Cognitive therapy and brain training
Spatial Operations
www.rehacom.com
Cognitive therapy and brain training by Hasomed GmbH
This manual contains information about using the RehaCom therapy system. Our therapy system RehaCom delivers tested methodologies and procedures to train brain performance . RehaCom helps patients after stroke or brain trauma with the improvement on such important abilities like memory, attention, concentration, planning, etc. Since 1986 we develop the therapy system progressive. It is our aim to give you a tool which supports your work by technical competence and simple handling, to support you at clinic and practice.
HASOMED GmbH Paul-Ecke-Str. 1 D-39114 Magdeburg Tel: +49-391-6107650 www.rehacom.com
Inhalt
I
Inhaltsverzeichnis Teil I Training description
1
1 Training ................................................................................................................................... task 1 2 Performance ................................................................................................................................... feedback 5 3 Levels ................................................................................................................................... of difficulty 5 4 Training ................................................................................................................................... parameters 7 5 Data ................................................................................................................................... analysis 9
Teil II Theoretical concept
10
1 F oundations ................................................................................................................................... 10 2 Training ................................................................................................................................... aim 13 3 Target ................................................................................................................................... groups 13 4 Bibliography ................................................................................................................................... 14
Index
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1
Spatial Operations
1
Training description
1.1
Training task The procedure Spatial operations trains the basic functions of visual-spatial performance in the following categories: Estimating position, Estimating angles, Estimating relations (Filling of vessels), Estimating one dimensional sizes and Estimating two dimensional sizes. The training works in an adaptive way, where a separate series of levels - 1 to 9, is available for every category, with the exception of 'estimating relations', which is only available with levels from 1 to 6. The short-term memory for spatial positions is also trained at the levels of difficulty from 7 to 9. The tasks of every category are explained to the patient in an instruction stage. By means of "learning by doing", two practice tasks have to be solved correctly before the actual training begins.
Picture 1. Estimation of position at level 1. The marks in the background help with the positioning. The green frame (brighter in the manual) indicates the position in which the object should be - a correct decision (the positioning being within the level of tolerance).
In the category Estimating position two large fields appear on the screen (Picture 1). One field shows and object or an animal in a fixed position. the second field shows the same object in a different position. It can then be adjusted with the
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Training description
2
mouse. The task is to move the object in the second field to the same position which it is in the first field (the fixed position). To confirm the patient just presses the OKkey. Marks and lines act as modifications for the levels of difficulty. To evaluate the performance three frames are used, the green frame, the red frame and the black frame. The green frame appears when the task has been correctly solved. This means that the rearranged object is now within an adaptable tolerance zone of the 'where it should be position'. The red frame is used if the task has been incorrectly solved. The object was then outside the tolerance zone. The black frame is used to indicate the actual position of the object as it appeared in the second field before any attempt to solve the task was made. When setting up the training for a patient the simple tolerance zone (5%) is used as standard. The structure of the level is set up in such a way that the task begins with a larger tolerance level (double tolerance 2 x 5% = 10%) and later the tolerance level is reduced (to the so called simple tolerance). For patients with particular problems the tolerance level can be increased. However, after improvements in performance the simple tolerance level should be restored.
Picture 2. Estimation of angle at level 6. The angle is shown in a different direction and is bigger than 90°. Blue shows the actual position (as per the beginning of the task) and red shows 'where it should be position'.
In the estimation of angles category two angles are shown in the fields (Picture 2). The angle can be adjusted with the 'arrow left' and arrow right' keys. Depending on the quality of the solution a red angle is shown (incorrect) or a green angle is shown (correct after the patient has solved the task. The position and size of the angles act
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Spatial Operations
as modifications for the levels of difficulty. Angles bigger than 90° are difficult to estimate.
Picture 3. Estimating relations at level 4. The vessel should be emptied until only half of the liquid is left. The green horizontal shows the recommended level.
In the estimation of relations the patient has to fill (or empty) a given vessel (e.g a jug - fill to 1/2 or fill to 1/3, see picture 3). By using the 'arrow up' key the vessel can be filled. And using the 'arrow down' key the liquid is removed from the vessel. When the patient is happy they press the OK-key to confirm. The green line shows the accepted level (i.e within the tolerance range of 5%). a red line indicates that the patient has guessed incorrectly as in the guess was outside the tolerance level. To asses the quality of the solution the procedure asses the quantity of the liquid in the vessel. The shape of the vessel determines the levels of difficulty. At first the patient works with containers which have square sides. Therefore filling the vessel or emptying the vessel is easier as the proportions are easier to judge. At higher levels of difficulty more complicated shapes are used (e.g. a conical champagne glass). The accepted level is then no longer in proportion to the vessel or to the amount to be filled.
