With Standard and Helmut Hildebrandt, PhD 3,4

den et alNeurorehabilitation and Neural Repair © The Author(s) 2010

Reprints and permission: http://www. sagepub.com/journalsPermissions.nav

NNRXXX10.1177/1545968311425927Möd

Occupational
Clinical Research Articles
Therapy During Abstract

Inpatient Stroke
A Randomized Rehabilitation
Controlled Trial Neurorehabilitation and

Comparing 2 Neural Repair

26(5) 463–469
Claudia Mödden, MSC 1, Marion
Interventions for
© The Author(s) 2012
Reprints and permission: http://www.
Behrens, MSC 2, sagepub.com/journalsPermissions.nav DOI:

Visual Field Loss Iris Damke1, Norbert Eilers,

10.1177/1545968311425927 http://nnr.sagepub.com

MD1, Andreas Kastrup, MD 3,

Background and Purpose. Compensatory and restorative treatments have been developed to improve visual field defects
after stroke. However, no controlled trials have compared these interventions with standard occupational therapy (OT).
Methods. A total of 45 stroke participants with visual field defect admitted for inpatient rehabilitation were randomized to
restorative computerized training (RT) using computer-based stimulation of border areas of their visual field defects or to
a computer-based compensatory therapy (CT) teaching a visual search strategy. OT, in which different compensation
strategies were used to train for activities of daily living, served as standard treatment for the active control group. Each
treatment group received 15 single sessions of 30 minutes distributed over 3 weeks. The primary outcome measures
were visual field expansion for RT, visual search performance for CT, and reading performance for both treatments.
Visual conjunction search, alertness, and the Barthel Index were secondary outcomes. Results. Compared with OT, CT
resulted in a better visual search performance, and RT did not result in a larger expansion of the visual field. Intragroup
pre–post comparisons demonstrated that CT improved all defined outcome parameters and RT several, whereas OT only
improved one. Conclusions. CT improved functional deficits after visual field loss compared with standard OT and may
be the intervention of choice during inpatient rehabilitation. A larger trial that includes lesion location in the analysis is
recommended.

Keywords
visual field defect, stroke, compensatory treatment, restitution training
Two main methods of rehabilitation have been proposed.
Restorative computerized training (RT) is based on visual
detection tasks without execution of saccades, aiming for
Introduction
direct restoration of a portion of the visual field by stimulat
Visual field deficits affect approximately 8% to 25% of all ing preserved neuronal representations of the visual system.
Compensatory therapy (CT) trains strategies to make more
stroke survivors.1-3 These deficits may have debilitating
efficient and systematic saccades into the hemianopic field
effects on mobility, visuospatial orientation, higher percep
to
tual or attentional functions, and reading. Although visual
indirectly expand the usable field of view. Several investiga
rehabilitative interventions suggest that homonymous
tions found that RT may mildly reduce visual field deficits,
hemianopia can be treated to some extent, complete restitu
on average, by less than 2°.6-11 One study did not find any
tion is rarely observed.3-5
reduc tion.12 CT also may enhance compensation for visual

field defects to improve functional outcome.13-21 To date,
only 1 study has directly compared RT with CT. In 2
groups of chronic brain-damaged patients with unilateral
field defects,
1
Rehabilitationszentrum Oldenburg, Oldenburg,
Germany 2Hedon Klinik Lingen, Lingen, Germany
3
Klinik für Neurologie, Bremen, Germany
4
Universität Oldenburg, Oldenburg, Germany
Corresponding Author:
Helmut Hildebrandt, Klinik für Neurologie, Züricher Str 40,
Bremen 28325, Germany
Email: helmut.hildebrandt@uni-oldenburg.de
464 Neurorehabilitation and Neural Repair 26(5)

Assessed for eligibility (n = 47)

Excluded (n = 0)
Not meeting inclusion criteria
(n = 0)
Declined to participate (n = 0)

