RehaCom Procedure Catalogue

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How do patients benefit from RehaCom? Brain damage, whether as a result of a stroke, an accident or old age, can often lead to cognitive dysfunctions.

Computer technology can help treat this impairment of the brain’s performance.

RehaCom is the ideal instrument for improving attention, memory and other brain functions. By adapting to individual progress made in the tasks, the system accurately responds to the level of skill of the patient, so that he is challenged to exactly the right extent.

This maximises the improvement in brain function. RehaCom offers variety and motivates the trainee.

Targeted, error-specific responses initialise learning processes and support the development of strategies.

High technical standards and good graphic design optimise the success of the treatment.

This is demonstrated by numerous clinical studies examining the effectiveness of the technique, and years of successful use across almost the entire range of neurological treatment clinics.

RehaCom is an efficient form of therapy for the maximum benefit of patients.

What is the story behind RehaCom? Prof. Hans Regel developed the theoretical concept behind RehaCom in 1986. Ever since, it has been undergoing continuous upgrading, initially at the University Clinic of the University of Magdeburg, and since 1992 by HASOMED GmbH. A team of psychologists and technicians is involved in an ongoing process of perfecting established programmes and developing new ones for the treatment of additional cognitive disorders.

With its innovative ideas, RehaCom is now the market leader in Europe.

HASOMED GmbH in Magdeburg is a medical technology manufacturer certified to quality standard ISO EN 13485. We are committed to quality. This extends not only to our programmes, but also to our technical specifications and our comprehensive aftercare service.

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

RehaCom Cognitive Therapy

Introduction into the system RehaCom

Cognitive defects are the frequent consequences of brain damage, and the need for an appropriate therapy instrument 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 the positive change of the cognitive abilities of the patients. The main success criterion 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-centered therapy, play therapy, logopaedics, physiotherapy or occupational therapy, the computer-assisted therapy gains ever more significance.

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

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

Resource orientated 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. However, this function transfer must be trained and stimulated, and this is done through the following therapy approaches: Exercise procedures

Giving over of internal strategies Supporting metacognition Using external help.

Computer-assisted training mainly consists of repetitive exercise and needs the therapist to give over strategies linking 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 therapy forms contributes to therapy success considerably.

The computer supports the patient as an untiring and never despairing teacher, even if the patient‘s progress is slow. New exercises are constantly generated, as long as the patient achieves the required therapy target. By editing own contents, the therapist can even widen the offer of tasks and adapt the tasks to local traditions.

Basic elements and features 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 uses concepts of psychological tests, others are „copies“ of computer games, and a third group developed for educational assumptions.

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:

Modular structure of the training procedures: training of basic functions up to complex demand Best possible interaction between the therapist, patient and computer as basic element of the training Adaptation of the training level to the patient’s capacities

Introduction into the system RehaCom

Powerful feedback for motivating the patient Effective process recording for finding deficits and capacities.

Modularity RehaCom trains different cognitive areas according to the procedure. 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 Selecting a procedure according to the cognitive deficit Selecting a combination of procedures according to the profile of cognitive deficits Variation of the training structure (number of tasks per session, changes in the level of difficulty etc.)

Interaction between therapist, patient and computer In the therapist-, patient- and computer relationship the dominant element should be the therapist-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 for solving the training tasks. The computer provides instruction on the training tasks, information on the progress of performance and positive feedback.

Patient adjusted panel A special keyboard (RehaCom panel) helps the patient to communicate with the computer. A conventional keyboard is mostly unsuitable for therapies since it is too confusing and requires high dexterity. The RehaCom panel is reduced to the minimum necessity.

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

Automatic adaptation to current performance 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 and feedback Individual training is necessary for maximum motivation. Adapted instructions and help menus are used to achieve optimal instruction comprehension (“learning by doing�). The client receives continuous performance feedback via pleasant sounds and images. Every training procedure is equipped with a large item pool to avoid habituation and boredom in the client.

Procedures which are highly realistic proved to be of growing importance.

After solving a task, the clients receive information on the quality of performance as well as instructions for the next tasks.

RehaCom Cognitive Therapy

Introduction into the system RehaCom

Continuity, patient progress and process recording Specific progress data are recorded for every training procedure. They are the basis for a change of level and the feedback. Saved in every session, the patient’s progress can be traced back to the very first session on 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 session finished.

Efficiency and economy The procedures generally allow the client to train on his own, instructed and verbally motivated by the PC. At the beginning of each training session, though, the therapist’s presence is needed in order to define the day’s 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 performance together and speak about difficulties that occurred.

The computer cannot 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 divercified training.

Language availability and distribution The procedures which operate under the system name RehaCom, which now number 29 (21 of themtranslated into English, have been on the market since 1992. Cognitive training with RehaCom is used in thousands of leading neurological rehabilitation clinics and out-patient departments and by practice therapists in Germanyand elsewhere. Improvements to the RehaCom system are, to a large extent, based on their experiences and on the results of a series of effectiveness studies 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 translated into more than 14 languages. RehaCom customers who wish to train their patients in their native tongue can benefit from this multilingual provision.

Continuing RehaCom treatment in clinical practices and at home after leaving hospital

It is often advisable to continue brain performance training with RehaCom in a clinical practice or at home after a hospital stay. For financial reasons, patients often spend too little time in hospital to achieve sustainable success in the long term. That is why an increasing number of neurological and occupational practices are offering their patients RehaCom training.

RehaCom enables customers to export patient 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 files and the results of treatment seamlessly, either in the practice or at home. With its dialogue-oriented structure, integrated instruction cycle for patients and auto-adaptive mode of operation, users are able, once instructed accordingly, to work with RehaCom independently for prolonged periods.

