This document discusses a study using an assistive technology called GUIDE to help a man with acquired brain injury complete morning tasks independently. In a single-subject experimental design, the man's performance improved with GUIDE prompts in both inpatient and home settings, requiring fewer caregiver prompts. GUIDE emulates caregiver support through conversation and could help facilitate discharge for rehabilitation patients needing assistance with daily living activity sequences.

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 Sequencing difficulties post brain injury
 Scaffolding
 What is GUIDE?
Lauren O’Neill and Louise McCombe Occupational
Therapists at Graham Anderson House, Glasgow,
Brain Injury Rehabilitation Trust
 Single n study as part of a wider randomised
control
 Activities of daily living are complex  Four categories of behaviour control
sequences impairments
 A set of actions that must be performed in a
certain order to achieve a goal state ◦ Energization (motivation / sustaining
activity) localized to SMPFC
 Inability to carry out a complex sequence ◦ Emotional regulation (prioritisation /
safely is widespread and disabling for many: inhibition) VMPFC
◦ Learning disability
◦ Task setting (verbal self regulation) LPFC
◦ Mental health problems
◦ Degenerative neurological conditions ◦ Meta cognition (monitoring) Area 10
◦ Stroke
◦ Acquired brain injury
 Within rehab units the use of scaffolding
techniques to prompt self-care task are  Support staff use a wide range of subtle
common strategies
 It facilitates ability to build on skills and  Service users are not passive
knowledge
 Instructions given are just beyond the level of  Service users often request help
what the service user could do without  But, service users often also resist help
prompts  Maybe service users are less likely to resist
 The staff member provides the service user scaffolding from a technology?
with the scaffolding to achieve an end goal
(Olsen and Pratt, 2000)
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 Assistive Technology for cognition is the use  Other media have also used text or auditory
of technology to extend or augment the prompts to overcome prospective memory
mental functions, with particular application difficulties;
meeting the needs of people with cognitive • Voice recorders with a timer function (eg. van
impairment den Broek, Downes, Johnson, Dayus, & Hilton,
2000);
 Research includes use of paging system to
• text messaging to mobile phones
provide reminders of everyday tasks (Wilson (Pijnenborg, Withaar, Evans, van den Bosch, &
et al 2001). Brouwer, 2007)
• smartphone reminders (Svoboda & Richards,
2009)
 Care-givers provide cognitive support  Rehabilitation relevant behaviour in persons
◦ Talking service users through tasks with early stage vascular dementia
◦ Providing prompts and checks  O'Neill, B. Moran, K. & Gillespie, A. (2010).
Scaffolding rehabilitation behaviour using a
 GUIDE models care giver cognitive support voice-mediated assistive technology for
◦ Prompts user through tasks cognition. Neuropsychological Rehabilitation,
◦ Receives verbal input 18, 1-19.
◦ Simulates naturalistic conversation
◦ Automated, non-judgemental and
emotionally neutral prompter (preferred by
some individuals)
Computer Computer
GUIDE software GUIDE software
Prompt or
User User Question
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 The only prompting system that uses speech
Speech
recognition
Recognition
◦ It simulates natural conversation
 No difficult technology interface
Computer
◦ It is as easy to use as having a conversation
GUIDE software
 Builds upon users abilities
o Rather than by-passing their abilities
Prompt or
User Question  Technology may aid the transition from
rehabilitation unit to home
Randomised control trial
To develop and test laundry and morning routine
GUIDE protocols for use by people with acquired brain
injury.
Three year research project 2010-2013 Single n experimental design – as part of the
larger randomised control trial
◦ at Brain Injury Rehabilitation Trust’s Graham Anderson
House in Glasgow
◦ funded by Chief Scientist Office of the Scottish Government
 62 year old man
 Twelve month history after intracerebral
haemorrhage
 Severe cognitive impairment - memory
 n=1, Inpatient A-B-A-B; At home A-B
 Morning Checklist a. sequence performance
score and b. carer prompts
 Inpatient = six weeks baseline then three
weeks intervention
 Home = one week baseline then two week
intervention (trial)
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 During the first intervention phase the
Morning Checklist score was significantly
increased in comparison with baseline
 This indicates that the number of prompts
given by support staff significantly decreased
in the first intervention phase, where the
participant approached perfect performance
(4.94/5.00).
 The use of guide was withdrawn due to  Similar pattern of improvement at home
subject error (being turned off ) for 4 days  Significant improvement in morning checklist
ratings from baseline and intervention
 Within this period the results demonstrate a conditions
greater number of prompts required  Guide error rates at home were slightly higher
 This may have been an artefact of difference
 When the GUIDE was re-introduced the in observers or due to the change of
results indicate an increase in function environment
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 Inpatient errors: getting up and going
straight back to bed, hesitating during
sequence, not being able to find clothes that
are in the room, and not getting all the
clothes ready to be fully dressed
 Home errors: not getting all clothes to be
fully dressed, wearing dirty or mismatched
clothes, forgetting to pick up phone/GPS and
inappropriate clothes for the weather
 Guide reduced participant errors to near zero  Many service users object to being observed
in the intervention phase and prompted. The use of an automated,
 Led to ratings of ‘independent’ on half of non-judgemental and emotionally neutral
intervention trials prompter may be preferable (O’Neill &
 Guide can emulate the supportive action of Gillespie, 2008; Lo Presti et al., 2004)
carers in the performance of a complex ADL  The technology may aid in the transition from
sequence rehabilitation centre to home
 Augmentation of rehabilitation, facilitating  This could have huge financial implications
discharge and home support
 Increased prompting without increasing staff
costs
 If the person can carry out the sequence with  Single n experimental design
prompting support, then Guide or a context  Participant had interested in technologies
aware prompter may allow that person to be  Highly motivated by hope of discharge home
independent  Increases in error rates and decreases in
prompt score ratings of independence
occurred on return home and baseline
 This could have functional implications in
terms of discharge planning and could  Feedback on appearance and performance
perhaps reduce the need for long term carer  Perhaps once more settled within his home
support
environment and into an established routine
with support the long term use of GUIDE
could have maximised his function
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 From a functional perspective the use of the
GUIDE system alongside a rehabilitation
program could maintain sequencing abilities
with complex ADL tasks
 It could be implemented as a less intrusive
way of supporting an individual with personal
care routines
 This could in turn perhaps have longer term
implications for reducing carer costs
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