Honduras: Matriz de competitividad y desempeño de “clusters” potenciales

The body of research on writing treatment for people with aphasia was relatively small, yet it offered some strong evidence of treatment effectiveness: other than the 28 participants receiving treatment via the two flawed RCT studies, only four (1.8%) of 217 individuals did not make significant gains on treated items. The degree of generalisation and maintenance of gains was not always tested or reported, but where it was indications were also encouraging.

Of note however, was the fact that generalisation more commonly extended to untrained words, and less often to other functional writing activities. This finding may be a by-product of the way in which outcomes were measured, whereby formal spelling assessment batteries rather than functional tasks were used in all but ten of the studies. While such impairment-based batteries are an effective means of measuring and reporting gain in a transparent way, they arguably lack the authenticity of functional, every-day tasks.

The studies in the literature may have been hampered by the lack of a standard measure of functional writing specifically designed for PWA, as noted in Thiel et al’s systematic review [206], which has sometimes resulted in the use of informal or novel tasks such as those listed in section 3.2.3 above. These have limitations, since the psychometric properties of the tests have not been tested, and studies used a range of tasks, making between study comparisons difficult.

The current study made use of both formal assessment batteries and functional tasks. Standardised writing assessments are used for diagnostic and monitoring purposes, in traditional pen and paper format. These also permit any potential remediatory effects of the writing treatment to be examined. Additionally, a novel functional email composition task is undertaken, using both pen and paper and keyboard. This allows observation of whether the training package supports independent production of spontaneously generated material, such that participants

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may wish to produce in real world circumstances beyond the clinic. The compensatory potential of assistive technology to support narrative writing via dictation will also be revealed through this assessment, if writing is significantly improved by the use of AT rather than typing alone once the training is complete. A variant of this assessment was used in a previous AT narrative writing study [115] and is continuing to be employed in the CommuniCATE project (in preparation), so further comparisons across participants will be possible. Linked normative data are also being collected, so some psychometric data for this task will eventually become available.

Finally, a picture description task is also undertaken in both of these formats, in order to explore whether a more scaffolded narrative task may be easier to perform than a free composition task.

The literature suggested a number of other areas in which further investigation is also warranted. Firstly, many more participants received single word level treatment than sentence/phrase or narrative level treatments. This may reflect the fact that treating writing at the level of narrative discourse is regarded as precarious, yet the findings from the small number of studies undertaken were promising. One striking finding was that the studies which made use of technology were considerably more balanced with respect to single word versus narrative goals (as shown in Table 3.1): this may reflect a more functional focus in these studies. Since the technological studies are relatively recent, they are perhaps indicative of a growing awareness that therapy needs to address targets that extend beyond the single word, as real world writing tasks are so often at the narrative level. Therefore, the current study will focus on narrative production, in line with its underpinnings in the social model of writing described in Chapter 1, and to add to the burgeoning literature as this area receives more attention.

Additionally, of particular interest was that all of the existing narrative studies were delivered via technology, suggesting this is an area especially

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ripe with potential as advances in this area continue. In the light of this, the seven narrative level compensatory studies were scrutinised with reference to the following criteria: software, treatment, dosage, frequency, participant profiles, assessments used and gains reported. This revealed four instances of success with mainstream voice recognition software Dragon NaturallySpeaking™, as described in Chapter 2, in treatments ranging from a single voice training session [149] to 17 sessions [109], besides one using Windows Voice Recognition [144]. Written picture description tests indicated that the software resulted in improved writing performance, and two studies [109, 107] also described generalisation to every-day functional writing; in the latter study this was explicitly measured with a novel composition task. The participant also increased social participation, and the size of his social network grew. Furthermore, two studies [107, 152] found that text to speech software can effectively promote auditory comprehension to support writing. Other useful background information for the current study was also gleaned from the seven studies which used technology to compensate for narrative writing difficulties, and was considered when designing the training intervention program described in this thesis. These included the usefulness of pasting together fragments of dictated written text to form longer compositions 152, 144] and the recommendation to reduce visual steps and navigation where possible [144]. The findings from the narrative compensatory studies using technology are summarised in Table 3.2.

