Occupational Therapy

We are a group of occupational therapists and a new client has come to our
office with the following case history: Don is a 63 year-old amateur poet. He
has several of his poems published in the local newspaper but has not yet been
accepted by any literary journals. Three months ago, Don had a cerebellar
cerebrovascular accident that has given him significant fine motor control
limitations. He is not able to hold a pencil or a pen, and when one is taped in
his hand, he can not produce recognizable printing. He is able to reach a range
of nearly 5 feet from side to side but cannot pick up a 1-inch cube from the
table. When asked to use a keyboard, he is as likely to strike two keys away
from the target as the key he is aiming for. He is able to put his finger
reliably into a square that is 2 inches on a side wherever it is located within
his reach. He is not able to accurately place his finger into a square that is
1.5 inches on a side, however, unless it is located directly in front of him
(Anson, 1997, p. 104). Don is frustrated by his condition and needs some
assistance to continue his writing. We used the decision tree to evaluate which
computer adaptation would be best for Don. We determined that Don has physical
limitations to the computer but has full range of the keyboard. Due to his
trouble targeting specific keys, it would be increasingly difficult to
simultaneously press more than one key at once. The client has frequent
accidental keystrokes because of the size of the small keys. His inability to
strike a single key on demand led us to expanded range of motion. Having
assessed that Don could strike larger keys accurately; we reached the
alternative of expanded keyboards. Upon researching expanded keyboards, we found
a great variety in what each keyboard offered. The 32 key layout with 2.5- inch
keys did not provide an adequate selection for Dons writing needs. Most of
the standard expanded keyboards with 128 keys only have 1.5-inch keys. Some
examples are Key Largo and Unicorn Expanded keyboards. Key Largo is an expanded
keyboard, which works through Discover KENX. It is useful for one with
coordination problems. Unicorn Expanded keyboard established the standard 128
key expanded keyboard design. We had the opportunity (in A.T. lab) to try and
compare the different expanded keyboards. We appreciated that a client with
difficulty reaching small keys would find these keyboards more beneficial. All
keyboards require an encoder, which interprets the key. When pressed it converts
it to a keyboard code, that the computer could understand. Some computers come
with a built in encoder and some without. These keyboards with encoders can be
connected directly to the keyboard port of the computer. Therefore no internal
adaptation is needed for the computer and it doesnt interfere with any
software in the computer. This is beneficial because it can be used with any
operating system and software the client may need. A disadvantage to this is
that the keyboard codes are not readily adaptable. This means that the keyboard
layout is fixed and cant be changed by the clinician. Another consideration
is that this keyboard can not be connected simultaneously with the standard
keyboard. Since plugging and unplugging the keyboard is not recommended, this
option is better suited for a client who would be the sole user of the computer.


Expanded keyboards that do not have the built in encoder, require an external
device that would interpret the codes to the computer. Although this keyboard
has the disadvantage of an external device, it offers flexibility in the
keyboard layout and allows for various overlays that change the layout. An
example of the latter is the Key Largo keyboard mentioned above. The problem
with 1.5-inch keys is the clients inability to accurately reach a key of that
size unless the keyboard is positioned right in front of him. An option would be
to position the client in front of the computer with the keyboard mounted close
enough for him to access. Although this alternative was a possibility we
preferred to find a keyboard with 2- inch keys. After researching this
alternative on the internet, we found a product that matched Dons needs more
efficiently. The name of the product is Expanded Keyboard for Apple II+ and IIE.

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This keyboard operates as a standard keyboard with the choice of 1.5 or 2-inch
keys. With continued research, this was the only product with a two-inch key
option. This is a perfect size key for Dons needs. This keyboard can be
connected at the same time as a standard keyboard. This would allow other family
members to use the computer without having to constantly connect and disconnect
his keyboard. Sticky key option is included in this keyboard. The flat surface
of the keyboard will allow the use of overlays. In addition this keyboard allows
all the same functions as a standard keyboard. This is an important fact
considering Dons interest in writing. The dimensions of the keyboard are 14
by 32 by 1, with the weight of six pounds. The pricing range is listed as 750 to
875 dollars. The manufacturer for this product is EKEG Electronics Co Ltd. An
additional way to address Dons problem of accidentally striking untargeted
keys is the option of delayed acceptance. With delayed acceptance the key must
be pressed for a certain amount of time before it produces any output. This
prevents haphazard striking from having an effect, and error can be avoided. You
can modify the amount of time delay. We would suggest starting at a minimal
level of delay until the optimal level of performance is achieved. A possible
disadvantage to delayed acceptance, is that it delays the reaction time of each
key pressed thereby slowing down the typing speed. Typing speed is a significant
factor to consider with Don, since his purpose for therapy was to increase his
typing abilities. However, if the disruption of constantly correcting mistakes
due to accidental keystrokes is great, the overall typing speed may increase by
preventing errors before they occur. This may be the case with Don and therefore
we would recommend this option. Furthermore, most delayed acceptance adaptations
are software; making it inexpensive, easily operated and deactivated. Delayed
acceptance, under the name “slow keys”, comes included in Macintosh and
Windows 95. Sticky keys is another option which addresses the problem of
simultaneously pressing two keys. For example pressing shift, releasing it and
then pressing another key would have the same effect as pressing both keys
together. Another technology we considered is word prediction. As the client
begins typing, with each letter the word predictor presents a list of words that
start with the letters he has typed. When the client spots his intended word, he
clicks on it and it will appear on his document. With each new letter the client
types, new words are displayed until the word appears on the list or is
completed by the client. While the purpose of word prediction is to increase
typing speed, it usually does the opposite. In addition many clients find it
irritating to constantly have to glance at the prediction list and look away
from where their attention is focused. For these very reasons we would not
suggest this adaptation for our client. Unless he fatigues, in which case this
option may increase productivity. Abbreviation expansion is an assistive
technology device, which aids in increasing typing speed. It allows the user to
assign an abbreviation to a longer phrase. When the user types the abbreviation,
the phrase appears on the screen. One can create their own abbreviations, based
on frequent words or phrases that they use. This would be very useful for Don.


He could customize the abbreviations according to his writing style.


Abbreviations are only recognized when spaced by themselves, and not when they
are found in the middle of a word. In order to benefit from this, the user must
have cognitive capabilities, as is the case with Don. Another option considered
for Don is Morse code. Morse code uses a combination of dots and dashes as a
code for alphabet and punctuation. Simply using one switch or two switches, the
user is able to fully communicate with minimal motor function. A purpose for
using two switches rather than one is to separate the two signals in case the
client has trouble releasing the switch at the appropriate time. (To separate
dots and dashes). Using large jellybean switches will make it easier for Don to
press. The cost of Morse code ranges up to 800 dollars (DADA Entry). One
advantage of morse code is speed. For a person with motor difficulties this
system provides an optimal speed. Another advantage is that the Morse code can
become automatic with increased usage. A disadvantage to Morse code is that it
has to be learned and the user has to be trained. Someone with learning problems
may have difficulty. Being that our client has motor problems and not learning,
this will not be a problem. The speed of typing is essential for his occupation
and training may be a worthwhile investment. In conclusion, After comparing and
considering our two options of expanded keyboard versus Morse code, we concluded
that an expanded keyboard would be the best access method for Don. Since the
expanded keyboard (Apple II+ and IIE) addresses Dons limitations we did not
find it necessary to go through the required training for Morse code. However if
expanded keyboard did not work, Morse code could be used. We searched many
websites and journals for a published reference on expanded keyboards, but to no
avail. We did, however, find an article on Morse code and its prevalence in
assistive technology today.