Funding from Wallace H. Coulter Foundation: BU-Coulter Translational Partnership Program

1. ASHA 2013 Validating Patient Outcomes Using an iPad-Based Software Platform for Language & Cognitive Rehabilitation SwathiKiran, Carrie Des Roches, Isabel Balachandran, *Stephanie Keffer, Elsa Ascenso, *Anna Kasdan Speech and Hearing Sciences, Boston University Department of Neurology, Massachusetts General Hospital Funding from Wallace H. Coulter Foundation: BU-Coulter Translational Partnership Program

2. ASHA 2013 Disclosure-SwathiKiran Has significant financial Interest • Chief Scientist for Constant Therapy • Ownership stock in Constant Therapy

3. ASHA 2013 Disclosure Other Authors: Carrie Des Roches, Isabel Balachandran, Elsa Ascenso • Nothing to disclose Significant contributors • Stephanie Keffer, Anna Kasdan • Nothing to disclose

4. ASHA 2013 Introduction • About 795,000 Americans each year suffer a new or recurrent stroke (NIDCD.gov). Also, about 1.7 million individuals suffer from traumatic brain injury each year (CDC.gov). • Individuals with language and cognitive deficits following brain damage likely require long-term rehabilitation. • Consequently, it is a huge practical problem to provide the continued communication therapy that these individuals require.

5. ASHA 2013 Using technology to improve treatment delivery • Recent studies have examined the efficacy of rehabilitation techniques, such as videoconferencing, for individuals with hearing, stuttering and motor speech issues • Other studies have provided aphasia therapy over the internet to individual patients • More recently, there have several computerized brain-training software designed for normal adults.

6. ASHA 2013 What is the evidence behind using technology to deliver treatment? • CogMed • A software targeted at improving working memory abilities in individuals with brain injury(Johansson & Tornmalm M, 2012; Lundqvistet al. 2012). These studies found improvements in working memory skills on the trained CogMed software as well as on other working memory tasks and functional settings. • . Posit Science • Barnes et al (2009) examined the effectiveness of the software Posit Science in improving auditory processing speed in individuals with mild cognitive impairment (MCI). • Although differences between the experimental and control group were not statistically significant, verbal learning and memory measures were higher in the experimental group than the control group.

7. ASHA 2013 What is the evidence behind using technology to deliver treatment? • Lumosity • Finn and McDonald (2011) used Lumosity software to target attention, processing speed, visual memory in experimental and waitlisted controls. Results showed experimental participants improved on the training exercises more than the controls. • There are other software programs- that function more like AAC- devices. • Therefore, there an increased awareness and momentum for applying computer technology in the rehabilitation of aphasia

8. ASHA 2013 Rationale • Additionally, there is increased patient demand to transition from traditional but outdated flashcard based therapy in order to keep up with the evolution of technology. • Nonetheless, the burden of evidence for technology-based treatment applications is no different than traditional treatment approach for rehabilitation after brain damage • Q1. Can we provide a technologically based rehabilitation program that meets the same benchmarks for clinical efficacy? • Q2. How do we individualize treatment for patients with brain damage as no two patients are alike?

9. ASHA 2013 Study Question: Does a structured therapy program that includes homework practice delivered through an IPAD result in significant gains in overall communication? Goal: Compare patients who receive a structured IPAD delivered therapy program that is practiced up to 7 days a week with patients who receive standard one-on-one individualized therapy that is provided 1 or 2 days per week by a therapist.

10. ASHA 2013 Study • Because of the flexibility that ipads provide to patients and the accessibility to free/paid apps that provide variable levels of exercises, it is important to standardize the nature and form of treatment that is provided to patients using ipads. • Since patients have access to ipads at home, it provides a unique opportunity to examine the extent of compliance when patients are provided with a homework regimen

11. ASHA 2013 Participants

12. ASHA 2013 Demographic data

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15. ASHA 2013 Experimental Design EXPERIMENTAL PATIENTS (N = 40) Pre-Tx Assessment Post -Tx Assessment Weeks Pre-Tx Assessment CONTROL PATIENTS (N = 10) Post -Tx Assessment

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18. ASHA 2013 Sample therapies/assessments for language and cognitive processing

19. ASHA 2013 Structure of the tasks- Language

20. ASHA 2013 Structure of the tasks- Cognitive

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22. ASHA 2013 Individualized therapy assignment based on initial performance

23. ASHA 2013 # 29 during week 6 homework # 25 during week 4 homework # 44 for all 10 weeks

24. ASHA 2013 Based on WAB, CLQT

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27. ASHA 2013 Carrie/ • Please insert snapshots of the patient dashboard- that shows start therapy, we will now do…

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29. ASHA 2013 Methods • During the weekly clinic sessions, the clinician would decide to continue the participant on the same task or to modify the treatment plan based on his/her performance. • If the participant achieved 95% or higher accuracy two times in succession, • The clinician would either progress the next level of difficulty (e.g., Addition Level 1 to Addition Level 2) • Would progress to a different task (e.g., assign category identification after category matching). • If participants performed at low accuracies or no change over several sessions, that therapy task was replaced with another task from the task list.

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31. ASHA 2013 Overview of data analysis • Total therapy duration in weeks • Compliance- weekly log in times • Individual patient level analysis • Analyze by week • Analyze by task • Analyze by item • Overall patient performance over time • Patient performance over time relative to population mean • Group level analysis: Analysis of tasks by patients • Group level analysis: Analysis of task by items, co-factors • Changes on standardized measures

32. ASHA 2013 1. Total therapy duration in weeks The average therapy period for controls was 12.964 weeks Average therapy period for experimental patients was 12.567 weeks

33. ASHA 2013 2. Compliance- Rates of log in to therapy Experimental patients Control patients

34. ASHA 2013 Patient usage by week Legend: Control patients Experimental patients

35. ASHA 2013 3. Individual patient level analysis: By week

36. ASHA 2013 3. Individual patient level analysis: By task

37. ASHA 2013 3. Individual patient level analysis: By items

38. ASHA 2013 4. Historical individual performance

39. ASHA 2013 4. Historical individual performance Time

40. ASHA 2013 5. Patient performance over time relative to population mean

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45. 6. Group level analysis: Analysis of tasks by patients- Individual Analysis Quantifying Change

46. Individual analysis: Quantifying Change • With tasks that had an R2 value of above 0.25, the average of the first two sessions was subtracted from the average of the last two sessions • Then each of those values was determined to be a “good” or a “bad” change • A “good” change in accuracy was any value above 0 • A “good” change in latency was any value below 0

47. ASHA 2013 Individual subject analysis by task High Language profile- low cognitive profile Low Language profile- Low cognitive profile High language profile- high cognitive profile Low language profile- high cognitive profile

48. ASHA 2013 Group analysis of task improvement

49. Group analysis of task improvement

50. Group analysis of task improvement