1. Susanne Trauzettel-Klosinski
TRAINING AFTER STROKE
Susanne Trauzettel-Klosinski
Centre for Ophthalmology, University of Tübingen, Germany

2. Hemianopia: main activity limitations and participation restrictions
Orientation disorder - bumping into objects or persons
- problems with wayfinding
- impaired communication
Reading disorder if the field defect involves the centre
Resulting in
- Reduced participation in the society
- Severe reduction of quality of life!

3. The hemianopic orientation disorder

4. General aspects of rehabilitation
Three main aspects need to be considered:
Optical devices
Spontaneous adaptive strategies their knowledge and potential utilization
Training

5. Spontaneous adaptive strategies
Are they helpful?
Which patients do develop them, which don`t ?
Can they be trained?

6. 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

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

8. Training

9. General 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?

10. Note the difference: Visual Field:
seen area during straight viewing direction – without eye movements
Field of Gaze:
Seen area WITH eye movements

11. 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 training in hemianopia: A randomized and controlled study
Roth T, Sokolov AN, Messias A, Roth P, Weller M, Trauzettel-Klosinski S Neurology 2009; 72:
This was the first randomized controlled study

12. Explorative saccade training EST: Digit search task

13. Summarized Results: Saccadic 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

14. Conclusions: 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

15. Further developments since 2009
Personal 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

16. Saccadic Training for Hemianopia
Developed at the Low Vision Clinic
Center for Ophthalmology
University of Tuebingen, Germany
Available in 17 languages
– also in Danish and Swedish
Thanks to the colleagues from
all over the world for the
translations!
Further information:
See
Distributed in Scandinavia by Indenova
VISIOcoach®

17. Reading performance 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

18. Reading training in hemianopia
Can adaptive strategies be trained?
How can eye movement strategies overcome the sensory deficit?

19. Approaches to improve reading in 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) 19

20. How to measure reading speed?
Standardized assessment
is necessary!

21. International Reading Speed Texts IResT
Paragraphs of text (approx. 130 words per text)
More accurate than single sentences, size of newspaper print, considering
the 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:
Hahn et al , BJO 2006

22. International Reading Speed Texts IReST
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 available
Further information see
and Flyer

23. Final summary: Evidence-based training methods for hemianopia
For reading
in right hemianopia: scrolled text
further studies are desirable
For orientation
Explorative saccadic training