Allocated to intervention RT
(n = 15 + 1)
One patient was unable to get
the allocated intervention
due to health impairment and
was replaced by next patient.
Analyzed (n = 15)
Excluded from
Randomized (n = 45 + 2)
analysis: n = 0 (n = 15)
Allocated to intervention All patients received the
CT (n = 15 + 1) allocated intervention.
One patient was unable to get
the allocated intervention
due to health impairment and
was replaced by next patient.
Analyzed (n = 15)
Excluded from
analysis: n = 0
Analyzed (n = 15)
Excluded from
analysis: n = 0
Allocated to intervention OT

Figure 1. Flow chart of recruitment and retention. Abbreviations: RT, restorative computerized training; CT, compensatory therapy;
OT, occupational therapy.

Roth et al16 showed that CT was superior to RT by Patients

decreasing search time at the follow-up investigation and
by improving eye movement strategies.
A recent systematic Cochrane review argues for further
studies to compare compensatory and restitutive interven
tions with a placebo control or usual care.22 According to
this review, there is only limited evidence for
compensatory treat ment and no evidence that restitutive
training improves out comes for hemianopic patients. In
addition, almost all studies focused on chronic patients and
included patients with hemi anopia that was a consequence
of various organic causes. A systematic treatment offered
early in the recovery process may be more effective than in
the late phase, and results may differ for patients with
stroke and traumatic brain injury. Therefore, the aim of this
prospective, randomized controlled trial was to compare
the efficacies of CT and RT with that of standard
occupational therapy (OT) on visual field defects and on
visual search during inpatient stroke rehabilitation.
Methods
A total of 45 consecutive admitted rehabilitation inpatients
with homonymous hemianopia with a posterior cerebral
artery stroke participated in this prospective randomized
con trolled, single-blind, single-center treatment study.
Patients
with visual neglect, eye-movement disorders, neuropsycho
logical disorders like aphasia, dysexecutive syndromes,
memory deficits, or higher order motor impairments like
apraxia were excluded. All patients gave written informed
consent. The study was approved by the ethics committee
of the Carl von Ossietzky University of Oldenburg.
Study Design
Patients were randomly assigned to receive either CT, RT,
or OT. Randomization by throwing dice and allocation
took place before starting with the initial assessment of
neuropsy chological tests (Figure 1). All patients were
recruited and assigned to treatment groups by a
neuropsychologist. The same neuropsychologist also tested
the patients before (time point t1) and after (time point t2)
the treatment and was not blinded to the type of training.
The training itself was per formed by a psychological
assistant or by the occupational therapists not involved in
the study, and they provided the test results at t1 and t2.
All participants moreover got inpa tient standard
rehabilitation treatment encompassing physio therapy,
speech therapy, and health education.
test from the Test Battery of Attentional Performance,23 the
latter having a sensitivity and specificity for visual field
defects similar to the Goldmann perimetry.24 For these tests,
head movements were prevented by a chin rest in front of
the monitor. Participants were instructed not to move their
eyes and were monitored by the examiner. For assessment
of visual exploration, we used the search tasks of the
Behavioural Inattention Test, which include line, stars, and
letter cancella tion tests.25 Reading ability was assessed by
the standardized texts of the Wechsler Memory Test.26
Independence in activities of daily living was scored by
nurses with the German Extended Barthel Index (EBI).27
Procedures
The daily duration of each session for all groups was 30
minutes (also OT was standardized on 30-minute sessions),
and each participant received a total of 15 sessions. The
participants in both PC-based therapy groups were seated
60 cm away from the screen (19-in. monitor) and had to
perform the tasks binocularly. As during testing, the head
was fixed by a chin rest. The sessions were always con
trolled by the assistant to make sure that the instructions
were followed.
Restitution therapy. A therapy-integrated perimeter pro
gram (provided by Teltra company) created the exact
measurement of the individual visual field border. Using
