INT J LANG COMMUN DISORD, SEPTEMBEROCTOBER 2013,

VOL. 48, NO. 5, 508521

Research Report
Using computers to enable self-management of aphasia therapy exercises for
word finding: the patient and carer perspective
Rebecca Palmer, Pam Enderby and Gail Paterson
School of Health and Related Research, University of Sheffield/Sheffield Teaching Hospitals, Sheffield, UK
School of Health and Related Research, University of Sheffield, Sheffield, UK
Sheffield Primary Care Trust, Sheffield, UK
(Received September 2012; accepted March 2013)

Abstract
Background: Speech and language therapy (SLT) for aphasia can be difficult to access in the later stages of
stroke recovery, despite evidence of continued improvement with sufficient therapeutic intensity. Computerized
aphasia therapy has been reported to be useful for independent language practice, providing new opportunities for
continued rehabilitation. The success of this option depends on its acceptability to patients and carers.
Aims: To investigate factors that affect the acceptability of independent home computerized aphasia therapy
practice.
Methods & Procedures: An acceptability study of computerized therapy was carried out alongside a pilot randomized
controlled trial of computer aphasia therapy versus usual care for people more than 6 months post-stroke. Following
language assessment and computer exercise prescription by a speech and language therapist, participants practised
three times a week for 5 months at home with monthly volunteer support. Semi-structured interviews were
conducted with 14 participants who received the intervention and ten carers (n = 24). Questions from a topic
guide were presented and answered using picture, gesture and written support. Interviews were audio recorded,
transcribed verbatim and analysed thematically. Three research SLTs identified and cross-checked themes and
subthemes emerging from the data.
Outcomes & Results: The key themes that emerged were benefits and disadvantages of computerized aphasia therapy,
need for help and support, and comparisons with face-to-face therapy. The independence, flexibility and repetition
afforded by the computer was viewed as beneficial and the personalized exercises motivated participants to practise.
Participants and carers perceived improvements in word-finding and confidence-talking. Computer practice could
cause fatigue and interference with other commitments. Support from carers or volunteers for motivation and
technical assistance was seen as important. Although some participants preferred face-to-face therapy, using a
computer for independent language practice was perceived to be an acceptable alternative.
Conclusions & Implications: Independent computerized aphasia therapy is acceptable to stroke survivors. Accept-
ability can be maximized by tailoring exercises to personal interests of the individual, ensuring access to support
and giving consideration to fatigue and life style when recommending practice schedules.

Keywords: aphasia, computer therapy, self-management, acceptability.

What this paper adds?

Previous studies have investigated the efficacy and effectiveness of using computers for intensive home practice
of aphasia therapy exercises post-stroke. Wade and Mortley in 2003 explored the acceptability of self-managed
word-finding therapy using the StepbyStep C computer program. This study further explored factors that contribute

to the acceptability of computer therapy using StepbyStep C to patients and their carers. The paper supports

previous findings that patients like the independence and repetitive practice of computer therapy and that they
perceive improvements in language impairment and confidence communicating. This paper further suggests that
acceptability can be maximized by tailoring exercises to personal interests of the individual; ensuring access to support
via volunteers where remote internet-based support is not possible; and giving consideration to fatigue and life style
when recommending practice schedules.

