We are a group of occupational therapists and a new client has come to ouroffice with the following case history: Don is a 63 year-old amateur poet. Hehas several of his poems published in the local newspaper but has not yet beenaccepted by any literary journals. Three months ago, Don had a cerebellarcerebrovascular accident that has given him significant fine motor controllimitations.

He is not able to hold a pencil or a pen, and when one is taped inhis hand, he can not produce recognizable printing. He is able to reach a rangeof nearly 5 feet from side to side but cannot pick up a 1-inch cube from thetable. When asked to use a keyboard, he is as likely to strike two keys awayfrom the target as the key he is aiming for. He is able to put his fingerreliably into a square that is 2 inches on a side wherever it is located withinhis reach.

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He is not able to accurately place his finger into a square that is1.5 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 someassistance to continue his writing. We used the decision tree to evaluate whichcomputer adaptation would be best for Don.

We determined that Don has physicallimitations to the computer but has full range of the keyboard. Due to histrouble targeting specific keys, it would be increasingly difficult tosimultaneously press more than one key at once. The client has frequentaccidental keystrokes because of the size of the small keys. His inability tostrike a single key on demand led us to expanded range of motion. Havingassessed that Don could strike larger keys accurately; we reached thealternative of expanded keyboards.

Upon researching expanded keyboards, we founda great variety in what each keyboard offered. The 32 key layout with 2.5- inchkeys did not provide an adequate selection for Dons writing needs.

Most ofthe standard expanded keyboards with 128 keys only have 1.5-inch keys. Someexamples are Key Largo and Unicorn Expanded keyboards. Key Largo is an expandedkeyboard, which works through Discover KENX. It is useful for one withcoordination problems. Unicorn Expanded keyboard established the standard 128key expanded keyboard design. We had the opportunity (in A.

T. lab) to try andcompare the different expanded keyboards. We appreciated that a client withdifficulty reaching small keys would find these keyboards more beneficial. Allkeyboards require an encoder, which interprets the key. When pressed it convertsit to a keyboard code, that the computer could understand.

Some computers comewith a built in encoder and some without. These keyboards with encoders can beconnected directly to the keyboard port of the computer. Therefore no internaladaptation is needed for the computer and it doesnt interfere with anysoftware in the computer. This is beneficial because it can be used with anyoperating system and software the client may need.

A disadvantage to this isthat the keyboard codes are not readily adaptable. This means that the keyboardlayout is fixed and cant be changed by the clinician. Another considerationis that this keyboard can not be connected simultaneously with the standardkeyboard. Since plugging and unplugging the keyboard is not recommended, thisoption 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 externaldevice that would interpret the codes to the computer. Although this keyboardhas the disadvantage of an external device, it offers flexibility in thekeyboard layout and allows for various overlays that change the layout.

Anexample of the latter is the Key Largo keyboard mentioned above. The problemwith 1.5-inch keys is the clients inability to accurately reach a key of thatsize unless the keyboard is positioned right in front of him. An option would beto position the client in front of the computer with the keyboard mounted closeenough for him to access. Although this alternative was a possibility wepreferred to find a keyboard with 2- inch keys. After researching thisalternative on the internet, we found a product that matched Dons needs moreefficiently. The name of the product is Expanded Keyboard for Apple II+ and IIE.This keyboard operates as a standard keyboard with the choice of 1.

5 or 2-inchkeys. With continued research, this was the only product with a two-inch keyoption. This is a perfect size key for Dons needs. This keyboard can beconnected at the same time as a standard keyboard. This would allow other familymembers to use the computer without having to constantly connect and disconnecthis keyboard. Sticky key option is included in this keyboard. The flat surfaceof the keyboard will allow the use of overlays.

In addition this keyboard allowsall the same functions as a standard keyboard. This is an important factconsidering Dons interest in writing. The dimensions of the keyboard are 14by 32 by 1, with the weight of six pounds. The pricing range is listed as 750 to875 dollars. The manufacturer for this product is EKEG Electronics Co Ltd.

Anadditional way to address Dons problem of accidentally striking untargetedkeys is the option of delayed acceptance. With delayed acceptance the key mustbe pressed for a certain amount of time before it produces any output. Thisprevents haphazard striking from having an effect, and error can be avoided. Youcan modify the amount of time delay.

We would suggest starting at a minimallevel of delay until the optimal level of performance is achieved. A possibledisadvantage to delayed acceptance, is that it delays the reaction time of eachkey pressed thereby slowing down the typing speed. Typing speed is a significantfactor to consider with Don, since his purpose for therapy was to increase histyping abilities. However, if the disruption of constantly correcting mistakesdue to accidental keystrokes is great, the overall typing speed may increase bypreventing errors before they occur. This may be the case with Don and thereforewe would recommend this option. Furthermore, most delayed acceptance adaptationsare software; making it inexpensive, easily operated and deactivated. Delayedacceptance, under the name “slow keys”, comes included in Macintosh andWindows 95.

Sticky keys is another option which addresses the problem ofsimultaneously pressing two keys. For example pressing shift, releasing it andthen pressing another key would have the same effect as pressing both keystogether. Another technology we considered is word prediction. As the clientbegins typing, with each letter the word predictor presents a list of words thatstart with the letters he has typed. When the client spots his intended word, heclicks on it and it will appear on his document. With each new letter the clienttypes, new words are displayed until the word appears on the list or iscompleted by the client.

While the purpose of word prediction is to increasetyping speed, it usually does the opposite. In addition many clients find itirritating to constantly have to glance at the prediction list and look awayfrom where their attention is focused. For these very reasons we would notsuggest this adaptation for our client. Unless he fatigues, in which case thisoption may increase productivity. Abbreviation expansion is an assistivetechnology device, which aids in increasing typing speed.

It allows the user toassign an abbreviation to a longer phrase. When the user types the abbreviation,the phrase appears on the screen. One can create their own abbreviations, basedon 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 theyare found in the middle of a word.

In order to benefit from this, the user musthave cognitive capabilities, as is the case with Don. Another option consideredfor Don is Morse code. Morse code uses a combination of dots and dashes as acode for alphabet and punctuation. Simply using one switch or two switches, theuser is able to fully communicate with minimal motor function. A purpose forusing two switches rather than one is to separate the two signals in case theclient has trouble releasing the switch at the appropriate time. (To separatedots and dashes). Using large jellybean switches will make it easier for Don topress. The cost of Morse code ranges up to 800 dollars (DADA Entry).

Oneadvantage of morse code is speed. For a person with motor difficulties thissystem provides an optimal speed. Another advantage is that the Morse code canbecome automatic with increased usage. A disadvantage to Morse code is that ithas to be learned and the user has to be trained. Someone with learning problemsmay 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 occupationand training may be a worthwhile investment. In conclusion, After comparing andconsidering our two options of expanded keyboard versus Morse code, we concludedthat an expanded keyboard would be the best access method for Don. Since theexpanded keyboard (Apple II+ and IIE) addresses Dons limitations we did notfind it necessary to go through the required training for Morse code. However ifexpanded keyboard did not work, Morse code could be used. We searched manywebsites and journals for a published reference on expanded keyboards, but to noavail.

We did, however, find an article on Morse code and its prevalence inassistive technology today.