An Eye-Tracking Assistive Device Improves the Quality of Life for ALS Patients and Reduces the Caregivers’ Burden

The psychosocial impact of eye-gaze assistive technology on everyday life of children and adults

PURPOSE

This study investigates the psychosocial impact of eye-gaze assistive technology (EGAT) in both children and adults with long-term experience using eye-gaze assistive technology in everyday life, as well as the psychosocial impact as related to duration of use.

METHODS

In this descriptive comparative study, 34 adult and 27 child EGAT users participated in a structured individual interview using the Psychosocial Impact of Assistive Devices Scale (PIADS).

RESULTS

The participants' age ranged from 5-74 years, 50% were female and 52% had been diagnosed with cerebral palsy. The EGAT had a positive psychosocial impact on competence, adaptability, and self-esteem among adult and child users. Competence was the only subscale with a higher value for adults (p = 0.038), compared to children. The items with the highest impact for the psychosocial aspects were quality of life, ability to participate, and self-esteem. The adults had longer duration of use than children, but for high-, medium-, and low-duration users, the device showed a positive psychosocial impact.

CONCLUSIONS

Participants considered EGAT to have high positive impacts for participation and quality of life. The study adds new knowledge in that high positive psychosocial impact may be found even among low-duration users of EGAT, which is important to consider for service providers.

Dilemma in patients with amyotrophic lateral sclerosis and expectations from brain-machine interfaces

OBJECTIVE

We hypothesized that patients with amyotrophic lateral sclerosis (ALS) face a dilemma between motivation to live and difficulty in living, and brain-machine interfaces (BMIs) can reduce this dilemma. This study aimed to investigate the present situation of patients with ALS and their expectations from BMIs.

MATERIALS AND METHODS

Our survey design consisted of an anonymous mail-in questionnaire comprising questions regarding the use of tracheostomy positive pressure ventilation (TPPV), motivation to live, anxiety about the totally locked-in state (TLS), anxiety about caregiver burden, and expectations regarding the use of BMI. Primary outcomes were scores for motivation to live and anxiety about caregiver burden and the TLS. Outcomes were evaluated using the visual analogue scale.

RESULTS

Among 460 participants, 286 (62.6%) were already supported by or had decided to use TPPV. The median scores for motivation to live, anxiety about TLS, and anxiety about caregiver burden were 8.0, 9.0, and 7.0, respectively. Overall, 49% of patients intended to use BMI. Among patients who had refused TPPV, 15.9% intended to use BMI and TPPV. Significant factors for the use of BMI were motivation to live (p = .003), anxiety about TLS (p < .001), younger age (p < .001), and advanced disease stage (p < .001).

CONCLUSIONS

These results clearly revealed a serious dilemma among patients with ALS between motivation to live and their anxiety about TLS and caregiver burden. Patients expected BMI to reduce this dilemma. Thus, the development of better BMIs may meet these expectations.

Is caregiver burden of patients with amyotrophic lateral sclerosis related to caregivers' mindfulness, quality of life, and patients' functional level

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the caregiver burden, mindfulness, and quality of life (QoL) of caregivers of ALS patients and the patient's functional level.

METHODS

This study was conducted with 57 ALS patients and their primary caregivers. The data were collected using the Zarit Burden Interview, Mindful Attention Awareness Scale (MAAS), the Short Form-36 (SF-36), and the ALS Functional Rating Scale (ALS-FRS).

RESULTS

The mean age of the caregivers was 49.7 ± 12 years; 66 % were female, and 73.7 % were spouses of the patients. Around 65 % of caregivers experienced a moderate to severe caregiver burden. A low and negative correlation was found between the caregiver burden and mindfulness of caregivers of ALS patients. As the mindfulness levels of the caregivers increased, the caregiver burden decreased, and the physical role difficulty score, one of the sub-dimensions of the QoL, increased. Also, caregivers' QoL decreased as caregiver burden increased (except physical function QoL, p < 0.05). Moreover, there was a positive correlation between the caregiver burden and ALSFRS-R scores (bulbar, motor, respiratory, and total) of the caregivers of ALS patients (p < 0.05).

DISCUSSION

Improved technology for managing ALS disease has increased patient life expectancy. However, caregivers may experience a high burden as the patient's functional level declines. Increasing caregiver mindfulness can help reduce the burden and improve their QoL.

Advances in symptom management and in monitoring disease progression in motor neuron disease

The aim of supportive management of motor neuron disease is to improve survival, promote good quality of life and patient independence and autonomy whilst preparing for future progression and the end of life. Multidisciplinary specialist care aims to address the multifaceted and interacting biopsychosocial problems associated with motor neuron disease that leads to proven benefits in both survival and quality of life. This chapter will explore principles, structure and details of treatment options, and make recommendations for practice and for future research.

Increasing participation in computer activities using eye-gaze assistive technology for children with complex needs

PURPOSE

Eye-gaze assistive technology offers children with severe motor and communication difficulties the opportunity to access and control a computer through eye movements. The aim of this study was to examine the impact of eye-gaze assistive technology intervention on participation in computer activities and technology usability among children with complex needs in Taiwan.

MATERIALS AND METHODS

This study involved a multiple baseline design across individuals. The participants were four children aged three to six years with severe motor and communication difficulties and low eye-control skills. The six-month intervention consisted of two collaborative team meetings and 12 individual supports to facilitate the use of eye-gaze assistive technology at home or in educational environments. Participation in computer activities (diversity, frequency, and duration) was repeatedly measured through a computer use diary. Other outcomes included assessments of goal achievements and parents/teachers' ratings on children's performance in computer activities.

RESULTS

The young children increased the diversity of their computer activities and their frequency and duration of computer use from baseline to the intervention phase. The children attained six of eight predefined goals related to play, communication, and school learning. Parents and teachers perceived the children's changes in performance as meaningful.