Address correspondence to: Rebecca Palmer, School of Health and Related Research, University of Sheffield/Sheffield Teaching Hospitals, 107
Innovation Centre, 217 Portobello, Sheffield S1 4DP, UK; e-mail: r.l.palmer@sheffield.ac.uk
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12024
Self-managed computerized aphasia therapy 509
Introduction Cherney et al. (2011) recognized the importance of
providing patient-reported outcomes to measure patient
Aphasia is a common consequence of stroke affecting
perceptions of computerized aphasia treatment for con-
all aspects of communication including the ability to
versational script training. They used patient interviews
understand spoken and written language, speaking and
as a method of eliciting patient reports to corroborate
writing (Department of Health 2007). Fifty people per
the data collected in the quantitative evaluation of com-
100 000 in the population will still have aphasia 6
puterized therapy. In addition to exploring patient per-
months post-stroke, limiting full participation in activi-
ception of the treatment effect, interviews can be used
ties of daily living (Enderby and Emerson 1995). There
to explore other factors that influence acceptability of
is evidence that whilst most recovery takes place in the
the intervention. Understanding the acceptability of an
first 6 months, people can continue to improve their
intervention is crucial as this affects its uptake and usage,
language skills for several years (Raymer et al. 2008, Kur-
ultimately influencing the impact on the target group
land et al. 2010). However, continued treatment places
(Keller et al. 2000). Maxwell (1992) recommend con-
high demands on limited resources and can therefore be
sidering six indicators to ensure/investigate the quality
costly and difficult to achieve with face-to-face therapy
of service delivery. Acceptability is specifically detailed
intervention. Consequently, the Department of Health
along with effectiveness, safety, equity, efficiency and
(2006) in the UK encourages self-management of long-
accessibility. Therefore, in order for self-managed com-
term conditions, supported through technological in-
puter therapy to be a good-quality method of service
novation. Computer programs have been developed to
delivery, it is important to identify factors that affect
support language rehabilitation, providing opportuni-
its acceptability. Wade and Mortley (2003) interviewed
ties for the self-management of continued aphasia ther-
six of the seven participants who received remote word-
apy (Mortley et al. 2004, Ramsberger and Marie 2007,
finding treatment using the StepbyStep C program re-
van de Sandt-Koenderman 2011). Aphasia computer
ported in Mortley et al. (2004). In addition to perceived
therapy programs facilitate practice of specific compo-
improvements in language, they reported perceived ben-
nents of successful aphasia therapy. These include the
efits of increased patient autonomy; a feeling of being
opportunity for repeated practice (Bhogal et al. 2003,
able to practise more intensively; and improved com-
Robey 1998, Kelly et al. 2010) and provision of practice
munication activity, participation and confidence.
material that is of personal relevance (Raymer et al. 2008,
This paper reports the results of interviews con-
van de Sandt-Koenderman 2011). There is growing evi-
ducted with participants and carers who carried out a
dence to suggest that the use of such software can help to
self-managed computerized aphasia therapy protocol as
improve reading, spelling and expressive language (Lee
part of a wider study to evaluate the clinical and cost-
et al. 2009, van de Sandt-Koenderman 2011). Mortley
effectiveness of computerized treatment for word find-
et al. (2004) report improved word-finding ability for
ing using the StepbyStep C program, compared with
all seven individuals in a case series study of people with
usual care in the long-term post-stroke (Palmer et al.
chronic aphasia who used the StepbyStep C therapy pro-
2012). Patient-reported outcomes elicited through in-
gram for word-finding practice independently. In this
terview can be used to corroborate the quantitative find-
study, monitoring and technical assistance was provided
ings of the pilot study: change in impairment measured
by the speech and language therapist (SLT). More re-
by the change in ability to retrieve words. Interviews
cently, the use of volunteers has been explored. The
also enable exploration of perceived effects on activ-
volunteer role in supporting computerized therapy with
ity, participation and well-being. This paper builds on
StepbyStep C is to provide technical assistance, moni-
the initial interviews conducted by Wade and Mortley
toring of progress and activities to promote carryover of
(2003) by interviewing a further 14 people who used
the vocabulary learned with the computer into every-
the StepbyStep C program for word-finding treatment
day life (Mortley and Palmer 2011). This approach to
a decade later. This will serve to support or refute the
self-managed computerized therapy with volunteer sup-
views of the six original participants and to explore new
port was compared with usual stimulation (attendance
perceptions following the rapid evolution of access to
at support groups and everyday conversation) through
technology; further developments of the StepbyStep C
a pilot randomized controlled trial of 34 participants
programme itself; and the addition of volunteers to sup-
with chronic aphasia. The members of the group who
port the self-managed computerized intervention.
received the computer intervention for a period of 5
months with volunteer support improved their word
finding by 19.8% more than the group who received Methods
usual stimulation (p = 0.014) (Palmer et al. 2012).
Design
These data focus primarily on the objective measure-
ment of efficacy and effectiveness of computer aphasia A single blind, parallel group randomized controlled trial
treatments. design was piloted in which participants with aphasia
510
were randomized to self-managed aphasia therapy us-
ing computers, or usual care (Palmer et al. 2012). This
paper reports on a nested study of acceptability of
self-managed aphasia therapy for word finding using
the StepbyStep C computer program. Semi-structured
interviews were carried out with participants who
were randomized to the computer therapy group. The
semi-structured interviews elicited both qualitative and
quantitative data on user perceptions of outcomes
and acceptability of self-managed computerized apha-
sia therapy. Qualitative data were elicited by asking
open-ended questions to explore participants experi-
ences and opinions (Pring 2005). In order to make the
interviews accessible to people with difficulty expressing
themselves spontaneously, participants were asked to se-
lect responses from a visual analogue scale and select
pictures that represented their experiences resulting in
quantitative data.
Participants
Eligible participants were identified from local support
groups and speech and language therapy department
records in South Yorkshire and Newcastle & North Ty-
neside, UK. Participants were included in the study if
they had a diagnosis of stroke and aphasia with word-
finding difficulties as one of the predominant features,
as assessed by the Object and Action Naming Battery
(Druks and Masterton 1992). Eligible participants no
longer received impairment-based speech and language
therapy. People with severe visual or cognitive difficulties
that reduced their ability to use the computer program
were excluded from the study, which was tested by the
ability to see and perform a simple, non-language-based
computer game (Palmer et al. 2012).
A research SLT carried out a short language screen
to enable provision of information about the study in
a format best suited to the individuals communication
needs (Palmer and Paterson 2011). Where the partic-
ipant was unable to understand fully aphasia-friendly
formats of the study information, but showed an inter-
est in participating, assent was sought from a relative.
The study received ethics approval from Bradford NHS
Ethics Committee (Reference Number 09/H1302/20,
19 March 2009).
Participants randomized to the control group con-
tinued usual care, i.e. participation in activities that pro-
vide general language stimulation as they had done pre-
viously: attendance at communication support groups;
conversation, reading, and writing activities that are
part of everyday life. Participants randomized to the
intervention group continued to participate in their
usual language activities (as above). In addition, they
received speech and language therapy intervention de-
livered through independent use of a computer therapy
Rebecca Palmer et al.
Table 1. Computer-based treatment approach
StepbyStep
C computer program
Exercises follow steps from listening to target words, producing
words with visual, semantic, phonemic, or written letter/word
cues, through to saying the words in sentences.
Photographic images can be added to enable practice of
personally relevant words.
Speech and language therapist role
Tailoring of steps in the therapy process as appropriate to the
needs of the individual
Initial tuition to the participant and carer on how to use the
computer exercises and progress through the therapy steps.
Independent practice
Participants were advised to use the computer exercises for at least
20 minutes, 3 days a week for 5 months.
Volunteers including SLT students and existing volunteers from
communication support groups had a 3 hour training session on
how to use StepbyStep and their role in supporting the
intervention:
o assistance in using the software and hardware,
o encouragement to practice,
o activities to promote use of the new words in daily life.
o contacting the participants once a week in the first month
and at least once a month thereafter by telephone or
home visit.
program called StepbyStep C (Steps Consultancy Ltd
n.d.) configured by an SLT, and supported by a volun-
teer. A research SLT performed baseline measures and a
blinded researcher carried out outcome measures after 5
months as described by Palmer et al. (2012). Seventeen
participants were randomized to the computer interven-
tion group with 13 of these having access to a volunteer.
Fifteen of the 17 participants completed the treatment.
Table 1 outlines the treatment approach used.
Following 5 months of treatment, participants who
received the computer therapy were invited to partici-
pate in an interview conducted by a research SLT who
had not been involved in the intervention.
Fourteen of the 15 participants who completed the
treatment and ten carers consented to be interviewed
about their experiences of the self-managed comput-
erized practice approach to speech and language ther-
apy. Table 2 details background information about the
participants. Seven male and seven female participants
were interviewed; their ages ranged from 37 to 82 years.
Participants ranged from one to 29 years post-onset of
aphasia following stroke with a mean of 6.2 years. Partic-
ipants had a relatively even distribution of word-finding
severity at baseline as tested by naming 48 words from
the Object and Action Naming Battery (Druks and
Masterton 1992) and 48 words of personal relevance.
Table 2 shows the pre- and post-treatment word-finding
scores out of a total of 96 for each participant, the fre-
quency of computer therapy practice and access to vol-
unteer support.
 Table 2. Participant characteristics

