Vision Restoration Training - VIST

Cognitive therapy and brain training

www.rehacom.com

Cognitive therapy and brain training

by NovaVision AG

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

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Table of contents Part I Description of the training

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

Part II Theoretical concept

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1 Basic ................................................................................................................................... foundations 9 2 Aim ................................................................................................................................... of the training 11 3 Target ................................................................................................................................... groups 11 4 Bibliography ................................................................................................................................... 11

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Description of the training

1.1

Training tasks

functions in patients with visual impairments due to neurological lesions, such as hemianopia or quadrantanopia. Typically, the patient performs the sessions binocularly, that is with both eyes at the same time. The program presents large, bright square-shaped light stimuli that appear at defined positions on the screen.

The patient’s task is to press the response button as soon as he/she perceives the light stimulus. Based on the response behaviour of the patient the program calculates the next position at which the light stimulus will be presented and thereby interactively ensures an intense light stimulation of the visual field border and the region with highest potential of improvement.

Before starting the training, the work place itself requires optimum adjustment. The patient sits in a comfortable but fixed position in front of the computer. Throughout the whole session he/she is required to look straight ahead at the monitor keeping the optimum distance that was determined during the calibration process (see chapter 4.4). This is best supported by a chinrest. The chinrest that Hasomed GmbH offers as a training accessory is recommended to fixate the heat and adhere to the predefined distance.

Picture 1: Training surface (43° horizontal, 32° vertical) with fixation point in the middle of the screen and bright quadratic stimulus (presentation of stimulus and

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Description of the training

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fixation color changes are not displayed at the same time) After starting the selected training sessions, in the center of the screen a fixation point will be visible that changes color and form intermittently (=fixation control). It is essential that the patient always looks at this point, and confirms all fixation control by pressing the OK-button on the Rehacom-panel. Watch this particularly and redirect the patient to the task if needed.

Additionally, a large white square light stimulus will be presented, starting in the intact visual field and then flashing up at neighboring positions along an imaginary horizontal path, seeming to move into the direction of the impaired area of the visual field. The patient is required to confirm every flash of the stimulus by pressing the OK button. It is essential that he/she does not follow the light stimulus with the eyes, but keeps them fixated at the fixation point. The light stimuli are supposed to be perceived at the retinal periphery, not involving central vision. Once the light stimulus appears within the defective area, the patient will not see it and not press the button any more. When this happens, the light stimulus will change direction and “wander” back on its path in direction of the intact field. As soon as it is again perceived and confirmed via button, the stimulus “jumps” back to its last position in the defective field and again wanders back in direction of the intact field, until confirmed via button. This will be repeated several times, then the light stimulus appears in the intact field on an new “path” and again moves in direction of the defect – the process starts from the beginning. This interactive algorithm ensures intense light stimulation in the area of the border zone with the highest potential for improvement.

The patient might have initial difficulties with attention to two tasks – response to the fixation control and the light stimuli – at the same time. Give the patient some time to get used to the tasks. Observe him/her closely and repeat instructions every time the patient neglects one of the tasks or follows the light stimulus with the eyes.

If the patient needs additional help, you can train him/her on the two tasks separately - for a start, instruct him/her to ignore the light stimulus and focus solely on the fixation point and the fixation control task. After this task is very well understood and performed, the second stage is to phase in the response to the stimulus. Select an easier program type if needed.

The first training sessions should be continuously supervised by a therapist, to confirm selection of the optimal grade of program difficulty and redirect the patient to the tasks if needed: - In case of fixation loss and eye movements the patient should be reminded of the importance of the fixation task - In case the patient hits the response button often even though no light stimulus or fixation control was presented (=produces false positive responses), he/she should be reminded to only press the button once he/she is sure of having perceived a light stimulus or a fixation control, not just a light shimmer.

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The patient’s level of attention and concentration might decrease after some time of training which could lead to unreliable results. It is therefore helpful to take at least one break during a training session.

Before the training begins the patient is instructed by the therapist. However, menu training parameters at any time (parameter: acoustic feedback).

1.2

Performance feedback

fixation point change (= fixation control) or presses the response button at a time when a response is not required by the program (= false positive response), a low pitched sound will be presented (characteristic RehaCom error sound).

A correct response after presentation of a light stimulus or a fixation is affirmed by a higher pitched pleasant sound. No acoustic feedback is given if a stimulus was missed. When the patient has missed the fixation control several times or pressed the response button several times without being required to, a message box appears with the written and spoken feedback: “Please make sure that you are looking directly at the fixation point on your screen” or „You are responding too slowly or too quickly“.

