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Remote Therapy for People with Aphasia.

Magnus Magnusson
University of Karlstad
Handikapp & SprŒk/ Utbildningsvetenskap
S-651 88 KARLSTAD, Sweden
Tel: +46 54 83 81 90/14 Fax: +46 54 83 23 12, 8 551 739 38
ISDN: +46 54 80 78 30/31
Internetaddress: Magnus_Magnussonƒtp44.bad.se


Olle Gunnilstam
Stiftelsen Stora Skšndal
Avdelning 1
S- 128 85 SK…NDAL, Sweden
Tel: +46 8 605 08 23 Fax: +46 8 605 08 35


Visually supported telecommunication is rapidly becoming more and more common. Fax-communication, electronic bulletin boards and shared areas in local networks are wellknown visually supported remote applications. The visual support, however, does not yet permit freely moving pictures, at least not in any broader sense. What we like to call picture or video telephony is still in its infancy. However, it is important that we have the possibilities to try the technology to ensure all groups of users the possibility to benefit from the technology.

Present visual tele-technology is more and more built around a combination of high-speed processor PC:s, integrated multimedia software and high-speed networks like ISDN. The main word is integration which means that it should be possible to do many different things over a distance with just one tool. The concept of just making calls over the telephone networks is just one of the many meanings of the word telematics today. The main tool seems to become the personal computer which rapidly is becoming a universal tool. The multifunctionality of such a tool creates a situation where the tool in reality is the whole immediate environment around the user. The personal computer with all its extensions and peripherals becomes an extension not only to the user and his or her personality but also to the whole environment. When you are surfing on Internet, using a computer and a modem, you never physically leave your physical room but mentally and figuratively you go anywhere and relate to anyone. The growth of remote work at home is another example of the capacity of the technology to make us independent of physical distances.

A multifunctional tool which demands possible use of all human senses - vision, hearing etc. - will of course offer experiences and feed-back close to the real thing. This means that a videophone would bring the user closer to the same possibilities and experiences that you get in a real physical situation. There could be the feeling of being in a common extended virtual room.

There are of course also dedicated tools available as for instance faxes, text-telephones, copying-machines, videophones etc. but there is certainly a strong tendency on the market to make modular systems where all specific applications are parts of greater systems. This means that someone who wants to have a video or picture-phone system could choose between a module to connect to the PC or a dedicated videophone. The future will show which type of application will become the most used one.

Another problem to cope with is the medium over which the video- telephony communication will be distributed. Narrowband analogue telephone communication demands so much of the compression software because of the limited space that the few applications that exist (7-10 picture/sec picture telephony) give very limited visual feedback. The much talked about ISDN-communication is spreading fairly rapidly but is still to expensive to be of any real interest to an average user. Besides, the quality of transmission is far from perfect over the basic standard speeds available today - 56 kb/s in the States and 64 kb/s in Europe, or multiples thereof. Broadband and satelite communication are economical impossibilities for anyone but the larger corporations. An interesting alternative to ISDN and analogue telephony is offered by the Internet where it is possible to transmit videocalls and VR-experiences over the net over WWW today.

Sofar, very few developers or vendors have off-the-shelves videophone- systems to offer and the market is still budding. However, it is not especially original to suppose that the market will offer cheaper and more powerful systems in the near future, in the same way as always in the computer business. The technological development is extremely rapid. However, the pace of the development of userÕs awareness or knowledge of new technology is much slower. This awareness is absolutely necessary to develop and analyze so that technology really will be available for all users. This paper is based on experiences in Sweden but most of it can be considered as general.

Telematics in Sweden.

Analogue narrowband telecommunication is very common in Sweden and every household has at least one telephone and some have two numbers. Faxes are very common and 1.2 million faxes are in use, most of them in companies however. Most faxes are separate faxes and not fax-modems. About 15% of Swedish households have computers by now and 10% of them have modems. And the market is growing rapidly. 64 kb/s ISDN - the main standard - is growing slowly, probably due to the fairly high cost of ISDNÊin Sweden. Cellular phones are spread all over the country and the digital standard GSM is competing with the analogue standard NMT.

