RehaCom Catalogue

RehaCom computer assisted cognitive rehabilitation

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HASOMED hard- and software for medicine

RehaCom systems are used successfirlly throughout Europe in: Stroke units Rehabilitation centres Hospitals Geriatric centfes University clinics Out-patient treatrnent units Psychological practices Neuropsychological establishments Occupationilthetapy Vocational training institutes for the disabled Neuropaediatry Retirement homes and by patients and sufferers at home

RehaCom

CognitiveTherapy

computerassisted cognitive rehabilitation

Introductioninto the systemRehaCom...............

Trainingof attention

Alertness Acousticreactivity(AKRE)........................................

Reactionbehavior(REVE)... ..................O Abilityto respond(REA1)................ ........1O Vigilance Vigilance(Vtct)...... ....................

1 Visualspatialattention Spatialoperations(RAUM)............... .......12 Twodi mensionaI operations(VROt)..............................

Threedimensional (RO3D).. operations .............1 Visuoconstructive abilities(KONS).....................15 Selectiveattention AttentionandConcentration (AUFM).. ...............1 Dividedattention Dividedattention(GEAU).. .....................

Dividedattention2 (GEAZ)........................................

Training of memory Topolocial memory(MEMO)...............

Physiognomic memory(GESI).....

Memoryof words(WORT) Figuralmemory(BILD).....

Verbalmemory(VERB)..

..................1 ...................... ................21 ...................2 ....................2

Executive functions Shopping(EINK) Plana day (PLAN)..

Logicalreasoninq(LODE)...................

Cafculations(CALC).........-.

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25 ................26 .................27

Trainingof visualfield Compensating Saccadig training(SAKA).. ...................28 (EXPL)....-.-.-....

Exploration .....................29 Overviewandreading(ZtFll-)................... ...............3O Restoring Visualtrainingto restore(VIST) ......31

Visuo-motoric coordination Visuomotoriccoordination(WISO).....--......

Overviewof procedures.......

Effectiveness studies Teamof development Technicalrequirements...........

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-;1ffi,'

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.....33 .......................

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RehaCom CognitiveTherapy

Cognitive defects are the frequent consequences of brain damage, and the need for anappropriate therapy instfument is enormous. progress in computer technology enables the application of computer-assisted therapy programs in cognitive rehabilitation. Disturbances in attention and concentration, in learning, in memory, in reactivity and in many other brain functions are treatable.

Cognitive rehabilitation aims first of all. at a reduction of the restrictions caused by brain damages. The aim of computeraided training procedures is thepositive change of the cognitive abilities of the patients. The main successcriterion is the patient's own estimation of how his quality of living changes. This training is executed in stroke units, in neurological rehabilitation centres, in psychological and occupational practices and also at home. In conjunction with classical therapy forms such as client-cenrered therapy, play therapy, logopaedics, physiotherapy or occupational therapy, the computer-assisted therapy gains ever more significance.

If certain brtrn areasare injured by stroke, traffic accident, tumour operation or other diseases, the possibiJity exists that healthy brain areas can take over the functions of the incapacitated areas. Computer-assisted neuropsychological rehabilitation realtzes highty individual and intensive training of the effected brain areas.

Wilson (1989) differentiates berween 3 kinds of rehabilitation: t Restitution of functions + Compensation of functions and + Substitution through intact functions.

Resourceorientated therapy approaches (Matthes, von Cramon & von Cramon) suggest those skills the patient has maintained and which can be used to reduce the patient's restriction. Howeveq this function transfer must be trained and stimulated, and this is done through the following therapy approaches: t Exerciseprocedures

-t

Giving over of internal strategies + Supportingmetacognition + Using external help.

Computer-assisted training mainly consists of repetitive exercise and needs the therapist to give over strategieslinking to daily routine. RehaCom procedures are structured in a way allowing the transfer to daily routine easily.

In the last years it was shown that the application of computers as a constituent of different rhet:lpy forms contributes to therapy successconsiderably.

The computer supports the patient as ^n untiring and never despairing teacher, even if the patient.s pfogress is slow: New exercises are constantly generated, as long as the patient achieves the required therapy t^rget. By editing own conrenrs, the therapisr can even w-iden the offer of tasks and adapt the tasks to local traditions.

Basicelementsandfeatures For more than two decades computer-assisted training of cognitive functions has been a basic constituent of neurological therapy. Many of the computer-aided training procedures usesconcepts of psychological tests, others afe ,,copies.. of computer games, and a third group developed for educationalassumptions.

RehaCom was developed to suit the needs of effective neuropsychological rehabilitation of cognitive functions. The theoretical concept is the result of intensive cowork of psychologists, neurologists, biomedical engineers and programmers. The following points describe RehaCom's theoretical concept: t Modular structure of the training procedures: ttaining of basic functions up to complex demand -t Best possible interaction between the therapist, patient and computer as basic element of the training t Adaptation of the training level to the patient's capacitres

+ +

Powerfirl feedback for motivating the patient Effective process recording for finding deficits and caoacities.

Modularity RehaCom trains different cognitive areasaccording to the procedue. Starting with simple procedures, more and more complex demands are set up for the client. As there is a wide spectrum of cognitive deficits, an effective training package should be able to train all aspects of cognitive functions, both basic and complex, using a common interface.

Modularity enables t t +

Selecting a procedure according to the cognitive deficit Selectinga combination of procedures according to the profile of cognitive deficits Variation of the training structure (number of tasksper session,changesin the level of difficulty etc.)

Interactionbetweentherapist, patientandcomputer In the therapist-, patient- and computer relationship the dominant element should be the therzpist-patient axis. The computer is part of a total therapy concept which allows individual treatment for every patient. This individual adjustment should help the patient to develop strategies fot solving the training tasks.The computer provides instruction on the training tasks, information on the progress of performance and positive feedback.

Patientadjustedpanel A special keyboard $ehaCom panel) helps the patient to communicate with the computer. A conventional keyboard is mosdy unsuitable for therapies since it is too confusing and requires high dexterity. The RehaCom panel is reduced to the minimum necessiry.

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RehaCom panel: Large, robust reaction buttons which are also for patients with motor disturbances

Automaticadaptation to currentperformance An effective training procedure works adaptively and adjusts to the current capabilities of the client automatically. The stress balance of the client is maintained in order to increase the motivation for the therapy.

Individual training andfeedback Individual training is necessary for maximum motivation. Adapted instructions and help menus are used to achieve optimal instruction comptehension ("learning by doing"). The client receives continuous performance feedback via pleasant sounds and images. Every training procedure is equipped vrith a large item pool to avoid habiruation and boredom in the client.

Procedures which ate highly tealistic proved to be of growing importance.

After solving a task, the clients receiveinformation on the quality of performance as well as instructions fot the next tasks.

RehaCom CognitiveTherapy

patientprogress Continuity, andprocessrecording Specific progress data zre recorded for every training procedure. They are the basis for a chznge of level and the feedback. Savedin every session, the patient's progress can be traced back to the very first sessionon the grounds of these data.

During training evaluation the data provide the therapist with details on patient progress. A new session starts at the same level at which the last sessionfinished.

Efficiency andeconomy The procedures generally allow the client to train on his own, instructed and verbally motivated by the PC. At the beginning of each ttaining session,though, the therapist's presence is needed in order to define the dayt training aim together and to estimate the emotional, motivational and performance state of the client. The same applies to the end of each session when therapist and client evaluate the petformance together and speak about difficulties that occurred.

The computer caflnot and should not replace the psychologist or therapist.Every patient needs social feedback and allowance and has a right to receive it.

The computer is only a part of the therapy concept, offering new possibilities, provides repeating divercifi ed training.

Language availability and distribution The procedures which operate under the system name RehaCom, which now number 29 e1. of themtranslated into English, have been on the market stnce 1992. Cognitive training with RehaCom is used in thousands of leading neurological tehabilitation clinics and out-patient departrnents and by practice therapists in Germany and eisewhere. Improvements to the RehaCom system ^te, to a large extent, based on their experiencesand on the results of a seriesof effectivenessstudies at clinics and universities.

In recent years,the method of treating brain function disorders with RehaCom has become firmly established in a number of countries. RehaCom is now the market leader in Europe and beyond.

The leading treatment programmes have been translatedinto more *tan 14 languages.RehaCom customers who wish to train their patients in their native tongue can benefit from this multilingual provision.

Continuing RehaCom treatment in clinicalpractices andat homeafter leavinghospital Itis often advisableto continue brain performance training with RehaCom in a clinical pracace or at home aftet a hospital stay. For financial reasons, patients often spend too litde time in hospital to achievesustainablesuccessin the long term. That is why an increasing number of neurological and occupational practices are offering their patients RehaCom training.

RehaCom enablescustomers to exportpatient data from the clinic (for instance,using a memory stick) and import it into the system used at the practice.

This enables one to continue brain performance training without interruption after the patient leaves hospital, and to update patient fi.les and the results of treatrnent seamlessly,either in the practice or at home. $7ith its dialogue-oriented stfuctufe, integrated instruction cycle for patients and auto-adaptive mode of operation, users afe able, once instructed accordingly, to work with RehaCom independendy for prolonged periods.

Litde time must be committed to observing the patient. The latest studies at the Neurological Rehabilitation Centre in Magdeburg, Germany, have shown that RehaCom is the most suitable tool for carrying out brain performance training at home.

