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Cognitive therapy and brain training

Saccadic Training

www.rehacom.com


Cognitive therapy and brain training by HASOM ED 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 Description of the training

1

1 Training ................................................................................................................................... tasks 1 2 Performance ................................................................................................................................... feedback 3 3 Levels ................................................................................................................................... of difficulty 4 4 Training ................................................................................................................................... parameter 7 5 Data ................................................................................................................................... analysis 11

Teil II Theoretical concept

14

1 Basic ................................................................................................................................... foundations 14 2 Aim ................................................................................................................................... of the training 16 3 Target ................................................................................................................................... groups 16 4 Bibliography ................................................................................................................................... 16

Index

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1

Saccadic Training

1

Description of the training

1.1

Training tasks The RehaCom training procedure Saccadic Training is a very realistic type of training. In maintaining this closeness to reality the patient can maintaine and improve on their level of motivation. In the training the patient is "standing on the side of a mountain", observing the horizon (see Picture 1). The patient's point of view is drawn towards a focus point a yellow son, which appears in the middle of the screen but can also be positioned on the edge of the screen. The patient's task is to recognize objects which appear on the horizon and confirm their appearance by pressing the appropriate key on the RehaCom panel. Objects which are easy to differ are used: silhouettes of vehicles and animals (high level of contrast - easier) and drawings (with a low level of contrast - more difficult). The objects appear on a line (horizontal line) which separates the countryside from the light blue sky. This line serves as "guide" for the patient as he searches for objects. By supporting the search for objects with a guide line, the procedure draws on similarities with other procedures for saccadic training and field of vision development.

Picture 1. The training where the horizontal line is being used as a guide. (Point of focus - middle - large object, a simple rolling horizontal line)

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Description of the training

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At higher levels the horizontal line is not used to guide the patient. At the higher levels an object has to be spotted in a night sky (see picture 2). At the bottom of the screen a sky line can be seen. As a point of focus the a whit moon is used. In this night sky flying objects appear: Helicopters, aeroplanes, rockets and zeppelins etc. The procedure works in an adaptive way.

Picture 2. Training "Night sky" When working with the procedure at higher levels a number of different tasks, which can be set up or varied in the parameter menu, are presented to the patients. Each task is dependent, in various phases, on the chosen training mode. Focus point "Middle", "Double object" not active 1. The patient focuses on the sun or the moon and waits for an acoustic signal after which an object appears on the left or the right of the sun and/or moon. 2. The patients task is to clarify if the object appeared on the left or the right of the focus point. He does this by pressing the "arrow left" or "arrow right" keys on the RehaCom - panel. The object then disappears from the screen. Focus point "left" and/or "right", "Double object" not active: 1. The patient focuses on the sun or the moon and waits on an acoustic signal. After this an object is shown, with a likelihood of 50%, contra laterally to the focus point or no object is shown.

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Saccadic Training

2. When an object appears the OK-key has to be pressed immediately. Then the object disappears from the screen. If no object appears then none of the keys should be pressed. "Double object" active: 1. The patient focuses on the sun or the moon and waits on an acoustic signal. After this and with a likelihood of 50% 2 objects are shown on the screen, with approx. 25% likelihood for 1 object and 25% for none. 2. The patient should react when he recognizes 2 objects. In all other cases he should not react at all. Here higher demands are made on the patients scanning ability. The reaction time can be set up by the patient in the parameter menu. Patients are notified of their errors visually. A new landscape appears then appears and the course of events begin again and the task is re-defined by the item distance (+-50%). After processing the determined number of items tasks, the level of difficulty is then ended. The patient's performance is evaluated and the patient is informed as to whether he should continue with the same level of difficulty or switch to a higher or lower level of difficulty. If required a method of control is available. This alters the sun from yellow to red in approx. 10 % of every tasks. The patient must be acknowledge this alteration by immediately pressing the OK-key. The input method has been deliberately designed to be a simple as possible. In general only the OK-key has to be used. Only when it comes to the task Focus point "middle", "Double object" not active are the keys "arrow right" and "arrow left" required to indicate direction. In the instructions short sentences are used to clarify the training to patients. The patients quickly gathers how the system works. However, it is recommended that with patients who suffer from visual disabilities, a therapist should be available at the beginning of the training.