Upon completion of the training, performance accuracy regarding fixation, stimulus detection, average reaction time and number of false positive responses is displayed on a report (see 1.5: Evaluation).

1.3

Levels of difficulty The program provides variants for six different types of visual field defect, and for every type three different levels of difficulty. “1” is the easiest difficulty level characterized by large light stimuli, a high contrast fixation point change (fixation control), longer presentation times and response waiting times. This is helpful for patients with additional deficits such as attention and/or concentration problems, slow motor response, a deficit in color perception or contrast sensitivity, or with cataracts. The parameters described are designed with a higher difficulty level for “2” and “3”.

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Description of the training

1.4

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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 2: Therapist menu As mentioned above, the therapist menu provides the option of three different levels of difficulty that allow for adaptation to the cognitive performance level, capacity and visual acuity of the patient.

Level 1 as the „entrance level program“ is suited for patients with impairments of attention, particularly divided attention, motor and/or perceptual slow-down, decreased visual acuity. Frequently, these patients are not very resilient, training duration should therefore last not more than 5-10 minutes.

Level 2 can be used when the patient displays small or no cognitive and/or visual impairments besides the visual field defect. Also, level 2 can be selected if the patient has already worked with level 1 and has improved to an extent that requires

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an increase in challenge. Session duration may last typically 10-15 minutes, in single cases maybe more.

Level 3 should only be used as a „first-time user“-program, if beside the visual field defect the patient has no impairments and is an overall high performer. Level 3 should be selected particularly for patients who have trained with level 2 and have displayed improvements that require higher training challenge by increasing the difficulty level.

Picture 3: Parameter menu Duration of session In the parameter menu the training session duration can be customized per patient and should be selected in accordance to the patient’s capacity.

Test Type Default Test Duration Test duration for Level 1 - 3 5 - 30 minutes (standard: 15 minutes) Visual field damage The program provides specific training variants for the six most frequent types of neurological visual field loss – left or right hemianopia, quadrantanopia to the top left or bottom left, quadrantanopia to the top right or bottom right. Here the

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Description of the training

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appropriate variant for each individual patient can be chosen.

Acoustic Instruction: is explained in chapter Performance feedback.

Calibration: After pressing the button „Calibrate“ the following window appears:

Picture 4: Calibration The red box corresponds to 3/4 of the monitor size. Measure width and height of the red box and click the button. Enter the measures values in millimeters in the parameter menu and click OK. The measured values determine the correct distance of the patient to the monitor.

The calculated optimum distance may not be exceeded because otherwise the scaling of the training area will no longer be accurate. If the patient sits closer to the monitor, this actual distance needs to be entered in the field „Distance eye screen“.

The training area on the monitor will then be decreased in accordance. A distance of less than 300mm is not recommended.

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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. All completed training sessions are stored in a list including date and time. After selecting a session, the results are displayed.

Picture 5: Training report The right half of the report shows the graphic display of the results. The training responses are depicted by coloured cells in a grid. The meaning of the colours is as follows: Yellow ochre: “background” at this positions no light stimulus was presented White: at this positions one or more light stimuli were presented and were every time confirmed by pressing the response button (conclusion: intact visual functions) Black: at this positions one or more light stimuli were presented and were never confirmed by pressing the response button (conclusion: no visual functions) Shades of Blue: at these positions light stimuli were presented several times and were confirmed by response button in some but not all instances. The lighter the shade of blue, the more often the patient has responded to a stimulus presented at this position. These areas in the result graph are names “transition zones” or

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Description of the training

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“area of residual vision (ARV)”. The basic principle of the InVISTATM-training is the presumption that in the blue shaded fields visual functions are only partially damaged and have the ability to improve visual perception and processing via targeted, high repetitive stimulation. Primary goal of the training is to excite the ARV via light stimulation in a way that visual functions learn better and more reliable processing. Secondary goal is to extend the ARV further into the direction of the visual field impairment, so that currently non-functioning visual areas (= black area) restart visual processing.

Please note: the area displayed in black (= no response to light stimuli) is not necessarily tested throughout the whole periphery. Once the light stimulus arrives at a position at which it is not perceived any more, it will not presented further into the defective area. For the graphic display it is assumed that there are no visual functions beyond this position. Positions peripheral to the area of residual vision at the border zone are displayed completely in black.