Little 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.

Introduction into the system RehaCom

Prescribing treatment and the 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 prescribes: when the patient should use which method of training and under what circumstances and can leave precise instructions for the patient to follow.

The information 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 smart 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 smart card

The therapist can access it from the RehaCom server, evaluate training and set new targets.

Future perspectives The development of new procedures is determined by the experiences with existing procedures, 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 everyday routine. Clients should clearly see that a progress in the training leads to a progress in activities of daily living.

Help desk 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�, or have a question on RehaCom, the staff of HASOMED, RehaComteam is always there for you.

RehaCom Cognitive Therapy

Alertness Acoustic reactivity (AKRE) Brief description The aim of the procedure “Acoustic reactivity� is to improve precision and speed of acoustic reactions. The sounds are familiar 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 ability. Furthermore the training makes a strong request to mental flexibility and focused attention. In clients liable to interferences the therapist should make sure they are not overstrained. For training with children from 8 years on child-oriented instructions are provided.

Basic requirements of the patient The ability to perceive 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 learns 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 ringing telephone etc.) are 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 (e.g. waves on the beach) are provided. Pictures on the screen and certain acoustic stimuli create a particular environment or situation (e.g. at home,

on a farm 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!

Levels of 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 scientifically. Because of the high closeness to real life a good transfer of the skills trained to everyday situations can be expected.

Alertness Reaction behaviour (REVE) Brief description Respondent behaviour of single and multiple choice reactions (speed and accuracy) towards optical signals is trained. On the edge of the screen traffic signs can be seen. Next to each a key of the RehaCom panel is displayed which has to be pressed when the traffic sign appears in the middle of the monitor. Thus, attention and memory are jointly trained.

Indications The training 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 damages as well as in frontal and prefrontal lesions (e.g. dementia, brain trauma, insult, formation of a tumour, ischemia, etc.).

Basic requirements of the patient The client needs to be able to understand and comply independently with easy instruction texts.

Task Very realistic stimuli (traffic signs) were chosen for this training. The task is to press the corresponding reaction key as quickly as possible whenever a target stimulus (i.e. a traffic sign) appears on the monitor.

Training material The training material consist of realistic traffic signs. In the learning phase the pictures of the target stimuli (traffic signs) and the corresponding reaction keys are presented. By pressing the OK-button the learning phase is terminated.

Then the target traffic signs (towards which the client must react within a certain time interval),

and in higher levels of difficulty also irrelevant traffic signs (which require no reaction), are displayed. The RehaCom panel is required to use this programme.

Levels of difficulty Three types of tasks with 4 or 6 levels of difficulty each have been constructed: The next traffic sign appears only after the response of the previous (6 levels of difficulty).

Fixed interval between the items (4 levels).

The interval changes adaptively. After a correct response a shorter interval is chosen, and vice versa (6 levels).

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

RehaCom Cognitive Therapy

Alertness Ability to respond (REA1) Brief description The objective of reactivity training is to improve the speed and accuracy 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 reactions and the speed and accuracy of reactions following cerebral lesions. It is recommended in the case of disorders of selective attention performance, and in the case of disorders of visual or acoustic discrimination, cognition and/or behavioural performance.

Basic requirements 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 strategies) and disorders affecting attention and concentration may impair the success of training.

Task Reactivity is trained using simple, simple choice and multiple choice reactions, and involves visual and/or acoustic stimuli. After a predefined visual stimulus appears 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 associate the stimuli with the relevant buttons on the panel. The assignment of stimulus to reaction which is learned can be consolidated

during a practice session. Training then proceeds with a selectable number of stimuli. The speed and accuracy of the patient’s reactions are measured and evaluated.

Training material Training incorporates more than 200 visual stimuli and 6 acoustic stimuli in 3 variations each. The therapist can add his own visual and acoustic stimuli (any pictures and sounds he chooses).

There is an integrated editor to create individualised training programmes.

Levels of difficulty The programme offers 20 levels of difficulty with 5 tasks per level. Each task comprises several combinations of stimuli. The various combinations are randomly selected by computer, ensuring that each patient experiences an extremely varied training programme. The programme works adaptively through the 20 levels of difficulty. The higher the level of difficulty, the greater the number of stimuli to be determined and the more varied the temporal sequence of stimuli.

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

Vigilance Vigilance (VIGI) Brief description 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 impairments 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 can be expected in cognitive performance as well as, to some extent, age-related transfer effects.

Basic requirements of the patient The task of this training is very simple. The patient has simple visual differentiations to solve. Children can be trained also to appropriate instructions.

Task The task of this training is designed to be very easy. Basic visual differentiation tasks are required 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 remove these from the conveyor at the point indicated.

Training material Objects are displayed on a conveyor belt and have to be compared to one or several fault-free „sample objects“. The client should find those objects that are not identical to the sample objects (= faulty objects).

Levels of difficulty According to the parameter settings concrete objects (e.g. a washing machine, a refrigerator, etc.) or abstract figures are displayed. Childfriendly instructions are provided to assist in its use by children.

15 levels of difficulty are available. With increasing degree of difficulty the following parameters grow: the number of differing („faulty“) objects, the number of differing elements, the number of objects displayed as well as the complexity of the pictures.

Effectiveness For detailed information please refer to the section „Effectiveness Studies“, especially to the studies of BECKERS, HÖSCHEL, PREETZ and FRIEDL-FRANCESCONI, PHUR, PFLEGER, GÜNTHER.

RehaCom Cognitive Therapy

Visual spatial attention Spatial operations (RAUM) Brief description 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 (filling 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 ability to understand words or language.

