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Field Test Report of the MagnaFlyer™ Computer Based Training Program for Steady-Eye Technique


CORI LAYTON, OTR, SCLV,
Director of Rehabilitation Services, Ensight Skills Centers for Visual Rehabilitation


Conducted under the auspices of the Ensight Skills Centers for Visual Rehabilitation,
DENNY MOYER,  BS. COTA. SCLV. Executive Director

Participating Low Vision Rehabilitation Professionals: CORI LAYTON, OTR, SCLV; CASSIE LORIE, OTR, SUSAN FORTNEY, OTR

 

Abstract:

Steady eye and eccentric viewing technique have been shown to provide significant benefit to those with vision loss. (Br J Ophthalmolo2010). Both of these skills require training in order to maximize their positive effects. Ensight Skills Centers for Low Vi son Rehabilitation has been engaged in delivering this training for more than ten years. Low vision professionals had been using paper based materials and static display methods to accomplish the practice required for the client to gain proficiency in these skills. A successful out come was considered to be the client's adoption of the skills and their use in every day life to enhance independence. The purpose of this field trial was to provided subjective analysis of the time required, ease of use and educational efficiency of the MagnaFlyer computer based learning and practice environment when compared to the standard procedures previously used in the Ensight environment. In actual training scenarios, the use of the MagnaFlyer system was found to decrease training time requirements sufficient to a successful client outcome by 50%

 

Purpose of this report:
The purpose of this report is to provide an answer to the question “Does MagnaFlyer represent a significant advance in training steady eye skills when compared with paper-based materials and methods previously employed in this training”. It is not intended to present new science regarding the efficacy of the training but rather to compare one method of training delivery with another. In this regard MagnaFlyer is to be considered in the category of assistive and educational technology similar to CCTV, smart boards or software magnification programs. This report includes my observations and those of the rehabilitation staff of Ensight Skills Centers with regard to relevant comparisons across several key dimensions.

  1. Amount of time required of practitioner and client to meet training goals
  2. Amount of time required of practitioner for materials preparation
  3. Efficiency and flexibility of the delivery of training in multiple environments
  4. Client outcome using comparable measures
  5. Client subjective perception of training experience and result

 

Background:


One of the key components of low vision rehabilitation is teaching the client how to optimize their remaining vision so as to have greater independence in their activities of daily living. Over the course of a number of sessions the low vision professional uses a protocol of guided exercises and techniques to train the client in the skills necessary to for everyday use.


Training begins by assisting the client to reliably locate their preferred retinal locus (PRL). The next step is to train the client how to consistently fixate their best vision to accomplish visual tasks. The first goal of training is for the client to learn how to optimize their vision by learning the use of steady-eye technique. With this training the client learns to habituate bringing their best remaining vision to bear on everyday visual tasks such as reading, managing their personal environment and navigating outside the home. This is a skill that requires training from a practitioner and practice and repetition on the part of the client to achieve the degree of facility appropriate to each client’s ability.


Traditional techniques to teach clients the location of their preferred retinal locus as well as eccentric viewing and Steady-Eye technique have relied on paper materials.  Some of these tools include the Learn to Use your Vision for Reading Workbook by Valjean Wright, M.A., M.Ed., C.V.R. and Gail R. Watson, M.A.Ed.; Mary Warren’s book Pre-reading and Writing Exercises for People with Macular Scotomas as well as the Pepper Visual Skills for Reading Test.

 
Training Steady-Eye technique was done previously by using “ticker tape” reading, that is where each word of the reading material was moved in front of the eyes either manually, or by utilizing a closed circuit television.  There are several inefficiencies inherent in this method which negatively impacts the best use of training time.

 

  1. These techniques required the therapist to put together reading materials appropriate for training, including enlarging the text of standard materials (the LUV series has fonts as large as 3M print, and the Mary Warren maximum size print is 20M, with very limited selection of training materials in that size).

