Occupational Therapy&

Visual Rehabilitation

Presenter: Linda Clemente, OTR/L

HealthSouth Rehabilitation Hospital of Tinton Falls

What is Occupational Therapy?

An allied health profession that uses “occupation” or purposeful activity to help people with physical, developmental, or emotional disabilities lead independent, productive, and satisfying lives.

Goals of Occupational Therapy

It is the application of core values, knowledge, and skills to assist clients to engage in everyday activities that they want and need to do in manner that supports health and participation. O.T.’s provide skills, compensatory techniques, and adaptive techniques in order to improve performance as a holistic approach.

• Occupational Therapy should be meaningful, purposeful, and enjoyable.

• A fundamental concept in O.T. is that the activity (occupation ) must be interesting and must intrinsically promote correct movement or behavior.

• The ultimate goal is to have people return to their highest level of independence in their self care and activities of daily living, including leisure, and work hardening.

Professionals on the Rehab Team Vision rehab is a team effort• Physiatrist• Internal Medicine• Nurses• Ophthalmologist• Neuro-optometrist• Occupational Therapist• Physical Therapist• Speech Therapist• Psychologist /Social Worker

Additional professionals include-

Orientation Mobility Specialists: When visual acuity is impaired to create travel limitations.

Certified Vision Rehabilitation Therapist: When vision is so impaired that blind technique is necessary.

Teacher of the Visually impaired: Involved if client is K- 12.

What O.T is NOT : O.T. is NOT visual therapy O.T.’s DO NOT diagnose O.T’s DO NOT consider low vision or visual deficits without it’s relationship to performance in A.D.L’s

Vision is a complex and dynamic neurologic process

The eyes collect light which is transferred into a signal that is sent to the visual center of the brain.It is those signals that the brain translate into what we know as vision.

TWO VISUAL SYSTEMS 1. Anterior Visual System

All structures anterior to the optic chiasm: cornea, iris, pupil, lens, aqueous and vitreous humor, retina, and optic nerve.

2. Posterior Visual System Optic chiasm, optic tracts, lateral geniculate nucleus, superior/inferior colliculi, geniculocalcarine tracts, and the occipital cortex

The cortical processing centers assist in processing visual information. These centers include: the temporal and parietal circuits, prefrontal and medial temporal lobe, the brain stem, and the cerebellum. The TRIAD of the anterior, posterior, and cortical system allows for functional vision. All components compliment one another.

The visual system is closely linked with our motor/postural and vestibular systems. This enables us to plan movements, move within our environment, an maintain an upright position in space.

The visual system allows us to accurately attend to environmental information, integrate it, and use it to make daily decisions

Vision is the primary way we acquire information

It is the primary way we acquire patterns.

1/3 to 1/2 of the brain is devoted to pure visual processing.

90% of sensory input is VISION.

*Vision is the FIRST system to alert us to danger or pleasure.

*Vision enables us to be anticipatory.

*Vision allows us to plan for situations.

Vision provides speed-We can instantly identify an item with vision.-We can also use other senses, but it will take longer.-Vision allows us to adapt to dynamic environments( a temporal/timing component things are moving in addition to you moving)

WE USE VISION FOR:-Decision Making-executive functioning.

-Social Interactions-facial expressions.

-Motor and postural control-planning ahead for what we will encounter ie. ice, stairs, closed door.

We are visually dependent!!!!!

It is NOT easy for other systems to take over, especially with age.

People will always attempt to use vision to complete occupations and activities.

Visual Hierarchy Model

Visual acuity needs to be assessed prior to treatment techniques of fixation, scanning,

tracking for eye hand coordination to perform ADL’s

The building block for increased independence with ADL’s and functional mobility.

Adaption through vision

Visuocognition

Visual memory

Pattern Recognition

Scanning

Attention= Alert and Attending

Oculomotor Control Visual Field Visual Acuity

vvVVpPsOOCOsasWWWWWW

Warren 2009

Visual Impairment: Can occur secondary to

illness, trauma, and age Disease/Condition:• Parkinson’s• Multiple Sclerosis• Degenerative myopia• Diabetic retinopathy• Glaucoma• Optic Nerve Trauma / Atrophy• Stargardt’s disease• Degenerative myopia

Trauma:StrokeTraumatic Brain InjuryAquired Brain Injury

Age:CataractsAge related Macular Degeneration******Combination of causes*******

Visual Impairment

1. The quality and amount of visual input into the brain can be altered. (the acuity can be changed)2. The brain’s ability to process normal visual input can be altered.3. BOTH can be altered.

