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.

Automatic feedback to promote safe walking and speech loudness control in persons with multiple disabilities: two single-case studies

OBJECTIVE

Assessing automatic feedback technologies to promote safe travel and speech loudness control in two men with multiple disabilities, respectively.

METHOD

The men were involved in two single-case studies. In Study I, the technology involved a microprocessor, two photocells, and a verbal feedback device. The man received verbal alerting/feedback when the photocells spotted an obstacle in front of him. In Study II, the technology involved a sound-detecting unit connected to a throat and an airborne microphone, and to a vibration device. Vibration occurred when the man's speech loudness exceeded a preset level.

RESULTS

The man included in Study I succeeded in using the automatic feedback in substitution of caregivers' alerting/feedback for safe travel. The man of Study II used the automatic feedback to successfully reduce his speech loudness.

CONCLUSION

Automatic feedback can be highly effective in helping persons with multiple disabilities improve their travel and speech performance.

Case Studies of Technology for Adults with Multiple Disabilities to Make Telephone Calls Independently

Recent literature has shown the possibility of enabling individuals with multiple disabilities to make telephone calls independently via computer-aided telephone technology. These two case studies assessed a modified version of such technology and a commercial alternative to it for a woman and a man with multiple disabilities, respectively. The modified version used in Study 1 (a) presented the names of the persons available for a call and (b) reminded the participant of the response she needed to perform (i.e., pressing a microswitch) if she wanted to call any of those names/persons. The commercial device used in Study 2 was a Galaxy S3 (Samsung) equipped with the S-voice module, which allowed the participant to activate phone calls by uttering the word ‘Call’ followed by the name of the persons he wanted to call. The results of the studies showed that the participants learned to make phone calls independently using the technology / device available. Implications of the results are discussed.

Mindfulness-Based Cognitive Approach for Seniors (MBCAS): Program Development and Implementation

A number of cognitive interventions have been developed to enhance cognitive functioning in the growing population of the elderly. We describe the Mindfulness-Based Cognitive Approach for Seniors (MBCAS), a new training program designed especially for seniors. It was conceived in the context of self-development for seniors who wish to enhance their relationship with their inner and outer selves in order to navigate their aging process more easily and fluently. Physical and psychosocial problems related to aging, as well as some temporal issues, were taken into account in developing this program. Unlike clinically oriented mindfulness-based programs, which are generally delivered during an 8-week period, the MBCAS training program is presented over a period of 8 months. The main objectives of this program are to teach seniors to observe current experiences with nonjudgmental awareness, to identify automatic behaviors or reactions to current experiences that are potentially nonadaptive, and to enhance and reinforce positive coping with typical difficulties that they face in their daily lives. Details of the program development and initial implementation are presented, with suggestions for evaluating the program's effectiveness.

New camera-based microswitch technology to monitor small head and mouth responses of children with multiple disabilities

OBJECTIVE

Assessing a new camera-based microswitch technology, which did not require the use of color marks on the participants' face.

METHOD

Two children with extensive multiple disabilities participated. The responses selected for them consisted of small, lateral head movements and mouth closing or opening. The intervention was carried out according to a multiple probe design across responses. The technology involved a computer with a CPU using a 2-GHz clock, a USB video camera with a 16-mm lens, a USB cable connecting the camera and the computer, and a special software program written in ISO C++ language.

RESULTS

The new technology was satisfactorily used with both children. Large increases in their responding were observed during the intervention periods (i.e. when the responses were followed by preferred stimulation).

CONCLUSION

The new technology may be an important resource for persons with multiple disabilities and minimal motor behavior.

Two Men with Advanced Amyotrophic Lateral Sclerosis Operate a Computer-Aided Television System through Mouth or Throat Microswitches

This study assessed a simple technology to enable two men affected by amyotrophic lateral sclerosis, in an advanced stage (i.e., with pervasive motor disabilities and lack of speech), to operate a computer-aided television system. The technology included microswitches, a portable computer, an interface connecting the microswitches to the computer, a commercial software package to allow the possibility of watching television via computer, and specific software to allow microswitch activations to be recorded as forward commands for channel change. The participants (a) gained control over the television programs to watch or not to watch (i.e., through channel changes) and (b) showed increased attention to the programs (i.e., an increase in their watching time). The practical relevance of the findings, the integration of the technology used in this study within the participants' wider recreation and communication program, and ways of extending the research were discussed.