Definition of numerical training results (on the left side of the report): Detected fixation controls

Amount of correctly confirmed colour/shape changes of the fixation point in regard to all controls presented – percentage of correctly confirmed fixation controls. A percentage of >= 90 suggests very good fixation. With a lower percentage the patient should be re-directed to the fixation task. If applicable, for the next session a lower level of difficulty or shorter session duration may be chosen.

False positive Number of hits of the response button that were responses registered as too early or too late and outside of any given response time window. A percentage of <= 3 represents a very good performance and indicates a precise response behaviour. With a higher percentage the patient should be redirected to the task. Since false positive responses are often the result of loss of attention, for the next session a shorter session duration time may be chosen.

Detected stimuli Number of correctly detected and confirmed light stimuli with regard to all stimuli presented – percentage of correctly confirmed light stimuli.

Border tests Absolute number of stimuli in the transition area that were perceived and confirmed by the patient.

Average reaction time Average time that was needed to respond to a light stimulus or a fixation control (averaged across all four quadrants)

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Please note: the values in the cells of the coordinate axial's are not included in the calculation of average response times.

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Theoretical concept

2.1

Basic foundations Already in the 1990s of the previous century, scientific research showed that in patients with a neurological visual field defect impaired visual functions improved notably after targeted and continuous light stimulation (Kasten et al. 1998). Goal of the according stimulation program VRT (Visual Restoration Therapy) is to achieve re-organization and hence complete or at least partial functional restoration of damaged but not destructed neuronal structures via intense stimulation. In daily life, visual impulses are always at the disposal of the complete visual field. Our brain prefers to use intact functions and have these also cover tasks assigned to the damaged functional areas. A compensational mechanism is therefore chosen instead of trying to strengthen damaged structures via activity and exercise. These are more and more eliminated from their active processing role. The basic concept of VRT is to create a training situation that does not allow to draw on intact functional areas for task completion, but to force activation of partially damaged visual structures as much as possible: in a dark room, the patient fixates on a dot on a dark monitor screen. Now the position of the intact visual field is exactly defined, here no visual information is offered. However, intense visual stimulation with light stimuli is provided in the area of the border zone between intact and defective visual field. This area displays the highest potential of improvement. The graphic below shows, how during training the “visual highway” in the intact visual field area changes to a “visual side road” while the „side road“ in the transition area along the border zone changes to „main street“.

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Theoretical concept

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Since foundation of the company NovaVision AG which offers VRT as a three- or six- months-therapy with continuous supervision and result evaluation, numerous outcome studies were performed. Significant improvements in stimulus detection were shown consistently ((Romano et al. 2008, Poggel et al. 2008) as well as functional improvements of visuoperceptual functions and reading (SchlĂźter et al.

2009). After a vision restoration training patients estimated their vision-related quality of life to be notably higher (Gall et al. 2008). Patients report frequently to encounter higher visual confidence, capacity and better orientation in their daily life.

As a side effect, improvements in overall visual attention performance and concentration have been found in many patients.

The program InVISTATM contains the initial training component of VRT, which stimulates the entire visual field border zone and activates re-organization processes in areas with high restoration potential. Very imported is regularity of training with an ideal schedule of two sessions per day.

If at all possible, training success should be measured by intermittent visual field

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testing.

InVISTATM should not be used in the first one or two weeks after onset of the neurological damage, after that there are no limitations. Studies have proven that VRT can achieve improvements not only in the first months after onset of damage, but also years later.

When InVISTATM training has been started with regular and continuous sessions, it can be used for about 2-3 months to achieve visual field improvements. To achieve additional visual improvements after completion, continuation of vision therapy is possible with NovaVision AG in an outpatient setting. NovaVision provides advanced training programs that are able to achieve further improvements by targeted stimulation of areas found to have the most restoration potential.

2.2

Aim of the training

the process of improvement and restoration of visual functions via intense light stimulation of the complete border zone between intact and impaired visual field.

The bright light stimuli activate partially damaged neuronal structures to resume participation in the visual process and to readopt their dedicated perceptual function within the visual field.

2.3

Target groups The training is designed for patients with neurologically induced visual field impairments such as hemianopia or quadrantanopia. The possibility to select different levels of difficulty and an individually adapted training duration makes the program accessible also for patients with attention and concentration disorders or slowdown of motor and perceptual functions. The same applies to additional visual impairments such as a dense cataract, color or contrast sensitivity disturbances.

