Compensatory Eye Movements Research Articles

Filtering on the Go: Effect of Filters on Gaze Pointing Accuracy During Physical Locomotion in Extended Reality.

Eye tracking filters have been shown to improve accuracy of gaze estimation and input for stationary settings. However, their effectiveness during physical movement remains underexplored. In this work, we compare common online filters in the context of physical locomotion in extended reality and propose alterations to improve them for on-the-go settings. We conducted a computational experiment where we simulate performance of the online filters using data on participants attending visual targets located in world-, path-, and two head-based reference frames while standing, walking, and jogging. Our results provide insights into the filters' effectiveness and factors that affect it, such as the amount of noise caused by locomotion and differences in compensatory eye movements, and demonstrate that filters with saccade detection prove most useful for on-the-go settings. We discuss the implications of our findings and conclude with guidance on gaze data filtering for interaction in extended reality.

Testing Visual Function by Assessment of the Optomotor Reflex in Glaucoma.

Optomotor response/reflex (OMR) is a fast and efficient first-in-line visual screening method, especially for rodents. It has the potential to evaluate both the scotopic and photopic visions of nonrestrained animals through tracking head movement, providing a quantitative estimate of visual functions. In restrained animals, optokinetic response (OKR), compensatory eye movements for visual shifts in the surroundings, is utilized. Both OMR and OKR capitalize on an individual's innate reflex to stabilize images for the purpose of capturing clear vision. The two reflexes have similar reliability when evaluating stimulus luminance, contrast, spatial frequency, and velocity. They have emerged as powerful tools to evaluate the efficacy of pharmacological treatments and phenotypes of subjects undergoing study. With OMR and OKR accurately assessing visual acuity (VA) as well as contrast sensitivity (CS), the gold standards for measuring clinical vision, they provide reliable and easily accessible results that further eye and brain research. These methods of sight evaluation have been used in multiple animal models, particularly mice and zebrafish. Through OMR assays, these animal models have been utilized to investigate retinal degenerative diseases, helping researchers differentiate between worsening stages. Alongside tests such as optical coherence tomography (OCT), OMR provides confirmation of visual status, where increased OMR function often correlates with improved visual status. OMR has continued to be used outside of glaucoma in various retinal diseases, such as retinitis pigmentosa (RP), diabetic retinopathy, and age-related macular degeneration.In this chapter, we will introduce the concept and application of visual stimulus-induced head or eye reflex movement in different animal species and experimental models of eye diseases, such as glaucoma and other neurodegenerative disorders, and in patients with glaucoma.

Elevated Smooth Pursuit Gain in Collegiate Athletes with Sport-related Concussion Immediately Following Injury.

Although there is evidence that sport-related concussion (SRC) affects oculomotor function and perceptual ability, experiments are often poorly controlled and are not replicable. This study aims to test the hypothesis that there are decreased values when assessing oculomotor impairment indicating poorer performance in SRC patients. Fifteen DI athletes presenting with SRC (7 females, 8 males) and 15 student volunteers (CON) (12 females, 3 males) completed a dynamic visual acuity (DVA) task that involved answering the direction of a moving stimulus (Landolt C) while wearing a head-mounted binocular eye tracker. There were 120 trials total with 60 trials presenting at 30º per second and 60 presenting at 90º per second. Various eye movement measurements, including horizontal smooth pursuit eye movements (SPEM) gain and saccadic peak velocity, were analyzed between groups using univariate ANOVAs. Saccade count in SPEM trials, accuracy, and vision were analyzed using Kruskal-Wallis tests. There was no statistical difference in saccadic peak velocity: SRC = 414.7 42º/s, CON = 406.6 40.6º/s. A significant difference was found between SRC patients and healthy controls in horizontal SPEM gain (SRC = 0.9 0.04, CON = 0.86 0.03, F(1,28) = 7.243, P = 0.012) indicating that patients demonstrated compensatory eye movements when tracking the target. There were significantly more saccades in all SPEM trials (P = 0.001). SRCoculomotor deficits manifest as elevated horizontal SPEM gain when assessed within 48 hours of injury and compared to healthy controls within the same age range. SRC demonstrates altered oculomotor ability. While accurate in tracking a stimulus, SRC patients may conduct less controlled eye movements.

A dynamic sequence of visual processing initiated by gaze shifts.

