering MCS participants' responding and stimulation control and (b) carry out a social validation check about the approach. METHODS: Eight MCS participants were exposed to the aforementioned approach according to an ABAB design. The technology included optic, pressure or touch microswitches to monitor eyelid, hand or finger responses and a computer system that allowed those responses to produce brief periods of positive stimulation during the B (intervention) phases of the study. Eighty-four university psychology students and 42 care and health professionals were involved in the social validation check. RESULTS: The MCS participants showed clear increases in their response frequencies, thus producing increases in their levels of environmental stimulation input, during the B phases of the study. The students and care and health professionals involved in the social validation check rated the technology-aided approach more positively than a control condition in which stimulation was automatically presented to the participants. CONCLUSIONS: A technology-aided approach to foster responding and stimulation control in MCS persons may be effective and socially desirable.

Supporting self-managed leisure engagement and communication in post-coma persons with multiple disabilities.

Post-coma persons affected by extensive motor impairment and lack of speech, with or without disorders of consciousness, need special support to manage leisure engagement and communication. These two studies extended research efforts aimed at assessing basic technology-aided programs to provide such support. Specifically, Study I assessed a program for promoting independent stimulation choice in four post-coma persons who combined motor and speech disabilities with disorders of consciousness (i.e., were rated between the minimally conscious state and the emergence from such state). Study II assessed a program for promoting independent television operation and basic communication in three post-coma participants who, contrary to those involved in Study I, did not have disorders of consciousness (i.e., had emerged from a minimally conscious state). The results of the studies were largely positive with substantial levels of independent stimulation choice and access for the participants of Study I and independent television operation and communication for the participants of Study II. The results were analyzed in relation to previous data in the area and in terms of their implications for daily contexts dealing with these persons.

Occupation and communication programs for post-coma persons with or without consciousness disorders who show extensive motor impairment and lack of speech.

These two studies were aimed at extending the assessment of technology-aided programs for post-coma persons with extensive motor impairment and lack of speech. Specifically, Study I assessed a new program arrangement, in which stimulation access and caregiver attention could be obtained with variations of the same response (i.e., single- versus double-hand closure) by three participants who were diagnosed at the upper level of the minimally conscious state at the start of the study. Study II was aimed at enabling two persons who had emerged from a minimally conscious state to engage in leisure activities, listen to audio-recordings of family members, and send and receive messages. The responses selected for these participants were hand pressure and eyelid closure, respectively. The results of both studies were positive. The participants of Study I increased their responding to increase their stimulation input and caregiver interaction. The participants of Study II managed to successfully select all the options the program included (i.e., the leisure options, as well as the family and communication options). General implications of the programs and the related technology packages for intervention with post-coma persons with multiple disabilities are discussed.

Microswitch-aided programs with contingent stimulation versus general stimulation programs for post-coma persons with multiple disabilities.

OBJECTIVE: Assessing the impact of microswitch-aided programs with contingent stimulation on response engagement (Study I) and post-session alertness (Study II) of post-coma participants with multiple disabilities. METHOD: Study I included three participants whose scores on the Coma Recovery Scale-Revised (CRS-R) were 11 or 13. Study II included three participants whose CRS-R scores were 19, 13, and 14. In both studies, the participants received sessions with contingent stimulation (i.e., sessions in which activation of a microswitch with an eyelid or hand response produced 15 s of preferred stimulation) and sessions with general, non-contingent stimulation (i.e., stimulation lasted throughout the sessions). RESULTS: Study I showed an increase in response engagement/frequencies only during the contingent stimulation sessions. Study II showed that the participants' level of vigilance after those sessions was higher than after non-contingent stimulation sessions. CONCLUSION: Microswitch-aided programs with contingent stimulation would be more beneficial than programs with general/non-contingent stimulation.

Assessing learning as a possible sign of consciousness in post-coma persons with minimal responsiveness.

A learning test procedure based on operant principles may be useful in the diagnosis (and eventually rehabilitation) of post-coma persons with minimal responsiveness. This study was aimed at extending the evaluation of such a procedure with seven participants who presented with very limited behavior and apparently severe disorders of consciousness. The procedure was evaluated through an ABACB design, in which A represented baseline phases without stimulation, B intervention phases with brief stimulation periods contingent on specific responses of the participants, and C a control phase in which stimulation was available all the time. Increased responding during the B phases, as opposed to the A and C phases, was taken to indicate learning and possibly a non-reflective expression of phenomenal consciousness. All participants were also evaluated with the coma recovery scale-revised (CRS-R) prior to the start of the learning test procedure and at the end of it. The results of the learning test showed that all participants had significantly higher responding levels during the B phases. The CRS-R scores suggested minimally conscious state for four of them prior to the learning test and for five of them after the completion of the learning test. The implications of the findings are discussed in terms of potential and time cost of the learning test.