CONCLUSION

This study strengthens the evidence that eye-gaze assistive technology is useful in everyday contexts for children with complex needs in Taiwan. The findings add knowledge that children with weak eye-control skills increased participation in computer activities as a result of the eye-gaze assistive technology. Implications for RehabilitationEye-gaze assistive technology (EGAT) as an access method to control a computer can provide opportunities for children with severe motor and communication difficulties to participate in computer activities.Children with severe motor and communication difficulties and low eye-control skills with sufficient practice can learn to use EGAT for communication and learning, with support from stakeholders and collaborative service.EGAT could be introduced for children with complex needs at early ages as a means of using computers for play, communication, and school learning, which could be helpful for later education and learning.Stakeholders in educational environments could include EGAT in educational computer systems so that pupils with severe motor and communication difficulties could interact with a computer, thereby enhancing their engagement and learning.

Impairment of oculomotor functions in patients with early to advanced amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) can result into an incomplete locked in state (iLIS), in which communication depends on eye tracking computer devices. Oculomotor function impairments in ALS have been reported, but there is little research, particularly with respect to patients in iLIS. In the present study, we compared reflexive and executive oculomotor function by means of an eye tracking test battery between three groups: advanced ALS patients in iLIS (n = 22), patients in early to middle ALS stages (n = 44) and healthy subjects (n = 32). Patients with ALS showed significant deteriorations in oculomotor functions, with stronger impairments in iLIS. More specifically, ALS patients produced visually guided prosaccades with longer latencies and more frequent hypometria compared to healthy subjects. Longest latencies were obtained in iLIS patients, with a stronger prolongation for vertical than for horizontal prosaccades. ALS patients made more antisaccade errors and generated antisaccades with longer latencies. Smooth pursuit was also impaired in ALS. In the earlier ALS stages, bulbar onset patients presented stronger antisaccade and smooth pursuit deficits than spinal onset patients. Our findings reveal a relevant deterioration of important oculomotor functions in ALS, which increases in iLIS. It includes impairments of reflexive eye movements to loss of executive inhibitory control, indicating a progressing pathological involvement of prefrontal, midbrain and brainstem areas. The assessment of oculomotor functions may therefore provide clinically relevant bio- and progression marker, particularly in advanced ALS.

Creating an AI-Enhanced Morse Code Translation System Based on Images for People with Severe Disabilities

(1) Background: Patients with severe physical impairments (spinal cord injury, cerebral palsy, amyotrophic lateral sclerosis) often have limited mobility due to physical limitations, and may even be bedridden all day long, losing the ability to take care of themselves. In more severe cases, the ability to speak may even be lost, making even basic communication very difficult. (2) Methods: This research will design a set of image-assistive communication equipment based on artificial intelligence to solve communication problems of daily needs. Using artificial intelligence for facial positioning, and facial-motion-recognition-generated Morse code, and then translating it into readable characters or commands, it allows users to control computer software by themselves and communicate through wireless networks or a Bluetooth protocol to control environment peripherals. (3) Results: In this study, 23 human-typed data sets were subjected to recognition using fuzzy algorithms. The average recognition rates for expert-generated data and data input by individuals with disabilities were 99.83% and 98.6%, respectively. (4) Conclusions: Through this system, users can express their thoughts and needs through their facial movements, thereby improving their quality of life and having an independent living space. Moreover, the system can be used without touching external switches, greatly improving convenience and safety.

Palliative Care in Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease of the motor neurons. Given the evolutive characteristics of this disease, palliative care principles should be a foundation of ALS care. A multidisciplinary medical intervention is of paramount importance in the different phases of disease. The involvement of the palliative care team improves quality of life and symptoms, and prognosis. Early initiation is of paramount importance to ensuring patient-centered care, when the patient has still the capability to communicate effectively and participate in his medical care. Advance care planning supports patients and family members in understanding and sharing their preferences according to their personal values and life goals regarding future medical treatment. The principal problems which require intensive supportive care include cognitive disturbances, psychological distress, pain, sialorrhrea, nutrition, and ventilatory support. Communication skills of health-care professionals are mandatory to manage the inevitability of death. Palliative sedation has peculiar aspects in this population, particularly with the decision of withdrawing ventilatory support.

Digital Alternative Communication for Individuals with Amyotrophic Lateral Sclerosis: What We Have

Amyotrophic Lateral Sclerosis is a disease that compromises the motor system and the functional abilities of the person in an irreversible way, causing the progressive loss of the ability to communicate. Tools based on Augmentative and Alternative Communication are essential for promoting autonomy and improving communication, life quality, and survival. This Systematic Literature Review aimed to provide evidence on eye-image-based Human-Computer Interaction approaches for the Augmentative and Alternative Communication of people with Amyotrophic Lateral Sclerosis. The Systematic Literature Review was conducted and guided following a protocol consisting of search questions, inclusion and exclusion criteria, and quality assessment, to select primary studies published between 2010 and 2021 in six repositories: Science Direct, Web of Science, Springer, IEEE Xplore, ACM Digital Library, and PubMed. After the screening, 25 primary studies were evaluated. These studies showcased four low-cost, non-invasive Human-Computer Interaction strategies employed for Augmentative and Alternative Communication in people with Amyotrophic Lateral Sclerosis. The strategies included Eye-Gaze, which featured in 36% of the studies; Eye-Blink and Eye-Tracking, each accounting for 28% of the approaches; and the Hybrid strategy, employed in 8% of the studies. For these approaches, several computational techniques were identified. For a better understanding, a workflow containing the development phases and the respective methods used by each strategy was generated. The results indicate the possibility and feasibility of developing Human-Computer Interaction resources based on eye images for Augmentative and Alternative Communication in a control group. The absence of experimental testing in people with Amyotrophic Lateral Sclerosis reiterates the challenges related to the scalability, efficiency, and usability of these technologies for people with the disease. Although challenges still exist, the findings represent important advances in the fields of health sciences and technology, promoting a promising future with possibilities for better life quality.

A simple smartphone-aided program to support meaningful occupation in people with severe neuro-motor and speech disabilities

We assessed a simple smartphone-aided program to help three participants with severe neuro-motor and speech disabilities access preferred songs, call or send messages to distant partners, and call the caregiver. The program relied on the use of a smartphone, five cards with identification tags, and a mini speaker. The participants could select one of the cards (engagement options) by touching it with the smartphone. Using the program, all participants managed to access songs, reach partners, and call the caregiver independently and engaged in the related forms of leisure and communication/interaction throughout the 10-min sessions available. The results suggest that the program might be a valuable aid for people with severe neuro-motor and speech disabilities.

