Visual Rehabilitation: Promoting Sight, Self-Care, Safety...
Transcript of Visual Rehabilitation: Promoting Sight, Self-Care, Safety...
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Visual Rehabilitation: Promoting Sight, Self-Care, Safety & Success May 14, 2015
LINDA CLEMENTE, OTR/L PATRICIA HIGGINS MS, OTR/L
NIDHI SHAH PT, DPT HEALTHSOUTH REHABILITATION HOSPITAL OF TINTON FALLS
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BACKGROUND AND INTRODUCTION
PATTI HIGGINS, MS, OTR/L
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Vision: One of the Most Important Senses
u Allows us to gather, process and react to the environment
u Enables us to plan movements, move within our environment, and maintain an upright position in space.
u Allows us to accurately attend to environmental information, integrate it, and use it to make daily decisions
u First system to alert us to DANGER and PLEASURE
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VISION is used for:
u Decision making-executive functioning
u Social Interactions and facial expressions
u Motor and postural control
u Planning ahead for what the environment presents us with
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VISION -> PRIMARY WAY OF ACQUIRING
INFORMATION
u 1/3 to 1/2 of the brain is devoted to pure visual processing
u 90% of sensory input is VISION
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“ ”
“Vision dominates the sensory context for the simple reason that it takes us further into the environment than any of the other senses do.”
(Pendleton and Schultz-Krohn, 2012)
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Professionals on the Rehabilitation Team
u Vision rehab is a team effort • Physiatrist
• Internal Medicine
• Nurses
• Ophthalmologist
• Neuro-optometrist
• Occupational Therapist
• Physical Therapist
• Speech Therapist
• Psychologist /Social Worker
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ROLE OF OCCUPATIONAL THERAPIST
u Observe functional activities
u Perform screening of gross visual function
u Work closely and collaboratively with the physiatrist and neuro-optometrist
u Implement vision strategies and interventions as advised by the physician
u Determine how the vision impairment impacts a persons ability to perform daily tasks
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Role of Occupational Therapy – cont’d
u Modify the task/environment to minimize those limitations
u Evaluate the environment and provide recommendations as necessary
u Recommend adaptive devices/assistive technology
u Provide interventions to improve visual attention, search and speed, and efficiency of visual processing
(American Occupational Therapy Association, 2011)
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“ ”
Occupational Therapy focuses on reducing the impact of disability by
promoting independence and participation in valued
activities.
- American Occupational Therapy Association
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What OT is NOT:
u O.T. is NOT visual therapy u O.T.’s DO NOT diagnose
u O.T’s DO NOT consider visual deficits without it’s relationship to performance in A.D.L’s
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ROLE OF PHYSICAL THERAPY
u Observe mobility and mobility related activities
u Perform screening of gross visual function when indicated
u Work closely and collaboratively with the physiatrist, neuro-optometrist and OT
u Determine how the vision impairment impacts a persons mobility
u Assessment of fall risk and fall prevention training
u Assessing and training for safe environmental navigation in the home and in the community
u Reintegration of an individual with brain injury and/or visual deficits into the community in a safe, yet independent manner
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Physical therapists are movement disorder specialists who provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities in patients with injury or disease.
- American Physical Therapy Association
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VISUAL HIERARCHY MODEL
u Visual acuity needs to be assessed prior to treatment techniques of fixation, scanning, tracking for eye hand
coordination to perform
ADL’s
u The building block for increased independence
with ADL’s and functional mobility.
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Adaption through vision
Visuocognition
Visual memory
Pattern Recognition
Scanning
Attention= Alert and Attending
Oculomotor Control Visual Field
Visual Acuity
vvVVpPsOOCOsasWWWWWW
Warren 2009
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VISUAL DEFICITS AFTER BRAIN INJURY
PATTI HIGGINS, MS, OTR/L
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VISION AND BRAIN INJURY
u Greater than 50% of those who suffer from a traumatic brain injury experience visual deficits (Politzer, T. 2015)
u These deficits include oculomotor dysfunction, accommodative dysfunction, binocular vision dysfunction, visual field deficit, topographic disorientation, and visual processing dysfunction
u Often times, an individual may not recognize the visual deficit themselves
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VISUAL IMPAIRMENT AND BRAIN INJURY
u The quality and amount of visual input into the brain can be altered. (the acuity can be changed)
u The brain’s ability to process normal visual input can be altered.