Technology-aided programs for post-coma patients emerged from or in a minimally conscious state.

Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.

Post-coma persons with multiple disabilities use assistive technology for their leisure engagement and communication.

BACKGROUND: Interventions for post-coma persons, who have emerged from a minimally conscious state but present with extensive neuro-motor impairment and lack of or minimal verbal skills, need to promote occupation and communication through the use of assistive technology. OBJECTIVE: These two studies were aimed at assessing two technology-aided programs to promote leisure engagement and communication for three post-coma participants with multiple disabilities. METHODS: Study I assessed a program to allow a woman and a man with extensive neuro-motor impairment and lack of speech to switch on music and videos, make requests to caregivers, and send messages to (communicate with) relevant partners and receive messages from those partners. Study II assessed a program to allow a post-coma woman with extensive motor impairment and reduced verbal behavior to activate music, videos and requests, send and receive messages, and make telephone calls. RESULTS: Data showed that both programs were successful. The participants of Study I managed leisure engagement, requests, as well as text messaging. The participant of Study II showed consistent leisure engagement, text messaging, and telephone calls. CONCLUSIONS: Assistive technology can be profitably used to provide post-coma persons with multiple disabilities relevant leisure and communication opportunities.

Technology-aided leisure and communication opportunities for two post-coma persons emerged from a minimally conscious state and affected by multiple disabilities.

This study assessed technology-aided programs for helping two post-coma persons, who had emerged from a minimally conscious state and were affected by multiple disabilities, to (a) engage with leisure stimuli and request caregiver's procedures, (b) send out and listen to text messages for communication with distant partners, and (c) combine leisure engagement and procedure requests with text messaging within the same sessions. The program for leisure engagement and procedure requests relied on the use of a portable computer with commercial software, and a microswitch for the participants' response. The program for text messaging communication involved the use of a portable computer, a GSM modem, a microswitch for the participants' response, and specifically developed software. Results indicated that the participants were successful at each of the three stages of the study, thus providing relevant evidence concerning performance achievements only minimally documented. The implications of the findings in terms of technology and practical opportunities for post-coma persons with multiple disabilities are discussed.

Technology-aided recreation and communication opportunities for post-coma persons affected by lack of speech and extensive motor impairment.

This study assessed technology-aided intervention programs for two post-coma men who had re-acquired consciousness, but were unable to engage in personally or socially relevant occupations, given their lack of functional speech and their extensive motor disabilities. The microswitches used for accessing the program contents consisted of (a) a pressure sensor fixed in the palm of the first man's hand that could be activated with a small hand closure movement, and (b) an optic sensor fixed under the chin of the second man that could be activated by mouth opening movements. The programs' content consisted of recreation and communication options, which involved activating music, videos, and basic requests, sending and receiving (listening to) text messages, and placing phone calls. The results showed that the men (a) used the technology-aided programs successfully to manage the recreation and communication options available and (b) showed consistent preference for the sessions with the technology-aided program over other daily events. Family and staff members interviewed about the participants' programs (seven members for each participant) thought that the participants enjoyed the intervention sessions with the programs and that the programs had beneficial effects for them. Implications of the findings are discussed.

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders.

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).

A learning assessment procedure as a test supplement for monitoring progress with two post-coma persons with a diagnosis of vegetative state.

OBJECTIVE: Evaluating a learning assessment procedure for monitoring progress with two post-coma adults with a diagnosis of vegetative state. METHOD: ABABCBCB and ABABCB designs were used for the two participants, with A representing baseline, B intervention and C control conditions. Participants' activation of an optic microswitch by eyelid closure produced stimulation during B phases. RESULTS: One participant increased responding during B phases and decreased it during the C condition, suggesting a non-reflective minimal level of consciousness. She showed P300 and mismatch negativity responses and scored at the vegetative level on the Coma Recovery Scale-Revised (CRS-R). The other participant increased responding during the initial B phases without decline during the first (viable) part of the C condition, suggesting a pre-conscious level. He showed indistinct P300 and mismatch negativity responses and vegetative-level scores on the CRS-R. CONCLUSION: Learning data seemed reconcilable with neurophysiological measures and more positive than CRS-R scores.