1.2

Performance feedback As with all the RehaCom procedures a performance feedback facility is available at all levels. If the patient makes and incorrect decision or if the patient reacted when no object was shown, a striking, large, red reference field always appears with the denotation "incorrect", as visual feedback. Correct decisions are not displayed. If a patient reacts in the inter stimulus interval an error tone is sounded. After completion of a each level the correct number of decisions is then calculated

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Description of the training

4

as a percentage and it is then established as to whether the patient should change to a different level of training. In addition, there is also a verbal feedback facility which sounds words of encouragement. If the patient reacts too slowly (i.e exceeds the max. reaction time) a piece of advice "You have to work a bit faster" is displayed.

1.3

Levels of difficulty Modifications to the level of difficulty are as follows: different types of horizons, different degrees of size in the objects, the movement of the object and/or its lack of motion, the distribution of the objects according to the visual angle degree and different types of contrast between the object/background. 5 horizon forms, with increasing difficulty, are used. In each case, these require a particular type of scanning ability: horizontal straight, inclined straight (defined in point 2), simple rolling line (defined in point 3), double rolling line (defined in point 5), sky (defined in the upper 2/3 of the screen) and no horizon. The countryside below the horizontal line is not structured in the lower levels and changes between two different blue shades (sea), green shades (meadow), brown shades (soil) and yellow shades (sand). The sky is displayed by one of three different blue shades. The details of the countryside are deliberately simplistic so as not to distract from the main goal -the search for objects on the horizontal line.

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Saccadic Training

Picture 3. Training surface in the different levels of difficulty (plain, textured, silhouetted and pictured display). The objects have level specific sizes and colours: large, medium and small. The contrast is defined as follows: high: black object in front of a light blue background; or white object in front of a night sky and low: the colour of the object is difficult to determine in front of a realistic background (clouds) and/or black night sky (Photos).

Structure of the level Level 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

Picture size large large large large large large large large large medium medium medium medium medium medium medium medium

Horizontal horizontal line simple mountain mountain simple mountain mountain simple mountain mountain silhouetted silhouetted simple mountain mountain silhouetted

Movement Contrast Visual Angle Textur Degree e with high 4° with slight 4° with high 4° with high 4° X without slight 4° without slight 4° without high 4° X without slight 4° without slight 4° with high 8° X with slight 8° with high 8° without slight 8° X without slight 8° without high 8° X without slight 8° without high 8°

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Description of the training

18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

medium small small small small small small small small small small large large medium medium small small

silhouetted simple simple mountain silhouetted silhouetted mountain mountain mountain silhouetted silhouetted without without without without without without

without with with with with with without without without without without with without with without with without

slight high slight slight high slight high slight slight high slight slight slight slight slight slight slight

8° 12° 12° 12° 12° 12° 12° 12° 12° 12° 12° 16° 16° 16° 16° 16° 16°

6

X X X X -

-

from level 29 the axis is completely waived and the procedure changes to the pictured background In order to assess the performance one must differ between four types of error: position error (only with Focus point "middle", Double object not active) irretrievable error fixation error and time error. Position errors occur when the incorrect directional (e.g. Object appeared on the left and the keys "arrow right" was pressed). Irretrievable errors are also registered with: Double object not active and Focus point not "centre": if the OK-key was pressed although no object was shown. Double object active: if the OK key was pressed although a second object was not shown. Appears the fixation control and no reaction is made within the max. reaction time, it is rated as fixation error. Time errors are counted if the latest reaction time exceeds the max. reaction time. When the item change is activated after an optimal reaction time, a missing reaction within the optimal reaction time is rated as a time error.

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1.4

Saccadic Training

Training parameter 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.