Number of words named Number of words named Computer usage: mean

Participant Age Time post- correctly at baseline correctly post-treatment sessions per week Volunteer Carer
with aphasia Gender (years) stroke (years) (out of a possible 96) (out of a possible 96) (mean minutes per session) support interview
Self-managed computerized aphasia therapy

RW Male 64 9 74 83 7 (18)a Yes No

FM Female 71 7 66 72 3 (46)a No No
SW Female 65 6 65 95 4 (10) Yes Yes
DC Male 61 2 56 77 < 1 (25) No No
RP Male 51 4 53 90 4 (8) Yes No
ME Female 77 29 53 70 5 (17)a Yes Yes
NH Male 67 3 54 71 6 (33)a Yes Yes
GJ Female 77 10 42 92 4 (24)a Yes Yes
BD Male 82 3 26 79 5 (20)a Yes No
PS Male 77 1 24 8 7 (20)a Yes Yes
JM Female 80 1 23 62 6 (39)a No Yes
PH, no interview Male 69 1 6 2 1 (15) Yes Yes
PR Male 65 9 7 8 1 (7) did not use in the last 2 months No Yes
BT Female 80 5 3 0 3 (18)a No Yes
JOR Female 37 3 0 1 3 (10) Yes Yes
Mean 69 6.2 38.6 56.3 4 (21)
Range 3782 129 078 099 17 (746)
Note: a Participants who practised with the recommended frequency or above.
511
512
Table 3. Number of participants selecting each visual analogue response to questions
Degree of negative
response
Visual analogue scale presented
Do you have previous experience 8 2
of using a computer?
How did you find therapy on a 0 0
computer?
Would you use it again? 0 0
Did it work? 1 0
Did you have help? 0 1
How was the help? 0 0
Have you used the words practised 1 1
in your daily life?
Note: Where there are fewer than 14 responses, this is due to some participants not understanding the question as a result of their aphasia.
Procedure
The semi-structured interviews combined three ap-
proaches to enable participants with a range of aphasia
severities to contribute their views. Together, the ap-
proaches confirmed perceptions anticipated by patient
and public involvement (PPI) group and explored fur-
ther issues.
Visual analogue responses
The first set of questions required a non-verbal selection
of a positive, negative or neutral response to a question
on a visual analogue scale. Such scales are a common
method of eliciting responses from people with aphasia
(Brumfitt and Sheeran 1999). Questions were derived
by two research SLTs in conjunction with a PPI group
made up of people with aphasia and their carers. The
questions were designed to provide a quantitative sum-
mary of participants experiences of key aspects to the
treatment including: computer use; volunteer support;
whether they perceived the treatment to be effective;
and whether they used the words they learned in their
everyday lives. The visual analogue scale consisted of five
points (two positive, one neutral and two negative) to
provide information on strength of opinion.
Responses to open-ended questions
Topic guides (one for people with aphasia and one for
carers) were developed by two research SLTs in collabo-
ration with the PPI group (see appendix A). This part of
the interview was exploratory in nature to allow for the
expression of thoughts that may not have been antici-
pated. The questions for the semi-structured interview
included open-ended questions to explore the breadth of
factors influencing acceptability (see appendix A). The
interviewer asked each question using spoken language
supported by a written sentence and a photographic im-
age illustrating the topic to be discussed. Participants
Rebecca Palmer et al.
Neither positive nor Degree of positive
negative response
0 + ++
0 2 0
2 6 4
2 4 6
0 3 7
1 6 2
0 4 6
2 6 1
were encouraged to provide responses verbally or using
writing, drawing or gesture. Figure 1 shows the writ-
ten question with picture support beneath and written
responses to that question in green pen.
Picture selection task
Following an opportunity to respond spontaneously to
each open-ended question, each participant was shown
a set of pictures representing possible responses that may
reflect their own perception. The project advisory group
and the research SLTs suggested possible responses to
the questions. These were based on the advisory groups
own experiences of using computer software for speech
therapy and the therapists experience. The ideas were
presented using a photograph and written keyword or
phrase. This part of the interview took a confirmatory
approach by asking the participants to select the pictures
that represented their own view. Figure 1 shows the pic-
ture cards that the participant selected as representative
of his/her own experience.
This method enabled those who were unable to con-
tribute spontaneous responses to the questions to offer
an opinion non-verbally. It also acted as a prompt for
them to expand on these ideas. A selection of pictures
was provided for each question with a verbal explanation
and written description. The participants were asked to
look at each picture and decide whether or not it was
representative of their experiences or opinions. The task
was therefore binary. All participants were asked to carry
out the picture selection task in order to indicate the rel-
ative importance of each idea to the participants as a
group.
Procedure
Patient interviews lasted between 20 and 45 min de-
pending on whether or not the participant was able to
provide spontaneous answers to open-ended questions.
Self-managed computerized aphasia therapy
Figure 1. Presentation of open ended interview questions, written responses and picture selection.
An observer was present at the interviews to make a writ-
ten record of any responses expressed non-verbally. If the
participant had a carer/relative, they were also invited to
be interviewed. Carers were interviewed separately from
the people with aphasia to ensure a distinction between
perceptions of acceptability of the patient from those of
the carer. Carer interviews lasted up to 30 min.
All interviews were recorded on a digital audio
recorder and transcribed verbatim within 1 week. Pic-
ture selection, drawings and written responses were pho-
tographed. The interviewer and observer discussed the
content of the interviews and where responses given by
participants with aphasia were unclear or it was thought
that they had not understood the question; this was
highlighted and not included in the analysis to main-
tain validity of the data.
Analysis
Results of the visual analogue-scale responses and the
picture selection task were analysed quantitatively by
totalling the number of participants that chose each
possible response.
Interview transcripts and photographs of pictorial or
written responses to open-ended questions were stored
and analysed in NVivo9 qualitative data analysis soft-
ware (QSR International 2011). A structured thematic
analysis was conducted. Two SLT members of the re-
search team selected parent nodes (themes) based on the
513
topic guides and transcript data were coded into these
main themes. New parent nodes were created where new
key themes emerged from the data (Pring 2005). Data
within each theme were reviewed and first- and second-
level subthemes were identified by three research SLTs
(one who had configured and introduced the computer
software to the participants, one who conducted the in-
dependent interviews, and one who had no contact with
the participants or carers). All new ideas were identified
as subthemes irrespective of the number of participants
expressing this view to capture the breadth of experience
of the participants. The number of participants express-
ing each idea was identified to preserve the pattern of
the data emerging across interviews but was not used as
a criterion for subtheme selection (Morgan 1993).
As quality control of the coding process, three of
the 24 transcripts (12.5%) were coded by a researcher
independent of the research team. Two transcripts were
from patients and one was from a carer. The indepen-
dent researcher recoded the transcripts using the the-
matic structure developed. The few discrepancies iden-
tified were discussed and resolved with the therapist that
carried out the interviews.
Results
Participants
Of the 14 participants interviewed with aphasia, 11
provided answers to visual analogue questions and 13
514 Rebecca Palmer et al.
Table 4. Perceived benefits of the computer treatment