that measurement, a series of colored targets appeared on a
blue screen anywhere at 1 of 10 positions on the border
line. A randomly presented first fixation target (a rotating
arrow) announced the second stimulus target in the hemi
anopic border zone (basic principle of covert attention
shift). The patients were instructed to respond (by press ing
a key) to each stimulus target (colored and flickering
frames, beams, and spots) as soon it was perceived. The
program contained no adaptive difficulty levels. Eye
movements were not allowed, and this was controlled by
the assistant.
Compensatory therapy. The “Exploration” task (from
RehaCom, provided by HASOMED GmbH, Magdeburg,
Germany) was adapted individually according to the side of
the hemianopia. On a dark background, different bright
stimuli arranged in rows and columns were presented. A
ring (diameter of 2 cm) moved line by line (interlaced) on a
matrix unit over the field. The participant was instructed to
follow the ring (starting point to an outmost fixation in the
blind side) by eye movements and to identify a critical tar
geted icon. The targets were not always distributed homo
Clinical Investigations
At t1 and t2, all patients underwent neuropsychological
tests, including visual scanning, an attention test, and a
perimetry
Mödden et al 465
geneously but were clustered in the blind side. Thus, the
exploration in the hemianopic field was further promoted.
The patients had to respond (by pressing a key) when the
targeted icon was perceived in the circle. The program con
tained several difficulty levels. In levels 1 to 20, all lines
were completely filled with symbols, whereas there were
omissions in the rows of symbols in levels 21 to 30 to
increase the difficulty.
Occupational therapy. After a standardized assessment
of daily living activities, the therapy consisted of
individually adapted stimulation of daily activity tasks to
compensate via eye-, head-, and body movements. These
compensation strategies included aspects of spatial and
body perception, searching or arranging objects, pen and
paper searching task, reading maps or newspapers, and
self-care activities. The participant was instructed to
perform systematic eye movements toward the lost visual
field. The interventions were carried out in the treatment
rooms, on the wards, in a kitchen or a bathroom, outside in
the park, or in a supermar ket. Patients receiving RT and
CT did not receive OT in the context of their standard
rehabilitation treatment.
Statistical Analysis
Based on the distribution of the visual field test of the TAP,
we defined a minimum reduction of 3 omissions, which cor
responds to an expansion of 1° over the whole visual field
(upper and lower quadrant) as a meaningful effect. Previous
work has shown that the standard deviation of visual field
testing after posterior brain artery stroke is about 5.9.28,29
For a given α and β error of .05, this leads to 15 patients per
group. Based on the results of the same studies, we know
that the standard deviation for omissions in the visual scan
ning test of TAP is 9.97. 28,29 Because the search array of the
scanning test is symmetrically organized in 5 lines and 5
columns, we defined a reduction of 5 omissions (ie, of 1
contralesional column) as a clinically meaningful end point.
For the already mentioned error level, this also leads to a
value of 15 patients per group. We were not aware of previ
ous relevant studies for the Behavioural Inattention Test.25
We therefore decided that 15 patients per group should be
included in our study. To compare the effects of the treat
ments, we subtracted the performance of the patients before
and after the treatment. To analyze the group differences,
we performed Mann-Whitney U tests for these difference
scores comparing RT/OT, CT/OT, and RT/CT. For the sec
ondary outcome parameters, the significance level was set
to P < .0166 (P < .05/3 domains: attention, conjunction
search, and activities of daily living) because of multiple
 testing. Intragroup comparisons of treatment effects were
done using the Friedman test.
Results
Patients were recruited on average about 4 weeks after their
stroke. At baseline, the 3 groups did not differ in demo
graphic and neuropsychological measures. Demographic
data are summarized in Table 1.
All patients were highly motivated to improve the visual
performance, and no one dropped out because of problems
466 Neurorehabilitation and Neural Repair 26(5)

Table 1. Summary of Demographic, Lesion, and Impairment Data of the 3 Treatment Groups a

