Assisted Speech

Slurred speech was one of Sharon’s early ALS symptoms.  Over the course of a year her speech became harder and harder to understand as she lost control of her tongue and mouth.  Tests showed that her vocal chords were just fine — she was able to make the right sounds but her mouth and tongue weren’t able to shape them into words that anyone could understand.

Dedicated Assisted Speech Devices
Sharon’s first assisted speech device was a used Dynavox Dynawrite that she received as a donation from a family member.  The device is essentially a typewriter keyboard with a display screen attached, and with a Speak button to initiate a computer-voiced reading of the words you type in.  Sharon still uses the device in many situations.  It’s fairly durable, putting up with some knocking around, and it works well for a self-contained device.  But it’s heavy and awkward to carry, and it’s not great at pronouncing certain words (there’s a way to override pronunciation but its use is not intuitive).  The device is Windows-based for some crazy reason (why would you use an unreliable operating system like Windows for a small dedicated device?) and so it takes a few minutes to start up and it “locks up” frequently.  We have to keep a paperclip with the device so that we can stick the paperclip in the hole in the back to regularly reboot it.

The Dynawrite we have is several years old, and I’ve got to believe that the newer models are better (I would certainly hope so).  But the one we have is good enough, and we haven’t yet explored the option of getting a replacement.

Advantages

• Simple to use (when it works): just turn it on, type, and press the Speak button.
• Can be paid for by medical insurance in most cases (I have no personal experience with this)

Disadvantages

• The device doesn’t do anything else: no Internet, no email, etc.
• As heavy as a small laptop.  Cumbersome.
• Typically very expensive.  I think the Dynawrite originally cost around $5,000, and I’m pretty sure that current dedicated devices are also in the thousands.  Of course, if your medical insurance covers most of the cost then you won’t pay this much.  But the dedicated device manufacturers are obviously charging the higher prices associated with medical devices — you could buy 10 or more laptop computers for this kind of price.

Assisted Speech Software for Your Home Computer
If you already have a computer at home, then you can get instant access to assisted speech capability just by downloading some free software.  There are multiple options available.  We use Etriloquist for a Windows PC and MyVoiceX for the Mac.  Both of these can be easily and quickly downloaded, so you can try them out to get an idea of how they will work.  Even if you have a dedicated assisted speech device or if you use an iPhone, iPod or iPad (see below), they are a good solution when the patient is already using a PC and just wants a quick way to say something.

They’ve also reasonable alternatives if you have a laptop PC and want to carry it around with you.  In that sense they’re a substitute for dedicated assisted speech devices.

Advantages

• Simple to use
• Free in many cases
• A number of alternative software packages are available.  You’ll have to pay for the sophisticated ones.  But basic function can be derived from free software like Etriloquist and MyVoiceX.
• Works on your existing PC

Disadvantages

• Requires you to have your PC available and turned on
• Uses your existing PC sound system, which may or may not be good enough

Assisted Speech Software for your iPhone, iPod Touch or iPad
Sharon and I have become increasingly frustrated recently with the difficulty of carrying around her dedicated assisted speech device.  There are certain situations where a large typewriter-keyboard-sized device doesn’t work very well.  In restaurants, for example, there often isn’t enough table space for the keyboard.  And when we’re having a private conversation, Sharon doesn’t use the Speak feature but instead types something and then shoves the device across the table for me to read her words.  This can be difficult with a heavy device.

Similarly in cars or while “walking” (I walk and Sharon uses her wheelchair), it’s a pain for Sharon to have to carry the device in her lap, wait a minute for it to turn on, and then use the device when she only has a few words to say.

Because of the need for a smaller instant-on speech device, I investigated alternatives.  I discovered that iPhones, iPads and current models of the iPod Touch (which is like an iPhone without the phone service) all have apps that can be used for assistive speech (there are probably apps for Android phones too — I just haven’t looked).  There are two basic types of app: text-to-speech and phrase-selection.

Text-to-Speech
This is the simplest kind of app; it works just like the dedicated assisted speech device or the PC speech software.  You use the virtual keyboard on the iPhone (or iPod Touch or iPad, but I’ll just use the word “iPhone” to refer to any of the three) to enter what you want to say, and then you touch a virtual button to make the device say those words.  There are multiple apps available on the iPhone for this purpose.  We use the Speak It! app, which you can obtain from the app store for a couple of dollars.