u BOTH can be altered
u EITHER WAY………. THERE IS A DECREASE IN THE ABILITY TO USE VISION FOR OCCUPATIONS
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COMPLICATIONS OF VISUAL IMPAIRMENTS
u Difficulty completing VISION DEPENDENT activities
u READING AND DRIVING
u Feeding, grooming, dressing are less dependent on vision.
u Decreased SPEED in completing tasks
u Errors in decision making when vision is impaired
u Postural Dysfunction
u Falls
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Behavioral Implications of Visual Impairments
u Decreased Confidence
u Increased anxiety and uncertainty in responding to the environment
u Increased passiveness in decision making
u Difficulty with tasks in dynamic environments
u Increased Fear of Falling
u Community activities are the most challenging:
u Driving
u Shopping
u Working
u Participation in Sports/Leisure Interests
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What do we do? Spontaneous and complete recovery may not occur for many clients
THE KEY IS COMPENSATION
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VISION SCREENING
u Record visual history
u Observe head posture and eye alignment
u Always watch what the eyes are doing throughout the screening process
u If the person wears glasses, be sure he/she has them on during screening process and that they are clean
u Assess acuity first
u Perform tasks monocularly and binocularly to ensure most accurate information
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Oculomotor Skills
u Ability of the six muscles of the eye to coordinate movement to move the eyes accurately
u Includes:
u Pursuits
u Fixation
u Saccades
u Scanning
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PURSUITS
u The ability to follow a moving object smoothly and accurately with one eye at a time and both eyes together
u Continuous clear vision of moving objects
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SYMPTOMS OF PURSUIT DYSFUNCTION
u Loss of Target
u Decreased visual attention span
u Difficulty crossing midline with the eyes
u Over/undershooting a target with refixation
u Difficulty with driving, mobility, sports, etc.
u Head movement
u Nystagmus, Jumpiness
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FIXATION
u The ability to maintain a “visual hold” on an object while stationary
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SYMPTOMS OF FIXATION DYSFUNCTION
u Inability to maintain focus on a target
u Attention Deficits
u Looking away from a task often (which may be interpreted as an inattention
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Saccades
u The ability to adjust fixations from one stationary object to another
u Speed and accuracy are important u Skill we use to read
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Symptoms of Saccades Dysfunction
u Decreased reading speed and comfort
u Eyes fatigue easily when reading
u Poor attention
u Losing place or skipping lines when reading
u Difficulty locating objects quickly
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Functional Implications of Oculomotor Deficits
u Difficulty Reading and Writing
u Skipping words and lines
u Difficulty with page navigation
u Excessive compensatory head movements
u Decreased attention to detail
u Exhibits jerky eye movements during reading or tracking
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Binocular Vision
u The ability to visually focus on an object with two eyes to create a single clear image
u Binocular Vision Dysfunction includes:
u Diplopia (double vision)
u Convergence Insufficiency
u Convergence – the ability of the eyes to simultaneously turn inward to focus on a near point of vision
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Symptoms of Binocular Vision Dysfunction
u Inability to read or perform close tasks
u Loss of place when reading
u Difficulty with depth perception
u Increased frustration with near tasks
u Squinting
u Headaches, nausea
u Closing one eye
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Functional Implications of Diplopia
u Complaints of double vision, either horizontal or vertical
u Complaints of blurred or shadowed vision
u Headaches, eye strain, fatigue
u Difficulty with accuracy during reaching, grooming tasks, going up/down curbs or stairs
u Repositioning task to self
u Covering or closing one eye
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Behavioral Implications of Diplopia
u This interferes with object identification
u Creates visual stress
u Almost always interferes with PARTICIPATION…..avoidance behaviors
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Functional Implications of Convergence Insufficiency
u Losing place when reading or writing
u Difficulty performing tasks close up
u Complaints of blurred or double vision when focusing on near targets
u Eye strain or fatigue when reading
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Accomodation
u Process of adjusting and sustaining focus from one distance to another
u Ability to change the focus of the eye so objects at different distances can be seen clearly
u Decreases with age
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Symptoms of Accommodation Dysfunction
u Excessive blinking u Headaches, eye strain, and fatigue u Sensitivity to light
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Functional Implications of Accommodation Dysfunction
u Complaints of blurred vision especially during grooming, buttoning, shaving, and makeup
u Difficulty reading with complaints of the print moving
u Decreased ability to focus
u Difficulty when reading at a distance and writing close up
u Driving difficulty
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Visual Perception
u Ability to see, perceive, and interpret the visual information around us
u Involves cognitive function as well
u Visual Motor Integration – eye-hand, eye body coordination
u Visual Auditory Integration – relate what is seen and heard
u Visual Memory – remember and recall information that is seen
u Visual Closure – ability to “fill in the gaps” to complete a visual image
u Spatial Relationships – knowing where you are in space
u Figure-Ground Discrimination – discern an object from background
(Politzer, T. 2015)
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Visual Perceptual Deficits
u Agnosia
u Figure Ground
u Form Constancy
u Topographical Disorientation
u Depth and Distance Deficits
u Apraxia
u Neglect
u Postural Dysfunction
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VISUAL FIELD DEFICITS
LINDA CLEMENTE, OTR/L
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Visual Fields/Peripheral Vision
u Ability to focus centrally and continue to see peripherally in all directions.