Picture 4. Parameter-Menu. Consultation duration in min: A training period of 20 to 30 minutes is recommended. Continue to the next level: After the patient has worked through the established amount of items, then the number of correct decisions is calculated as a percentage. The total number of correct decisions is looked at in relation to the total number of items. If the percentage calculated exceeds the established level for "continue to the next level" then the patient may continue to the next level of difficulty.

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Description of the training

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Repeat previous level: If the percentage level is below the established level for "repeat previous level" then the patient falls back to lower level of difficulty. If the patient falls between these previously mentioned levels then a similar level is repeated. Number of Items: The number of tasks (items) per level is clearly set. Inter stimulus interval: The time between the patient's reaction to an object and the appearance of the next object is clearly established. The time span between the appearance of objects is stochastically set up in intervals of +-50%. If the distance between the appearance of objects is increased, then the patient has more time to prepare himself for the next task. For patients with a high performance level, reducing the distance between the appearance of objects acts as an additional stress factor. The number of the tasks to be processed in the given period of time is then increased. Maximum reaction time: The maximum time which is available for a reaction to the appearance of an object is clearly defined. The measurement of the reaction time begins the moment an object appears on the screen. The maximum reaction time can be increased (e.g. by 10 sec) for patients at a lower performance level. Here the focus of the training is on the recognition of objects. The time stress factor is excluded. Performance is assessed on the basis of "correct decision" only. On the other hand, for patients with a high performance level, reducing the max reaction time can also act an additional stress factor. Optimal reaction time: The time, which is available for an optimal reaction, is clearly defined. The measurement of the time starts like the maximum reaction time, when the object appears on the screen. In the performance evaluation, an exceeding of the optimal reaction time is not considered as an error. It is noted as an additional information. Exception forms the item change after optimal reaction time, because after a change of the item to the next, no reaction can occur on this item. Focus point place: In choosing the focal points one must consider that during the training the screen is divided into 3 identical fields. In the first mode the focus point is in one third and the object in another. In the mode Double object, the focus point is in one third and objects appear in the other two thirds. The choice of the focal point has an influence on the strategy which should be taken. If the focal point "middle" is chosen than objects appear to the left and the right of the focus point. The angle for the saccadic training is then limited to half the width of the screen. This type of training is recommended for haenmian optical patients. If the focal point "left" or "right" is used then the objects appear in a contra lateral manner. The saccadic training angle, when compared to the Fixation "middle" becomes larger and is only limited by the

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Saccadic Training

width of the screen. This training is recommended for patients who suffer form Neglect and the training can be focused on the particular side or direction where the neglect has most effect. New from version 6.2: When setting "left" or "right", 10% of the item are displayed in the strong area. I.e. at fixation point left, 10% left of this and at fixation point right, 10% right of this. Item change automatically to: If this setting is enabled, it is not longer waited for the input of the patient, but the next task starts automatically after the expiry of the chosen setting option. Depending on which of the two options (optimal reaction time or max. reaction time) was selected, the change is caused after the expiry of the optimal or the maximum reaction time. If the change is set after optimal reaction time, the evaluation system evaluates the missing reaction during the optimal reaction time as an error, because after the expiry of the optimal reaction time the item change takes place and no further reaction to the previous item can occur anymore. The missing reaction is noted both at the optimum and at the maximum reaction time as omission. Focus point control: When the focus point control is activated, the sun alters from yellow to red and/or the moon alters from white to yellow, with a likelihood of 10%. The patient must press the OK-key when these alterations occur. Naturally he/she can only do this when he/she observes the sun or the moon. If the patient doesn't notice these changes in the color then a focal point failure is registered. The patient is then informed as to the error which has occurred. A piece of advice appears on the screen "Please look at the sun". The focal point control errors are not counted in the assessment which determines whether the patient should continue to the next level or repeat a previous level. However they appear in evaluation for control purposes. The Focus point control should only be activated when the patient clearly understands the training process. Otherwise, this can lead to irritation which can complicate training. Double object: If the "double object" option is activated then the patient should only react when 2 objects appear on the screen. This places a high demand on the patients scanning abilities. Moving objects: An additional help offers the option moving objects. Here, the objects move along the horizon line or free across the screen. The corresponding levels with moving objects are shown in the Level structure. Optokinetic stimulation: Optokinetic stimulation with pursuit eye movements (hereafter abbreviated as PEM) is an effective method for the therapy of visual neglect (Kerkhoff 2000; Kerkhoff et al. 2006). Scientific studies prove, that the presentation of many visual stimuli on the

