Susanne Trauzettel-Klosinski Centre for Ophthalmology, University of Tübingen, Germany TRAINING...
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Transcript of Susanne Trauzettel-Klosinski Centre for Ophthalmology, University of Tübingen, Germany TRAINING...
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