People with multiple disabilities learn to engage in occupation and work activities with the support of technology-aided programs

These two studies were aimed at assessing technology-aided programs to help persons with multiple disabilities engage in basic occupation or work activities. Specifically, Study I focused on teaching two participants (an adolescent and an adult) with low vision or total blindness, severe/profound intellectual disabilities, and minimal object interaction to engage in constructive object-manipulation responses. The technology monitored their responses and followed them with brief stimulation periods automatically. Study II focused on teaching three adults with deafness, severe visual impairment, and profound intellectual disabilities to perform a complex activity, that is, to assemble a five-component water pipe. The technology regulated (a) light cues to guide the participants through the workstations containing single pipe components and the carton for completed pipes and (b) stimulation events. The results of both studies were positive. The participants of Study I showed consistent and independent engagement in object-manipulation responses. The participants of Study II showed consistent and independent pipe assembling performance. General implications of the two programs and the related technology packages for intervention with persons with multiple disabilities are discussed.

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.

Technology to help persons with extensive neuro-motor impairment and lack of speech with their leisure occupation and communication

These two studies were aimed at extending the assessment of technology-aided programs to enhance leisure occupation or communication with persons with extensive neuro-motor impairment and lack of speech. Specifically, Study I implemented the program for leisure occupation with two post-stroke patients. Study II implemented the program for communication with two persons affected by amyotrophic lateral sclerosis (ALS). In Study I, a computer system presented the participants with a variety of stimuli. The participants could select/access those stimuli by microswitch activation or could bypass them by abstaining from microswitch responses. In Study II, the participants used a computer-aided telephone system that allowed them to choose via microswitch activation the persons to call. On the computer screen, they also had words and phrases that they could activate during the calls to influence the conversation with the persons called. Data from both studies were largely positive. The post-stroke patients showed high levels of stimulus selection (access) and extended engagement. The patients with ALS were able to make phone calls and to select the words/phrases to influence the conversations. The relevance of technology-aided programs for leisure occupation and communication of persons with extensive multiple disabilities was discussed.

Technology-based intervention programs to promote stimulation control and communication in post-coma persons with different levels of disability

Post-coma persons in a minimally conscious state and with extensive motor impairment or emerging/emerged from such a state, but affected by lack of speech and motor impairment, tend to be passive and isolated. A way to help them develop functional responding to control environmental events and communication involves the use of intervention programs relying on assistive technology. This paper provides an overview of technology-based intervention programs for enabling the participants to (a) access brief periods of stimulation through one or two microswitches, (b) pursue stimulation and social contact through the combination of a microswitch and a sensor connected to a speech generating device (SGD) or through two SGD-related sensors, (c) control stimulation options through computer or radio systems and a microswitch, (d) communicate through modified messaging or telephone systems operated via microswitch, and (e) control combinations of leisure and communication options through computer systems operated via microswitch. Twenty-six studies, involving a total of 52 participants, were included in this paper. The intervention programs were carried out using single-subject methodology, and their outcomes were generally considered positive from the standpoint of the participants and their context. Practical implications of the programs are discussed.

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.

Further evaluation of a telephone technology for enabling persons with multiple disabilities and lack of speech to make phone contacts with socially relevant partners

This study assessed whether a girl and a woman with multiple disabilities could (a) make phone contacts with relevant partners through a special telephone technology, and (b) enjoy their telephone-mediated communication with them. The technology involved a net-book computer, a global system for mobile communication modem (GSM), an optic microswitch, and specific software. The technology was programmed to present the names of the partners available for contact, and the participants could choose at each presentation sequence the one they wanted to contact with a simple microswitch response. Such response triggered the computer to place a phone call to that partner. Both participants (a) learned to use the technology quite rapidly to contact relevant partners and maintained the successful use of it over the intervention and post-intervention sessions, (b) showed high levels of indices of happiness during the phone calls as opposed to pre-baseline control sessions, and (c) showed preferences among the partners. Implications of the findings are discussed.

