Cognitive Rehabilitation
Orders, Questions, and Feedback Feel free to contact us from Monday to Thursday between 9 am and 5 pm and Friday between 9 am and 4 pm GMT.
T: +49 391.61 07 645 F: +49 391.61 07 640 E-Mail: info@rehacom.com Internet: www.rehacom.com System Requirements
• Regular PC, not older than 3 years • 1 GB RAM • DVD drive • 100 GB hard drive • Windows XP SP3 or newer • 128 MB RAM Direct3D Graphic card (Nvidia, ATI) • Screen, at least 19”, preferably touch screen • Printer • Patientenpult (1990-1997) mit seriellem Anschluss wird nicht mehr unterstützt
• German • English • French • Spanish • Italian • Portuguese • Russian • Dutch • Greek • Finnish • Norwegian • Swedish • Polish • Turkish • Estonian • Korean • Hebrew • Arabic • Chinese
Languages
Further information on www.hasomed.com: Cognitive Rehabilitation
Our products are EN/ISO-13485-certified.
2
HASOMED – Hard- and Software for Medicine
Functional Electrical Stimulation
Gait Analysis
32 Training Modules for
Adaptive and
all Rehab Phases
Deficit -Specific
21 Languages Easy Handling
Close to Reality
Motivating for Patients
Varied Therapy Material
HASOMED – Hard- and Software for Medicine
3
Table of Contens
RehaCom
Introduction into the system RehaCom................................................. 06
Training of Attention
Alertness............................................................................................................................... 12 Acoustic Responsiveness (AKRE) Reaction Behaviour (REVE) Ability to Responsiveness (REA1)
Vigilance (VIGI).............................................................................................................. 15 Visuel-Spatial Attention.............................................................
16
Spatial Operations (RAUM) Two-Dimensional Operations (VRO1) Three-Dimensional Operations (RO3D) Visuo-Constructive Abilities (KONS)
Attention and concentration (AUFM).. ................................................... 20 Divided Attention........................................................................................................ 21 Divided Attention (GEAU) Divided Attention 2 (GEA2)
Training of Memory
4
HASOMED – Hard- and Software for Medicine
Topological Memory (MEM0)........................................................................... Physiognomic Memory (GESI)........................................................................ Memory for Words (WORT)................................................................................. Figural Memory (BILD).......................................................................................... Verbal Memory (VERB)..........................................................................................
23 24 25 26 27
Table of Contens
Executive Functions
Training of Visual Field
Shopping (EINK)........................................................................................................... Plan a Day (PLAN)...................................................................................................... Logical Reasoning (LODE) ................................................................................. Calculationsg (CALC)...............................................................................................
28 29 30 31
Compensating...........................................................................................................
32
Saccadic Training (SAKA) Exploration (EXPL) Overview and Reading (ZIHL)
Restoring............................................................................................................................... 35 Visual Restitution Training (VIST)
Visuo-Motoric Coordination Important Information
Visuo-Motoric Coordination (WISO).....................................................
36
Effectiveness Studies............................................................................................. 38 Team of Development.............................................................................................. 40 Patient Keyboard and Chin Rest................................................................... 09 Overview of Training Modules.......................................................................... 10
HASOMED – Hard- and Software for Medicine
5
RehaCom 2012 – Developed by Therapists for Therapists Cognitive Therapy in Rehabilitation
Effectiveness
For a long time the main emphasis in rehabilitation had been put on teaching people with diseases or those who had had an accident to relearn certain physical functions. From today’s perspective, however, training cognitive functions is considered equally important, particularly in the sectors of neuropsychology and occupational therapy. Some basic principles should be taken into account, such as: helping the patient to build self-confidence, offering a variety of training material, communicating problem solving strategies, giving clearly structured tasks and providing for an appropriate length of training sessions.
More than 25 years ago scientific studies first proved RehaCom’s effective functioning. Since then, more and more studies have shown similar results. Those studies were based on more than theoretical concepts of a diagnostic test and its transfer to a similar training tool. Find current studies on our website at www.rehacom.com.