Animals move their head and eyes as they explore the visual scene. Neural correlates of these movements have been found in rodent primary visual cortex (V1), but their sources and computational roles are unclear. We addressed this by combining head and eye movement measurements with neural recordings in freely moving mice. V1 neurons responded primarily to gaze shifts, where head movements are accompanied by saccadic eye movements, rather than to head movements where compensatory eye movements stabilize gaze. A variety of activity patterns followed gaze shifts and together these formed a temporal sequence that was absent in darkness. Gaze-shift responses resembled those evoked by sequentially flashed stimuli, suggesting a large component corresponds to onset of new visual input. Notably, neurons responded in a sequence that matches their spatial frequency bias, consistent with coarse-to-fine processing. Recordings in freely gazing marmosets revealed a similar sequence following saccades, also aligned to spatial frequency preference. Our results demonstrate that active vision in both mice and marmosets consists of a dynamic temporal sequence of neural activity associated with visual sampling.

TREYESCAN: configuration of an eye tracking test for the measurement of compensatory eye movements in patients with visual field defects

The Traffic Eye Scanning and Compensation Analyzer (TREYESCAN) is introduced as an innovative eye tracking test designed to measure compensatory eye movements in individuals with visual field defects. The primary objective of the test is to quantitatively assess and analyze the compensatory eye movements employed by patients with visual field defects while viewing videos of various traffic scenes from the viewpoint of a driver of a passenger car. The filming process involved capturing a wide range of driving conditions and hazards, aiming to replicate real-world scenarios. Specific dynamic areas of interest within these scenes were selected and assessed by a panel of experts on medical and practical fitness to drive. Pilot measurements were conducted on a sample of 20 normally-sighted individuals during two different measurement sessions. The results provide valuable insights into how individuals without visual impairment view the dynamic scenes presented in the test. Moving forward, the TREYESCAN will be used in a case–control study involving glaucoma patients and control subjects, with the goal of further investigating and understanding the mechanisms employed by individuals with glaucoma to compensate for their visual field defects.

Prosthetic Stimulation of the Vestibular Nerve Can Evoke Robust Eye and Head Movements Despite Prior Labyrinthectomy.

Prosthetic electrical stimulation can evoke compensatory eye and head movement despite vestibular implant electrode insertion occurring years after prior labyrinthectomy. Vestibular implants sense head rotation and directly stimulate the vestibular nerve, bypassing damaged end organs. Animal research and current clinical trials have demonstrated the efficacy of this approach. However, candidacy criteria for vestibular implants currently require presence of a patent labyrinth in the candidate ear and at least aidable hearing in the opposite ear, thus excluding patients who have undergone prior labyrinthectomy for unilateral Menière's disease that later progressed to bilateral vestibular hypofunction. Eight years after right unilateral labyrinthectomy, we implanted stimulating electrodes in the previously exenterated right ear ampullae of a rhesus macaque monkey. The left labyrinth had long-standing hypofunction due to intratympanic gentamicin injection and surgical disruption. We used three-dimensional video-oculography to measure eye movement responses to prosthetic electrical stimulation. We also measured head-movement responses to prosthetic stimulation with the head unrestrained. Bilateral vestibular hypofunction was confirmed by absence of vestibuloocular reflex responses to whole-body rotation without prosthetic stimulation. For a subset of the implanted electrodes, prosthetic vestibular stimulation evoked robust compensatory eye and head movements. One electrode reliably elicited responses aligned with the implanted ear's anterior canal nerve regardless of the return electrode used. Similarly, a second electrode also elicited responses consistent with excitation of the horizontal canal nerve. Responses grew quasilinearly with stimulation rate and current amplitude. Prosthetic electrical stimulation targeting the vestibular nerve can be effective years after labyrinthectomy, if at least some parts of the vestibular nerve's ampullary branches remain despite destruction or removal of the membranous labyrinth.

Placebo effect after visual restitution training: no eye-tracking controlled perimetric improvement after visual border stimulation in late subacute and chronic visual field defects after stroke.

A significant number of Restitution Training (RT) paradigms claim to ameliorate visual field loss after stroke by re-activating neuronal connections in the residual visual cortex due to repeated bright light-stimulation at the border of the blind and intact fields. However, the effectiveness of RT has been considered controversial both in science and clinical practice for years. The main points of the controversy are (1) the reliability of perimetric results which may be affected by compensatory eye movements and (2) heterogeneous samples consisting of patients with visual field defects and/or visuospatial neglect. By means of our newly developed and validated Virtual Reality goggles Salzburg Visual Field Trainer (SVFT) 16 stroke patients performed RT on a regular basis for 5 months. By means of our newly developed and validated Eye Tracking Based Visual Field Analysis (EFA), we conducted a first-time full eye-movement-controlled perimetric pre-post intervention study. Additionally, patients subjectively rated the size of their intact visual field. Analysis showed that patients' mean self-assessment of their subjective visual field size indicated statistically significant improvement while, in contrast, objective eye tracking controlled perimetric results revealed no statistically significant effect. Bright-light detection RT at the blind-field border solely induced a placebo effect and did not lead to training-induced neuroplasticity in the visual cortex of the type needed to ameliorate the visual field size of stroke patients.