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Training description
4
Picture 4. Estimation of size at level 4. The black frame indicates the size at the beginning of the task and the red frame is the patient's attempt to match the size (to what it should be). In this case the patient has made a mistake.
In the category estimation of sizes, there are two objects to be seen - one in each field. The task is to reduce or increase the size of the object, by using the arrow keys, until both objects are the same size - see (picture 3). In the one dimensional version the patient can increase and/or decrease the size of the object proportionately along the x coordinates or y coordinates. In the two dimensional version the x coordinates are controlled by the 'arrow right' and 'arrow left' keys. Similarly the y coordinates are established by moving the 'arrow up' and 'arrow down' keys. The object is then squeezed or stretched until the patient thinks that it matches the given field size in the field on the left-hand side. Unlike the one dimensional model establishing the size of the object does not occur proportionately. The task is considered to be solved when the given coordinate are within the tolerance range (A green frame will appear). Changing the angles i.e. turning them to 90°, 180° or 270° and changing the objects from symmetric to asymmetric are the modifications which are used to establish different levels. In order to train the short-term memory at the levels 7 - 9 in each category once the patient touches a cursor key the object in the left field disappears. The patient must then attempt to judge the position, angle and size of the objects from memory. When the patient presses the OK-key the object will then reappear and the task can be assessed.
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1.2
Spatial Operations
Performance feedback The quality of the solutions is assessed through the use of the colouerd frames or angles. If the positioning is within the tolerance range (an acceptable guess), then a green frame or angle appears. If the positioning is outside the accepted tolerance range then a red frame or line appears. On the left hand side of the screen a performance column can be seen. With every correct decision (position within the tolerance range) the performance column increases. If the column reaches the top level then the next task will be more difficult. With every incorrect decision (position outside the tolerance range) then the column decreases. Above the column one can see the current level of dificulty for the category which the patient is working on. If the acoustic feedback is activated then an error signal is sounded at every false decision. If there are more than one patients working in the room it is advisable that the acoustic feedback should be deactivated or head phones should be employed. The patient learns how to use the procedure by employing the method of 'learning by doing' which is clarified in the instruction in the RehaCom basic manual.
1.3
Levels of difficulty An adaptive method for the levels of difficult is guaranteed in the procedure. In the section Training tasks the tasks have already been clarified. As there are different categories in the procedure spatial operations then only the level within a given category is relevant. There are 5 categories with 9 levels of difficult in each. If the patient reaches the top level of one category then the training of the next category begins at the lowest level. In this way, springing to easier tasks is compensated by the adaptive qualities of the procedure. If a patient does not achieve an acceptable level within a category then the patient has to continue to practise this level (no springing to a higher level). It is then the task of the therapist to decide as to how the training should continue (i.e. if the tolerance range should be increased). Table 1 to 5 shows the levels of difficult for the categories The level in the first column indicates the level in the therapist menu. The level in the second column indicates the level as per category. Table 1 Levels of difficult for the category estimation of position
Level Level int. Tolerance Memo Specifications 1 1 doubled no guiding marks 2 2 simple no 3 3 doubled no without guiding marks 4 4 simple no 5 5 doubled no irritating lines
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Training description
6 7 8 9
6 7 8 9
simple doubled simple simple
no yes yes yes
6
guiding marks without guiding marks
Table 2 Levels of difficult for the category estimation of angles
Level Level int. Tolerance Memo Specifications 10 1 doubled no angles < 90°, the opening direction of the angles is the same for 'given' and the 'should be' angles 11 2 simple no 12 3 doubled no angles < 90°, the opening direction varies 13 4 simple no 14 5 doubled no angles >90°, the opening direction varies 15 6 simple no 16 7 doubled yes angles < 90°, the opening direction of the angles is the same for 'given' and the 'should be' angles 17 8 doubled yes angles <90°, the opening direction varies 18 9 simple yes Table 3 Levels of difficult for the category relations.