Most graphical telecommunication still consists of text and simple pictures as in fax and BBS-communication. Internet, however, is growing rapidly with the strongest concentration of users at the universities and among the media people. The big industries have started experimenting with videoconferencing systems but there has been no real break-through for moving picture telematics yet, neither in the business world, nor in the private sector. The trends are the same all over Europe although ISDNÊis growing more rapidly on the continent.

In Sweden there has been only one telephone agency up until two years ago under the name Swedish Telecom. Then it became privatized under the name Telia. Although there are several other companies in our country by now, Telia is still the largest, and the only one with a special research department dealing with videotelephony and related subjects.

Videophony in Sweden.

In 1971 the first Swedish videophone-systems were developed by the company Ericsson in cooperation with Philips in the Netherlands. This system never became a commercial product although it had its use. Most of the videotelephone technology in Sweden since that time has been imported. During the 1980Õs the Norwegian company Tandberg started developing an originally Italian 2x64 kb/s videophone. It was used in early tests, especially in the education field. The first system used in any disability project in Sweden, however, was a specially developed 2 mb/s system which was used by the Swedish organization for the deaf as a link between their two main offices.

In the late 80Õs and the early 90Õs some trials were made with analogue systems where the pictures were still-pictures or moving at a very low frame rate, e.g. 7 frames/sec. For one year the forerunner to Telia marketed a black&white stillpicture system from Panasonic with a capacity for up to seven to ten pictures/minute. It was rather a paper- less fax and it never became a success. It was used in several experiments with people with mental retardation or Aphasia with some success. The results are documented in several reports, some in English. In the early 90Õs Telia tried to market the new analogue videophone technology with a capacity of 10 pictures/second and color. They made some trials with the american AT&T-phones and the British Telecom equipment called Relate. The results were very ambiguous and indicates that the monitor is to small to perceive details clearly, that the monitor is too sensitive for surounding light and that the perception of simultaneous sound to the picture is rather difficult.

Description of the problem.

People with Aphasia have a language disability. This means that they have difficulties in handling concepts and ideas when communicating with others. Speech is difficult to handle since the language capability is disturbed. Aphasia is a result of a brain damage, for instance a stroke and is often mixed with other problems as well, for instance hemi- paresis. The language problems can result in reading and writing difficulties as well as in speech problems. Many persons with Aphasia find that they have to literally be seen to be understood since they can support their ways of communication with gestures and signs and pictures. This means that traditional distance communication could be difficult to handle for someone afflicted with Aphasia.

Aphasia in Sweden.

Statistical figures are very vague and no real study has been made for many years. Out of the Swedish population of 8.000.000 inhabitants, about 30.000 are supposed to have Aphasia and about 5.000 more get afflicted every year. There is a special organization called the Swedish Aphasia Society that has about 5.000 members. The average age of people with Aphasia tends to get lower although it is still expected to be between 50 - 60 years.

Thee Society has been managing several projects with technological content during the last few years. It is supporting software development and has initiated a Nordic R&D-group and also made connections in other countries, for instance with the group in the US that is developing the program Lingrafica. The main project, however, is called the Trial and Error project and is concerned with creating rooms all over Sweden with a basic set of computerized equipment where members can meet the new technology in their own way. Those rooms will cover all the country and be connected through telematics.

Telematics and disability.

During the last 10 - 15 years, the government and more recently the Telia company has spent a lot of efforts on disability and telematics. Today, there is a permanent disability research group at Telia and the government is spending several millions of crowns every year on R&D in the field of disability and telematics through the agency The Board of Communication Research. My own work is funded in that way. At the moment the main efforts are spent on standardization of text telephony and BBS- communication and initializing work on videotelephony for different groups of people with special needs. A lot of work is spent on developing special interfaces for special groups of people to more general communication systems. Since Sweden became a part of the European community, Sweden has become involved in many joint Europena projects.

Videotelephony and disability.