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Description of the training

10

screen, which all move towards the neglected side, can reduce the visual neglect significantly and durably. During the PEM-therapy point patterns are shown which move with constant speed of 5-50° to the left in the neglected half of the room. The clients are encouraged to follow the dots with their eyes, which means they have to make pursuit eye movements towards the neglected half of the room. By the flow movement of small elements, a so-called deadweight is promoted. The direction of movement depends on the patient-specific setting. This can be found in the area clients -> edit, in the tab file. There the category hemianopia can be chosen individually for client. Depending on the disorder, the PEM-movement is now adjusted within the module. To define the speed of the elements, the values screen width and distance to the screen are consulted. The smaller the screen at the same distance, the slower is the speed of the dot pattern. In a standard ratio 1x screen width to 2x distance to the screen (1:2), i.e. when the screen gets larger, the speed slows. It also slows when the distance gets smaller (for example 1:1). Additionally the speed can be adjusted individually by using the buttons 1 and 2. Distribution on visual angle degree: If this option is enabled, the stimulation objects are distributed with a predefined visual angle degree around the fixation point. The respective degree values can be found in the Level structure. The distribution on visual angle degree can be enabled only for the fixation point middle, because only in this setting variant a consistent and on the screen visible distribution can be guaranteed. The size of the visual angle degrees is calculated by the screen width and the distance to the screen. Is this not known, a ratio of 1:2, is used as a basis. Screen width: The screen width is a necessary setting for the optokinetic stimulation and the distribution to visual angle degree. It is given in mm. It is defined by the width of the output medium (monitor, laptop, projector etc.), whereby here the active part of the screen is meant. From the there set value and the value for the distance to the screen, the flow movement for the optokinetic stimulation and the distribution by visual angle degree is calculated. If the measure is not known, the field can be skipped and RehaCom automatically adjusts a size with the ratio of 1:2 (screen width : distance to screen). For this the value zero must be entered for both the screen width and the distance to the screen. Distance to the screen: This value defines the distance from the patient to the actual output medium and is also given in mm. It is crucial for the accurate calculations of the visual angle degree with the setting distribution on visual angle degree and the optokinetic stimulation. Default values: When newly defining a training, the system automatically uses the following default values:

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Saccadic Training

Duration of consultation: 25 minutes Level up: 90% Level down: 70% Number of Items: 30 Inter stimulus interval: 3000 ms Optimal reaction time: 500 ms Maximum reaction time: 4000 ms Fixation point: Middle Item change automatically to Off (opt. reaction time, (on, max. reaction time) off) Fixation check: Off Double object: Off Optokinetic stimulation : Off Moving objects: Off Distribution on visual angle degree:Off Screen width: 0 mm Distance to screen: 0 mm

1.5

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 Number Stimuli Number errors direction le. and ri.

Omissions le. and ri. Number errors irretation Number total errors Reac.-time Quartile1 Reac.-time Median

Current level of difficulty Effective Training time Number of pauses by the client Number of stimuli Number of incorrect direction choices left / right (only during focus point "middle", "Double object" not active, from ver. 5.3 separate collection of data according to left and right side stimuli) Omissions left / right There was a reaction, although the required number of objects was not shown Total number of errors without double errors (a late additional reaction whereby the wrong key was pressed does not count as a double error) Reaction time quartile 1 [ms] Median of all reaction times [ms]

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Description of the training

Reac.-time Quartile 3 (le.) and ri.