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

Task and training material When estimating positions, two fields with structured backgrounds are displayed on the screen.

One of them shows an object (e.g. a car) at a fixed position. In the second field the same object is displayed at a different 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 buttons on the RehaCom panel.

Photographs and drawings are used. When estimating angles, 2 angles have to be made equiangular. When estimating relations, vessels have to be filled with “liquid” (half full, 1/3 etc.)

When estimating sizes, the fields display objects – drawings or photographs - of different sizes which have to be brought to equal size by

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

The short-term memory for spatial perception is trained in higher levels when the original object vanishes with the first adjustment of the “copy”.

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

Levels of difficulty The procedure works adaptively, for each category a separate serial of levels from 1 to 9 has been validated, in total 42 levels. The tasks of each category are explained in an instruction phase via “learning by doing”.

Effectiveness Studies for this procedure are not yet available.

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

Visual spatial attention Two-dimensional operations (VRO1) Brief description The procedure “Two-dimensional operations” trains the positioned relationship with twodimensional presentation. The task is to find the picture of a matrix which exactly corresponds to a „comparison picture“. The corresponding picture is twisted towards the „comparison picture“.

Indications A decline in the performance in visual-constructive tasks, items of the position-in-space-exploration as well as in spatial orientation are observed for right hemispheric temporal and parietal and damages of the frontal lobe. The training is indicated for patients with lesions in this location, diffuse brain damage or mental defectives.

Basic requirements of the patient Two-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 are a precondition. On the other hand considerable correlation with the ability to solve abstract „brain-teasers“ and intelligence in general have been found in various investigations. For clients with extreme intellectual impairments or a pronounced attention disturbance the training is less suitable.

Task On the screen various pictures (objects) are displayed that should be compared to an

object at the edge of the screen. The corresponding picture, which has to be found out, is twisted towards the comparison picture.

Training material Geometric figures, e.g. squares, arrows, hexagons, are used as objects. At higher levels of difficulty, the training material increases in complexity – up to concrete objects and street-maps.

Levels of 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 corresponding picture increases. Whilst at lower levels of difficulty the tasks can be solved by estimating sizes and lengths, at higher levels the patient must visualise the rotation of objects.

Effectiveness For detailed information please refer to the section „Effectiveness Studies“, especially to the study of FRIEDL-FRANCESCONI.

RehaCom Cognitive Therapy

Visual spatial attention Three dimensional operations (RO3D) Brief description Spatial sense and attention performance are trained. This is achieved by showing several threedimensional 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 for a genuine 3D representation are an additional option.

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

Basic requirements 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 intellectual impairment or for those suffering from serious attention disorders. Intact vision is required, particularly at higher levels of difficulty where 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.

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

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

Levels of difficulty The programme works adaptively. Twenty-four levels have been validated altogether. Training commences with simple bodies and shapes, later progressing to compound objects with and without an indication of direction. At the highest levels of difficulty, the complexity of the bodies increases 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 are at a preparatory stage. With the indications described above, however, good rehabilitation results can be anticipated, because the training the patient receives is specific to his disorder. The experiences and results obtained using the ‘Twodimensional Operations’ RehaCom programme appear to be transferable.

Disorders in Visual spartial attention Spatial Operations Visuo-constructive Abilities (KONS) Brief description The procedure “Visuo-constructive abilities” trains visual reconstruction of concrete pictures.

The client memorizes a picture in every detail.

Afterwards the picture is displayed divided into several pieces as in a puzzle. Then the puzzle has to be reconstructed correctly.

Indications Specialists literature claims that parietal lesions cause constructional apraxia. For managing tasks as in this procedure, 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 capacity of the visuo-constructive field as well as in other generalized functional disorders. Often such a general decline in the performance can be observed in organic brain damages (e.g. through intoxication, alcohol abuse etc.). Since only pictorial material is used, the training is also suitable for children from about 8 years on.

Basic requirements of the patient For clients with serious apraxia, amnesia, and concentration disturbances the training is rather unsuitable.

Task The training is constructed analogue to traditional „puzzle“ games. In the beginning of a task a picture is displayed which 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 reconstructed.

Training material The pictures appear in very high resolution (256 color mode) on the screen. Pictures of houses, faces, paintings, landscapes etc. are used.

Levels of difficulty Altogether 18 levels of difficulty are provided. The main criteria for the change in the level is the number of puzzle 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 playing (often also in combination with other programms and exercises). 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

Selective attention Attention and concentration (AUFM) Brief description The RehaCom procedure “Attention & concentration” is based on the pattern-comparisonmethod. The patient has to find the picture from a matrix which corresponds exactly to the „comparison picture“.

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

Basic requirements 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 panel are necessary.

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

Training material A total of 49 picture pools - each containing 16 pictures - has been set up. Because of the use of VGA-graphics with high resolution, the pictures appearing on the screen are of good quality. They represent different types of objects according to the parameter settings: either

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

Levels of difficulty The adaptive change in the difficulty of the tasks guarantees that the client will be confronted with neither too difficult nor too easy tasks. Altogether 24 levels of difficulty are 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 GÜNTHNER, BECKERS, HÖSCHEL, POLMIN, PREETZ, FRIEDLFRANCESCONI, PUHR and PFLEGER.

Divided attention Divided Attention (GEAU) Brief description 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 reacts towards different signals „during the journey“.

Indications Problems in focusing attention towards several different objects simultaneously occur with almost all diffuse brain damages (e.g. intoxication or alcohol abuse) as well as with local damages of 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. Because of the animated presentation the training is very motivating and suitable also for children from 11 years on.

Basic requirements of the patient The client should be able to understand and comply with easy instructions independently.