Does one size fit all? An update on chronic ventilatory support in different respiratory illnesses

Home noninvasive ventilation (HNIV) improves outcomes in different disease categories. In this article, we discuss indications for when and how to initiate HNIV in COPD, obesity hypoventilation syndrome (OHS) and neuromuscular disorders (NMD). While in COPD, significant diurnal hypercapnia and high-intensity HNIV are essential ingredients for success, in NMD and OHS, early respiratory changes are best detected during sleep through oxy-capnography associated (or not) with respiratory polygraphy. In COPD and OHS, it is crucial to consider the coexistence of obstructive sleep apnoea because treatment with continuous positive airway pressure may be the simplest and most effective treatment that should be proposed even in hypercapnic patients as first-line therapy. In NMD, the need for continuous HNIV and eventual switching to tracheostomy ventilation makes this group's management more challenging. Achieving successful HNIV by improving quality of sleep, quality of life and keeping a good adherence to the therapy is a challenge, above all in COPD patients. In OHS patients, on top of HNIV, initiation of other interventions such as weight loss management is crucial. More resources should be invested in improving all these aspects. Telemonitoring represents a promising method to improve titration and follow-up of HNIV.

Current State and Future Directions in the Therapy of ALS

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder affecting upper and lower motor neurons, with death resulting mainly from respiratory failure three to five years after symptom onset. As the exact underlying causative pathological pathway is unclear and potentially diverse, finding a suitable therapy to slow down or possibly stop disease progression remains challenging. Varying by country Riluzole, Edaravone, and Sodium phenylbutyrate/Taurursodiol are the only drugs currently approved in ALS treatment for their moderate effect on disease progression. Even though curative treatment options, able to prevent or stop disease progression, are still unknown, recent breakthroughs, especially in the field of targeting genetic disease forms, raise hope for improved care and therapy for ALS patients. In this review, we aim to summarize the current state of ALS therapy, including medication as well as supportive therapy, and discuss the ongoing developments and prospects in the field. Furthermore, we highlight the rationale behind the intense research on biomarkers and genetic testing as a feasible way to improve the classification of ALS patients towards personalized medicine.

Palliative care principles in ALS

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease associated with progressive dysphagia, dysarthria, extremity weakness, and dyspnea. Although there are some disease-modifying pharmacological treatments available which can modestly slow disease progression, the disease is relentlessly progressive and is ultimately fatal. Patients living with ALS should be supported using the principles of palliative care, and in particular, the use of a holistic approach to support the patients and their families. Evidence would support management of patients living with ALS by a multidisciplinary ALS specialty clinic. These multidisciplinary clinics will help support the multitude of symptoms a patient living with ALS can experience, including dysphagia, communication impairments, dexterity impairments, mobility deficits, and respiratory insufficiency. Formal involvement of specialist-trained palliative practitioners can occur throughout the course of the illness, or when the patient is open to their involvement. There are several models of palliative care that can be followed, including integration of palliative care into the multidisciplinary ALS clinic, separate involvement of a palliative care specialty team, home-based palliative care, telemedicine supported care, and hospice care. Key components of palliative care in ALS are goals-of-care discussions advance directive planning, symptoms management, and end-of-life support.

Towards clinical application of implantable brain-computer interfaces for people with late-stage ALS: medical and ethical considerations

Individuals with amyotrophic lateral sclerosis (ALS) frequently develop speech and communication problems in the course of their disease. Currently available augmentative and alternative communication technologies do not present a solution for many people with advanced ALS, because these devices depend on residual and reliable motor activity. Brain-computer interfaces (BCIs) use neural signals for computer control and may allow people with late-stage ALS to communicate even when conventional technology falls short. Recent years have witnessed fast progression in the development and validation of implanted BCIs, which place neural signal recording electrodes in or on the cortex. Eventual widespread clinical application of implanted BCIs as an assistive communication technology for people with ALS will have significant consequences for their daily life, as well as for the clinical management of the disease, among others because of the potential interaction between the BCI and other procedures people with ALS undergo, such as tracheostomy. This article aims to facilitate responsible real-world implementation of implanted BCIs. We review the state of the art of research on implanted BCIs for communication, as well as the medical and ethical implications of the clinical application of this technology. We conclude that the contribution of all BCI stakeholders, including clinicians of the various ALS-related disciplines, will be needed to develop procedures for, and shape the process of, the responsible clinical application of implanted BCIs.

An Evaluation of the P300 Brain-Computer Interface, EyeLink Board, and Eye-Tracking Camera as Augmentative and Alternative Communication Devices

PURPOSE

Augmentative and alternative communication (AAC) systems are important to support communication for individuals with complex communication needs. A recent addition to AAC system options is the brain-computer interface (BCI). This study aimed to compare the clinical application of the P300 speller BCI with two more common AAC systems, the EyeLink board, and an eye-tracking camera.

METHOD

Ten participants without communication impairment (18-35 years of age) used each of the three AAC systems to spell three-letter words in one session. Accuracy and speed of letter selection were measured, and questionnaires were administered to evaluate usability, cognitive workload, and user preferences.

RESULTS

The results showed that the BCI was significantly less accurate, slower, and with lower usability and higher cognitive workload compared to the eye-tracking camera and EyeLink board. Participants rated the eye-tracking camera as the most favorable AAC system on all measures.

CONCLUSIONS

The results demonstrated that while the P300 speller BCI was usable by most participants, it did not function as well as the eye-tracking camera and EyeLink board. The clinical use of the BCI is, therefore, currently difficult to justify for most individuals, particularly when considering the substantial cost and setup resourcing needed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21291384.