Single case - or small case series - studies were conducted much more frequently than group studies; besides the two weak RCT studies there were only five group studies in the literature, and one qualitative interview group study. With particular reference to VRS studies, with the exception of Wade et al’s voice training program there are not yet any group studies. Of the three single case studies, two reported promising levels of generalisation to a range of independent functional writing tasks. More research examining group outcome measures is therefore warranted, in

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Software Treatment Dosage and

frequency

Assessments used Gains reported

Al Mahmud & Martens 2013 [152]

Modified email tool for PWA: ‘Amail’

12 PWA interviewed regarding writing emails and barriers to use, testing of design and feedback

Three visits Experimental use of modified software

End users recommended text to speech to assist with reading, pasting function to support composition, reduced visual steps and navigation

Bruce, Edmundson & Coleman 2003 [109]

Dragon NaturallySpeaking Single case training program 17 one hour sessions over 8 months

CAT written picture description with and without software, PALPA subtests, Reading Comprehension Battery for Aphasia, WAB, pen and paper and dictated writing samples

Number of recognition errors reduced over training time Generalised to using writing as a main form of communication, began keeping a diary and writing emails Caute & Woolf

2016 [107]

Dragon NaturallySpeaking and Read+Write Gold

Single case 16 one hour treatment sessions

CAT picture description, constrained writing task (novel task devised by authors and independently rated for social validity), social network analysis, social activities checklist

Significant improvements in efficiency and communicative effectiveness ratings, gains generalised to functional writing and were maintained, social participation increased, social network grew Dahl, Linebarger & Berndr 2008 [144] Windows Voice Recognition, Sentence Shaper, CoolEdit 2000 and two bespoke programs

Recording fragments of speech and assembling them into longer structures to make written sentences

One session None stated Three of four participants produced more accurate text with the software (descriptive only)

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Estes & Bloom 2011 [108]

Dragon NaturallySpeaking Single case 10 one hour training sessions over four weeks plus email exercises

BDAE including written picture description, BNT, ASHA FACS, Quality of Communication Life Scales

Dictation accuracy and error recognition increased; no

generalisation to functional writing – picture description remained superior to spontaneous writing Mortley,

Enderby & Petheram 2011 [127]

INTACT (designed for people with aphasia)

Single case 3 stage intervention to develop writing/ typing skills, train compensatory strategy (operating predictive text) and promote functional generalisation (correspondence with daughter)

6 month therapy plus homework; intensity of dose not stated

PALPA subtests (pen and paper) and informal spelling assessment

Spelling improved (from3/51 to 50/51 on informal assessment), and significant PALPA gains;

generalisation to correspondence, maintained at 8 week follow up Thiel, Sage &

Conroy 2017 [159]

CoWriter™ Case series with eight individuals with aphasia

10 one-hour sessions of therapy over five weeks

Email skills assessment, keyboard skills assessment, email

composition, hand-written picture description, CAT disability questionnaire

Four of eight participants showed statistically improved spelling accuracy within emails; group level significant increase in word length Wade,

Petheram & Cain 2001 [149]

Dragon NaturallySpeaking Six individuals with aphasia (and five controls) - tested whether VRS is useful for spoken language therapy but findings relevant to

compensatory writing

Single session PALPA naming, word repetition, oral reading

Software successfully trained by PWA as well as controls, bypassing need for reading with use of a set vocabulary

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order to strengthen the evidence base for the use of AT in writing therapy, and to gather further information on which individuals may benefit most. Most writing treatment studies in the literature had remediatory goals. Only eight studies focused specifically on compensating for writing impairments (the remaining compensatory treatments sought to compensate for severely impaired speaking via the use of single word writing). The usefulness of writing remediation is not disputed in this thesis; rather, it reports a study designed specifically to extend the functional writing capabilities of individuals with chronic dysgraphia for whom remediatory therapy may have reached the limits of its usefulness. Of the eight writing compensation treatments in the literature, seven were delivered using AT, again suggesting an area rich in potential as technology continues to progress.

The literature rarely considered the role of reading in functional writing. In the small number of studies which featured it, there were indications that reading support may be beneficial: Caute and Woolf’s positive findings were particularly encouraging for the current study, since both the reading and writing software they made use of was similar to that employed here. Neglecting the role of reading in writing is problematic, since writing production and reading comprehension need to work in tandem for any writing attempts to be truly functional. This training intervention program will therefore feature reading support software as an integral aspect of three elements of participant training: checking and editing their own writing; accessing written text received from others, as part of the reciprocal, social aspect of writing; accessing existing written texts such as information on the Internet.

Finally, only two treatment studies in the literature used qualitative methodologies. This study uses a mixed methods design, gathering and analysing statistical data, then illuminating this with detailed descriptions from training observations and in depth interviews. Qualitative data is particularly useful for gaining insight into the perspectives and priorities of

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participants themselves, and as such is well suited to a social model approach to dysgraphia. Further, participant views, for example regarding acceptability of treatment, are particularly important for early stage intervention treatments in which the therapy is still being developed and refined.

To summarise, the current study was intended to make a contribution to the existing literature in the following ways. It examined group narrative writing outcomes, using both standardised assessments and a novel functional narrative task. It had compensatory treatment aims, and endeavoured to support reading in an attempt to ensure that participants could fully access their own writing and that of others. Finally, it used both quantitative measures and qualitative methods, and examined the wider impact of dysgraphia on the emotional and social well-being of people with aphasia.

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Chapter 4: A pilot study to test the acceptability of an AT training