EITHER WAY………. THERE IS A DECREASE IN THE ABILITY TO USE VISION FOR OCCUPATIONS

Consequences of Visual Impairment

Difficulty completing VISION DEPENDENT activities (reading and driving are the two most important vision dependent tasks).

Feeding, grooming, dressing are less dependent on vision.Decreased SPEED in completing tasks andErrors in decision making when vision is impaired

Behavioral Changes that can occur with vision impairment:*Decreased Confidence*Increased anxiety and uncertainty in responding to the environment*Increased passiveness in decision making*Difficulty with tasks in dynamic environments*Community activities are the most challenging:• driving• shopping• working• participation in sports

O.T. Screening *** Make sure client has glasses on***

***Make sure they are clean*** ** Check side effects of medication**

Make sure vision is assessed appropriately through a optometrist and continue the communication between staff to ensure success of treatment goals and patient satisfaction.

THREE GENERAL PRINCIPLESFOR

ENHANCINGVISUAL PERFORMANCE

1. Increase visibility of the task or the environment…..make things brighter

A. Use contrast to increase visibility

B. Minimize the background Pattern Clean up the clutter Organize similar items/separate colors.

Minimize background pattern

Organize

C. Provide Optimal Lighting Even illumination Minimize glare Flexible placement: aim for even illumination and brightness Task lighting Carry a penlight

*Fluorescent Lighting: even illumination, but limited placement flexibility ( pulsing light bothers some people) **Halogen Lighting: high quality light minimum glare, but is “hot light” ***LED Lighting: Instant on, high intensity, low glare ****Simulated daylight light: increases contrast, increases clarity, low energy

D. ENLARGE: make things BIGGER Enlarge with Contrast ie. Large button calculator Large button remote Large print cards, bingo Move in closer

E. MANAGE GLARE SENSITIVITY Reduce glare sources Use proper window covering Cover reflective surfaces( floors, shiny counter) Use filters to control incoming light(wear clip on or fitover glasses, visor may be helpful)

2. ORGANIZE

Structuring your physical space helps with cognitive functioning. Increased participation if things are organized. Predictability of the physical space.

3. Simplify Tasks

Eliminate steps that require vision Address both the cognitive and visual impairment

Homonymous Hemianopia

Behavior Changes in H.H

1.Persons will adopt a narrow search pattern confined to the sound side or midline

2.Person will scan VERY slowly towards deficit side—This slows down a person during ADL’s and can affect their ability to navigate through dynamic environments

3. Person misses or misidentifies visual detail on the blind side Person has impaired reading performance Person has difficulty with tasks that have small detail

4. Person has reduced monitoring of the hand Person has impaired grapho-motor skills Person has difficulty pouring liquids

5. Person has changes in Mobility

Appears hesitant, anxious Person prefers to follow vs lead Person exhibits an uncertain gait Person tends to watch their feet Trailing of arms with ambulation Comes very close to obstacles Often stops to search

6. Changes in Orientation Insufficient visual input to accurately map space on involved side. An inability to scan fast enough to comprehend scene as a whole

Tendency to get lost Tends to avoid independent travel Very uncomfortable navigating alone

7. Changes in reading **** Omissions on the involved side Misidentification of words and numbers Poor page navigation may skip lines Reduced reading accuracy and speed

***** reading is not always involved if the fovea is not

8. Changes in Handwriting*** Writing may drift up/down on the line May write on top of other words Positions words incorrectly

****This occurs only if the H.H is on the same side as the dominant hand

9. Changes in A.D. L. This happens in areas that depend on vision to complete Requires monitoring of a wide visual field Driving Shopping Community Events Yard Work Meal Preparation Financial Management Housekeeping Selfcare

What do we do? Spontaneous and complete recovery will not occur for many clients

THE KEY IS COMPENSATION

To teach compensatory strategies , you must know the location and extent of the visual field deficit

Person must learn to use their remaining vision more effectively to compensate for missing vision

Environment must support participation

Compensation/adaptation is a client’s only option since a visual field deficit might have a permanent impairment

Education is a KEY adjunct to intervention.

Education assists a client to become aware of location and extent of deficit.

Education lets a client know how it has affected their occupational performance.