Task On the lower part of the monitor a driver’s cabin is represented. Above, one can observe the track (like 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 driver’s panel contains a speedometer, a so called „deadman lamp“ and the “emergency break lamp”. On the speedometer a target speed is set the client should comply with. On the flashing of one of the lamps the client must press the

corresponding button 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 at a red block signal).

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

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

RehaCom Cognitive Therapy

Divided attention Divided attention 2 (GEA2) Brief description Driving a car the patient has to pay attention parallel 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.

Later on, with growing level of difficulty, there are further tasks, which wait for certain reactions of the training person in other area of attention.

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

Basic requirements 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 by instructions appropriate for children also children up from age 10 are able to train with this procedure.

Task On your monitor you will have simulated a look through a frontal window 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 away in 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 drive. Below the green area there is a red arrow, which shows you the current speed. The red arrow must always be located in

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

Training material 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 expired time. The aim is to drive a certain distance in a limited time. It is to pay attention 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. While 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.

Levels of difficulty The procedure works adaptive. In total there are 22 levels validated. Within the training the difficulties vary by adding more and more levels of attention and by modifying the interval of the stimuli.

Effectiveness Good results of rehabilitation can be estimated because the client is trained specifically to his disturbances. Studies are in process.

Training of memory Topological memory (MEMO) Brief description This procedure trains topological memory.

Like in a memory-game the position of cards with pictures (e.g. a lion, a flower, a house, a car, etc.) or geometric figures should be memorized.

Once the cards are turned “upside down”, their position has to be remembered.

Indications The indication for this training is given for all memory disorders or impairments regarding verbal and non-verbal contents. Amnesiac syndromes can be observed for all diffuse cerebroorganic diseases (dementia, intoxication, chronic alcohol abuse etc.) as well as for all left or both sided lesions of the medial or basolateral limbic lemniscus. More over vascular diseases, brain trauma, or brain tumours in prefrontal, temporal up to parietal cortical areas can lead to memory deficits.

Basic requirements 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 difficulty) with concrete pictures or geometric figures 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 picture will be displayed and the client indicates which of the hidden pictures corresponds to it.

Training material In total 464 pictures (pictures of concrete objects, geometric figures and letters) are available. The number of simultaneously displayed pictures varies from 3 to a maximum of 16.

Levels of difficulty There are 20 degrees of difficulty defined by a number of cards and complexity.

Effectiveness

For detailed information please refer to the section „Effectiveness Studies“, especially to the studies of GÜNTHNER, BECKERS, HÖSCHEL, PREETZ, FRIEDL-FRANCESCONI, PUHR and PFLEGER.

RehaCom Cognitive Therapy

Training of memory Physiognomic memory (GESI) Brief description With this training the recognition of faces and the pairing of faces to a name and a profession is practiced very realistically. Faces are displayed from different sides. The client decides whether the picture of a person has been shown before.

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

Indications With prosopagnosia the ability to recognize faces and establish meaningful associations with them is impaired or lost. The problem can also be related to memory components that are responsible for remembering faces. This disorder is caused by lesion of the temporal 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.

Basic requirements of the patient It is necessary that the client is able to perform easy recognition tasks and handle the patient panel.

Task Faces are memorized during a „learning phase“.

Afterwards these faces are picked out from a number of different faces pictured from different sides. In higher levels of difficulty a name and a profession are to be memorized additionally. It is the client‘s task then to find out the face corresponding 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 specialities or the familiar surrounding of the patient there is an editor to embed own pictures.

Levels of difficulty Three levels have been designed: Memorizing faces (1-6 pictures: level 1 to 6) Connecting face with a name (2-6 pictures: level 7 to 11) Memorizing faces with the corresponding name and profession (2-6 pictures: level 12 to 16) Memorizing faces with the corresponding name and phone number (2-6 pictures: levels 17 to 21)

Effectiveness With this training procedure exactly those abilities are trained that are impaired in clients with the above mentioned lesions. Therefore a high effectiveness of the training can be expected.

Training of memory Memory of words (WORT) Brief description This RehaCom procedure trains the recognition capability for individual words. In the so-called „learning phase“ a certain number of words is shown. Afterwards a variety of words „roll by“ like on a conveyor belt. The client‘s task is to recognize and pick out the words shown in the learning phase.

Indications The training is especially suitable for clients with an impairment of the word span or reduced recognition capability - especially for clients with a beginning amnesic syndrome. This syndrome occurs of patients with diffuse cerebro - organic damage and left hemispheric or bilateral lesion (especially of the limbic lemniscus with damage of the thalamic parts). The training is also suitable for clients with functionally caused impairments and for children from 11 years on.

Basic requirements 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 learning phase a list of words is memorized (from 1 up to 10 words). The higher the degree of difficulty, the higher are the number and the difficulty of the words to be memorized. The words presented in the learning phase should be selected afterwards from a number of other (irrelevant) words.

Training material The words appear big and plainly visible on the screen. The moving of the words on the screen is carried out continuously and without jerking. The speed of the words „rolling by“ can be adapted.

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

Effectiveness For detailed information please refer to the section „Effectiveness Sudies“, especially to the studies of HÖSCHEL, POLMIN, PREETZ, FRIEDLFRANCESCONI and PUHR.

RehaCom Cognitive Therapy

Training of memory Figural memory (BILD) Brief description This procedure trains the medium-term non-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 presses the 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 for children from 11 years on.

Basic requirements of the patient It is required that the client is able to name concrete objects and read easy words. For independent training the client must be able, regarding his motor skills, to press 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 terms „roll by“ on the screen from the left to the right 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.

