App-delivered Therapy for Arabic Readers With Hemianopic Alexia
App-delivered Therapy for Arabic Readers With Hemianopic Alexia
Hemianopia refers to compromised vision in one half of the visual field, in either one or
 both eyes. Hemianopic Alexia (HA) is a reading disorder related to such impairment, usually
 caused by stroke or head injury. In order to read, participants have to move their eyes along
 a line of text three to four times per second. Such eye movements are called saccades. One
 makes use of peripheral visual information to the right (if reading from left to right, e.g.,
 in English) or to the left (if reading from right to left, e.g., in Arabic) of words. HA
 patients are deprived of much of this information. Patients with HA require far more
 saccades, which slows their reading significantly and often prevents them from reading
 efficiently for work or pleasure. It follows that the reading ability of those who read
 left-to-right would be compromised more by right-sided HA, and in those who read
 right-to-left by a left-sided HA. This study proposes to explore the rehabilitation of
 left-sided HA following stroke, in Arabic readers. An online treatment package has been
 developed in English (http://www.readright.ucl.ac.uk/). Currently, no assessment or treatment
 resources exist for the condition in right-to-left readers. The aim is to develop novel
 Arabic reading tests and rehabilitation material. The current project proposes to 1)
 translate this package into Arabic, 2) develop new Arabic reading test materials and 3)
 collect data from Arabic reading stroke patients in a Phase 2 clinical trial. The hope is to
 develop an effective, novel, and empirically supported reading treatment package for Arabic
 readers with HA.
Background

 Purpose and Experimental Design Reading a line of text is usually achieved by planning a
 series of saccades, which allow the eyes to jump from one word to another (reading
 scan-path). Arabic readers use peripheral visual information to the left of the word in order
 to plan their reading eye movements. Patients with HA are deprived of this information and
 compensate by creating inefficient reading scan-paths with many additional saccades,
 resulting in accurate but slow reading. Some patients abandon reading altogether, or lose
 their jobs because they cannot read fast enough.

 Healthy subjects read moving (scrolling) text faster than static text. This type of text,
 also called "Times Square" presentation, induces a form of involuntary eye movement called
 optokinetic nystagmus (OKN) in the reader and, when used as part of a rehabilitation program,
 has been shown to improve subsequent reading performance of static text.

 This study proposes to adapt these techniques for scrolling Arabic text, and to test them in
 Arabic-reading patients with left-sided HA. Rehabilitation material will be made available on
 the Internet (via an iPhone and/or iPad Application ('app')) for suitable subjects, in order
 to investigate whether patients benefit from using them outside of controlled trial
 conditions. During pre- and post-therapeutic intervention the investigators will record the
 following: reading speeds, visual field test scores, visual search test scores,
 eye-movements, and Activities of Daily Living scores. Length of time for which patients
 access rehabilitation material, will also be recorded.

 This study will help determine the efficacy of Internet-based behavioural rehabilitation. It
 will also provide information as to: 1) how much improvement may be gained through this
 program, and 2) how much practice patients will likely require in order to improve their
 reading significantly.

 Objectives

 This study proposes:

 1. Adapt and test reading rehabilitation techniques in patients with left-sided HA, using
 scrolling Arabic text;

 2. Investigate whether patients benefit from using such material outside of controlled
 trial conditions.

 Hypothesis

 1. Patients will report a significant improvement in the speed at which they read static
 text (newspaper, books, letters, etc.) as a function of quality activity of daily
 living.

 2. Patients will decrease the number of fixations (both progressive and regressive type
 saccades) when reading static text.

 Methods Thirteen Arabic-reading patients with left-sided homonymous HA following stroke will
 be studied over a period of three months. A single-subject baseline control design will be
 employed. There will be a treatment-free interval before and after reading therapy. Baseline
 assessments of visual fields, eye movement performance during text reading, text reading
 speed, and visual search performance will be carried out pre-intervention. Behavioural
 assessments will be repeated immediately following every five hours of therapy, and during
 follow-up. Patients will determine how long to wait between testing points, as they will
 differ in reading speeds.

 Patients meeting the study criteria will be identified through Dr. Alex Leff's Alexia clinic
 at the National Hospital for Neurology and Neurosurgery, University College London Hospital
 (UCLH), as well as through formal collaboration with the neuropsychology department at
 Wellington Hospital. In addition, patients will be given the option to join the study when
 downloading the reading therapy app from the Apple iTunes store. An online consent form will
 be included in the registration. The aim is to recruit at least thirteen patients to this
 study over the following three years.

 Thirteen healthy age-matched Arabic reading controls will be recruited from a variety of
 sources, including relatives and friends of patients. Controls will undergo the same
 assessment as patients, but will be assessed only once. They will not undergo the reading
 therapy.