Occupational Therapy Intervention Reading: Must learn how to use new perceptual span Client has to adapt to the new span Requires PRACTICE, PRACTICE, PRACTICE Important to approach it in small, achievable steps: Pre-reading exercises Read in large print Read desired materialClient needs to be successful with letters and words before reading. 20-30 minutes a day is recommended

Functional Mobility The Desired Compensatory Behaviors: Wider head turn Increased head movement in anticipatory behavior Faster head movement Organized, efficient search pattern Increased attention to visual detail

O.T. Intervention

Light Boards / Laser Pointers * Elicits and increases head turning, width and speed * Increases attention/focus to involved side * Creates anticipation to the involved side *Improves the efficiency of the visual search through repetition

Scanning Routes

*Starting to incorporate scanning into movement *Teach a client to consciously observe environment during ambulation tasks *Begin with activities in the gym/clinic a. Scan course b. “Find a color” c. Narrated walk d. Treasure hunts: incorporate language, memory, executive functioning

If possible progress to outside/community environments. It is critical to educate clients about potentially dangerous situations.

ALWAYS increase visibility, think about good contrast, create the best illumination, and minimize the pattern. Organized and structured environmentTherapy should create context that support participation GOAL ORIENTED

The ultimate goal of O.T is independence and participation in daily occupations.In summary:

*Effective compensation for field deficit

**Improved search of environment and for task

***Develop supportive routines and habits

Hemi-Inattention/ Neglect

This is a complex condition Multiple areas of the brain may be involved It may involve areas that were not directly damaged when injury occurred****Predominantly results from RIGHT parietal –temporal-frontal circuitry****

Three Primary Characteristics

1. A lateralized spatial bias

- An avoidance of left space; difficulty exploring space on the left side of body - An Asymmetrical search pattern; initiates search on the right, limited on the right

2. Impaired Conceptualization of Space

- Impaired spatial cognition and orientation Brain loses the ability to ‘map’ left space In the worst case…left space does not exist - Disrupts working memory; client receives no information of left space ; context of the moment is disrupted…only information from the right is used for decision ***poor insight and ability to improve is decreased****

3. Non-Lateralized Decrease in Attention -Affects attention to both sides - Client experiences difficulty generating and sustaining attention(a core characteristic of neglect) - Impairs spatial orientation and exploration Clients will be unable to sustain a search Clients will repeat already observed targets(keep going over and over) Clients will perseverate ****In general clients will move more slowly, will have a difficult time focusing /shifting to a new task*******

Left Hemianopsia vs. Inattention/Neglect

Similar test outcomes BUT the search performance is different( random, disorganized and abbreviated) Length and intensity of intervention are NOT the same Most neglect clears up with time..NEUROPLASTICTY! Most prevalent immediately after injury Diminishes by 3 months in 2/3 of clients Chronic neglect is defined exceeding three months

O.T. INTERVENTION Always want to consider all factors that might limit performance.Always want to modify the environment and facilitate attention.Always want to sustain attention/ use compensatory strategies.Always want to reduce factors that stress visual demands: 1. reduce patterns/reduce clutter 2. reduce glare 3. increase the contrast 4. increase the brightness/illumination 5. organize/structure the task/environment

Reduce patterns

Cover surfaces to reduce the glare

Increase the contrast

Increase the brightness

Cicerone et al in 2000 and in 2011Evidenced based review of Visual Scanning Training (VST) and developing skillsA compensatory strategyConsidered an important ,even critical intervention for clients with neglect

What is Visual Scanning Therapy? Developing skills to COMPENSATE for spatial bias and to execute a COMPREHENSVE search

Reinforce client takes in visual information in a systematic manner

Use language and cognition to REDIRECT search ****can not be successful if client does not have adequate language and cognition*****

Visual Scanning activities Initiate search from the left Execute a symmetrical search pattern Execute complete search to the left Observe all visual detail Anticipate all visual input occurring on the left Rapidly dividing/shifting attention between left and right fields ***Make the activities as interactive as possible*** Kim et al 2011

Engage the client completely O.T.’s use valued activities/occupation Clients will learn compensatory strategies more easily when attempting to apply them in everyday activities that are relevant and valued Clients demonstrate increased motivation Tham, Borell, Gustavsson (2000) Use a multi-sensory approach Use activities with clear outcome Client should be involved in treatment goals