Training material Because of VGA-graphics with high resolution the pictures appearing on the screen are of good quality. Regarding the terms, a big and easy to read typeface has been selected. The moving of the words through the screen is carried out continuously and without jerking. The speed of the words „rolling by“ can be adapted to reading speed.

Levels of difficulty The number of displayed objects in the „learning phase“ corresponds exactly to the nine levels of difficulty provided. In the lowest level the client should memorize one object - in the highest level nine objects - and later recognize the corresponding term(s).

Effectiveness For detailed information please refer to the section „Effectiveness Studies“, especially to the studies of HÖSCHEL and FRIEDL-FRANCESCONI.

Training of memory Verbal memory (VERB) Brief description Aim of the procedure “Verbal memory” is to improve the short-time memory for verbal information. Short stories displayed on the screen contain a range of details the client is asked to memorize and later reproduce when questioned by the PC.

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

Basic requirements of the patient The client must be able to read and understand simple language. For independent training 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 as many details of the story as possible (dates, numbers, events, objects). The “memorizing phase” can be determined through pressing the OK-button. Finally questions about the content of the story are asked.

Training material More than 80 short stories are available. Depending on the setting, either the computer or the therapist selects a story for training. The pool of stories available can be extended by virtue of an integrated editor.

Levels of difficulty There are 10 levels of difficulty. The higher the level of difficulty, the greater 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 please refer to the section “Effectiveness Studies”, especially the studies by REGEL& FRITSCH.

RehaCom Cognitive Therapy

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

Indications This procedure is recommended for clients with deficits in working memory, concept attainment or planning an action sequence. Training with children from 11 years on is possible, and with elderly persons in order to maintain their mental abilities.

Basic requirements 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 displaying groups of goods (e.g. fruits, dairy products, stationery).

In order to pick out a particular item (e.g. a bucket) he needs to “enter” the goods department (in this case household articles) by clicking on the shelf. The shelves content with a variety of products is displayed then and goods are “put into the trolley” by clicking at them. Checking the trolleys content, taking items out again 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 whether there is enough money.

Training material The programme currently uses some 100 articles illustrated photo-realistically (foodstuffs, household objects, etc.) These articles appear on shelves, from which they must be selected by the patient. The training programme features a voice response; in other words, all of the articles are named when selected.

Levels of 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 certain 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 grows.

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

Executive functions Plan a day (PLAN) Brief description This procedure is very closely related to the daily routine in which the patient has to organize 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 organize everyday life belongs to the most complex human skills. This skill can be impaired as a result of any brain 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 very heavy serious disturbances.

Basic requirements 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 requires the client to realize a set of tasks in optimal order. On the screen a “town” from 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:

Realize priorities

Minimize path lengths (and thus the time needed)

Maximize the number of tasks carried out successfully The levels of difficulty are characterized by variation of different parameters.

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

Levels of difficulty The procedure works adaptively following a validated structure of 55 difficulties. Additional adjustment to the client’s capacities is 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 (University of Heidelberg). Prof. Funke proved an improvement of clients` planning skills with a DOS-Version of the procedure. Evaluation studies for the procedure are in progress.

RehaCom Cognitive Therapy

Executive functions Logical reasoning (LODE) Brief description This training aims at improving logical thinking (reasoning). The client picks out the symbol correctly completing a row of symbols which is constructed following a logical rule, or a combination of logical rules.

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

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 frequently as a cause of chronic alcohol abuse, dementia and insult, but also schizophrenia.

Basic requirements of the patient The precondition for using the training is the ability in the client to focus attention over a longer period of time. He/she should be able to draw easy abstract-logical conclusions. In order to perform the training independently, 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 are capable of performing abstract-logical conclusions.

Task From various symbols („response pool“) the client is asked to select the one which correctly continues a given sequence.

Training material A sequence of symbols (circles, triangles, squares, etc.) of different shape, colour, and size, interconnected by a rule, are displayed on the screen. For a false respond specific hints concerning the type of error (shape, colour, and/or size) are given.

Levels of 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 rhythms.

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

Executive functions Calculations (CALC) Brief description Mathematical training enables patients to improve their arithmetic skills. Such skills are essential in many areas of daily life. The problems to be solved are very varied in nature. Thus, depending on the type of disorder concerned, training can be given in basic mathematical operations or more complex tasks. The basic mathematical problems include size comparisons, quantitative comparisons, arranging according to quantity and basic mathematical operations at various levels of difficulty. Tasks relating to money handling and written addition and subtraction are included to train patients to solve complex mathematical problems.

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

Basic requirements of the patient The patient should be capable of understanding the task and have the necessary motor 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 variety 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 practised, both mentally and in writing. At more advanced levels, the patient is trained in very real-life 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.

Training material 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 are shown in a smaller font. Money handling is practised using pictures of genuine bank notes and coins.

Levels of difficulty The programme comprises 42 levels of 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 are currently being conducted into mathematical training.

RehaCom Cognitive Therapy

Training of visual field compensating Saccadic Training (SAKA) Brief description 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 right from the centre a figure (e.g. animal, vehicle, person ‌) appears.

Indications This procedure is designed for patients with contra-lateral visual neglect phenomena on one-side and representation 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 cause of these lower functions.

Basic requirements 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 patient looks at the horizon of a simple (2-dimensional) landscape. A big sun is placed in the middle of the screen. A figure appears left 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 screen you can see a horizon. In the simpler levels a sun is in the middle of the pricture.

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

figures or 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.

Levels of difficulty Three levels of difficulty are available with three sizes of the objects (big, 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 are 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.

Training of visual field compensating Exploration (EXPL) Brief description The procedure deals with problems in visual exploration. The procedure uses a slow serial search for objects which must undergo a precise interpretion or analysis.

