Occupational Therapy & Vision Rehabilitation

Presented by:Margaret A. Waskiewicz MS, OTR/LUnit Supervisor, Adult Outpatient OT

Defining Vision

•More than 20/20

•Ability to interpret and understand what we are seeing

•“It is the total ability to organize light input and recognize spatial relationships between things and to build an internal representation of reality” (Paul Harris, 1998)

Diagnosis

CVA/Stroke

**TBI**

Parkinson’s Disease

Multiple Sclerosis

Concussion

Cranial Nerve Involvement

Common Vision Diagnoses

•Homonymous Hemianopsia•Homonymous Quadrantonopsia •Optic Neuritis•Convergence Insufficiency•Chronic Optic Neuropathy

Common Visual Complaints

•“I get tired when trying to read”•“When I turn too quickly I get dizzy”•“I feel like it is difficult to find things”•“I am seeing double”•“My vision is blurry”•“My depth is off”•“I am skipping lines when reading”

•Fig. 1 (a) Screening visual field test from a 34year-old man with a four year history of MS who had developed blurred vision in both eyes. The visual field test demonstrates a left upper incongruous quadrantinopia.

• (b)Subsequent magnetic resonance imaging showed MS lesions including the symptomatic lesion in the right optic radiation(arrowed).

•(c)Visual field test performed 5 months later showing complete recovery.

Impact on Functional Activities

•Self-Care/ADL

•Household/IADL

•Reading/Computer/Work-Related Tasks

•Community Mobility & Driving

•Quality of Life

Occupational Therapy Evaluation & Vision Screen: What Do We Look At?

OT Evaluation:•Functional complaints

•ADL:•Managing buttons/fasteners •Lower body self-care•Showering

•IADL: •Community:

•Grocery Shopping•Crossing the street•Navigating from home to destination

•Household:•Cooking•Cleaning•Laundry •Paying bills/writing checks

•Work Related Tasks•Writing, reading, computer use

•Writing sample•Reading sample

•QOL: NFQ-25**Consider quality and safety not just independent or not!

•Physical Function•Basic AROM •Hand Eye Coordination:

•9 hole peg test •Purdue pegboard

•Grip/Pinch•Qualitative observations about posture (head tilt, rotated head, tilted pelvis)

OT Vision Screen:•Basic Test of Near & Far Acuity•Oculomotor:

•Pursuits•Saccades •Ocular ROM (monocular and binocular)

•consider if symptoms are provoked

•Binocular: •Convergence/Divergence •Brock String•Stereopsis•Worth 4 Dot for Suppression

•Eye Alignment:• Phoria cards• Cover/Uncover Test

•Visual Fields

•Visual Perceptual Testing (LOTCA, Behavioral Inattention Test, MVPT)

Adaptations, Interventions & Treatment

Adaptations to Improve Comfort with Reading and Computer Use

•Line Guide•Colored Tints•Anti-Glare screen•Reduce Glare•Ergonomics/Rest Breaks

Adaptations for Low Vision

•Increase Contrast

•Reduce Glare

•Reduce Clutter

•Assistive Technology:•Screen Readers•Screen Magnifiers•Large button keyboards

OT Treatment for Oculomotor Skills

•Improving visual scanning/saccades

•Improving smooth pursuits/tracking

•Incorporate into functional activity

Posture & use of body movements are all considered!

OT Treatment for Oculomotor Skills

•Monocular/binocular strengthening•H, X, O•4-corners•Clock•Post-its•Crossword Puzzle•Letter cancellation•Multi-matrix•Vision coach•Biometrics

Management of Double Vision/Binocular Impairments in OT•Compensation•Partial Occlusion•Teach eye teaming skills and how to use in a functional context•Integration of body movements with eye movements

Management of Double Vision/Binocular Impairments in OT

•Pencil push-ups•Straw Piercing•Brock string•Thumb/Post-it

•Static•Dynamic•With environmental distractions

Case Study #1: BackgroundPatient is a 56 y/o female who was flying home from South Carolina when she experienced severe headache Was found to have-bilateral SDH and CSF leak

•Prior to injury:• Independent with all self-care and home management•Working full-time•Single parent•Driving•Busy social life•Type A personality•Travelled frequently

Case Study #1: Initial PresentationPhysically Emotionally

Dizzy Anxious/depressed

Headache Tearful

Pressure behind right eye -c/o horizontal double vision -difficulty looking up and to the right

Spiritually preoccupied “God did this to me for a reason”

Ataxic Perseverative

Right sided weakness Decreased concentration

Decreased balance Decreased attention

Decreased strength Easily fatigued

Decreased coordination Decreased insight

“Jumpy” /sensitive to loud noise, light, movement and excessive environmental stimuli

Fearful/scared

Case Study #1: Initial Presentation Cont.Activity Function

Dining Moderate difficulty/increased time

Grooming Moderate/maximal difficulty and increased time seated

Bathing Minimal/moderate (A) seated on tub bench. Fell x1 after d/c from RUSK

Toileting Moderate difficulty and increased time using RTS

Dressing UB: Minimal difficulty donning shirt; moderate/maximal difficulty with fastenersLB: Maximal difficulty threading pants; maximal (A) with socks/shoes; dependent with tying laces

Reading Unable to tolerate

Writing Moderate difficulty/fair legibility

Household Activities Dependent with cooking, cleaning, laundry and grocery shopping

Safety Awareness Fair/fair minus; requires increased time to process; denial

Words from the patient…

“I don’t leave my house unless I have to come to therapy or go to the doctor; I’m scared to.”