Teaching Video NeuroImage: One Bedside Test, 2 Clinical Signs

A 60-year-old patient had progressive imbalance. Examination revealed saccadic smooth pursuit, downbeat nystagmus, ataxia of stance and gait, and reduced vibration sense. Video head impulse and caloric testing both showed vestibulo-ocular reflex (VOR) deficits (figure). The patient has cerebellar ataxia with neuronopathy and vestibular areflexia syndrome.1,2 Slow head turns while looking at an earth-fixed target produce saccadic rather than smooth compensatory eye movements (Videos 1) due to impairment of both the VOR and smooth pursuit (the visually enhanced VOR): 1 simple bedside test, 2 clinical signs, and 1 precise diagnosis.

Rotational Distortion and Compensation in Optical Coherence Tomography with Anisotropic Pixel Resolution.

Accurate image registration is essential for eye movement compensation in optical coherence tomography (OCT) and OCT angiography (OCTA). The spatial resolution of an OCT instrument is typically anisotropic, i.e., has different resolutions in the lateral and axial dimensions. When OCT images have anisotropic pixel resolution, residual distortion (RD) and false translation (FT) are always observed after image registration for rotational movement. In this study, RD and FT were quantitively analyzed over different degrees of rotational movement and various lateral and axial pixel resolution ratio (RL/RA) values. The RD and FT provide the evaluation criteria for image registration. The theoretical analysis confirmed that the RD and FT increase significantly with the rotation degree and RL/RA. An image resizing assisting registration (RAR) strategy was proposed for accurate image registration. The performance of direct registration (DR) and RAR for retinal OCT and OCTA images were quantitatively compared. Experimental results confirmed that unnormalized RL/RA causes RD and FT; RAR can effectively improve the performance of OCT and OCTA image registration and distortion compensation.

Automatic measurement of mouse visual acuity based on optomotor response: SKY optomotry.

In the field of visual science study using rodents, several assessment methods have been developed for measuring visual function. However, methods such as electroretinograms tests, visual evoked potentials tests and maze tests have limitations in that they measure function of only a specific type of cells, are difficult to quantify or require sufficient training time. The method which uses an optokinetic reflex and optomotor response, a compensatory eye and head movement in response to changes in the visual scene, became the most widely used method. However, this method requires highly trained experimenters and is time consuming. We showed that measured visual acuity values are significantly different between beginner and expert. Here we suggest an automated optometry program, 'SKY optomotry', which automatically tracks rodents' optomotor response to overcome subjectivity and the lengthy scoring procedure of the existing method. To evaluate the performance of SKY optomotry using 8-12-week-old C57BL/6 mice we compared the binomial decision of SKY optomotry with a skilled expert, and the area under the curve of SKY optomotry was 0.845. Comparing the final visual acuity, the intraclass correlation coefficient value between SKY optomotry and an expert was 0.860 (95% confidence interval (CI) 0.709-0.928), whereas that between an expert and a beginner was 0.642 (95% CI 0.292-0.811). SKY optomotry showed an excellent level of performance with good inter-rater agreements based on the visual acuity measured by an expert. With the use of our application, researchers will be able to test an experimental animal's eyesight more accurately while saving time on specialized training.

Role of locomotor efference copy in vertebrate gaze stabilization.