Regarding videotelephony in general for disabled people three main efforts are running at the moment:

The largest disability organization in Sweden is also planning to install video-conferencing systems in all its local affiliations.

In the work with people with Aphasia or mental retardation, trials have been made with all types of video-telephony. However, the only trials within the field of disability in Sweden with the Relate-type of analogue videophone were made by me for people with Aphasia. All the trials have been made with dedicated equipment, that is, no trial has been made yet with equipment that is integrated into standard PC:s.

Videotelephony and Aphasia.

During 1993 and 1994 several trials have been made with all three different sorts of videotelephony. Almost all trials were interpersonal communication trials, that is, very few trials contained any language training in an organized form.

  1. Several trials were made with the black&white stillpicture telephone, mainly showing that the users thought that it was good to be able to see pictures but that everyone expected that things could only become better. Picture support was considered important and the most positive reactions came from a man who used the stillpicture phone as an interpretation tool, sendong copies of messages over the phone to a daughter who also had a phone and asked her to help him to interpret the content. The trials were funded by Swedish Telecom and the Aphasia Society.
  2. The trials with the Relate-type phone were fewer since most users thought that it was difficult to handle the monitor. When the surrounding light was acceptable the quality of the picture was considered to be acceptable, too. Otherwise, the users thought it an improvement that the monitor and the telephone were built together as one composite tool. The trials have sofar been funded by Telia.
  3. The third type of videophone - the ISDN-based 2x64 kb/s-phone - has been used in one complete experiment sofar. During the month of February two phones were connected between Stockholm and the northern city of UmeŒ, 700 kilometres distance from each other. During this month about one hundred persons, most of them people with Aphasia, tried to communicate with someone else over the videophone. Several patterns of communication were recognized during this trial and I just want to give a few examples. For instance, the Ódiscovery callÓ was very common. That means that someone made a call to try to find out how it looked on the other side. Another not too common type of call was the Óproblem- solvingÓ call where someone made a call to get answers to some specific question. AÊthird type of call was also rather common, that is the Ógetting to know youÓ call, that someone simply made a call to see if there was someone interesting on the other end. This trial was funded by the Swedish chapter of ISAAC and myself.

There were interesting reactions found in several of the participants regarding the feeling of closeness or distance. The phone was connected sometimes for a very long while. Some people started to make comments on those people in the other room and talking about the people 700 kilometres away as if they were in the room across the corridor. There really started to grow a feeling as if we all were in a common (virtual) room.

At one very special occasion a daughter to an elderly man in the northern city came to the trial site in Stockholm and made a Ódropping byÓ call to her father, without him knowing it beforehand. The surprise was quite touching when he was sitting in the room and working with the computers as he was doing every week, and suddenly his daughter was appearing on a screen just beside him. The effect became much stronger than over the audio-phone.

What will be done.

Two PC-based videophone-systems have been installed,one in the city of Karlstad and one in the city of Stockholm. The distance is 120 miles between the two sites. The basic equipment consists of 75 Mhz Pentium computers with 20 MBÊRAM and 1 GB HD, 15Ó Super-VGA monitors, built in 4-speed CD-ROM, SoundBlaster and the Vistium videophone-card with camera, microphone and loudspeakers fro AT&T. We also have a common camera to make photo-CD:s with, a color scanner and a digital Quick-Take camera. To that we have added two ISDN-subscriptions, two analogue subscriptions and two modems. On the software side we use all the necessary standard software to handle the system under Windows 3.11. We also use two therapeutical software packages developed in Sweden. One is called PicBox and is related to the American system Lingrafica, that is, an AAC communiction software package. The other program is a treatment program called Lexia which contains 70 different sets of practices. It is developed during several years of clinical practice by Mr Olle Gunnilstam, speech therapist and programmer. Both types of software are designed to be used either by the user on his/her own or together with a therapist.

At a later stage Internet-based communication will be tried and possibly also the Quick-Time based Apple multimedia system. However, it is important not to force the participants in the project to learn to handle too many different applications, because then they will be dominated by the technology and the task before them will be how to survive the onset of technology, not to use technology as a door to reach each other and the therapist in a less complicated way.