Prescribing treatmentandthe internet A modern therapeutic system such as RehaCom must engage with the new challenges presented by global networking and communication. As a result, RehaCom has integral modules which allow data to be exchanged through the internet between the therapist in a hospital or practice and the patient at home in a simple, unproblematic way. Needless to say,we comply with the strictest data protection guidelines. The therapist is thus able to set the patient precise tasks from the convenience of his workplace. He prescdbes:when the patient should use which method of training and under what circumstances and can leave precise instructions for the patient to follow.

The informaion can be retrieved either from a server on the internal hospital network (intranet) or from a HASOMED RehaCom server (internet).

The patient logs into the RehaCom system with his name and password or with a smaft card, and receives only the prescription which the therapist has left for him. If the patient has worked without supervision, the data charting the progress of training is automatically left on the server.

The RehaCom smarr card

The therapist can accessit from the RehaCom sefvef, evaluate training and set flew targets.

Futureperspectives The development of new procedures is determined by t the experienceswith existing procedures, t the results of studies for effectiveness, and validity and new computer technology' Training procedures will utilise multimedia computer technology which make them even more realistic to situations and requirements of evetyday routine. Clients should clearly see that a progress in the training leads to a progress in activities of daily living.

H e l pd e s k In case you want to share your experiences with us, look for other people who want to share experiences, need more information or literature about "Computer assisted training of brain functions", ot have a question on RehaCom, the staff of HASOMED, RehaComteam is aiways there for you.

RehaCom CognitiveTherapy

Acousticreactivity (AKRE) Briefdescription The aim of the procedure'Acoustic teactivity" is to improve precision and speed of acoustic reactions. The sounds zre fzmihar to the patient from his everyday environment.

Indications The procedure is recommended in adults with a diagnosed deficit of reaction speed and reaction precision but also in impairments of acoustic differentiation abiJity. Furthermore the training makes a strong request to mental flexibility and focused attention. In clients liable to interferences the therapist should make sure they arc not overstrained. Fot training with children from 8 years on child-odented instructions are provided.

Basicrequirements of the patient The ability to petceive sounds and to differentiate between them are precondition. For an independent training the client needs to be able to handle the RehaCom panel.

Task During the preparation phase the client leatns to associate the sounds with the buttons of the RehaCom panel. If desired, a practising phase follows. Finally the actual training starts.Now a range of sounds (a barking dog, a.irgmg telephone etc.) ate heard and the corresponding buttons on the RehaCom panel have to be pushed as quickly as possible.

Training material At the moment about 60 different sounds with their typical background sounds (..g. waves on the beach) are provided. Pictures on the scfeen and cetain acoustic stimuli cte te a p^rticular environment or situation (e.g. at home,

on a fzrm etc.). The RehaCom panel is required to use this programme. The computer must be equipped with a DirectX-compatible Soundcard and suitable loudspeakers or headphones!

Levelsof difficulty The difficulty is modified through the number of sounds to be differentiated, the use of irrelevant stimuli and the use of background sounds (e.g. quiet music).

Effectiveness At the moment the procedure is tested scientifi.ily.Because of the high closenessto real life a good transfer of the skills trained to everyday situations can be expected.

Reactionbehaviour (REVE) Briefdescription Respondent behaviour of single and multiple choice reactions (speed and accuracy) towards optical signals is trained. On the edge of the scfeen lraffr,c signs can be seen. Next to each a key of the RehaCom panel is displayed which has to be pressed when the taffic sign appears in the middle of the monitor. Thus, attention and memory are joindy trained.

Indications The raining is indicated for all patients with reduced response speed induced by the central nervous system. Such a reduction of response speed almost always occurs in diffuse brain damagesaswell asin frontal and prefrontal lesions (e.g. dementia, brain trauma, insult, formation of a tumour, ischemia, etc.).

Basicrequirements of the patient The client needs to be able to understand and comply independendy with easyinstruction texts.

Task Veryrealistic stimuli (taffrc signs)were chosen for this training. The task is to press the corresponding reaction key as quickly as possible whenever a txget stimulus (i.". z traffic sign) appears on the monitor.

Trainingmaterial The training material consist of realistic ttaffi,c signs. In the learning phase the pictures of the t^rget stimuli (uaffi,c signs) and the coresponding reaction keys are presented. By pressing the OK-button the learning phase is tetminated.

Then the target taffrc signs (towards which the client must react within a certa:tntime interval),

and in higher levels of difficulty also irrelevant taffi,c signs (which requke no reaction), ate displayed. The RehaCom panel is required to use this Pfogfamme.

Levelsof difficulty Thtee types of tasks with 4 or 6levels of difficulty each have been constructed: + The next traffic sign appears only after the response of the previous (6levels of difficulry). + Fixed interval between the items (4levels). + The interval changes adaptively. After a correct fesponse a shorter interval is chosen, and vice versa (6 levels).

Effectiveness Investigation results fot this training piogramm are not yet available. However, good rehabilitation results afe expected for the above mentioned indications because a specific disorder is trained.

RehaCom CognitiveTherapy

Abilityto respond (REAl) Briefdescription The objective of reactivity training is to improve the speed and accutacy of reactions to visual and acoustic stimuli. Simple, simple choice and multiple choice reaction tasks are designed to train the patient to react as quickly and differentially as possible to signals.

Indications The objective of reactivity training is to improve the speed of rcactions and the speed and accrxaciJ of reactions following cerebral lesions.It is fecommended in the caseof disorders of selectiveattention performance, and in the case of disorders of visual or acoustic discrimination, cognitionandf or behavioural performance.

Basicrequirements of the patient The training programme is less suitable for patients with serious ametropia or poor hearing (acoustic stimulation). The patient must be capable of pressing the large reaction buttons of the RehaCom panel accurately. Serious memory impairment (forgetting srategies) and disordets affecting attention and concentration may impair the successof training.

Task Reactivity is trained using simple, simple choice and multiple choice reactions, and involves visual zndf or acoustic stimuli. After a predefined visual stimulus appeafs and/or after an acoustic stimulus is played, the patient must press a particular button on the RehaCom panel as quickly as possible.

During an acquisition phase, the patient familiarises himself with the practicalities of the task.

He learns to associatethe stimuli with the relevant buttons on the panel. The assignment of stimulus to reaction which is learned can be consolidated

dudng z pncilce session. Training then proceeds with a selectable number of stimuli. The speed and accutacy of the patient's reactions ^re measued and evaluated.

Training material Training incoqporates more than 200 visual stimuli and 6 acoustic stimuli 1n 3 vaiaions each. The therapist can add his own visual and acoustic stimuli (any pictutes and sounds he chooses).

There is an integrated editor to create individualised training programmes.

Levelsof difficulty The programme offets 20 levels of difficulty with 5 tasksper level. Each task comprises severalcombinations of stimuli. The various combinations are randomly selectedby computer, ensuring thateach patient expedences an extremely varied training progralnme. The programme works adaptively tkough rhe 2}levels of difficulty. The higher the level of difficulty, the greater the number of stimuli to be determined and the more vaded the temporal sequenceof stimuli.

Effectiveness The effectiveness of alertness training has been demonstrated in many scientific studies.

Vigilance

(vtGr)

Briefdescription The ability to maintain one's attention over a longer period of time is trained in a design with limited response time towards the items. The task of the patient is to monitor a conveyor belt and to select those objects that differ from a sample object in one or several details.

Indications The training is indicated for all disorders or impaitments of the long-term (continuous) attention of different etiology and genesis. The Vigilance' training programme is particularly suitable where there are disorders affecting tonic attention. In the case of patients with vascular brain damage, craniocerebral injuries and dementia, improvements c 17.be expected in cognitive petformance as well as, to some extent, age-related transfer effects.

Basicrequirements of the patient The task of this taining is very simple. The patient has simple visual differentiations to solve. Children c fl be trained also to appropriate instructions.

Task The task of this training is designed to be very easy.Basic visual differentiation tasks are requked in the client. Objects move past on a conveyor and must be compared continuously with one or more permanently visible specimen objects. The patient must identify which objects are not identical to the specimens,and femove these from the conveyor at the point indicated.

Trainingmaterial Objects are displayed on a conveyor belt and have to be compated to one or several fault-free ,,sample objects". The client should find those objects thztzre not identical to the sample objects (= faulty objects).

Levelsof difficulty According to the parameter settings concfete objects (e.9. washing machine, z refigerator, " etc.) or abstract figures are displayed. Childfriendly instructions are provided to assist in its use by children.

15 levels of difficulty zre avaifable.Ifith increasing degtee of difficulty the following parameters grow: t the number of diffedng (,faulty') objects, t the numbet of differing elements, t the number of objects displayed as well as t the complexity of the pictures.

Effectiveness For detailed information please refer to the section,,Effectiveness Studies", especially to the studies of BECKERS, HOSCHEL, PREETZ and FRIEDL-FRANCESCONI. PHUR. PFLE-

GER. GUNTHER.

RehaCom CognitiveTherapy

Spatialoperations (RAUM) Briefdescription The ability to imagine something spatially is focus of the procedure "spatial operations". It is trained in 5 categories: estimating positions, estimating angles,estimating relations (fillirg of vessels)and estimating sizes one- and two-dimensionally.

Indications The procedure is recommended especially for training basic cognitive functions of spatial perception. Through using non-verbal material it is also suitable for patients with impaired abiJity to understand words or language.

Basicrequirements of the patient Visual basic skills belong to the complex cognitive skills. For that, on the one hand, performances in attention are ptecondition, on the other hand, there proved to be significant correlations to the ability of abstract thinking. In highly impafued intellectual skills or disturbances of attention this procedure is less suitable.