Vertebrate locomotion presents a major challenge for maintaining visual acuity due to head movements resulting from the intimate biomechanical coupling with the propulsive musculoskeletal system. Retinal image stabilization has been traditionally ascribed to the transformation of motion-related sensory feedback into counteracting ocular motor commands. However, extensive exploration of spontaneously active semi-intact and isolated brain/spinal cord preparations of the amphibian Xenopus laevis, have revealed that efference copies (ECs) of the spinal motor program that generates axial- or limb-based propulsion directly drive compensatory eye movements. During fictive locomotion in larvae, ascending ECs from rostral spinal central pattern generating (CPG) circuitry are relayed through a defined ascending pathway to the mid- and hindbrain ocular motor nuclei to produce conjugate eye rotations during tail-based undulatory swimming in the intact animal. In post-metamorphic adult frogs, this spinal rhythmic command switches to a bilaterally-synchronous burst pattern that is appropriate for generating convergent eye movements required for maintaining image stability during limb kick-based rectilinear forward propulsion. The transition between these two fundamentally different coupling patterns is underpinned by the emergence of altered trajectories in spino-ocular motor coupling pathways that occur gradually during metamorphosis, providing a goal-specific, morpho-functional plasticity that ensures retinal image stability irrespective of locomotor mode. Although the functional impact of predictive ECs produced by the locomotory CPG matches the spatio-temporal specificity of reactive sensory-motor responses, rather than contributing additively to image stabilization, horizontal vestibulo-ocular reflexes (VORs) are selectively suppressed during intense locomotor CPG activity. This is achieved at least in part by an EC-mediated attenuation of mechano-electrical encoding at the vestibular sensory periphery. Thus, locomotor ECs and their potential suppressive impact on vestibular sensory-motor processing, both of which have now been reported in other vertebrates including humans, appear to play an important role in the maintenance of stable vision during active body displacements.

Effectiveness of vestibular rehabilitation therapy in patients with idiopathic Cerebellar Ataxia with Bilateral Vestibulopathy (iCABV).

To evaluate the benefit of vestibular rehabilitation therapy (VRT) in the management of patients with idiopathic cerebellar ataxia with bilateral vestibulopathy (iCABV). iCABV is a hindbrain degenerative disorder with impairment of both central and peripheral vestibular pathways. There is combined failure of four compensatory eye movement systems including the vestibulo-ocular reflex (VOR), optokinetic reflex, smooth pursuit and the visually enhanced vestibulo-ocular reflex (VVOR). Phenotypic presentation includes postural and gait instability, oscillopsia and dizziness with active head movement. The benefit of VRT in iCABV patients has not been established. A retrospective review was performed on a cohort of twelve patients diagnosed with iCABV in a multidisciplinary neuro-otology clinic. All participated in VRT and completed their suggested course of VRT. The following clinical measures were assessed before starting and after finishing VRT: 1) Dizziness Handicap Inventory (DHI), 2) Activities-Specific Balance Confidence (ABC) Scale, 3) Catastrophization scale, 4) Positive Affective Negative Affective Score (PANAS), 5) Dynamic Gait Index (DGI) and 6) Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). The number of falls historically was recorded in addition to gait speed (ft./sec). Following VRT, patients were found to have improved balance on mCTSIB (condition 4 : 7 vs 18 seconds, P = 0.04) and a better postural stability with a reduced number of falls (p = 0.01). No statistically significant improvement was seen in the DHI, ABC, Catastrophization scale, DGI, PANAS and gait speed (p > 0.05). iCABV patients who underwent VRT were found to have a better postural stability and reduced risk of falls. VRT was not found to significantly improve patients' overall subjective perception of their symptoms or their psychological status.

Low Gain Values of the Vestibulo-Ocular Reflex Can Optimize Retinal Image Slip.

The angular vestibulo-ocular reflex (aVOR) stabilizes retinal images by counter-rotating the eyes during head rotations. Perfect compensatory movements would thus rotate the eyes exactly opposite to the head, that is, eyes vs. head would exhibit a unity gain. However, in many species, but also in elderly humans or patients with a history of vestibular damage, the aVOR is far from compensatory with gains that are in part considerably lower than unity. The reason for this apparent suboptimality is unknown. Here, we propose that low VOR gain values reflect an optimal adaptation to sensory and motor signal variability. According to this hypothesis, gaze stabilization mechanisms that aim at minimizing the overall retinal image slip must consider the effects of (1) sensory and motor noise and (2) dynamic constraints of peripheral and central nervous processing. We demonstrate that a computational model for optimizing retinal image slip in the presence of such constraints of signal processing in fact predicts gain values smaller than unity. We further show specifically for tadpoles of the clawed toad, Xenopus laevis with particularly low gain values that previously reported VOR gains quantitatively correspond to the observed variability of eye movements and thus constitute an optimal adaptation mechanism. We thus hypothesize that lower VOR gain values in elderly human subjects or recovered patients with a history of vestibular damage may be the sign of an optimization given higher noise levels rather than a direct consequence of the damage, such as an inability of executing fast compensatory eye movements.