Functions that are not damaged should be trained first, in order to evoke a sense of achievement leading to a better self-esteem. Then, therapists can treat the impaired functions by giving clear tasks, leaving no room for misunderstandings. Furthermore, it is important to use diverse training methods and exercises, preferably involving visual, linguistic, tactile and auditory elements. By observing the patient’s actions, the therapist can figure out ways to ideally apply strategies to achieve best training results for the individual situation. The length of a session depends on the patient’s ability to work under pressure. According to clinic guidelines patients should train 10 to 15 minutes per day in the acute phase of rehabilitation. After this phase, training sessions of 45 to 6o minutes should be held every day or at least three times a week for a time period of 6 to 8 weeks. In the late phase of rehabilitation patients should train two or three times per week for about three to five months.
The Role of Computers in Cognitive Therapy Therapy programmes used to be based on psychological tests. The requirement profile of a therapy procedure however deviates from the one of a test. A psychological test is not aimed to have an impact on cognitive performance, whereas training is meant to improve cognitive capacities. RehaCom is an ideal tool, it meets the necessary conditions: 1. adaptivity and individualisation, 2. consistency and monitoring, 3. efficiency and economy, 4. patient-friendly input device, 5. multilingual structure and modularity.
6
HASOMED – Hard- and Software for Medicine
Adaptivity and Individualisation A good training system guarantees individual training sessions in several dimensions. RehaCom adapts automatically and offers the possibility to adjust parameter settings. Every training unit is built up in different levels of difficulty with varying training tasks. The difficulty of a task given always corresponds with the patient’s current performance level. RehaCom gives constant positive feedback oriented to the individual performance. Thus, it fosters to develop learning patterns and contributes to figuring out strategies.
Consistency and Monitoring After having finished one training level in a session, the next one will start from the achieved level. All training results are saved. Hence, therapists can check on how the patient’s overall performance develops as, view results of single tasks and objectives and adjust parameter settings promptly.
Efficiency and Economy With RehaCom many patients can train independently. At the beginning and at the end of a training session the patient and the therapist can agree on particular training aims to focus on and discuss results. There is less patient-related work to do for the therapist who can now use free capacities, for example to put a bigger emphasis on communicating strategies.
RehaCom 2012 – Developed by Therapists for Therapists Modularity RehaCom is a theory-based system which comprises diverse procedures. It helps to train different areas of cognitive functions. Starting at a low level of difficulty, patients are confronted with more complex tasks at higher levels. During training RehaCom gives positive feedback on the patient’s performance. Its modular structure allows for basic training in several areas, such as: • differentiated components of attention, • different area of memory, • executive functions • treatment of visual field, and • visuo-motor functions. Moreover, patients can do more complex exercises in areas such as: • action planning and developing strategies, • situations from everyday life, e.g. shopping, • commercial environment of vocational training. Apart from achieving particular aims of training, RehaCom has further welcome side effects. Experience with RehaCom has shown that patients are much more motivated in terms of training independently at a computer. Due to its individual functioning, requirements are neither too high nor too low for the patient. The computer functions as an observer making neutral comments and giving feedback specifically directed to patient’s errors. Even patients with severe impairments benefit from improvements in performance which leads to a stronger self-confidence. In addition, RehaCom contributes to minimise signs of secondary consequences after brain damage, such as depressions and lack of self-confidence.
Specific Cognitive Training for all Phases of Rehabilitation and Home Training RehaCom fulfils all conditions necessary for a specific and complex training during all phases of cognitive rehabilitation. Treating cognitive impairments usually takes quite long. The therapy begun in a hospital can thus be continued at home under supervision of a neuropsychologist in a private practice or an occupational therapist. The therapist sets up a training schedule with tasks which the patient has to fulfil at home. After the training, the therapist can evaluate results promptly and intervene if necessary. During therapy sessions, the focus is on communicating strategies while evaluating results and discussing further therapy plans. Frequently, patients can thus receive ambulant treatment.
Diagnostics and Intervening Thanks to a long experience with standardised diagnostic tests, we can give recommendations for therapy methods based on results gathered from neuropsychological diagnostics. That is why we are constantly working on relating scientifically proven standardised tests to our RehaCom procedures. Results then undergo a clinical trial. These recommendations however are not sufficient to make an if-then setting. They exclusively serve as a guideline.
Multilingual Structure and Distribution A high number of our procedures are available in different languages, free of extra-charge. Hence, patients can train in their mother tongue. Thanks to the variety of procedures thousands of RehaCom systems have been used in several fields such as neurology, psychiatrics, geriatrics, paediatrics as wells as in vocational rehabilitation since 1992. In recent years, therapy dedicated to help improve brain performance deficits has gained international recognition. RehaCom has become market leader in Europe.