Second-level subtheme (number of

First-level subtheme respondents expressing an idea) Illustrative quotes
Perceived beneficial Improved language:
outcomes
Word finding (7) he were beginning to be able to say each one as picture come up. He
could say it. He could really do it (PH carer)
Conversation (4) She can have a proper conversation (ME carer)
Generalization (3) shes keeping using the words now that she used on the computer so
shes using them outside now not on the computer (GJ carer)
Yeah . . . I like . . . avocado please [mimed pointing to object]
(FM)
Sentence production (3) Shes had her stroke 30 years and shes never strung a sentence
together. It was quite nice when she said what have you been
doing? (ME carer)
Talking (2) She knows what she wants to say but it can be difficult to get it out
but she has improved since doing that programme (JM carer)
Spelling (1) now I know how to spell all the childrens names which Id never
have done that before (SW)
Improved confidence (6) her confidence is more and she can say things without being
frightened of saying the wrong thing (BT carer)
Improved participation (4) I think that generally hes probably more interested in things and
that its given him something to do and a goal to reach (NH carer)
Improved well-being (3) It helps feeling better (RP)
Wider impact (2) because of what she was doing on there she now wants to further her
computer education (SW carer)
Raised carer awareness of participants It has made us appreciate how difficult it actually is for her and how
experience of aphasia (1) keen she is to learn as well (ME carer)
Perceived benefits of the Motivation to practice (4) in the beginning he didnt try at all but I think this has made him try
therapy process a bit more and got him going a little bit better (PH carer)
Independence (4) He would sit and do it himself (PH carer)
Cognitive stimulation (3) Yes in a strange way, makes me use my brain (RP)
Providing an activity/joint activity (3) It involved my wife (RP)
Freeing up carer time (3) and reducing it just gave us something to do to sit down together and we could
reliance on carer feedback laugh at things if he was stumbling on words we used to have a
giggle and say how well hed done (PH carer)
a lot of the time P would sit and do it himself and I didnt have to be
stood by him. You know I could get on with something else (PS
carer)
Personalization (2) What I liked about the programme that were on there was that they
were related to S. There was certain input into what was on it from
her about places that she liked (SW carer)
Flexibility (2) Some days hed go through all 4 programs some days hed only want
to do one (PH carer)
Repetition (2) theres repetition which gets things in better than just you know, like
an hour a week or something with a Speech Therapist (JM carer)
Support available from volunteer (2) I think it was good because theyre always out there on the other end
of the phone if I needed it and I knew C [volunteer] was going to
come every 2 weeks (PS carer)
Its just nice knowing that somebodys there. I didnt want them to
come through but . . . Im fortunate that email or ring (RP)
Positive relationship with volunteer (2) It was followed up by the young lassie [volunteer] who was equally as
nice and that was you loved her to come didnt you? (SW carer)
Routine (1) You did it daily, didnt you, routine, thats what you liked (PS carer)
Variation (1) Itd come up with encyclopedia, but I just want it to show me the
first letter. G [therapist] said okay and changed it to that and it was
so much better (RP)
Computer program always available (1) Say in 3 months when you come check those things and Im not as
brilliant as I was. It dont matter. If you go back to the things you
did before (RP)
Self-managed computerized aphasia therapy
Table 5. Perceived disadvantages of computer therapy
Second-level subtheme (number of
First-level subtheme respondents expressing an idea)
Outcome disadvantages No effect (4)
Disadvantages of the process Not fully independent (4)
Frustrating (3)
Intrusion into daily activities (3)
Boring (2)
Software errors (2)
Reliance on memory (2)
Restricted access to computer (1)
Anxiety (1)
Fatigue (1)
Time consuming (1)
were able to carry out the picture-selection task iden-
tifying pictures that represented their views about the
intervention. Six of the participants with aphasia and
all carers were able to respond to open-ended questions
generating original ideas.
Visual analogue responses
Table 3 provides an overview of the views on self-
managed computer therapy expressed by the partici-
pants with aphasia. Many of the participants had little
experience of using a computer. However, the majority
found it acceptable and would use it again and all but
one participant felt that it worked for them. The major-
ity of participants with aphasia received help with the
computer practice and appreciated this. The majority
(seven out of 11 respondents) also reported using words
they practised in computer therapy in their daily life,
although this was not the case for all participants.
Responses to open-ended questions
Four main themes including benefits and disadvantages
of computer therapy; help and support; and computer
versus face-to-face therapy were identified from the the-
matic analysis of the responses to open-ended questions.
These are shown in the schematic diagram (figure 2),
with 13 first level subthemes.
Subtheme analysis from responses to open-ended
questions from participants and their carers are pre-
515
Illustrative quote
he just tends to stick to same words. He doesnt tend to say much
more (PH carer)
Id come in one day and she were with laptop up to show shed got
stuck and couldnt get onto next stage or something (JM carer)
He were getting annoyed with himself because he couldnt do them
because he know hed done them and suddenly again he couldnt
do them (PH carer)
I wanted to watch the golf but no she had to get on her computer
(GJ carer)
It took probably about an hour . . . with most that is not a problem
but it is a problem if I am going out somewhere (NH)
I think he got somewhat bored with it (PR carer)
well sometimes it didnt work, it went all funny (PS)
just annoyed me that Id open it up and couldnt remember how to
use it (DC)
my son didnt help because hed forever got the computer upstairs
(PH carer)
I sometimes get a bit . . . doing the study I get quite anxious (RP)
I think probably sometimes a computer can make you feel ill . . .
feel very fatigued . . . L [wife] always says no more than 20
minutes . . . thats itbecause she has learnt (RP)
we were trying to do it 5 or 6 nights a week, which, if I am honest,
was quite time consuming for us (ME carer)
sented for each theme. The first three themes have first-
and second-level subthemes. The number of participants
expressing second-level subtheme ideas are represented
in parentheses in Tables 46 along with illustrative
quotes. The first-level subthemes of the fourth theme
(comparisons with face-to-face therapy) did not need
to be further divided into second-level subthemes and
thus the number of participants expressing first-level
subtheme ideas are presented.
Perceived benefits of self-managed computer therapy
in aphasia
Table 4 shows that subthemes identified as being of
benefit related to the outcomes of the therapy and to
the computer therapy process.
Participants and carers perceived improvements in
word-finding and sentence production and generaliza-
tion of the new words to functional communication
settings. In addition to improvements in language im-
pairment and activity, participants perceived improve-
ments in their confidence, participation and well-being.
The key benefits of the self-managed computer therapy
process were the independence and motivation to prac-
tise it afforded as well as providing a regular opportunity
for repetitive practise of personally relevant vocabulary.
The support from a volunteer and the positive relation-
ship with the volunteer were perceived to be benefits of
the treatment approach.
516 Rebecca Palmer et al.