u The space one sees around them when they look out at the world.
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Visual Field Deficit (VFD)
u May occur due to damage to the eye, optic nerve, or brain
u VFD is when an area of the visual field is missing
u Various types: u Central Scotoma – Missing the central field of vision
u Quadrantonopsia – Loss of vision in a specific quadrant
u Homonymous Hemianopsia – Loss of vision from one half of each eye resulting in missing information from one half of the field of vision
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(Retrieved from Google images)
Full Visual Field Homonymous Hemianopsia
Central Scotoma Quadrantonopsia
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Functional Implications of Visual Field Deficits
u Difficulty walking – steps/curbs, poor balance, walking along the wall
u Leaving food on the plate
u Misreading words, reading slowly
u Difficulty finding grooming items
u Missing details
u Writing off the line
u Increased time/assistance for dressing
u Trouble navigating the environment
u Difficulty driving and shopping in a crowded place
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Behavior Changes in Field Deficits
u Persons will adopt a narrow search pattern confined to the sound side or midline
u 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
u Misses or misidentifies visual detail on the blind side
u Impaired reading performance
u Difficulty with tasks that have small detail
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Behavior Changes in Visual Field Deficit
u Reduced monitoring of the hand
u Impaired grapho-motor skills
u Difficulty pouring liquids
u Changes in reading
u Omissions on the involved side
u Misidentification of words and numbers
u Poor page navigation may skip lines
u Reduced reading accuracy and speed
u ***** reading is not always involved if the fovea is not
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Behavior Changes in Visual Field Deficit
u Changes in Handwriting***
u Writing may drift up/down on the line
u May write on top of other words
u Positions words incorrectly
u ****This occurs only if the visual field deficit is on the same side as the dominant hand
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Functional Changes in Visual Field Deficit
u Changes in A.D. L. u This happens in areas that depend on vision to complete u Requires monitoring of a wide visual field
u Driving u Shopping u Community Events
u Yard Work u Meal Preparation u Financial Management u Housekeeping
u Self care
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More Behavior Changes in Visual Field Deficit
Changes in Orientation
u Insufficient visual input to accurately map
u space on involved side.
u An inability to scan fast
u enough to comprehend scene as a whole
Tendency to get lost
u Tends to avoid independent travel
u Very uncomfortable navigating alone
u At risk for injury and bumping into objects
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Treatment
u Person must learn to use their remaining vision more effectively to compensate for missing vision
u Environment must support participation
u Compensation/adaptation may be a client’s only option since a visual field deficit might have a permanent impairment
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Education
u Education is a KEY adjunct to intervention.
u Education assists a client to become aware of location and extent of deficit.
u Education lets a client know how it has affected their occupational performance
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INTERVENTIONS FOR VISUAL SCANNING, FIELD AND ACUITY DEFICITS AFTER A BRAIN INJURY
LINDA CLEMENTE, OTR/L
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What is Visual Scanning Therapy?