Increased Depth, Reduced Extent, and Sharpened Edges of Visual Field Defects Measured by Compass Fundus Perimeter Compared to Humphrey Field Analyzer.

PurposeThe purpose of this study was to compare visual field results of the COMPASS fundus perimeter (CMP) and the Humphrey Field Analyzer (HFA) in the same eyes; to compare structure-function concordance between circumpapillary retinal nerve fiber layer (Cp-RNFL) profiles and the two perimetry results; and to evaluate whether differences between the two results reflect postulated advantages of real-time eye movement compensation during perimetry.MethodsWe retrospectively analyzed 24-2 visual field data measured with CMP and HFA together with Cp-RNFL optical coherence tomography (OCT) scan data from 95 eyes of 65 people with glaucoma. We defined visual field locations with total deviation (TD) less than −5 dB as defective. The CMP and HFA fields were compared on measures of: spatial extent (number of defective locations); depth (TD values); and sharpness of scotomata edges (maximum TD difference between defective locations and their neighbors). Structure-function concordance between Cp-RNFL profile and respective visual field was also compared.ResultsCompared to the HFA, scotomata measured by CMP were of reduced spatial extent (mean difference = −3.14 locations, p < 0.001), greater depth (median TD of CMP = −17 dB versus HFA = −13 dB, p = 0.029) and steeper edges (median of maximum TD difference of CMP = 10.6 dB versus HFA = 6 dB, p < 0.001). Structure-function concordance between Cp-RNFL profile and either visual field were comparable despite the reduced scotoma spatial extent measured by CMP.ConclusionsGlaucomatous visual fields measured by CMP displayed characteristics consistent with expected effects of using real-time eye movement compensation technology compared to the widely used HFA.Translational RelevanceGlaucomatous visual field defects measured by the CMP are more localized, deeper, and steeper than those of the HFA.

How Free-Viewing Eye Movements Can Be Used to Detect the Presence of Visual Field Defects in Glaucoma Patients.

Purpose: There is a need for more intuitive perimetric screening methods, which can also be performed by elderly people and children currently unable to perform standard automated perimetry (SAP). Ideally, these methods should also be easier to administer, such that they may be used outside of a regular clinical environment. We evaluated the suitability of various methodological and analytical approaches for detecting and localizing VFD in glaucoma patients, based on eye movement recordings.Methods: The present study consisted of two experiments. In experiment 1, we collected data from 20 glaucoma patients and 20 age-matched controls, who monocularly viewed 28 1-min video clips while their eyes were being tracked. In experiment 2, we re-analyzed a published dataset, that contained data of 44 glaucoma patients and 32 age-matched controls who had binocularly viewed three longer-duration (3, 5, and 7 min) video clips. For both experiments, we first examined if the two groups differed in the basic properties of their fixations and saccades. In addition, we computed the viewing priority (VP) of each participant. Following a previously reported approach, for each participant, we mapped their fixation locations and used kernel Principal Component Analysis (kPCA) to distinguish patients from controls. Finally, we attempted to reconstruct the location of a patient's VFD by mapping the relative fixation frequency and the VP across their visual field.Results: We found direction dependent saccade amplitudes in glaucoma patients that often differed from those of the controls. Moreover, the kPCA indicated that the fixation maps of the two groups separated into two clusters based on the first two principal components. On average, glaucoma patients had a significantly lower VP than the controls, with this decrease depending on the specific video viewed.Conclusions: It is possible to detect the presence of VFD in glaucoma patients based on their gaze behavior made during video viewing. While this corroborates earlier conclusions, we show that it requires participants to view the videos monocularly. Nevertheless, we could not reconstruct the VFD with any of the evaluated methods, possibly due to compensatory eye movements made by the glaucoma patients.

Mouse visual cortex contains a region of enhanced spatial resolution

The representation of space in mouse visual cortex was thought to be relatively uniform. Here we reveal, using population receptive-field (pRF) mapping techniques, that mouse visual cortex contains a region in which pRFs are considerably smaller. This region, the “focea,” represents a location in space in front of, and slightly above, the mouse. Using two-photon imaging we show that the smaller pRFs are due to lower scatter of receptive-fields at the focea and an over-representation of binocular regions of space. We show that receptive-fields of single-neurons in areas LM and AL are smaller at the focea and that mice have improved visual resolution in this region of space. Furthermore, freely moving mice make compensatory eye-movements to hold this region in front of them. Our results indicate that mice have spatial biases in their visual processing, a finding that has important implications for the use of the mouse model of vision.