Benecial Disadvantages
outcomes of the process

Benets of Outcome
the process disadvantages
Benets of Disadvantages
computer of computer
therapy therapy

Self managed
computer
Cost
From therapy
carer

Help and Computer Need for

support therapy versus social
needed face to face contact
From
volunteer
Computer
Face to beer
From On face beer Computer
SLT screen acceptable
alternave

Figure 2. Themes and subthemes emerging from interviews.

Perceived disadvantages of self-managed computer
therapy for aphasia
It is important to note that seven of the interviewees
reported that they did not perceive any disadvantages of
the computer therapy. Four of the respondents perceived
no improvement in expressive language. The majority of
the disadvantages illustrated in Table 5 are related to the
therapy process itselfincluding the need for assistance
for some participants and the time-consuming nature
of this, interfering with everyday life. Five participants
experienced problems using the computer due to soft-
ware errors, poor memory for how to use it or difficulty
accessing a computer to use for practice. Although only
expressed by one participant, side-effects of fatigue and
anxiety were noted.
Help and support
The need for help and support throughout the process of
self-managed computer therapy emerged as a key theme
from the open-ended interviews. The aspects of help and
support identified as important are presented in Table 6.
It shows that carers were often engaged in supporting
the self-managed aphasia therapy on the computer, tak-
ing on roles of motivating the participant to practise,
helping with use of the computer software and hard-
ware, monitoring when a break was needed, and offering
cues to support word finding. The carers themselves also
demonstrated a need for support in the form of training
on use of the software from an SLT and for some par-
ticipants the carers felt the support of a volunteer would
be more appropriate than a relative.
Computer therapy compared with face-to-face
therapy
The comparison between face-to-face and computer
therapy emerged as a theme from the open-ended in-
terviews with subthemes presented in Table 7. It shows
mixed views about the relative preferences of face-to-
face or computer speech and language therapy. Some
described a preference for the social contact and face-
to-face conversation provided by an SLT, while others
perceived advantages of self-managing therapy with a
computer. Although the majority of participants like
face-to-face therapy, they recognized that it is costly.
Of particular note is that the quotes illustrating a
strong preference for face-to-face therapy come from
the carer of PH who had severe word-finding difficulties
Self-managed computerized aphasia therapy 517
Table 6. Help and support