Restitution Training Compensatory Training Occupational Therapy

Sex Male: 10, Female: 5 Male: 9; Female: 6 Male: 7; Female: 8

Primary stroke localization Left: 7 (o = 3; tm = 3;ph = Left: 5 (o = 2;to = 2;tm = 1) Left: 5 (to = 1; tm = 1; ph = 1)
(reported by the 1) Right: 8 (o = 4; to = 2; Right: 10 (o = 4; to = 1; tm = Right: 10 (o = 4; to = 2; tm =
neuroradiologists) tm = 2) 4; ph = 1) 4)
QA)
Visual field defect (hemianopia: HA, quadrantanopia: HA: 10; QA: 5 HA: 12; QA: 3 HA: 10; QA: 5
(number in parentheses => than 2° sparing 3/15 (2/15) Patients with less
Visual field sparing in hemianopicsame number after the 3/15 (2/15) Patients with less than 2° sparing
patients before treatment treatment) than 2° sparing plus 1 (0)
3/15 (2/15) Patients with less patient with no sparing

Mean SD Mean SD Mean SD

Age, y 58.3 11.4 57.1 8.3 59.0 11.1 Time since onset, wk 4.7 4.9 4.3 Cancellation tasks, BIT; omissions 15.3 23.3 6.5 7.4
5.4 7.2 Reading, omissions 1.0 2.5 1.6 2.7 0.9 1.1 TAP Alertness without cueing, ms 304.2 80.8 383.7 205.2 308.1 58.6 TAP
Conjunction Search, omissions 9.1 9.0 10.7 6.7 10.3 5.6 Extended Barthel Index 59.2 7.0 59.3 5.0 59.9 3.4
Abbreviations: o, occipital; to, temporo-occipital; tm, temporomedial; ph, parahippocampal; SD, standard deviation; BIT, Behavioural Inattention Test;
TAP, Testing Battery for Attention Performance.
a
No significant difference between groups at baseline.

Table 2. Significant Improvement per Training Group (Only Intragroup Pre/Post Comparisons)

Restitutional Training Compensatory Treatment Occupational Treatment

Yes (3.9 ± 4.9)a,b Yes (2.9 ± 4.0)a No (1.3 ± 4.7)a
Visual field enlargement (TAP,Visual Field Assessment)

Cancellation tasks of the BIT (omissions) Yes (5.3 ± 10.5) Yes (5.4 ± 5.2) No (2.3 ± 5.0) Reading performance (errors) No (0.9 ±
2.4) Yes (0.9 ± 1.1) No (0.7 ± 1.0) Attention (TAP, Alertness) Yes (28.5 ± 56.9) Yes (77.8 ± 112.9) No (−13.3 ± 112.7) Visual
conjunction search (TAP, visual scanning) No (2.7 ± 5.1) Yes (7.0 ± 5.0) No (3.5 ± 6.8) Extended Barthel Index Yes (1.5 ± 2.8) Yes
(3.3 ± 3.6) Yes (1.8 ± 2.0)
Abbreviations: BIT, Behavioural Inattention Test; TAP, Testing Battery for Attention Performance.
a
Number of additional detected stimuli during testing.
b
The figures in parentheses show the difference score between t2 (after treatment) and t1 (before treatment) and the standard deviation for this differ
ence score. Positive values indicate improvements, negative values deteriorations.
not after OT (P = .316).
Visual search performance. At t1, omissions in search
(BIT, cancellation tasks) did not differ between the groups
in compliance, but some patients complained that RT was (RT/OT, P = .444; CT/OT, P = .554; RT/CT, P = .752).
exhausting and led to sensitive eyes. There was a significant improvement of performance in
visual search for CT and OT (P = .048), but no significant
benefit for RT could be found in comparison with OT.
Primary End Points There were also no significant differences in improvement
Visual field expansion. The mean visual field size (TAP com
visual field—omissions) at t1 did not differ between the paring RT with CT. Significant intragroup changes compar
groups (RT/OT, P = .852; CT/OT, P = .506; RT/CT, P = ing t1 and t2 were only observed for RT (P = .005) and CT
.589), and there was no significant group difference for the (P = .003) but not for OT (Table 2).
increase of the visual field after treatment. However, the Reading performance. At t1, errors in reading did not dif
intragroup comparisons (Table 2) showed a significant field fer between the groups: RT/OT, P = .437; CT/OT, P = .781;
expansion after both RT (P = .003) and CT (P = .013) but RT/CT, P = .257. Compared with OT, neither RT nor CT
 Mödden et al 467
e
Visual expansion c