Technology-aided programs to enable persons with multiple disabilities to choose among environmental stimuli using a smile or a tongue response

Persons with multiple disabilities, including pervasive motor impairment, may have problems controlling even small responses (e.g., vocal emissions, finger movements, or prolonged eyelid closures) within time-sensitive situations, such as those involved in choice programs. Recent research has indicated that smile expressions can be used as functional choice responses for some of these persons. The present two studies were aimed at assessing the smile response for a child with congenital multiple disabilities and a tongue response for a post-coma man who had recovered his consciousness but presented with pervasive multiple disabilities. The first of the two studies represented a research extension (i.e., a new case with a slightly adapted microswitch technology) concerning the smile response, which had recently been evaluated with few other cases. The second study represented a new effort to assess the tongue response within a choice program and for a post-coma man with multiple disabilities. The results showed that the participants used the smile and the tongue responses successfully while they were apparently unsuccessful in using a slight head/chin movement response. Their choice behavior focused reliably on preferred stimuli and avoided non-preferred stimuli. Implications of the results are discussed.

A man with amyotrophic lateral sclerosis uses a mouth pressure microswitch to operate a text messaging system with a word prediction function

OBJECTIVE

To assess whether a man with amyotrophic lateral sclerosis could benefit from using (a) a mouth pressure microswitch instead of an optic microswitch activated via head movement and (b) a special word prediction function within a text messaging system.

METHOD

Initially, both microswitches were used for operating the text messaging system, and their effectiveness and the man's preference were assessed. Subsequently, only the mouth microswitch was used and the messaging system was provided with a word prediction function.

RESULTS

The man was more efficient/rapid in using the text messaging (i.e., in writing) with the mouth microswitch and preferred such a microswitch. Similarly, he was more rapid in writing when the word prediction function was added (as opposed to the initial phase of the study when such function was not available) and preferred to use it.

CONCLUSION

Technology updates are critical in helping persons with motor degeneration.

Persons with multiple disabilities increase adaptive responding and control inadequate posture or behavior through programs based on microswitch-cluster technology

Study I used typical microswitch-cluster programs to promote adaptive responding (i.e., object manipulation) and reduce inappropriate head or head-trunk forward leaning with a boy and a woman with multiple disabilities. Optic, tilt, and vibration microswitches were used to record their adaptive responses while optic and tilt microswitches monitored their posture. The study included an ABB(1)AB(1) sequence, in which A represented baseline phases, B represented an intervention phase in which adaptive responses were always followed by preferred stimulation, and B(1) represented intervention phases in which the adaptive responses led to preferred stimulation only if the inappropriate posture was absent. Study II assessed a non-typical, new microswitch-cluster program to promote two adaptive responses (i.e., mouth cleaning to reduce drooling effects and object assembling) with a man with multiple disabilities. Initially, the man received preferred stimulation for each cleaning response. Then, he received stimulation only if mouth cleaning was preceded by object assembling. The results of Study I showed that both participants had large increases in adaptive responding and a drastic reduction in inappropriate posture during the B(1) phases and a 2-week post-intervention check. The results of Study II showed that the man learned to control drooling effects through mouth cleaning and used object assembling to extend constructive engagement and interspace cleaning responses functionally. The practical implications of the findings are discussed.

Post-coma persons emerging from a minimally conscious state with multiple disabilities make technology-aided phone contacts with relevant partners

Post-coma individuals emerging from a minimally conscious state with multiple disabilities may enjoy contact with relevant partners (e.g., family members and friends), but may not have easy access to them. These two single-case studies assessed whether those individuals could make contact with partners through computer-aided telephone technology and enjoy such contact. The technology involved a computer system with special software, a global system for mobile communication modem (GSM), and microswitch devices. In Study I, the computer system presented a 23-year-old man the names of the partners that he could contact, one at a time, automatically. Together with each partner's name, the system also presented the voice of the partner asking the man whether he wanted to call him or her. The man could (a) place a call to that partner by activating a camera-based microswitch through mouth movements or (b) bypass that partner and wait for the next one to be presented. In Study II, the system presented a 36-year-old man the partners' names only after he had activated his wobble microswitch with a hand movement. The man could place a call or bypass a partner as in Study I. The results showed that both men (a) were able to contact relevant partners through the technology, (b) seemed to enjoy their telephone-mediated communication contacts with the partners, and (c) showed preferences among the partners. Implications of the findings are discussed.