Second-level subtheme (number of

First-level Subtheme
Help/support From carer
Help/support from SLT
Help/support from volunteer
Help/support from computer
program
respondents expressing an idea)
Motivation (4)
With computer hardware (3)
Navigating software (2)
Controlling frequency of practice (2) she probably had two or three days at it and give her a days rest,
With language therapy (2)
Wanting more SLT support (2)
Remote support (1)
Wanting a volunteer (2)
Instructions (1)
Illustrative quote
sometimes [I] would get really good on there and I would say L,
come listen and she would go youre doing really, really well.
(RP)
wed sit with her and wed have to click the mouse or something
(ME carer)
I think its an individual thing really and if theres a carer there
then do encourage that to continue. You know, if they cant do
the full programme then just encourage them to do a little bit
of it and then have an hours gap and then try and do a little bit
more (NH carer)
then she was ready to start again (BT carer)
he usually did it but sometimes if he got a bit stuck then I could
give him the first letternot tell him the answer but just help
him, and then he could get on with it himself (NH carer)
If hes struggling on a word, we tend to find that writing it down,
he can say it a lot easier (PH carer)
I know that [SLT] did give me a sort of a crash job, but it wasnt
enough because it got fuddled up a bit (BT carer)
to start with particularly. There was a couple of emails to [SLT]
(RP)
He didnt really like me to assist. You know. But I think
somebody coming in, might have motivated him a bit more
(PR carer)
When you get the instructions, theyre quite aphasic so thats
good (RP)

Table 7. Face-to-face SLT versus computer therapy

First-level subthemes (number of

respondents expressing an idea)
Face-to-face better (3)
Balance of computer and face-to-face favoured (2)
Computer better (2)
Recognition of the cost of face-to-face therapy (2)
A need for social contact (1)
Computer therapy an acceptable alternative (1)
Illustrative quote
I think a Speech Therapist, someone coming to talk to him would actually be
better for him (PH carer)
I would feel much obliged if the support was there initially. And then by all means,
if they could show me in the right direction and then leave me to it (NH)
if theres face to face, it might be somebody that you like or somebody that you
dont like and so it always better to have a go with that [computer] (NH)
in real life is to have a Speech and Language Therapy person to actually discuss but
then thats not going to be there because it costs too much money (RP)
Yes well face to face therapy is always better but it [computer therapy] is very
cost-effective isnt it? (NH)
Again the advantage of having someone come to your home to do a bit of speech
therapy is that it is social as well and when she spends so much time by
herself . . . (SW carer)
I think face to face is nice but I dont think its necessary all the time (NH carer)

before treatment and showed no improvement with
the computer intervention. The quotes in support of
self-managed computer intervention are from NH and
RP who had moderate word-finding difficulties be-
fore treatment and both showed marked improvement
(Table 2).
Picture selection task
Figure 3 shows that the majority of participants (711
out of 13) agreed with all the potential positive aspects of
self-managed computerized word-finding therapy pre-
sented to them. The last four options presented in fig-
ure 3 all represent potential negative aspects of the self-
managed computer word-finding treatment approach.
Six of the 13 participants carrying out the picture-
selection task experienced difficulties with the computer
software; five of the 13 preferred face-to-face therapy;
four thought it took a lot of time; and three found it
difficult to practise regularly. However, figure 3 shows
that participants experienced more of the positive than
negative aspects of the approach to therapy.
518 Rebecca Palmer et al.

Figure 3. Number of participants selecting pictures that represented their views.