“I spend most of my time in the dark; I don’t watch T.V. and I won’t listen to the radio…it’s too much.”

“I hate that I have to rely on my daughter for simple things; I feel like I’m a baby.”

Case Study #1: Sensory Profile

Low Registration Sensation Seeking

Sensory Sensitivity

Sensory Avoiding

More than most people

Much less than most people

Much more than most people

Much more than most people

Case Study #1: Treatment Techniques Used

•Proprioceptive Input:•Weighted vest•Palming•Gentle rocking•Pillow Hugging•Deep pressure/joint compression

•Vision Exercises:•Monocular/Binocular

•Matrix•Furniture gliders/bean bags•H, X, O•Brock string•Biometrics•Vision Coach•Word Find

•Activity Log

Activity LogActivity Mon Tues Wed Thurs Fri Sat Sun How do you

feel?

Read a book

Listen to radio

Word find

Rocking at counter

Talk on phone

Use computer

Go for a walk outside

Go to the store

Clapping hands/stomping feet

Directions: Choose 3 activities each day and perform them for 5-10 minutes. Write down how you feel after the activity is performed. Rate how you feel on a scale of 0-10 in the day of the week box; 0=“I feel fine”; 10=“The worst I’ve ever felt”

Case Study #1: Standardized Assessments Pre and Post

Initial Discharge

9 hole peg RUE: 59.03 s(Norm 17.8 s)

LUE: 39.28 s(Norm 19.4 s)

RUE: 24.2 s

LUE: 17.56 s

Convergence9 inches 6 inches

Case Study #1: Functional Outcomes

Activity Function

Dining Minimal difficulty and increased time

Grooming Minimal difficulty and increased time while standing

Bathing Minimal difficulty and increased time while standing

Toileting Increased time with RTS

Dressing UB: Increased time; minimal difficulty with fasteners/buttonsLB: Minimal difficulty and increased time threading pants, socks and shoes. Unable to tie shoe laces.

Reading Tolerates for 15-20 minutes before needing rest break.

Writing Minimal difficulty; fair plus legibility

Household Activities Simple hot/cold meal prep with moderate difficulty; light house cleaning with moderate difficulty and increased time; grocery shops with daughter and (A) with folding laundry

Safety Awareness Good awareness of limitations/deficits

After-Words from the patient…“When I started my therapy I couldn’t even shower by myself…I

couldn’t do anything…I was helpless.”

“Now, I don’t cry anymore; I don’t feel like I have to, because I know that I’m getting better…I feel it, but more importantly, I can

see it everyday.”

“I’m finally starting to feel like a real person again; I’m getting my independence back.”

Referrals for Vision Rehab•Appropriate Referrals

•Concussion with saccadic impairment•Visual Disturbance•Diplopia•Visuospatial neglect•Concussion with convergence insufficiency•TBI with impaired saccades•Dizzy patient of unknown etiology with oculomotor impairments

•Inappropriate Referrals

•Strabismus for several years

•Elderly patient with changes in vision (ie. accommodation)

•Macular degeneration

•Glaucoma

•Cataracts

•Occupational Therapist•Neuro-ophthalmologist•Neuro-optometrist•Physiatrist•Other rehab services

•PT •Vestibular PT•SLP •Neuropsychology/psychology •Nursing•Social work•Vocational rehab

Who Is Involved?

•The visual system allow us to make sense of our world and to be able to adapt to our ever changing environment.

•Our vision is also involved in up to 85% of our perception, learning and mental acquisition of knowledge.

•Please feel free to contact us with patients that you suspect may have visual deficits. We’ll be more than happy to perform a vision screen and share the results.

Conclusion

References•Brown, C., Tolefson, N., Dunn, W., Cromwell, R. & Filion, D. (2001). The adult sensory profile: measuring patterns of sensory processing. American Journal of Occupational Therapy, 55, 75-82.•Ciuffreda, K.J., Kapoor, N., Rutner, D., Sucholf, I.B., Han, M.E., & Craig, S. Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis (2007)•Goodrich, G.L., Flyg, H.M.,Kirby, J.E., Chea-Yo Chang, C., Martinsen, G.L. (2013). Mechanisms of TBI and Visual Consequences in Military and Veteran Populations. Optometry and Vision Science, 90, 105-112.•Khan, F., Baguley, I.J., & Cameron, I.D. (2003). Rehabilitation after traumatic brain injury. MJA Practice Essentials, 178, 290-295.