  2. Materials must be transported to the training site

  3. Set up time for the specific training needs of each client is required

  4. Consistency in exact placement of materials for each client across sessions is difficult to maintain

  5. Reading speed is slow and relatively inflexible using paper or CCTV which can introduce comprehension issues

  6. The client’s effective use of practice materials in the home can be diminished by environmental concerns such as lighting and repeatable physical placement

  7. Client’s physical condition may make manipulation of printed materials problematic resulting in less practice between training sessions and a loss of progress

 

Introduction to MagnaFlyer Training Program:


Ensight Skills Centers for Low Vision Rehabilitation in conjunction with SoftOlogy IdeaWorks, a software development company, jointly developed the MagnaFlyer computer based training program for visual rehabilitation. MagnaFlyer was designed to mitigate some of the factors that create inefficiencies when delivering Steady-Eye training. The development of this tool was seen as a possible way to further Ensight’s mission by delivering more care in less time through the use of electronic media. The goal of the software design was to provide a comprehensive computer-based teaching environment for client skill building in the use of Steady-Eye technique.


Central to a successful outcome for the client are the standardized exercises used for practitioner guided practice sessions in the clinical setting as well as self-paced practice in the client's home. The specifications of the software required that content curriculum of the training program be equivalent to training conducted at Ensight using the existing paper-based materials and protocols.
As the Director of Rehabilitation at Ensight Skills Center for Low Vision Rehabilitation I had oversight in the design of the training materials and was responsible for content and instructional development of the MagnaFlyer protocol.


After a two-year period of research and development a field test was undertaken to determine the utility and effectiveness of this program for instruction in both the clinical setting and the client’s home environment. The purpose of the field test was to provide a platform for the assessment by the practitioner staff as to whether or not the MagnaFlyer program was, from their experience with both methods and in their professional opinion, an advance over existing methods.

 

Description of Field Test:
The duration of the field test was a six-month period. The subject pool was comprised of clients referred to Ensight skills centers during that period, who, after their intake assessment, were determined to be candidates for reading and visual rehabilitation.


The rehabilitation staff that would be interacting with the clients had been trained in the use of the MagnaFlyer software and the curriculum of content.


In all particulars the training was conducted in the same environment and under the same conditions as would have transpired using previous methods and materials. The only significant change in the instruction process was that the MagnaFlyer program was substituted to provide the display modality, content, exercises and practice materials. The content and exercises were derived from and consistent with the original print materials that had been used successfully by Ensight and other organizations to provide vision rehabilitation.


A key difference between the two protocols was the display of the text used to provide the curriculum exercises. The MagnaFlyer display is driven by a patented software engine. This display places the text characters to be viewed in a sequential manner with each word placed one after the other in a consistent location within the frame of the computer screen. The text is displayed in a pale yellow on a dark background. This means of text display is in contrast to the inconsistencies introduced with the manual manipulations required in the use of paper materials or CCTV to bring the target text into view.


An additional variable was that for some of the clients the use of a computer itself was novel and required a brief period of adjustment. The practitioner explained to them what they were going to see and do in the training process.


The clients were seated in a comfortable chair roughly an arm’s length away from the computer screen. The height of the computer screen was positioned such that the top of the frame was 2 to 3 inches above eye level when the client was looking forward. Lighting in the room was adjusted if necessary to minimize glare.
The practitioner had been trained in customizing the software display for each client. The variable parameters include:

 

  1. Font size of the text display: 60pt – 96 pt.
  2. Position of the text display: centered, 1-4 positions descending from top
  3. Choice of font type of the text display: full complement of fonts on the system

 

The trainer could also adjust the speed at which the words are displayed to accommodate each client’s ability. Further speed adjustments can be made during the instruction based on the clients comfort and desire.
Training was conducted with each client until a positive outcome was achieved equivalent to the standard applied with previous techniques.


Results:
During and after the trial period I gathered together the observations and assessments of the rehabilitation staff and together with my own can draw several conclusions representing the experiential consensus of the participants.