u Developing skills to COMPENSATE for spatial bias
and to execute a COMPREHENSVE search
u Reinforce client takes in visual information in a systematic manner
u Use language and cognition to REDIRECT search
****can not be successful if client does not have
adequate language and cognition*****
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Visual Scanning Activities
u Initiate search from the left
u Execute a symmetrical search pattern
u Execute complete search to the left
u Observe all visual detail
u Anticipate all visual input occurring on the left
u Rapidly dividing/shifting attention between left and right fields
u ***Make the activities as interactive as possible***
Kim et al 2011
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Sample of scanning activities
u Eye and Head movements to the affected side
u Use of scan boards
u Use a flashlight to walk around room toward the affected side
u Use post its around the room to “find” objects
u Have patient move eyes toward the deficit. Encourage the patient to become aware of the feel of their eyes when gazing as far as possible toward the deficit.
u Playing various games like puzzles and cards
u Use balloon and ball toss to encourage movement into the area of deficit and to attend to space on the deficit side.
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Central Field Tasks: Cancellation Sheet
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Scanning sheet
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Crowded Word Search
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Small saccadic
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Harte Chart
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Occupational Therapy Interventions
u Reading: Must learn how to use new perceptual span
u Client has to adapt to the new span
u Requires PRACTICE, PRACTICE, PRACTICE
u Important to approach it in small, achievable steps: Pre-reading exercises
u Read in large print
u Read desired material
u Client needs to be successful with letters and words before reading. 20-30 minutes a day is recommended
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TECHNOLOGY
u Dynavision/Light Board
u Computer Assisted Biofeedback
u Hand Mentor
u Laser Pointers
u IPad
u Neuro Eye Coach, BITS
u Internet Websites, computer games, apps
u Eyecanlearn.com
u Highlight.com
u Tacustherapy.com
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Goal of Interventions
u Elicits and increases head turning, width and speed
u Increases attention/focus to involved side
u Creates anticipation to the involved side
u Improves the efficiency of the visual search through repetition
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GOAL of THERAPY
The ultimate goal is independence and participation in daily occupations.
In summary:
u Effective compensation for field deficit
u Improved search of environment
u Develop supportive routines and safe habits
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LOW VISION
LEGAL BLINDNESS : VISUAL ACUITY WITH BEST CORRECTION IN THE BETTER EYE WORSE THAN OR EQUAL TO 20/200 OR A VISUAL FIELD EXTENT OF LESS THAN 20 DEGREES
LOW VISION: FUNCTIONAL LIMITATIONS THAT HAMPER ENJOYMENT AND PERFORMANCE OF EVERYDAY ACTIVITIES
WWW.NIH.GOV.COM
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Definition of Low Vision
u A visual impairment that can not be corrected by conventional glasses, contact lenses, surgery, or medicine.
u Eye diseases/Brain injury cause one or more of these symptoms:
u A loss of ability to see detail (visual acuity)
u A loss of peripheral vision (visual field)
u Constant double vision (diplopia)
u Difficulty navigating steps or curbs (contrast sensitivity)
u An inability to distinguish colors
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General Principles for Enhancing Visual Performance
Increase visibility of the task or the environment
u Make things brighter u Make things bigger u Use contrast to increase visibility
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Interventions
u *****The main principle is to MAGNIFY the image using various tools*****
u Low vision reading glasses
u Magnifiers(hand held and stand)
u Telescopes (hand held or mounted onto glasses)
u Microscopes (reading lenses)
u Computer devices( text to speech programs
u e-books readers (ie. Kindle with larger font/changing contrast screen)
u Smart phones and tablets
u Electronic Video Magnifiers (CCTV)
u Talking watches and clocks
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Increase the contrast
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Minimize the background Pattern Clean up the clutter Organize similar items/separate colors
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Reduce patterns
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Minimize background pattern
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ORGANIZE u Structuring your physical space helps with
cognitive functioning. u Increased participation if things are
organized. Predictability of the physical space.