Level 19 20 21 22 23 24
Level int. 1 2 3 4 5 6
Tolerance Specifications doubled vertical vessel walls. Filling only 1/2 simple doubled vertical vessel walls. Filling 1/4, 2/3, 1/2 etc. simple doubled any type of vessel walls. Filling as per Level 3 simple
Table 4 Levels of difficult for the category estimation of sizes (1 degree of freedom).
Level
Level int.
25 26 27 28 29
1 2 3 4 5
doubled simple doubled simple doubled
no no no no no
30
6
simple
no
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Tolerance Memo
Specifications symmetric pictures asymmetric pictures asymmetric pictures turned to 90°, 180° or 270°
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Spatial Operations
31 32 33
7 8 9
doubled simple simple
yes yes yes
symmetric pictures asymmetric pictures turned to 90°, 180° or 270°
Table 5 Levels of difficult for the category estimation of sizes (2 degree of freedom).
1.4
Level
Level int.
Tolerance Memo
34 35 36 37 38
1 2 3 4 5
doubled simple doubled simple doubled
no no no no no
39 40 41 42
6 7 8 9
simple doubled simple simple
no yes yes yes
Specifications symmetric pictures asymmetric pictures asymmetric pictures turned to 90°, 180° or 270° symmetric pictures asymmetric pictures turned to 90°, 180° or 270°
Training parameters In the Basic manual RehaCom general hints are given about the training parameters and their effects. These hints shall be taken into consideration in the following.
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Training description
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Picture 5. Parameter-Menu.
Current level of difficulty / Category: The level of difficulty can be set up in the 5 categories(see training tasks) from levels 1 to 9 (and in estimation of relations from 1 to 6). Please do not forget that the individual categories are added together in the parameter menu; i.e. for example, if you want to work in level 4 of the estimation of relations (fill), you must set up the level of difficulty 22 (9+9+4) (see the table - structure of the level of difficulty column 1). Duration of the training/Consultation in mins: A duration time of 25-30 minutes is recommended. Only after a task is completed should it be checked to see that the duration time is okay. Continue to the next level: The next level of difficulty is set up for the patient when the patient reaches the top of the performance column on the left. In order to achieve the level 'continue to the next...' an established number of tasks must be solved in a row. Incorrect decisions lead to drop in the performance column. They must be compensated by correct decisions. Repeat the previous level: The previous level is set up for the patient if the established number of tasks has not been solved in a row, i.e. the performance column level disappears.
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Spatial Operations
Tolerance: Tolerance defines a field in which a positioning is evaluated as correct - the 'should be' position. When tolerance is decreased the task be comes more difficult. For patients with problems in spatial perception, the tolerance should be increased in order to increase motivation and encourage some degree of success at the beginning of the training. The 100% value of tolerance is defined differently for the categories. During the position estimation, the width of the field corresponds to 100%. During the angle estimation, 90° are defined as 100%. During the size estimation, the size of the 'should be' subject corresponds to 100%. During the relation estimation, a full vessel to 100% is defined. Acoustic feedback: See the section performance feedback. Memory: In addition at level 7 and up in the category estimation of relation the short-term memory is trained. For patients for whom a training of memory is not indicated, the option should be disregarded. After successful training of level 6 then level 1 of the next category should be set up for these patients. With a new set up of the training the following defaults are automatically installed: Duration of training/Consultation level of difficulty Category continue to the next level repeat previous level Tolerance Acoustic feedback Memory
1.5
25 Minutes 1 Position 20 5 5% on on
Data analysis The various possibilities of analyzing the data in order to find strategies how to continue the training are described in the Basic manual RehaCom. In the pictures as well as the tables, alongside the setting for the trainings parameter, the following information is available: Level Training time(effective) Pauses Category
Current level of difficulty Effective Training time Number of breaks by the patient Category (Position, Angle, Size 1, Size 2 and Filling)
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Training description
Category level Number of attempts Number of errors Quartile 1 Tolerance x Quartile 1 Tolerance y Median Tolerance x Median Tolerance y
Quartile 3 Tolerance x Quartile 3 Tolerance y
10
Level of difficulty within each category (1-9(6)) Number of solved tasks until level change Number of errors Precision of positioning quartile 1 (x- coordiante) Precision of positioning quartile1 (y- coordinate) Median for the deviation from the 'given' and 'should be' [%] (x- coordinate) Median for the deviation from the 'given' and 'should be' [%] (y- coordinate) (not used in the categories angle and relations) Precision of positioning quartile 3 (x- coordinate) Precision of positioning quartile 3 (y- coordinate)
In this way it is possible to give the patient advise on their short-comings.