Taskandtrainingmaterial When estimating positions, two fields with structured backgrounds are displayed on the screen.

One of them shows an object (e.g. a cat) at a fixed position. In the second field the same object is displayed at a dtffercnt position. The task is to move the second picture to the same position in its field as the first picture by means of the cursor buttoris on the RehaCom panel.

Photographs and drawings are used. When estimating angles,2 angleshave to be made equiangulat When estimating relations, vessels have to be filled with "liquid" (half full, 1/3 etc.) $[hen estimating sizes, the fields display objects - drawings or photographs - of different sizes which have to be brought ro equal size by

means of the cursor buttons. This task is avatlable in a one- and in a two-dimensional version.

The shot-term memory for spatial perception is tained in higher levels when the original object vanishes with the first adjustment of the ,.copy,,.

Reconstructing the odginal position then has to be carried out from memory.

Levelsof difficulty The procedure works adapttvely,for each category ^ sep^ete serial of levels from 1 to 9 has been validated, in total 42levels. The tasks of each category are explained in an insttuction phase via "learning by doing".

Effectiveness Studies for this ptocedure are not yet available.

However, good rehabilitation success can be expected in the indications described above since the client trains disturbance specifically.

Two-dimensional operations

(vRol)

Briefdescription The ptocedure "Tlwo-dimensional operations" trains the positioned relationship with twodimensional presentation. The task is to find the picture of a matitx which exactly corresponds to a ,,comparison picture". The corresponding picture is t'wisted towards the ,,comparison pictute".

Indications A decline in the performance in visual-constructive tasks, items of the position-in-space-exploration as well as in spatial orientation ate observed for dght hemisphedc temporal and parietal and damages of the frontal lobe. The training is indicated for patients with lesions in this location, diffu sebrain damageor mefital defectives.

Basicrequirements of the patient TVo-dimensional and spatial operations, in which the position-in-space-relation must be perceived and the object turned or tilted in order to find out the corresponding picture, belong to the more complex cognitive abilities. Therefore basal attention capabilities ^re ^ precondition. On the other hand considerable correlation with the ability to solve absffact and ,,bfain-teasers" intelligence in general have been found in various investigations. For clients with extreme intellectual impairments or a pronounced attention disturbance the ttaining is less suitable.

Task On the screen various pictures (objects) ate displayed that should be compared to ^n

object ^t the edge of the screen. The corresponding picture, which has to be found out, is nvisted towards the compadson picture.

Trainingmaterial Geometric figues, e.g. squares, arroua, hexagons, are used as objects. At higher levels of difficulty, the training mateid, increasesin complexity - up to concfete objectsand street-maps.

Levelsof difficulty With increasing difficulty the number of pictures in the matrix grows. Additionally more and more similar objects are displayed. So the differentiation capacity needed to find the cortesponding picture increases. S(hilst at lower levels of difficulty the tasks can be solved by estimating sizesand lengths, at higher levels the patient must visualise the rotation of objects.

Effectiveness For detailed infotmation pleaserefer to the section ,,Effectiveness Studies", especially to the study of FRIEDL-FRANCESCONI.

RehaCom CognitiveTherapy

Threedimensional operations (RO3D) Briefdescription Spatial sense and attention performanc e ^re trained. This is achieved by showing severalthreedimensional bodies on the screen which must be compared with a reference body. All of the bodies on the screen can be rotated freely, making a three-dimensional view possible. Stereo glasses fot a genuine 3D represenration ^re ^n additional option.

Indications The programme is suitable for treating cognitive disorders, particulady of spatial perception functions. The programme can also be used as a highlevel continuation of attention training. By using non-verbal matedals, it is possible to work with the programme even if language is restricted or there are problems understanding words.

Basicrequirements of the patient A spatial sense is one of the more complex cognitive activities. It requires a basic level of attention, and many studies have found not inconsiderable correlations with the capacity for abstract reasoning. The training is less suited in the case of profound inteilectual impaitment or for those suffering from serious attention disorders. Intact vision is required, particulady at higher levels of difficultywhere details have to be recognised. Initial findings indicate that the training can be used from the age of 10 years. The patient needs to be able to move the mouse of the computer.

Taskandtrainingmaterial A three-dimensional object is shown on the upper half of the screen.Below are 3 to 6 objects,whose

degtee of similarity varies with the level of difficulty. The patient must identify th. object which matches the object at the top of the screen exactly.All of the objects on the screencan be rotated in three dimensions, and can therefore be viewed from every side. A total of 432 3D bodies in 67 groups arc availableas training material.

Levelsof difficulty The programme works adaptively. TVenty-four levels have been validated altogether. Training commences with simple bodies and shapes,later progressing to compound objects with and without an indication of dits6tisn. At the highest levels of difficulty, the compleity of the bodies incteases considerably; differentiation becomes increasingly challenging. The level of difficulty is also varied by using 3, 4, 5 or 6 objects of comparison.

Effectiveness Studies on this training programme zre at ^ ptep^t^toty stage. With the indications descdbed above, however, good rehabilitation results can be anticipated, because the training the patient teceives is specific to his disorder. The experiences and results obtained using the 'Tlwodimensional Operations' RehaCom programme ^ppe r to be ransferable.

Visuo-constructive Abilities (KONS) Briefdescription The procedure'Visuo-constructive abilities" trains visual reconstruction of concfete pictures.

The client memorizes a picture in every detail.

Afterwards the picture is displayed divided into severalpiecesasin a puzzle. Then th epazzle has to be reconsttucted correcdy.

Indications Specialists litetature claims that partetal lesions cause constructional apraiz. For managing tasks as in this procedute, however, not only abilities to solve visual reconstruction tasks are needed but also memory and attention. The training is indicated for patients with a light or medium decline in the czpacity of the visuo-constructive field as well as in other generalized functional disordets. Often such a general decline in the performance can be observed in organic btain damages (e.g.through intoxication, alcohol abuse etc.). Since only pictorial rr'aterial is used, the training is also suitable for children from about 8 years on.

Basicrequirements of the patient For clients with serious apraxia, amnesia, and concentration disturbances the training is rathet unsuitable.

Task The trainingis constructed analogue to traditional ,,puzzle" games. In the beginning of a task a picture is displayedwhich has to be memorized as detailed as possible. When the client presses the OK-button, or after a defined time, the picture is divided into a certain amount of puzzle pieces and has to be reconsttucted.

Trainingmaterial The pictures appear in very high resolutton Q56 color mode) on the screen. Pictures of houses, faces,paintings, landscapes etc. are used.

Levelsof difficulty Altogethet lS levels of difficulty are provided. The main ctiteita for the change in the level is the number of ptzzle pieces the picture is divided into (ranging from 4 to 36 pieces).

Effectiveness Effectiveness studies are not yet available. However, many investigations of neuropsychological rehabilitation report good training effects after regular puzzle pl"yrng (often also in combination with other programms and exetcises).One can assume that the results of these investigations are also true for this RehaCom procedure since it is constructed in analogy.

RehaCom Cognitive Therapy

Attentionandconcentration (AUFM) Briefdescription The RehaCom procedure 'Attention & concentration" is based on the pattern-compadsonmethod. The patient has to find the picture from amati'tx which cotresponds exacdy to the,,comparison picture".

Indications Functionally and organically caused attention distwbances represent the most widespread neuropsychological petformance deficit after an acquired brain damage. They are found in 80 % of the patients after stroke (apoplexy), brain tauma, diffuse organic btain impairments (e.g. caused by chronic alcohol abuse or intoxication), as well as in other diseasesof the central nervous system. The training is suitable for adult clients and for children vzith attention and concentration disturbances from 6 yeats on.

Basicrequirements of the patient Besides the comprehension of easy instruction texts, the abilities to perform visual differentiation tasks and to handle the big buttons of the patient partel ate necessary.

Task A pictute presented separately on the screen is compared to a matrix of pictures. The one picture exacdy corresponding to it has to be found.

Training material A total of 49 picture pools - eachcontaining 16 pictures- has been set up. Becauseof the use of VGA-gaphics with high resolution, the pictures appearing on the screen are of good quality. They represent different qrpes of objects accordingto the parametersettings:either

concrete objects (fruits, animals, faces, etc), geometrical objects (citcles, rectangles, tdangles in different sizes and orders), or letters and numbers.

Levelsof difficulty The adaptive change in the difficulty of the tasks guarantees that the client will be confronted with neither too difficult nor too easytasks.Altogethet 24Ievels of difficulty arc available.With increasing capability, three,later six, and finally 9 similar pictures are displayed on a matrix. Only one of these is identical with the comparison picture.

Effectiveness For detailed information please refer to the section ,,Effectiveness Studies", especially to the studies of GUNTHNER" BECKERS, HOSCHEL, POLMIN, PREETZ, FRTEDLFRANCESCONI, PUHR and PFLEGER.

Divided Attention (GEAU) Briefdescription In this attention training - like in every day life - several circumstances must be observed simultaneously. Like an engine driver the patient monitors the driver's cab, regulates the speed and teacts towards different signals ,,during the journey".

Indications Problems in focusing attention towards sevetal diffetent ob jects simultaneously occut with almost all diffuse brain damages (e.g. intoxication ot alcohol abuse)aswell aswith local damagesof the right hemisphere, especially of the parietal parts of the brain. Effected patients have difficulties to focus their attention to different objects at the same time. Becauseof the animated presentation the training is very motivating and suitable also for children from 11 years on.