12

Reaction time quartile 3 [ms] In the measurement of reaction time only the correct reactions are counted the error reactions are not counted. from ver. 5.3 separate collection of data according to left and right side stimuli Number errors reaction time Within "max. reaction time" - there was no reaction (le.) and ri. On left or right side Opt. react. time not fulfilled The optimal reaction time was not fulfilled. le. and ri. Num. fixation checks Number of fixation controls Number errors fixation Number of errors during fixation control Number reac. inter.stim. Number of reactions during interstimulus interval Number correct reactions The reaction was given within the adjusted reaction (top left, top right, bottom left time. and bottom right) The reactions are divided by quadrants, depending on where the item appears. Reaction time median Median of all reaction times for each quadrant. (top left, top right, bottom left and bottom right) No. correct le. half / right halfNumber of correct reactions left half / right half Correct % le. half /right half Correct reactions left half / right half [%] Omissions Total number of omissions Correct % double obj. Number of correct reactions with double object enabled Reac. time median double Median of all reaction times of correct reactions with odouble object enabled b j . In this way it is possible to give the patient advise on their short-comings. (Results with "ri." (right) are 0 (zero): if focus point place is not "middle", or if trainingmode is "Doubleobject", or if result data are from training with version before 5.3.)

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Saccadic Training

Picture 5: Performance graph and error distribution in a level. In the upper region of the window the patient data, the level and the parameter settings are shown. Directly below are single information about the error distribution. The reaction time for each item can be taken from the represented performance graphic. On the y-axis the reaction time in ms, and on the x-axis the associated item number is given. If there was an incorrect reaction in a task, it is marked with a red bar. Correct reactions are marked with a yellow bar. For the fast assignment to the associated quadrant are abbreviations above the reaction shown. The common abbreviations (TL: top left, TR: top right, BL: bottom left, BR: bottom right) apply here as well. Bars without quadrant abbreviations are representing the fixation control. If these reactions have taken place in the specified time frame they are marked by the corresponding color. If the setting is double object, there is no quadrant mark shown, because the representation of the items is not limited to one quadrant.

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Description of the training

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Picture 6: Quadrant overview and quadrant analysis in a level. Above the quadrant matrix the quadrant analysis of the single quadrants can be seen. The number of correct reactions is shown, as well as the median of all reaction times in the respective quadrant. In the graphic are the fields, in which an item appeared, marked colored. Depending on the set reaction time the color distribution from 0 to the maximum reaction time is composed as follows: green, yellow-green, yellow, orange for times below the maximum reaction time and black for omissions.The fixation point is marked by a clearly visible point. Depending on the set fixation place for the chosen level, it is positioned on the left, in the center or on the right. In addition to the fixation place "center" are the positions of the visual angle drawn. Thus, weaknesses of the reaction time in a certain quadrant can be recognized by the colored-markers. Particularly omissions (not reactions) catch the eye by their black color immediately.

2

Theoretical concept

2.1

Basic foundations Two main reasons for a loss in the visual exploration (or which have a negative influence on visual exploration), in one or in both halves of the brain caused by injuries to the brain, lead to:

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Saccadic Training

impairments to filed of vision and visual neglect. Impairments to the field of vision are responsible for the highest cases of sensory disturbances after injuries to the brain. The restrictions in the visual range caused by deficits to the field of vision generally lead to a reduction in visual exploration. Clinical discoveries have shown, that only 9% of the patients with homonymous Hemianopsia and approximately 15% of the patients with Quadrantenanopsia (total group 10%) show a residual field of vision of more than 10% and therefore have a presumably sufficient visual range and an undamaged visual exploration. On the other hand, patients with a residual field of vision under 10 degrees have been shown to have a clear disability caused by the loss in the field of vision. The reason for this is that the spontaneous eye and head movements do not compensate for what is lacking in the field of vision. (Zihl & von Cramon, 1986). Patients with unilateral Neglect, according to definition, are incapable of reacting to stimuli which present themselves in a contra lateral position to those areas in the brain where the lesion occurred (Heilman, 1985). These patients are greatly affected by this in all areas of their everyday life. As a result, all aspects of these patients everyday lives are greatly affected. They find it difficult to negotiate their general environment, bumping into objects on their visually weak side and injuring themselves, as they are incapable of registering any sort of a threat on this side. Patients with unilateral Neglect are also greatly restricted, because they, in the case of simultaneous Stimulation, both field of sight halves, are incapable of reacting to contra lateral Stimuli, when the ipsi-lateral is stimulated at the same time. This is known as the extinction phenomenon. (Heilman, 1985, Poeck, 1989). As most problems occurring in connection with unilateral Neglect can be traced back to visual degradation phenomena, the emphasis in the training is on a purposeful functional training of compensatory strategies in order to improve the visual exploration(Säring, 1988). Due to the everyday relevance and nature of these abilities, which are damaged by hemianoptical impairments and Neglect, the necessity for compensatory training is then quite clear. A possible treatment of the disturbances to visual exploration lie in the enlargement of the saccadic searching motion(scanning ability) of the eye. An increase in the amplitude of the scanning ability leads to a noticeable increase in the searching areas of the affected half of the visual field. (Zihl, 1988).

