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Journal of Clinical and Experimental Neuropsychology

Volume 38, 2016 - Issue 10
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Original Articles

The influence of reading direction on hemianopic reading disorders

Denise de Jong Perception and Eye Movement Laboratory, Departments of Neurology and Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Center for Cognition, Learning and Memory, University of Bern, Bern, SwitzerlandView further author information
,
Sigal Kaufmann-Ezra Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, SwitzerlandView further author information
,
Jurka R. Meichtry Perception and Eye Movement Laboratory, Departments of Neurology and Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Center for Cognition, Learning and Memory, University of Bern, Bern, SwitzerlandView further author information
,
Sebastian von Arx Perception and Eye Movement Laboratory, Departments of Neurology and Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, SwitzerlandView further author information
,
Dario Cazzoli Perception and Eye Movement Laboratory, Departments of Neurology and Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Gerontechnology and Rehabilitation Group, University of Bern, Bern, SwitzerlandView further author information
,
Klemens Gutbrod Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Center for Cognition, Learning and Memory, University of Bern, Bern, SwitzerlandView further author information
&
René M. Müri Perception and Eye Movement Laboratory, Departments of Neurology and Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Division of Cognitive and Restorative Neurology, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland; Center for Cognition, Learning and Memory, University of Bern, Bern, SwitzerlandCorrespondencerene.mueri@insel.ch
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Pages 1077-1083
Received 02 Mar 2016
Accepted 08 May 2016
Published online: 28 Jun 2016

Original Articles

The influence of reading direction on hemianopic reading disorders

ABSTRACT

ABSTRACT

Hemianopic reading impairment is a consequence of a visual field defect to either the right or the left side and is characterized by an increased reading time and reduced reading performance. Depending on the side of the visual field defect, reading will be affected differently: Patients suffering from a visual field defect to the right side have noticeable difficulties in reading fluently with slowing. Patients suffering from a visual field defect to the left usually struggle to find the beginning of a line and read more fluently. It was suggested in the literature that changing the reading direction from horizontal to vertical may be a training strategy to reduce reading problems in patients with hemianopia. The aim of the study was to investigate the influence of reading direction on reading speed in patients with left- or right-sided visual field defects and in healthy controls. Method: In 13 patients with hemianopia and in 13 age-matched controls, reading speed was calculated for texts in standard as well as in clockwise rotated orientation of 90, 180, and 270°. Results: In both groups, text rotation reduced reading speed compared to standard reading. Patients with left-sided hemianopia had the greatest reduction after text rotation. Patients with right-sided hemianopia had the smallest speed reduction in 90° vertically rotated texts. Conclusions: Text rotation has different effects in left- or right-sided hemianopia patients. For patients with left-sided heminanopia, rotation of the text may not be a helpful training strategy, for right-sided hemianopia vertical rotation of the text of 90° may be a beneficial training strategy to reduce reading deficits.

Homonymous hemianopia is the most frequent form of acquired visual field defect (VFD) in suprachiasmal lesions (Zhang, Kedar, Lynn, Newman, & Biousse, 2006). In the majority of cases, hemianopia is due to a lesion to areas subserved by the posterior cerebral artery or the middle cerebral artery (Trobe, Lorber, & Schlezinger, 1973; Zhang et al., 2006). The reported frequency of poststroke visual field defects ranges from 8.3 to 25% (Barker & Mullooly, 1997; Gilhotra, Mitchell, Healey, Cumming, & Currie, 2002). Hemianopic reading disorder is due to hemianopia reaching the central part of the visual field on the right or the left side of fixation (Leff, 2014). The severity of the reading impairment depends on the degree of involvement of the macular region (Trauzettel-Klosinski & Reinhard, 1998). The macula consists of a foveal, a parafoveal, and a perifoveal region. While the foveal region subtends the two central degrees of vision, and is therefore crucial for reading, the parafoveal region is important for reading in horizontal direction, as an intact visual field of at least 5° is needed to be able to read (Leff et al., 2000; Starr & Rayner, 2001; Trauzettel-Klosinski & Brendler, 1998).

Depending on the lateralization of a VFD, reading will be differentially affected. Patients with a left-sided VFD (LVFD) show increased reading errors, mainly due to difficulties in finding the beginning of a line or of a word. Patients with right-sided VFD (RVFD) have problems in reading entire words and are therefore unable to read fluently (Kerkhoff, 1999). Although the reading speed is reduced in both LVFD and RVFD, the reading rate has been shown to be more affected in RVFD, since in western civilizations the reading direction proceeds from the left to the right (Kerkhoff, Münssinger, Eberle-Strauss, & Stögerer, 1992; Leff, 2014; Trauzettel-Klosinski & Reinhard, 1998).