 Consent Initially, both the information sheet and consent forms will be delivered in hard
 copy (written in both Arabic and English). When the application has been developed, pilot
 study will be conducted. Participants will complete online consent forms, and will be
 required to click certain key boxes to confirm that they have read or listened to, and
 understood, the information.

 Risks, Burdens, and Benefits:

 Benefits. App-delivered reading therapy has never before been available as a rehabilitation
 package for Arabic reading patients with HA. The app may be used as stand-alone self-help
 reading therapy, or as part of formal speech-language therapy. Additional benefits include
 real-time activity monitoring, tracking of treatment progress, personalised feedback and
 motivation support, portability and flexibility of use, and the potential to improve with
 practice.

 Risks/Burdens. This will be the first study in patients with left-sided HA using scrolling
 Arabic text. Thus there is little literature to guide the study. In order to maximize its
 potential, the investigators will adapt the established English-reading treatment approach
 used for patients with right-sided HA. There is no way of predicting how many patients will
 use the application. Some participants may not meet the study criteria. In addition, the
 patients themselves will manage their use of the application. There is therefore an inherent
 risk of their not accessing the rehabilitation materials for the required period of time, and
 not entering the data correctly.

 Data Collection

 Participants will be required to enter the following data in order to gain full access to the
 rehabilitation material:

 Data to be collected on App-based patients

 1. A unique login, created by themselves. (This does not have to be their real name.) This
 will ensure that each time they access the application; their data is collected under
 their name.

 2. Their email address (optional), for use only if they forget their login details.

 3. The extent and side of their hemianopia. If they have not had this test performed by
 their own doctor or optometrist, a section of this application provides self-testing.

 4. A test of their reading speed. This will be self-administered. Participants will time
 themselves (a timer on the application will be activated by the touch screen) reading a
 standard text aloud. Their text reading speed will be calculated and feedback to them.
 Participants may check or recheck this at various times during the study.

 5. A test of their performance on a visual search test. This will be self-administered.
 Participants will be tested on their accuracy and speed when finding objects on a
 section of the application. Their performance scores will be calculated and feedback to
 them. Participants may check or recheck this at various times during the study.

 6. Participants will rate themselves on their ability to perform activities of daily living
 (ADLs) as a measure of their functional status in regards to their reading impairment.
 Their scores will be calculated but not feedback to them.

 Other optional fields, which may prove useful in data analysis if enough subjects complete
 them will include:

 1. The cause of their hemianopia. (This is usually stroke or head injury, but a free text
 option will be provided.)

 2. How much reading they can manage with their hemianopia

 3. Whether their hemianopia has caused them to change or loose their employment

 Participants will access the app and enter all personal data themselves. The only data we
 will collect that is not directly controlled by the participants is the amount of time they
 access the rehabilitation materials and their logon identification. The latter will ensure
 that the same participant is not logging on to the application under multiple names.

 Rehabilitation materials used in the app-based reading training The rehabilitation materials
 will consist simply of chapters of text, which scroll from left-to-right: that is, from the
 blind visual field of the participants to their normal visual field. The texts will be
 sourced from books out of copyright, freely available on the Internet. The aim is to provide
 streaming text from other websites, such as news, current affairs etc. The participant may
 control the speed at which the text scrolls. Participants will be advised to practice the
 reading therapy on most days and to aim for 20 to 40 minutes per day. They will also be asked
 to test their reading speeds every time they complete five hours of rehabilitation. Subjects
 will be prompted to check their reading speeds after every five hours of exposure to therapy.
 If they choose not to record any of this data, their access to the rehabilitation materials
 will not be affected.

 Data to be collected on Face-to-Face patients Patients with HA adopt an inefficient reading
 strategy to compensate for their visual impairment on the hemianopic side. Therefore, we want
 to compare the patients' reading scan-paths to those generated by healthy controls reading
 the same static passages. We will be recording eye movements of participants as they read 10
 passages using an eye-tracking device. A between groups statistical analysis will be
 performed.
Inclusion Criteria:

 -  Participants must:

 1. Have a right-sided hemispheric stroke, tumor or head injury

 2. Demonstrate a fixed left visual field homonymous deficit as defined by missing
 one or more stimuli on the automated visual field test developed for the
 application

 3. Have a baseline text reading speed of more than 40 words per minute

 4. Have been Arabic readers premorbidly

 Exclusion Criteria:

 -  Patients presenting:

 1. impaired speech production, speech comprehension or writing (to rule out those
 with central alexia)

 2. a premorbid history of neurological or psychiatric illness

 3. a baseline text reading speed of less than 40 words per minute (to exclude
 patients with pure alexia) will be excluded from the study