HASOMED – Hard- and Software for Medicine
7
RehaCom 2012 – Developed by Therapists for Therapists Licencing via Network RehaCom can be licensed via an in-house computer server (computer network in your house). The server version enables the installation of RehaCom licences on a network (server) computer. Several working stations (client computers) will have access to the RehaCom server licences at the same time.
8
HASOMED – Hard- and Software for Medicine
Patient Keyboard and Chin Rest Chin Rest In order to train the visual field, it is recommended to use a chin rest. Thus, the patient can maintain a comfortable and straight posture that is easy to reproduce. This is important because the position in front of the screen has to stay the same during the whole training session. The chin rest can be adjusted individually and its height can be changed. Concerning the material, it is made of light and stable aluminium and wood. With a screw clamp you can fix the chin rest at a table. The rest made of varnished wood allows for easy cleaning.
Patient Keyboard 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.
HASOMED – Hard- and Software for Medicine
9
Overview of Training Modules
GROUP
SUP-GROUP Alertness
Vigilance
Attention
Visual-Spatial Attention (spatial-perceptive) Visual-Spatial Attention (spatial-cognitive) Visual-Spatial Attention (spatial-constructive) Selective Attention Divided Attention
Memory
Executive Functions
Visual Field Visuo-Motoric Abilities
10
HASOMED – Hard- and Software for Medicine
REHACOM TRAINING MODULES
LEVEL
Acoustic Responsiveness
20
Reaction Behaviour
16
Responsiveness
20
Vigilance
15
Spatial Operations
42
Two-Dimensional Operations
24
Spatial Operations 3D
24
Visual-Constructional Ability
18
Attention and Concentration
24
Divided Attention
14
Divided Attention 2
22
Topological Memory
20
Physiognomic Memory
21
Memory for Words
20
Figural Memory
09
Verbal Memory
10
Shopping
18
Plan a Day
55
Logical Reasoning
23
Calculations
42
Saccadic Training
28
Exploration
30
Overview and Reading
69
Visual Restoration Training
00
Visuo-Motoric Coordination
96
Overview of Training Modules
TRAINING MATERIAL
Neurological Rehab
Geriatrics
Psychiatry
Pediatrics
Multiple Sclerosis
60 sounds 43 traffic signs over 200 stimuli, editor 88 objects in 4 variations 80 objects in photo quality 46 pools with each 16 photos 432 3-D bodies in 67 categories over 100 photos and drawings 77 pools with each 16 photos 3D, visual and acoustic 3D, visual and acoustic 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 than 80 short stories, editor photos of 100 different goods task generator geometric symbols 17 types of tasks with 76 pictures 20 objects in variations 80 symbols in 2 sizes words, letters, numbers, forms visual stimuli 25 pictured objects
Severe to intermediate leveled disturbances
Intermediate to mild leveled disturbances
Mild leveled disturbances
HASOMED – Hard- and Software for Medicine
11
Acoustic Responsiveness (AKRE) 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 over-strained. 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.
12
HASOMED – Hard- and Software for Medicine
Reaction Behaviour (REVE) 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 dam-ages 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 correspond-ing 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.
HASOMED – Hard- and Software for Medicine
13
Responsiveness (REA1) 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.
14
HASOMED – Hard- and Software for Medicine
Vigilance (VIGI) 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. HASOMED – Hard- and Software for Medicine
15
Spatial Operations (RAUM) 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 BWhen 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.
16
HASOMED – Hard- and Software for Medicine
Two-Dimensional Operations (VRO1) 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.
HASOMED – Hard- and Software for Medicine
17
Three-Dimensional Operations (RO3D) Spatial sense and attention performance are trained. This is achieved by showing several three-dimensional 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 high-level 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 im-pairment 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 ‘Two-dimensional Operations’ RehaCom programme appear to be transferable.
18
HASOMED – Hard- and Software for Medicine
Visuo-Constructive Abilities (KONS) 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.
HASOMED – Hard- and Software for Medicine
19
Attention and Concentration (AUFM) The RehaCom procedure “Attention & concentration” is based on the patterncomparison-method. 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, FRIEDL-FRANCESCONI, PUHR and PFLEGER.
20
HASOMED – Hard- and Software for Medicine
Divided Attention (GEAU) 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.