In healthy subjects, several studies (Byrne, 2002; Laarni, Simola, Kojo, & Risto, 2004; Tinker, 1955; Yu, Park, Gerold, & Legge, 2010) have compared reading speed between horizontal and vertical texts and have found that reading speed is faster for horizontal texts. There were no differences in reading speed between vertical texts rotated clockwise or anticlockwise, and horizontal reading speed was always faster than vertical reading. Furthermore, Byrne (2002) has shown that vertical reading is slowest when letters are presented in marquee order. Most native Western speakers have little experience in reading vertical text. Oda, Fujita, Mansfield, and Legge (1999) found that Japanese readers, who have experience in reading both horizontal and vertical text, can read in both directions at a similar speed. This result suggests that there is a potential to improve vertical reading speed with practice.

In the rehabilitation of hemianopic reading impairments due to right-sided hemianopia, a rotation of the reading text is proposed to improve reading speed (Schmidt, Ullrich, & Rossner, 1993; Trauzettel-Klosinski, 2010). Instead of reading along the horizontal direction, patients with RVFD could read into their working visual field—that is, along the vertical or the diagonal direction (Trauzettel-Klosinski, 2010). However, up to now, no systematic studies assessing the efficacy of this manipulation have been conducted in patients with hemianopia (Trauzettel-Klosinski, 2010). Furthermore, it is not known which reading direction is more suitable to ameliorate reading performance in left- or right-sided VFD.

The present study aimed to examine the effects of text rotation on reading speed performance in chronic hemianopic patients, suffering from LVFD or RVFD, compared to healthy controls. To this end, we presented texts in four different reading orientations. After text presentation in normal reading direction, the texts were then presented with a clockwise rotation of 90°, 180°, and 270°. We analyzed the number of reading errors per text in all four conditions, the word per minute (WPM) reading speed, and the percentage change in WPM after rotation. We expected that the rotation of the texts would reduce reading speed in all groups, but that this reduction would be smaller in the patient groups, especially when patients would “read away” from their visual field defect (i.e., that the presence of LVFD or RVFD would lead to different results) by reading into their intact visual field areas.

Method

Participants

Thirteen patients with hemianopia or quadrantanopia to either the right (N = 6; 1 female; mean age = 57.5 years, SD = 5.4 years; mean education = 15.2 years, SD = 0.7 years) or the left side (N = 5; 2 female; mean age = 62.6 years, SD = 5.2; mean education = 12.9 years, SD = 1.2) were recruited from the Division of Cognitive and Restorative Neurology at the University Hospital of Bern. Etiology of the visual field defects and demographic data of the patients are shown in Table 1. All patients were native German speakers and had no signs of aphasia, as evaluated by the Token test (Lang, Dehm, Dehm, & Leuschner, 1999), and no neglect symptoms, as evaluated by the Bell’s test (Gauthier, Dehaut, & Joanette, 1989).

Table 1. Demographic data of the patients.

The degree of macular sparing was evaluated by automated static perimetry of the central 10° of the visual field (M2 program; OCTOPUS 101™, Haag-Streit AG, Koeniz, Switzerland) and is indicated as the degrees of intact visual field, measured horizontally, from the center of fixation. The individual degree of macular sparing of the patients is shown in Figure 1.

Figure 1. Individual degree of macular sparing of the central 10°. Gray-scale: relative deficits; black: absolute deficit.

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Thirteen age-matched control subjects (N = 13; 5 female; mean age = 57.0 years, SD = 4.3; mean education = 13.9 years, SD = 0.8) with normal or corrected-to-normal vision were recruited and were matched with the patients’ demographic data. They did not significantly differ from the patients with respect to age, gender, or education (Kruskal–Wallis test, p > .10). The study was carried out in accordance with the Declaration of Helsinki and was approved by the local Ethics Committee. All participants gave written informed consent prior to participation to the study.