Indications The training is recommended for patients with a homonymous restriction in their field of vision, and for 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 or 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 restrictions and restrictions in their ability to understand words, by combining the use of none verbal material with the procedure.

Basic requirements 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 (inability to remember strategies) limits the success of the training. It appears that children of 8 years and older could use this training procedure. However, practice is encouraged so that experience can be gained.

Task and training material The objects are in lines and columns and are divided up in a pre-arranged 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 always distributed uniformly but are frequently to be found in an unusual area of the field of vision. It is advisable to use the chin rest.

Levels of 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 are included: the number 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 (larger distance less symbols larger cursor), the variation of the symbols. An additional modification in the levels of difficulty is the speed of the cursor (Explorations-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�. It can be assumed that with this computer-assisted system, positive training effects can be achieved which are at least as good as those achieved during conventional training with patients who suffer from a visual neglect-phenomena, in half of their field of vision.

Controlled tests have to be carrierd out.

RehaCom Cognitive Therapy

Training of visual field compensating Overview and reading (ZIHL) Brief description Both programmes are used to treat non-aphasic reading disorders (e.g. in the case of homonymous visual field defects near the fovea) and overview and/or visual search dysfunctions in patients with homonymous visual field defects, visual neglect or Balint’s syndrome. They were developed and clinically tested by Prof. Zihl, Professor of Neuropsychology at the University of Munich.

Indications The programmes are not suitable for patients with serious ametropia (visual acuity < 20%) or with alexia. 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: Words or numbers of different lengths appear on the screen, and are read aloud by the patient. The display time is restricted, 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 screen, 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 stimulus by pressing a button. Responses are given to the therapist, who also monitors the progress of the compensation strategy.

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

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

Levels of difficulty Reading training and visual search training increase in difficulty through several levels depending on the patientâ&#x20AC;&#x2122;s progress until predefined performance criteria 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 are available on the level of effectiveness of both training programmes.

Training of visual field restoring Visual training to restore (VIST) Brief description Vision Restoration Training (InVISTA™) is a computer based programm to initiate restorative processes in 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 CentraVIEW™ (computer based visual field screening with static supra-threshold stimuli).

Indications InVISTA™ was specifically designed for patients experiencing vision loss such as hemianopia following neurological lesions. Functional improvements have been observed in patients with visual neglect, impairments of visual perception and processing, and problems with reading and attention. Patients with long existing impairments have been shown to also benefit from the training. It is applicable for patients with aphasia too.

Basic requirements of the patient To perform InVISTA™ the patient should be motivated, compliant, and be able to concentrate for at least 10 to 15 minutes. There is no age limit to the training. The patient should always wear prescribed visual correction. A head rest for head stabilization and keeping correct distance to the monitor is highly recommended. The patient should be able to press the space button of the keyboard 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 ensure their eyes focus on the center of the screen.

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

A bright stimulus is presented on the monitor, moving from the intact into the defect visual field.

Patients are instructed to respond to the moving stimulus by pressing a key as long as they still perceive it. When the stimulus is no longer responded to, it will change direction and move from defect to intact visual field until the patient sees the stimulus again and responds.

Training material InVISTA™ comprises of four versions to accommodate for different patterns of impairment. The parameterization is based on clinical expert knowledge.

Levels of difficulty The procedure consists of 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 / cataract. Areas of stimulation are self-adaptive and adjust to the individual patient’s results and progress.

Effectiveness Clinical studies have shown that after subsequent performance of several months of customized Vision Restoration Therapy (VRT), 65% of patients achieved improvements in visual perception.

RehaCom Cognitive Therapy

Visuo-motoric coordination Visuo-motoric coordination (WISO) Brief description The object here is to train clients with disorders in visuo-motor coordination. A cursor and a rotor (both abstract or concrete) are displayed on the screen. The client moves the cursor into the middle of the rotor and tries 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 diseases and damages, like cerebral insults, hemorrhage, extensive tumours, brain trauma, etc., visuo motor functions are effected as well. The training is indicated for all disorders of the minute motor activity.

Basic requirements 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 very serious apraxia 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 butterfly are called “cursor”, the circle and the flower “rotor”. The client moves the cursor into the rotor by means of the joystick. Then the rotor starts moving along a predictable track. The client tries to follow the movements with the joystick (represented by the cursor). The RehaCom panel is required to use this programme.

Levels of difficulty The difficulty level is adapted to the current performance level of the client. The parameters are:

the size of the rotor, the speed of the rotor, and the type of movement (e.g. predictable or unpredictable, curves)

Effectiveness The training “Visuo-motor coordination” follows the object persecution paradigm. Therefore one can expect at least the same training success as under conventional training conditions.

Overview of procedures

Arrangement Procedures in groups

Levels

Material used

AKRE REVE

REA1 VIGI RAUM VRO1 RO3D KONS AUFM GEAU GEAU 2

20 16 20 15 42 24 24 18 24 14 22

60 sounds 45 traffic signs over 200 stimuli, Editor 88 objects in 4 variations 80 objects in phptpquality 46 pools with each 16 photos 432 3-D bodys in 67 categories over 100 photos and drawings 49 pools with each 16 photos visual and acustic visual and acustic

MEMO

GESI WORT BILD VERB

20 21 20 09 10

4 pools with up to 60 pictures 47 persons in 4 different views each 3 groups with 200 words each 200 photos of concrete objects more then 80 short stories

EINK PLAN LODE CALC

18 55 23 42

photos of 100 different goods task generator geometric symbols 17 types of tasks with 76 pictures