2
Theoretical concept
2.1
Foundations One defines visual spatial performance as perception abilities which require a visual comparison of spatial stimulus without manual effort from the patient. In contrast to this, spatial-constructive performance demands this exact manualconstructive component to be under visual control (cf.Kerkhoff, Münßinger & Marquardt, 1993). The precondition for visual-constructive performance is an intact spatial-operation perception. The visual-spatial perception is a component of elementary visual efficiency and consists of the following basic functions (Kerkhoff, 1988): Visual spatial perceptive performance Distance estimation (horizontal / vertical), Estimation of distances, Estimation of relative positions, Estimation of angles, Main visual spatial (subjective perpendicular / horizontal), Subjective straight ahead direction / subjective middle. Visual spatial operation mental rotation, Transformation performance (measure, angle, size transformations, tasks with varied spatial systems). In contrast to the visual spatial perception, with visual room operations it is a question of cognitive services which require a intermediate step separated by the stimulus material.
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Spatial Operations
Basic functions of the visual spatial perception like estimating lengths and distances, the size and position of objects and angles as well as recognition of main spatial directions are in everyday life, in particular in traffic, of great relevance. From the straight line directing while walking to fine motor adjustment while reading, (which are dependent on the elementary aspect of visual performance), spatial disturbances can affect all practical everyday activities which require a visual spatial operation or a partial spatial-constructive performance. Patients with technical professions who suffer from these deficits will often loose their positions and therefore are clearly more affected than others. Several investigations into the predicators of the rehabilitation (v. Cramon & Zihl, 1988; Kerkhoff & Marquardt, 1995) showed a statistical connection between visualconstructive and visual-spatial problems and impaired ADL-activities (activities of daily living); where a causal relationship was discussed. This is not surprising when one only considers some examples from everyday life, where there is dependency on an intact visual-spatial perception and/or spatial-constructive subsets of the system: Dressing Folding of washing Estimating and separating amounts Decorating a table Tidying Grabbing objects Estimating the depth of steps/stairs Reading of plans or sketches The filling in of forms and documents Maintain lines and columns while drawing Finding the way Wheel chair navigation More complex disturbances to perception are often a result of disturbances to the elementary visual efficiency, like the depth perception. Loss of depth of vision means that everything appears to be flat (e.g. a dice appears to be a six cornered object). The trouble with disturbances to depth of vision is that it is sometimes combined with changes in the perception of the sizes of objects (Micropsia and Macropsia), however, it can also affect the appearance of objects and faces.The latter is also to be seen in the case of cerebral of amblyopia, problems with the shaping and colour perception which occurs in most cases after post-chiasmatic injuries. A damaged visual localisation of stimulus affects the appraisal of distances. The patient then over- or under-estimates distances. Impairments the appraisal of the main visual spatial directions leads, in most cases
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Theoretical concept
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to a shift of the subjective vertical, horizontal and of the straight ahead directions. In the case of unilateral lesions, upright and straight line direction perception is normally shifted to the opposite side of the area of brain damage - the horizontal perception is mostly displaced equally to the upright axis. (v. Cramon, 1988). Visual-spatial orientation problems express themselves in the loss of the spatial organization of a pattern of stimuli, which is often coupled with "difficulties in measuring" through impairments in the recognition or localising of spatial positions and regions as well as the ability for spatial imagination. Visual spatial perception deficits are often correlated with visual-constructive impairments, (see Cramon, 1988)i.e when we are referring to a causal relationship. Spatial-constructive problems or constructive apraxia refer to the decreased ability or inability in patients, with brain damaged, to draw 2- dimensional or 3dimensional shapes and figures correctly and/or to join elements of a figure together to form a total figure. While processing such tasks, length and angular distortions, changes in size or the erroneous ordering of individual elements of a total figure can occur, which are also sometimes reconstructed in a completely fragmented manner. Also independent constructive performances like the drawing of a spatial series, for example a room with described/defined deficits is no longer possible. An innate medical history of the complaints is reasonable only with patients without visual neglect, anosognosia or anosodiaphoria. For the patient group with reduced insight Kerkhoff & Blaut have developed (1992, cf.Kerkhoff, Münßinger & Marquardt, 1993) a clinical hetero-medical history curve. For the diagnosis of performance in visual-spatial perception, the following tests are suitable, for example line orientation, line halving, spatial sub tests in intelligence tests or the computerassisted procedure is also suitable(cf.Kerkhoff, Münßinger & Marquardt, 1993). The latter registers elementary performances of the visual spatial perception in contrast to all other procedures. The tests for visual object and spatial perceptions (VOSP, Warrington & James, 1992) also tests the visual basic functions problems which often occur together with constructive apraxia and are possibly its cause. For the diagnosis of the spatial-constructive troubles - the free copying of geometric or other patterns, the copying of perspective drawings or the drawing test according to Grossmann (1988) are suitable. The mosaic test or the sub test 'figure placing' from the Hamburg change/switching intelligence test (HAWIE-R, Tewes 1991),der Benton-Test (Benton, 1981) or the Rey-Osterrieth-Figur (Osterrieth, 1944) are also suitable as diagnostic instruments. However there are in part particular aspects; partial combination of many aspects of more complex functions registered. i.e. several spatial basic functions are tested simultaneously.