Quality of life and mental health in the locked-in-state-differences between patients with amyotrophic lateral sclerosis and their next of kin

For both patients with amyotrophic lateral sclerosis (ALS) and their next of kin (NOK), the maintenance of quality of life (QoL) and mental health is particularly important. First studies suggest significant discrepancies between QoL reports by patients and NOK, but little is known for advanced ALS stages. To address this issue, we screened 52 ALS patients in incomplete locked-in state (iLIS). Final results were obtained for 15 couples of iLIS patients and NOK. We assessed patients' and NOK's subjective QoL, depression and anxiety and NOK's caregiver burden. Gaze controlled questionnaires allowed direct assessment of patients. Patients and NOK self-reported comparable, mostly moderate to high levels of QoL. Of note, NOK indicated stronger anxiety symptoms. Higher anxiety levels in NOK were associated with stronger caregiver burden and reduced QoL. No significant misjudgment of patient's QoL by the NOK was evident, while patients overestimated NOK's global QoL. However, NOK with severe caregiver burden and depression symptoms gave poorer estimations of patients' QoL. This relationship is relevant, considering NOK's impact on life critical treatment decisions. While the daily time NOK and patient spend together was positively correlated with NOK's QoL and mental health, this was not reversely found for the patients. Our results suggest that NOK adapt less successfully to the disease and concomitant experience of loss and point to an urgent need for specialized psychosocial support. The findings emphasize the importance of direct psychological wellbeing assessment of both patients and NOK in clinical practice, enabled by eye-tracking technology for patients in iLIS.

Eye-gaze control of a wheelchair mounted 6DOF assistive robot for activities of daily living

Background

Building control architecture that balances the assistive manipulation systems with the benefits of direct human control is a crucial challenge of human–robot collaboration. It promises to help people with disabilities more efficiently control wheelchair and wheelchair-mounted robot arms to accomplish activities of daily living.

Methods

In this study, our research objective is to design an eye-tracking assistive robot control system capable of providing targeted engagement and motivating individuals with a disability to use the developed method for self-assistance activities of daily living. The graphical user interface is designed and integrated with the developed control architecture to achieve the goal.

Results

We evaluated the system by conducting a user study. Ten healthy participants performed five trials of three manipulation tasks using the graphical user interface and the developed control framework. The 100% success rate on task performance demonstrates the effectiveness of our system for individuals with motor impairments to control wheelchair and wheelchair-mounted assistive robotic manipulators.

Conclusions

We demonstrated the usability of using this eye-gaze system to control a robotic arm mounted on a wheelchair in activities of daily living for people with disabilities. We found high levels of acceptance with higher ratings in the evaluation of the system with healthy participants.

Expanding Availability of Speech-Generating Device Evaluation and Treatment to People With Amyotrophic Lateral Sclerosis (pALS) Through Telepractice: Perspectives of pALS and Communication Partners

Purpose To examine the experiences of people with ALS (pALS) and their communication partners (cALS) regarding receiving speech-generating device (SGD) evaluation and treatment via telepractice. Method Eight pALS along with a primary cALS participated in telepractice SGD evaluation and treatment with an augmentative and alternative communication (AAC) specialist and representatives from multiple SGD vendors. Participants were interviewed postevaluation and post-SGD training to examine their experiences. Mixed methods data were collected through Likert scale responses and qualitative interviews. Results Telepractice SGD evaluation and training were feasible and resulted in all pALS receiving SGDs they were able to use to communicate. In both Likert rating items and qualitative interviews, participants rated the telepractice experience very highly in terms of giving them access to AAC services via an AAC specialist that they would not have otherwise been able to access, and doing so in a format that was possible given their limitations in mobility, endurance, and caregiver availability. Suggestions for improving the telepractice experience were provided. Conclusions Telepractice should be considered as an option to provide vital SGD services to patients who are geographically remote, mobility impaired, unable to leave their home, experience fatigue with travel, or otherwise would not have access to these specialized services. Telepractice allows patients to preserve their time and energy for the assessment and treatment sessions, resulting in perhaps deeper and more frequent engagement in evaluation and training. Telepractice could serve as an alternative to outpatient, in-person evaluations, or be utilized in conjunction with in-person appointments. Supplemental Material https://doi.org/10.23641/asha.15094257.

New technologies and Amyotrophic Lateral Sclerosis - Which step forward rushed by the COVID-19 pandemic?

Amyotrophic Lateral Sclerosis (ALS) is a fast-progressive neurodegenerative disease leading to progressive physical immobility with usually normal or mild cognitive and/or behavioural involvement. Many patients are relatively young, instructed, sensitive to new technologies, and professionally active when developing the first symptoms. Older patients usually require more time, encouragement, reinforcement and a closer support but, nevertheless, selecting user-friendly devices, provided earlier in the course of the disease, and engaging motivated carers may overcome many technological barriers. ALS may be considered a model for neurodegenerative diseases to further develop and test new technologies. From multidisciplinary teleconsults to telemonitoring of the respiratory function, telemedicine has the potentiality to embrace other fields, including nutrition, physical mobility, and the interaction with the environment. Brain-computer interfaces and eye tracking expanded the field of augmentative and alternative communication in ALS but their potentialities go beyond communication, to cognition and robotics. Virtual reality and different forms of artificial intelligence present further interesting possibilities that deserve to be investigated. COVID-19 pandemic is an unprecedented opportunity to speed up the development and implementation of new technologies in clinical practice, improving the daily living of both ALS patients and carers. The present work reviews the current technologies for ALS patients already in place or being under evaluation with published publications, prompted by the COVID-19 pandemic.

Eye Gaze Gaming Intervention in Children with Dyskinetic Cerebral Palsy: A Pilot Study of Task Performance and Its Relation with Dystonia and Choreoathetosis

OBJECTIVES

To investigate the operational competences screen navigation and dwell function underlying eye gaze performance, and the relation of dystonia and choreoathetosis with eye gaze performance in children with dyskinetic cerebral palsy (DCP).

METHODS

During a 5-week intervention, ten participants with DCP played eye gaze video games daily for 30 minutes. Six games were used to assess task performance, fixation count, and eye movement accuracy during four measurements. Dystonia and choreoathetosis were evaluated using the Dyskinesia Impairment Scale.

RESULTS

Eye gaze performance improved over time (p = .013). Moderate to strong within-subject correlations were found between eye movement accuracy and task performance, and between eye movement accuracy and fixation count. No significant correlations were found with the movement disorders.

CONCLUSIONS

Eye gaze technology shows great potential to be a successful computer interface for children with severe DCP, thereby potentially improving their communication skills, participation levels, and quality of life.