HASOMED – Hard- and Software for Medicine
21
Divided Attention 2 (GEA2) 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 und Training material 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. 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.
22
HASOMED – Hard- and Software for Medicine
Topological Memory (MEMO) 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 cerebro-organic 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.
HASOMED – Hard- and Software for Medicine
23
Physiognomic Memory (GESI) 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.
24
HASOMED – Hard- and Software for Medicine
Memory for Words (WORT) 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, FRIEDL-FRANCESCONI and PUHR.
HASOMED – Hard- and Software for Medicine
25
Figural Memory (BILD) 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 OK-button.
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.
26
HASOMED – Hard- and Software for Medicine
Verbal Memory (VERB) 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 mediumterm 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.
HASOMED – Hard- and Software for Medicine
27
Shopping (EINK) 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. 28
HASOMED – Hard- and Software for Medicine
Plan a Day (PLAN) 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-eyeview 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. HASOMED – Hard- and Software for Medicine
29
Logical Reasoning (LODE) 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 RehaCompanel 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. 30
HASOMED – Hard- and Software for Medicine
Calculations (CALC) 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.
HASOMED – Hard- and Software for Medicine
31
Saccadic Training (SAKA) 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.
32
HASOMED – Hard- and Software for Medicine
Exploration (EXPL) 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 patient 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 adap-ted 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 Its speed can be set up by the therapist to suit each individual patient.
HASOMED – Hard- and Software for Medicine
33
Overview and Reading (ZIHL) Both programmes are used to treat nonaphasic 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 train-ing. Training appears to be possible for children aged 8 and over.
Basic requirements of the patient Die Verfahren sind für Patienten mit hoher Fehlsichtigkeit (Visus < 20%) sowie mit Alexie nicht geeignet. Schwere Gedächtnisstörungen (Vergessen von Instruktionen und Strategien) sowie Störungen der Aufmerksamkeit beeinträchtigen den Trainingserfolg. Die Anwendung ist bei Kindern ab dem achten Lebensjahr möglich.
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 patient’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. 34
HASOMED – Hard- and Software for Medicine
Visual Restitution Training (VIST) 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 s upra-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 concen-trate 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 right- and 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. HASOMED – Hard- and Software for Medicine
35
Visuo-Motoric Coordination (WISO) 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 manycerebroorganic 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.
36
HASOMED – Hard- and Software for Medicine
Notes
HASOMED â&#x20AC;&#x201C; Hard- and Software for Medicine
37
Effectiveness Studies RehaCom has evolved since it was first launched 25 years ago. It was developed by therapists and is meant to be used by therapists. RehaCom’s origins date back to 1986 when Professor Hans Regel first started doing research in the field of attention. Since then, numerous studies and results of research covering diverse areas have proven the effectiveness of RehaCom. You can read these studies on our website at www.rehacom.com.
Evaluation Study Conducted on Computer-Assisted Cognitive Training of Psychological Basic Functions Final report on a funded research project: Bonn. Curatorship CNS. 120 cerebrally impaired patients (88 of them had a stroke, 21 had an acquired brain injury, 11 had other causes of damages) were treated with occupational standard therapies, standard logotherapy and computer-based training programmes (RehaCom procedures) for at least four weeks. The evaluation included 182 different psychometric measures. In pre-post-comparisons, significant improvements in performance were made. Regel distinguishes between three transfer effects: • Transfer effect of first rank (training effect): Training cognitive functions leads to improvements in the particular tests (e.g. training of attention capabilities brings better results in attention tests). • Transfer effect of second rank (generalisation effect): Training cognitive functions leads to improvements of those cognitive abilities which were not rained (attention training, checking memory functions) • Transfer effect of third rank: Training cognitive functions helps to better tackle everyday problems Transfer effects of first rank were proven thanks to subsamples involving 24 patients. These patients only trained attention leading to a high increase of attention capabilities. In many cases there was a correlation between improvements in performance and the course of training using RehaCom. This correlation proved the positive impact computer-assisted cognitive training has on patients’ performance. Surveys and interviews with patients as well as results of observing patients’ behaviour suggest a transfer effect of third rank. Prof. Regel, H. and Fritsch, A. (1997)