Discussion participants who were interviewed practised their com-

puter exercises at least three times a week over a 5-month
The acceptability of self-managed computer treatment
period. This provides further evidence that speech and
for people with aphasia is a key concern when consid-
language therapy delivered on a computer is acceptable.
ering this as a method of providing ongoing speech and
The interview data suggest that participants per-
language therapy practice in the long-term post-stroke.
ceived improvements in their language skills. In addi-
The Oxford Internet Survey (Dutton and Blank 2011)
tion to improvements in the word-finding impairment
found that 77% of households in the UK now have
itself, participants perceived improvements in their use
a computer, suggesting that the majority of the pop-
of language in conversation and to meet daily needs.
ulation can access technology for delivery of therapy
Aphasia after stroke poses challenges to participat-
intervention. However, only two of the 11 participants
ing fully in daily life (Wallace 2010). Increased con-
carrying out the visual analogue scale task in this study
fidence was frequently identified in the interviews as a
reported having previous experience of using a com-
benefit of the computerized therapy, contributing to im-
puter. This is consistent with the fact that people over
provements in participation, even for those who showed
the age of 65 years are the least confident group of
limited linguistic benefit. This supports the finding of
computer users with only 37% of them using the in-
improved confidence by Wade and Mortley (2003). Bab-
ternet (Dutton and Blank 2011). Although Wade and
bitt and Cherney (2010) propose a three-way interaction
Mortley (2003) provided remote support from an SLT,
between increased autonomy and self-determination, in-
the majority of participants in our study did not have
creased communication confidence and increased par-
access to the internet. Despite requiring assistance to ac-
ticipation in life activities. This theory offers an explana-
cess and use the computer therapy, ten of the 11 visual
tion for the impact of self-managed use of computerized
analogue scale respondents liked using a computer for
speech and language therapy on confidence and partic-
speech therapy and would use it again given the oppor-
ipation.
tunity, demonstrating acceptance of the approach and
In order for self-managed computerized therapy
the technology. Table 2 showed that the majority of par-
practice to be acceptable, people with aphasia need to
ticipants complied with the treatment as nine of the 14
Self-managed computerized aphasia therapy
be motivated to participate in the process. Factors in-
fluencing motivation included the opportunity for un-
limited repetition and flexibility of practice as reported
previously by Wade and Mortley (2003). This study
highlights the need for personally relevant practice ma-
terial as an additional factor influencing motivation to
practise. Help and support from a volunteer for comput-
erized aphasia intervention was an integral part of the
treatment approach used in this study as remote access
to an SLT to monitor progress was not possible for the
majority of participants. Input from a competent SLT
to set up appropriate therapy exercises was seen as an
important part of the intervention. A few participants
felt that they needed more help initially from a speech
therapist before they felt able to use the program alone.
Many of the carers took on a supportive role providing
encouragement and prompts with language exercises.
However, for some help was more acceptable from an ex-
ternal volunteer than a family member. Although carers
are often relied upon to encourage compliance with in-
terventions (Kaufman 1994), many balance their caring
role alongside family responsibilities and careers (Lopez
et al. 2005). Aggar et al. (2011) therefore recommended
regular formal support to lessen the time required from
the informal carer. Knowledge that ongoing support for
language rehabilitation was available was of benefit to
the carers in this study. Besides technical support and
assistance with therapy exercises, volunteer involvement
provided a social relationship which helped motivate
participants to practise, as found in the study of aphasia
treatment using volunteers by David et al. (1982).
As all participants had received face-to-face speech
and language therapy initially post-stroke, it was natural
for them to discuss the acceptability of the computer
approach in light of their face-to-face experiences. Face-
to-face therapy was preferred to the computer-based
therapy approach evaluated in this study, particularly
by carers of people with severe aphasia, due to the per-
ceived advantages greater social interaction affords. De-
spite this, computer therapy was viewed as acceptable
and the affordability of computers to continue to pro-
vide a therapy option in the light of limited human
resources was recognized.
Although the views of the participants generally sug-
gest that the benefits of self-managed computer aphasia
intervention outweigh the disadvantages, it is impor-
tant to consider the few disadvantages of the process
to maximize future acceptability. Improving the stabil-
ity of software programs and assisting patients to access
computers requires continued attention. An appropri-
ate level of practice exercises is important. The patient
needs to experience some success to reduce anxiety and
frustration but should not be 100% successful as this
can cause boredom and lack of motivation to practise
(Brookshire 1981). It may be beneficial to recommend
519
a maximum amount of practice time as well as a min-
imum to prevent fatigue and intrusion into time for
other daily activities.
Limitations of the study
This paper reports the experiences of only 14 patients
and ten carers so is not exhaustive of all possible per-
ceptions of self-managed computerised aphasia therapy.
Only six of the patient participants were able to pro-
vide spontaneous responses to questions, limiting the
exploratory potential of the interviews. Only one piece
of software was used in this study with one specific proto-
col for delivering the intervention (SLT assessment and
tailoring of exercises, 5 months of independent practice,
and support from carers and volunteers). The data are
therefore not generalizable to other pieces of software or
indeed the StepbyStep C software provided with differ-
ent levels and types of support. The authors therefore
warn against extrapolating these results directly to other
pieces of software and treatment protocols. However,
clinicians can be mindful of factors shown to affect ac-
ceptability in this study when choosing other pieces of
software and in deciding upon appropriate amounts of
face or face or remote support for an individual.
Summary and implications for practice
Participants with aphasia perceived that they benefitted
from speech and language therapy exercises carried out
independently on a computer. Support for self-managed
practice was highlighted as a key factor in compliance
with the intervention. Some patients required more sup-
port than others from different combinations of SLTs,
carers and/or external volunteers. Both advantages and
disadvantages of using computers for independent lan-
guage practice were identified. The number of benefits
and the number of participants expressing these out-
weighed the disadvantages identified. Despite the many
advantages of self-managed computer therapy expressed
by all of the participants and carers, face-to-face ther-
apy was still preferred by some participants and carers,
although for many, use of computers for self-managed
practice was viewed as an acceptable alternative.
Independent home practice using computer soft-
ware designed specifically for aphasia therapy can be