28 30 18 00

20 objects in variations 80 symbols in 2 sizes words, letters, numbers, forms visual stimulations

96

25 pictured objects

Training of attention

Training of memory

Executive functions

Training of visual field SAKA EXPL ZIHL VIST Visuo-motoric coordination WISO

RehaCom Cognitive Therapy

Effectiveness studies

Friedl-Francesconi, H., Binder, H. (1996): Cognitive function training in the neurological rehabilitation of craniocerebral injuries. Zeitschrift für Experimentelle Psychologie, Vol. XLIII, Issue 1, 1-21. In a study on 36 patients with a serious organic psychosyndrome resulting from craniocerebral injury, two forms of the computer-assisted cognitive function training were compared with one another: 12 patients were given attention training on the Vienna Determination Device (20 x 40 minute sessions over one month) in addition to their conventional neurological treatment, 12 patients were trained instead with the RehaCom programmes ‘Topological Memory’ and ‘VisualSpatial Operations’, while the 12 patients in the control group were treated only by conventional methods. Both before treatment started and after it was completed, a battery of psychological tests comprising HAWIE, TÜLUC, 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 significantly higher values in verbal IQ and performance IQ in the HAWIE 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-assisted cognitive training programme with schizophrenic patients.

Münster/New York: Waxmann - Internationale Hochschulschriften, Vol. 204. The effectiveness of computer-assisted training in schizophrenia was investigated in a study using a sample group of 28 patients with chronic schizophrenia. It was designed as a multi-level study examining not only the directly trained areas of attention and memory, but also psychosocial functions and psychopathological symptoms in a pre/post comparison.

The 14 patients in the experimental group were trained with both RehaCom programmes (‘Attention and Concentration’ and ‘Topological Memory’) over 16 sessions. The 14 patients in the control group received the clinic’s conventional programme of therapy. The results were that improvements could be seen in cognitive performance 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 parties on rating scales (Frankfurt Complaint Questionnaire, Brief Psychiatric Rating Scale, NOSIE and SANS). During self-assessment, patients claimed to notice no effect, but third-party assessments attested to the trained patients exhibiting changes in social adaptability, social interest and their level of irritability.

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

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

Effectiveness studies

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

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

The effects of training were examined using a battery of tests comprising performance tests (d2test, Vienna Test System/work performance series, Colour-Word Interference Test, Standard Version of Progressive Matrices, HAWIE/number repetition, Vienna Test System/reaction time measurement, WMS/pair association test, Diagnosticum for Cerebral Defects, Benton Test and LGT-3/objects) and questionnaires. It was observed that the experimental group, but not, however, the control group, demonstrated significant improvements in performance in the trained areas of attention and memory, as well as generalisation effects affecting cognitive functions not directly trained, such as intellectual capacity and cognitive adaptability. The PC training also improved the patients’ subjective mood.

Wenzelburger, K.T. (1996): The change in and trainability of cognitive functions among alcohol-dependent patients undergoing withdrawal

– a controlled study. Dissertation at the Medical Faculty of Eberhard Karls University, Tübingen.

Two treatment programmes were compared with one another during a three-week period of controlled in-patient alcohol withdrawal. An experimental group of 18 patients was given 4 training sessions lasting 45 minutes each with RehaCom’s ‘Attention’ and ‘Topological Memory’ programmes. A second experimental group of 18 patients took part in memory training (games) in the same timeframe. The control group was treated as normal in-patients.

Beckers (Düsseldorf Neurological Treatment Centre): In: Weber, P.; Regel, H. & Krause, A. (1998). RehaCom computer-assisted programmes for cognitive rehabilitation. (Newsletter 9/98). Mödling: Schuhfried.

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

WAIS-R, WMS-R, RBMT, d2 and the Vienna Determination Device were used to examine cognitive performance before and after training. The training comprised 9 x 20 minute sessions with the ‘AUFM’, ‘VIGI’ and ‘MEMO’ programmes.

A ‘before and after’ comparison showed significant improvements 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 craniocerebral injury patients, it improves performance in the functions being trained.

RehaCom Cognitive Therapy

Effectiveness studies

Günthner, A., Jung, V. (Thesis, University of Tübingen, 1997): Effectiveness of the RehaCom programmes ‘Attention and Concentration’, ‘Divided Attention’, ‘Topological Memory’, ‘Memory for Words’ and ‘Logical Reasoning’ in neuropsychological rehabilitation. Günthner/Jung studied 60 alcoholics during detoxification using a threegroup experimental design. The first group was trained with RehaCom (AUFM and MEMO) in four sessions of 40 minutes each (20 minutes per dimension). The second group was given memory training with (non-computer) memory games in the same timeframe. 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-game groups in the Benton Test. In a second study, Günthner examined 20 schizophrenic patients using the same battery 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, because there were again significant improvements in the Benton Test. No effects on other test performances (LPS) could be proven in either study.

Höschel, K., Uhlendorff, V., Biegel, K., Kunert, Weniger, G. & Irle, E. (1996): Effectiveness of out-patient neuropsychological attention and memory training in the late phase following craniocerebral injury. Zeitschrift für Neuropsychologie, 7, Issue 2, 69-82. Höschel 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 clear and enduring improvements in attention functions (TAP, 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 memory-related functions.

Jutblad & Erikson (Mölndal): Schuhfried (2000). Newsletter. (No. 9). Mödling: Schuhfried.

