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Main Tasks Participants were asked to undertake three tasks when instructed. Each task was chosen from the no hands menu by performing a click as the system scanned the menu options. The first task was to choose and play Ping-Pong, which was the first option on the menu. After each game control returned to the no-hands menu options. The participants were then asked to perform a communication task using the typing program with the dwell time set at two seconds. Participants were prompted what to type. The third task was to operate an appliance such as a lamp or radio connected to the computer via the X-10 environmental controller. An option called switch select was available from the no-hands menu. Once in switch select, six boxes could be observed. Navigation of the cursor into a box caused highlighting of that box. A click would then initiate a switching action. The Cyberlink is still under development and minor intervention was required from the experimenter once the participant had successfully chosen a switch. The device has since been modified so that this intervention is no longer required. It is rare that all activities can be performed in one day. The effects of medicine or fatigue often shorten a test session. Participants also had varying attention spans. Sessions were terminated when a participant indicated that they no longer wished to continue. Apparatus and Software A Trogon Pentium laptop computer with a Windows 95 operating system was used. A Cyberlink was used as the interface device. An X10 Environmental Controller (Tandy Corporation) was attached via the serial port. A grounding strap that was worn on the wrist and attached to the back of the Cyberlink prevented static electricity from interfering with the operation of the interface. The vertical motion of the cursor was controlled by an alpha wave of approximately 4-hertz (brainfinger four), while simultaneous horizontal control was performed using a 2-hertz theta wave (brainfinger two). The first setting rather than the default brainfinger (a beta wave) had to be used for participants with TBI, as they have great difficulty controlling their beta waves.
Table 3 - Environmental Control Actions Environmental Control All participants were able to use the environmental controller except for participant four, the reasons for this being given above. Actual tasks completed are given in Table 3 above. Music Three participants tested the music program, which became available some time after the start of this study. Details of their reactions to the program are given below. It should be noted that participant 4 is deaf. She was able to get some appreciation of the music being played by tactile feedback, obtained by placing her hands on the speaker. The results of the music inquiry are listed in Table 4 below. Participant Reactions The participants and a mental health professional who assisted in this study made some interesting comments. Participant eight used a system of eye spelling to indicate that he had fun creating the music with brain waves, facial movements and eye movements but did not fully understand the process. He suggested that the sound should be fed into a stereo so that all the subtleties of the sound can be enjoyed. He indicated by eye-spelling to his nurse that he was once in a coma for six weeks and was aware of his surroundings as well as his own physical condition part of the time. The participant had been a classical music conductor, and stated that he would have enjoyed having a Cyberlink to allow him to create music again, play games, and communicate while in his comatose state. He eye spelled that there is an overwhelming feeling of being locked in, and there were vast amounts of time with nothing to do. Psychiatric evaluation of completely paralyzed individuals indicates that boredom or "downtime" is a serious problem and that these patients need some form of active recreation (Knapp & Lusted: 1990, p.45). There were other issues relating to the Cyberlink upon which participant eight commented. He felt if he had an opportunity to use a Cyberlink during his time in a coma, he could have navigated a cursor through a maze (Appendix A) with guidance. This would not only help establish his cognitive state as sentient, but provide relief from boredom while in the coma. The participant states that fun from creating music or playing games can make an intolerable situation a little better. Evidence from the health professional, and from the work of. (Resnick,1996,p. S136) leads us to believe that playing video game Ping-Pong and navigating the Labyrinth maze can help the disabled person to stimulate their mind and develop lost proficiencies. The challenge of improving a score or improving a completion time acts as a positive reinforcement. We also consider that when doctors and staff members who once saw the person as unable to communicate and comprehend, begin to realize that the person has abilities, they reverse the isolation that formally existed. Verbal reinforcement is provided and once again opportunities for non-verbal communication can be explored. This can be considered a first step toward mental health. Participant one who is a quadriplegic verbal man, indicated that the music program was fun. He verbalized that EMG emanating from eyebrow movements could move a sliding scale that allowed note playing on a certain instrument. The participant found that the volume on the laptop was quite adequate when adjusted for maximum loudness. He had a music background and played the piano before his spinal chord injury. Whilst the music was easy to create he felt he needed extensive practice to fully understand and control it. Participant four has been deaf since birth. She experienced the music by putting her hands on the speakers, a technique which she has used on other occasions in the group home where she lives. The song called "Postcard from Bali" had a strong beat that vibrated the speakers. The vibration of the speakers caused her to smile and her head bobbed to the beat. The researcher observed some gestures that indicated that the experience with the music made her very happy. The young woman then touched both the happy and good symbols on the communication board at the conclusion of the session. Songs with a less pronounced beat that did not vibrate the speakers did not seem to evoke emotion or head bobbing. Our initial investigation causes us to consider the music program to be of use for the following reasons. The Cyberlink music program can operate on a standard laptop, only takes a few megabytes and does not need a MIDI interface. It allows deaf people an additional opportunity to experience music through the small vibrating internal laptop speakers. The physical space required by the system allows motor impaired individuals an opportunity to create some music. A laptop and Cyberlink can easily fit on top of a hospital tray. The Cyberlink hardware requirements are only for a minimum of a 80486 DX at 75 megahertz. Many institutions that have such older computer hardware that has been donated or handed down from commercial sources. The researcher has also observed that the participants at the institutions tend to have older PCs with slower processors and smaller hard drives. The digital signal processor hardware is also small. Many of the institutionalized residents stated that they have limited living space and that the Cyberlink is good because it can be stored easily on a shelf.
