Susanne Trauzettel-KlosinskiCentre for Ophthalmology,

University of Tübingen, Germany

TRAINING AFTER STROKETRAINING AFTER STROKE

Hemianopia: main activity limitations Hemianopia: main activity limitations and participation restrictionsand participation restrictions

Orientation disorder - bumping into objects or persons

- problems with wayfinding

- impaired communication

Reading disorderif the field defect involves the centre

Resulting in

- Reduced participation in the society

- Severe reduction of quality of life!

The hemianopic orientation disorderThe hemianopic orientation disorder

General aspects of rehabilitationGeneral aspects of rehabilitation

Three main aspects need to be considered:

Optical devices Spontaneous adaptive strategies

their knowledge and potential utilization

Training

Spontaneous adaptive strategies Spontaneous adaptive strategies

Are they helpful?

Which patients do develop them, which don`t ?

Can they be trained?

Spontaneous adaptive strategies Spontaneous adaptive strategies

Eye movements towards the blind side

- small during fixation tasks

- larger during exploration tasks:allow a better use of the field of gaze

Attentional shift towards the blind side Head turn - unfavorable

Can these spontaneous adaptive Can these spontaneous adaptive strategies be used for training?strategies be used for training?

TrainingTraining

General aspects of training studiesGeneral aspects of training studies

specifity: exclude spontaneous recovery exclude placebo effects by using a control group

reliability: assess the potential success by suitable methods

aim: which improvement is clinically relevant? can the newly learnt ability be applied to everyday life? does the effect persist after training?

Note the difference:

Visual Field:

seen area during straight viewing direction – without eye movements

Field of Gaze:

Seen area WITH eye movements

As it had turned out that methods to restitute the visual field did not produce

the desired results and methods to compensate by eye movements

were not yet verified by control groups

We performed the following study:

Comparing explorative saccade and flicker Comparing explorative saccade and flicker training in hemianopia: A randomized and training in hemianopia: A randomized and controlled study controlled study

Roth T, Sokolov AN, Messias A, Roth P, Weller M, Trauzettel-Klosinski S Neurology 2009; 72: 324-331

This was the first randomized controlled study

Explorative saccade training EST: Explorative saccade training EST: Digit search taskDigit search task

Summarized Results: Summarized Results: Saccadic Training StudySaccadic Training Study

Explorative Saccadic Training EST

selectively improves saccadic behaviour, natural search and natural scene exploration

The new saccadic strategy can be applied to everyday life The training effect remained stable after end of training Even patients with long-standing hemianopia improved Quality of life in social domain improved

Flicker stimulation training FT (control group)

Did not change visual fields Exploration was unchanged

Roth et al, Neurology 2009

Conclusions: Saccadic Training StudyConclusions: Saccadic Training Study

Compensational approach: Explorative Saccadic Training EST

is specific to improve utilization of the field of gaze is evidence-based and recommendable The training developed and used in this study is available as software

Compared to other saccadic training methods, which use mostly

oculomotor training or single target search tasks,

the training of this study has special features:

- multiple target search task (relevant for everyday demands)

- diagnosis specific (hemianopia, quadrantanopia)

- easy to use, also for patients without prior PC experience

- independent training at home

- low costs

Further developments since 2009Personal Version for Patients

Available as software

To use independently at home with USB-Stick

3 levels of difficulty

Feedback for the patient during the training

Professional Version – additional options

Patient data bank

Several patients trainable simultaneously or successively

Import of external data (from patient`s USB-stick)

Network-compatible

Areas of application

Rehab-Units, private practice and at home

Available in 17 languages

Saccadic Training for HemianopiaSaccadic Training for Hemianopia

Developed at the Low Vision Clinic Center for Ophthalmology

University of Tuebingen, Germany

Available in 17 languages – also in Danish and SwedishThanks to the colleagues fromall over the world for thetranslations!

Further information: See www.visiocoach.deDistributed in Scandinavia by Indenova VISIOcoach®

Reading performance Reading performance in hemianopia depends on:in hemianopia depends on:

the side of the field defect (reading direction)

its distance to the midline (size of reading visual field)

presence or absence of adaptive strategies, such as eccentric fixation predictive saccades

Reading training in hemianopiaReading training in hemianopia

Can adaptive strategies be trained?

How can eye movement strategies overcome the sensory deficit?

Approaches to improve reading Approaches to improve reading in hemianopiain hemianopia

Support for orientation on the page:visual and tactile aids (index finger, ruler or slightly magnifying ruler with red guide-line)

Predictive saccades to the beginning of the next line

Turn text in vertical or diagonal orientation

Computer training with scrolled text (Zihl et al 1984, Kerkhoff et al 1992, Spitzyna et al 2007)

The only randomized and controlled reading training study in right hemianopia reported an improvement of reading speed. (Spitzyna et al Neurology 2007: 68)

How to measure reading speed?How to measure reading speed?

Standardized assessmentStandardized assessment

is necessary!is necessary!

International Reading Speed Texts International Reading Speed Texts IResTIResT

Hahn et al , BJO 2006

Paragraphs of text (approx. 130 words per text)More accurate than single sentences, size of newspaper print, consideringthe everyday-demand

Standardized: Same length, difficulty, content and linguistic characteristics in the different languages

Set of 10 equvalent texts in each language for repeated measurements and international studies

Now available in 17 languages

Trauzettel-Klosinski S, Dietz K and the IReST Study Group (2012) IOVS 53:5452-5461

The tool for an evidence-based procedure!• reproducibility

• comparability

• success documentation

The tool for international multi-language reading studies!

The 2nd edition with 17 languages is now availableFurther information seewww.amd-read.net and Flyer

International Reading Speed Texts IReSTInternational Reading Speed Texts IReST

Final summary:Final summary:Evidence-based training methods for Evidence-based training methods for

hemianopiahemianopia

For reading

in right hemianopia: scrolled text

further studies are desirable

For orientation

Explorative saccadic training