Rehabilitation in a complex case of topographical disorientation.

This paper describes the rehabilitation process of a patient with severe topographical disorientation. The study demonstrates the sustained effects of a tailor-made, meticulous rehabilitation programme based on the gradual development of compensatory strategies. The patient (RB) had a memory impairment specific to environmental landmarks. He was able to recognise objects in his environment, but was unable to identify any salient object as a landmark and was also unable to derive any directional information from a chosen landmark. As such, his topographical disorientation syndrome was complex in that he had elements of both landmark agnosia and a heading disorientation, as described by Aguirre and D'Esposito (1999). Because of this dual damage to the exocentric framework, the tools and methods used in RB's rehabilitation programme were all based on his intact egocentric frame of reference. Remarkable training effects were found for routes he used frequently. After years of training he could walk these routes without the aid of the written information he had used previously, which can be interpreted as a form of implicit learning. In the 12 years we followed this patient some transfer occurred, as the patient was ultimately able to identify his own landmarks. However, RB remains dependent on other people to construct new routes for him on the basis of these landmarks.

The effect of visual training for patients with visual field defects due to brain damage: a systematic review.

The objective of this review was to evaluate whether systematic visual training leads to (1) a restitution of the visual field (restoration), (2) an increase in the visual search field size or an improvement in scanning strategies (compensation) and (3) a transfer of training-related improvements in activities of daily living such as reading. To retrieve relevant publications, computer-aided searches of databases (Medline, Embase, Cinahl, Cochrane Central Registers of Controlled Trials) and extensive reference tracing and hand searching were performed. Subsequently, all retrieved and blinded studies were scored on methodological quality. 14 studies were included, 2 randomised controlled trials (RCTs) and 12 within-subject repeated-measures designs (RMD). One of the two RCT studies had good quality. The internal validity of the RMD studies varied from poor to good. Five studies reported a significant effect of the vision restoration therapy (VRT), whereas two studies reported no effect using scanning laser ophthalmoscopy or Goldmann perimetry as outcome measure. All authors of the studies on scanning compensatory therapy (SCT) found a significant effect of up to 30 degrees visual search field, a significant increase in reading speed or decrease in reading errors. It is unclear to what extent patients benefit from restoration therapy in relation to a more efficient scanning strategy which enables them to read faster or to avoid obstacles in a better way. No study has given a satisfactory answer. SCT seems to provide a more successful rehabilitation with more simple and user-friendly training techniques. Validated questionnaires provide the most reliable subjective data to assess the transfer of the relevance of training procedures to activities of daily living of the patient. Hence, SCT is recommended until the effect of the VRT is defined.