Therapist-Guided Tablet-Based Telerehabilitation for Patients With Aphasia: Proof-of-Concept and Usability Study

Background Aphasia is the loss or impairment of language functions and affects everyday social life. The disorder leads to the inability to understand and be understood in both written and verbal communication and affects the linguistic modalities of auditory comprehension, verbal expression, reading, and writing. Due to heterogeneity of the impairment, therapy must be adapted individually and dynamically to patient needs. An important factor for successful aphasia therapy is dose and intensity of therapy. Tablet computer–based apps are a promising treatment method that allows patients to train independently at home, is well accepted, and is known to be beneficial for patients. In addition, it has been shown to ease the burden of therapists. Objective The aim of this project was to develop an adaptive multimodal system that enables aphasic patients to train at home using language-related tasks autonomously, allows therapists to remotely assign individualized tasks in an easy and time-efficient manner, and tracks the patient’s progress as well as creation of new individual exercises. Methods The system consists of two main parts: (1) the patient’s interface, which allows the patient to exercise, and (2) the therapist’s interface, which allows the therapist to assign new exercises to the patient and supervise the patient’s progress. The pool of exercises is based on a hierarchical language structure. Using questionnaires, therapists and patients evaluated the system in terms of usability (ie, System Usability Scale) and motivation (ie, adapted Intrinsic Motivation Inventory). Results A total of 11 speech and language therapists (age: mean 28, SD 7 years) and 15 patients (age: mean 53, SD 10 years) diagnosed with aphasia participated in this study. Patients rated the Bern Aphasia App in terms of usability (scale 0-100) as excellent (score >70; Z=–1.90; P=.03) and therapists rated the app as good (score >85; Z=–1.75; P=.04). Furthermore, patients enjoyed (scale 0-6) solving the exercises (score>3; mean 3.5, SD 0.40; Z=–1.66; P=.049). Conclusions Based on the questionnaire scores, the system is well accepted and simple to use for patients and therapists. Furthermore, the new tablet computer–based app and the hierarchical language exercise structure allow patients with different types of aphasia to train with different doses and intensities independently at home. Thus, the novel system has potential for treatment of patients with aphasia as a supplement to face-to-face therapy.


23.02.2019
Exercise structure Bern Aphasia App Page 2 of 11 1 Category Assigning

Single picture-word matching
The task of single picture-word matching is to select the correct word from phonematically respective semantically related distractors (i.e. words). For example (figure 1), which of the words matches the image of an ancient document best? Old would be the correct answer, whereas new, digital, electronic, and visual would be the distractors. The number of distractors can be varied. Additionally, as supportive elements to the picture, a video or an audio file of a speech and language therapist spelling the correct word can be displayed. To adapt the task to the patients, the exercise structure (figure 2) is hierarchically structured into decks focused on adjectives, substantives, and verbs.

Single word-picture matching
The task of single word-picture matching is to select the correct picture from phonematically respective semantically related distractors (i.e. pictures). For example (figure 3), which of the images contains a sour fruit/vegetable? Lemon would be the correct answer, whereas strawberry, pear, and pumpkin would be the distractors. The number of distractors can be varied. Additionally, as supportive elements to the word, a video or audio file of a speech and language therapist spelling the correct word can be displayed. To adapt the task to the patients, the exercise structure (figure 4) is hierarchically structured into decks focused on adjectives, substantives, and verbs.

Word completion
The task of word completion is to select the correct letter(s) and insert them into the correct position(s) of the word. For example (figure 7), the word we are looking for is kalt (cold). Thus, the correct letter to complete the word is the a, and i would be the distractor. The number of distractors can be varied. Additionally, as supportive elements to the picture, a video or audio file of a speech and language therapist spelling the correct word can be displayed. To adapt the task to the patients, the exercise structure (figure 8) is hierarchically structured into decks focused on phonematic criteria.

Anagram
The task of anagram is to bring the letters into the correct order to complete the word. For example (figure 11), the letters should be ordered to complete the word Maler. Additionally, as supportive elements to the picture, a video or audio file of a speech and language therapist spelling the correct word can be displayed. To adapt the task to the patients, the exercise structure (figure 12) is hierarchically structured into decks focused on phonematic and semantic criteria.

Sentence ordering
The task of sentence ordering is to bring the words into the correct order. For example (figure 13), the words should be ordered to complete the sentence "Der Wäschekorb ist nicht leer." (The laundry basket is not empty.) Additionally, as supportive elements to the word, a video or audio file of a speech and language therapist spelling the correct word can be displayed. To adapt the task to the patients, the exercise structure ( figure 14) is hierarchically structured into decks focused on sentences with three -six words.

Word repetition
The task of word repetition is to repeat the audio-visually recorded spoken word by a speech and language therapist. For example (figure 15), the patient must mimic the word dollar. To adapt the task to the patients, the exercise structure (figure 16) is hierarchically structured into decks focused on sentences' different dialects.

Copy and recall
The task of copy and recall is to write or type the word presented. For example (figure 17), the word Takt must be copied and written correctly. To adapt the task to the patients, the exercise structure (figure 17) is hierarchically structured into decks focused on high-and low-frequency words.

Category Comprehension
The task of comprehension is to select the correct answer to a question about the auditory, audiovisual, text-based respective image-based information. For example ( figure 19), based on the image information the question is what the women carries with her for sure. The correct is answer is Pass, whereas the Paar (couple) and Fass (barel) are distractors. The number of distractors can be varied. To adapt the task to the patients, the exercise structure (figure 20) is hierarchically structured into decks focused on the four language modalities.