Phrase Selection
Another app available for the iPhone includes the text-to-speech capability but also offers another way to communicate that doesn’t require typing.  Proloquo2Go has a unique approach to assistive speech that lets the user touch icons on the screen that represent different patient needs or different types of phrases.  The software comes with an initial set of phrases and icons, but you can modify their set and add your own to create an easy-access language that is tailored to the particular needs of the patient.  The goal is to allow a patient to communicate with just a few touches of the screen.

The concept of phrase selection is difficult to explain in words, so here’s a video from Proloquo2Go that will give you a better idea of how this works.

For more videos on Proloquo2Go, see their tutorial page.

Why Use Phrase Selection Instead of Text-to-Speech?
Text-to-Speech is great for people who can type rapidly on their mobile device, but if you’re not a great typist or if you’re having trouble controlling your fingers to use the small virtual keyboard, then phrase selection might work better.  Phrase selection is also good if you find yourself saying the same things over and over — for example, giving that same speech about how you have a disease which prevents you from speaking.  Using the customized capabilities of Proloquo2Go you can type in the speech once and then repeat it whenever you like just by touching the appropriate icon.

Our App Choice
Sharon is using Proloquo2Go, even for text-to-speech.  She hasn’t done much with icons yet, although I think they may come in handy as ALS advances.  But Proloquo2Go seems to offer better pronunciation and voices than Speak It!, and it retains a history of things you’ve said so you can repeat them if you wish.

Unfortunately Proloquo2Go is much more expensive than Speak It! — Proloquo2Go costs around $190.  So to save money you might want to try out Speak It! for $1.99 and then go to Proloquo2Go only if you think the additional value justifies the cost.

External Speakers for iPhone, iPod or iPad
Although an iPhone is great for portability, and it works well for a private conversation in a restaurant where you show the other person what you want to say, the internal speaker in Apple’s devices isn’t loud enough for a conversation with a group, and it’s barely loud enough for a conversation in a moving car.  Fortunately, all of these devices support a method of short-distance wireless communication called Bluetooth (I know, it’s a stupid name).  The nice thing about Bluetooth is that there is a wide variety of Bluetooth devices available, including some very small, battery-powered speakers.  One Bluetooth speaker that I particularly like is the Motorola MOTOROKR EQ5, which is available for just $26.99 from Amazon.  This small speaker is about the same size and shape as the iPhone, has a fold-out stand and a rechargeable battery, and uses Bluetooth to automatically link to the iPhone when you turn on the speaker (after a one-time initial configuration step).  It has a built-in volume control, and the speaker is loud enough to be heard in most normal-sized rooms.

External Keyboard for iPhone, iPod or iPad
With the addition of an external speaker like the MOTOROKR, the iPhone is an excellent assisted speech device.  But when compared to the dedicated assisted speech device or a PC, it suffers from having an awkward virtual keyboard.  Of course you gain portability: with an iPhone and a MOTOROKR speaker you can keep your assisted speech device in your pocket.  But for the iPhone to be used as a full-time device you’re probably going to need a full-size keyboard.

Fortunately, the iPhone devices work with Apple’s excellent wireless keyboard, available from Amazon for $69.  Like the external speaker, it uses Bluetooth technology to communicate with the iPhone, and automatically links up whenever you turn the keyboard on.  So use the virtual keyboard on the iPhone when you like, and then if you want to type/say a lot, turn on the Apple wireless keyboard.  You can have portability when you want it, and high-speed typing when you need it.

Conclusion
There are a lot of different ways to do assisted speech.  You can buy (often using medical insurance) a dedicated assisted speech device.  You can use your existing PC and download free software.  Or for a portable solution, you can use an iPhone (or iPod Touch or iPad) in combination with one of the apps mentioned above, then add an optional wireless speaker and/or wireless keyboard to enhance the experience.  Most of these alternatives require typing, but Proloquo2Go’s icon-based phrase selection approach gives you an easy way to have simple conversations without any typing at all.

Pick the solution that’s best for you.  Or, like Sharon, employ multiple solutions — each for its appropriate use.