Communication opportunities via special messaging technology for two post-coma persons with multiple disabilities.

This study extended the assessment of a special messaging technology with two additional post-coma adults who had emerged from a minimally conscious state, but showed multiple disabilities including profound motor and communication impairments. For each participant, the study involved an ABAB design, in which the A represented baseline phases and the B represented intervention phases with the special messaging technology. The technology involved a net-book computer provided with specific software, a global system for mobile communication (GSM) modem, microswitches, and prerecorded verbal lists of persons' names and messages. Both participants learned to send out and receive (listen to) messages independently during the intervention, thus providing clear support for previous data in the area. They sent out means of about three and 17 messages and received means of about two and six messages per 20- and 30-min session, respectively. The positive impact of the technology was discussed in relation to previous data in this area and the possibility of helping post-coma persons with multiple disabilities engage in basic communication with distant partners.

Post-coma persons with motor and communication/consciousness impairments choose among environmental stimuli and request stimulus repetitions via assistive technology.

This study assessed whether a program based on microswitch and computer technology would enable three post-coma participants (adults) with motor and communication/consciousness impairments to choose among environmental stimuli and request their repetition whenever they so desired. Within each session, 16 stimuli (12 preferred and 4 non-preferred) were scheduled for the participants. For each stimulus, a computer system provided a sample of a 3-s duration. During the intervention, participants' responding (e.g., eye blinking and hand closure) in relation to a stimulus sample activated a microswitch and led the computer system to turn on that stimulus for 20 s. Participants' lack of responding led the computer system to pause briefly and then present the next scheduled stimulus sample. When participants responded immediately after (i.e., within 6s from) the end of a stimulus presentation, that stimulus was repeated. Intervention data showed response increases, which were very consistent for two participants and moderate for the third one. All participants asked for the repetition of preferred stimuli and showed minimal responding in relation to non-preferred stimuli. The results were discussed in light of their possible implications for new, person-centered rehabilitation programs for post-coma persons with multiple disabilities.

A technology-assisted learning setup as assessment supplement for three persons with a diagnosis of post-coma vegetative state and pervasive motor impairment.

Post-coma persons in an apparent condition of vegetative state and pervasive motor impairment pose serious problems in terms of assessment and intervention options. A technology-based learning assessment procedure might serve for them as a diagnostic supplement with possible implications for rehabilitation intervention. The learning assessment procedure adopted in this study relied on hand-closure and eye-blinking responses and on microswitch technology to detect such responses and to present stimuli. Three participants were involved in the study. The technology consisted of a touch/pressure sensor fixed on the hand or an optic sensor mounted on an eyeglasses' frame, which were combined with a control system linked to stimulus sources. The study adopted an ABABCB sequence, in which A represented baseline periods, B intervention periods with stimuli contingent on the responses, and C a control condition with stimuli presented non-contingently. Data showed that the level of responding during the B phases was significantly higher than the levels observed during the A phases as well as the C phase for two of the three participants (i.e., indicating clear signs of learning by them). Learning might be deemed to represent basic levels of knowledge/consciousness. Thus, detecting signs of learning might help one revise a previous diagnosis of vegetative state with wide implications for rehabilitation perspectives.

Evaluation of technology-assisted learning setups for undertaking assessment and providing intervention to persons with a diagnosis of vegetative state.

OBJECTIVE: To evaluate the viability of technology-assisted learning setups for undertaking assessment and providing intervention to persons in vegetative state. METHOD: Study I investigated whether three persons with a diagnosis of vegetative state could associate eye blinking or hand closure responses with contingent, positive stimulation, thus increasing their frequencies (showing signs of learning). Study II extended the learning process (introducing a new response and new stimuli) for one of the participants of Study I. RESULTS: Two of the participants of Study I succeeded in increasing their responses, indicating signs of learning. Study II showed that the participant (one of the two succeeding in Study I) acquired a new response to access new stimuli and could alternate this response with the one acquired in Study I. CONCLUSION: Learning might represent a basic level of knowledge and consciousness. Detecting signs of learning might help modify a previous diagnosis of vegetative state and support intervention/rehabilitation efforts.