Basicrequirements of the patient The client should be able to understand and comply with easyinsttuctions independendy.

Task On the lower part of the monitor a driver's cabin is represented. Above, one can observe the track (ike through the wind shield of the engine). The client has to react simultaneously towards the elements in the cab and towards certain signals on the track.

Training material The driverb panel contains a speedometer, a so called,, deadman l amp" and the "emergency break lamp". On the speedometer^ tmget speed is set the client should comply with. On the flashing of one of the lamps the client must press the

correspondingbutton on the RehaCom- panel (e.g. the stop-button). If an important sign appears on the track the client also has to react (e.g. stopping zt a red block slgnal).

Levelsof difficulty The training contains 14 levels of difficulty. In the begrnning the client needs to regulate the train's speed only. From level two onwatd new tasks are added step by step. This implies reactions towards different train signals, the deadman lamp and emergency break signals.

Effectiveness Fot detailed information pleasetefer to the section "Effectiveness Studies", especially to the study of PUHR.

RehaCom

CognitiveTherapy

Dividedattention2 (GEA2) Briefdescription Driving z car the patient has to pay attention patallel on several issues: observing attentively the landscape and car dashboard as well as reacting differentiated on acoustic information.

In the beginning there is only the speed to keep.

L^ter on, with growing level of difficulty, there are further tasks,which wait for certain reactions of the training person in other areaof attention.

Indications Patients with disturbances in focussing on certain aspects of a task, in fast reacting on relevant impulses and at the same time ignodng irrelevant impulses. These disturbances occur in 80o/o of patients after stroke, craniocerebral injury, diffuse brain organic impairment (e.g. as a result of chronic alcohol abuse or intoxication) as well as othet diseasesof the central nervous svstem.

Basicreeuirements of the patient There are simple texts of instruction to comprehend. The patient has to push the buttons on the panel or keybord by himself. Supported byinstructions appropriate for children also children up ftom age 10 zre able to train with this procedure.

Task On your monitor you will have simulated a look through a frontalwindow of a car as well as look at the car's dashboard. Through the window you see the street in front of the car, which trails 'tn away the distance of a landscape. Left hand is shown the speed-indicator. Within the tachometer there is a green area which marks the speed you should ddve. Below the green atea there is a ted ztrow, which shows you the current speed. The red arrow must always be located in

the green arca. The car moves on the stfeet on a fixed track, also in curves, so that the patient has not to pay attention to keep the car on the stfeet.

Trainingmaterial To speed up the car you have to push the arrow key up, to slow down the arrow key down. There is a display for the way to go and the expfued time. The aim is to drive a ceftain distance in a limited time. It is to pay anention that the display for the way is always in front of the display for the time. A level is finished when the time is over or the way is done. \X4rile the car is set in motion through pushing the arrow keys on the RehaCom panel, relevant as well as irrelevant objects are moving perspectively towards the user.

Only the relevant objects and acoustic stimuli are counting as results for the training of the patients.

Levelsof difficulty The procedure works adaptive.In total there are22 levels validated. l7ithin the training the difficulties vary by adding more and more levels of attention and by modi$ring the interval of the stimuli.

Effectiveness Good results of tehabilitation can be estimated because the client is trained specifically to his disturbances.Studies arein process.

Topological memory (MEMO)

Briefdescription This procedure trains topological memory.

Uke in a memory-game the position of cards with pictures (e.g.a lion, a flowet, a house, a caf, etc.) ot geometric figures should be memorized.

Once the cards ate turned "upside down", theit position has to be remembered.

Indications The indication for this training is given fot all memory disorders or impairments regarding verbal and non-verbal contents. Amnesiac syndtomes can be observed for all diffu secerebroorganic diseases(dementia, intoxication, chtonic alcohol abuse etc.) as well as for all left or both sided lesions of the medial or basolateral limbic lemniscus. Mote over vascular diseases, brain ttuvrrra, or btain tumorts in ptefrontal, tempotal up to parietal cotical ate s c n lead to memory deficits.

Basicrequirements of the patient Beside basic task comprehension the handling of the big buttons of the RehaCom panel is a precondition.

Task In the so called ,,memorizing phase" a number of cards (depending on the level of difficutry) with concrete pictures or geometric figwes are displayed. The client memorizes the position of the pictures. After a preset time - or manually by pressing the OK-button - the pictures of the matrix are hidden (turned ,,upside down'). At the edge of the screen a pictue udll be displayed and the client indicates which of the hidden pictures corresponds to it.

Training material In total 464 picnxes (picturesof concreteobjects, geometric figutes and lettets) arc available.The numbet of simultaneouslydisplayedpicturesvaries from 3 to a maximum of 76.

Levelsof difficulty There arc 20 degreesof difficulty defined by a numbet of cardsand complexity.

Effectiveness For detailed information pleaserefer to the section ,,Effectiveness Studies", especially to the studies BECKERS, Of GUNTHNE& HOSCHEL, PREETZ, FRIEDL-FRANCESCONI, PUHR and PFLEGER.

RehaCom CognitiveTherapy

Physiognomic memory (GESI) Briefdescription $7ith this training the recognition of faces and the pairing of faces to a flame and a profession is practiced very realistically. Faces are displayed ftom different sides. The client decides whether the picture of a person has been shown befote.

In highet levels of difficulty additional verbal information regarding the person (name, profession) has to be memorized.

Indications With ptosopagnosia the ability to recognize faces and establish meaningful associations with them is impaired or lost. The problem can also be related to memofy components that are tesponsible for remembering faces. This disorder is caused by lesion of the tempotal lobe (more often left hemispheric). The training is therefore indicated for all clients with right-sided or bilateral temporal lobe damage of different pathogenesis if the above mentioned impairments are observed.

Basicrequirements of the patient It is necessary that the client is able to perform easy tecognition tasks and handle the patient panel.

Task Faces are memorized during a ,,leaning phase".

Afterwards these faces are picked out from a number of different faces pictured ftom different sides. In higher levels of difficulty a name and a profession ^re to be memorized additionally. It is the client's task then to find out the face conesponding to the name or the profession.

Training material Altogether 47 persons have been photographed from four different views. The pictures almost reach photo quality (16,7 million colours in the SVGA mode; 24 BPP). To adapt the training to local speciaiitiesor the familiar sutrounding of the patient there is an editor to embed own pictures.

Levelsof difficulty Three levels have been designed: t Memorizing faces (1-6 pictures: level 1 to 6) + Connecting face with a n me (2-6 pictures: level 7 to 11) t Memorizing faces with the corresponding name and ptofession Q-6 pictares: Ievel 12 to 16) t Memorizing faces with the corresponding name and phone number (2-6 pictutes: Ievels 17 to21)

Effectiveness Ifith this ttaining ptocedure exacdy those abilities arc tarned that arc impaired in clients with the above mentioned lesions. Therefore a high effectiveness of the training can be expected.

Memorof Y words

(WORT )

Briefdescription This RehaCom procedure trains the recognition capability for individual words. In the so-called ,,learning phase" a cettun number of words is shown. Afterwards ^ vznety of words ,,roll bf' like on a conveyor belt. The client's task is to rccogrttze and pick out the words shown in the Iearning phase.

Indications The taining is especially suitable for clients with an impairment of the word span or reduced tecognition capability - especially for clients with a beginning amnesic syn&ome. This syndrome occurs of patients with diffuse cerebro - organic damage and left hemisphedc or bilateral lesion (especially of the limbic lemniscus with damage of the thalamic parts). The training is also suitable fot clients with functionally caused i-p^itments and for childten from 1.1.years on.

Basicrequirements of the patient Beside the ability to read words, it is a precondition that the client is able to master easy recognition tasks and to press the OK-button on the RehaCom panel.

Task In the learningphasea list of words is memodzed (from 1 up to 10 words). The highet the degree of difficulty, the higher are the number and the difficulty of the words to be memorized. The words presentedin the leatning phaseshould be selectedafterwardsfrom a number of other 6rrelevant)words.

Training material The wotds ^ppex big and pl"inly visible on the screefl. The moving of the words on the scteen is carried out continuously and without jerking. The speed of the words ,,rolling by" can be adapted.

Levelsof difficulty The displayed words are divided into three groups of 200 words each.These groups include: easyand short, easy compound, and complex compound words.

Effectiveness For detailed information please refet to the section ,,Effectiveness Sudies", especially to the studies Of HOSCHEL, POLMIN, PREETZ, FRIEDLFRANCESCONI and PUHR.

RehaCom CognitiveTherapy

Figuralmemory (BILD) Briefdescription This procedure trains the medium-term nofl-verbal and verbal memory (working memory). The patient memorizes pictures with concrete (describable) objects or terms. After the ,,learning phase" according terms or objects roll by like on a conveyor belt. The patient pressesthe OK-button whenever a term or picture of an object of the ,,learning phase" rolls by.

Indications This training is indicated for all memory disturbances (especially for the working memory) for verbal and non-verbal contents. The procedure can also be used in clients with an - organically or functionally caused - impaired ability to name objects and difficulties in conceptual pairing.

Average vocabulary assumed, Figural Memory is suitable fot children from 11 years on.

Basicrequirements of the patient It is required that the client is able to name concrete objects and rcad easy wotds. For independent training the client must be able, regatding his motor skills, to ptess the big buttons on panel.

Task Pictures or terms of concrete objects are displayed. All terms or pictures of these objects have to be memorized now. The ,,learning phase" is terminated by pressing the OK-button.

