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Susanne Trauzettel-Klosinski

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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

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