improvements after RT (P = .027), CT (P = .005), and OT

16
(P = .003).
n

a whether these groups differed in our

8
m

fr

p 4
n

i
t

0
primary and secondary outcome
no improvement improved parameters and found that improved
e

v
EBI visual search was the only parameter
o

r To analyze the association between that differed significantly between the

treatment effects and ADL on a more groups (Z = −3.001; P = .003). Patients
p

global level, we divided the total group with an improvement in ADL also
m

Search performance
Reading performane of patients into those who improved in showed significantly improved search
12
ADL performance (n = 27) and those performance and
who did not (n = 18). We then analyzed
when comparing RT/OT, CT/OT, and RT/CT, the
Figure 2. Patients with improvement in the EBI also improved in
intragroup comparisons (Table 2) demonstrated significant
visual search performance significantly but not in field expansion.
Abbreviation: EBI, extended Barthel Index. vice versa (Figure 2).
Intercorrelation of improvements in primary outcome
param eter with secondary outcome parameter. The
significantly reduced reading errors. There were also no dif nonparametric correlational analysis of improvement in
ferences between RT and CT. In contrast, the intragroup the different tasks for all patients showed that visual field
comparisons comparing t1 and t2 showed a significant expansion was not significantly correlated with any other
reduction in reading errors after CT (P = .016) but not after improvement, but visual search performance correlated
RT or OT (Table 2). with improvement in the Barthel Index (P = .004), in
There were no significant differences of the treatment attention performance (P = .016), and in conjunction
effects in reading speed (measurement in words per sec search (P = .046).
ond). The intragroup comparisons comparing t1 and t2
showed a significant improvement of reading perfor mance
Discussion
after CT: from 64.2 to 51.8 s (P = .006) but not after RT or
OT (RT from 86.6 to 101.5 s and OT from 58.8 to 49.4 s). We compared the efficacy of RT and CT for visual field
loss in stroke patients in a placebo-controlled randomized
trial. Whereas previous studies have shown that both
Secondary End Points treatment strategies can principally improve lost visual
Attention. At t1, the alertness test (TAP Phasic functions at least to a small extent, our results demonstrate
Alertness) did not differ between the groups: RT/OT, P = that CT appears to be superior to RT and thus should be
.443; CT/OT, P = .547; RT/CT, P = .330. After Bonferroni the treat
correction, nei ther CT nor RT led to an improvement in ment modality of choice in this patient group. To date,
attention perfor mance compared with OT, although the several studies have reported an enlargement of the visual
comparison between CT and OT was almost significant (P field in hemianopic patients after RT.6-11,30 Yet none of
= .020). Intragroup comparisons comparing t1 and t2 these studies used an active control group. We also found a
showed that only RT (P = .033) and CT (P = .001) small increase of the visual field of about 1° to 1.5° after
significantly improved alertness (Table 2). CT and RT in this study, but such a small enlargement of
Conjunction search. Omissions in the exploration task the visual field is unlikely to improve functional outcome
(TAP visual scanning) at t1 did not differ between the of the patient groups. In addition, the improvement was
groups: RT/OT, P = .454; CT/OT, P = .868; RT/CT, P = only found in the intragroup comparisons of RT and CT.
.289. Compared with OT, both the neuropsychological Because of the nature of our study design, the reason for
treatments did not result in superior improvements, and the the visual field enlargement cannot be explained
improvement of the CT compared with the RT group did adequately. It might be attributable to the responsiveness
not meet the defined significance level after Bonferroni of neurons adjacent to the lesioned visual cortex, a
correc phenomenon that has been shown in human and animal
tion (P = .023). For intragroup comparisons only CT (P = studies.8,31 On the other hand, patients might also have
.001) led to a significant improvement (Table 2). Activities learned to focus their atten tion toward the hemifield and