Text reading tasks

Four German texts from the International Reading Speed Texts (IReST, Hahn et al., 2006; Trauzettel-Klosinski, Dietz, & Group, 2012) were selected as stimuli. Each text consisted of 129 to 132 words. One text was presented in the standard reading direction, while the three other texts were rotated by 90°, 180°, and 270°, respectively (see Figure 2). The text in standard reading direction was always presented first, followed by the three rotated texts in random order. The texts were presented on a 17″ monitor, with a screen resolution of 1024 × 768 pixels (Nokia 446XS, Nokia, Finnland). The head of the participants was at the distance of 40 centimeters and was stabilized with a headrest, in order to avoid head turns.

Figure 2. Schematic representation of text rotation. Standard reading direction, 90° clockwise rotation, 180° clockwise rotation, and 270° clockwise rotation.

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Participants were instructed to read the text aloud as quickly as possible. All readings were audio-recorded for offline analysis. Words that were repeated, omitted, or incorrectly read were counted. Reading time for each text was calculated. Reading speed was expressed as the number of correct words per minute (WPM)—that is, the total number of words minus the sum of repeated, omitted, and incorrectly read words. Furthermore, we calculated, for each participant and each rotation, the percentage of WPM in relation to the standard reading direction.

Results

Error analysis

Control subjects made on average few errors (mean = 0.2, SEM = 0.1). The mean error increased after rotation of the text. Ninety-degree rotation showed a mean error of 2.6 (0.6); 270° rotation showed one of 2.8 (0.6). The highest mean error was found for 180° rotation (mean: 5.3 with SEM of 1.3). In patients with RVFD, mean error was 7.0 (0.4), 7.4 (1.9), 7.7 (1.6), and 11.6 (2.5) for standard reading, 90° rotation, 270° rotation, and 180° rotation, respectively. In LVFD, mean errors were 1.8 (0.8), 4.3 (1.0), 2.7 (1.1), and 6.2 (2.3). A repeated measures analysis of variance (ANOVA) with the within factor “reading direction” (standard, 90°, 180°, and 270° rotation) and the between factor “group” (RVFD, LVFD, and controls) revealed significant main effects of group, F(2, 23) = 5.287, p < .05, and of reading direction, F(3, 69) = 27.373, p < .001. The Group × Reading Direction interaction was significant, F(6, 69) = 2.585, p < .05. Patients with RVFD had constantly the highest mean error rate for all conditions. The 180° rotation condition elicited the highest error rate for all groups. However, post hoc testing showed no significant differences between the tree groups (all p= 1.0, post hoc Bonferroni test).

Reading speed (WPM)

The results are shown in Figure 3. As expected, a significant main effect of group, F(2, 23) = 19.89; p < .001, and for direction, F(3, 69) = 93.40; p < .001, was found. Furthermore, a significant Group × Reading Direction interaction, F(6, 69) = 8.08; p < .001, was found. To interpret this interaction, Bonferroni-corrected post hoc tests were performed. Healthy participants did read notably faster than both patient groups in all conditions except for the 180°-rotated text, for which healthy participants did not read significantly faster than the patient groups. For the normal reading direction, 90° rotation, and 270° rotation, both patient groups with RVFD and LVFD were significantly slower than controls. The reading speed was not significantly different between the two patient groups in any of the rotation conditions.

Figure 3. Influence of the different rotation conditions on reading speed (words per minute, WPM). Open circles: individual values. Full circles: mean. Bars: 2 standard deviations. R: patients with right-sided visual field defects; L: patients with left-sided visual field defects; C: controls.

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Percentage of reading speed after rotation with respect to standard direction

Since reading speed was already different between groups in the standard reading direction condition, it can be argued that the calculation of the individual percentage of reading speed in the rotated conditions with respect to the reading speed in the standard direction condition [i.e. (WPM in rotated orientation divided by WPM in the standard orientation condition) × 100%] would better reflect a gain or loss due to nonstandard reading directions. Results are shown in Figure 4. A repeated measures ANOVA was conducted on the percentage of WPM data, with the between factor “group” (LVFD, RVFD, control), and the within factor “rotation” (90°, 180°, and 270°), and revealed a significant main effects of group, F(2, 23) = 14.497, p < .001, and reading direction, F(3, 46) = 12.916, p < .001. However, there was no significant Group × Reading Direction interaction. Subjects suffering from LVFD had the greatest reduction in rotated texts, with a mean percentage of 34% (range = 26–40%). Bonferroni-corrected post hoc tests revealed that subjects suffering from LVFD showed a significantly lower percentage than patients suffering from RVFD (mean = 67%; range = 56–80%) and controls (mean = 53%; range = 41–60%).