With regard to (1) the amount of time required of the practitioner and client to meet training goals.
The consensus of observations was that the use of the MagnaFlyer protocol resulted in up to a 50% reduction in training time for teaching the key skill of fixation with a PRL. Fixation is paramount prior to introduction of magnifiers and other assistive technologies for use in activities of daily living. Using MagnaFlyer for training allowed magnification to be introduced in 1-2 visits versus 3-5 visits using traditional methods.
The automated display of text inherent in the MagnaFlyer software allows the client to have more practice events for fixating their best vision in less time. The ability to have more viewing opportunities with fewer interruptions (due to manipulating paper materials) translates into a consolidation of skills in a condensed time frame. The noted reduction in training time required to achieve a successful client outcome when compared with previous methods may be due to a combination of elements:

  1. Repeatability of exact placement of the text in the clients PRL,
  2. The elimination of interruptions due to manipulating practice materials
  3. The ability of the client to easily implement practice materials in their home thereby encouraging self-paced learning between training sessions.

 

With regard to (2) the amount of time required of the practitioner for preparing materials for a training session:
Ensight previously utilized traditional techniques to teach clients the location of their preferred retinal locus as well as eccentric viewing.  Some of these tools include the Learn to Use your Vision for Reading Workbook by Valjean Wright, M.A., M.Ed., C.V.R. and Gail R. Watson, M.A.Ed.; Mary Warren’s book Pre-reading and Writing Exercises for People with Macular Scotomas as well as the Pepper Visual Skills for Reading Test. 
These tools required the therapist to put together reading materials appropriate for training, including enlarging the text of the standard materials so as to be customized to meet the client’s particular needs. Clients with severe vision loss required larger training materials, which were either made manually on the computer or enlarged on a copy machine (as stated above regarding print materials the LUV series has fonts as large as 3M print, and the Mary Warren maximum size print is 20M, with very limited selection of training materials in that size). The MagnaFlyer software inherently allows for larger font sizes, from 60 point to 96 point font size that can quickly be adjusted for every exercise.  This is beneficial, as therapists do not typically use optics at the beginning of EV training, so font sizes must be larger. With MagnaFlyer, the exercises and training materials are contained in the software program. This means the therapist can eliminate the time spent altering the training materials in preparation for client sessions (generally from between five and 20 min. per session).


With regard to (3) the efficiency and flexibility of training in multiple environments:
Previously, paper materials had to be carried to the training location. In practice this may be the clinic, the home of the client or another site such as a school. Variations in environmental conditions such as lighting, space limitations and other considerations could make training outside the clinical setting problematic. The time necessary for setting up an appropriate training location in the clients home for instance, invaded the amount of time that could otherwise be spent training.


Training conducted with MagnaFlyer requires only a laptop or other computer. As it is self-contained set up time is virtually eliminated. Training can take place in most environments with only minor modifications for optimizing the screen view.


In some cases clients who had their own computers could access a copy of practice exercises for use in their home. This creates a built-in consistency for practice. This is in contrast to the traditional model where the practitioner would "leave behind" paper materials that the client would use for practice. These materials required the client to manipulate them in such a way as to consistently bring the target text into their PRL.


With regard to (4) client outcome equivalent to outcome from traditional protocol
The exercises and methodology inherent with the MagnaFlyer program are sequential and progressive in nature. Each exercise is an advance on the previous exercise. The client begins learning to fixate their PRL on a single character displayed on the screen. Once facility for fixation is acquired the following exercises expand capability. There are a number of client success indicators available to the practitioner. These include the practitioner's observations, the client’s self-reporting and vocalized recognition of the text on the screen. Included in the program are a number of exercises that indicate client comprehension of what they're reading. Some of these are short humorous stories in which the reaction of the client indicates their understanding. Finally the exercises are completed with a reading comprehension story and quiz.


From these indicators the practitioner can assess the client’s facility and skill level when using Steady-Eye technique.