Smart home and communication technology for people with disability: a scoping review

PURPOSE

The links between disability, activity limitation and participation restriction are well established. Recent and continued advancement of technology, particularly smart home and communication technologies, presents new ways in which some of the limitations and restrictions experienced by people with disabilities can be overcome. The aim of this scoping review was to explore the impact of smart home and communication technology on the outcomes of people with disabilities and complex needs.

METHOD

This review involved systematic searching of four databases, hand searches and data extraction. Eligibility criteria included [1] participant outcomes of [2] technology used within the home [3] among adults with a disability and complex needs.

RESULTS

Of the 2400 studies identified, 21 met our inclusion criteria. Studies were characterized by significant diversity in relation to disability and type of technology. Overall, technology appeared to improve independence, participation and quality of life among people with a disability and complex needs. Despite this, ethical considerations were raised given the vulnerability of this population, including potential risks through social participation and privacy concerns of using monitoring technology.

CONCLUSIONS

Smart home and communication technology can improve outcomes for people living with disabilities and complex needs. However, a number of factors impact the successful implementation of technology, including personalization, flexibility and ongoing support to the person with a disability and their close others. Future research should utilize high-quality study designs and established measures of important outcomes for this group.IMPLICATIONS FOR REHABILITATIONThere is a broad range of smart home and communication technology devices and systems available that may support the independence and participation of people with disabilities and complex needs; however, high-quality evidence documenting the impact of technology is lacking.Soft-technology supports, including assessment, training and evaluation of technology implementation, may play just as important a role in shaping outcomes as the technology itself.Systematic research is required to ensure there is quality evidence to inform investment in both technologies, and the soft-technology supports that promote its successful use.

Mainstream technology to support basic communication and leisure in people with neurological disorders, motor impairment and lack of speech

OBJECTIVE

To assess a simple technology solution to support basic communication and leisure in people with neurological disorders, extensive motor impairment, and absence of speech.

DESIGN

The design was a non-concurrent multiple baseline across participants.

METHODS

The study included eight participants and assessed a technology setup including a Samsung Galaxy Tab S2 LTE tablet and a Samsung Galaxy A3 smartphone. The smartphone, automated via MacroDroid, presented the participant with leisure, messages, and caregiver options. Choosing leisure or messages (by activating the smartphone's proximity sensor) led the smartphone to present the alternatives available for that option and eventually verbalize the alternative selected. This verbalization triggered the tablet's Google Assistant and led the tablet to present a leisure event or start a message exchange. Choosing the caregiver led the smartphone to invite the caregiver to interact with the participant.

RESULTS

During baseline (i.e., when a standard smartphone was available), the participants did not activate any of the options. During intervention and post-intervention (i.e., with the technology described above), participants activated all options and spent most of the session time positively engaged with them.

CONCLUSIONS

The aforementioned technology seems to be a useful tool for individuals like those involved in this study.

Auditory Electrooculogram-based Communication System for ALS Patients in Transition from Locked-in to Complete Locked-in State

Patients in the transition from locked-in (i.e., a state of almost complete paralysis with voluntary eye movement control, eye blinks or twitches of face muscles, and preserved consciousness) to complete locked-in state (i.e., total paralysis including paralysis of eye-muscles and loss of gaze-fixation, combined with preserved consciousness) are left without any means of communication. An auditory communication system based on electrooculogram (EOG) was developed to enable such patients to communicate. Four amyotrophic lateral sclerosis patients in transition from locked-in state to completely locked-in state, with ALSFRS-R score of 0, unable to use eye trackers for communication, learned to use an auditory EOG-based communication system. The patients, with eye-movement amplitude between the range of ±200μV and ±40μV, were able to form complete sentences and communicate independently and freely, selecting letters from an auditory speller system. A follow-up of one year with one patient shows the feasibility of the proposed system in long-term use and the correlation between speller performance and eye-movement decay. The results of the auditory speller system have the potential to provide a means of communication to patient populations without gaze fixation ability and with low eye-movement amplitude range.

A systematic review investigating outcome measures and uptake barriers when children and youth with complex disabilities use eye gaze assistive technology

Children with complex disabilities sometimes have difficulty communicating with their parents, caregivers, and teachers. For these children, eye gaze assistive technology can be used to facilitate communication. Eye gaze assistive technology outcomes for children and youth were analyzed in this systematic review. Database and hand-searches yielded 4412 unduplicated results, of which 11 articles were eligible for this review. Outcome measures, as well as environmental and personal factors, were mapped to the World Health Organization's International Classification of Functioning, Disability and Health framework. Communication outcomes were most prevalent and co-occurred with outcomes in all reported activities and participation domains. Environmental and personal factors were classified as either facilitators or as barriers in relation to device uptake and success. Although comprehensive professional and caregiver support was the primary facilitator for success, barriers could lead to rejection of the technology even when children were successful using the system.

Usability of Eye-Gaze Controlled Computers in Sweden: A Total Population Survey

Eye-gaze technology allows individuals with severe physical disabilities and complex communication needs to control a computer or other devices with eye-gaze, thereby enabling them to communicate and participate in society. To date, most research on eye-gaze controlled devices related to persons with disabilities has focused on a single diagnosis in either adults or children and has included only a few participants. This current study utilized a total population survey to identify the prevalence and perceived usability of eye-gaze technology among adults and children in Sweden. Participants were 171 eye-gaze technology users with severe physical and communication impairments, ranging between 4 and 81 years. Cerebral palsy was the most common diagnosis. Daily usage was found in 63%, while 33% had weekly, and 4% had less frequent usage. Adults, compared with children, reported using their computers more frequently (65%/38%; p < 0.01), and for the activities they needed to perform (59%/31%; p < 0.01) and were more satisfied with services, indicating that service providers should prioritize and develop more effective services for children and their parents.