of daily living. The EBI score at t1 did not differ between thereby improve the size of their visual field
groups: RT/OT, P = .495; CT/OT, P = .916; RT/CT, P = conceptualized as “an unspecific increase of alertness in
.649. Although no significant treatment effects were found unattended areas.”11,17 In this respect it seems noteworthy
 that a small but significant enlargement of the visual field
was found in this and other studies using com pensatory
training strategies.14 Moreover, our RT and CT groups
improved significantly in alertness.
With respect to visual search, CT was superior to RT
theoretically, the chances for restitution might be greater in
patients with cortical lesions not extending deeply into the
search than RT. The study of Roth et al involved patients in optic radiation.
a chronic stage of hemianopia caused by various diseases.
Our study results, therefore, extend their findings to a
homoge neous group of first-ever stroke patients treated
In conclusion, visual field deficits improve mildly after
relatively early in their recovery process.
both RT and CT compared with usual OT training.
The specific PC program we used for CT (“Exploration” However,
task from RehaCom, HASOMED) forces the patients to use
a particular search strategy associated with improved eye
movement patterns.16 Hence the reduction of omissions in
visual search in our CT group may be interpreted as a result
of an improved top-down compensation strategy.19
Whereas some previous studies reported increased
reading abilities after RT,7,32 we and others did not observe
such an effect.30 In our study, only CT had a small but
significant effect on reading. Generalization of CT to
reading performance has not been documented.16,17 Our
result might be attributable to the structure of CT used in
this study. As already mentioned, the Exploration task of
the RehaCom forces the patients to fix on an outermost
starting point on the left, where a circular cur sor starts
moving rightward, item by item, until it reaches the
outermost item on the right and then jumps back to the next
outermost item on the left in the next line. This is highly
simi
lar to the eye movements during reading and this similarity
in top-down control might be the reason our CT group also
improved in reading.
We used the EBI to analyze the impact of our treatments
on the activities of daily living because the Barthel Index
focuses exclusively on basic skills like transfer, dressing,
and eating among others. The EBI includes some cognitive
and percep
tual items, so we anticipated that it might be more sensitive
for the functional problems of our patient group. The
pretreat ment EBI scores for all groups were high, however,
which may have created a ceiling effect. In a post hoc
evaluation only improvements in visual search were
associated with increases in the EBI scores, whereas the
visual field enlarge ments were not associated with ADL
improvements. The association between the increase in
ADL score and improve ment in visual search underscores
the impact of compensation of visual field defects for
functional outcome.
Limitations of our study design include the relatively
small sample size of each group and no follow-up data
beyond the inpatient stay to test for stability of the
treatment effects. Although the number of treatment
sessions was realistic for postacute inpatient treatment,
more sessions might be needed to achieve a restitutive
effect. Finally, the location of the lesions (cortical vs white
matter) was not obtained in this study. At least
and also to OT in visual conjunction search. Roth et al16
also found that CT led to a higher improvement in visual
conjunction
468 Neurorehabilitation and Neural Repair 26(5)
Summary
for most of the outcome parameters analyzed in this study,
CT was superior to RT and thus should be further evaluated
as the modality of choice in the early phase of treatment for
stroke.
Acknowledgments
We thank all patients for participating. The authors thank
TELTRA (Neurological Department, University of Bochum,
Bochum, Germany) and HASOMED (GmbH, Magdeburg,
Germany) for support in providing their programs.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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