Afterwards according to the displayed term various pictures or according to the displayed picture various tefms ,,roll by" on the scfeen from the left to the dght like on a conveyor belt.

Whenever a term or picture of an object of the learning phase appears - terms or pictures that

had to be memorized - the client pushes the OKbutton.

Trainingmaterial Because of VGA-graphics with high resolution the pictures appearing on the screerr are of good quality. Regarding the terms, a big and easyto read typeface has been selected. The moving of the words thtough the screen is carried out continuously and without jetking. The speed of the words ,,rolling by" can be adapted to teading speed.

Levelsof difficulty The number of displayedobjects in the,,learning phase" corresponds exacdy to the nine levels of difficulty provided. In the lowest level the client should memoize one object - in the highest level nine objects - and later recognize the corresponding term(s).

Effectiveness For detailed information pleaserefer to the section ,,Effectiveness Studies", especially to the studies of HOSCHEL and FRIEDL-FRANCESCONI.

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Verbalmemory (VERB) Briefdescription Aim of the procedure 'Verbal memory" is to improve the short-time memory for verbal information. Short stories displayed on the screen contain ^ r^nge of details the client is asked to memorize and later reproduce when questioned by the PC.

Indications The ptocedure is recommended for clients with a disturbance or an impairment of their short-time or medium-term memofy. These might be consequences of almost any diffuse brain damage (dementia, alcohol abuse etc.) as well as of full or left-hemisphedc lesion. The training can also be used to improve memory skills in childten from 11 yeatson.

Basicrequirements of the patient The client must be able to read and understand simple language. For independent :r:urung he/ she should be able to use the RehaCom panel.

Task A short story is displayed on the screen. The client is required to memorize ^s m^ny details of the story as possible (dates, numbers, events, objects). The "memoizing phase" can be determined through pressing the OK-button. Finally questions about the content of the story afe asked.

Trainingmaterial More than 80 short stories arc avulable. Depending on the setting, either the computer or the therapist selects a story fot training. The pool of stories available can be extended by virtue of an integrated editor.

Levelsof difficulty There zre lllevels of difficulty. The higher the level of difficulty, the greatet the length and information content of the story. The number of names, numbers, events and objects to be recalled also increases.

Effectiveness For detailed information pleaserefer to the section "Effectiveness Studies", especially the studies by REGEI-6. FRITSCH.

RehaCom CognitiveTherapy

Shopping (EINK) Briefdescription This procedure realistically trains an everyday situation: shopping in a supermarket. All steps necessary are just like in reality. Planning and cootdinating an action are trained as well as the short-time memory (interval between looking into the trolley and looking at the shopping list)'

lndications This procedure is recommended fot clients with defi cits in working memory, concept attainment or planning an action sequence.Trainingwith children from 11 years on is possible, and with eldedy persons in order to maintain their mental abilities.

Basicrequirements of the patient Clients should be able to read and understand a shopping list. To work on his own the client needs the dexterity to handle a mouse or the OK button on the panel. Training is not recommended for clients with attention deficits.

Task The client gets a shopping list with a range of goods. Then he/she moves through a symbolic supermarket with shelves displaytng grouPs of goods (e.g. ftuits, dairy products, stationery).

In order to pick out a particular item (e.g. a bucket) he needs to "entef" the goods department (in this case household articles) by clicking on the shelf. The shelves content with ^ variety of products is displayed then and by the trolley'' into goods ^re "pnt clicking at them. Checking the ttolleys content, taking items out agatn as well as - if adjusted - having a look at the shopping list is possible.

After the client has collected all the goods he thinks he was supposed to buy he finishes shopping by moving to the check out. Here the goods in the trolley are compared to those on the shopping list.

At a higher level the client "receives" an amount of shopping money. The goods then are marked with prices. The task is to check whethet there is enough money.

Trainingmaterial The programme currendy uses some 100 articles illustrated photo-realistically (foodstuffs, household objects, etc.) These articles ^pPe^r otr shelves,from which they must be selected by the patient. The training programme features a voice fesponse; in other words, all of the articles are named when selected.

Levelsof difficulty The procedure provides 18 levels of difficulty with 2 modes. In the first mode the goods on the shopping list have to be bought only.

In the second mode a ceftatn amount of shopping money is available and the client has to check whether there is enough money.

In both modes with increasing difficulty the shopping list gtows.

Effectiveness At the moment studies are conducted. A ttansfet to activities of daily living is expected.

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Plana day (PLAN) Briefdescription This procedure is very closely related to the daily routine in which the patient has to orgarize a day following time schedules.It aims at improving the executive functions or rather at establishing strategies how to plan. It practices basic and - in higher levels of difficulty - complex cognitive skills.

Indications Using this training is recommended to adult clients with disturbances of the executive functions, especially of the ability to plan. This ability to plan and to orgatize everyday life belongs to the most complex human skills. This skill can be impaired as a result of any brun damage, especially of damages of frontal structures or in diffuse cerebral damages.The procedure Plan a day may also be used for training memory skills. However, it is not recommended in cases of verv heaw sedous distutbances.

Basicrequirements of the patient The client needs to be able to understand the task and move hands according to the task. The therapist's presence is strongly recommended for seriously effected clients.

Task The training requkes the client to realtze a set of tasks in optimal ordet. On the screen a "town" ftom birds-eye-view is displayed, it shows buildings which the client needs to go to according to his time schedule. There are three kinds of tasks: t Realize pdorities t Minimize path lengths (and thus the time needed)

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Maximize the number of tasks carried out successfrrlly The levels of difficulty are characterrzedby v^flation of different parameters.

Trainingmaterial The procedure can generate an almost infinite number of different tasks through ever new combinations of rasks, thus providing change and vaiety.

Levelsof difficulty The procedure works adaptively following a validated structure of 55 difficulties. Additional adjustment to the client's capacitiesis possible via the parameter window

Effectiveness Plan a day is a follow-up development of a procedure set up in cooperation with Prof. Dr. Joachim Funke pniversity of Heidelberg). Prof. Funke proved an improvement of clients' planning skills with a DOS-Vetsion of the procedure. Evaluation studies for the procedure are in progress.

RehaCom CognitiveTherapy

LogicaI reasoning (LODE) Briefdescription This training aims at improving logical thinking (reasoning). The client picks out the symbol correcdy completing a row of symbols which is constructed following aloglcal rule, or a combination of logical rules.

Indications Most authors relate the frontal lobes above all vrith abstract reasoning. However, isolated lesions of the frontal lobe seldom ^ppear separately.For that reason there is a high degree of disagreement about which cortical parts are responsible for solving reasoning tasks with non-verbal mateiil.

The training is indicated for patients with acquired cerebro-organic (frontal lobe) damage, when an impairment in logical thinking can be observed.

Those declines in performance occur e.g. quite frequendy as a cause of chronic alcohol abuse, dementia and insult, but also schizophrenia.

Basicreeuirements of the patient The precondition for using the raining is the abi[ty itr the client to focus attention over a longer period of time. He/she should be able to draw easy absftactJogical conclusions. In order to perform the training independendy, the comprehension of easy instruction texts and basic motor skills to handle the RehaCom-panel are preconditions. The training can also be used by children from 12 years on if they arc capable of performing abstractJogical conclusions.

Task From various symbols (,response pool') the client is askedto selectthe one which correctly continuesa given sequence.

Trainingmaterial A sequenceof s).nnbols(citcles, triangles, squares, etc.) of different shape,colour, and size, interconnected by a de, are displayed on the screen.For a false tespond specific hints concerning the type of error (shape, colour, andf or size) zre given.

Levelsof difficulty 23 levels of difficulty are available.With increasing difficulty the client must observe various levels of abstraction in order to find the solution. In the easier levels the symbols maintain e.g. size and colour. Only the shape of the symbol changes.

In higher levels all three components - shape, color and size - change according to sophisticated rhlthms.

Effectiveness For detailed information please refer to the section,,Effectiveness Studies", especially to the study of PUHR.

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Calculations (cALC) Briefdescription Mathematical training enables patients to improve their arithmetic skills. Such skills are essential in many ateas of daily life. The problems to be solved ^revery vaned in natute. Thus, depending on the type of disorder concetned, training can be given in basic mathematical operations or more complex tasks. The basic mathematical problems include size comparisons, quantitative comparison s, atranging according to quantity and basic mathematical operations at various levels of difficulty. Tasks telating to money handling and written addition and subtraction are included to train patients to solve complex mathematical ptoblems.

lndications The treatment programme was developed for patients with impaired arithmetical cognitive skills. These disorders of cognitive function can vary grearJyin nature. They range from restricted basal disorders, such as the inabiJity to estimate sizes and quantities, to problems in applying basic areas of mathematics and difficulties solving complex mathematical problems.

Basicrequirements of the patient The patient should be capable of understanding the task and have the necessarymotor skills to complete it. The presence of a therapist is strongly recommended in the case of severely affected patients.

Task The training involves a wide varrety of tasks.

The patient begins with simple comparisons of size and quantity, and with sorting tasks. Then the basic mathematical operations of adding and

subtracting are ptactised, both mentally and in writing. At more advanced levels, the patient is trained in very rcal-hfe situations to handle money; he must be able to show that he can count, give change or check his own change to the appropriate standard. Finally there are multiplication and division tasks.

Trainingmaterial Size and quantity tasks are practised using pictures of simple objects, until the patient progresses to counting with numbers. During written addition and subtraction, the numbers carried over afe shown in a smaller font. Money handling is practised using pictutes of genuine bank notes and coins.