u Label things clearly. Use tactile sensory input
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Organize
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Provide Optimal Lighting
u Even illumination
u Minimize glare
u Flexible placement: aim for even illumination and brightness
u Task lighting
u Carry a penlight
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Increase the
brightness
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Types of lighting
u Fluorescent Lighting: even illumination, but limited placement flexibility
u ( pulsing light bothers some people)
u Halogen Lighting: high quality light minimum glare, but is “hot light”
u LED Lighting: Instant on, high intensity, low glare
u Simulated daylight light: increases contrast, increases clarity, low energy
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Glare
MANAGE GLARE SENSITIVITY
u Reduce glare sources
u Use proper window covering
u Cover reflective surfaces( floors,shiny counter)
u Use filters to control incoming light(wear clip on or fit over glasses, visor may be helpful)
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Cover surfaces to reduce the glare
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Enlarge- make things bigger
u Enlarge with contrast u ie. Large button calculator
u Large button remote
u Large print cards, bingo
u Move in closer u ie. Sit closer
u Magnify: u electronic magnification devices
u hand held or stand magnifiers
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Summary
u Rehabilitation therapists encourage patients to make the most of their remaining vision.
u Occupational Therapists can educate patients in understanding the neurological component of visual field loss, contrast, glare and lighting needs.
u Occupational Therapists are trained in incorporating compensatory and adaptive techniques.
u Occupational Therapists use the building blocks of the visual hierarchy model for achieving success and increased independence with A.D.L.’s, functional mobility, and SAFETY!
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VISION AND MOBILITY NIDHI SHAH, PT, DPT
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VISUAL IMPAIRMENTS AFFECT MOBILITY, ORIENTATION AND GAIT
u Hesitation, Anxiety during all mobility related tasks
u Person prefers to follow vs lead
u Person exhibits an uncertain gait – difficulty following the appropriate path, disorientation to vertical and to the surroundings
u Person tends to watch their feet and trails arms with ambulation
u Comes very close to obstacles and stops often to search
u All this in conjunction with reduced attention to task, and/or inattention to one side often leads to falls
u Sometimes complicated by physical impairments that may have occurred with a brain injury (limb weakness, hemiparesis, contractures or spasticity)
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HOW VISUAL DEFICITS AFFECT POSTURE AND ORIENTATION
Karnath et al, 2003
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BALANCE AND FALL RISK ASSESSMENT
u Assess reliance on vision for balance u Clinical Tests of Sensory Integration and Balance
u Assess fall risk using appropriate clinical testing u Timed Up and Go test u Berg Balance test
u Postural assessment –visual field deficits and other visual perceptual deficits alter the person’s perception of vertical and force postural change u Assess posture in different positions (bed, wheelchair, standing) from
different planes
u Posturography to assess center of gravity displacement in different postures on varying surfaces
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INTERVENTIONS TO IMPROVE BALANCE AND REDUCE FALL RISK
u Static sitting and standing training to improve postural stability
u Dynamic training that challenges stability, explore stability limits in different environments, on different surfaces
u Reduce reliance on vision for balance, enhance somatosensory and vestibular inputs for balance
u Improve posture in different positions using tactile, visual and somatosensory feedback
u Performance and task practice to promote a sense of independence
u Assess home and proximities to recommend changes and ensure safety - Balliet et al, 1987, Brown et al 1987, Gill-Body et al 1997, Stoykov et al, 2005, Freund and Stetts, 2010
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INTERVENTIONS TO IMPROVE BALANCE AND REDUCE FALL RISK
- Bastian et al, 1997
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GAIT ASSESSMENT
u Observational assessment
u Video assessment (HIPPAA!)
u Clinical testing u Functional Gait Assessment
u Gait speed testing
u Two minute walk test
u Other timed tests
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INTERVENTIONS TO IMPROVE LOCOMOTION
u Assess and recommend appropriate assistive device
u Train to improve gait in the following ways u Open environments
u Around & over fixed obstacles
u Sudden change in direction
u Head turns while walking
u Change in speed
u Different surfaces and changing surfaces
Jeka et al, 1997;
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FUNCTIONAL MOBILITY ASSESSMENT
u Includes mobility like transfers to the bed, toilet or shower, walking to the closet to retrieve clothes for dressing, etc.