considered for provision of ongoing opportunities for
practice in the long-term post-stroke. However, this op-
tion may not be acceptable to all patients. It is im-
portant to provide sufficient training to patients and
carers on the use of the software and identify a carer and
or volunteer who can provide regular support. Clini-
cians should pay particular attention to tailoring the
difficulty of exercises to be easy enough to limit frus-
tration/anxiety and to be challenging enough to limit
520
boredom and maintain motivation to practise. Although
intensive practice is likely to yield best results, consid-
eration should also be given to thresholds for fatigue
and competing demands on patient and carer time
when recommending frequency and length of practice
sessions.
Acknowledgements
This paper presents independent research commissioned by the Na-
tional Institute for Health Research (NIHR) under its Research for
Patient Benefit (RfPB) Programme (Grant Number PB-PG-1207
14097). This study was also supported by the Stroke and Telehealth
themes of the South Yorkshire Collaboration for Leadership in ap-
plied health research and care (CLAHRC). NIHR CLAHRC for
South Yorkshire acknowledges funding from the NIHR. The study
also received support from North of Tyne PCT. The views expressed
are those of the authors and not necessarily those of the NHS,
the NIHR or the Department of Health. Contributors: Audrey De-
laney and Helen Hughes (Speech and Language Therapists, Sheffield
Teaching Hospitals Foundation Trust). Declaration of interest: The
authors report no conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
References
AGGAR, C., RONALDSON, S. and CAMERON, I., 2011, Reactions to
care giving in frailty research. Archives of Gerontology and
Geriatrics, 53, e138e143.
BABBITT, E. and CHERNEY, L., 2010, Communication confidence in
persons with aphasia. Topics in Stroke Rehabilitation, 17(3),
214223.
BHOGAL, S., TEASELL, R. and SPEECHLEY, M., 2003, Intensity of
aphasia therapy, impact on recovery. Stroke, 34, 987993.
BROOKSHIRE, R., 1981, Introduction to Aphasia (Chichester: Wiley).
BRUMFITT, S. M. and SHEERAN, P., 1999, The Visual Analogue Self
Esteem Scale (Bicester: Winslow).
CHERNEY, L., HALPER A. and KAYE, R., 2011, Computer based script
training for aphasia: emerging themes from post treatment
interviews. Journal of Communication Disorders, 44(4), 493
501.
DAVID, R., ENDERBY, P. and BAINTON, D., 1982, Journal of Neurology,
Neurosurgery, and Psychiatry, 45, 957961.
Department of Health, 2006, Our Health, Our Care, Our Say: A
New Direction for Community Services (London: Department
of Health).
Department of Health, 2007, National Stroke Strategy (London: De-
partment of Health).
DRUKS, J. and MASTERTON, J., 1992, An Object and Action Naming
Battery (London: Psychology Press).
DUTTON, W. and BLANK, G., 2011, Next Generation Users: The
Internet in Britain [Oxford Internet Survey] (Oxford: Oxford
Internet Institute).
ENDERBY, P. and EMERSON, J., 1995, Does Speech and Language
Therapy Work? (London: Whurr).
KAUFMAN, S., 1994, The social construction of frailty: an anthropo-
logical perspective. Journal of Aging Studies, 8, 4558.
KELLER, M. B., MCCULLOUGH, J. P. and KLEIN, D. N., 2000, A
comparison of nefazodone, the cognitive-behavioral analysis
system of psychotherapy and their combination for the treat-
ment of chronic depression. New England Journal of Medicine,
342, 14621470.
Rebecca Palmer et al.
KELLY, H., BRADY, M. and ENDERBY, P., 2010, Speech and lan-
guage therapy for aphasia following stroke. Cochrane Database
of Systematic Reviews, issue 5. art. no. CD000425. doi:
10.1002/14651858.CD000425.pub2.
KURLAND, J., BALDWIN, K. and TAUER, C., 2010, Treatment-
induced neuroplasticity following intensive naming therapy
in a case of chronic Wernickes aphasia. Aphasiology, 24, 737
751.
LEE, J., KAYE, R. and CHERNEY, L., 2009, Conversational script
performance in adults with non-fluent aphasia: treat-
ment intensity and aphasia severity. Aphasiology, 23, 885
897.
LOPEZ, J., LOPEZ-ARRIETA, J. and CRESPO, M., 2005, Factors as-
sociated with the positive impact of caring for elderly and
dependent relatives. Archives of Geronotology and Geriatrics,
41, 8194.
MAXWELL, R. J., 1992, Dimensions of quality revisited: from thought
to action. Quality in Health Care, 1(3), 171177.
MORGAN, D., 1993, Qualitative content analysis: a guide to paths
not taken. Qualitative Health Research, 3(1), 112121.
MORTLEY, J. and PALMER, R., 2011, From idealism to realism, step
by step. Speech and Language Therapy in Practice, Winter,
2932.
MORTLEY, J., WADE, J. and ENDERBY, P., 2004, Superhighway to pro-
moting a clienttherapist partnership: Using the Internet to
deliver word-retrieval computer therapy monitored remotely
with minimal speech and language therapy input. Aphasiology,
18, 193211.
PALMER, R., ENDERBY, P., COOPER, C., LATIMER, N., JULIOUS, S.,
PATERSON, G., DIMAIRO, M., DIXON, S., MORTLEY, J.,
HILTON. R., DELANEY, A. and HUGHES, H., 2012, Com-
puter therapy compared with usual care for people with long
standing aphasia post stroke: a pilot randomised controlled
trial. Stroke, 43, 19041911.
PALMER, R. and PATERSON, G., 2011, One size does not fit all: ob-
taining informed consent from people with aphasia. Advances
in Clinical Neurosciences and Rehabilitation, 11, 3031.
PRING, T., 2005, Research Methods in Communication Disorders (Lon-
don: Wiley).
QSR International, 2011, NVivo 9 (Doncaster, Victoria, Australia:
QSR International Pty Ltd).
RAMSBERGER, G. and MARIE, B., 2007, Self-administered cued nam-
ing therapy: a single-participant investigation of a computer-
based therapy program replicated in four cases. American Jour-
nal of SpeechLanguage Pathology, 16, 343358.
RAYMER, A., BEESON, P., HOLLAND, A., KENDALL, D., MAHER, L.
and MARTIN, N., 2008, Translational research in aphasia:
from neuroscience to neuro-rehabilitation. Journal of Speech,
Language and Hearing Research, 51, 259275.
ROBEY, R., 1998, A meta-analysis of clinical outcomes in the treat-
ment of aphasia. Journal of Speech, Language and Hearing
Research, 41, 172187.
Steps Consultancy Ltd, n.d., StepbyStep C Software (available at:
http:// www.aphasia-software.com) (accessed on 24 January
2012).
VAN DE SANDT-KOENDERMAN, M., 2011, Aphasia rehabilitation and
the role of computer technology: can we keep up with modern
times? International Journal of SpeechLanguage Pathology, 13,
2127.
WADE, J. and MORTLEY, J., 2003, Talk about IT: views of people with
aphasia and their partners on receiving remotely monitored
computer-based word finding therapy. Aphasiology, 17(11),
10311056.
WALLACE, G., 2010, Profile of life participation after stroke and
aphasia. Topics in Stroke Rehabilitation, 17(6), 432450.
Self-managed computerized aphasia therapy 521
Appendix r Have there been any benefits of computer therapy?
r Are there any disadvantages of computer therapy?
Topic guide for interviews with participants with r What would influence your decision to do com-
aphasia puter therapy?
Questions using visual analogue-scale responses:
r Do you have previous experience of using a com- Topic guide for interviews with carers
puter? The topics below were included in the semi-structured
r How did you find doing therapy on a computer? interview:
r Did it work?
r Have you used the words practised on the com- r Prior expectations of computer therapy
puter in your daily life? r Ease/acceptability of using computer
r Did you have help? r Benefits of computer therapy for participant
r How was the help? r Disadvantages of computer therapy for partici-
r How much help did you need with the computer pant
therapy? r Limitations of computer therapy
r Would you use it again? r Perceived change in talking
r Changes in daily activity
Questions with open responses and picture r Benefits of computer therapy for carer
selection: r Disadvantages of computer therapy for the carer