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2.2
Spatial Operations
Training aim The aim of the training procedure Spatial operations is the specific training of two dimensional visual spatial basic functions like the estimation of angles, the position of objects as well as the estimation of sizes and surfaces. In the case of these tasks, the importance of the relevance to everyday life was considered, like the filling of vessels of different forms. In addition, a therapeutic benefit in relation to more complex problems is expected with an improvement in the visual-spatial basic functions. Each single procedure concentrates on a component visual-spatial basic functions while the involvement of other intellectual abilities is greatly reduced. It is to be expected, that the improvement in the visual spatial basic performance has a favourable effect in the ADL- area (Activities of Daily Living) , since problems with spatial perception and spatial operations hinder numerous practical activities, in particular, if these activities depend on a precise visual-motor co-ordination. Under the premise of maximum specificity of therapy,one should always precede with a differentiated problem specific neuro psychological diagnostic (for specific tests see basic functions). In consideration of the lack of methods to diagnose and handle visual spatial perceptions and the disturbances to spatial operations, the procedure also offers the possibility of a more differentiated recording of the underlying problems for above-mentioned basic functions as well as a continuous control/observation. For additional training, the RehaCom-procedures visual-constructive abilities (visual-motor co-ordination (WISO) and Two-dimensional operations (VOR1) can be used.
2.3
Target groups The procedure is recommended for patients who suffer from impairments to their visual spatial perception and their spatial construction. It is mainly patients whose brain has been damaged after posterior and/or parieto-occipital uni- and bilateral lesions or injuries to the visual system, who are affected. In particular visual-spatial problems often occur after right-hand parietal lesions. The visual-spatial functions can be affected by injuries to the brain which have different origin (insult, Hypoxie, SHT, tumours). Additional patients who will also benefit from this training are patients with visuo-constructive problems, visual neglect, field of vision problems and patients with impairments to their objective perception due to deficits in their elementary visual capabilities. For patients with to the right hemispheric injuries to the brain there is a clear indication of a covariance between impairments to the visual spatial perception and visual constructive problems (cf.Kerkhoff, 1988). Also a decreased ability for mental rotation, which is observed after right- and left hemispheric posterior lesions, impairs
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Theoretical concept
14
the visual constructive performance. In addition to a half-side paralysis, visual-constructive and visual-spatial problems is the most important predictor for the rehabilitation process in patients with injuries the right hemi-sphere of the brain(cf.basic foundations). It was repeatedly found, that in particular patient groups with deficits of visual perception to the left hemispheric Hemiplegiker (cf.Kerkhoff, 1988) a more unfavourable rehabilitation process was observed. In addition the training tasks at level 7 train the visual memory (except in the category of estimation of relations). The procedure can be used with children from the age of 8 and upwards. In this case appropriate language suitable to the linguistic range of the average 8 year old should be used. A therapist should also be present.