A Hybrid Speller Design Using Eye Tracking and SSVEP Brain-Computer Interface

Steady-state visual evoked potentials (SSVEPs) have been extensively utilized to develop brain-computer interfaces (BCIs) due to the advantages of robustness, large number of commands, high classification accuracies, and information transfer rates (ITRs). However, the use of several simultaneous flickering stimuli often causes high levels of user discomfort, tiredness, annoyingness, and fatigue. Here we propose to design a stimuli-responsive hybrid speller by using electroencephalography (EEG) and video-based eye-tracking to increase user comfortability levels when presented with large numbers of simultaneously flickering stimuli. Interestingly, a canonical correlation analysis (CCA)-based framework was useful to identify target frequency with a 1 s duration of flickering signal. Our proposed BCI-speller uses only six frequencies to classify forty-eight targets, thus achieve greatly increased ITR, whereas basic SSVEP BCI-spellers use an equal number of frequencies to the number of targets. Using this speller, we obtained an average classification accuracy of 90.35 ± 3.597% with an average ITR of 184.06 ± 12.761 bits per minute in a cued-spelling task and an ITR of 190.73 ± 17.849 bits per minute in a free-spelling task. Consequently, our proposed speller is superior to the other spellers in terms of targets classified, classification accuracy, and ITR, while producing less fatigue, annoyingness, tiredness and discomfort. Together, our proposed hybrid eye tracking and SSVEP BCI-based system will ultimately enable a truly high-speed communication channel.

Hybrid Eye-Tracking on a Smartphone with CNN Feature Extraction and an Infrared 3D Model

This paper describes a low-cost, robust, and accurate remote eye-tracking system that uses an industrial prototype smartphone with integrated infrared illumination and camera. Numerous studies have demonstrated the beneficial use of eye-tracking in domains such as neurological and neuropsychiatric testing, advertising evaluation, pilot training, and automotive safety. Remote eye-tracking on a smartphone could enable the significant growth in the deployment of applications in these domains. Our system uses a 3D gaze-estimation model that enables accurate point-of-gaze (PoG) estimation with free head and device motion. To accurately determine the input eye features (pupil center and corneal reflections), the system uses Convolutional Neural Networks (CNNs) together with a novel center-of-mass output layer. The use of CNNs improves the system’s robustness to the significant variability in the appearance of eye-images found in handheld eye trackers. The system was tested with 8 subjects with the device free to move in their hands and produced a gaze bias of 0.72°. Our hybrid approach that uses artificial illumination, a 3D gaze-estimation model, and a CNN feature extractor achieved an accuracy that is significantly (400%) better than current eye-tracking systems on smartphones that use natural illumination and machine-learning techniques to estimate the PoG.

Quality of life and functional independence in amyotrophic lateral sclerosis: A systematic review

Amyotrophic Lateral Sclerosis (ALS) leads to functional capacity decline, generating great impact in quality of life. Quality of life is directly related to physical integrity and functional independence. This systematic review aimed to analyze treatment protocols and their outcomes from clinical trials with focus on ALS rehabilitation that evaluated the effects on quality of life and functional independence from their intervention process. A literature search was conducted through MEDLINE-PubMed, Science Direct, Web of Science and Scopus databases. A total of 3630 articles were identified. Eleven studies met the inclusion criteria. They focused on different aspects of quality of life or functional independence, which are: respiratory care, mental health, communication skills and exercises. Use of bipap and inspiratory muscle training, anxiety and depression, communication devices implementation and exercises safety and tolerability were considered as key points. However, the drastic evolution of the disease is a limiting factor to the perception of quality of life improvement by patients. Further studies should be done to validate the benefits on patients' quality of life.

Technological Advancements in Cerebral Palsy Rehabilitation

Smaller, smarter, more portable rehabilitation technology has the potential to improve the ability of individuals with cerebral palsy to perform activities and increase participation. Robotics and virtual reality may improve movement by maximizing exercise dose, providing feedback, and motivating users. Augmentative and alternative communication technology is facilitating communication. Robots can help with self-care and provide encouragement and instruction in rehabilitation programs. Mobile applications can provide education and resources. Conducting high-quality research to validate technological advances in our field has been a major focus of researchers and advocacy groups.

Appraising the quality of tools used to record patient-reported outcomes in users of augmentative and alternative communication (AAC): a systematic review

PURPOSE

People who have complex communication needs (CCN), and who use augmentative and alternative communication (AAC) to help them express themselves, can be difficult to engage in decision making about their healthcare. The purpose of this review was to identify what patient-reported outcome measures (PROMs) have been employed with people who use AAC. Of the tools identified, the review aimed to establish what conceptual frameworks were used and how the reports describe completion of the PROM.

METHODS

A systematic literature review was carried out. A pre-defined set of search terms was entered into five main health and education databases. Titles and abstracts were sifted for relevance. Full text papers were screened against inclusion/exclusion criteria. Data pertaining to the type and nature of the PROM used was extracted. Complementary data sources were analysed to construct a narrative synthesis of the papers identified.

RESULTS

Within 15 papers that met the review criteria, 25 PROMs were used with people who rely on AAC comprising of 15 separate measures. The conceptual frameworks for 12 of these tools were reported from which 62 items, or concepts being measured, were identified. Following synthesis of these items, 9 conceptual domains and 11 sub-domains were generated. Limited information was available about who completed the PROM nor how much, if any, support they received.

CONCLUSIONS

No PROM that has been developed specifically for people who use AAC was identified by this review. Of the tools that have been used with people who use AAC, the concepts measured were broad and varied. The quality of reporting concerning who completed the PROM was limited, undermining the trustworthiness of many of the studies.

Eye tracking - The overlooked method to measure cognition in neurodegeneration?

Eye tracking (ET) studies are becoming increasingly popular due to rapid methodological and technological advances as well as the development of cost efficient and portable eye trackers. Although historically ET has been mostly employed in psychophysics or developmental cognition studies, there is also promising scope to use ET for movement disorders and measuring cognitive processes in neurodegeneration. Particularly, ET can be a powerful tool for cognitive and neuropsychological assessments of patients with pathologies affecting motor and verbal abilities, as tasks can be adapted without requiring motor (except eye movements) or verbal responses. In this review, we will examine the existing evidence of ET methods in neurodegenerative conditions and its potential clinical impact for cognitive assessment. We highlight that current evidence for ET is mostly focused on diagnostics of cognitive impairments in neurodegenerative disorders, where it is debatable whether it has any more sensitivity or specificity than existing cognitive assessments. By contrast, there is currently a lack of ET studies in more advanced disease stages, when patients' motor and verbal functions can be significantly affected, and standard cognitive assessments are challenging or often not possible. We conclude that ET is a promising method not only for cognitive diagnostics but more importantly, for potential cognitive disease tracking in progressive neurodegenerative conditions.