The project will last for several years and at least 30 persons with Aphasia will be invited to receive treatment for an extended period over videophone in a virtual ÓroomÓ by me. A control group will also be treated in a ÓrealÓ room. The therapeutical software will be used in the videophone setting as well as treatment using equipment in the physical rooms on each side of the connection. This project will be funded by The Board of Communication Research. AÊfew pilot trials have been done, testing the possibility to share software between the stations. This is of cours a form of non-immersive virtual reality so the metaphor for the the trial stations would be that they are doors leading to either the common videoplace-room of Mr KruegerÕs or to each others physical rooms - welcome to step in and have a look!

Expected results.

The forthcoming project will show in what way therapy is experienced and possible results from therapy over the videophone. The results will be documented in a dissertation. The dissertation is supervised by professor Irene Johansson, University of Karlstad.


General information is available through the Swedish Aphasia Society about projects in the field of Aphasia and information technology.

Address: Aphasia Society of Sweden
Kampementsgatan 14
S-115 38 STOCKHOLM, Sweden
Tel: +46 8 660 44 04 Fax: +46 8 660 00 04
ISDN: +46 8 442 02 05


Brodin, Jane & Magnusson, Magnus (1992) Videotelephones and Disability - a Review Stockholm University, Dept of Educ, Technology, Communication and Disability Report nr 5

Magnusson, Magnus & Brodin, Jane (1993) Virtuella VŠrldar och handikapp (Virtual Reality and Disability) Stockholm University, Dept of Education, Technology, Communication and Disability Report nr 5

Brodin, Jane & Magnusson, Magnus (1993) Using New Technology in Communication or People with Speech and Language Disabilities in Sweden Technology and Disability, 2(1993)2 ppg 063-070

Magnusson, Magnus & Brodin, Jane (1995) Virtual Reality and Disability - State of the Art , Stockholm, In press

Gunnilstam, Olle (1989) Datorprogram fšr logopeder (Computer Software for Speech Pathologists) Nord T log fon 14(1989)2, ppg 29-32

Magnusson, Magnus & Brodin, Jane (1994) Virtual Reality and Disability - Conference Proceedings, Stockholm University, Dept of Education, Technology, Communication and Disability, Report nr 9

Magnusson, Magnus (1992/a) UtvŠrdering av stillbildstelefoni och telefax fšr afatiker (Evaluation of Still-Picture Telephony and Fax for People with Aphasia) Stockholm, Afasifšrbundet i Sverige

Magnusson, Magnus (1992/b) Still Picture Telephony for People with Aphasia CSUN/California State University, In H. Murphy (Ed): Proceedings of the Seventh Annual Conference: "Technology and Persons with Disabilities", ppg 325-330

Magnusson, Magnus (1992/c) Utilisation du VidŽo-tŽlŽphone pour les Aphasiques et les deficients visuels Paper presented at Logicom, Nantes

Magnusson, Magnus (1993) Picture Based Distance Communication for Dysphasic and Dysartric People - Another Step towards Everyday Multimedia-communication CSUN/California State University, In H. Murphy (Ed): Proceedings of the Eighth Annual Conference: "Technology and Persons with Disabilities"

Magnusson, Magnus (1994) Videotelephony and Aphasia - A Pilot Trial Paper at the International Aphasia Conference in Aalborg

Magnusson, Magnus (1995/a) Bildtelefoni och Afasi (Picture Telephony and Aphasia) Paper presented at the conference Handikapp, MŠnniska, Miljš

Magnusson, Magnus (1995/b) Videotelefoni fšr afatiker - ett pilotfšrsšk, (Videotelephony for People with Aphasia - AÊPilot Trial)ÊMalmš, Hadar, ISAAC-Sverige

Nicklasson, Laila (Ed.) (1994) AÊPresentation of Projects, Report 4, Stockholm, Swedish Aphasia Association, 40 pp

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