2.4
Bibliography Benton, A.L. (1981): Der Benton Test. Handbuch. Bern: Huber. Boettcher, S. (1991): Zusammenhänge zwischen visuell-räumlichen und visuokonstruktiven Leistungseinbußen bei Patienten mit Hirnschädigung und psychiatrischen Patienten. Zeitschrift für Neuropsychologie, Vol. 2 (1), S. 3-13. von Cramon, D. Y. (1988): Sehen. In: von Cramon, D. Y. & Zihl, J (Hrsg.). Neuropsychologische Rehabilitation. Berlin: Springer-Verlag, S. 105-129. Grossmann, M. (1988): Drawing deficits in brain-damaged patients' freehand pictures. Brain Cog., Vol. 8, S. 189-205. Hartje, W. & Sturm, W. (1989): Räumliche Orientierungsstörungen und konstruktive Apraxie. In: Poeck, K. (Hrsg.): Klinische Neuropsychologie. Stuttgart, New York: Thieme Verlag. Kerkhoff, G. (1988): Visuelle Raumwahrnehmung und Raumoperationen. In: von Cramon, D. Y. & Zihl, J (Hrsg.): Neuropsychologische Rehabilitation. Berlin: Springer-Verlag. S. 197-214. Kerkhoff, G. (1989): Störungen der visuellen Raumwahrnehmung bei Patienten mit Hirnschädigung. Frankfurt am Main: Haag und Herchen Verlag. Kerkhoff, G. & Marquardt, C. (1995): Quantitative Erfassung visuell-räumlicher Wahrnehmungsleistungen in der Neurorehabilitation. Neurol. Rehabil., Vol. 2., S. 101-106. Kerkhoff, G., Münßinger, U. & Marquardt, C. (1993): Sehen. In: von Cramon, D.Y.,
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Mai, N, & Ziegler, W. (Hrsg.): Neuropsychologische Diagnostik. Weinheim: Chapman & Hall. Marquardt, C. & Kerkhoff, G. (1994). VS - Computerunterstützte Erfassung visuellräumlicher Wahrnehmungsleistungen. Version 2.0. Bedienungshandbuch. München. Münßinger, U. & Kerkhoff, G. (1993): Therapie räumlich-konstruktiver und räumlichvisueller Störungen bei hirngeschädigten Patienten. Praxis Ergotherapie, Vol. 6. S. 215-221. Osterrieth, P.A. (1944): Le test de copie d'une figure complexe. Arch. Psychol., Vol. 30, S. 206-353. Poeck, K. (Hrsg.) (1989): Klinische Neuropsychologie. Stuttgart, New York: Thieme Verlag. Tewes, U. (Hrsg.) (1991): Der Hamburg-Wechsler-Intelligenztest für Erwachsene. Huber: Bern. Warrington, E.K. & James, M. (1992): VOSP - Testbatterie für visuelle Objekt- und Raumwahrnehmung. Thames Valley Test Company (Deutsche Übersetzung).
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Index
Index
estimation of relations 1, 5, 7 estimation of sizes one dimensional estimation of sizes two dimensional
10, 13
field of vision 13 foundations 10 frames green/red 5
-Gguiding marks
level of difficulty 5 levels of difficulty 5, 9 limited number of errors
basic functions 1 basic performance 10 bibliography 14 brain damage 13
13
-D-
median 9 medical history memory 7 mental rotation
data analysis 9 description of the training 1 disturbance in performance 10 disturbances in orientation 10 duration of training/Cons. in min 7
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10 10
-Nneglect 13 neuropsychological diagnostic
-Oorientation
error 9 estimation of angles 1, 5 estimation of positions 1, 5
7
-M-
-C-
-E-
1
-L-
-B-
category 5, 7, 9 closeness to everyday activities conceptual definition 10 continue to the next level 7 continuous consultation 9 continuous data analysis 9 cortex areale 13 current level of difficulty 7
1, 5 1, 5
-F-
-Aacoustic feedback 7 activities of Daily Living (ADL) adaptive 5 aetiology 13 aim of the training 13 alternative procedures 13 angle 7
16
7
-Ppauses 9 performance column 5 performance feedback 5 position 7 predictor 13 process of rehabilitation 13
10, 13
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17
visuo motor co-ordination 13 visuo-motoral disturbances 10
-Qquartile
9
-Rrepeat previous level
7
-S'Should be' position 5 size one dimensional 7 size two dimensional 7 sonstructive Apraxia 10 spatial operationes 5 spatial positions 1 spatial-constructive disturbances spatial-constructive performance specifics of the training 13
10, 13 10
-Ttarget groups 13 theoretical concept tolerance 9 tolerance area 7 tolerance range 1, training aim 13 training categoy 7 training parameter training parameters training task 1 training tasks 1 training time 9
10
5
7 7
-Vvasic performance 13 visua spatial perception 13 visual Deficits 13 visual memory 13 visual short-term memory 1, 5 visual spatial operationen 10, 13 visual spatial perception 10, 13 visual spatial performance 13
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