u Involves assessment of patient performance of transfer, % assistance needed and possible safety considerations
u Barthel Index
u Functional Independence Measure
u Consider other physical impairments as well
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INTERVENTIONS FOR FUNCTIONAL MOBILITY
The Desired Compensatory Behaviors: u Using the appropriate assistive
device u Using the recommended
adaptive equipment u Wider head turn
u Increased head movement in anticipatory behavior
u Faster head movement to compensate for possible lack of scanning or field
The Desired Remediation in Behaviors:
u Improved sequencing to complete functional mobility
u Improved motor planning
u Improved posture and improve orientation to vertical
u Organized, efficient search pattern
u Increased attention to visual detail
u Improved patient understanding of their deficits
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VISUAL CHANGES AFFECT ORIENTATION
u Insufficient visual input to accurately map space on involved side. An inability to scan fast enough to comprehend scene as a whole
u Tendency to get lost
u Tends to avoid independent travel
u Very uncomfortable navigating alone
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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 courses
b. “Find a color”
c. Narrated walk
d. Treasure hunts: incorporate language, memory, executive functioning
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OBSTACLE AND SCANNING ROUTES
A simplified sketch of an obstacle course used in schools, can be adapted for adults with brain injury to train for orientation and mobility
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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.
! A lack of this awareness could be hazardous to the patient’s safety.
! Education about safety with the use of recommended assistive device, and why it is needed.
! Education about possible changes to be made in the home/ proximity to ensure patient safety
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Education is a KEY adjunct to intervention
u Education of the caregiver is as essential as educating the patient
u Assess the patient (& caregiver’s) health literacy,
u Assess appropriate learning mode. Remember that for a person with a brain injury affecting vision, reading material might not be the most appropriate learning mode, use auditory information instead
u UTILIZE TEACHBACK to assess patient understanding
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FINAL THOUGHTS TO ADDRESS MOBILITY
u If possible progress to outside/community environments. It is critical to educate clients about potentially dangerous situations.
u ALWAYS link clinic activities with the outside world to make them more meaningful
u ALWAYS increase visibility, think about good contrast, create the best illumination, and minimize the pattern. Organized and structured environment
u Therapy should create context that support participation
u ALL THERAPY MUST BE GOAL ORIENTED
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REFERENCES Balliet et al. (1987) Retraining of functional gait through the reduction of upper extremity weight bearing in chronic cerebellar ataxia. International Rehabilitation Medicine, 8, 148-153.
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Bateni et al. (2004) Can use of walkers or canes impede lateral compensatory stepping movements? Gait and Posture, 20, 74-83.
Bynum H, Rogers J (1987) The Use and Effectiveness of Assistive Devices Possessed by Patients Seen in home care. American Occupational Therapy Journal 7: 181-184
Carlton RS (1987) The effects of body mechanics instruction on work performance. American Journal of Occupational Therapy 41: 16-20
Ciuffreda ,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.
Geiger CM (1989) the utilisation of assistive devices by patients post discharges from an acute rehabilitation setting. Unpublished Masters Thesis. Temple University
Jeka JJ (1997) Light touch contact as a balance aid. Physical Therapy, 77, 5, 476-487.
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Katz, Noomi; Hartman-Maeir, Adina; Ring, Haim; Soroker, Nachim, "Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect." Archives of Physical Medicine & Rehabilitation 80.4 (1999) 379-384 Markowitz, Michelle, "Occupational Therapy Interventions in Low Vision Rehabilitation" Canadian Journal of Opthalmology 41. 3 (2006): 340-347. 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. Ponsford, Jennie. "Rehabilitation Interventions after mild head injury." Current Opinion in Neurology 18. 6 (2005): 692 - 697. Pambakian,A.L., Currie, J & Kennard,C. (2005) Rehabilitation strategies for patients with homonymous visual field deficits. Journal of Neuro-Ophthalmology, 25, 136-142. Pendleton and Schultz-Krohn. (2012). Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 7th edition. Mosby. Politzer, T. (2015, April 22) Introduction to Vision and Brain Injury. Retrieved from Neuro-Optometric Rehabilitation Association website https://nora.cc/for-patients-mainmenu-34/vision-a-brain-injury-mainmenu-64.html
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Riggs, R.V., Andrew, K., Roberts, P. Gilewsk, M. (2007). Visual Deficit Interventions in Adult Stroke and Brain Injury: A Systematic Review. American Journal of Physical Medicine and Rehabilitation, 86, 853-860. 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. Zoltan B (1996) Vision, perception and cognition – a manual for the evaluation and treatment of the neurologically impaired adult. Slack. Thorofare. Hans-Otto Karnath and Doris Broetz PHYS THER. 2003; 83:1119-1125. Understanding and Treating ''Pusher Syndrome''
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