Figure 4. Percentage of reading speed (words per minute, WPM) performance in the rotated conditions (90°, 180°, and 270°) in the three groups: R = right visual field defect; L = left visual field defect; C = controls. Points indicate mean; error bars indicate 2 standard deviations.

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In contrast, patients with RVFD showed a less clear reduction of performance, and Bonferroni-corrected post hoc tests revealed no significant differences between the RVFD group and the control group. In this group, the performance at 180° was significantly different from the one at 90° and at 270° rotation, respectively. There was no significant post hoc difference between the performance at 90° and that at 270° rotation.

Since the RVFD group seemed to be the least affected by text rotation, we evaluated the influence of the individual degree of macular sparing on reading speed in these patients. We plotted the individual percentage of WPM against the individual degree of macular sparing (see Figure 5).

Figure 5. Individual percentage of reading speed (words per minute, WPM) performance in the rotated conditions in the patients with right visual field defect, plotted against the individual degree of macular sparing.

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For the 90° rotation condition, the degree of macular sparing seemed not to have an influence on performance. However, rotation of the text by 180° seemed to have profound consequences for patients with a spared macular portion smaller than 5°, triggering a conspicuous deterioration of their performance. Rotation of the text by 270° seemed also to worsen performance in these patients, but the amplitude of this deterioration was more moderate.

Discussion

The aim of the present study was to evaluate the effects of text rotation on reading speed both in healthy controls and in patients with LVFD or RVFD. In line with previous literature, we found reduced reading speed in standard direction in both patient groups, as compared to the control group, and this was especially true for the group with RVFD. The rotation of the texts resulted in a reduced reading speed in healthy controls, which confirms the finding of several previous studies (Byrne, 2002; Laarni et al., 2004; Tinker, 1955; Yu et al., 2010). The effect was most pronounced for a clockwise rotation of the text of 180°.

For patients with VFD, we found similar effects of rotation. However, there were differences between patients with LVFD or RVFD. Patients with LVFD were most severely affected by the rotation procedure. Their reading speed dropped to 30–40% of reading speed in standard conditions on average, irrespective of the rotation angle. This observation is surprising, especially for the 90° and 270° rotated text: In these conditions, patients with LVFD read into their intact visual field areas. A mediating effect of visual attention (i.e., visual hemineglect in right-hemispheric patients) is not very likely, since neuropsychological testing did not evidence corresponding deficits in these patients. Patients with LVFD did not show a higher error rate than controls. Furthermore, the patients did not exhibit typical neglect dyslexia signs, such as omissions of words located in the left part of the text, particularly for longer words (Ardila & Rosselli, 1994; Kinsbourne & Warrington, 1962; Reinhart, Schaadt, Adams, Leonhardt, & Kerkhoff, 2013). However, right-brain damage may affect higher right-hemispheric cognitive processes such as mental rotation (Corballis, 1997; Harris et al., 2000; Ornstein, Johnstone, Herron, & Swencionis, 1980), which may reduce reading speed in nonstandard directions. These results seem thus to challenge the assumption that the use of a “reading away from the visual field deficit” strategy may be promising for compensation of visual field deficits.

Patients with RVFD showed the highest error rate and the most reduced reading speed already in standard reading. In contrast to patients with LVFD, in patients with RVFD the effect of rotation on reading speed was not so prominent, and was not statistically different from the one observed in the control group. The extent of reading speed reduction was dependent on the degree of rotation of the text. The reduction of reading speed was less pronounced for 90° and 270° rotations, suggesting a certain “reading away” effect. Interestingly, reading into the intact visual field was most pronounced at 90° rotation, since RVFD patients without any macular sparing or only a marginal sparing (i.e., 2.5°) showed similar reading speed to patients with 5° macular sparing. Taking into account that, for reading horizontally, an intact macular field of at least 5° is needed (Leff et al., 2000; McConkie & Rayner, 1975), patients with a less extensive macular sparing may benefit from a reading training with texts rotated 90° clockwise. The limitation of our study, however, is the rather small group of patients included, and further studies have to confirm these effects.

In conclusion, the present study shows that text rotation may be a helpful training strategy for patients with RVFD. The reading speed of rotated texts in RVFD patients is not different from the one observed in healthy controls. In patients with LVFD, however, rotation of texts seems to have detrimental effects, probably also due to impared mental rotation capacities after right-hemispheric lesions. Thus, text rotation seems not to be a promising training approach in these patients.

Disclosure statement

No relevant financial relationship exists.

Additional information

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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