After thorough initial instruction, patients with aphasic symptoms should be able to work with the program without problems. Whereas no visual field improvement is expected in a case of severe multimodal Neglect, a slight, regressive visual Neglect should not interfere with training success.

2.4

Bibliography Bibliography Kasten, WĂźst, Behrens-Baumann, Sabel (1998). Computer based training for the treatment of partial blindness. Nature Medicine. Nr. 4, S. 1083-1087 Romano, Schulz, Kenkel, Todd (2008). Visual field changes after a rehabilitation intervention: Vision restoration therapy. Journal of the Neurological Sciences

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Poggel, Müller, Kasten, Sabel (2008). Multifactorial predictors and outcome variables of vision restoration training in patients with post-geniculate visual field loss. Restorative Neurology and Neuroscience. Nr. 26, S. 321-339 Schlüter, Schulz, Kenkel, Romano (2009). Functional Improvements after a Visual Rehabilitation Intervention for Patients with Homonymous Visual Field Defects.

Poster presented at the Annual Meeting of the American Academy of Neurology, Seattle, April 26-May 2, 2009 Gall, Müller, Gudlin, Lindig, Schlüter, Jobke, Franke, Sabel (2008). Vision- and health-related quality of life before and after vision restoration training in cerebrally damaged patients. Restorative Neurology and Neuroscience. S. 341-353 Overview articles: Romano (2009). Progress in Rehabilitation of Hemianopic Visual Field Defects.

Cerebrovascular Diseases. Nr. 27, S. 187-190 Haferkemper (2008). Neurovisuelle Störungsbilder bei schweren Hirnschädigungen und Behandlungsmöglichkeiten in der Ergotherapie. praxis ergotherapie, Nr. 5, S. 290-293 Gall, Kasten (2007). Kompensatorische und restitutive Methoden des Gesichtsfeldtrainings. Zeitschrift für Neuropsychologie. Nr. 18, S. 255-273 Kerkhoff, Oppenländer, Finke, Bublak (2007). Therapie cerebraler visueller Wahrnehmungsstörungen. Der Nervenarzt, Nr. 78, S. 457–470

For further information please contact:

NovaVision AG Center for Vision Therapy D-39112 Magdeburg Klausenerstr. 12 Fon: +49 (0)391 6 36 00 50 Fax: +49 (0)391 6 36 00 70 Web: www.novavision.de E-Mail: info@novavision.de

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Index

detected stimuli 7 distance 1 distance eye screen

-E-

-Aacoustic feedback 3 acoustic instruction 4 activation 9 adaptation 4 adjustment 1 aim of the training 11 area 9 ARV 7 attention and concentration disorders attention performance 9 average reaction time 7

-Bbasic concept 9 basic foundations 9 bibliography 11 binocularly 1 border tests 7 border zone 7, 11

entrance level program error sound 3 eye movement 1

4

-F11

false positive response 3 False positive responses 7 feedback 3 first-time user 4 fixation control 3 fixation loss 1 fixation point 1 fixation task 1 functional improvements 9

-Ggraphic display

7

-H-

-C-

help

1

-I-

calibration 4 calibration process 1 capacity 4 cells 7 central vision 1 chinrest 1 cognitive performance level coloured cells 7 concentration 9 conclusion 7

improvement 11 instructions 1 interactive 1 4

-Ddamaged structures 9 data analysis 7 detected fixation controls

4

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-Llarge light stimuli 3 level of attention and concentration levels of difficulty 3 light stimulation 9 light stimulation training 1 light stimuli 7 light stimulus 1 list 7

1

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Index longer presentation times

3

therapist menu 4 training area 4 training duration 4 training parameter 4 training report 7 training task 1 transition zones 7

-Mmessage box monitor 4

3

-N-

-V-

neglect 11 neighboring positions 1 neuronal structures 11 numerical training results

vision restoration training 9 visual acuity 4 visual confidence 9 visual field 9 visual field border 1 visual field damage 4 visual field defect 3 visual field impairment 7 visual field impairments 11 visual field loss 4 visual functions 11 visual highway 9 visual impairments 4 visual side road 9 voice output 1 VRT 9

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-Pparameter menu 4 parameters 4 performance accuracy 3 performance feedback 3 pleasant sound 3 position 1 potential of improvement 1 program type 1

-R-

-W-

red box 4 re-organization processes 9 repetitive stimulation 7 response waiting times 3 restoration 11 restoration potential 9, 11 results 7

work place

-Sslowdown of motor and perceptual functions stimulation 11 stimulus 1 surface 1

-Ttarget group task 1

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1

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