In a Swedish study, eight patients aged between 20 and 58, all with cognitive function impairments, were examined. Based on the test results (WAIS-R, TMT A and B, Gottschald test battery, Cronhol-Molanders memory test and the AMPS), three RehaCom programmes (AUFM, REA1, WORT, MEMO, 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 WAIS-R, in the Gottschald test battery and in the TMT A were found in the follow-up diagnosis. The AMPS indicated a general improvement in motor tempo and planning ability. A survey of the patients’ families produced the following results: the relatives 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 cognitive training with alcohol dependants during the detoxification phase. Dissertation at the Medical Faculty of Eberhard Karls University, Tübingen.

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

Effectiveness studies

of detoxification and motivational treatment, in which the patients were trained using the ‘Attention and Concentration’ and ‘Topological Memory’ RehaCom programmes. The performance of patients was recorded before and after training in a number of neuropsychological tests.

All in all, training and the tests revealed distinct improvements in performance. The author concludes that it is completely feasible and worthwhile to carry out cognitive training even during detoxification.

Mellfeldt Milchert, S. (2002): Datoriserad kogntiv rehabilitering psykiatrisk öppenvård (Västra Stockholms psykiatriska sektor Spånga psykiatriska område) Schuhfried (2000).

Newsletter. (No. 9). Mödling: 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, VIGI, MEMO and BILD. The following tests were used to analyse the effectiveness of training: WAIS-R, Benton Visual Retention Test, Wisconsin Card Sorting Test, TMT A and TMT B and Beck Depression Inventory. The final examination was evaluated as a ‘single 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): Evaluation study of computer-assisted training of basic mental functions. Final report on the funded research project. Bonn: Kuratorium ZNS. One hundred and twenty patients with cerebral damage (88 follow-

ing a stroke, 21 following craniocerebral injury, 11 from other causes) were treated with the logotherapeutic and ergotherapeutic conventional treatments and computer-based training programmes (RehaCom programmes) for at least four weeks.

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

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

Second-order transfer effect (generalisation effect): training cognitive function results in improvements in a cognitive area which was not the subject of the training (attention training, testing memory function). Third-order transfer effect: training cognitive function results in improvements when responding to everyday or professional challenges.

A number of correlative connections between increased performance and training progress using RehaCom programmes show that computer-assisted cognitive training plays an important role in improving performance.

Many indications were found of a third-order transfer by questioning patients, conversing with them and observing their behaviour.

RehaCom Cognitive Therapy

Effectiveness studies

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, 1998, 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 various age groups (nursery school children [15] and primary school children from Classes 2 [12] and 4 [15]). 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 diagnosis was not possible for reasons of time and money. The results were therefore based on the data recorded online from training 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 performance parameters of training (level 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.; Saoud, M.; Gabriele, S.; Broallier, V.; El Asmar, C.; Dalery, J.; d´Amato, T. (2006): Impact of cognitive remediation on problem solving skills and social autonomy in schizophrenia: application of the RehaCom® software.

L´Encéphale; 32: 189-195. EA 3092, vulnérabilité à la psychose de la prediction à la prevention, UCBL Lyon1, IFR 19, Institut Fédératif des Neurosciences de Lyon (IFNL), CH “Le Vinatier”, 95 boulevard Pinel, 69 677 BRON cedex, France.

30 patients who were diagnosed with schizophrenia (DSM IV) attended an explorative study.

It was a precondition for those patients to have been taking antipsychotica since at least three months. In seven sessions happening 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 executive functions via a virtual 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:

Team of development

The company HASOMED GmbH thanks all partners who are and were involved in the development of RehaCom. Without your collaboration the development of such a sophisticated system for cognitive therapy wouldn´t have been possible.

Prof. Hans Regel (†) Medical faculty University of Magdeburg Idea, theoretical concept RehaCom, Attention, memory

Dr. Peter Weber HASOMED GmbH Magdeburg Ideas and concepts RehaCom

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

Dipl.- Ing. Frank Schulze HASOMED GmbH Magdeburg Product manager Conceptual design and development software

Prof. Dr. Joachim Funke Psychological institute University of Heidelberg Executive functions

PD Dr. Sandra Verena Müller University Medical Centre Magdeburg Clinic for Neurology Director dpt. Neuropsychology Occupational rehabilitation

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

Prof. Dr. Josef Zihl Clinical neuropsychology Department psychology University of Munich Visual disorders

Johannes Werres Organisation of integration Occupational rehabilitation centre Sachsony-Anhalt Occupational rehabilitation

What is RehaCom? RehaCom is a system used to treat cognitive dysfunctions. More than 25 programmes for the effective treatment of brain function disorders are united under the name RehaCom. The following cognitive areas can be treated:

Training of attention • Alertness • Vigilance • Visual spartial attention • Selective attention • Divided attention Training of memory Executive functions Training of visual field • compensating • restoring Visuo-motoric coordination

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

The use of RehaCom offers the following benefits: Adaptive training – optimal operation Available in 14 languages – training in the patient’s own language Special patient keyboard – training 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 introduction time Automatic record of past treatment – progress can be followed clearly

Technical requirements

Computer:

Prozessor ab 1 GHz, 512 MB RAM (depending on the system) At least 1 GB free space on harddisk USB port for the RehaCom panel or a seriell/parallel or USB port for a dongle DirectX compatible graphic card Mouse, Keyboard and CD/DVD optical drive soundcard, speakers or headphones (for audio response) Windows 98/ME/2000/XP/Vista

Monitor:

VGA colour monitor, 15“ or larger (recommendation 17” to 21“) for easier handling some of the procedures use a touch screen

Printer:

any printer supported by Windows

info@rehacom.com www.rehacom.com

hard- and software for medicine Paul-Ecke-StraĂ&#x;e 1, 39114 Magdeburg, Germany Phone: +49 391.62 30 112, Fax: +49 391.62 30 113 E-mail: info@hasomed.com, Internet: www.hasomed.com