Two men with multiple disabilities carry out an assembly work activity with the support of a technology system

OBJECTIVE

To assess whether two persons with multiple disabilities could learn a work activity (i.e., assembling trolley wheels) with the support of a technology system.

METHOD

After an initial baseline, the study compared the effects of intervention sessions relying on the technology system (which called the participants to the different workstations and provided feedback and final stimulation) with the effects of intervention sessions carried out without technology. The two types of intervention sessions were conducted according to an alternating treatments design. Eventually, only intervention sessions relying on the technology system were used.

RESULTS

Both participants managed to assemble wheels independently during intervention sessions relying on the technology system while they failed during sessions without the system. Their performance was strengthened during the final part of the study, in which only sessions with the system occurred.

CONCLUSION

Technology may be critical in helping persons with multiple disabilities manage multi-step work activities.

Three non-ambulatory adults with multiple disabilities exercise foot-leg movements through microswitch-aided programs

This study assessed the use of microswitch-aided programs to help three non-ambulatory adults with multiple disabilities exercise foot-leg responses. Those responses served to activate a largely neglected part of the participants' body, with possibly positive physical implications (e.g., for blood circulation, swelling, and muscle strength). Intervention focused on the left and right foot-leg response, separately. Eventually, sessions with one response were alternated with sessions with the other response. Responses were monitored via microswitches and followed by 8s of preferred stimulation (e.g., music and vibrotactile stimulation), which was automatically delivered. The results showed that all three participants had high levels of foot-leg responses during the intervention phases and a 3-week post-intervention check. The participants also displayed expressions of positive involvement during those study periods (i.e., engaged in behaviors, such as music-related head movements, smiles, or touching the vibratory devices) that could be interpreted as forms of interest/pleasure and happiness. These results are in line with previous findings in this area and can be taken as an important confirmation of the strength and dependability of the approach in motivating non-ambulatory persons with multiple disabilities to engage in foot-leg movements. The practical implications of these findings 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.

Supporting daily activities and indoor travel of persons with moderate Alzheimer's disease through standard technology resources

These two studies were aimed at evaluating standard technology resources for supporting activity and travel among patients with moderate Alzheimer's disease. Specifically, Study I assessed a pictorial instruction program relying on the use of a portable computer and a commercially available and inexpensive video editing software for supporting the performance of daily activities with three patients. Study II assessed the indoor travel performance of four patients (i.e., the three involved in Study I and a fourth patient with no previous research exposure) using a commercially available, basic doorbell system with sound and light cues. The percentages of correct activity steps obtained with the instruction program used in Study I were relatively high and largely similar to the percentages reported in previous studies using more sophisticated technology. During Study II, the percentages of correct travels of two patients matched the data of the most successful patients involved in previous studies with more sophisticated technology. The percentages of the other two patients tended to be lower than those obtained previously, but were still practically relevant. The implications of the results of the two studies and a number of issues for new research are discussed.

Technology-aided programs to support exercise of adaptive head responses or leg-foot and hands responses in children with multiple disabilities

OBJECTIVE

Assessing the effectiveness of technology-aided programs to help three children with multiple disabilities exercise adaptive head or leg-foot and hands responses independently.

METHOD

The response selected for the two children included in Study I was head rotation (i.e. movements of at least 25 degrees to the left that could start from a full right position as well as from other positions). The responses selected for the child included in Study II involved forward movement of the left leg-foot and forward movement of his hand(s) to touch objects. Tilt or optic microswitches were used to monitor the responses and a computer system regulated the stimuli contingent on them.

RESULTS

The responses targeted in the two studies showed large frequency increases during the intervention phases of the studies (i.e. when followed by stimulation).

CONCLUSION

Technology-aided programs can be a useful resource to help children with multiple disabilities exercise relevant responses independently.