Levelsof difficulty The programme comprises42 levelsof difficulty and works adaptively

Effectiveness As the training was developed in accordance with precise pedagogic principles, a high level of validity can be assumed.Studies ate currendy being conducted into mathematical taining.

RehaCom CognitiveTherapy

Saccadic Training (SAKA) Briefdescription This procedure is devoloped for patients with reduced visual capacities and visual neglect phenomena (neglect, hemianopsis, hemiamblyopis e.g.).

The patients are instructed to push the left or right reaction button, when left or dght from the centre a f,gxe (e.g. animal, vehicle, person ...) aPPeafs.

Indications This procedure is designed for patients with contra-lateral visual neglect phenomena on one-side and reptesentation disorders. A lower visual exploration on one-side of the sight occurs often with visual neglect or extended cerebral infarcts in the area of the Arteria cerebri or posterior. Also other hear-organic disorders could be the causeof these lower functions.

Basicrequirements of the patient This procedure is less suitable for patients with strong defective vision organic based. Patients must be able to push the large reaction button.

Task The patientlooks at the horizon of a simple (2-dimensional) landscape.A big sun is placed in the middle of the screen.A figure appearsleft or right of the sun with irregular distances. Everytime the patient spots a figure, he/she must push the appropriate reaction button on the panel.

Training material On the scfeenyou can seea horizon. In the simpler levels a sun is in the middle of the pricrure.

A figure appears on this horizon left or right of the sun with irregular distances, different

figures ot symbols, i.e. animals, cars, bikes. The symbols get smaller at the higher levels, the horizon vanishes and additional diversions appear.

It is advisable to use the chin rest.

Levelsof difficulty Three levels of difficulry arc avatTablewith three sizes of the objects ftig, middle, small). They are variable defined by the background contrast (black or grey) and the moving position (fixed or moving) of the object. All together there arc 28 levels of difficulties.

Effectiveness With this RehaCom procedure the visual exploration is trained ,,symptom-orientated". There is a priori expected that with this computer assisted procedure at least the same good training effects are being accomplished as with conventional training with patients who suffer from visual neglect phenomena on one-side.

Exploration (EXPL) Briefdescription The procedure deals with problems in visual exploration. The procedure uses a slow serial searchfor objects which must undergo a precise interpretionor analysis.

lndications The training is recommended for patients with a homonymous restriction in their field of vision, and fot patients who have problems with their visual exploration due to failure in their field of vision, visual neglect. It is also recommended to patients who suffer from Balintsyndrome ot a combination of several of these types of disturbances as a result of some type brain damage.

The procedure can also be used to help patients who suffer from linguistic resrictions and restdctions in their ability to understand words, by combining the use of none vetbal material with the procedure.

Basicrequirements of the client The training programm is less suitable for patients with strong defective vision. The patient must be able to press the large reaction keys on the RehaCom panel Serious disturbances in memory (inabiJity to remember strategies) limits the success of the training. It appears that children of 8 years and oldet could use this training procedure. However, practice is encouraged so that experience can be gained.

Taskandtrainingmaterial The objects are in lines and columns and are divided up in a pre-arcanged manner. The patient searches over the given field with a circular cursor which is the size of a single matrix unit. In this way, the exploration movement of the patient is kept under control. The relevant

objects are not alwaysdistributed unifotmly but are frequendy to be found in an unusual area of the field of vision. It is advisableto use the chin rest.

Levelsof difficulty The exploration training procedure can be adapted to suit up to 30 different levels of difficulty.

In order to adapt certain strategies, the following modifications of difficulty ate included: the numbet and the distance between the number of lines which have to be, the width of the exploration field (number and distance between columns), the recognisability of the different symbols, the distance between the symbols which have to be recognised and therefore, the size and clarity of the cursor (atger distance t less symbols i larger cursor), the variation of the symbols. An additional modification in the levels of difficulty is the speed of the cursor @,xplorations-speed).Its speed can be set up by the therapist to suit each individual patient.

Effectiveness As with all of the RehaCom-procedures the training is ,,symptom orientated". ft can be assumed that with this computer-assisted system, positive training effects can be achieved which are zt Iezst as good as those achieved during conventional training with patients who suffer from a visual neglect-phenomena,in hatf of their field of vision.

Conttolled tests have to be carrierd out.

RehaCom Cognitive Therapy

Overviewandreading

(ztHL)

Briefdescription Both programmes are used to treat non-aphasic teadingdisorders (e.g.in the caseof homonymous visual field defects near the fovea) and overview andf or visual searchdysfunctions in patients with homonymous visual field defects, visual neglect or Balint's syndrome. They were developed and clinically tested by Prof. Zlkl, Prcfessor of Neuropsychology at the University of Munich.

Indications The programmes are not suitable for patients with serious ametropia (visual acuity < 20o/o)or with alexj,z. Serious memory disorders (forgetting instructions and strategies) as well as attention disorders will adversely affect the success of training. Training appears to be possible for children aged 8 and over.

Task Reading: \X/ords or numbers of different lengths appezr on the screen, and ate read aloud by the patient. The display time is resfficted, so that the whole word or number must be registered.

Responses are given to the therapist, who also monitors the progress of the new reading strategy.

Visual search: Combinations of stimuli appear on the scteen, with a predefined stimulus serving as the target stimulus, and the other stimuli as distractions. The patient must search the screen quickly and carefully and indicate the presence or absence of the target stimuius by pressing a button. Responsesare given to the thetapist, who also monitors the progress of the compensation stfategy.

Trainingmaterial Words of different lengths (3-16 letters), short sentences(2-4 words) and numbers (3-6 digits) are

used fot reading training; their length and the time they are displayed can be tailored to the individual patient. Different-coloured letters and shapescan be used for visual seatches.It is advisableto use the chin rest.

Levelsof difficulty Reading training and visual search training increase in difficulry through several levels depending on the patient's progress until predefined performance crtteria are achieved. The following parameters which influence the level of difficulty are incorporated in the adaptation strategy: - the length and display time of the words and numbers, - the difference between target and distraction stimuli and the density of stimuli.

Effectiveness Scientific results arc avallable on the level of effectiveness of both training programmes.

InVISTA'M

Visualtrainingto restore

(vrsr)

Briefdescription Vision Restoration Training (InVISTAT) is a computer based pfogramm to initiate restorative processesin patients with visual impairments due to neurological lesions. The self-adapting programm presents kinetic supra-threshold stimuli on a dark background. The patient is asked to respond to these stimuli by pressing a key.

The therapy progress can be monitored by means of CentraVIEWrM (computer based visual field screening with static supra-threshold stimuli) .

lndications In\{STATM was specifically designed for patients experiencingvision lo ss suchashemianopia following neurological lesions.Functional improvements have been observed in patients with visual neglect, impaitments of visual perception and processing, and problems with reading and attention. Patients with long existing impairments have been shown to also benefit from the taining. It is applicable for patients with aphasiatoo.

Basicrequirements of the patient To perform InMSTATM the patient should be motivated, compliant, and be able to concentr"te for at least 10 to 15 minutes. There is no age limit to the training. The patient should always wear prescribedvisual correction. A head rest for head stabilizatlon and keeping correct distance to the monitor is highly recommended. The patient should be able to press the space button of the kevboard or the buttons of the RehaCom panel.

Task Patients sit in front of the computer monitor and put their chin and forehead in a chin rest to ensuretheir eyesfocus on the centerof the screen.

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Each time the fixation point changes color patients are asked to respond by pressing a button.

A bright stimulus is ptesented on the monitor, moving from the lnta.ctinto the defect visual field.

Patients are instructed to tespond to the moving stimulus by pressing a key as long as they still perceive it. \X/hen the stimulus is no longer responded to, it v/ill change direction and move from defect to intact visual field until the patient seesthe stimulus agun and responds.

Trainingmaterial In\IISTATM comprises of fout vetsions to accommodate for different patterns of impairment. The parameteitzation is based on clinical expert knowledee.

Levelsof difficulty The procedure consistsof four versions for rightand left sided visual field defects. Versions 3 and 4 differ from 1 and 2 by employing high-contrast fixation color changes and longer delay times for responses.This is especially helpful for patients with problems in attention and concentration or deficits in color perception f catanct. Areas of stimulation arc self-adaptiveand adjust to the individual patient's tesults and ptogress.

Effectiveness Clinical studies have shown that after subsequent perfotmance of several months of customized Vision Restoration Thetapy O'RT), 65ohof patients achieved improvements in visual perception.

RehaCom CognitiveTherapy

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F],ri Visuo-motoric coordination

(wrso)

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Briefdescription The object here is to train clients with disorders in visuo-motor coordination. A crrrsor and a rotor @oth abstract or concrete) are displayed on the screen. The client moves the cursor into the middle of the rotor and fties to keep it there following the movements of the rotor.

Indications Damages of the motor cortex (frontal lobe) lead to deficits in the control of the minute motor activity which can be observed most clearly in coordination disorders of the hand and finger movement. In many cerebro-organic diseasesand damages, like cerebral insults, hemorrhage, extensive tumoufs, brain tfauma, etc., visuo motor functions are effected as well. The training is indicated for all disorders of the minute motor activity.

Basicrequirements of the patient In extreme visual disorders as well as in loss of one visual field, the procedure is less suitable.

Demands to the attention capabilities are also made. For vety serious apnxja the training is indicated only if the client is capable of handling the joystick.