Oculomotor Impairment Frequently associated with T.B.I Brainstem injury significantly disrupts oculomotor functioning -90% of T.B.I. affects brainstem compared to 10% of CVA’s Parkinson’s and Multiple Sclerosis also impairs eye movements

Primary Gaze

9 Points of Gaze

3 Cranial Nerves - Oculomotor Nerve (CN3)

-Trochlear Nerve (CN4) - Abducens Nerve (CN6)

2 Types of Eye Movements

Saccadic: Those movements that change the line of sight. Activated by attention…quick movements

Smooth Pursuits: Movements that stabilize vision…tracting eye movements person is stationary…eyes move

Oculomotor deficits cause: *** Difficulty focusing: difficulty shifting between near and far difficulty sustaining focus difficulty with reading Accommodative dysfunction(Convergence insufficiency, binocular instability, convergence excess, divergence excess, divergence insufficiency) Intervention: lenses / exercise …an optometric approach Prisms Broch String Enlarged print ….OT approach

*** Changes in Perception Diplopia: double vision blurring of vision ghosting images distortionThis interferes with object identificationCreates visual stressCan impair reading performanceAlmost always interferes with PARTICIPATION…..avoidance behaviors

O.T. Approach Modification and adaptation Manage the condition until it resolves GOAL: Eliminate the stress from diplopia so client is willing to participate in daily activities and therapy Two Forms of Occlusion to achieve single vision - Complete occlusion ( with order) - Partial occlusion (with order) - Prisms: prescribed and fitted by optometrist or ophthalmologist -Eye Exercises: for binocular function -Surgical Interventions

LOW VISION A visual impairment that can not be corrected by conventional glasses, contact lenses, surgery, or medicine. The leading causes of low vision in adults over 45 years include: age- related macular degeneration, glaucoma, and diabetic retinopathy.Eye diseases cause one or more of these symptoms: A loss of ability to see detail (visual acuity) A loss of peripheral vision (visual field) Constant double vision( diplopia) Difficulty navigating steps or curbs ( contrast sensitivity) An inability to distinguish colors

Classification of Low Vision

The World Health Organization uses this: When the vision in the better eye with the best possible glasses correction is;20/30 to 20/60: mild vision loss: or near normal vision

20/70 to 20/160: moderate visual impairment or moderate low vision

20/200 or visual field extend less than 20 degrees in diameter: “legal blindness “ 20/200 to 20/400: severe visual impairment or severe low vision20/500 to 20/1,000: profound visual impairment or profound low visionMore than 20/1,000 : near-total visual impairment or near total blindnessNo Light Perception: total blindness or total visual impairment

Interventions*****The main principle is to MAGNIFY the image using various tools*****

Magnifiers( hand held) Telescopes (hand held or mounted onto glasses) Microscopes ( reading lenses) Computer devices( text to speech programs)and enlargement e-books readers (ie. Kindle with larger font) Closed circuit t.v’s that electronically magnify papers Talking watches and clocks

Thank You!

RESOURCESCiuffreda ,K., Rutner ,D,. Kappoor, N., Suchoff, I, Craig, S & Han,ME(2007) . Occurrence of oculomotor dysfunction in acquired brain injury. A retrospective analysis. Optometry,78,155-161.

Cohen, JM.(1992) An overview of enhancement techniques for peripheral field loss. Journal American Optometric Association, 63,60-70. Mennem ,T.A., Warren, M., Yuen, H.K.(2012) Preliminary validation of a vision dependent activities of daily living instrument on adults with homonymous hemianopsia. American Journal of Occupational Therapy, 64(4) 478-48.

Pambakian,A.L.,Currie, J& Kennard,C. (2005) Rehabilitation strategies for patients with homonymous visual field deficits. Journal of Neuro-Ophthalmology, 25, 136-142.

Tham, K., Ginsburg, E.,Fisher , A.G., & Tegner ,R. (2001) Training to improve awareness of disabilities in clients with unilateral neglect. American Journal of Occupational Therapy, 54, 398-406.

Warren, M.,(2009) A pilot study on activities of daily living limitations in adults with hemianopsia. American Journal of Occupational Therapy,63 626-633.

Zhang, X., Kadar, S., Lynn, M.J., Newman, N.J., & Biousse , V.(2006) Homonymous hemianopsia in stroke. Journal of Neuro-Ophthalmolgy,26,180-183.