Skilled use of the Cyberlink was established by the study. However, this was only achieved by a change to the Cyberlink and by application of improved understanding of environmental and individual factors that can impede successful use. We will discuss these issues before considering extensions to the use of the Cyberlink. Perseveration The participants needed extensive practice and training to produce an acceptable click or switching action. Some participants produced a constant flow of involuntary clicks after the first click had been attempted. This was generally due to a quivering action of the jaw or eyebrow and is termed perseveration. This is highlighted in Table 3 for participants seven and eight. Modifying the Cyberlink software so that signals after the first click was disregarded solved the problem. The length of 'dead' time allowed after a click is now part of the set-up routine. It was generally found that a delay of half-a-second was sufficient. This feature was added in August, approximately half-way through the study. Static Electricity In the earlier part of the study it was found that participants seven and eight could not perform a click satisfactorily under any of settings tried. The signal obtained was always in a high state and could not be varied. Junker (private communication) had experienced similar problems. The cause was traced to static electricity that may develop with wheelchair users in dry atmospheres. A grounding strap, worn on the wrist and attached to the back of the Cyberlink was thus fitted. The signal amplitude then fell to a level that allowed normal clicking. Power Supply Participant eight had an Ascentia 950N laptop computer from AST. The amplitude of the brain-body signal was raised to a high state when the power supply was plugged into the laptop was operated off the mains supply. The signal could not be brought to a low state under any setting. Junker had found that some power supplies might interfere with the normal operation of the Cyberlink interface. The participant thus used the laptop battery supply in all subsequent sessions. Difficulties in Relaxing Some participants in the longitudinal study have physical, cognitive, and multi-sensory impairments. It is difficult, at times, to explain the concept of relaxation them. The researcher has tried miming relaxation, deep breaths, or blowing against a piece of paper repeatedly in order to demonstrate the concept, but this is not always successful. It is then necessary to increase the left bias on the cursor movement to compensate for their inability to relax. A familiar movement, such as a head bob, is then used to activate the brainfinger that moves the cursor to the right. GENERAL ISSUES RELATING TO USE OF THE CYBERLINK Participant four felt that he might have been able to establish communication while in his comatose state by using the Ping-Pong game. He could have used left and right movement of the paddle to indicate 'yes' and 'no'. There are sensitivity, debounce, and gravity (bias) settings which can be adjusted to filter out signals from involuntary motion and make yes/no communication easier. Simple yes/no questions answered by a person with the Cyberlink could show they are sentient and allow their diagnosis to be upgraded. This is a difficult area medically, and one where diagnosis may not always be 100% correct. The implication of mis-diagnosis for the 'comatosed' person are significant. In some cases the person becomes more of an object than a human being. Simple things like a knock on the door when entering a room or hello seem unnecessary, and are not done. No one can be sure if the resident can hear and possibly comprehend what is happening around him or her. What staff do observe is that the person has not communicated with them. This makes staff less likely to notice non-verbal forms of communication such as eye blinks or other movements. The person loses the opportunity for recreation and mental stimulation without the ability to communicate. This leads to the increased likely and severity of depression, loneliness, and anxiety (Resnick, 1996,p. S136). Any new ability to communicate because of the Cyberlink, even in the simplest form, can help improve the person's mental health. CYBERLINK - A DOCTOR'S TOOL FOR DIAGNOSIS? We observed a comatosed young man in an earlier study, reported elsewhere (Doherty, 1999). He used an alpha wave to navigate a cursor through the Labyrinth (Appendix A) under instruction, and was able successfully to navigate the maze seven times out of eighteen attempts with the completion times in the range of 212 to 860 seconds. As indicated earlier, there are certain variables which we cannot control such as medicine or time of visit. The participant often has seizure medicines changed and experiences colds, flu, and aspirating pneumonia. The above observations, combined with expert testimony of medical personnel in his facility provided his doctor with enough data to determine that he is sentient. His diagnosis was upgraded from coma to traumatic brain stem injury. The new diagnosis allowed a higher level of care. The participant has subsequently typed 'HI' using the typing program described previously. We suggest that this device has potential diagnosis value which should be investigated by medical professionals. We have demonstrated the use of the Cyberlink interface as a communication and recreational device for quadriplegic, traumatic brain-injured, and non-verbal persons. These initial results have been promising in that the majority of participants were able to navigate a maze, play Ping-Pong, communicate by typing and use an environmental controller. The device would appear to have some application in the diagnosis of coma, and as a communication and recreational device for patients who have previously been considered unable to carry out such functions. Further studies are required in this area. Some very preliminary studies of the music program again indicate its validity.
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The United States Constitution states that people
have the inalienable right to the pursuit of
happiness. Also, US residents in government-funded
long-term care facilities often have a right to
recreation. It has been estimated that there are
approximately 4.7 million people, or one in 65
Americans, with traumatic brain injury (TBI) (Cambell
1998). Their condition often impairs their ability to
be active and communicate. To withhold recreation from
an institutionalized person because of a handicap, is
a form of discrimination. Recreational activities need
to be complemented by communication in order to
express ideas, wants, and needs. This communication is
necessary to participate in society. A substantial
percentage of the population thus has a potential need
for assistive communication, environmental
controllers, and recreational devices. Many people who
cannot speak depend upon a computer or augmentative
device for communication. Current input devices tend
to require the use of voice or some form of physical
movement, be it limb, facial or eye movement. However,
users who have limited use of their eyes, no use of
their limbs or face, cannot speak or move their head
are severely disadvantaged and often cannot use
existing, physically-manipulated assistive
technologies. Their needs could be met by mental
interfaces that
make use of signals from facial movements and mental
activity. There have been some early developments of
mental interfaces with limited success in Austria (Kalcher
1994) and Australia (Craig et al. 1997,p.8) using EEG
waves.