Presentation on theme: "Susanne Trauzettel-Klosinski"— Presentation transcript:
1 Susanne Trauzettel-Klosinski TRAINING AFTER STROKESusanne Trauzettel-KlosinskiCentre 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 communicationReading disorder if the field defect involves the centreResulting in- Reduced participation in the society- Severe reduction of quality of life!
4 General aspects of rehabilitation Three main aspects need to be considered:Optical devicesSpontaneous adaptive strategies their knowledge and potential utilizationTraining
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 gazeAttentional shift towards the blind sideHead turn - unfavorable
7 Can these spontaneous adaptive strategies be used for training?
9 General aspects of training studies specifity:exclude spontaneous recoveryexclude placebo effects by using a control groupreliability:assess the potential success by suitable methodsaim: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 movementsField 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 resultsand methods to compensate by eye movements were not yet verified by control groupsWe performed the following study:Comparing explorative saccade and flicker training in hemianopia: A randomized and controlled studyRoth 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 ESTselectively improves saccadic behaviour, natural search and natural scene explorationThe new saccadic strategy can be applied to everyday lifeThe training effect remained stable after end of trainingEven patients with long-standing hemianopia improvedQuality of life in social domain improvedFlicker stimulation training FT (control group)Did not change visual fieldsExploration was unchangedRoth et al, Neurology 2009
14 Conclusions: Saccadic Training Study Compensational approach: Explorative Saccadic Training ESTis specific to improve utilization of the field of gazeis evidence-based and recommendableThe training developed and used in this study is available as softwareCompared to other saccadic training methods, which use mostlyoculomotor 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 PatientsAvailable as softwareTo use independently at home with USB-Stick3 levels of difficultyFeedback for the patient during the trainingProfessional Version – additional optionsPatient data bankSeveral patients trainable simultaneously or successivelyImport of external data (from patient`s USB-stick)Network-compatibleAreas of applicationRehab-Units, private practice and at homeAvailable in 17 languages
16 Saccadic Training for Hemianopia Developed at the Low Vision ClinicCenter for OphthalmologyUniversity of Tuebingen, GermanyAvailable in 17 languages– also in Danish and SwedishThanks to the colleagues fromall over the world for thetranslations!Further information:SeeDistributed in Scandinavia by IndenovaVISIOcoach®
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 aseccentric fixationpredictive 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 lineTurn text in vertical or diagonal orientationComputer 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 assessmentis necessary!
21 International Reading Speed Texts IResT Paragraphs of text (approx. 130 words per text)More accurate than single sentences, size of newspaper print, consideringthe everyday-demandStandardized: Same length, difficulty, content and linguistic characteristics in the different languagesSet of 10 equvalent texts in each language for repeated measurements and international studiesNow available in 17 languagesTrauzettel-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!reproducibilitycomparabilitysuccess documentationThe tool for international multi-language reading studies!The 2nd edition with 17 languages is now availableFurther information seeand Flyer
23 Final summary: Evidence-based training methods for hemianopia For readingin right hemianopia: scrolled textfurther studies are desirableFor orientationExplorative saccadic training