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Theoretical concept

2.2

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Aim of the training The saccadic training procedure was formed to help patients with deficits in Neglect, Hemianopsia or to help patients with general restrictions in their field of vision or in their visual efficiency. The aim of the training is therapeutic treatment of visual Neglects and/or an enlargement in the patient's field of vision.

2.3

Target groups The training is recommended for patients who suffer from impairments to their visual exploration as a result of deficits to their field of vision and visual neglect. By using not verbal material, one can also work on restrictions in language and the patients comprehension of vocabulary. It appears that the training can also be used with children from the age of 8 and up. With regard to the previous point more information has yet to be gathered.

2.4

Bibliography Heilmann, B. M. (1985). Neglect and related Disorders. In Heilmann, B. M. & Valenstein, E. (Ed.). Clinical Neuropsychology., 2nd Edition. New York: Oxford University Press. S. 243-294. Poeck, K. (1989). Anosognosie und halbseitige Vernachlässigung. In Poeck, K. (Hrsg.). Klinische Neuropsychologie. Stuttgart, New York: Thieme Verlag. S.340350. Säring, W. (1988). Neglect. In Cramon, von D. & Zihl, J. (Hrsg.), Neuropsychologische Rehabilitation. Berlin: Springer Verlag. S. 182-194. Zihl, J. (1988). Sehen. In Cramon, von D. & Zihl, J. (Hrsg.), Neuropsychologische Rehabilitation. Berlin: Springer Verlag. S. 105-131. Zihl, J. & Cramon, von D. (1986). Zerebrale Sehstörungen. Stuttgart: Kohlhammer Verlag.

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Saccadic Training

Index

-Hhaemianoptical 16 hemianopsia 16 horizon line 4 horizon type 4

-Aadaptive 1 aim of the training 16 assesment of performance

-I4

-B-

impairmants to vision 14 impairments to the field of vision incorrect 3 instruction 1 inter stimulus interval 3, 7 irretation 11 irretrievable error 4

basic foundations 14 bibliography 16 brain damage 14

-C-

-L-

comprehension of words continue to the next level contrast 1, 4 countryside 4

16 7

-Ddirectional decision 11 double error 11 double object 1, 7 duration of consultation 7

-Eerror tone 3 exploration impairmants

-Ffield of vision 1 focal point 7 focal point control focus area 1 focus point 1 focus ponit control

14

14

language 16 left 1 level 4, 11 level of difficulty 11 level of training 1 level structure 4

-Mmaximum reaction time 7 measurement of reaction time median 11 movement 4

-Nneglect 14, 16 night sky 1 number 11 number of items

7

11

11

1, 7

-Oobjects

11

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Index

-Pparameter-menu 7 patient panel 1 pauses 11 performance feedback position error 4

3

-Rreaction time 1, 3, 11 repeat previous level 7 right 1

-Ssaccadic training 16 scanning ability 4 search for an object 4 searching motion / scanning ability 14 size 4 size of the picture 4 structure of the level of difficulty 4

-Ttape of error 4 target groups 16 time error 4 training procedure 1 training task 4 training tasks 1 training time 11

-Vverbal feedback 3 visual Neglect 14

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Saccadic Training - SAKA