All cases during the MagnaFlyer trial resulted in a successful outcome for the client. With this training completed the client can move on to learning about assistive technologies for implementing Steady-Eyetechnique in their daily lives.


With regard to (5) the client’s subjective perception of the training experience and the result of the training:
All of the training providers reported comments from their clients with regard to their experience during and post MagnaFlyer training. There were a number of recurring themes that indicated that the clients found MagnaFlyer to be a positive experience. Following is a representative sampling of their subjective perceptions.


MagnaFlyer has many benefits, which reach beyond reading.  Utilizing Eccentric Viewing effectively allows clients to manage activities of daily living (ADL’s) safely and independently. 


One client who had a visual field deficit, was pleased that she was now not only able to spot birds in her backyard using her PRL, but was also able to see herself in the mirror.  She had not been able to do so for 5 years. 
A client with Age Related Macular Degeneration was able to read a short story at 350 WPM using MagnaFlyer after just four visits.  At the time of evaluation, he was using high powered stand magnifiers to read, and was able to read at 38 WPM, as measured by the Pepper Visual Skills and Reading Test and with his computer, using a 46 inch monitor for text enlargement, he was able to read at 75 WPM using Zoomtext™.  Because of the difficulty he experienced progressing to scanning activities with eccentric viewing, the MagnaFlyer program offered him an excellent means to access reading material and read with comprehension at a high level of speed.


MagnaFlyer also offers clients a means to measure success.  Their ability to get to the through the different levels offers a sense of accomplishment.  Progress is easily measured, through comprehension, reading speed as well as the client’s ability to successfully complete the various levels of exercises.  It also allows the client control over their reading speed, allowing them to not only pause the reading material, but increase and reduce speed as well.
One client stated “I can’t believe I just read that paragraph at 100 words per minute!” 

  
Many clients appreciated the dynamic training environment that MagnaFlyer allows, with no more of the complaints frequently received when giving them traditional paper exercises including “I feel like I am in the first grade again!” 


In summary, the client experience with MagnaFlyer indicated that it is a useful tool to progress a client through the initial phases of locating their PRL, all the way to the end product of using assistive technology for reading standard written materials. 


SUMMARY AND CONCLUSION:
In my professional judgment and based on the consensus of the Ensight rehabilitation staff the MagnaFlyer low vision rehabilitation program does represent a significant advance over traditional paper-based methods in the delivery of vision rehabilitation training. It is our view that the MagnaFlyer program can provide substantial benefit to both the client when receiving the training and the service organization responsible for delivering it.
For the client MagnaFlyer has many benefits, which reach beyond reading.  Utilizing Eccentric Viewing and study eye technique effectively allows them to manage activities of daily living safely and independently. Therefore when training can be accomplished in approximately half the time, the client derives the benefit of having a new independence building skill available to them more quickly.


In addition, after having received training using MagnaFlyer, the MagnaFlyer software then can become an everyday assistive reading technology for use in the home. It is capable of displaying virtually every type of electronic document, web pages and e-mail. This allows the client to generalize the reading skills learned using MagnaFlyer in the training sessions to the reading they wish to do in their everyday lives.


For organizations, institutions and individuals charged with teaching skills to those with low vision the benefits come in the form of reduced preparation work, ease of deployment, flexibility in training environment this results in greater efficiency and more time to spend focused on the client’s success.


We therefore recommend the MagnaFlyer program for use in low vision rehabilitation training.
Cori Layton, OTR, SCLV,

Director of Rehabilitation Services, Ensight Skills Center for Visual Rehabilitation

 

1) British Journal of Ophthalmology,

Article rss Br J Ophthalmol 2010;94:494-497 doi:10.1136/bjo.2008.152231 Clinical science Effective rehabilitation of reading by training in the technique of eccentric viewing: evaluation of a 4-year programme of service delivery Shelagh Palmer1, David Logan1, Shahriar Nabili2, Gordon N Dutton2,3,4

 



 

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