Hope and Technology: Other-Oriented Hope Related to Eye Gaze Technology for Children with Severe Disabilities

Introducing advanced assistive technology such as eye gaze controlled computers can improve a person's quality of life and awaken hope for a child's future inclusion and opportunities in society. This article explores the meanings of parents' and teachers' other-oriented hope related to eye gaze technology for children with severe disabilities. A secondary analysis of six parents' and five teachers' interview transcripts was conducted in accordance with a phenomenological-hermeneutic research method. The eye gaze controlled computer creates new imaginations of a brighter future for the child, but also becomes a source for motivation and action in the present. The other-oriented hope occurs not just in the future; it is already there in the present and opens up new alternatives and possibilities to overcome the difficulties the child is encountering today. Both the present situation and the hope for the future influence each other, and both affect the motivation for using the technology. This emphasises the importance of clinicians giving people opportunities to express how they see the future and how technology could realise this hope.

Eye-gaze control technology for children, adolescents and adults with cerebral palsy with significant physical disability: Findings from a systematic review

PURPOSE

The primary objective of this systematic review was to examine the effectiveness of eye-gaze control technology for facilitating communication across different social contexts for people with cerebral palsy and significant physical disability.

METHODS

Systematic review.

RESULTS

The search identified 756 potentially eligible articles, of which two, low level articles were eligible. One study reported positive results for achieving communication goals for children with cerebral palsy. The second concluded that eye-gaze control technology resulted in greater quality of life and less depression for adults with late stage amyotrophic lateral sclerosis when compared to non-users.

DISCUSSION

Research regarding the effectiveness of eye-gaze control technology used to access a laptop, tablet or computer on communication outcomes, participation, quality of life and self-esteem in children, adolescents and adults with cerebral palsy and significant physical disability is sparse. A scoping review to fully identify issues to inform clinical practice and future research is required.

Linking the Psychosocial Impact of Assistive Devices Scale (PIADS) to the International Classification of Functioning, Disability, and Health

PURPOSE

Assistive technologies are widely implemented in clinical and research settings. Despite their dissemination, the psychosocial impact of their adoption still deserves further consideration. The aim of the present study is to determine the degree of compatibility between the Psychosocial Impact of Assistive Devices Scale (PIADS) and the International Classification of Functioning, Disability, and Health (ICF).

METHODS

Six health professionals (two neurologists, one neuro-rehabilitation technician, two psychologists, one university professor of rehabilitation) created a technical board to discuss upon the PIADS-ICF linking. The standardized linking methodology was applied, and a Delphi technique was used to examine consensus.

RESULTS

Five Delphi sessions were required to reach 100% of consensus and to finalize the procedure. Of the 26 PIADS' items, 23 were linked to an ICF category: 9 items were endorsed at the 3rd ICF level, and 14 items at the 2nd ICF level. Two items were classified as "not defined" and 1 item as "not covered".

CONCLUSION

The study highlighted the conceptual connection between the PIADS and the ICF framework and set a bio-psychosocial standpoint by which accounting the role of assistive devices in rehabilitation settings.

Communication Matters-Pitfalls and Promise of Hightech Communication Devices in Palliative Care of Severely Physically Disabled Patients With Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease, leading to progressive paralysis, dysarthria, dysphagia, and respiratory disabilities. Therapy is mostly focused on palliative interventions. During the course of the disease, verbal as well as nonverbal communicative abilities become more and more impaired. In this light, communication has been argued to be “the essence of human life” and crucial for patients' quality of life. High-tech augmentative and alternative communication (HT-AAC) technologies such as eyetracking based computer devices and brain-computer-interfaces provide the possibility to maintain caregiver-independent communication and environmental control even in the advanced disease state of ALS. Thus, they enable patients to preserve social participation and to independently communicate end-of-life-decisions. In accordance with these functions of HT-AAC, their use is reported to strengthen self-determination, increase patients' quality of life and reduce caregiver burden. Therefore, HT-AAC should be considered as standard of (palliative) care for people with ALS. On the other hand, the supply with individually tailored HT-AAC technologies is limited by external and patient-inherent variables. This review aims to provide an overview of the possibilities and limitations of HT-AAC technologies and discuss their role in the palliative care for patients with ALS.

Usability of a Low-Cost Head Tracking Computer Access Method following Stroke

Assistive technology devices for computer access can facilitate social reintegration and promote independence for people who have had a stroke. This work describes the exploration of the usefulness and acceptability of a new computer access device called the Nouse™ (Nose-as-mouse). The device uses standard webcam and video recognition algorithms to map the movement of the user's nose to a computer cursor, thereby allowing hands-free computer operation. Ten participants receiving in- or outpatient stroke rehabilitation completed a series of standardized and everyday computer tasks using the Nouse™ and then completed a device usability questionnaire. Task completion rates were high (90%) for computer activities only in the absence of time constraints. Most of the participants were satisfied with ease of use (70%) and liked using the Nouse™ (60%), indicating they could resume most of their usual computer activities apart from word-processing using the device. The findings suggest that hands-free computer access devices like the Nouse™ may be an option for people who experience upper motor impairment caused by stroke and are highly motivated to resume personal computing. More research is necessary to further evaluate the effectiveness of this technology, especially in relation to other computer access assistive technology devices.

Survey of the functional priorities in patients with disability due to neuromuscular disorders

TITLE

Survey of the functional priorities in patients with disability due to neuromuscular disorders.

OBJECTIVE

This study attempts to determine the functional priorities for patients with neuromuscular disorders.

METHODS

A survey asking about functional priorities with respect to activities of daily living, ankle foot orthotic design, and assistive device design, was distributed to patients with neuromuscular disorders to assess the needs of patients from their perspectives. Descriptive statistics were used to analyse answers.