38
HASOMED – Hard- and Software for Medicine
Is the Neuropsychological Treatment of Memory Specific or Unspecific? – Comparing Treatment Effects on Memory and Attention. Primary objective and research design: In order to analyze whether neuropsychological memory therapy acts specifically on the memory domain or in a more generalized fashion on further cognitive domains, 27 patients with organic memory deficits due to different etiologies (cerebrovascular, traumatic, infectious, etc.) were randomly assigned to two different memory treatment programs and investigated for changes in memory and attention. Methods and procedures: Patients treated by a specific computer-based training of story recall (Training of Verbal Memory, TVM) were compared to a group in which compensational strategies for everyday memory problems were trained (Memory Therapy in Groups, MTG). Both therapies were conducted over 12 to 15 sessions, 4-5 times per week, in addition to standard program of neurorehabilitation. Training effects were accessed for verbal and figural memory (Verbal Learning Test, Nonverbal Learning Test) and for attention (Alertness and Divided Attention in Test Battery of Attentional Performance). Results and conclusions: Both treatment groups resulted in improvement in tests of memeory but not attention. This finding provides good evidence for the assumption of specificity of effects in neuropsychological treatment of memory. Spahn, V., Kulke, H., Kunz, M., Thöne-Otto, A., Schupp, W., Lautenbacher, S. Source: Zeitschrift für Neuropsychologie , 21 (4), 2010, 239-245
Effectiveness Studies Efficacy and specificity of intensive cognitive rehabilitation of attention and executive functions in multiple sclerosis. Objective: To evaluate the efficacy of a computer-based intensive training program of attention, information processing and executive functions in patients with clinically-stable relapsing–remitting (RR) multiple sclerosis (MS) and low levels of disability. Design, patients and interventions: A total of 150 patients with RR MS and an Expanded Disability Status Scale (EDSS) score of ≤4 were examined. Information processing, working memory and attention were assessed by the Paced Auditory Serial Addition Test (PASAT) and executive functions by the Wisconsin Card Sorting Test (WCST). Twenty patients who scored below certain cut-off measures in both tests were included in this double-blind controlled study. Patients were casually assigned to a study group (SG) or a control group (CG) and underwent neuropsychological evaluation at baseline and after 3 months. Patients in the SG received intensive computer-assisted cognitive rehabilitation of attention, information processing and executive functions for 3 months; the CG did not receive any rehabilitation. Setting: Ambulatory patients were sent by the MS referral center. Outcome measures: Improvement in neuropsychological test and scale scores. Results: After rehabilitation, only the SG significantly improved in tests of attention, information processing and executive functions (PASAT 3" p=0.023, PASAT 2" p=0.004, WCSTte p=0.037), as well as in depression scores (MADRS p=0.01). Neuropsychological improvement was unrelated to depression improvement in regression analysis. Conclusions: Intensive neuropsychological rehabilitation of attention, information processing and executive functions is effective in patients with RR MS and low levels of disability, and also leads to improvement in depression. Flavia, M., Stampatori, C., Zanotti, D., Parrinello, G., Capra, R. (2010) Journal of Neurological Sciences 288 (2010) 101-105
HASOMED – Hard- and Software for Medicine
39
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.
40
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 Neuropsychology Stroke Unit Clinical centre Bremen-Mitte gGmbH Occupational rehabilitation
Dr. Thomas Krüger Centre for evaluation and methods University of Bonn Executive functions
Dipl.-Psych., Dipl. Soz.-Päd. Petra Rigling Petra Rigling Reha-Service Waldbronn Attention
Prof. Dr. Josef Zihl Clinical neuropsychology Department psychology University of Munich Visual disorders
Dr. DP Angelika Thöne-Otto Clinical Neuropsychologist GNP Psychological Psychotherapist University Leipzig KöR Medical Faculty Daytime Clinic for Cognitive Neurology
Dipl.- Psych. Johannes Werres Organisation of integration Occupational rehabilitation centre Sachsony-Anhalt Occupational rehabilitation
Dr. Stefan Frisch Clinical Neuropsychologist GNP Psychological Psychotherapist Clinic for Neurology Clinic of J. W. Goethe University 60528 Frankfurt am Main
HASOMED – Hard- and Software for Medicine
Team of development
HASOMED â&#x20AC;&#x201C; Hard- and Software for Medicine
41
Paul-Ecke-Str. 1 39114 Magdeburg Germany
T: +49 391.61 07 645 F: +49 391.61 07 640
info@rehacom.com www.hasomed.com