Translations of Steinhausen's Publications Provide Insight Into Their Contributions to Peripheral Vestibular Neuroscience.

The quantitative relationship between angular head movement and semicircular canal function is most often referenced to the well-known torsion-pendulum model that predicts cupular displacement from input head acceleration. The foundation of this model can be traced back to Steinhausen's series of papers between 1927 and 1933 whereby he endeavored to document observations of cupular displacements that would directly infer movement of the endolymph resulting from angular rotation. He also was the first to establish the direct relationship between cupular displacement and compensatory eye movements. While the chronology of these findings, with their successes and pitfalls, are documented in Steinhausen's work, it reflects a fascinating journey that has been inaccessible to the non-German speaking community. Therefore, the present compilation of translations, with accompanying introduction and discussion, was undertaken to allow a larger component of the vestibular scientific community to gain insight into peripheral labyrinthine mechanics provided by this historical account.

Differential spatiotemporal development of Purkinje cell populations and cerebellum-dependent sensorimotor behaviors.

Distinct populations of Purkinje cells (PCs) with unique molecular and connectivity features are at the core of the modular organization of the cerebellum. Previously, we showed that firing activity of PCs differs between ZebrinII-positive and ZebrinII-negative cerebellar modules (Zhou et al., 2014; Wu et al., 2019). Here, we investigate the timing and extent of PC differentiation during development in mice. We found that several features of PCs, including activity levels, dendritic arborization, axonal shape and climbing fiber input, develop differentially between nodular and anterior PC populations. Although all PCs show a particularly rapid development in the second postnatal week, anterior PCs typically have a prolonged physiological and dendritic maturation. In line herewith, younger mice exhibit attenuated anterior-dependent eyeblink conditioning, but faster nodular-dependent compensatory eye movement adaptation. Our results indicate that specific cerebellar regions have unique developmental timelines which match with their related, specific forms of cerebellum-dependent behaviors.

Super-resolution ophthalmoscopy: Virtually structured detection for resolution improvement in retinal imaging.

Quantitative retinal imaging is essential for advanced study and clinical management of eye diseases. However, spatial resolution of retinal imaging has been limited due to available numerical aperture and optical aberration of the ocular optics. Structured illumination microscopy has been established to break the diffraction-limit resolution in conventional light microscopy. However, practical implementation of structured illumination microscopy for in vivo ophthalmoscopy of the retina is challenging due to inevitable eye movements that can produce phase artifacts. Recently, we have demonstrated the feasibility of using virtually structured detection as one alternative to structured illumination microscopy for super-resolution imaging. By providing the flexibility of digital compensation of eye movements, the virtually structured detection provides a feasible, phase-artifact-free strategy to achieve super-resolution ophthalmoscopy. In this article, we summarize the technical rationale of virtually structured detection, and its implementations for super-resolution imaging of freshly isolated retinas, intact animals, and awake human subjects.

Maximizing Telerehabilitation for Patients With Visual Loss After Stroke: Interview and Focus Group Study With Stroke Survivors, Carers, and Occupational Therapists.

BackgroundVisual field defects are a common consequence of stroke, and compensatory eye movement strategies have been identified as the most promising rehabilitation option. There has been a move toward compensatory telerehabilitation options, such as the Durham Reading and Exploration (DREX) training app, which significantly improves visual exploration, reading, and self-reported quality of life.ObjectiveThis study details an iterative process of liaising with stroke survivors, carers, and health care professionals to identify barriers and facilitators to using rehabilitation tools, as well as elements of good practice in telerehabilitation, with a focus on how the DREX package can be maximized.MethodsSurvey data from 75 stroke survivors informed 12 semistructured engagement activities (7 focus groups and 5 interviews) with 32 stroke survivors, 10 carers, and 24 occupational therapists.ResultsThematic analysis identified key themes within the data. Themes identified problems associated with poststroke health care from both patients’ and occupational therapists’ perspectives that need to be addressed to improve uptake of this rehabilitation tool and telerehabilitation options generally. This included identifying additional materials or assistance that were required to boost the impact of training packages. The acute rehabilitation setting was an identified barrier, and perceptions of technology were considered a barrier by some but a facilitator by others. In addition, 4 key features of telerehabilitation were identified: additional materials, the importance of goal setting, repetition, and feedback.ConclusionsThe data were used to try to overcome some barriers to the DREX training and are further discussed as considerations for telerehabilitation in general moving forward.