Task On the screen a dot and a coloured circle (abstract mode) are presented, or e.g.a butterfly and a flower (concrete mode). The dot and the butrerfly are called "cufsor", the circle and the flower "rotor", The client moves the cursor into the rotor by means of the joystick. Then the totor starts moving along a predictable track. The client tries to follow the movements with the joystick (represented by the cusor). The RehaCom panel is requited to use this programme.

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Levelsof difficulty The difficulty level is adapted to the current performance level of the client. The p^rametefs afe: t the size of the rotor, t the speed of the rotot, and t the type of movement (e.g.predictable or unpredictable, curves)

Effectiveness The training'Visuo-motor coordin L'jon" follows the object persecution paradigm. Therefore one can expect at least the same taining success as under conventional training conditions.

Arrangement in groups

Procedures

Levels

Materialused

AKRE REVE REAl VIGI RAUM VROl RO3D KONS AUFM GEAU GEAU 2

20 16 20 15 42 24 24 18 24 1,4 22

60 sounds 45 traffic signs over 200 stimub Editot 88 obiects in 4 variations 80 obiects in phptpqudity 46 pools with each16 photos 4323-D bodys in 67 categories ovet 100 photos and dmwings 49 pools with each 16 photos visual and acustic visual and acustic

MEMO GESI TTORT BILD VERB

20 2l 20 09 10

4 pools with up to 60 pictures 47 petsonsin 4 diffetentviews each 3 groups with 200 wotds each 200 photos of concreteobiects more then 80 shot stodes

EINK PI-AN LODE CALC

18 23 42

ptroosof 100diftrâ&#x201A;Źntgoods task generator geometric symbols 17 typesof asks with 76 pictues

SAKA E)(PL ZTIfL VIST

28 30 18 00

20 objects in variations 80 symbolsin 2 sizes v/ofidEletterc,nurnbergfoflrls visul stimulations

55

25 pictured objects

RehaCom CognitiveTherapy

Friedl-Francesconi, H., Binder, H. (1996): Cognitive function training in the neurological rehabilitation of craniocerebral injuries. Zeitschift fiir Experimentelle Psychologie, Vol. XLI[, fssue 1,,1-21. In a study on36 patientswith a serious organic psychosyndtome re sulting from craniocerebral injury, two forms of the computer-assisted cognitive function training were compared with one another: 1,2panents were given attention training on the Vienna Determination Device (20 x 40 minute sessionsover one month) in addition to their conventional neurological treatment, 1,2 patients were trained instead with the RehaCom programmes 'Topological Memory' and VisualSpatial Operations', while the 1.2 patients in the control group were treated only by conventionai methods. Both before treatrnent started and after it was completed, a battery of psychological tests comprising HA\XTE, TULUC, the Aachen Aphasia Test and the Benton Test were carried out, as well as a special neuropsychological battery of tests relating to hemispheric specialisation. In comparison with the other two groups, the experimental group using RehaCom achieved significandy higher values in verbal IQ and performance IQ itt the HArff{IE and Benton tests. Moreover, cognitive stimulation in the two right-hemisphere dimensions 'Topological Memory' and VisualSpatial Operations' proved superior to Attention Training with the Vienna Determination Device,.

Pfleger, U. (1996): Computer-assistedcognitive training programme with schizophrenic patients.

Mtinster/New York: Waxmann - Internationale Hochschulschdften, YoL 204. The effectiveness of computer-assisted training in schizophrenia was investigated in a study using a sample group of 28 patients with chronic schizophrenia. ft was designed as a multi-level study examining not only the direcdy trained ateasof attention and memory, but also psychosocialfunctions and psychopathological symptoms in apre/post comparison.

The'14 patients in the experimental gtoup were trained with both RehaCom programmes (.Attention and Concentration' and'Topological Memory) over 16 sessions. The L4 patients in the control group received the clinict conventional programme of therapy. The results were that improvements could be seen in cognitive perfotmance in terms of attention, but not in terms of memory (multiple-choice vocabulary test, syndrome short test, d2 test and scales from the performance testing system); psychopathological symptoms and the level of psychosocial function were rated by the patients themselves and by third panies on rating scales @rankfurt Complaint Questionnaire, Brief Psychiatdc Rating Scale, NOSIE and SANS). During self-assessment, patients claimed to notice no effect, but third-party assessmentsattested to the trained patients exhibiting changes in social adaptabthqr,social interest and their level of irritabiliw.

Puhr, U. (1997): Effectiveness of the RehaCom programmes Attention and Concenration','Divided Attention','Topological Memory', 'Memory of Words' and'Log1cal Reasoning,in neuropsychological rehabilitation. Thesis at the University of Vienna, Institute of Psychology.

Sixty-three stroke patients, 22 cratiocerebral injury patients and 12 patients with viral encephalitis were ftained using two out of five RehaCom programmes (Attention, Divided Attention, Logical Reasoning, Topological Memory and Memory of Words), depending on their most serious cognitive p erformance defi cit. Training was subdivided into 1,2x 15 minute sessionsover the course of a month. Before and after training, deductive reasoning (coloured progressive matrices), genetal attention (Cognitrone), verbal and figural memory (verbal and non-verbal learning test) and visual petception (Corsi) were examined. Pre/post comparison showed first-order transfer effects (training effects), but no generalisation effects.

Preetz, N. (1992): Study to validate a computer-assisted neuropsychological memory and concentration training programme for patients with cerebral damage at a chtic for neurological and orthopaedic rehabilitation. Dissettation ^t Magdebutg Medical Academy.

Thirty neurological patients with mainly vascular brain damage who were undergoing out-patient treatment at a neutological-orthopaedic rehabilitation clinic took part in this study. The experimental group comprised 15 patients with cognitive defects requiring treatment, and the control gfoup 15 patients with no serious cognitive defects. The patients in the experimental group received 16 training sessionsat the PC lasting ca. 45 minutes each, at which two of a possible four RehaCom programmes wefe used on each occasion (Iopologrcal Memory, Memory of \Words, Attention, Vigilance).

The effects of training were examined using a bzttery of tests comprising perfotmance tests (d2test, Vienna Test System/work performance series, Colour-Word Interfetence Test, Standard Version of Progre ssiveMatrices, HA\ME / numb et repetition, Vienna Test System/reaction time measurement, NTMS/pair association test, Diagnosticum for Cerebral Defects, Benton Test and LGT-3/objects) and questionnaires. It was observed that the experimental group, but not, howevet, the control gfoupr demonsttated significant improvements in performance in the trained areas of attention and memory, as well as genetalisation effects affecting cognitive functions not directly trained, such as intellectual capacityand cognitive adaptability. The PC training also improved the patients' subjectivemood.

Wenzelbutger, K.T. (7996): The change in and trainability of cognitive functions among alcohol-dependent patients undergoing withdrawal

- a controlled study. Dissertation at the Medical Faculty of Eberhard Kads University, Tiibingen.

Two treatment pfogfammes v/efe compared with orre another during a thtee-week period of An controlled in-patient alcohol withdrawal.

18 patients was experimental group of given 4 training sessions lasting 45 minutes each 'Topological with RehaCom's Attention' and Memory' progfammes. A second experimental group of 18 patients took part in memory training (games) in the same timeframe. The conttol group was treated as notmal in-patients.

Beckers (Diisseldorf Neurolo gical Tteatment In: Sfeber, P.; Regel, H. & KrauCentre): (1998). RehaCom computer-assiSe, A. sted programmes fot cognitive rehabilitation. (I\ewsletter 9/98). Modling: Schuhftied.

This study was conducted on six patients suffering craniocerebral injuries, all. of whom exhibited serious deficits in attention and memory.

SYAIS-R, WMS-R, RBMT, d2 and the Vienna Determination Device were used to examine cognitive pedormance before and after training. The training comptised 9 x 20 minute sessions with 'MEMO' programmes. the 'AUFM', ry'IGI' and A 'befote and aftef comparison showed significant imptovements in WMS-R subtests and with the Vienna Determination Device. A single case analysis led to the following conclusions: the effects of the specific computer-assisted cognitive training are most apparent in tests which relate to the same function as the programme. Each type of training improves only the intended dimension, and exhibits no global effect on other functions.

With craniocetebtal injury patients, it improves performance in the functions being trained.

RehaCom CognitiveTherapy

Giinthner, A., Jung, V. (Thesis, University of Tiibingen, 1997): Effectiveness of the RehaCom progfammes Attention and Concentration','Divided Attention','Topological Memory','Memory for Words' and'Log1cal Reasoning' in neuropsychological rehabilitation. Giinthn er/ Jung studied 60 alcoholics during detoification using a threegroup experimental design. The first group was trained with RehaCom (AUFM and MEMO) in four sessionsof 40 minutes each (20 minutes per dimension). The second group was given memory training with (non-computer) memory games in the sametimeframe. The third group was used as a control, and received no training. All three groups were tested before and after with a battery of paper/pencil tests (LPS [short form], revision test, trail-making test B and Benton Test). One important result was the significant intervention effect found in the RehaCom and memory-g megroups in the Benton Test. In a second study, Giinthner examined 20 schizophrenic patients using the same battety of tests. In this case,however, he omitted the 'games' comparison group. In this study too, memory training was found to have had an effect, becausethere were again significant imptovements in the Benton Test. No effects on other test performances (LPS) could be proven in either study.