RESULTS

A total of 171 subjects with neuromuscular disorders responded to the questionnaire. Of the respondents with weakness in both the upper and lower extremities, 45% stated that if they had to choose between correction of one or the other, they would prefer that of their lower extremities. Activities that patients most frequently wanted to gain independence with were mobility and transfers (46%), followed by toilet use and hygiene (32%). The most popular control mechanism of an assistive device was voice activation (35%).

CONCLUSION

This study assessed the functional priorities of those with neuromuscular disorders. Although such individuals can experience a range of weakness in the upper and/or lower extremities, common functional priorities were reported: independence with mobility, transfers, toilet use and hygiene. Knowledge of these priorities will help guide development of assistive devices that will restore function in the future. Implications for Rehabilitation     Neuromuscular Disorders  • Neuromuscular disorders result in disabling weakness; there are few cures and many are unable to carry out activities of daily living.  • Information that would be helpful in determining functional priorities is limited.  • In a survey of 171 patients with neuromuscular disorders, functional priorities included mobility and transfers (46%), followed by toilet use and hygiene (32%).  • Of the respondents with weakness in both the upper and lower extremities, 45% stated that if they had to choose between correction of one or the other, they would prefer that of their lower extremities.  • If an assistive device were to be created to help those with neuromuscular disorders, the most popular control mechanism would be voice activation (35%).

Usability of eyetracking computer systems and impact on psychological wellbeing in patients with advanced amyotrophic lateral sclerosis

Restrictions in communicative abilities are well known in patients with amyotrophic lateral sclerosis (ALS), but only few approaches in terms of evaluation of supportive technologies have been made. We aimed to assess the use and perceived usability of eye-tracking computer devices (ETCS) of severely impacted patients with ALS in an independent, direct manner and relate it to psychological well-being. ETCS enable active communication and social participation in the quadriplegic and anarthric disease state. Therefore, ETCS-based versions of widely used psychosocial questionnaires (ADI-12, SeiQoL-DW, WHO-5) as well as structured questions on communicative functioning and ETCS usage were developed to assess ALS patients, their next of kin and professional caregivers. Eleven patients (ALSFRS-R: 5.3 ± 5.9; ALS duration: 6.5 ± 3.8 years, range 1‒12; 82% invasively ventilated), nine next of kin and 10 professional caregivers could be assessed. Patients reported a mean use of their personal ETCS of 9.1 h per d (range 0.5‒16), with a high user satisfaction, preservation of communicative abilities and subjective indispensability of the ETCS. ETCS use was associated with higher psychological well-being. Next of kin and professional caregivers also nominated some critical aspect, which remains to be clarified. Our results strengthen the evidence that preserved mental autonomy influences psychological well-being in ALS and might even modify disease course and end-of-life-decisions in ALS.

Development of an electrooculogram-based eye-computer interface for communication of individuals with amyotrophic lateral sclerosis

BACKGROUND

Electrooculogram (EOG) can be used to continuously track eye movements and can thus be considered as an alternative to conventional camera-based eye trackers. Although many EOG-based eye tracking systems have been studied with the ultimate goal of providing a new way of communication for individuals with amyotrophic lateral sclerosis (ALS), most of them were tested with healthy people only. In this paper, we investigated the feasibility of EOG-based eye-writing as a new mode of communication for individuals with ALS.

METHODS

We developed an EOG-based eye-writing system and tested this system with 18 healthy participants and three participants with ALS. We also applied a new method for removing crosstalk between horizontal and vertical EOG components. All study participants were asked to eye-write specially designed patterns of 10 Arabic numbers three times after a short practice session.

RESULTS

Our system achieved a mean recognition rates of 95.93% for healthy participants and showed recognition rates of 95.00%, 66.67%, and 93.33% for the three participants with ALS. The low recognition rates in one of the participants with ALS was mainly due to miswritten letters, the number of which decreased as the experiment proceeded.

CONCLUSION

Our proposed eye-writing system is a feasible human-computer interface (HCI) tool for enabling practical communication of individuals with ALS.

Eye-tracking-based assessment suggests preserved well-being in locked-in patients

We assessed quality of life (QoL) and psychological well-being in patients with amyotrophic lateral sclerosis-induced locked-in state and their next of kin in a fully unbiased manner using eye-tracking computer systems. Eleven of 30 screened patients and 9 next of kin completed study procedures. Patients reported good QoL, which appeared to be at the cost of the QoL of their next of kin. Next of kin rated their own or patients' QoL similarly, but they identified different areas as important as compared with patients. Our results are of importance for the discussion of end-of-life decisions and the evaluation of patients' presumed wishes as well as for psychosocial interventions. Ann Neurol 2017;81:310-315.

Fusion of P300 and eye-tracker data for spelling using BCI2000

OBJECTIVE

Various augmentative and alternative communication (AAC) devices have been developed in order to aid communication for individuals with communication disorders. Recently, there has been interest in combining EEG data and eye-gaze data with the goal of developing a hybrid (or 'fused') BCI (hBCI) AAC system. This work explores the effectiveness of a speller that fuses data from an eye-tracker and the P300 speller in order to create a hybrid P300 speller.

APPROACH

This hybrid speller collects both eye-tracking and EEG data in parallel, and the user spells characters on the screen in the same way that they would if they were only using the P300 speller. Online and offline experiments were performed. The online experiments measured the performance of the speller for sixteen non-disabled participants, while the offline simulations were used to assess the robustness of the hybrid system.

MAIN RESULTS

Online results showed that for fifteen non-disabled participants, using eye-gaze in a Bayesian framework with EEG data from the P300 speller improved accuracy ([Formula: see text], [Formula: see text], [Formula: see text] for estimated, medium and high variance configurations) and reduced the average number of flashes required to spell a character compared to the standard P300 speller that relies solely on EEG data ([Formula: see text], [Formula: see text], [Formula: see text] for estimated, medium and high variance configurations). Offline simulations indicate that the system provides more robust performance than a standalone eye gaze system.

SIGNIFICANCE

The results of this work on non-disabled participants shows the potential efficacy of hybrid P300 and eye-tracker speller. Further validation on the amyotrophic lateral sceloris population is needed to assess the benefit of this hybrid system.