Fldschel, K., Uhlendodf, V., Biegel, K., Kunert, Weniger, G. & Ide, E. (7996\: Effectiveness of out-patient neuropsychological attention and memory training in the late phase following craniocerebral injury. Zeitschrift fiir NeuropsychoIog1e,T,Issue 2, 69-82. Hcischel and colleagues conducted a pilot study to examine how effective neuropsychological attention and memory training might be in the case of craniocerebral injury out-patients in late rehabilitation. Seven such patients were given individualised attention and memory training over about 3 months using a number of programmes, including RehaCom (Attention, Vigilance, Reactivity, Figural

Memory, Topological Memory and Memory for Words). Pre/post comparison and a follow-up six months later revealed cleat and enduring improvements in attention functions GAP, divided attention, set shifting) and a significant, but only moderately stable improvement in memory performance (selective reminding). There was no conclusive evidence of generalisation to other attention and memorv-related functions.

(Mdlndal): Schuhfried Jutblad & Erikson (2000). Newsletter. (I.I". 9). Modling: Schuhfried.

In a Swedish study, eight patients aged between 20 and 58, all with cognitive function impairments, were examined. Based on the test results flWAIS-R, TMT A and B, Gottschald test battery, Cronhol-Molanders memory test and the AMPS), thtee RehaCom programmes (AUFM, REA1, !fORT, MEMq RAUM or WISO) were selected for each patient. For a period of 10 weeks, each of the patients trained with each programme twice a week for a maximum of 30 minutes.

Significant improvements in the'$7AIS-R, in the Gottschald test battery and in the TMT A were found in the follow-up diagnosis. The AMPS indicated a genenl improvement in motor tempo and planning abiJiry. A survey of the patients' families produced the following results: the reIatives of five patients stated that, even in everyday situations, they had noticed improvements in attention. In the case of four patients, their relatives observed improved memory performance when faced with everyday challenges.

Liewald, A. (1996): Computer-assisted cognitlve training with alcohol dependants during the detoxification phase. Dissertation at the Medical Faculty of Eberhard Katls Universiry Ttibingen.

Four x 40 min. sessions at the PC were attended over a period of two weeks by 20 alcohol-dependent men participating in a three-week course

of detoxification and motivational treatment, in 'Atwhich the patients v/ere trained using the 'Iopological tention and Concentration' and Memory' RehaCom programmes. The performance of patients was tecorded before and zfter training in a number of neuropsychological tests.

All in all, training and the tests revealeddistinct improvements in performance. The author concludes thatitis completelyfeasible andworthwhile to carry out cognitive training even during detoxification.

Mellfeldt Milchert, S. (2002)z Datorisetad kogntiv rehabilitering psykiatrisk oppenvird Stockholms psykiatriska sektor Spinga $/istra (2000). psykiatriska omride) Schuhfried Newsletter. QtIo. 9). Modling: Schuhfried.

Another Swedish study looked at computerassisted cognitive rehabilitation in out-patient psychiatric treatment. Eight psychiatric patients suffering from problems of depression and cognitive dysfunction were trained using a selection of RehaCom programmes. For each patient, training comprised 40 sessions (of no more than 60 minutes each), split between the programmes AUFM, GEAU, \TGI, MEMO and BILD. The following tests were used to analyse the effectiveness of training: \7AIS-R, Benton Visual Retention Test, Wisconsin Card Sorting Test, TMT A and TMT B and Beck Depression Inventory. The final examination was evaluated 'single as a case analysis'; all patients showed significant improvements in the WAIS-R, TMT A and B and the Beck Depression Inventory.

Regel, H. & Fritsch, A. (1997)z Evaluation study of computer-assisted training of basic mental functions. Final repott on the funded reseatchproject. Bonn: Kuratorium ZNS. One hundred and twenty patients vrith cerebral damage (88 follow-

ing a stroke, 21 following ctaniocerebralrnjvy,ll ftom other causes)were treated with the logotherapeutic and ergotherapeutic convention al tteatmerits and computer-based training programmes (RehaCom programmes) fot at least four weeks.

One hundred and eighty-two psychometric values were included in the evaluation. Pre/post comparisons revealed 37 - 45 o/oconfirmed differences.

Regel distinguishes three transfer effects: Firstorder transfer effect (training effect): training cognitive function results in improvements in the approprratetests(e.g.training an attention function leads to improved petformance in attention tests).

Second-order transfer effect (generalisationeffect) : training cognitive function resultsin improvements in a cognitive atea which was not the subject of the training (attention training, testing memory function). Third-order transfer effecc training cognitive functjon results in improvements when responding to everydayor ptofessional challenges. correlative connections A number of between increased performance and training progress using RehaCom programmes show that computer-assisted cognitive training plays an important role in improving performance.

Many indications wete found of a third-order transfet by questioning patients, conversing with them and obsetving their behaviour.

RehaCom CognitiveTherapy

Diebel et al. (1998, Magdeburg Social Paediatric Centre):Diebel, A.; Feige,C.; Gedschold,J.; Goddemeier, A.; Schulze,F. & Weber, P. (1998).

Computer-assisted attention and concentration training for healthy children. In: Praxis der Kinderpsychologie und Kinderpsychiatrie, 7998, Issue 9, pp.641-656.

The aim of the study was to examine the RehaCom AUFM programme for use in the treatment of children. The programme was evaluated in the case of children of normal health and from vadous age groups (nursery school children [15] and primary school children from Classes2 [1.2] and 4 t15]). The nursery group trained twice a week, and the primary school children once a week.

Each training session lasted about 15 minutes.

According to the authors, neuropsychological diagnosiswas not possible for reasonsof time and money. The results were therefore based on the data recorded online from ttaining and on questionnaires, from observing behaviour and from the verbal comments of the children. The results achieved by the various age groups differed significantly in terms of the heightened perfotmance parameters of training (evel of performance achieved). Schoolchildren benefited more from training than did nursery school children. The implications of changing the training programme for use by children were also discussed.

Cochet, A.1 Saoud, M.; Gabriele, S.; Broallisl, V.; ElAsmar, C.; Dalery,J.; d'Amato, T. (2006): Impact of cognitive remediation on problem solving skills and social autonomy in schizophtenia: application of the RehaCom@ software.

L' Enc1phale; 32: 189- 195. E A 3092,',.uln6rabilit6 i la psychose de la prediction i la prevention, UCBL Lyon1, IFR 19, Instirut F6d6ratif des Neurosciencesde Lyon (IFNL), CH "Le Vinatier", 95 boulevard Pinel, 69 677 BRON cedex, France.

30 patients who were diagnosed with schizophrenia @SM f\D attended an explorative study.

It was a precondition for those patients to have been taking antipsychotica since at least three months. In sevensessionshappening once a week the following RehaCom@ procedures for cognitive remediation were applied: Reha-AUFM, that trains the attention/concentration, Reha-MEMO, which trains the topological memory, RehaLODE with training of the executive functions using a procedure of logical reasoning, as well as Reha-EINK, which also trains the execurive functions vta z virf:al shopping exercise. So far there was no control group since this happened to be a preliminary study. Alternatively results of similar studies were consulted. Those patients showed a clear improvement of all trained skills as well as their functional skills. Furthermore clinical symptoms of schizophrenia were reduced which was e.g. reflected in a low termination rate.

Notes:

The companyHASOM ED GmbHthanksall partnerswho are and were Withoutyour collaboration involvedin the development of RehaCom. systemfor cognitivetherapy the developmentof such a sophisticated wouldn'thavebeenpossible.

Prof. Hans Regel (f) Medical facuity University of Magdeburg Idea, theoretical concept RehaCom, Attention, memofy

Dr. Peter \X/eber HASOMED GmbH Magdeburg Ideas and concepts RehaCom

Dr. Andreas Krause Medical faculty University of Magdeburg Theoretical concept RehaCom, Attention. memorv

Dipl.- Ing. Frank Schulze HASOMED GmbH Magdeburg Product m n ger Conceptual design and development softwate

Prof. Dr. Joachim Funke P sychological institute Univetsiry of Heidelberg Executive functions

Dr. Thomas Kriiger Centre for evaluation and methods University of Bonn Executive functions

Prof. Dr. Josef Z*1, Clinical neuropsychology Department psychology Univetsity of Munich Visual disotdets

PD Dr. Sandra Verena Mriller Neuropsychology Stroke Unit Clinical centre Bremen-Mitte gGmbH Occupational rehabilitation

w-erres iohannes

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Organisation of integration Occupational rehabilitation ceritre Sachsony-Anhalt

The name RehaCom stands for a system that includes mote than 25 ptocedures for effective cognitive therapy of functional brain disorders. RehaCom contains procedures for specific and basal as vrell as fot complex and realistic training.

The use of RehaCom offers the following

+ + + + + + +

benefits:

Adaptive training - optimal operation Available in 14 languages - ttaining in the patient's own language Special patient keyboard - raining possible even with restricted motor function Central patient administration - low administrative costs Home training on the internet - observed by a therapist if required Standardised operation and Help function - short inttoduction time Automatic record of past treatment - progress can be followed cleady

Computer:

Prozessorzb 1GH4512 MB RAM (dependingon the system) At least1 GB free spaceon harddisk USB po. for the Rehacom panel or a seierf parallelor uSB port for a dongle t DirectX compatiblegraphic card + Mouse,Keyboard and CD/DVD optical drive t soundcard,speakersor headphones(for audio response) t STindows98/ \/IE / 2000/Xp/Vista t t t

Monitor:

VGA colour monitor, L5,, otlatget (recommendation 1.7,, to 2,!.,) fot easierhandling some of the procedures use a touch screen

Printer:

any printer supported by Windows